respiratory pharmacy & the ward pharmacist experience
DESCRIPTION
Respiratory Pharmacy & the Ward Pharmacist experience. by Abdol Malek bin Abd Aziz, MSc. Respiratory pharmacy. Emphasis on pharmaceutical care of respiratory patients plus Other conditions that the patient is concurrently suffering. Respiratory Pharmacy. Covers: Asthma COPD - PowerPoint PPT PresentationTRANSCRIPT
Clinical Pharmacy Conference , Port Clinical Pharmacy Conference , Port Dickson, 9-11 Jan 2003Dickson, 9-11 Jan 2003
Respiratory Pharmacy & the Respiratory Pharmacy & the Ward Pharmacist experienceWard Pharmacist experience
by by
Abdol Malek bin Abd Aziz, Abdol Malek bin Abd Aziz, MScMSc
Respiratory pharmacy
• Emphasis on pharmaceutical care of respiratory patients
plus
• Other conditions that the patient is concurrently suffering
Respiratory Pharmacy
Covers:
•Asthma•COPD•Idiopathic interstitial lung disease•Pleural disorders•Pneumonia•Drug-induced pulmonary disease
NHMS 1996 - Findings
• High percentage (62.4%) not on inhalers
• Mild asthmatics: 65.3%
• Moderate : 52.1%
• Severe : 23.7%
Compliance / adherence
• Generally non-compliance rate ~ 50% (out patients)
• 56% in Melaka (1999)*• Leads to hospital admission• 51.7% in Hospital Melaka **• 13.3% were asthmatics (6/45 patients)• Non-compliance to inhaled medications: 50%
(McGann & Elizabeth. Am J Nursing 1999)
• Aziz AMA, Ibrahim MIM. Med J Malaysia 1999.• ** Aziz AMA, Senthil N, Jenny W. J Pharm Sci. 2003 (in press)
Some avenues to patient care…
• Patients with allergic rhinitis often experience symptoms of asthma (Linneburg.
Allergy 2002,57)
• Allergic rhinitis preceded or developed at the same time as allergic asthma
• Tx of allergic rhinitis reduced asthmatic symptoms or reduce risk of asthma
Inhaler technique
• “good” rating ranged from 5-86% using MDIs• Technique improved after proper training*• 37.5% of pharmacy staff & 45.4% (15/33)
outpatients having good technique€
€Inhaler technique survey among pharmacy staff and patients at the specialists clinic pharmacy, Hospital Melaka. Abstract of the Konferens R&D Farmasi, Kota Bharu 2002.
* Cochrane MG, Bala MV, Downs KE et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices , and inhalation technique. Chest 2000;117(2):542-550
Lung deposition of medication
• Terbutaline: MDI – 8%, DPI – 22%*• Effect of spacer device:Lung deposition increase from 9 to 21%Oropharynx deposition reduced from 81 to 17%#
* Borgstrom L, Derom E, Stahl E, et al. The inhalation device influences lung deposition and bronchodilating effect of terbutaline. Am J Respir Care Med 1996;153:1636-1640.
#Newman SP, Millar AB, Lennard-Jones TR et al. improvement of pressurised aerosol deposition with Nebuhaler spacer device. Thorax 1984;39:936-941.
* National Health and Morbidity Survey Vol. 11, Public Health Institute. 1996
Bronchial asthma
• Defn: Reversible airways obstruction , airway inflammation, airways
hyperreactivity to a variety of stimuli
• Incidence: 3-6% in Australia, 4.2% in Malaysia* , 2-5% in Africa
• Symptoms: Wheezing, dyspnoea, chest tightness, cough
Asthma in children
Children:• Dry powder inhalers has greater systemic
effects than MDIs§
• Pharmacists: recommend MDI with spacer device for children.
§ Kereem E . Ann Allergy Asthma International 2002;89.
