Practice Guidance on the Care of People with Asthma and Chronic Obstructive Pulmonary Disease Authors: Asthma: Trisha Weller Respiratory BSc and Diploma Programme Lead Education for Health Warwick, UK E mail: t.weller@nrtc.org.uk COPD: Rachel Booker COPD Lead Education for Health Warwick, UK E mail: r.booker@nrtc.org.uk October 2005. Revised July 2006

Practice Guidance on the Care of People with Asthma and Chronic Obstructive Pulmonary Disease 1. Introduction .......................................................................................................6

1.2 Asthma Overview ........................................................................................7 1.3 COPD Overview ..........................................................................................7 1.3.1 Smoking facts and COPD: ........................................................................8 1.3.2 COPD is also associated with: ..................................................................8 1.4 Economic impact of asthma and COPD ......................................................8 1.5 Long term conditions ...................................................................................9 1.6 Non-medical prescribers ...........................................................................10 1.7 Role of the pharmacist ..............................................................................11

2. Clinical history.................................................................................................12

2.1 Asthma ......................................................................................................12 2.1.1 Asthma Triggers......................................................................................12 2.1.2 Asthma symptoms...................................................................................12 2.1.3 Differential diagnosis in children..............................................................13 2.1.4 Differential diagnosis in adults.................................................................14 2.2 COPD........................................................................................................14 2.2.1 COPD symptoms.....................................................................................14 2.2.2 Differential diagnosis ...............................................................................15

3. Diagnostic tests...............................................................................................17

3.1 Tests of lung function ................................................................................17 3.1.1 Peak flow measurement..........................................................................17 3.1.2 PEF meter changes.................................................................................17 3.1.3 Spirometry...............................................................................................18 3.2 Reversibility testing ...................................................................................18 3.2.1 A history suggestive of asthma ...............................................................20 3.2.2 A history suggestive of COPD.................................................................20 3.2.3 Serial Peak Flow measurements.............................................................20 3.2.4 Asthma diagnosis ....................................................................................20 3.2.6 Occupational asthma...............................................................................21

4. Aims of treatment............................................................................................22

4.1 Aims of asthma treatment..........................................................................22 4.2. Aims of COPD treatment ..........................................................................22 4.3 Non-pharmacological treatment for asthma and COPD ............................23 4.3.1 Smoking cessation ..................................................................................23 4.3.2 Nicotine replacement therapy..................................................................24 4.3.3 Bupropion................................................................................................25 4.4 Non-pharmacological treatment of asthma................................................26 4.4.1 Obesity ....................................................................................................26 4.4.2 Gastro-oesophageal reflux ......................................................................26 4.4.3 Immunotherapy .......................................................................................26

4.5 Non pharmacological treatment of COPD .................................................27 4.5.1 Pulmonary rehabilitation..........................................................................27

5. Drug therapies ................................................................................................28

5.1 Short acting beta2 agonist bronchodilators- often referred to as ‘relievers’28 5.2 Long acting beta2 agonists ........................................................................29 5.3 Oral beta2 agonist bronchodilators ............................................................30 5.4 Anti-cholinergic bronchodilators ................................................................30 5.6 Long acting anticholinergic bronchodilators ..............................................31 5.7 Anti-cholinergic and short acting beta2 agonist bronchodilators ................32 5.8 Methylxanthines ........................................................................................32 5.9 Inhaled corticosteroids – often referred to as ‘preventers’ .........................34 5.10 Combination therapies ............................................................................35 5.11 Oral corticosteroids .................................................................................36 5.12 Other anti-inflammatories - cromones .....................................................37 5.13 Leukotriene receptor antagonists ............................................................38 5.14 Mucolytics in COPD ................................................................................39

6. Inhaler devices................................................................................................40

6.1 Inhaler devices for asthma ........................................................................40 6.2 Inhaler devices for COPD..........................................................................41 6.3 Spacer Devices .........................................................................................41 6.4 Nebulisers .................................................................................................43

7. Pharmacological management of asthma and COPD.....................................45

7.1 Asthma ......................................................................................................45 7.2 COPD........................................................................................................47 7.2.1 Bronchodilators .......................................................................................47 7.2.2 Inhaled corticosteroids ............................................................................49 7.2.3 Oral corticosteroids .................................................................................49 7.2.4 Mucolytics ...............................................................................................49 7.3 Oxygen in asthma and COPD ...................................................................50 7.3.1 Pulse Oximetry........................................................................................50 7.3.2 Oxygen in acute asthma..........................................................................50 7.3.3 Oxygen in stable COPD ..........................................................................51 7.4 Long-term oxygen therapy (LTOT) ............................................................51 7.4.1 Assessment for LTOT .............................................................................52 7.4.2 Advice for patients on LTOT....................................................................52 7.4.3 Ambulatory oxygen therapy.....................................................................53 7.4.4 Short-burst oxygen therapy .....................................................................53 7.5 Oxygen delivery systems...........................................................................54 7.5.1 Oxygen during exacerbations of COPD ..................................................54 7.5.2 Masks and nasal cannulae......................................................................55 7.6 Asthma Review .........................................................................................55 7.6.1 What happens at an asthma review? ......................................................56 7.6.2 Inhaler technique.....................................................................................56

7.6.3 Quality of life ...........................................................................................56 7.7 Allergic rhinitis ............................................................................................56 7.8 COPD review.............................................................................................57 7.8.1 What happens at a COPD review?..........................................................57 7.9 Smoking ....................................................................................................58 7.10 Flu vaccination ........................................................................................59

8. Exacerbations of asthma and COPD ..............................................................60

8.1 Asthma ......................................................................................................60 8.1.1 Asthma deaths ........................................................................................60 8.1.2 Symptoms of worsening asthma .............................................................60 8.1.3 Early warning signs and symptoms include:............................................60 8.1.4 Signs and symptoms of life threatening asthma......................................61 8.1.5 Signs of moderate and severe asthma....................................................61 8.2 Managing the acute asthma attack............................................................61 8.2.1 Bronchodilators .......................................................................................61 8.2.2 Poor response to high doses of bronchodilator .......................................62 8.2.3 Response to high doses of bronchodilator ..............................................62 8.2.4 Oral corticosteroids in acute asthma .......................................................62 8.2.5 Under 2’s.................................................................................................62 8.5.6 Treatment in the under 2’s ......................................................................63 8.5.7 Follow Up ................................................................................................63 8.6 COPD........................................................................................................63 8.6.1 Symptoms of an exacerbation of COPD..................................................64 8.6.2 Symptoms of a severe exacerbation of COPD........................................64 8.6.3 Differential diagnosis ...............................................................................65 8.7 Managing exacerbations of COPD............................................................65 8.7.1 Bronchodilators .......................................................................................65 8.7.2 Oral corticosteroids .................................................................................66 8.7.3 Antibiotics................................................................................................66

9. Management issues........................................................................................68

9.1 Adherence to treatment.............................................................................68 9.2 Asthma Education .....................................................................................69 9.3 Asthma action plans ..................................................................................69 9.4 Trigger avoidance......................................................................................70 9.5 COPD Education .......................................................................................70 9.6 Advice for COPD patients..........................................................................70 9.7 COPD action plans....................................................................................71

10. Clinical governance.......................................................................................72

10.1 Audit and record keeping ........................................................................72 10.2 Training ...................................................................................................72

References .........................................................................................................73 Additional information and further reading.......................................................74

Sources of information ........................................................................................75

Asthma ............................................................................................................75 Guidelines...........................................................................................................76

Oxygen............................................................................................................76 Patient organisations ..........................................................................................77

Asthma, COPD and other lung disease...........................................................77 Other Patient organisations & information ..........................................................77

Drug information:.............................................................................................78 Medicines Management Partnership ...............................................................78 Pollen information............................................................................................78 Smoking information........................................................................................79

Professional Organisations .................................................................................79

Respiratory training for health professionals ...................................................79 Training in spirometry......................................................................................79

Manufacturers of Asthma and COPD drugs and inhaler devices........................80

Manufacturers of Peak Flow meters................................................................82 Manufacturers of Spirometers .........................................................................83 Appendix 1 Template CMP 1 ..........................................................................84 Appendix 2 Template CMP 2 ..........................................................................85 Appendix 3 Inhaler devices .............................................................................86 Appendix 4 Contact list for asthma and COPD................................................87

1. Introduction The information in this practice guidance is based on current evidence based guidelines. It has been written for pharmacists in Great Britain to help them develop their knowledge of asthma and chronic obstructive pulmonary disease (COPD). This information is timely because of the introduction of the Pharmacy Contract and the opportunities for developing services for patients with long term conditions (Department of Health 2005). There have also been legislative changes which have enabled non-medical prescribing by pharmacists to be introduced. These developments will help to improve access to health services by patients where pharmacists are often a first point of contact for healthcare advice and for monitoring those where the diagnosis of asthma or COPD has already been confirmed. This document is a resource which will help Pharmacists to:

• Offer appropriate smoking cessation advice and support • Ensure appropriate prescribing and use of medicines for asthma and

COPD • Ensure inhaler technique is correct and the inhaler device is appropriate • Identify inappropriate high use of reliever medication by asthma patient • Recognise increasing respiratory symptoms and poor control of both

asthma and COPD • Understand the role of nebulisers in asthma and COPD • Understand the changes in the supply of long term oxygen and the role of

the pharmacist in prescribing for short term oxygen use • Contribute to the education of patients with asthma and COPD to enable

them to be confident in managing their respiratory condition • Provide advice and support to the asthma and COPD patients • Work within the primary care team with referral and discussion where

appropriate.

1.2 Asthma Overview Asthma is a reversible, obstructive airways disease. Airflow obstruction is reversible spontaneously or with treatment. It is characterised by:

• Bronchoconstriction • Airway inflammation, oedema and mucus production.

In the United Kingdom there are 5.2 million people with asthma (Asthma UK 2005) of which there are:

• 1.1million children and • 4.1 million adults.

Asthma often develops in childhood in association with exposure to viral infections or other triggers. A family history of asthma or the associated atopic conditions of eczema, hayfever and rhinitis increases the likelihood of asthma in childhood. In adults, asthma can develop:

• For the first time in mid-life, often as a result of a virus infection, • As a recurrence of childhood asthma, and • As a direct result of occupational exposure.

The severity of asthma is often underestimated and approximately 1400 people still die from asthma each year despite the availability of:

• Better asthma medicines • Improved primary care asthma services and • Evidence based guidelines for health professionals involved in the care of

people with asthma (British Thoracic Society (BTS)/ Scottish Intercollegiate Guideline Network (SIGN) 2005).

Practical Pointer Asthma and COPD are both obstructive lung conditions but the pathology and the outcomes are very different.

1.3 COPD Overview COPD is characterised by airflow obstruction. The airflow obstruction is usually progressive, not usually reversible and does not change markedly over several months. The disease is predominantly caused by smoking (NICE 2004). COPD is the preferred term for those who have airflow obstruction: this was previously termed chronic bronchitis or emphysema or chronic obstructive airways disease. COPD is rare under the age of 35. In addition, chronic and under-treated asthma may be present, which can also lead to fixed and irreversible airways disease.

COPD is common, with approximately 900,000 diagnosed cases, although the real numbers are likely to be in the region of 1.5 million. Mortality is high with about 30,000 deaths due to COPD. In severe COPD, 30% of men and 24% of women survive for five years. COPD accounts for 1 in 8 emergency hospital admissions.

1.3.1 Smoking facts and COPD: • Smoking accounts for around 90% of COPD in the UK but although rare,

can occur in a small number of non-smokers. • Only 15-20% of smokers are susceptible to COPD and in this group, lung

function deteriorates rapidly: this is in direct association to the number of cigarettes smoked.

• Stopping smoking will reduce the rate of decline in lung function to that of a non-smoker but lost lung function cannot be regained.

1.3.2 COPD is also associated with: • Low birth weight • Recurrent childhood respiratory infections • Low socio-economic status • Genetic susceptibility and • Occupational exposure to certain dusts, fumes and solvents.

The major cause of COPD is cigarette smoking. Other risk factors are thought to be additive to the effects of smoking and are rarely sufficient to cause COPD on their own. The exception to this is alpha 1 antitrypsin deficiency, a rare genetic deficiency of an enzyme that protects the lungs against the damaging effects of cigarette smoke. It probably accounts for less than 2% of all cases of COPD. Practical Pointer The major cause of COPD is cigarette smoking.

1.4 Economic impact of asthma and COPD Both asthma and COPD have a major economic impact both to the health service and to the individual. Prescription costs are quite difficult to separate out between asthma and COPD because:

• Prescription data does not include a diagnosis and • Similar drugs are used across a number of respiratory disease areas.

In England and Wales respiratory prescribing is in the top six therapeutic areas by prescription volume. In the year 2003-04 there was an increase of 8% in these prescribing costs with the costs of approximately £770 million. The number of respiratory prescriptions is in the top six in Scotland and in the top three in

Northern Ireland. Table 1 summarises the economic impact of asthma and COPD in the UK.

Asthma COPD

Deaths per year in the UK

@ 1400 @ 30,000

Working days lost each year

12.7 million 24 million

Costs to the health service

@ £890 million @ £817 million

Social security benefits £260 million £600 million

Lost productivity £1.2 billion £2.7 billion

Table 1. Summary of economic costs of asthma and COPD The introduction of the new General Practitioner contract and the Quality Indicator Framework has been an opportunity for primary care to focus on both asthma and COPD (Department of Health (2003). Respiratory disease is not a government priority and there is no national service framework although links with respiratory disease can be made with a number of established National Service Frameworks (NSFs) as follows: National Service Framework

Respiratory disease link

Cardiovascular disease Smoking Elderly COPD Children Asthma Another of the Quality Framework indicators is medicines management which tries to ensure patients use their medicines to maximum effect. Included within the medicines management umbrella are:

• Repeat prescribing • Adherence • Patient information and • Education.

1.5 Long term conditions There are over 17 million people with a chronic or long term health condition. Issues relating to chronic conditions are often similar, such as:

• The need to take regular treatment • The emphasis on control rather than cure • Adherence to treatment • Self-management

A recent publication from the Department of Health (2005) focuses on long-term conditions with the aim of improving chronic disease management through:

• Earlier detection • Monitoring of condition – involvement of health professionals • Good control to minimise effects of disease and reduce complications • More effective medicines management • Reduction in the number of crises • Promoting independence, empowering patients and allowing them to take

control of their lives, and • Prolonging and extending the quality of life.

