respiratory pharmacy & the ward pharmacist experience

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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 Presentation


  • Respiratory Pharmacy & the Ward Pharmacist experienceby Abdol Malek bin Abd Aziz, MSc

    Clinical Pharmacy Conference , Port Dickson, 9-11 Jan 2003

  • Respiratory pharmacyEmphasis on pharmaceutical care of respiratory patients plusOther conditions that the patient is concurrently suffering

  • Respiratory PharmacyCovers:

    AsthmaCOPDIdiopathic interstitial lung diseasePleural disordersPneumoniaDrug-induced pulmonary disease

  • NHMS 1996 - FindingsHigh percentage (62.4%) not on inhalersMild asthmatics: 65.3% Moderate : 52.1%Severe : 23.7%

  • Compliance / adherenceGenerally non-compliance rate ~ 50% (out patients)56% in Melaka (1999)*Leads to hospital admission51.7% 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 carePatients with allergic rhinitis often experience symptoms of asthma (Linneburg. Allergy 2002,57)Allergic rhinitis preceded or developed at the same time as allergic asthmaTx of allergic rhinitis reduced asthmatic symptoms or reduce risk of asthma

  • Inhaler techniquegood rating ranged from 5-86% using MDIsTechnique 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 medicationTerbutaline: 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.

  • Bronchial asthmaDefn: Reversible airways obstruction , airway inflammation, airways hyperreactivity to a variety of stimuliIncidence: 3-6% in Australia, 4.2% in Malaysia* , 2-5% in AfricaSymptoms: Wheezing, dyspnoea, chest tightness, cough

    * National Health and Morbidity Survey Vol. 11, Public Health Institute. 1996

  • Asthma in childrenChildren: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.

  • Pharmacists rolesAs educator and support personCounsel on role of each medicationDifference between preventer relieverEmphasise safety of inhaled csteroidsDiscuss adverse effects ways to minimiseCheck and correct proper use of inhalersEncourage use of spacers and peak fl. meters

  • Pharmacists rolesCheck compliance 56% noncompliance rate1Check usage of medications for other illnesses, OTC products, GPs drugs, etcDispels myths about asthma and inhaler useEncourage asthma action plan

    AMA Aziz, MIM Ibrahim. Medication noncompliance - a thriving problem. Med J Malaysia 1999;54:192-5.

  • Objective To have an influence on prescribing and related clinical practice

  • How to start?Ward pharmacy


    Respiratory pharmacy

  • Ward pharmacyBack to basicsSupplies, inventory, pricing, Dosage, category of drug in MOH listList A, std item

    Synergistic activity with in-patient pharmacist/satellite pharmacist

  • At the wardFamiliarise with the ward- acquaint with ward staff ie. sister & nursesWard proceduresOwn reading on common drugs used

    develop confidence

  • Ward roundsConsultants rounds: already have a high level of interest in optimising drug therapy

    Vigilant on ADR and side effects

  • Preparation before roundsVery, very importantMay take an hour or more initially

    Objective:to anticipate areas where information is likely to be requestedTo identify topics for discussion

  • Becoming prepared



  • Clerking Same as any other ptBiodata, diagnosis, investigations, lab results, x-rays, etc, Document using card or form Monitor, Identify drug-related problems or issuesPlan for solution - check-up- talk to Dr or specialist, nurse

  • Things to doEstimate creatinine clearance ClCr if the serum creatinine is >150mol/l in adults less than 70 yrs using Cockcroft and Gault equationAbnormal levels of urea or albumin may alter the disposition of some drugs

  • Patient parametersPt. with liver disease elevated liver function testsSevere 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 roundsBe PUNCTUALDegree of involvement and pharmacists role depend on the leading physicianDoctors may undertake management or teaching role or bothThey may not ask for pharmacists comments

  • A successful attendance in ward roundsAdequate preparationBeing tactful, yet assertiveprioritiseRegular attendancePresent info on a problem conciselyProvide adequate follow up

  • Pharmacists commentsUnlikely to be a personal insult and no offence should be takenThe advice may be used on a similar pt in futureOccasionally 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 developmentShift in promotion ladder *Dual career pathway management sister matronClinical 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 preferableSometimes not necessaryMSc, MPharmPhD

    Experience, confidence, way of thinking, networking, research-oriented, etc

  • Specific situationsAsthmaCounsellingPharmacoherapy issues ie. Drug of choice: -2 agonists (short-acting, long-acting, corticosteroids (inhaled , oral), Drug forms: inhalers, oral tablets, nebs

  • Other rolesConformance to guidelines: MTS, GINAResearch: eg.drug useclinical trials on outcomes of pharmacist-treated pt vs non-pharmacist pts, counselled vs non-counselledInhaler technique relate to outcomesAsthma clinic check peak flow, compliance to tx, appointments for counselling, etc

  • What others have achievedPediatric asthma management programme Covenant Health System, Texas, US Found many asthma pts admitted for various reasons ie. Lack of medication, non-compliance, improper inhaler techniqueRemedy: face-to-face counselling. Pharmacists counselled pts and families Complete pt information leaflets given, videotapesSpent 30-60 mins per pt

    Razia M, Gordon H. Am J Health-Syst Pharm 2002;59. p. 1829.

  • results69 pt counselled: 106 vs 51 ER visits or admissions pre and post counselling (52%)Cost avoidance: USD126,500/=

    Counselling beneficial and reduces admission rates.

  • COPD

  • C.O.P.D.-X PlanC = Confirm diagnosis, severity, complicationsO = Optimise patient function (impairment, disability and handicap)P = Prevent deteriorationD = Develop self-monitoring and self-management care planX = guide for managing exacerbations

  • C.confirm...Exclude asthma, cardiac disease etcAssess severityAssess reversible componentsIdentify complications and co-existing conditionshistory, examination, spirometry, xray chest, FBE

  • O.optimise.Smoking cessationOptimise drugssafe and effective - dont over-prescribeTreat complicationsOptimise psychosocial issuesOptimise nutrition (consider dietician)Encourage exercise (consider physio gym)Pulmonary rehabilitationLung reduction surgery or transplantation

  • P.prevent.Smoking cessation (help and monitor)AAAAAOccupation and other dustsStop unhelpful drugsPrevent infectionsinfluenza vaccination (?Pneumococcal)relevant antibiotics for purulent sputum and feverPulmonary RehabilitationTransplantation

  • P.prevent.Check for complications & concurrent conditions osteoporosis, depression, cor pulmonale, OSA/hypoventilationConsider oxygen if hypoxaemic Regular reviewlung function

  • D.discuss, develop.Educate patient and carersPulmonary Rehabilitation and Patient Support GroupsAssess self-management capacityDevelop a collaborative care planmonitor to identify exacerbations earlyhow to self-initiate treatmentwhat to do in an emergency

  • X ExacerbationsInhaled 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 PlanDesigned for pts with asthma to:^ recognise deterioration and^ respond appropriatelyAction Plan will prevent ^ delay of initiation of preventer dose increases^ prolonged exacerbation^ adverse effects on pts life


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