Pharmacist’s roles
• As educator and support person• Counsel on role of each medication• Difference between preventer – reliever• Emphasise safety of inhaled c’steroids• Discuss adverse effects – ways to minimise• Check and correct proper use of inhalers• Encourage use of spacers and peak fl. meters
AMA Aziz, MIM Ibrahim. Medication noncompliance - a thriving problem. Med J Malaysia 1999;54:192-5.
Pharmacist’s roles
• Check compliance – 56% noncompliance rate1
• Check usage of medications for other illnesses, OTC products, GP’s drugs, etc
• Dispels myths about asthma and inhaler use
• Encourage asthma action plan
Ward pharmacy
• Back to basics
• Supplies, inventory, pricing,
• Dosage, category of drug in MOH list
• List A, std item
• Synergistic activity with in-patient pharmacist/satellite pharmacist
At the ward…
• Familiarise with the ward- acquaint with ward staff ie. sister & nurses
• Ward procedures• Own reading on common drugs used
• develop confidence
Ward rounds
• Consultant’s rounds: already have a high level of interest in optimising drug therapy
• Vigilant on ADR and side effects
Preparation before rounds
• Very, very important
• May take an hour or more initially
Objective:
‡ to anticipate areas where information is likely to be requested
‡ To identify topics for discussion
Clerking
• Same as any other pt• Biodata, diagnosis, investigations, lab results, x-
rays, etc, • Document using card or form • Monitor, • Identify drug-related problems or issues• Plan for solution - check-up- talk to Dr or specialist, nurse
Things to do…
• Estimate creatinine clearance ClCr if the serum creatinine is >150µmol/l in adults less than 70 yrs using Cockcroft and Gault equation
• Abnormal levels of urea or albumin may alter the disposition of some drugs
Patient parameters
• Pt. with liver disease – elevated liver function tests
• Severe cardiac failure may affect both renal and hepatic clearance of drugs may necessitate dose individualisation
• Calculate predicted blood levels if therapeutic monitoring of a drug is required
Attending ward rounds
• Be PUNCTUAL
• Degree of involvement and pharmacist’s role depend on the leading physician
• Doctors may undertake management or teaching role or both
• They may not ask for pharmacist’s comments
A successful attendance in ward rounds
• Adequate preparation• Being tactful, yet
assertive• prioritise
• Regular attendance• Present info on a
problem concisely• Provide adequate
follow up
Pharmacist’s comments
• Unlikely to be a personal insult and no offence should be taken
• The advice may be used on a similar pt in future• Occasionally it may be used by the consultant
against his junior staff – communicate with the houseman to avoid unnecessary embarrassment
• Follow up on pts where comments have been accepted ie. supplies and instructions on usage
Specialisation
• Collins English Dictionary and Thesaurus:defines special as ‘distinguished’ or ‘set apart from’
• Specialisation ~ characteristics that distinguish a clinical pharmacist from other pharmacists
• Obtained thru’ further education and training
Nursing profession development
• Shift in promotion ladder *
• Dual career pathway
• management sister – matron☞• Clinical nurse advanced practice nurse ☞
(same ranking as sister/tutor)
• Similar to UK and Canada situation*Nafsiah Shamsudin. Specialisation of the clinical nurse in the
Malaysian setting. Sept. 2000.
Specialisation
• Extra qualifications preferable
• Sometimes not necessary
• MSc, MPharm
• PhD
• Experience, confidence, way of thinking, networking, research-oriented, etc
Specific situations
• Asthma
• Counselling
• Pharmacoherapy issues ie. Drug of choice: β-2 agonists (short-acting, long-acting, corticosteroids (inhaled , oral),
• Drug forms: inhalers, oral tablets, nebs
Other roles
• Conformance to guidelines: MTS, GINA• Research: eg.