This report identifies the need to help people with long-term conditions such as asthma and COPD to develop the knowledge skills and confidence to be involved in managing their own conditions. Practical Pointer Pharmacists can play an active part in the care of patients with long-term conditions.

1.6 Non-medical prescribers Pharmacists and nurses can now practice as non-medical supplementary prescribers after appropriate training and registration with their individual professional regulatory bodies. Competency frameworks have been developed for non-medical prescribers by the National Prescribing Centre in order to help maintain quality and standards. http://www.npc.co.uk/ Supplementary prescribing can contribute to asthma and COPD management because it can help:

• Improve access to medications • Identify any issues around treatment and • Provide an alternative service which complements traditional healthcare.

Supplementary prescribing requires the diagnosis to be made by a medical prescriber and a clinical management plan agreed between the doctor, non-medical prescriber and the patient. Appendix 1 gives an example of clinical management plans and can be found on the following web site: http://www.dh.gov.uk/assetRoot/04/06/84/28/04068428.rtf Community Pharmacists in England and Wales also have a new contract (Department of Health 2005), which provides an opportunity to expand their current role. Pharmacists will have to provide essential services but with the option of providing advanced or enhanced services. Table 2 summarises the new roles.

Essential service

Advanced service Enhanced service

Dispensing of medicines Repeat prescribing Disposal of unwanted medicines Public health – health promotion Sign-posting Support for self care Support for people with disabilities Clinical governance

Medicine use review Prescription intervention service

Range of services e.g. Minor ailment schemes Smoking cessation service Supervised administration of prescribed medication Needle exchange schemes Anti-coagulant monitoring Medicines assessment and compliance support Care home support Patient group direction service Full clinical medication review Supplementary prescribing

Table 2. Summary of new services of the Pharmacy Contract A new contract will also be introduced at a later date for Scotland and Northern Ireland.

1.7 Role of the pharmacist The majority of asthma or COPD management takes place in the primary care setting. Pharmacists have a unique role in that they are often consulted prior to seeing a nurse or doctor. Supplementary prescribing and the pharmacy new contract provide an opportunity for pharmacists to build on their pharmacological knowledge and become actively involved in disease management. Communication with the different health professionals and the patient is essential.

2. Clinical history A good clinical history is essential to inform the likely diagnosis of both asthma and COPD.

2.1 Asthma Unfortunately there are no routine blood tests that can confirm the diagnosis of asthma. Although respiratory symptoms are common to many respiratory diseases, a good clinical history, together with supporting objective lung function tests, will enable the diagnosis of asthma to be confirmed. Where lung function tests are not possible the clinical presentation, history and response to therapy will confirm or refute the diagnosis of asthma.

2.1.1 Asthma Triggers Understanding what triggers asthma symptoms will help to add to the overall clinical picture. There are a number of things which are known to trigger asthma. These are:

• Allergic triggers e.g. house dust mite; pollens; cats; dogs; • Viruses e.g. upper respiratory tract infections • Occupational triggers e.g. isocyanates, flour and grains, colophony and

fluxes, latex, aldehydes and animals • Hormonal triggers • Irritants e.g. environmental tobacco smoke, weather changes • Drugs e.g. beta blockers, aspirin and other non-steroidal anti-

inflammatory drugs • Exercise.

Asthma can also present later in life where there is no previous history of asthma and usually occurs following a respiratory infection. The diagnosis of asthma is more likely if:

• Rhinitis and eczema are present with respiratory symptoms. These three conditions are part of the atopic spectrum.

• There is a positive family history of asthma.

2.1.2 Asthma symptoms Asthma symptoms are:

• Wheeze • Cough • Breathlessness • Shortness of breath • Mucous production (phlegm/sputum).

Symptoms do not always occur together.

In asthma, symptoms are either: • Episodic (intermittent) • Seasonal • Persistent or • Exercise induced.

Symptoms may be mild, persistent or severe. In late onset asthma symptoms are usually more persistent. Episodic symptoms are often triggered by viral infections and are common in pre-school children. Seasonal symptoms are often triggered by allergic triggers such as pollens. Pollens include tree, grass and weed pollens. In children, predominant symptoms are coughing which is usually worse at night or with exertion. Tummy aches and vomiting can occur especially if there is mucous production where it is swallowed rather than expectorated. Wheeze may only be present with exacerbations and should be distinguished from upper airway noises. Occupational triggers may exacerbate known asthma or cause asthma or rhinitis. The British Occupational Health Research Foundation (BOHFR) case management guidelines should be followed if an occupational trigger is suspected. http://www.bohrf.org.uk/ The most important questions to ask if a diagnosis of occupational asthma or occupational rhinitis is suspected are: “Are your symptoms better when you are away from work?” “Are your symptoms better when you are on holiday?” Asthma UK has developed an Asthma at Work Charter to highlight the impact of asthma in the workplace and the expectations for people with occupational asthma. http://www.asthma.org.uk

2.1.3 Differential diagnosis in children Although asthma is common, the presenting symptoms and clinical history will help to provide a clinical impression as to the diagnosis of asthma or an alternative diagnosis. Practical Pointer. A failure to respond to treatment should cause the health professional to question the diagnosis. In infants who have persistent respiratory symptoms there should be a low threshold for referral to a respiratory paediatrician or a paediatrician with a

respiratory interest to exclude more serious disease, especially if there is failure to thrive. Cystic fibrosis is the commonest inherited hereditary disease and although it is usually diagnosed with pre-natal screening, neonatal screening or shortly after birth there are occasions where the diagnosis is missed at this stage. Cystic fibrosis is rare in the South East Asian population.

2.1.4 Differential diagnosis in adults Asthma can co-exist with COPD in smokers and ex-smokers. COPD and asthma share many clinical features (See Table 3). A smoking history increases the likelihood of lung cancer.

2.2 COPD COPD gives rise to similar symptoms to asthma and is often confused with it. However, it is overwhelmingly a disease of current and ex-smokers and symptoms are rare under the age of 35 years. Although the diagnosis can usually be made on the basis of the clinical history, spirometry is essential to confirm the presence of airflow obstruction. Measurement of peak expiratory flow is insufficiently sensitive to detect airflow obstruction in mild and moderate cases and will often underestimate the degree of airflow obstruction in more severe disease.

2.2.1 COPD symptoms COPD should be suspected in any person over the age of 35 years who has a history of exposure to a risk factor (usually cigarette smoking) and one or more of the following symptoms:

• Chronic cough • Regular sputum production or a ‘smoker’s cough’ • Exertional breathlessness • Frequent ‘winter bronchitis’ • Wheeze.

A smoking history of more than 15-20 pack years is significant for the development of COPD, although only about 15-20% smokers are at risk. A pack year is a useful way of assessing total exposure to tobacco smoke. 20 cigarettes per day for one year = 1 pack year

No of cigarettes x no of years smoked = Total pack years 20

In its early stages COPD is usually asymptomatic. The onset of breathlessness on exertion is insidious and slowly progressive. It is often attributed to increasing age or accepted as a normal consequence of smoking. Patients tend not to seek medical help until the symptoms are severe enough to interfere with normal daily activities. By this stage considerable, irretrievable loss of lung function has usually occurred. For these reasons COPD is not often diagnosed in its early stages. Symptoms in COPD are persistent. The lack of variability is a key feature. People with COPD, unlike asthma patients do not have ‘good days and bad days’. Their symptoms are the same from day to day but get worse with viral upper respiratory tract infections.

2.2.2 Differential diagnosis Asthma is an important differential diagnosis to consider. Table 3 lists the main clinical features that help to differentiate between COPD and asthma. COPD Asthma

Smoker or ex-smoker Nearly all Possibly Symptoms under age 35 Rare Often Chronic productive cough Common Uncommon Breathlessness Persistent and

progressive Variable

Night time waking with breathlessness and or wheeze

Uncommon Common

Significant diurnal or day to day variability of symptoms

Uncommon Common

Table 3. Clinical features differentiating between COPD and asthma National Collaborating Centre for Chronic Conditions (NCCCC) (2004). COPD affects middle aged and elderly current and ex-smokers who, because of their smoking habit are at high risk of other conditions that can mimic COPD, co-exist with it, or complicate its management. Cardiovascular disease is an important differential diagnosis and a common co-morbidity. Symptoms of shortness of breath on exertion and fatigue are similar in both COPD and heart failure. Chest tightness can be confused with angina. A cardiac cause for symptoms should be suspected in the following circumstances:

• Previous history of hypertension or hyperlipidaemia • Previous history of ischaemic heart disease or myocardial infarction • Diabetes • Positive family history of cardiovascular disease.

Anaemia is a cause of breathlessness on exertion and will need to be excluded. Lung cancer can also give rise to symptoms that are similar to COPD. Smokers who develop COPD are at higher risk of developing lung cancer than smokers who are not at risk of COPD. Lung cancer should be suspected and patients referred immediately if there are symptoms of:

• Haemoptysis • Chest pain • Persistent ‘chest infection’ that is slow to clear • Weight loss.

Bronchiectasis occurs in patients with:

• Cystic fibrosis • Immunodeficiency and • Complications from respiratory infections such as whooping cough and

pneumonia. It is characterised by:

• Dilation of the bronchi due to destruction of the elastic tissue of the lungs • Impaired ciliary clearance • Chronic infection and • Airways inflammation.

Bronchiectasis causes chronic production of mucopurulent sputum and can cause frequent infections and slowly progressive breathlessness on exertion. The production of excessive amounts of sputum on a daily basis is a key feature of this condition. High resolution computerised tomography (HRCT) scanning is used to diagnose bronchiectasis. Therapy is focussed on physiotherapy to remove secretions and the more liberal use of antibiotics, in higher doses to combat infection.

3. Diagnostic tests Whenever possible the diagnosis of both asthma and COPD should be confirmed objectively with lung function tests. Lung function tests in the community setting are of little value in children under the age of six or seven because results are generally not reliable or repeatable. In these circumstances, a trial of anti-asthma treatment is usual. Failure to respond to therapy should call the diagnosis of asthma into question.

3.1 Tests of lung function In community settings simple tests of lung function with a peak flow meter and/or a spirometer are commonly undertaken. Peak flow measurement is useful in the diagnosis of asthma, but the diagnosis of COPD must be confirmed with spirometry.

3.1.1 Peak flow measurement The role of peak expiratory flow (PEF) measurement is:

• To identify variable airflow obstruction in asthma • To guide changes in treatment as part of an asthma action plan.

Peak expiratory flow is the maximum flow rate achieved in the first 10th of a second of an exhalation from maximum inhalation, using maximum effort. It is an effort dependant test and results are only reliable if the patient inhales fully and blows out with maximum effort. Predicted normal PEF values are based on age, gender and height in adults and height in children. These values were determined by Nunn and Gregg (1973; 1989) on the old Wright McKerrow scale.

3.1.2 PEF meter changes From September 2004 the scale on PEF meters in the UK changed to comply with European Union Standard EN13826. The new EU scale overcomes the problem of inaccuracy of some meters and will bring the UK in line with the rest of Europe and North America. Readings on the new EU scale are lower than those on the old meters. Predicted values for PEF using the EU scale have been calculated from the original Nunn and Gregg data and are available at http://www.peakflow.com, together with useful information about the change to EU scale and its implications for patients and pharmacists.

3.1.3 Spirometry Spirometers are essential for diagnosing COPD and provide information about lung volumes and air flow rates. It is essential for detecting early airflow obstruction in COPD; measurement of PEF is insufficiently sensitive. Spirometry is generally more informative than PEF, but the test is more difficult to perform and the equipment more expensive. A spirometer should produce:

• A hard copy print out of lung volume measurements and graphs • A graph of volume against time (and preferably flow against volume as

well) of sufficient size to allow manual checking of the results and accuracy of the technique

• A ‘real time’ graphic display of the patient’s effort. Personnel conducting spirometry tests must be properly trained and ideally certified as competent. They should be able to:

• Obtain a good spirometry technique from patients • Recognise poor technique and know how to correct it and • Interpret the results accurately.

Practical Pointer Poorly performed spirometry is of no value and misleading.

3.2 Reversibility testing Asthma and COPD both cause airflow obstruction. The key difference between them is that airflow obstruction in asthma is reversible and in COPD it is fixed. Testing for reversibility is therefore a key diagnostic test to:

• Objectively confirm a diagnosis of asthma. • Help differentiate asthma from COPD in cases where the diagnosis is not

clear from the clinical history Reversibility can be tested with both bronchodilators and corticosteroids (Table 4). Reversibility testing with bronchodilators is suitable for all ages providing they can perform lung function tests reliably and repeatably. Oral corticosteroid reversibility testing is generally only used in adult patients and is particularly helpful in identifying and differentiating adult onset asthma from COPD.

Table 4. Procedure for reversibility testing Bronchodilators Corticosteroids 1. Measure PEF or FEV1 before and 15 minutes after administering a beta2 agonist e.g.

• 200-400mcg salbutamol via MDI and large volume spacer, or

• Equivalent doses of terbutaline or • 2.5-5 mg salbutamol via nebuliser

N.B. Appropriate for the diagnosis of both asthma and COPD

1. 30mg prednisolone as a single morning dose for 14 days Measure post-bronchodilator FEV1 before and at the end of a course N.B. Appropriate for the diagnosis of both asthma and COPD Oral steroid trial not appropriate for the diagnosis of asthma in children

2. Measure FEV1 before and 30 minutes after administering an anticholinergic e.g.

• 250-500mcg ipratropium bromide via nebuliser, or

• 40-80mcg ipratropium bromide via MDI and spacer

N.B. Not appropriate for the diagnosis of asthma

2. Where there are contraindications to oral corticosteroids consider:

• 6-12 week course of inhaled corticosteroids e.g.500mcg beclometasone b.d. (or equivalent dose of an alternative inhaled corticosteroid

• post-bronchodilator FEV1 at the beginning and end of oral corticosteroid trial

N.B. Appropriate for the diagnosis of both asthma and COPD

3. Measure FEV1 before and 30 minutes after administering combined anticholinergic and beta2 agonist e.g.

• 2.5-5mg salbutamol + 250-500mcg ipratropium bromide via nebuliser, or

• 200-400mcg salbutamol + 40-80mcg ipratropium bromide via MDI and spacer

N.B. Not appropriate for the diagnosis of asthma

3.2.1 A history suggestive of asthma In a patient where the clinical history suggests asthma, a reversibility test is considered positive if:

• The FEV1 improves by 15% AND 200ml or more, or • The PEF improves by 20% and 60 litres/minute or more from

baseline, or • The lung function returns to within normal limits (BTS/SIGN 2005).

