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Australian Journal of Pharmacy : October 2006
‘There are quite a lot of things that shortness of breath can be due to and I think it is quite a challenge for a phar- macist to have to essentially screen a patient with a few words in a non-private environment with no testing,’ she said. ‘The main things to consider are asthma, smoking-related lung disease and cardiac failure, and then there are the rarer things...if someone has progres- sive shortness of breath it may be due to a lung cancer,’ she said. Dr Reddel said common causes of cough were post-nasal drip following a viral infection, reflux and chest infections. ‘Patients with smoking-related lung disease are more prone to getting chest infections; patients with asthma are more prone to getting chest infections after they have a cold,’ she said. Dr Reddel said triaging medical prob- lems was becoming an increasingly important role for pharmacists. ‘A lot of people will use their pharma- cist as a surrogate GPor as a sort of screen- ing “do I need to go to a GP” service. ‘Pharmacists really serve an extremely important function in the triaging of medical problems. The important thing they do there is make the decision as to whether they should tell the patient that they need to see their GP or to give the patient a short- lived treatment. ‘And generally pharmacists do this really, really well,’ she said. Identifying triggers However, even when the nature of the respiratory disease was evident, the opportunity for a pharmacist to identify problems and provide appropriate advice did not always come easily. Dr Sinthia Bosnic-Anticevic, senior lecturer at the Faculty of Pharmacy, the University of Sydney, said the very nature of asthma meant many sufferers did not consider they needed to seek help when their conditions exacerbated. ‘I don’t know how common it is for people to come in and say to the phar- macist: “my asthma has got worse, what can I do?”,’ Dr Bosnic-Anticevic said. ‘People with asthma are used to having periods where their asthma flares and they are not really used to the pharmacist doing anything other than giving them medication. ‘There are always things we can do but people don’t tend to come into the phar- macy and specifically ask for help with their asthma. So it is up to the pharma- cist to ask them,’ she said. On the other hand, many people with symptoms of GORD or allergic rhinitis, for example, sought the help of a phar- macist. That then opened the door for the pharmacist to ask about asthma and ascertain whether or not these conditions were making their asthma worse, Dr Bosnic-Anticevic said. Risk assessment Dr Bosnic-Anticevic suggested conduct- ing a risk assessment to gain a bigger pic- ture of an asthma patient’s health and wellbeing. ‘While it is great to ask how is your asthma going, that doesn’t always give you much to go with it so we would expect pharmacists to ask direct questions such as: “Have you been needing to use your medication more than usual?”; “Have you been waking up at night?”; “Have you been waking up feeling tighter in the chest?”; or “Have you been find- ing it difficult to exercise?”,’ she said. ‘Then, depending on what the response is, we would expect the phar- macist to probably look at asthma lifestyle interventions first. ‘The first thing you would think of is whether the person is on preventer med- ication and if they aren’t, whether per- haps they should be. ‘Then look at lifestyle to determine if how their asthma is at the moment is characteristic of how it has been over the last six months, or if there is something that has made it worse recently. ‘Do they know what has made it worse? Have they been exposed to any- thing they haven’t usually been? This line of questioning would help to identify whether there were any sorts of triggers, and whether they were new or existing triggers they hadn’t thought about and had become routine. ‘GORD, perhaps would be one of those, although usually it isn’t one of the first triggers you would think about, especially if the patient hasn’t mentioned GORD symptoms,’ Dr Bosnic-Anticevic said. ‘There are other triggers which are more easily identifiable, especially around spring time, when there are lots of pollens around,’ she said. Extreme temperatures also have an impact on the health of respiratory patients, Dr Reddel said. ‘Some people will hate the summer and others will hate the winter; in gen- eral, winter is worse for patients with smoking-related lung disease because they tend to [get] chest infections in the colder months,’ she said. Allergy According to the Australasian Society of Clinical Immunology (ASCI), allergy is one of the major factors associated with the cause and persistence of asthma— around eight in 10 people with asthma have positive allergy results. Dr Bosnic-Anticevic said that if allergy was a problem there was a variety of interventions that pharmacists could start, depending on the trigger. ‘If pollen is identified as the problem a pharmacist could advise staying indoors (when possible) during pollen season and closing windows to prevent pollen blow- ing into the house,’ she said. Many people with asthma also had problems with allergic rhinitis, especially in spring and summer, Dr Bosnic-Antice- vic said. ‘So the pharmacist should also look to see if there’s something they could do for the patient’s nose. ‘These days the standard treatment is low-dose inhaled corticosteroids, using that as well as a normal saline wash in the nose.’ ASCI spokesman Associate Professor Raymond Mullins said untreated allergic rhinitis (inflammation of the mucous membranes that line the nasal passages) could make the symptoms of asthma more difficult to control. The current management options for allergic rhinitis were organised into a step-wise approach from simple strategies for allergen avoidance to pharmacother- apies and immunotherapy. Symptoms occurring mainly in spring and summer were usually triggered by allergy to wind-blown pollen grains from grasses, weeds or trees, he said. THE AUSTRALIAN JOURNAL OF PHARMACY VOL.87 OCTOBER 2006 ? 43