Respiratory Conditions

Objectives:

1. Be aware of classical symptoms and risk factors of COPD, Asthma and Pneumonia
2. Recap the pathology of COPD, Asthma and Pneumonia
3. Understand the evidence in support of current treatment and management, and how pharmacy can help patients understand their treatment.

Introduction:

Respiratory diseases are one of the world’s biggest health concerns, causing one sixth of all deaths worldwide, with 600,000 respiratory related deaths in the European Union each year ^[1]. Over half of these deaths are due to lung cancer and Chronic Obstructive Pulmonary Disease (COPD), and they are mainly caused by smoking ^[1]. Respiratory illnesses are the most common long-term conditions in children and babies with 21% of children having been diagnosed with asthma ^[2]. Respiratory diseases cause disability and a premature death and are an economic burden, especially the ones that are preventable. COPD is the fourth leading cause of death worldwide, and the World Health Organization estimates that by 2030, it will be the third leading cause of death worldwide ^[3]. One in eight emergency hospital admissions are for COPD patients, making this the second largest cause of emergency admissions^[4]. This also makes it one of the most expensive inpatient conditions treated by the NHS,  as it is estimated to cost around £982 million each year ^[5].

Table 1: Table showing the cost of various lung diseases to the European Union ^[1]

Overview of the conditions

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disorder, characterized by airflow limitation. This limitation is defined as a FEV₁/FVC ratio <0.7. COPD is treatable, but not curable and unlike asthma and it is has little to no reversibility ^[6]. The cardinal symptoms of COPD are: dyspnoea (shortness of breath), chronic cough and sputum production. COPD is caused by a combination of two conditions: chronic bronchitis and emphysema (parenchymal damage). In chronic bronchitis, there is inflammation and fibrosis of the bronchial wall, which causes bronchoconstriction. There is also hypersecretion of mucus caused by the increase and hypertrophy of goblet cells. The combination of broncho-constriction and excess mucus leads to obstruction of airflow, thus causing the mismatch of ventilation and perfusion. Emphysema is caused by an inflammatory response which causes the breakdown of elastin in the alveolar wall, leading to loss of alveolar integrity as the alveoli are unable to recoil. Loss of alveolar recoil decreases ventilation, thus causing air trapping. Air trapping is the cause of the barrel chest appearance in patients with emphysema because the air is still trapped in the lung.

Asthma is the most common respiratory condition, and it characterized by: airflow obstruction, inflammation and bronchial hyperresponsiveness. When an allergen is inhaled, it triggers a reaction within the cells of the bronchus, Through a process of events, there inflammation and an increase in mucus production which causes bronchoconstriction leading to a difficulty in breathing. Asthma can be atopic (most common) or non-atopic (uncommon). Symptoms of asthma would include: dyspnoea, wheeze, chest tightness and a dry, irritating cough^[7].

Pneumonia is an infection of one or both lungs, and can be caused by either a bacteria, virus or fungi. In pneumonia, there is inflammation and fluid build-up in the lung which makes it hard to breathe. There are many different types of pneumonia; however, community acquired pneumonia (CAP) is the most common. Signs and symptoms include: malaise, confusion, fever and chills, rigor, tachycardia, dyspnoea and a productive cough. The most common causative agents are: Strep. pneumoniae, influenza and the respiratory syncytial virus (RSV). Fungal pneumonia is uncommon and is mainly seen in patients who are immunocompromised. People with existing respiratory conditions are more likely to suffer from pneumonia.

Risk Factors

Tobacco smoking is the biggest risk factor in the development of respiratory conditions ^[6]. About 90% of COPD cases are caused by cigarette smoke. Inhalation of oxidative toxins from occupational exposure (exposure to dust, chemicals and particles), air pollution and from second hand smoke are all risk factors for developing COPD, asthma and pneumonia. Some other risk factors for developing pneumonia are: being immunocompromised, older than 65 years, malnourishment and taking certain medications (such as amiodarone and methotrexate). Other risk factors for asthma include: being overweight and genetics (having a blood relative with asthma or having another allergic condition such as eczema or hay fever). Genetic risk factors for would include people who have an alpha-1 antitrypsin deficiency.

Diagnosis

There are a range of investigations that can be used to diagnose various respiratory conditions; however, spirometry is the first-line diagnostic test that will need to be performed on a patient that presents with either asthma or COPD^[6][7]. Since the symptoms of asthma and COPD are similar, when differentiate between the two, the doctor will look at: the age of onset of the symptoms, characteristics of the cough and the symptom variability^[8]. According to NICE guidelines, a diagnosis of COPD should be considered in patients over 35 years that have exposure to a risk factor and presents with one or more of the following^[4]:

• exertional breathlessness
• chronic cough
• regular sputum production
• recurrent chest infections or frequent winter ‘bronchitis’
• wheeze

Table 2: Clinical features differentiating COPD and asthma

Pneumonia is mainly diagnosed by the doctor performing a physical exam and a chest x-ray. Other investigations would include a blood test to check white blood cell count and identify the pathogen, and also sputum culture, again to identify the infecting organism. However, when a patient presents with pneumonia, they are treated empirically first, then the tests are done ^[9].