3.2.2 A history suggestive of COPD In a patient where the clinical history suggests COPD, the diagnosis is called into question if there is a reversibility of more than 400ml of FEV1. This is more compatible with a diagnosis of asthma (NCCCC 2004). If the improvement is less than this, it supports the clinical diagnosis of COPD. If the lung function returns to normal then this is not compatible with a diagnosis of COPD.

3.2.3 Serial Peak Flow measurements A key feature of asthma is variability in airflow obstruction. Serial measurements of PEF by the patient can be used to confirm a diagnosis of asthma. These can to help differentiate asthma from COPD. To perform serial PEF measurements:

• The patient will need to record their PEF at home over at least a two week period.

• They should be asked to record the best of three readings twice a day, first thing in the morning and again in the early evening, before using any inhalers.

3.2.4 Asthma diagnosis A positive result, supporting a diagnosis of asthma is:

• A variation of at least 60 litres/minute and 20% or more amplitude % best ideally for at least three days a week, over a two week period. (See Box 1),

Box 1. Calculating amplitude % best PEF Highest PEF – Lowest PEF X 100 = amplitude % best Highest PEF

3.2.5 Interpretation There will be some asthma patients who demonstrate less than 20% PEF variability but symptoms and history suggest a diagnosis of asthma. Chronic under-treated asthma may result in persistent airway obstruction. Further tests such as a corticosteroid reversibility test may need to be considered (See Table 4).

3.2.6 Occupational asthma In cases of suspected occupational asthma a serial PEF recorded two hourly at work and during periods away from work is used to support the diagnosis (BOHRF 2005). Practical Pointer Reversibility tests and serial peak flow should only be interpreted in the light of the clinical history.

4. Aims of treatment

4.1 Aims of asthma treatment The aims of asthma treatment are similar for both health professional and asthma patients; however the patient is more concerned with how it affects their lifestyle. What the health professional wants: What the patient wants:

Minimal or no symptoms during day and night

No sleep disturbance as a result of night-time wheezing and coughing

Minimal episodes of worsening asthma or acute attacks

No asthma attacks

No emergency visits to doctors or hospitals

No emergency visits

Minimal need for quick-relief ß2-agonist therapy

No need for extra inhaled treatment

No limitations of physical activities and exercise

No limitations to work, exercise or social activities

Minimal or no side-effects from medication

No adverse effects from treatment

Normal lung function (Peak flow at least 80% or more)

No limitations because of asthma

4.2. Aims of COPD treatment COPD is a slowly progressive disorder and usually it is not possible to eliminate symptoms completely. The aims of treatment are therefore slightly different from asthma. Although it is not possible to cure COPD it is a treatable condition. There are a number of effective pharmacological and non-pharmacological therapies available. A nihilistic approach is no longer justifiable.

The key aims of therapy for both COPD patients and health professionals are similar: What the health professional wants What the COPD patient wants Reduced rate of disease progression Not to get worse and to stay as well as

possible for as long as possible Maximum possible symptom relief To be less breathless To reduce the disability associated with chronic breathlessness

To be able to continue to carry out normal activities of daily living

Maintain or improve health related quality of life

To have a reasonable quality of life; to maintain self esteem and independence

Reduced exacerbation frequency To avoid bad attacks Prompt and effective treatment for exacerbations

To be able to get attacks treated promptly

4.3 Non-pharmacological treatment for asthma and COPD

4.3.1 Smoking cessation Smoking cessation is of paramount importance in both asthma and COPD. People with asthma who smoke are more likely to develop fixed airflow obstruction and will gain less benefit from their inhaled corticosteroids. Children exposed to passive smoke are more likely to experience repeated lower chest infections and worsening of their asthma. Practical Pointer Smoking reduces the efficacy of inhaled corticosteroids. Continued smoking in COPD leads to accelerated decline in lung function and worsening prognosis. Smoking cessation is the only intervention that alters the natural history of COPD. Lost lung function cannot be regained, but the rate of lung function decline will slow to that of a non-smoker or non-susceptible smoker. It is never too late to stop smoking. Worthwhile salvage of lung function and life expectancy is achievable at every stage of the disease. Practical Pointer Smoking cessation is the only intervention that alters the natural history of COPD.

Smokers may go through several stages before successfully quitting: • Pre-contemplation (the contented smoker) – they do not intend to stop

smoking in the near future and may not perceive smoking to be a problem • Contemplation – they will consider stopping smoking but are not yet ready to

do anything active about it • Preparation – they are beginning to make plans to stop smoking and may

already have started to make small changes, such as cutting down on the number they smoke, switching to lower tar cigarettes (neither strategy is likely to be successful on its own, but should be viewed as a step in the right direction)

• Action – they have stopped smoking, but are in the early (less than 6 months) stage of being a non-smoker

• Maintenance – they have managed not to smoke for 6 months or more • Relapse – occasional lapses are normal and should be expected. However,

relapse into regular smoking may also occur. You can be effective in helping a smoker to consider stopping, make a plan to stop and make a serious quit attempt by raising the issue in a non-confrontational manner at every opportunity. Smokers who are followed-up, advised and actively supported during a quit attempt are more likely to succeed. As a health professional you should be using the ‘five A’s’: • ASK – about smoking status at every opportunity • ADVISE – Urge smokers to quit • ASSESS – willingness to quit. Ask if they are willing to set a quit date within

the next 30 days • ASSIST – with a quit plan, practical counselling, support and advice on the

use of NRT or bupropion • ARRANGE – follow-up contact, preferably on the quit day and within 2 weeks

of quitting Practical Pointer Helping a smoker to stop smoking is the most important thing you can do to improve their health.

4.3.2 Nicotine replacement therapy Nicotine replacement therapy (NRT) will double the chances of a successful quit attempt and smokers who are committed to stopping smoking should be encouraged to use it. All forms of NRT are effective and the choice of formulation is a matter of the smoker’s personal preference.

Help the smoker chose an appropriate form of NRT and advise them how to use it properly:

• Using an appropriate starting dose • Using it regularly for at least 8 weeks • Not attempting to cut the dose down early.

Continuing to smoke while using NRT is potentially dangerous and the quit attempt is likely to fail Side effects of NRT can occur and include:

• Local irritation (with patches) • Sleep disturbance or insomnia.

However, the side effects of NRT are the same as those associated with smoking. As a general rule the benefits of using NRT and successfully stopping smoking far outweigh the risks of continued smoking. Practical Pointer Use of Nicotine Replacement Therapy (NRT) doubles the chances of stopping smoking.

4.3.3 Bupropion Bupropion (Zyban) is at least as effective as NRT, but like NRT, is not suitable for the smoker who is not genuinely committed to stopping. Bupropion is generally well tolerated, but prescribers need to be aware of some important contraindications: • Current or past seizure • Use of medications that lower the seizure threshold, e.g. antidepressants,

antipsychotics or theophyllines • Current or past eating disorder, e.g. anorexia or bulimia • History of bipolar disorder, e.g. manic depressive psychosis • Hepatic cirrhosis • Brain tumour or previous severe head injury • Withdrawal from alcohol or benzodiazepines Side effects of buproprion are generally minor and reversible, but there have been some highly publicised deaths associated with it. However, a causal link is disputed. The risks of continuing to smoke far outweigh the risk of using bupropion, provided it is prescribed with care to appropriate people. NICE technology appraisal on NRT and bupropion is available at: www.nice.org.uk/article.asp?a=30631

4.4 Non-pharmacological treatment of asthma Complementary and alternative therapies are being used increasingly in the UK, often because of cultural beliefs or in the search to avoid the need to take regular medicines. In asthma there is a lack of evidence to support most of these therapies and there are some concerns about their safety (BTS/SIGN 2005) The Department of Health is in the process of introducing regulation of acupuncture practitioners and herbal medicines. The Medicines and Healthcare products Regulatory Agency (MHRA) have established the Herbal Medicines Advisory Committee to provide expert advice on the safety and quality of herbal medicines. Both this and the proposed Europan directives on herbal medicines will regulate an industry where these medicines are in use without efficacy or patient safety data. Regulation of complementary healthcare, such as homeopathy, aromatherapy and reflexology is not included in current proposals. www.mca.gov.uk/ourwork/licensingmeds/herbalmeds/herbalsafety.htm

4.4.1 Obesity Obesity reduces activity and leads to loss of physical fitness. In asthma, obese patients will benefit from losing weight in order to improve their fitness and mobility. This may then help to improve overall asthma control.

4.4.2 Gastro-oesophageal reflux Gastro-oesophageal reflux (GOR) can cause respiratory symptoms especially coughing, because of aspiration and make asthma symptoms worse. If GOR is present, it should be treated according to recommended current treatment guidelines. Treating GOR can eliminate symptoms completely in some individuals. GOR should be considered along with other possible diagnoses, if there is a failure to respond to asthma treatment.

4.4.3 Immunotherapy Immunotherapy is available for people who have severe asthma or rhinitis symptoms in response to particular allergens such as grass pollens. Desensitisation is not used routinely in the UK because there is always the potential for an anaphylactic reaction. It is only carried out where full emergency resuscitation facilities are available in case of an anaphylactic reaction. Desensitisation also requires significant individual commitment because of frequent hospital visits for the regular injections over a period of many months. Immunotherapy is particularly effective for individuals with severe allergic reactions to wasp and bees stings.

4.5 Non pharmacological treatment of COPD

4.5.1 Pulmonary rehabilitation Pulmonary rehabilitation is of proven benefit in COPD. It can produce: • Significant improvements in functional ability • Greater maximum exercise capacity • Improved quality of life • Reduced breathlessness • Reduced number of hospital admissions • Reduced health service utilisation. Pulmonary rehabilitation is a multidisciplinary programme of care that is individually tailored and designed to optimise physical and social performance and autonomy (NICE 2004). Programmes last for a minimum of 6 weeks with at least 2 supervised, group sessions a week. The core components are:

• Individually prescribed exercise to improve both aerobic capacity and functional ability

• Education to improve understanding and self-management skills • Psychological and social support.

Despite ample evidence for its effectiveness service provision remains patchy. The NICE guideline recommends that programmes should be available to all suitable patients who feel functionally disabled by their disease. Programmes should be available locally in buildings that are accessible and within a reasonable time of referral. Practical Pointer Pulmonary rehabilitation is of proven benefit in COPD.

5. Drug therapies There are a number of drugs that are used to treat both asthma and COPD but indications for their use vary. The British Thoracic Society (BTS) /Scottish Intercollegiate Guideline Network (SIGN) asthma guidelines are the accepted management guidelines for the diagnosis and treatment of asthma (BTS/SIGN 2005) while the National Collaborating Centre for Chronic Conditions (NCCCC) have produced guidelines for the diagnosis and management of COPD (NCCCM 2004). A summary of the management recommendations for asthma and COPD are found in Section 8.

5.1 Short acting beta2 agonist bronchodilators- often referred to as ‘relievers’ These drugs have a rapid onset of action with maximal bronchodilator effect at 15-20 minutes and duration of 4-6 hours. Side effects include tremor and tachycardia but are usually dose related. Table 5. Indications for use of short acting beta2 agonist bronchodilators for asthma and COPD

Indications for Asthma

Indications for COPD

Immediate symptomatic relief of asthma symptoms. Mild episodic asthma - used as required. Step 1 of the BTS/SIGN Asthma Guideline.

Rapid symptomatic relief and maintenance therapy. They reduce breathlessness and improve exercise tolerance without producing large improvements in FEV1. The efficacy of any therapy is assessed in terms of subjective, symptomatic improvement rather than improvements in lung function.

Table 6. Availability of short acting beta2 agonist bronchodilators Short acting bronchodilators- drug name

Pressurised Metered Dose inhaler Available as:

Breath actuated inhaler Available as:

Dry powder inhaler Available as:

Salbutamol Ventolin Evohaler Airomir Salbulin Salamol

Airomir Salamol Easi-breathe

Asmasal Clickhaler Pulvinal salbutamol Ventolin Accuhaler Salbutamol Easyhaler

Terbutaline Terbutaline (Bricanyl) Turbohaler

Practical pointer Inhaled short-acting bronchodilators are used in preference to oral bronchodilators.

5.2 Long acting beta2 agonists These drugs have a 12 hour bronchodilator effect. Side effects are similar to the short acting ones. Table 7. Indications for use of long acting beta2 agonists in asthma and COPD

Use in Asthma Use in COPD Symptoms are troublesome despite the use of regular low dose inhaled steroids. First choice add on therapy to low dose inhaled corticosteroids at Step 3 of the BTS/SIGN asthma guidelines.

Symptoms are inadequately controlled on short acting bronchodilators. 2 or more exacerbations a year. Improve exercise tolerance and quality of life, reduce breathlessness and exacerbation frequency

Table 8. Availability of long-acting beta2 agonists Long-acting beta2 agonists

Metered dose Inhaler Available as:

Dry powder inhaler Available as:

Salmeterol (Serevent) Serevent Evohaler Accuhaler Diskhaler

Formoterol (Oxis)

Formoterol (Atimos Modulite)

Turbohaler

Formoterol (Foradil)

Aerolizer

5.3 Oral beta2 agonist bronchodilators Oral bronchodilators are rarely used in asthma and COPD because inhaled therapy is more effective and there are fewer side effects. Table 9. Availability of oral short acting beta2 agonist bronchodilators

Short acting bronchodilators Oral Available as:

Bambuterol Salbutamol

Bambec Volmax

5.4 Anti-cholinergic bronchodilators Anti-cholinergic bronchodilators work via the cholinergic pathway. Onset of action is about 40 minutes and is much slower than with short acting beta2 agonist bronchodilators. They are also available in combination with short acting beta2 agonist bronchodilators. They are poorly absorbed systemically and are well tolerated. Side effects are generally minor and include an unpleasant taste or a dry mouth. However, nebulised mist of anticholinergic drug has been reported to have precipitated acute closed angle glaucoma. Mouthpieces, rather than masks should be used with a nebuliser if possible.

