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Australian Journal of Pharmacy : May 2008
Professional feATure | resPirATory cAre are more sensitive to the adverse effects of tobacco smoke than men. ‘The typical COPD patient at the beginning of my career was a 70–75 year old man with advanced emphysema. Now, if you walk into the pulmonary rehabilitation program at Toronto Hospital, 75% of patients are women aged 55 or 60. Women are developing the disease earlier than men. We are dealing with patients who are trying to work through to retirement. We are not dealing with people who are sedentary and already retired. These are people trying to live active lives; they are the baby boomer generation who want to be active.’ Professor Chapman said by the year 2020, COPD would be the third most common cause of death on the planet. That includes all western nations. And increasing prevalence of women with COPD is going to make it a key health issue. ‘We want to give COPD the same prominence as breast cancer. COPD is out there: it is common, it can be lethal. We need to find it early, use comprehensive strategies- comprehensive inhaled therapies that allow people who live with this disease to have a good quality of life. And a longer life.’ According to Professor Chapman an estimated one in seven smokers goes on to develop COPD. ‘This tells us there is a genetic predisposition, or there are other factors. This includes birth weight, socio economic class, probably nutrition and tobacco smoking. But tobacco smoking is only one factor. Around 10% of people who are not smokers go on to develop COPD.’ Pulmonary rehabilitation In addition to smoking cessation, medications and bronchodilator therapy, COPD management should include pulmonary rehabilitation. Pulmonary rehabilitation, like cardiac rehabilitation following a heart attack, is an exercise program The AusTrAliAn journAl of PhArmAcy vol. 89 mAy 2008 44 it would be great to see pharmacy more interactive with patients when they are getting their inhaler designed specifically for COPD patients. The objective is to improve exercise capacity and keep people out of hospital. ‘Pulmonary rehabilitation is very effective and has been shown to reduce hospital admissions between 25 and 50%,’ said Ms Allan. ‘We have many patients who have experienced first hand the benefits of pulmonary rehabilitation. One of these patients found that her COPD had limited her life to such a degree that walking into the kitchen to make a cup of tea was a challenge. After pulmonary rehabilitation she has been able to walk 3km a day. So, it has a huge impact on the quality of life for those with COPD.’ Pulmonary rehabilitation is usually available through hospitals or community health services. According to Mrs Allan, this is because the effectiveness of the program is not widely understood at a primary care level and many programs struggle for funding in the hospital system. ‘Some state governments are starting to recognise the significant benefits of the program. There are now around 200 programs nationally, mainly through hospitals but not exclusively.’ role for Pharmacists Pharmacists may assist COPD patients in self-management by recommending increased use of bronchodilators when they become more symptomatic, said Dr Jenkins. ‘If they do not already have a written action plan, this should be suggested, in addition to keeping a script available for antibiotics and oral steroids. Two-thirds of COPD exacerbations are triggered by respiratory tract infections. Increased sputum volume is an early symptom especially if sputum is coloured.’ Pharmacy could also check inhaler technique to help promote better outcomes. ‘Pharmacy is in a position to take this up vigorously and often this is not happening. The pharmacy assistant is usually not the person to advise the patient on how best to use an inhaler. Older patients often do not use inhalers properly and COPD patients tend to be older. It would be great to see pharmacy more interactive with patients when they are getting their inhalers. Pharmacists probably think it is a GPs role and I would agree with that but many GPs don’t do it unfortunately.’ Dr Jenkins said pharmacists could help identify COPD in people particularly those older than 40 who may be coming into the pharmacy with a productive cough, who smoke, or who were smokers and are breathless. COPD is a likely diagnosis. ‘If the person is repeatedly coming back to the pharmacy for cough mixtures, pharmacists can ask about the duration of the cough and direct patients to a GP. ‘Unfortunately stigma is still attached to COPD. Many people see it as a self-inflicted illness as a result of smoking, although most have given up by the time of diagnosis. This taboo is not helpful to the patient.’ According to Professor Chapman, one frustration in asthma for a long time is that a vast majority of