drug use
clinical trials on outcomes of pharmacist-treated pt vs non-pharmacist pts, counselled vs non-counselled
Inhaler technique – relate to outcomes• Asthma clinic – check peak flow, compliance to
tx, appointments for counselling, etc
What others have achieved…
• Pediatric asthma management programme Covenant Health System, Texas, US ±
• Found many asthma pts admitted for various reasons ie. Lack of medication, non-compliance, improper inhaler technique
• Remedy: face-to-face counselling. Pharmacists counselled pts and families
• Complete pt information leaflets given, videotapes
• Spent 30-60 mins per pt± Razia M, Gordon H. Am J Health-Syst Pharm 2002;59. p. 1829.
results
• 69 pt counselled: 106 vs 51 ER visits or admissions pre and post counselling (↓52%)
• Cost avoidance: USD126,500/=
→ Counselling beneficial and reduces admission rates.
C.O.P.D.-X Plan• C = ConfirmConfirm diagnosis, severity,
complications• O = OptimiseOptimise patient function
(impairment, disability and handicap)• P = PreventPrevent deterioration• D = DevelopDevelop self-monitoring and
self-management care plan• X = guide for managing
exacerbations
C….confirm...C….confirm...
• Exclude asthma, cardiac disease etc
• Assess severity
• Assess reversible components
• Identify complications and co-existing conditions– history, examination, spirometry, xray
chest, FBE
O….optimise….O….optimise….
– Smoking cessation– Optimise drugs
• safe and effective - don’t over-prescribe
– Treat complications– Optimise psychosocialpsychosocial issues– Optimise nutrition (consider dietician)– Encourage exercise (consider physio gym)– Pulmonary rehabilitationPulmonary rehabilitation– Lung reduction surgery or transplantation
P….prevent….P….prevent….
– Smoking cessation (help and monitor)• AAAAA
– Occupation and other dusts– Stop unhelpful drugs– Prevent infections
• influenza vaccination (?Pneumococcal)• relevant antibiotics for purulent sputum and
fever
– Pulmonary RehabilitationPulmonary Rehabilitation– Transplantation
P….prevent….P….prevent….
– Check for complications & concurrent conditions
• osteoporosis, depression, cor pulmonale, OSA/hypoventilation
– Consider oxygen if hypoxaemic – Regular review
• lung function
D….discuss, develop….D….discuss, develop….
• Educate patient and carers
• Pulmonary Rehabilitation and Pulmonary Rehabilitation and Patient Support GroupsPatient Support Groups
• Assess self-management capacity
• Develop a collaborative care plan– monitor to identify exacerbations early– how to self-initiate treatment– what to do in an emergency
X… Exacerbations
• Inhaled bronchodilators and systemic glucocortocoids are effective treatments for acute exacerbations (Evidence A)
• Patients with clinical signs of infection(change in sputum colour and/or fever, leucocytosis) benefit from antibiotics (Evidence A)
Asthma Action Plan
• Designed for pts with asthma to:^ recognise deterioration and^ respond appropriately• Action Plan will prevent ^ delay of initiation of preventer dose
increases^ prolonged exacerbation^ adverse effects on pts life
Peak Flow Monitoring
• Peak Expiratory Flow (PEF) – the greatest flow velocity which can be generated during a forced expiration starting with fully inflated lungs
• Simple, quantitative, reproducible measure of airway obstruction
• Meters are cheap, lightweight and portable• Repeated measures highly reproducible with
each individual patient, if the same meter is used
Peak Flow Monitoring
• Actual number not important, but the trend is• Measures response to bronchodilator therapy –
increase by 20% post treatment (provided the baseline reading > 300ml/min adults)
• Measures early deterioration before pt. feels the change in his disease
{diabetics monitor blood sugar, asthmatics measure lung function…}
Pulmonary Rehabilitation Program
• Established in the Repatriation General Hospital, Adelaide since many yrs ago
• A structured program using weekly lectures spanning over 3 months
• 2 hrs session (1 hr lecture each person ) @1.30pm
• Coordinated by the Resp. Rehab. Clinic • Pharmacist • Talked about “Medications and Airways
Disease”