Table 10. Indications for use of short acting anti-cholinergic bronchodilators for asthma and COPD

Use in Asthma Use in COPD The asthma guidelines recommend that ipratropium bromide is used to treat severe asthma attacks. It is nebulised in combination with salbutamol. It is not recommended for regular maintenance therapy.

Increased cholinergic tone is thought to be an important component of airflow obstruction in COPD and anticholinergic bronchodilators are particularly helpful. Generally used regularly three or four times a day rather than on an as required basis

Table 11. Availability of short acting anti-cholinergic bronchodilators Anti-cholinergic bronchodilators

Metered dose inhaler

Available as:

Dry powder

Available as:

Nebules

Available as: Ipratropium bromide

Atrovent

Aerocaps for use in the Aerohaler

Atrovent

Practical Pointer A mouthpiece should be used with nebulised ipratropium bromide whenever possible.

5.6 Long acting anticholinergic bronchodilators Currently there is only one long acting anticholinergic bronchodilator available. Tiotropium has a duration of action of at least 24 hours, making it suitable for once daily use. Table 12. Indications for use of long acting anti-cholinergic bronchodilators for asthma and COPD

Use in Asthma Use in COPD

NOT INDICATED

Symptoms inadequately controlled on regular short acting bronchodilators 2 or more exacerbations a year Effective at reducing exacerbation frequency and improving quality of life and symptoms

Table 13. Availability of long acting anti-cholinergic bronchodilators Anti-cholinergic bronchodilators

Metered dose inhaler

Available as:

Dry powder

Available as:

Nebules

Available as: Tiotropium

NOT AVAILABLE

Spiriva capsules for use with the Handihaler

NOT AVAILABLE

5.7 Anti-cholinergic and short acting beta2 agonist bronchodilators A combination preparation of short acting bronchodilators is used to treat COPD . Table 14. Indications for use of anti-cholinergic and short acting beta2 agonist bronchodilators for asthma and COPD

Use in Asthma Use in COPD

NOT INDICATED

Combinations of short acting bronchodilators may provide additional benefit to separate administration of the two drugs. . Recommended for regular use, three – four times daily

Table 15. Availability of anti-cholinergic and short acting beta2 agonist bronchodilators Anti-cholinergic & short

acting beta2 agonist bronchodilators

Metered dose inhaler

Available as:

Nebules

Available as: Ipratropium bromide & salbutamol

Combivent

Combivent

5.8 Methylxanthines Theophylline and aminophylline belong to the group of drugs known as methylxanthines. They are generally given orally except for aminophylline which can also be given parenterally. Modified release drugs should always be prescribed by brand rather generic name because of the differing absorption rates of the various preparations. There are a number of factors which will affect the absorption and drug half life. See Table 16.

Table 16. Factors affecting the half life of methylxanthines Factors which increase the half life

of methylxanthines Factors which decrease the half life

of methylxanthines Heart failure Viral infections Cirrhosis Age i.e. elderly Drugs e.g.

• Cimetidine, • Ciprofloxacin, • Erythromycin • Oral contraceptives

Smoking Chronic alcoholism Drugs e.g.

• Phenytoin • Carbamazepine • Rifampicin • Barbiturates

Table 17. Indications for use of methylxanthines for asthma and COPD

Use in Asthma Use in COPD Indicated at Step 3 of the asthma guidelines for adults and children aged 5-12 years, if there is no response to long acting bronchodilators and/or leukotriene receptor antagonists Indicated at Step 4 of the guidelines if poor control persists despite increasing inhaled steroids to maximum doses

May be tried when additional symptom relief is required. They are generally third line therapy as side effects and interactions can be particularly troublesome in this age group If they are used, serum theophylline levels will need to be monitored 6 monthly

Table 18. Availability of methylxanthines

Methylxanthines Oral Aminophylline

Aminophylline

Aminophylline (modified release)

Phyllocontin Continus

Theophylline

Nuelin (Tablets + liquid)

Theophylline (modified release) Nuelin SA (capsules) Slo-Phyllin Uniphyllin Continus

Practical Pointer Modified release methylxanthines should always be prescribed by brand rather than generic name.

5.9 Inhaled corticosteroids – often referred to as ‘preventers’ Inhaled steroids are effective anti-inflammatory agents and are administered once or twice daily. They need to be used regularly to control symptoms in asthma. In moderate and severe COPD they are used to reduce exacerbation frequency in patients who suffer 2 or more exacerbations a year. They are not indicated in mild COPD. Local side effects are oral thrush and voice hoarseness but use of a spacer holding device and metered dose inhaler can eliminate them. Systemic side effects are possible with doses over 800mcg beclometasone or equivalent. In asthma the lowest dose of corticosteroids that control symptoms should always be used. In COPD however studies indicate that moderate to high doses are needed and that lower doses are ineffective. Table 19. Indications for use of inhaled corticosteroids in asthma and COPD

Use in Asthma Use in COPD Used at Step 2 and above of the asthma guideline as first line preventer treatment in all age groups.

The NICE guideline recommends their use in patients whose FEV1 is 50% predicted or less and who have had 2 or more exacerbations in a 12 month period, to reduce exacerbation frequency. Given in addition to long acting bronchodilators (beta2 agonist or anticholinergic) since these drugs also reduce exacerbation rates. Meta analysis suggests that high doses (1000mcg beclometasone per day, or equivalent) are required (Van Grunsven et al 1999)

Table 20. Availability of inhaled corticosteroids Inhaled corticosteroid

Metered dose inhaler Available as:

Breath actuated inhaler Available as:

Dry powder inhaler Available as:

Beclometasone Becotide Beclazone Becloforte Filair Filair Forte Qvar

Qvar Easi-breathe Beclazone Easi-breathe

Asmabec Clickhaler Becodisks Pulvinal beclometasone Beclomet Easyhaler

Budesonide Pulmicort Pulmicort Turbohaler Budesonide Novolizer Budesonide Easyhaler

Fluticasone Flixotide Flixotide Diskhaler Flixotide Accuhaler

Mometasone Asmanex Twisthaler

Ciclesonide Alvesco

Practical Pointer In asthma the lowest dose possible of inhaled corticosteroids should be used to control symptoms. In COPD moderate to high doses are required. Low doses are not effective.

5.10 Combination therapies Combination therapies simplify treatment and eliminate the need for two separate inhalers.

• In asthma the lowest dose possible to control symptoms should be used.

• Only high dose combination therapy is licensed for use in COPD. Lower doses are not indicated.

Table 21. Indications for use of combined inhaled corticosteroids and long-acting bronchodilators in asthma and COPD

Use in Asthma Use in COPD • Useful in chronic asthma once

symptoms stable • Simplifies treatment as only one

inhaler is required • Reduces prescription costs to

patient as only one inhaler is needed

Recommended to reduce exacerbation frequency in patients whose:

• FEV1 is 50% predicted or less and

• who have had 2 or more exacerbations in a 12 month period.

Table 22. Availability of combination inhaled corticosteroids and long-acting bronchodilators

Combination inhalers

Metered dose inhaler Available as:

Dry powder Available as:

Fluticasone/ salmeterol

Seretide Seretide Accuhaler

Budesonide/ formoterol

Symbicort Turbohaler

5.11 Oral corticosteroids Oral corticosteroids are reserved for treating exacerbations of asthma and COPD and to gain rapid control of respiratory symptoms in severe persistent asthma. Oral corticosteroids can be taken continuously for up to 3 weeks without systemic side effects and then stopped. It is not necessary to taper the dose before stopping although in some clinical circumstances this may be indicated. Long term oral corticosteroid use makes systemic side effects more likely. Side effects include:

• Raised blood pressure: this should be monitored • Diabetes mellitus: this may present with vaginal thrush and increasing

thirst. • Osteoporosis: increasingly common in older populations as well.

Osteoporosis treatment guidelines are available from: http://www.nos.org.uk

• Cataracts.

Growth delay in children although severe asthma also affects growth. Growth should be monitored in children taking oral and inhaled corticosteroids

Practical Pointer Patients should be given a Steroid Treatment card if they are taking maintenance oral corticosteroids. Table 23. Indications for use of oral corticosteroids in asthma and COPD

Use in Asthma Use in COPD Essential for treatment of acute asthma attack Can be given at any step of the asthma guideline to gain rapid control of symptoms Additional treatment at Step 5 of asthma guidelines for maintenance therapy in severe persistent asthma Patients on regular oral corticosteroids must be under specialist respiratory care physicians Regular oral corticosteroids can be given on alternative days in children to limit systemic effects

Short courses of 30mg prednisolone a day for up to 14 days are indicated for exacerbations where severe breathlessness is a prominent symptom. Longer courses confer no additional benefit. Long-term maintenance therapy should be avoided if at all possible because of the adverse risk/benefit profile Some patients with very severe COPD may require maintenance therapy. They should be under specialist care and using the lowest possible dose

Practical Pointer Patients on maintenance oral corticosteroids should be under specialist care.

5.12 Other anti-inflammatories - cromones Cromones are non steroidal preparations and work by stabilising the mast cells. They are effective in children over the age of 5 years. Their disadvantage is that they take 4-6 weeks of regular use to have any effect and are taken up to 4 times a day. In allergic eye symptoms of hay fever, regular sodium cromoglicate is effective. Table 24. Indications for use of cromones in asthma and COPD

Use in Asthma Use in COPD Effective for prevention of exercise symptoms if used 30 minutes prior to exercise Cromones are not effective for immediate relief of symptoms

NOT INDICATED

Table 25. Availability of cromones Metered dose

inhaler Available as:

Breath actuated inhaler Available as:

Dry powder inhaler Available as:

Sodium cromoglicate

Intal Cromogen Intal Syncroner

Cromogen Easi-breathe

Intal Spinhaler

Nedocromil sodium

Tilade Syncroner

5.13 Leukotriene receptor antagonists Leukotriene receptor antagonists (LTRAs) block the cysteinyl leukotriene receptor sites in bronchial smooth muscle. They are effective against early and late bronchodilator response to antigen challenge. LTRAs are oral preparations and are taken once or twice daily according to the brand. Table 26. Indications for use of leukotriene receptor antagonists in asthma and COPD

Use in Asthma Use in COPD Introduced at Step 3 of the asthma guideline if long-acting bronchodilators ineffective. Can be used from 6 months of age as additional therapy. In adults considered as an additional therapy at Step 4, as a fourth drug. In children age 2-14 with mild to moderate asthma, used as an alternative to low dose inhaled steroids, if no recent history of serious asthma attacks and if inhaled steroid use not possible e.g. administration difficulties. Indicated over 15 years of age for the treatment of asthma and concomitant allergic rhinitis. Effective for the prophylaxis of asthma in which the predominant component is exercise-induced bronchoconstriction.

NOT INDICATED

Table 27. Availability of leukotriene receptor antagonists Leukotriene receptor antagonists

Tablets Available as:

Granules Available as:

Montelukast Montelukast

Singulair Singulair

Singulair

Zafirlukast Accolate

Practical Pointer Leukotrienes are useful where exercise is the predominant symptom in asthma and there is associated allergic rhinitis.

5.14 Mucolytics in COPD These therapies reduce symptoms of productive cough by reducing the viscosity of sputum and enabling easier sputum clearance. Systematic review indicates that they also help reduce exacerbation frequency (Poole et al 2003). Table 28. Indications for use of mucolytics in asthma and COPD Use in Asthma Use in COPD NOT INDICATED

Relief of troublesome productive cough. They should be continued if there is a documented improvement in symptoms following a month’s therapeutic trial

Table 29. Availability of mucolytics Mucolytics Available as:

Carbocisteine

Mucodyne

Mecysteine Visclair

6. Inhaler devices There are an increasing number of inhaler devices on the market. These can be divided into three main groups:

1. Pressurised metered dose inhalers (pMDI’s) 2. Breath activated devices • Autohaler • Easi-breathe

3. Dry powder devices • Aerohaler • Accuhaler • Aerolizer • Clickhaler • Diskhaler • Easyhaler • Handihaler • Novolizer • Pulvinal • Turbohaler • Twisthaler

An inhaler device should only be prescribed after inhaler technique has been taught. The range of available drugs in each inhaler device will determine which devices can be considered for any individual patient. See Appendices for information on how to use the different inhalers. Practical Pointer Inhaler device technique must always be taught and checked.

6.1 Inhaler devices for asthma There are National Institute of Health and Clinical Excellence (NICE) recommendations for inhaler devices for children (NICE 2000, 2002).

• In children under 5 years of age, a metered dose inhaler together with a spacer holding chamber is the preferred option

• In children under 3 years of age the addition of a face mask to the spacer is required because they do not have enough inspiratory effort to activate the one way mouthpiece valve. The face mask should fit snugly around the nose and mouth.

In children aged 5-15 years and adults with stable asthma, device selection should take account of:

• Drug availability • Patient preference - so long as the device can be used correctly.

Practical Pointer Inhaler preferences should be taken into account in children.

6.2 Inhaler devices for COPD There is a Health Technology Assessment (Brocklebank et al 2001) of the effectiveness of inhaler devices in COPD Practical Pointer COPD patients are often elderly and may experience particular difficulty learning and retaining good inhaler technique. Their ability to use a device should be regularly assessed and technique re-taught if necessary. Bronchodilators are best administered with hand held devices. Dry powder and breath activated inhalers are particularly useful. Patient preference and ability should guide selection of the most appropriate inhaler. Metered dose inhalers used on their own are seldom appropriate for elderly patients and the addition of a spacer device will be necessary. Small volume spacers are particularly useful as they are more portable and will enable the patient to get out of their home and socialise more easily. Inhaled corticosteroids are best administered via a spacer as high doses are required and spacers will reduce the incidence of local side effects. Regular nebulised bronchodilators are only necessary for a small number of patients with severe COPD and are an expensive option (see below). They should not be recommended without specialist assessment (BTS 1997, Boe et al 2001).

