Pharmacists can be key in not only identifying and managing COPD, but preventing it too, write Jarrod and Carlene McMaugh

COPD is a term used to describe a group of obstructive lung conditions that limit – or obstruct – the capacity of the individual’s respiration. Generally speaking, the lung’s surface area is reduced, limiting the ability of oxygen transport into the blood via alveoli.

Typical structural changes in the lung that contribute to COPD include destruction of the alveoli, reduced elasticity of the lung, excessive sputum production, and altered cilia function. This causes air trapping, breathlessness, recurrent infections, exercise intolerance, and eventually death. Inflammation may be present from time to time, but it is acute in nature, rather than chronic.

The causes of COPD in Australia are primarily lifestyle, with smoking being the overwhelming cause of the majority of cases. Despite this, there are a portion of people who will develop COPD due to chronic untreated inflammation of the lungs or occupational exposure to irritants. Exacerbations of COPD are commonly caused by infection and acute inflammation, requiring short courses of antibiotics and oral corticosteroids.

Like all chronic diseases, pharmacists have two primary roles in assisting people who have COPD – helping to identify the condition in those individuals who are not yet aware that they have the condition, and assisting with education and adherence to therapy for those individuals who have been diagnosed.

Given that COPD is heavily influenced by modifiable risk factors, there is a third role that pharmacists should be involved – prevention. Pharmacists are ideally placed to address risky behaviours that contribute to the development of COPD; we can make a significant impact on the burden of the disease on individuals and the health system

COPD in Australia

According to Australian data,[1] COPD affects 600,000 Australians, with a roughly even distribution (50.2% men, 49.8% women).

Close to 8000 people die each year, representing 5% of all deaths. While the incidence and mortality rates from COPD are declining in Australia due to the impact of QUIT campaigns, it should be noted that the incidence of COPD in Indigenous Australians is 2.6 times greater than non-indigenous Australians, and the mortality rates is three times greater.

COPD and asthma

COPD is a distinct condition from asthma. Despite this, the two conditions may overlap/coexist. Symptoms may be difficult to differentiate without spirometry, especially for younger patients. Remodelling of lung tissue in asthma due to chronic untreated inflammation may contribute to development of COPD.

Treatment of each condition may be similar pharmacologically, but the purpose and guidelines for treatment are based on different clinical endpoints.

For instance, use of inhaled corticosteroids is a mainstay of asthma treatment to control the chronic inflammation, while COPD treatment will only require inhaled corticosteroids during exacerbations. Individuals with COPD will have exacerbations that require antibiotics, while those with asthma will require SABA with temporary ICS escalation.

For further discussion on the treatment of asthma, refer to the previous clinical tips article https://ajp.com.au/news/clinical-tips-asthma/

The mainstay of COPD treatment is the use of LABA and/or LAMA inhalations to reduce sputum production and improve the capacity to move oxygen effectively to the remaining alveoli. Smooth muscle relaxation within the lungs improves airway patency and can have an impact on reflexive cough.

COPD management

Management of COPD is based on the COPD-X guidelines:[2]
Confirm diagnosis (includes identification and clinical investigation)
Optimise function through appropriate treatment and lifestyle changes
Prevent deterioration by managing exacerbations and preventing complications
Develop a care plan
X manage eXacerbations.

Pharmacists can support individuals through each of these steps by providing motivation, education, screening services, and referral to other health professionals.

Counselling

At each presentation, the pharmacist has the opportunity to improve COPD treatment outcomes by detecting any issues the patient has with their treatment or symptom control, and assessing inhaler technique.

During this interaction, the pharmacist can briefly discuss COPD and the patient’s understanding of treatment, if they are experiencing any side effects, if their symptoms are well controlled (and if they know what to do when symptoms are not well controlled), and exacerbations.

The astute reader will realise that this is very similar to asthma counselling, and realistically applies to counselling on all chronic conditions. The key is to know the condition well, and understand the issues that lead to treatment failure or disengagement for the individual.

Inhaler technique

Inhaler technique is important for the adequate treatment of COPD symptoms. Addressing this at each dispensing will help to ensure the patient is getting the best effect from their medication.

There is a wide range of COPD inhaler devices – the majority are dry powder inhalations. Each device is unique, and the skills to operate them are not always transferrable. Pharmacists need to ensure that they understand the differences.

It should never be assumed that an individual who is changing devices will know how to operate a new device based on their previous experiences.

COPD affects respiratory volume – the ability to inhale quickly or deeply may be compromised. This is important for the operation of dry powder and metered dose inhalers.

For those pharmacists with a specific interest in respiratory health, up-skilling in the operation of the In-Check Dial device is a practical approach to assisting patients and prescribers identify the most appropriate inhalation device. This device can be incorporated in to MedsCheck or similar services; identification of an inappropriate inhaler should generate a referral to the prescriber for consideration of a change in device.

Medscheck

When the pharmacist detects a significant issue with the patient’s COPD treatment, this provides the opportunity to provide a medscheck service. During the Medscheck, the pharmacist can provide a full assessment of inhaler technique and an overview of the nature of COPD, the role of each medication, why these medications and treating symptoms are important, how identify exacerbations early, and the importance of regular vaccination for respiratory infections such as pneumonia and influenza.

The pharmacist should ensure that patients understand the underlying treatment paradigm for COPD when undertaking a medscheck for an individual with COPD. For instance, inhaled corticosteroids are not a standard treatment, due to the lack of persistent inflammation and risks of pneumonia associated with long-term use.

“Rescue” prescriptions may be provided to the individual – consisting of short-course antibiotics and oral corticosteroids – to be implemented at the onset of an exacerbation. Understanding the role of these rescue prescriptions and when to implement them is as important as ensuring regular use of LABA/LAMA medications for symptomatic control

Pharmacists who have a specific interest in respiratory health may also use this opportunity to provide information about more structured COPD services in their pharmacy.

Motivational counselling

Motivational Counselling may be used by pharmacists in their consultation with people who have poorly controlled COPD as an advanced pharmacy service.

This may focus specifically on attaining a high level of treatment persistence in patients who are struggling to use their medications adequately, or it may focus on risk factors such as smoking cessation.

Pharmacists who are interested in providing motivational counselling services in their pharmacy may benefit from undertaking further education in this area, such as Spiromety or Smoking Cessation courses through The Alfred Hospital.

Spirometry

Spirometry requires accredited training and regular review of skills. When a pharmacist has obtained this level of training, they may offer spirometry for their patients. Spirometry in COPD is primarily used as a diagnostic aid.

Spirometry may also be used as a motivational tool for people who smoke, in combination with The Lung Foundation’s lung age calculator[3], to assist in Quitting.

Referral

During the provision of each of these roles, the pharmacist will likely encounter a situation that requires referral. It is important that the pharmacist understands their own competency in the areas of respiratory health, and can identify the appropriate time to refer the patient to their GP.

This could be during the counselling stage if a patient discusses regular exacerbations, or it could be during a COPD review service if it is discovered that they require a low-inspiratory strength inhalation device.

Regardless of the situation, the pharmacist needs to document the referral adequately.

Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.

Carlene McMaugh has worked in the healthcare field for over 20 years in varied roles and as a pharmacist for ten years including three years working as a pharmacist in the UK. She currently works in Capital Chemist Coburg and in the pharmaceutical industry.

[1] http://www.health.gov.au/internet/main/publishing.nsf/content/chronic-respiratory

[2] http://copdx.org.au/

[3] https://lungfoundation.com.au/health-professionals/clinical-resources/copd/primary-care-respiratory-toolkit/