Table 3: Respiratory diseases and differential diagnosis ^[6]

Management

COPD, asthma and pneumonia are all managed according to guidelines. The NICE guidelines can be used to provide appropriate treatment; however, there are other guidelines that can be used also. For the treatment of COPD, guidelines published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) could be followed and for the treatment of pneumonia guidelines from the British Thoracic Society (BTS) could be used. Treatment for COPD and asthma should be done on an individual basis and should aim to reduce the patient’s symptoms and reduce the patient’s risk. Pharmacotherapy a patient would receive includes: inhaled bronchodilators and corticosteroids, oxygen therapy, immunization and medication used to relieve other symptoms. Selection of inhaled bronchodilators, corticosteroids, or even the combination of them used to treat a patient would be selected based on the severity of the COPD or asthma symptoms. Other medicines would include: theophylline, phosphodiesterase inhibitors, and mucolytics (eg. 4 week trial of Carbocisteine), diuretics (patient with peripheral oedema) and promethazine or dihydrocodeine (both used to treat the sensation of breathlessness) for patients with COPD. Patients may receive a course of oral antibiotics or oral corticosteroids as rescue medication if they are having frequent exacerbations. Non-pharmacological therapy would include: smoking cessation, pulmonary rehabilitation and surgical intervention. Surgical intervention would be lung volume reduction and lung transplant, which would have its own set of guidelines.

Table 4: NICE Guidance 2010 COPD severity and staging

* Symptoms should be present to diagnose patients with mild severity

⁺ FEV₁ < 50% with respiratory failure

When recommending treatment for CAP, a patient is first given a CURB-65 score and empirical treatment will be given based on the score. The patient scores one point for every feature that is present. If a patient has a score that is less than one, they can be treated at home; however, if the patient has a score greater than one, or any other unstable comorbid illness, they would need to be treated in hospital ^[9].

Table 5: CURB-65 Scoring ^[9]

Smoking cessation is the most important intervention that can be made, as it helps with reducing the risk of asthma exacerbations and the severity of COPD. Most people find this hard, especially people with COPD as the majority of them have been smoking for years. It is important to let these patients know that, although quitting is the end-game, even a reduction in the amount of tobacco smoked can help to slow down the progression of COPD ^[10]. Pulmonary rehabilitation is a multidisciplinary program that incorporates: physical training, education of condition, nutritional counselling and breathing exercises which help with gas management.

Practical respiratory consultation points

Below are some key points that should be mentioned when counselling a patient with COPD or in a respiratory MUR.

• Does the patient know the difference between their inhalers – are they aware which inhaler is used as a reliever and which is used as a preventer?
• Checking and teaching good inhaler techniques – now that there has been an increase in the number of different inhaler devices, pharmacists should make sure that they know how to use each one. Also check to see if there are any dexterity or co-ordination issues with using the inhaler
• Does the patient get confused with the number of inhalers they are using – if the patient is on a number of inhalers and confused how to take each one, perhaps a suggestion could be made to the doctor or nurse about prescribing a combination inhaler.
• Compliance and frequency – is the patient using their reliever frequently? Are they using their preventer or steroid inhaler everyday?
• Do they know how to check if the inhaler is almost empty?
• Ask if the patient is experiencing any side effects
• Smoking status of the patient – advice can be offered in the pharmacy or they can be signposted to local pharmacy that offers the smoking cessation service.
• Signs of an exacerbation and frequency of exacerbations – does the patient know the signs of an exacerbation? Do they know how to use their rescue medication? Are they having exacerbations frequently?
• Have they received the flu vaccine?

Conclusion

As the incidence of death and disability caused by respiratory diseases increases, people should be made aware of the risk factors and how they can be reduced as many respiratory conditions are preventable. Smoking cessation is the most important intervention that can be made as it helps to reduced the severity and the exacerbations of the disease. Pharmacists should continue to give advice to patients about managing their long-term respiratory condition and encourage them get the best out of their medications.

References

1. Lung Health in Europe: Facts and Figures [Internet]. European Lung Foundation. 2013 [cited 15 December 2016]. Available from: http://www.europeanlung.org/assets/files/publications/lung_health_in_europe_facts_and_figures_web.pdf

2. Society B. Burden of Lung Disease | British Thoracic Society | Better lung health for all [Internet]. Brit-thoracic.org.uk. 2006 [cited 15 December 2016]. Available from: https://www.brit-thoracic.org.uk/working-in-respiratory/burden-of-lung-disease/

3. WHO | Chronic obstructive pulmonary disease (COPD) [Internet]. Who.int. 2016 [cited 14 December 2016]. Available from: http://www.who.int/respiratory/copd/en/

4. Chronic Obstructive Pulmonary Disease [Internet]. NICE Clinical Knowledge Summaries. 2015 [cited 15 December 2016]. Available from: https://cks.nice.org.uk/chronic-obstructive-pulmonary-disease

5. British Thoracic Society, 2012. COPD Care Bundles Project, London

6. Global Strategy for Diagnosis, Management, and Prevention of COPD – 2016 – Global Initiative for Chronic Obstructive Lung Disease – GOLD [Internet]. Global Initiative for Chronic Obstructive Lung Disease – GOLD. 2016 [cited 14 December 2016]. Available from: http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/

7. Asthma [Internet]. NICE Clinical Knowledge Summaries. 2013 [cited 15 December 2016]. Available from: https://cks.nice.org.uk/asthma

8. Yawn B. Differential Assessment and Management of Asthma vs Chronic Obstructive Pulmonary Disease [Internet]. PubMed Central (PMC). 2009 [cited 15 December 2016]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654706/

9. A Quick Reference Guide for the Management of Community Acquired Pneumonia in Adults [Internet]. Brit-thoracic.org.uk. 2009 [cited 15 December 2016]. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/pneumonia/adult-pneumonia/a-quick-reference-guide-bts-guidelines-for-the-management-of-community-acquired-pneumonia-in-adults/

10. How smoking cessation affects the progression of COPD – Stop-Tobacco.ch – Help and advice on quitting smoking [Internet]. Stop-tobacco.ch. [cited 15 December 2016]. Available from: http://www.stop-tobacco.ch/en/how-smoking-cessation-affects-the-progression-of-copd