6.3 Spacer Devices Spacer devices are holding chambers into which the inhaled medication is released (actuated). This ‘traps’ the medication and allows sufficient time for the medication to be breathed in through the one way valve of the spacer. It is especially useful where:

• There is poor co-ordination or • High doses of inhaled corticosteroid are required.

Spacers help to reduce the likelihood of local corticosteroid side effects, such as oral thrush and hoarse voice. There are a number of spacers on the market both large and small. See Table 30 below. Figure 30. Available spacer devices Small volume spacer devices plus masks

Small volume spacer devices

Large volume spacer devices

Aerochamber Plus • Infant • Toddler • Adult

Aerochamber Plus Volumatic Volumatic with mask (Production of Volumatic ceased October 2005)

Able spacer Able spacer Nebuhaler Nebuhaler with mask

Nebuchamber* Nebuchamber* Pocket chamber * made of stainless steel Although further supplies of the Volumatic are no longer be available, patients are likely to continue using their current Volumatic devices until a replacement spacer is necessary. Caution needs to be exercised during the changeover from a large to a small spacer and additional symptom monitoring and medication review will be necessary. Practical Pointer Spacers are helpful when inhaler technique is poor or where there are oral side effects or corticosteroids. All the plastic spacer devices that are currently available are susceptible to static charge. The static attracts the medication to the spacer walls reducing the amount of drug available for inhalation. This static charge can be reduced by:

• Washing the spacer in warm soapy water (using washing up liquid) • Soaking for a few minutes • Allowing the spacer device to ‘drip dry’.

The anti-static effects last for 3-4 weeks. Large volume spacers do not need to be washed more frequently unless the one way valve fails to move freely. Spacer devices should be replaced according to manufacturers’ instructions or if the valves of the devices are damaged.

Practical Pointer Spacers must be washed correctly to avoid static effects.

6.4 Nebulisers A nebuliser is a device that atomises solutions or suspensions of drug into small particles for inhalation. Particles of 2-5 microns are needed for penetration to small airways. There are three main types of nebuliser technology available:

• Jet nebuliser • Ultrasonic nebuliser • Vibrating mesh nebuliser.

Nebulisers are able to deliver bronchodilators to the airways without the need for the patient to co-ordinate. They are however relatively inefficient at producing respirable aerosols and bronchodilator preparations for use through a nebuliser are expensive. The most commonly used system the jet nebuliser, may only deliver 25% of the nominal dose of drug to the lungs under a controlled environment. Practical Pointer In most cases of both asthma and COPD a MDI and spacer is as effective as a nebuliser and is a cheaper, more convenient method of drug delivery. More efficient refinements of the jet nebuliser are available such as:

• Breath assisted nebulisers and • Adaptive aerosol delivery devices.

These are expensive and rarely used for asthma and COPD: More recent innovations, like the vibrating mesh nebuliser are far more efficient but, because of their enhanced efficiency may deliver too high a dose of drug if currently available nebuliser solutions are used. With newer nebuliser technologies, drug doses will need to be carefully titrated to patient response. Most nebuliser systems require a power source, making them unsuitable for use outside the home. However, battery powered systems are available for those patients who need to use them away from home. Nebuliser systems are not available on prescription. They require regular servicing, maintenance and replacement of disposables such as nebuliser chambers, tubing, mouth pieces and masks. A health professional who supplies a patient with a nebuliser system is legally responsible for ensuring its electrical safety and should also ensure that the:

• System is regularly serviced • Equipment is appropriately maintained • Patient has a regular supply of disposables • Patient and their carers know how to use and care for the nebuliser.

The provision of central nebuliser services in district general hospitals was recommended in the 1997 BTS guidelines. Yet service provision remains extremely poor and the practice of advising patients to purchase their own nebuliser is widespread. This is far from satisfactory. See Table 31 for indications for nebuliser use. Nebuliser use in Asthma Nebuliser use in COPD Rarely required in the treatment of asthma because inhaler devices are the preferred delivery option.

May give best symptom relief for a few patients with severe COPD, but should only be recommended following thorough assessment by a specialist.

In severe asthma attacks nebulisers are used for the delivery of combined short acting bronchodilators and anti-cholinergic drugs.

When nebulisers are used during an exacerbation, patients should be switched back to their usual inhaler as soon as they are stable.

Table 31 Nebuliser use in asthma and COPD Practical Pointer A health professional must ensure that the patient knows how to look after the nebuliser correctly and safely.

7. Pharmacological management of asthma and COPD There are nationally accepted evidence based guidelines for the management of both Asthma and COPD. These guidelines should form the basis of planned care.

7.1 Asthma The British Asthma Guideline advocates that treatment starts at the most appropriate level according to severity. The Asthma guidelines are divided into three age groups:

• Children less than 5 years • Children aged 5-12 years • Adults (including children over 12 years)

There are a number of different treatment steps in each age group. Step 1 is for mild episodic asthma, with Step 5 for those with severe persistent asthma. Treatment should be started at the most appropriate step (See Figures 1-3). Oral steroids can be added at any stage to gain rapid control. The key treatment steps are:

• Inhaled steroids are indicated if inhaled bronchodilators are used more than once a day

• Inhaled steroids should be introduced at low doses

• If there is a failure to respond to low dose inhaled steroids, long-acting

bronchodilators (LABA) are the first choice add-on therapy

• If there is a failure to respond to this additional treatment, the LABA should be stopped and leukotriene receptor antagonists (LTRAs) tried. Alternatively the dose of inhaled steroid can be increased

• If symptoms persist a fourth drug should be tried e.g. theophylline.

• Maintenance oral steroids should be considered only after referral to a

respiratory physician or paediatrician.

Asthma guidelinesAsthma guidelines-- children less than 5 yearschildren less than 5 years

BTS/SIGN 2004

Refer to Respiratory Paediatrician

Consider trial of leukotriene receptor antagonist (LRTAs). In children under 2 yrs consider

proceeding to Step 4

Add inhaled steroids 200-400mcg per day (startat dose appropriate to disease severity) or leukotriene receptor antagonist if steroid inhaler cannot be used

Inhaled short acting bronchodilators as required

Step 4Step 4

Step 3Step 3

Step 2Step 2

Step 1Step 1

Figure 1. Asthma Guidelines in the under 5’s

Asthma guidelinesAsthma guidelines-- children aged 5children aged 5--12 years12 years

BTS/SIGN 2004

Use daily steroidsMaintain high doses inhaled steroids 800mcg per day

Refer to Respiratory Paediatrician

Increased inhaled steroids up to 800 mcg per day

1.Add inhaled long acting bronchodilator (LABA). 2.No response- stop LABA –

Increase inhaled steroids to 400mcg per day. Consider Leukotrienes (LRTAs) or SR Theophyllines

Add inhaled steroids 200-400mcg per dayAppropriate starting dose 200mcgs

Inhaled short acting bronchodilators as required

Step 5Step 5

Step 4Step 4

Step 3Step 3

Step 2Step 2

Step 1Step 1

Figure 2. Asthma Guidelines in the 5-12’s

Asthma guidelines Asthma guidelines -- adultsadults

BTS/SIGN 2004

Use daily steroids. Maintain high doses inhaled steroids 2000mcg per day

Add inhaled steroids 200-800mcg per day

Inhaled short acting bronchodilators as required

Consider trials of: Increased inhaled steroids up to 2000mcg/ day. Addition of 4th drug – LTRA/SR Theophylline/oral beta2

1.Add inhaled long acting bronchodilator (LABA). 2.No response- stop LAB2 – Increase inhaled steroids to 800mcg/day. Consider Leukotrienes (LRTAs) or SR Theophyllines

Step 5Step 5

Step 4Step 4

Step 3Step 3

Step 2Step 2

Step 1Step 1

Figure 3. Asthma Guidelines in adults

7.2 COPD At all times treatment should be aimed at maximum possible relief of breathlessness and reduction of the frequency of exacerbations.

7.2.1 Bronchodilators Bronchodilators are the mainstay of therapy for the relief of breathlessness. Since COPD is progressive treatment is intensified as the disease progresses and symptoms increase. See Fig 4.

Fig 4. Approach to bronchodilator therapy in COPD

Short acting bronchodilators as necessary Either beta2 agonists or anticholinergics

dependant on symptomatic response

Combined short acting beta2 agonist and anticholinergics

Long acting bronchodilator Either beta2 agonist or anticholinergic

depending on response

(In a l

Increasing symptoms

Although bronchodilators significant improvements itherapy should therefore bimprovement: • “Has your treatment m• “Is your breathing easi

Moderate and severe COPD and symptomatic consider: Inhaled corticosteroid

haled corticosteroid should be added toong acting bronchodilator – either beta2

agonist or anticholinergics) Discontinue if no benefit

Consider methylxanthines

Consider nebulised bronchodilators – but only after specialist assessment

may have little effect on lung function they can produce n breathlessness and disability. The effectiveness of e assessed in terms of subjective, symptomatic

ade a difference to you?” er in any way?”

• “Can you do some things now that you couldn’t do before or the same things but faster?”

• “Can you do the same things as before, but are now less breathless when you do them?”

• “Has your sleep improved?” (Jones et al 2001)

7.2.2 Inhaled corticosteroids Inhaled corticosteroids are not indicated in patients with mild COPD – FEV1 greater than 50% predicted. In patients with an FEV1 less than 50% predicted who suffer frequent exacerbations inhaled corticosteroids have been shown to reduce exacerbation frequency and reduce the associated decline in quality of life (Burge et al 2000). Inhaled corticosteroids should be added to long acting inhaled bronchodilator therapy, either beta2 agonist or anticholinergics, since both these agents also reduce exacerbation frequency. Meta analysis (van Grunsven et al 1999) indicates that moderate to high dose inhaled corticosteroids (1000mcg beclometasone a day or equivalent) are required to produce an effect. Lower doses are not effective and, once established on inhaled corticosteroids stepping down of dose is not advised.

7.2.3 Oral corticosteroids Short courses of oral corticosteroids (not more than 14 days) are used to treat exacerbations of COPD characterised by marked increases in breathlessness. Maintenance oral corticosteroids are not recommended. The side effect profile in this age group of elderly, immobile smokers and ex-smokers is poor and the risks generally outweigh the benefits. There are, however some patients with severe disease who will require maintenance oral corticosteroids. In these cases the patient should be under specialist care and the dose of oral corticosteroids used kept as low as possible. All patients over the age of 65 years on maintenance oral corticosteroids will require osteoporosis prophylaxis. Guidelines for the prevention of osteoporosis should be followed in younger patients http://www.nos.org.uk

7.2.4 Mucolytics Mucolytics have been shown to reduce exacerbation frequency and symptoms of chronic cough and sputum production. A therapeutic trial of mucolytics is indicated for patients with troublesome productive cough and should be continued if it results in symptomatic relief.

7.3 Oxygen in asthma and COPD Adequate exchange of oxygen in the lungs is vital to the maintenance of life. Both asthma and COPD can impair this process and lead to low blood oxygen levels known as hypoxia. Hypoxia may be clinically apparent as central cyanosis; a blue tinge to the lips and tongue. Cyanosis is, however a subjective clinical finding and is not always readily seen. Children with acute asthma, in particular are not always cyanosed, but may look pale. Cyanosis may be extremely difficult to detect in Afro-Caribbean and Asian ethnic groups.

7.3.1 Pulse Oximetry Pulse oximeters measure the percentage of haemoglobin in the peripheral circulation that is saturated with oxygen (SpO2). Pulse oximetry is an easy, non-invasive, quick and objective method of assessing oxygenation. Normal SpO2 is between 95% and 97%. Levels below 93% are abnormal. When SpO2 is less than 90% the arterial oxygen level will be significantly abnormal. Clinical cyanosis may not become apparent until the SpO2 is well below this level. Practical Pointer The BTS and SIGN asthma guideline and the NICE guideline recommend that pulse oximetry should be made widely available in all health care settings for the assessment of acute asthma and COPD.

7.3.2 Oxygen in acute asthma Hypoxia during an acute attack of asthma indicates that the attack is life-threatening. It will require prompt and vigorous treatment. If the patients is:

• cyanosed and/or • the SpO2 is less than 92% or • there are other features of a life-threatening attack (See 8.1.4 on features

of life threatening asthma) Patients should be given high flow rates of oxygen during administration of high dose bronchodilators, whilst awaiting an ambulance and during transit to hospital. (See 8.2 on the management of acute asthma) In life-threatening asthma high flow oxygen is life saving.

Practical Pointer In a patient with known asthma and an acute attack it is safer to err on the side of caution and administer oxygen, if it is available, whilst awaiting an ambulance.

7.3.3 Oxygen in stable COPD Oxygen has been known to improve exercise capacity in COPD for at least 40 years. It has also been known to improve survival of patients with chronic hypoxia for at least 20 years. Despite this oxygen has often been prescribed haphazardly and oxygen prescriptions account for a large proportion of the total prescribing costs for COPD. Changes to oxygen prescribing coming into force in late 2005 are designed to address these shortcomings and ensure that oxygen is prescribed appropriately. From late 2005 patients requiring oxygen will be assessed and managed long-term by a specialist oxygen service. This service will prescribe the most appropriate oxygen delivery system. Oxygen equipment will be supplied by a regional contractor and the service will be funded from a unified Primary Care Trust budget. General Practitioners will only be able to prescribe cylinders for short burst oxygen therapy. All other forms of oxygen therapy will be available via the specialist service. Oxygen is used in three ways in stable COPD:

• Long-term oxygen therapy (LTOT) • Ambulatory oxygen therapy • Short –burst oxygen therapy

7.4 Long-term oxygen therapy (LTOT) When used for 15 hours a day or more LTOT improves survival in patients with chronic hypoxia [MRC 1981, NOTT 1980]. Other benefits for patients and the health service include:

• Improved exercise tolerance • Improved appetite and general well-being • Reduced ankle oedema • Reduced hospital admissions

Assessment for LTOT should be considered in all patients with:

• An FEV1 less than 30% predicted value • Cyanosis • Polycythaemia • Peripheral oedema • Raised jugular venous pressure • Oxygen saturations of 92% or less at rest and in a stable condition.

Patients with less severe COPD (FEV1 30-49% predicted) may also benefit if they have any of the above features of chronic hypoxia and cor pulmonale. Practical Pointer The NICE guideline recommends the routine measurement of oxygen saturation with a pulse oximeter in all patients with an FEV1 of less than 50% predicted as part of a routine review. This will ensure that all patients who might benefit from LTOT are identified at an early stage. A saturation of less than 92% should prompt referral for specialist assessment and arterial blood gases [NICE 2004].

7.4.1 Assessment for LTOT Patients should be assessed during a stable period, at least four weeks after an exacerbation, and should be on optimal medical management. The current criteria for LTOT are based on arterial blood gases:

• PaO2 less than 7.3kPa, or • PaO2 between 7.3 and 8kPa and one or more of:

o Secondary polycythaemia o Nocturnal hypoxia (oxygen saturation less than 90% for more than

30% of the time) o Peripheral oedema o Pulmonary hypertension [NICE 2004, RCP 1999]

Arterial blood gases should be assessed on 2 occasions, at least 3 weeks apart. Ideally patients should have stopped smoking although this is not an absolute contraindication to the use of LTOT. However smoking does create a significant fire and explosion hazard in the presence of oxygen. Practical Pointer Patients on LTOT must use oxygen for at least 15 hours a day in order to benefit. The greater the number of hours of oxygen used the greater the improvement in life expectancy. Once on LTOT, patients should be reviewed by the specialist service at least annually to ensure that their oxygen needs are being met.

7.4.2 Advice for patients on LTOT Patients and carers of patients on LTOT need to be able to recognise the symptoms of worsening respiratory failure:

• Increasing drowsiness • Mental confusion • Headache.

Patients with chronic hypoxia may be dependant on a degree of hypoxia to drive their respiration (hypoxic respiratory drive). Too high a flow rate of oxygen will depress their respiratory drive, but too low a flow will fail to correct their hypoxia. The optimum flow rate of oxygen needs therefore to be determined by a specialist. Practical Pointer Patients and carers need clear advice on when to call a doctor in the event of worsening respiratory failure. They need to understand the dangers of increasing the oxygen flow rate.

7.4.3 Ambulatory oxygen therapy Ambulatory oxygen is used for:

• Patients on LTOT who regularly leave their homes and are motivated to use a portable system.

• Improving exercise tolerance in those COPD patients who experience drops in oxygen saturation during exercise, but are not significantly hypoxic at rest.

Ambulatory oxygen is not recommended if:

• The patient is not hypoxic at rest or • If the oxygen saturation does not drop with exercise.

7.4.4 Short-burst oxygen therapy Short-burst oxygen is widely prescribed and is one of the most expensive therapies for COPD. Evidence for the benefit of oxygen used in this way and clear evidence–based criteria for its prescription are lacking. Under the new arrangements for oxygen prescribing this is the only oxygen therapy that general practitioners are able to prescribe. It is generally given to relieve distressing breathlessness and improve exercise capacity. Short-burst oxygen therapy should:

• Only be considered for patients who experience distressing breathlessness not relieved by other therapies

• Only be continued if there is a documented improvement in breathlessness with its use. [NICE 2004].

Practical Pointer Before short-burst oxygen is prescribed it is worth considering whether the patient may fit the criteria for long-term oxygen therapy. Referral for specialist assessment may be appropriate.

7.5 Oxygen delivery systems Under the new oxygen prescribing arrangements all the following delivery systems should be available and the system most suitable for each individual patient will be prescribed:

• Oxygen concentrators • F sized cylinders for domiciliary use • PD, DD and CD cylinders for portable and short-term use • Small portable cylinders • Oxygen conserving devices and • Liquid oxygen

7.5.1 Oxygen during exacerbations of COPD During exacerbations patients become increasingly breathless and this is often associated with hypoxia. Oxygen is commonly given to relieve breathlessness and increase the SpO2, with the aim of avoiding life threatening hypoxia. However, caution needs to be exercised. If too high a flow rate of oxygen is given to patients who are reliant on a hypoxic respiratory drive, they will develop:

• Increasing hypercapnia (raised CO2) • Worsening respiratory acidosis and • Respiratory failure.

Too high a flow rate of oxygen can produce:

• Suppression of respiratory drive • Carbon dioxide narcosis and • Respiratory arrest.

The NICE guideline recommends that:

• SpO2 should be measured • If necessary oxygen should be given to increase the SpO2 to between

90% and 93% • Oxygen should be commenced at 40% • Oxygen flow should be titrated upward if the SpO2 is less than 90% • Oxygen flow should be titrated downward if the SpO2 exceeds 93 - 94% or

the patient becomes drowsy. Practical Pointer When pulse oximetry is not available it is advised that oxygen should still be given to breathless COPD patients. Careful observation of the patient is necessary. Should they become drowsy oxygen flow rates should be decreased.

7.5.2 Masks and nasal cannulae Oxygen masks are of two basic types:

• Fixed percentage • Variable performance.

As their name suggests, fixed percentage marks will deliver an accurate percentage of oxygen to the patient regardless of their respiratory rate and effort. These masks are preferable during exacerbations of COPD and the flow rate of oxygen recommended for each mask must be adhered to. Variable performance masks are appropriate for delivering high flow oxygen to the patient with a life threatening asthma attack. Delivery of oxygen via nasal cannulae is dependent on the patient’s respiratory rate and the flow rate from the oxygen source. They are less obtrusive, more convenient and more suitable for LTOT. Nasal cannulae are not suitable for COPD patients during an exacerbation as the exact percentage of oxygen delivered is less exact.

7.6 Asthma Review All patients with asthma should have their asthma reviewed at least annually. More frequent review will be necessary in the following circumstances:

• Severe asthma • Patients requiring high levels of therapy e.g. high doses of inhaled steroids • Recent changes to asthma treatment; in order to ensure achievement or

maintenance of good asthma control • After a worsening of symptoms or an asthma attack • If the patients’ asthma action plan is not helping them to control their

symptoms Children should be seen more frequently, at least every six months, and their growth should be monitored to identify any systemic effects or a worsening of asthma control. Practical Pointer An asthma review in the last 15 months is a quality indicator in the GP contract.

7.6.1 What happens at an asthma review? The following three questions are helpful to identify asthma control:

1. Have you had difficulty sleeping because of your asthma? 2. Have you had your usual asthma symptoms during the day (cough,

wheeze, chest tightness or breathlessness)? 3. Has your asthma interfered with your usual activities (e.g. housework or

work)?

If the patient answers ‘Yes’ to any of these questions, their asthma treatment should be reviewed. These questions are known as the Royal College of Physicians (RCP) 3 questions.

7.6.2 Inhaler technique Inhaler technique should be checked and corrected if necessary. If inhaler technique is still poor despite tuition, a change of device should be considered.

7.6.3 Quality of life Ask patients how their asthma affects them? What does it stop them from doing? Don’t forget to ask about exercise symptoms Ask patients if they have any concerns or questions. Practical Pointer Always consider what lifestyle issues are important to the patient; not just what the asthma symptoms are, but the impact they have on the patient’s ability to lead a normal life.

7.7 Allergic rhinitis Ask about seasonal allergic rhinitis (hay fever) and how it affects them. Check patients are on appropriate non-sedating antihistamines and advise accordingly. The international rhinitis guidelines, Allergic rhinitis and its impact on asthma initiative (ARIA) (2001) are summarised in Figure 5 below.

Moderate/severe

Oral or nasal H1 blocker*+/- decongestantIntranasal corticosteroid*Intranasal cromone*

Stepwise allergic rhinitis treatment

MildOral or nasal H1

blocker*+/- decongestant

Intermittent symptoms Persistent symptoms

Moderate/ severe

Intranasal steroid

Mild

* Not in preferred order Review 2-4 weeksImproved? Continue 1 month

Failure?

Itch?Add H1 blocker

Rhinorrhoea?Add anticholinergic

Increasenasal steroid?

Blockage?• Decongestant• Short course oral steroid• Referral

Allergen avoidance

Figure 5. Rhinitis Treatment Guidelines (ARIA 2001). Practical Pointer Allergic rhinitis is part of the atopic spectrum and may co-exist with asthma. Poorly controlled rhinitis may impact adversely on a patient’s asthma control.

7.8 COPD review The NICE guideline recommends that patients with COPD should be reviewed every 6 months or annually depending on the severity of their disease. There is a discrepancy between the guideline and the GP contract. Practical Pointer A COPD review in the last 15 months is a quality indicator in the GP contract.

7.8.1 What happens at a COPD review? Mild and moderate COPD (FEV1 30-80% predicted):

• Ask how adequately therapy is controlling symptoms and assess the effects of each therapy. Consider intensifying therapy if this is inadequate

• Ask about exercise tolerance – is this worsening? • Assess whether the patient considers himself functionally disabled and, if

so consider referral for pulmonary rehabilitation

• Ask about the frequency of exacerbations and consider intensifying therapy if there have been more than 2 exacerbations in the previous 12 months

• Consider whether the patient needs referral for a specialist opinion or specialist therapy services

• Assess smoking status and desire to quit • Measure the FEV1 and FVC, calculate the BMI and record the MRC

dyspnoea score. See Table 34. Severe COPD (FEV1 less than 30% predicted) As well as reviewing the same areas as for mild and moderate COPD:

• Ask about the signs of cor pulmonale – cyanosis, ankle oedema • Assess the patient’s nutritional state – ask about weight loss or gain • Assess the psychological state. Are they anxious or depressed? • Consider whether the patient needs Social Service or Occupational

Therapy Services • Measure the FEV1 and FVC, the BMI and oxygen saturation and record

the MRC Dyspnoea Score. Table 32. The MRC Dyspnoea Score

1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying on the level or walking up a slight hill 3 Walks slower than people of the same age on the level because of

breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100 metres or after a few minutes on

the level 5 Too breathless to leave the house or breathless when dressing or

undressing

7.9 Smoking If the patient is a smoker, always ask if they have thought about stopping and offer advice and support. Always bring up the subject because this may be the time when they are thinking of stopping and advice and support from you can be effective in helping them to successfully stop. (See section 4.3 on smoking cessation) Practical Pointer Smoking cessation advice in the last 15 months is a quality indicator of the GP contract.

7.10 Flu vaccination Flu vaccinations are recommended for adults with asthma and COPD. In children flu vaccinations are helpful for those with severe asthma. Practical Pointer Flu vaccinations for children age 16 and over with asthma and for patients with COPD are quality indicators of the GP contract.

8. Exacerbations of asthma and COPD Management of exacerbations of asthma and COPD require very different approaches.

8.1 Asthma Worsening asthma or an acute asthma attack is regarded as a failure of asthma management. Worsening asthma occurs for many reasons. These reasons include:

• Poor adherence to medication • Inadequate medication • Inappropriate medication e.g. no inhaled steroid, antibiotics etc. • Seasonal triggers e.g. pollen • Other new triggers • Exercise triggers • Viral infections

8.1.1 Asthma deaths Deaths still occur because of asthma but fortunately they are a rare occasion. They occur because there is:

• Lack of appreciation of severity by the patient • Lack of appreciation of severity by the health professional • Under use of corticosteroids.

Practical Pointer Objective measures of worsening and acute asthma are valuable because improvement in the patient’s condition can be monitored.

8.1.2 Symptoms of worsening asthma Increased asthma symptoms are often an early warning that asthma is going out of control. These are sometimes ignored and the early warning signs progress towards an acute attack.

8.1.3 Early warning signs and symptoms include: • Increasing respiratory symptoms e.g. wheeze, cough, breathlessness and

shortness of breath • Increased nocturnal symptoms • Increased exertional symptoms

• B2 agonist medicines less effective than usual • B2 agonist inhalers used more frequently than usual and • Fluctuating peak flow readings.

8.1.4 Signs and symptoms of life threatening asthma • Silent chest • Difficulty completing a sentence • Difficulty talking • Use of accessory intercostals muscles, abdominal muscles to aid

breathing • Tracheal ‘tug’ in children

8.1.5 Signs of moderate and severe asthma

Pulse rate Moderate Severe 2-5 years 130 or less More than 130 More than 5 years 120 or less More than 120 Adults Less than 110 110 or more

Respiratory rate Moderate Severe 2-5 years 50 or less More than 50 More than 5 30 or less More than 30 Adults Less than 25 25 or more Peak flow best or predicted

Moderate Acute severe Life threatening

2-5 years Not appropriate More than 5 50% or more Less than 50% Less than 33% Adults More than 50% 33-50% Less than 33% Practical Pointer A peak flow meter is essential to obtain an objective measure of asthma severity in acute asthma.

8.2 Managing the acute asthma attack

8.2.1 Bronchodilators High doses of bronchodilator (salbutamol or terbutaline) via a holding spacer device are as effective as a nebuliser. In acute asthma, bronchodilator treatment should be administered as follows:

• In children 1 puff x 10 times –use a spacer (and face mask as required) • In adults 1 puff x 10-20 times

It is important to: • Assess response to bronchodilator treatment after 15 minutes i.e. pulse,

respiratory rate and PEF where appropriate and • Always remain with the patient during this time.

8.2.2 Poor response to high doses of bronchodilator • If the patient is deteriorating or there are concerns call the emergency

services immediately by dialling 999 • Repeat bronchodilator treatment whilst waiting for the ambulance • Administer oxygen if it is available.

8.2.3 Response to high doses of bronchodilator • Continue with regular bronchodilators as needed • Course of oral corticosteroids essential which should be commenced

immediately or as soon as possible. Practical Pointer High doses of a short acting bronchodilator via a spacer device are as effective as a bronchodilator via a nebuliser.

8.2.4 Oral corticosteroids in acute asthma Age Dose Time 2-5 years 20mg for up to 3 days 5 years and over 30-40mg for up to 3 days Adults

40-50mg

at least 5 days or until better

Practical Pointer Oral steroids are essential in acute asthma to re-gain rapid control and prevent asthma death. Always provide clear instructions to patients/carers about starting oral steroids. They should be started immediately or as soon as possible.

8.2.5 Under 2’s Viral infections are a common trigger of wheeze in young children and the diagnosis of asthma is not always easy to confirm. In the under 2’s:

• Viral infections trigger audible wheeze and • Accessory muscles are used to aid breathing • Feeding may still be possible • They may or may not be distressed.

8.5.6 Treatment in the under 2’s • High doses of bronchodilator – up to 10 puffs - via a spacer device and

mask 1-4 hourly as required. • Soluble prednisolone 10mg for 3 days.

If the child does not respond to initial bronchodilator treatment or is getting worse, call the emergency services immediately. Practical Pointer Acute wheezing and coughing is not always due to asthma.

8.5.7 Follow Up Follow up is essential after an acute asthma attack to ensure the patient has recovered and their asthma is under control. It provides an opportunity to:

• Review why asthma control deteriorated • Identify whether there are new asthma triggers • Check inhaler technique - amend or change inhaler device if necessary • Review current asthma medication • Check asthma knowledge and provide information where necessary • Review or provide a written action plan and ensure the patient knows what

to do if their asthma deteriorates. Practical Pointer Most asthma deaths are preventable An asthma attack is a failure of good asthma management

8.6 COPD As COPD progresses, exacerbations become more frequent and more severe. Frequent exacerbations are associated with worsening prognosis and declining quality of life. They are a major cause of health service utilisation and hospital admission. The causes of exacerbations of COPD include:

• Infections: o Viruses – rhinovirus (common cold), influenza, parainfluenza,

coronavirus, adenovirus, respiratory syncitial virus (RSV) o Bacteria – C. pneumoniae, H. influenzae, S. pneumoniae, M.

catarrhalis, Staph. aureus and P. aeruginosa • Pollution:

o Nitrogen dioxide o Particulates o Sulphur dioxide o Ozone

In 30% of cases the cause cannot be identified.

8.6.1 Symptoms of an exacerbation of COPD COPD exacerbations are defined in terms of symptoms: “a sustained worsening of the patient’s symptoms from his or her usual stable state that is beyond normal day-to-day variations, and is acute in onset.” Commonly reported symptoms include:

• Worsening breathlessness • Cough • Increased sputum production • Change in sputum colour.

Other symptoms include:

• Upper airway symptoms such as sore throats and runny nose • Wheeze and chest tightness • Fatigue • Fluid retention • Acute confusion.

8.6.2 Symptoms of a severe exacerbation of COPD The following signs indicate a severe exacerbation:

• Marked breathlessness, causing a marked reduction in normal activity • Increased respiratory rate • Purse lip breathing – unless this is habitual for this patient • Use of accessory muscles of respiration at rest • Acute confusion • New onset of cyanosis • New onset of peripheral oedema.

The decision to admit a patient with an exacerbation of COPD is complex and involves consideration of a variety of social as well as clinical factors. Table 33. The more factors suggesting the need for admission the more likely the patient will need to be managed in hospital. Clinical Factors Admit to hospital Treat at home Level of breathlessness Severe Mild Worsening oedema Yes No Cyanosis Yes No Level of consciousness Impaired Normal General condition Poor or

deteriorating Good

Rapid rate of onset Yes No Significant co-morbid disease e.g. diabetes, Yes No

cardiovascular disease Acute confusion Yes No Already on oxygen therapy Yes No Table 33. Factors affecting the decision to admit a patient to hospital during an exacerbation. Social Factors Admit to hospital Treat at home Able to cope at home Yes No Social circumstances Poor/lives alone Good In some areas ‘hospital at home’ and ‘supported early discharge’ schemes enable patients with exacerbations of COPD to be safely managed in their own homes or to be discharged after a short stay in hospital. Such schemes are often nurse led and are generally cost effective and well received by patients and their relatives.

8.6.3 Differential diagnosis Other conditions can present with similar symptoms and can co-exist with COPD:

• Pneumonia • Pneumothorax • Cardiac failure • Pulmonary embolus • Lung cancer

Practical Pointer Chest pain, fever, a very rapid onset of worsening breathlessness or failure to respond to therapy should raise the possibility of an alternative cause for the patient’s symptoms.

8.7 Managing exacerbations of COPD

8.7.1 Bronchodilators Increased breathlessness is a common feature of an exacerbation. The first line of therapy for this symptom is inhaled short acting bronchodilators. Most patients will require increased doses of their usual bronchodilator or will need to take it on a regular basis. The delivery system needed generally reflects the dose of bronchodilator required. Multiple dosing from a hand held inhaler (particularly pMDI and volume spacer) is as effective as a nebuliser. However, some patients with severe breathlessness may find nebulised therapy easier during the acute stage.

Practical Pointer If a nebuliser is necessary during an exacerbation the patient should be changed back to their usual hand held inhaler as soon as their condition has stabilised. During an exacerbation patients with COPD may develop respiratory failure. In these circumstances the high flow rate of oxygen required to power a nebuliser can increase hypercapnia and worsen respiratory acidosis. In the community setting nebulisers must be driven with compressed air, not oxygen. In the hospital setting the driving gas must be prescribed by the physician, dependant on the arterial blood gas results.

8.7.2 Oral corticosteroids Short courses of oral corticosteroids are indicated for:

• All patients admitted to hospital for an exacerbation • Community based patients whose increased breathlessness interferes

with their normal daily activities. 30mg prednisolone for 7-14 days is recommended. There is no additional benefit from prolonged courses. Some patients who suffer frequent exacerbations benefit from keeping a course of oral steroids at home so that they can initiate treatment promptly.

8.7.3 Antibiotics Antibiotics should be used if the sputum has become purulent. Initial antibiotic therapy is prescribed empirically and should take account of local microbiologist’s guidelines. Commonly used antibiotics include:

• Aminopenicillins • Macrolides • Tetracyclines.

The British National Formulary (www.bnf.org) contains doses and indications for antibiotic use. Previous reactions to antibiotics or known allergies should be identified, as well as cross sensitivities. Antibiotics are not usually needed if the sputum is not purulent, unless:

• There are clinical signs of pneumonia, or • There are signs of consolidation on the chest X-ray

Patients admitted to hospital should have sputum samples taken and antibiotic therapy reviewed when the results of sputum culture and sensitivities are available.

Practical Pointer COPD patients who experience frequent exacerbation may benefit from keeping a course of antibiotics and/or oral corticosteroids at home to enable them to initiate therapy promptly.

9. Management issues

9.1 Adherence to treatment Many patients with asthma do not take their medicines as prescribed. There are many reasons for this. It may be due to:

• Practical difficulties e.g. can’t use the inhaler, can’t get to the surgery or pharmacy for repeat prescriptions

• Forgetfulness, or life style not conducive to regular therapy e.g. adolescence

• Not understanding what the different treatments do • Getting inhalers muddled up • Poor understanding of prescribed treatment and what to expect from it e.g.

disappointed at the poor response to inhaled corticosteroids because it does not provide immediate relief of symptoms

• Denial or disbelief of the diagnosis • Belief that treatment is no longer needed • A lack of symptoms resulting in cessation of preventer treatment if

prescribed • Running out of asthma or COPD medicines • Concerns about side effects • Preferring to rely on the immediate symptom relief obtained from a short

acting beta2 agonist • Concerns about the financial cost of regular treatment.

Adherence to treatment in COPD is thought to be less problematic than in asthma. Patients are generally more symptomatic and less likely not to take treatment. However, there are some barriers to adherence that may need to be considered:

• Cognitive deficit e.g. early dementia or chronic hypoxia may interfere with patients’ ability to remember to take treatment

• Practical difficulties with inhalers e.g. many elderly patients are unable to use pressurised metered dose inhalers (pMDIs) effectively without a spacing device; they may have dexterity problems if they have arthritis or poor sight

• Concerns about side effects or becoming ‘dependent’ on drugs The Medicines Partnership is an initiative supported by the Department of Health, aimed at helping patients to get the most out of medicines. Patients are involved as partners in treatment decisions to support them in taking their medicine. http://www.medicines-partnership.org/

9.2 Asthma Education What patients need to know? All patients with asthma need to know:

• What asthma is? • What their asthma medicines do? • Why they need to preventer treatment regularly? • How to monitor their asthma? • What to look for in worsening and acute asthma? • What they can do to treat worsening or acute asthma? • When to seek help? • How often they should be seen? • Who to contact for advice?

Asthma UK has an excellent range of booklets and information on asthma. They are available from Asthma UK or from their web site http://www.asthma.org.ukIt includes:

• Peak flow diaries • Asthma action plans • Asthma medicine cards • Making the most of your asthma review.

In addition Asthma UK has an advice line with immediate access to 150 different languages. This means that conversation can be had with an asthma specialist nurse through an interpreter. Frequently asked questions are also posted on the Asthma UK web site which is translated into many of the commonly spoken languages in the UK.

9.3 Asthma action plans Involving the patient in the planning of their care is important because they need to understand that asthma can be controlled by the right asthma medicines. All patients with asthma need an asthma action plan as a reminder of what their asthma treatment is. The action plan can be:

• Peak flow or • Symptom based

Symptom management has been shown to be more effective in day to day asthma management because of the difficulties in remembering to use the peak flow meter. Patients with more difficult or severe asthma benefit from having a peak flow meter because:

• Their perception of disease severity may alter. This is because they may be frequently breathlessness or wheezy and increasing asthma severity may not be recognised or ignored.

Other reasons for a patient with chronic asthma to have their own peak flow meter include:

• Previous hospital admissions due to asthma • Frequent courses of oral corticosteroids, • Maintenance oral corticosteroids.

9.4 Trigger avoidance If the patient identifies a specific asthma trigger it can sometimes be avoided e.g. smoky atmospheres. If the patient is atopic it is likely they are allergic to many triggers and avoiding specific triggers is not always possible. Dust mite bed covers have not been shown to improve lung function in adult asthma patients but may improve symptoms. Exercise triggers can be prevented or reduced by pre-treatment with a short acting beta2 agonist bronchodilator.

9.5 COPD Education What patients need to know All patients with COPD need to understand:

• What COPD is • How to use their medication • How to live as healthy and active a life as possible for as long as possible • How to recognise worsening COPD • What they can do to treat worsening COPD • When to seek help and who to contact • How often they should be seen

The British Lung Foundation produces useful leaflets and resources for patients with COPD. In addition they run a telephone advice line for patients and the development of local self-help groups; ‘Breathe Easy’ http://www.lunguk.org

9.6 Advice for COPD patients • Stopping smoking is the most important thing they can do to help

themselves. It is the only thing that will slow down the rate of disease progression. Offer support with smoking cessation

• Breathlessness is not harmful. Regular, daily exercise to the point of moderate breathlessness is beneficial and will preserve general fitness and functional ability

• Achieving and maintaining a healthy body weight and eating a healthy diet with plenty of fresh fruit and vegetables will help reduce breathlessness on exertion and may help preserve lung function

• Annual flu vaccination is very important. The vaccine is safe and will not make them ill. They should also have Pneumococcal vaccination every 5-10 years.

• If they are experiencing regular breathlessness they should use their bronchodilators regularly. They are safe and there is no benefit in trying to do without them.

9.7 COPD action plans Evidence to support the use of action (self-management) plans in COPD is lacking, and asthma action plans are not appropriate. Until evidence is available the NICE guideline recommends that COPD patients be encouraged to

• Develop an awareness of their usual state • Take prompt action if their usual symptoms worsen; particularly if they

experience a sustained worsening of o breathlessness o cough o sputum or o Increased sputum purulence

Prompt intervention in the course of an exacerbation may shorten its duration and reduce its severity. Some COPD patients are given a course of antibiotics and/or a course of oral steroids to keep at home so that they can initiate treatment promptly. The appropriate use of these medications will need to be monitored. Patients should be advised to:

• Start oral corticosteroids if increased breathlessness interferes with activities of daily living

• Start antibiotics if their sputum becomes purulent • Adjust their bronchodilator therapy to control their symptoms

If oral corticosteroids or antibiotics are started they should let their doctor know as soon as possible.

10. Clinical governance Clinical governance is the system through which National Health Service organisations are accountable for improving the quality of their services and safeguarding high standards of care.

10.1 Audit and record keeping Audit is an essential component of clinical governance. Clinical governance provides an opportunity to question and improve practice. There are a number of things that can be audited. These include:

• Inhaler device checks • Appropriate information leaflets offered to patients e.g. Asthma UK or

British Lung Foundation leaflets • Counselling opportunities • Spotting poor asthma control • Inappropriate requests for cough medicines • Smoking cessation advice • Referral to practice nurse or doctor • Emergency prescriptions for asthma or COPD inhalers • Identifying the number of patients on the different asthma steps • Identifying the number of COPD patients on inhaled steroids • Identifying the number of COPD patients using nebulisers.

10.2 Training Continuing Professional Development (CPD) is essential under the new pharmacy contract. Non-medical prescribing offers opportunities to the pharmacist to become actively involved in long-term conditions. Appropriate training in asthma and COPD and smoking cessation advice are needed if enhanced services are offered under the new contract. Multi-disciplinary training courses are available.

References Asthma UK (2005). Where do we stand? Asthma in the UK today. http://www.asthma.org.uk/about/pdf/wheredowestand.pdf Asthma UK Cymru (2005). A Quarter of a Million Voices – Asthma in Wales today.http://www.asthma.org.uk/about/pdf/quartermillion.pdf Asthma UK Northern Ireland (2005). A Moving Picture - Asthma in Northern Ireland today.http://www.asthma.org.uk/news/pdf/movingpicture.pdf Asthma UK Scotland (2005). Out of Sight, Out of Mind – Asthma in Scotland Today.http://www.asthma.org.uk/about/pdf/outofsight.pdf Boe J, Dennis JH, O’Driscoll BR et al (2001). European Respiratory Society Guidelines on the use of nebulizers. European Respiratory Journal 18; 228-42 British Occupational Health Research Foundation (BOHRF) (2005). Occupational Asthma:Identification, Management and Prevention: Evidence Based Review and Guidelines. Available from: http://www.bohrf.org.uk/content/asthma.htm British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Revised ed. Edinburgh: SIGN; 2005. (SIGN publication no. 63). [cited 31 Oct 2005]. Available from url:http://www.sign.ac.uk/guidelines/fulltext/63/index.html Brocklebank D, Ram F, Wright J et al (2001). Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive pulmonary disease: a systematic review of the literature. Heath Technology Assessment 5; 1-149 Burge PS, Calverly PMA, Jones PW et al (2000). Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease. British Medical Journal 320; 1297-303 Department of Health (2003). Investing in General Practice: the New General Medical Services Contract, Department of Health, London http://www.dh.gov.uk/assetRoot/04/07/19/67/04071967.pdf

Department of Health (2005a). The new contractual framework for community pharmacy. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPAmpGBrowsableDocument/fs/en?CONTENT_ID=4100661&MULTIPAGE_ID=4973313&chk=p3dDJB Department of Health (2005b). Supporting People with Long Term Conditions. An NHS and Social Care Model to support local innovation and integration. Department of Health, London http://www.dh.gov.uk/assetRoot/04/09/98/68/04099868.pdf Gregg I, Nunn AJ (1973).Peak expiratory flow in normal subjects. Br Med J. 4; 3 (5874):282-4. Jones (2001). National Collaborating Centre for Chronic Conditions (NCCCC) (2004). Chronic obstructive pulmonary disease: national clinical guideline on the management of chronic obstructive pulmonary disease in primary and secondary care. Thorax 59 (Suppl 1), 1-232 http://www.nice.org.uk/CG012fullguidelinehttp://www.nice.org.uk/CG012NICEguideline Nunn AJ, Gregg I (1989) New regression equations for predicting peak expiratory flow in adults BMJ; 298: 1068-70 Poole PJ, Black PN (2003). Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease. (Cochrane Review). The Cochrane Library. Update Software; Issue 3, Oxford Van Grunsven PM, van Schayck CP, Derenne JP et al (1999). Long term effects of inhaled corticosteroids in chronic obstructive pulmonary disease: a meta –analysis. Thorax 54; 7-14

Additional information and further reading Non-pharmacological asthma treatment British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Revised ed. Edinburgh: SIGN; 2005. (SIGN publication no. 63). [cited 31 Oct 2005]. Available from url:http://www.sign.ac.uk/guidelines/fulltext/63/index.html Smoking cessation NICE (2002) Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. Technology appraisal guidance No 38. http://www.nice.org.uk/article.asp?a=30631

Raw M, McNeill A, West R (1998) Smoking cessation guidelines for health professionals. Thorax 53(Suppl 5): S1-S38 http://www.brit-

thoracic.org.uk/public_content.asp?pageid+7&catid_368&subcatid+158 West R, McNeill A, Raw M (2000). Smoking cessation guidelines for health professionals: an update. Thorax 55: 987-999 http://www.brit-

thoracic.org.uk/public_content.asp?pageid+7&catid_368&subcatid+158 Pulmonary rehabilitation British Thoracic Society (2001). Pulmonary rehabilitation. Thorax, 56(11): 827- 834. http://www.brit-thoracic.org.uk/docs/Pulmonaryrehab.pdf National Collaborating Centre for Chronic Conditions (2004) Chronic obstructive pulmonary disease: National Clinical Guideline for management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax, 59 (Suppl 1): 1-232. http://www.nice.org.uk/pdf/CG012_niceguideline.pdf

Sources of information

Asthma Asthma UK Summit House 70 Wilson Street London EC2A 2DB Telephone: 020 7786 4900 Fax: 020 7256 6075 Asthma UK Adviceline Telephone: 08457 01 02 03 http:www.asthma.org.uk Asthma UK Scotland 2a North Charlotte Street Edinburgh EH2 4HR Telephone: 0131 226 2544 Fax: 01 31 226 2401

Guidelines BTS/SIGN Asthma guidelines British Thoracic Society http://www.brit-thoracic.org.uk Scottish Intercollegiate Guideline Network http://www.sign.ac.uk COPD guidelines http://thorax.bmjjournals.com/content/vol59/suppl_1/ http://thorax.bmjjournals.co,/content/vol59/suppl_1 Nebuliser guidelines British Thoracic Society (1997) Current best practice for nebuliser treatment. Thorax 52 (Suppl 2), S1-S106 http://www.brit- thoracic.org.uk/guideline_since_1997.html/cqs/dlfsa.list/dlcpti.128 Boe J, Dennis JH, O’Driscoll BR, Bauer TT. Carone M, Dautzenberg B et al (2001). European Respiratory Society Guidelines on the use of nebulizers. European Respiratory Journal 18, 228-42 NICE inhaler guidelines Inhaler device guidelines for the Under 5’s and 5-15 year olds http://www.NICE.org.uk Occupational asthma guidelines Information for health professionals, employers and employees. British Occupational Health Research Foundation. http://www.bohrf.org.uk

Oxygen Medical Research Council (1981). Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1, 681-686 Nocturnal Oxygen Therapy Trial (NOTT) Group (1980). Continuous or nocturnal oxygen therapy in hypoxaemic chronic obstructive lung disease. A clinical trial. Annals of Internal Medicine 93, 391-398

Royal College of Physicians (1999). Domiciliary oxygen therapy services: clinical guidelines and advice for prescribers. Royal College of Physicians. London

Patient organisations

Asthma, COPD and other lung disease British Lung Foundation 73-75 Goswell Road London EC1V 7ER Tel: 020 7688 5555 Fax: 020 7688 5556 Email: enquiries@blf-uk.org Northern Ireland Chest, Heart and Stroke 22 Great Victoria Street Belfast BT2 7LX Tel: +44 (0)28 9032 0184 Fax: +44 (0)28 9033 3487 Advice Helpline: 084 5769 7299 Chest, Heart and Stroke Scotland Head Office 65 North Castle Street Edinburgh EH2 3LT Telephone: (0131) 225 6963 Fax: (0131) 220 6313 E-mail: admin@chss.org.uk

Other Patient organisations & information Allergy Allergy UK No 3 White Oak Square London Road Swanley, Kent. BR8 7AG http://www.allergyuk.org

Anaphylaxis: Anaphylaxis Campaign, PO Box 275, Farnborough, Hampshire GU14 6SX. Anaphylaxis Help Line Tel no: 01252 542029 http://www.anaphylaxis.org.uk/home.html Eczema

Hill House, Highgate Hill, London, N19 5NA Tel: 020 7281 3553 Fax 020 7281 6395 Eczema Help Line: 0870 241 3604 http://www.eczema.org Medic Alert 1 Bridge Wharf 156 Caledonian Road London N1 9UU Freephone: 0800 581420 Tel: 020 7833 3034 Fax: 020 7278 0647 Email:info@medicalert.org.uk http://www.medicalert.org.uk National Osteoporosis Society http://www.nos.org.uk/

Drug information: British National Formulary http://www.bnf.org

Medicines Management Partnership http://www.medicines-partnership.org/

Pollen information The National Pollen and Aerobiology Research Unit http://www.pollenuk.co.uk/aero/pm/PM2.html

Smoking information Useful web sites for people who want more information on smoking cessation http://www.givingupsmoking.co.uk/http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Tobacco/fs/enhttp://www.ash.org.uk/html/factsheets/html/fact11.html

Professional Organisations

Respiratory training for health professionals Education for Health (Incorporating National Respiratory Training Centre and Heartsave) The Athenaeum 10 Church Street Warwick CV34 4AB Tel: +44 (0) 1926 493313 Fax: +44 (0) 1926 493224 Information available from: http://educationforhealth.org.ukE mail: enquiries@educationforhealth.org.uk

Training in spirometry Available from: Education for Health Information available from: http://educationforhealth.org.ukE Mail: enquiries@educationforhealth.org.uk General Practice Airways Group (GPIAG) is a professional organisation for Primary Care health professionals with a specific interest in respiratory disease: http://www.gpiag.org AirwaysExtra Airways Extra is a collaboration between the Education for Health and Asthma UK. Subscription includes a quarterly journal called Airways. Contact: Sally Atkinson - Scheme ManagerEducation for Health The Athenaeum 10 Church Street Warwick CV34 4AB Tel: +44 (0) 1926 838978 Fax: +44 (0) 1926 493224E mail: http://www.airwaysExtra.org.uk

Manufacturers of Asthma and COPD drugs and inhaler devices Manufacturer Address Contact details Inhaler device/

tablets Altana Pharma Ltd

Three Globeside Business Park Fieldhouse Lane Marlow Bucks SL7 1HZ

Tel: 01628 646 400 Fax: 01628 646 401

Metered dose inhaler

AstraZeneca UK Ltd

Horizon Place 600 Capability Green Luton Bedfordshire LU1 3LU

Tel: 0800 7830 033 Fax: 01582 838 003

Turbohaler Metered dose inhaler Nebuhaler Nebuchamber Accolate Tablets

Aventis Pharma (includes Rhône-Poulenc Rorer)

RPR House 50 Kings Hill Avenue West Malling Kent ME19 4AH

Tel: 01732 584 000 Fax:01732 584 080

Spinhaler Metered dose inhaler

Syncroner

Boehringer Ingelheim

Ellesfield Ave Bracknell Berkshire RG12 8YS

Tel: 01344 424600 Fax: 01344 741444

Metered dose inhaler HandiHaler Nebuliser solution

GlaxoSmithKline Stockley Park West Uxbridge Middlesex UB11 1BT

Tel: 0800 221 441 Fax: 0800 8900 4328

Metered dose inhaler Diskhaler Accuhaler Volumatic Babyhaler

3M Health Care Ltd

3M House Morley Street Loughborough Leics LE11 1EP

Tel: 01509 611611 Fax: 01509 237288

Metered dose inhaler Autohaler

Ivax Pharmaceuticals UK Ltd. (now Teva)

Ivax Quay Albert Basin Royal Docks London E16 2QJ

Tel: 08705 020304 Fax: 08705 323334

Easi-breathe Autohaler Metered Dose Inhaler

Medeva Pharma Limited

Medeva House Regent Park Kingston Road Leatherhead Surrey KT22 7PQ

Tel: 01372 364000 Clickhaler

Merck Sharp & Dohme Ltd (MSD)

Hertford Road Hoddesdon EN11 9BU

Tel: 01992 467272 Fax: 01992 451066

Montelukast tablets

Ranbaxy (UK) Ltd 6th Floor

CP House 97-107 Uxbridge Road Ealing London W5 5TL

Tel: 020 8280 1600 Fax: 020 8280 1616

Easyhaler

Schering-Plough Ltd Shire Park Welwyn Garden City Herts AL7 1TW

Tel: 01707 363 636 Fax: 01707 363 763

Twisthaler

Trudell Medical International

Biocity Nottingham Pennyfoot Street Nottingham NG1 1GF

Tel: 0115 912 4380 Fax: 0115 912 4289

Aerochamber Plus

Viatris Pharmaceuticals Ltd – (now Meda)

Building 2000 Beach Drive Cambridge Research Park Waterbeach Cambridge CB5 9PD

Tel: 01223 205 999 Fax: 01223 205 998

Novolizer

Trinity-ChiesiPharmaceuticals

Cheadle Royal Business Park Highfield Cheadle SK8 3GY

Tel: 0161 488 5555 Fax: 0161 488 5566

Pulvinal

Manufacturers of Peak Flow meters Manufacturer Address Contact details PEF meter Clement Clarke International Ltd

Edinburgh way Harlow Essex CM20 2TT

Tel: 01279 414 969 Fax: 01279 456 304

Mini-Wright

Ferraris Medical Ltd

4 Harforde Court John Tate Road Hertford Herts SG13 7NW

Tel:01992 526 300 Fax: 01992 526 320

Ferraris

Micro Medical Ltd PO Box 6 Rochester Kent ME1 2AZ

Tel: 01634 893500 Fax: 01634 893600

Micro Medical

Vitalograph Ltd Maids Moreton Buckingham MK18 1SW

Tel: 01280 827 110 Fax: 01280 823 302

Vitalograph

Manufacturers of Spirometers Clement Clarke International Ltd

Edinburgh way Harlow Essex CM20 2TT

Tel: 01279 414 969 Fax: 01279 456 304

Ferraris Medical Ltd 4 Harforde Court John Tate Road Hertford Herts SG13 7NW

Tel:01992 526 300 Fax: 01992 526 320

Micro Medical Ltd PO Box 6 Rochester Kent ME1 2AZ

Tel: 01634 893500 Fax: 01634 893600

Vitalograph Ltd Maids Moreton Buckingham MK18 1SW

Tel: 01280 827 110 Fax: 01280 823 302

Inter Medical 60 Churchill Square Kings Hill West Malling Kent ME19 4DU

Tel: 01732 522444 Fax: 01732 872883

Appendix 1 Template CMP 1 Blank CMP: for teams that have full co-terminus access to patient records

Name of Patient:

Patient medication sensitivities/allergies:

Patient identification e.g. ID number, date of birth: Independent Prescriber(s):

Supplementary Prescriber(s)

Condition(s) to be treated

Aim of treatment

Medicines that may be prescribed by SP: Preparation

Indication Dose schedule .

Specific indications for referral back to the IP .

Guidelines or protocols supporting Clinical Management Plan: Frequency of review and monitoring by:

Supplementary prescriber Supplementary prescriber and independent prescriber Process for reporting ADRs: Shared record to be used by IP and SP: Agreed by independent prescriber(s)

Date Agreed by supplementary prescriber(s)

Date Date agreed with patient/carer

Appendix 2 Template CMP 2 Blank: for teams where the SP does not have co-terminus access to the medical record

Name of Patient:

Patient medication sensitivities/allergies:

Patient identification e.g. ID number, date of birth: Current medication:

Medical history:

Independent Prescriber(s): Contact details: [tel/email/address]

Supplementary prescriber(s): Contact details: [tel/email/address]

Condition(s) to be treated:

Aim of treatment:

Medicines that my be prescribed by SP: Preparation

Indication

Dose schedule

Specific indications for referral back to the IP

Guidelines or protocols supporting Clinical Management Plan: Frequency of review and monitoring by:

Supplementary prescriber

Supplementary prescriber and independent prescriber

Process for reporting ADRs: Shared record to be used by IP and SP: . Agreed by independent prescriber(s):

Date Agreed by supplementary prescriber(s):

Date Date agreed with patient/carer

Appendix 3 Inhaler devices Device illustrations and instructions to be included here.

Appendix 4 Contact list for asthma and COPD. You may find it helpful to keep a record of key asthma and COPD contacts. Contact name Telephone number/E mail