HHE Respiratory 2019 | Page 17

to this and medicines optimisation incorporating the patient’s perceptions and practicalities of living with the disease and how this impacts medicine-taking behaviour 16,17 • Inhalers – device best suited to patient, appropriate for inspiratory flow, coordination, dexterity etc – technique checked and corrected by appropriately trained HCPs, ensuring maximal lung deposition (further assisted by use of a spacer device with metered dose inhalers (MDIs)). Use of combination inhalers to minimise polypharmacy 2,16,17 • Empowerment and education for patients and HCPs (including co-created self-management plans, strategies for managing exacerbations and escalating therapy) safety-netting/signposting to support groups, digital solutions and further reliable information sources for example, from the British Lung Foundation • Air pollution (indoor and outdoor) – impact to patient • Environmental impact – waste/recycling, carbon footprint and ozone damage by hydrofluoroalkane propellants in MDIs • Passive smoke – other members of the household who smoke might impact on the patient’s health (including eligibility for oxygen) and could benefit from smoking cessation interventions • Multi-morbidity and frailty – effect of this on functionality of the patient, including increased likelihood of polypharmacy and potential non-adherence to therapies 18 • Palliation – early discussions with patient and referral for palliative input. 19 asthmatic features should have an ICS in combination with a LABA) • Smoking cessation can benefit most diseases and should be offered as a ‘treatment’. 10 Studies in the UK and overseas have demonstrated that behavioural support plus access to pharmacotherapy is effective in helping smokers to quit. Regular meetings (group or one to one) with a trained adviser using structured, withdrawal-oriented behavioural therapy combined with smoking cessation medications such as nicotine replacement therapy (NRT), bupropion or varenicline 11,12 • Vaccination – Annual flu and five-yearly pneumococcal vaccinations to minimise incidence of respiratory infections 2,13 • Mucolytic drug trial (anecdotally 4–6 weeks) could be considered for chronic productive cough but should be stopped if not beneficial and used with caution in those with peptic ulceration history 2,14 • Oral theophyllines may be beneficial in patients who remain breathless despite trialling inhaled therapy or for those who cannot use inhaled therapy (noting potential for interactions and requirement for plasma monitoring) • Roflumilast (phosphodiesterase IV inhibitor) can be used as adjunctive therapy in patients with severe COPD associated with chronic bronchitis and frequent exacerbations • Oxygen – assessment for long term/ambulatory oxygen therapy in non-smokers with more severe chronic hypoxaemia (assessing risks to patient and others of prescribing). Supplemental oxygen should be used >15 hours a day; long-term oxygen therapy is not effective for isolated nocturnal hypoxaemia caused by COPD • Prophylactic azithromycin may reduce exacerbations in non-smokers who have had all other interventions optimised yet continue to have >1 of the following: frequent exacerbations (typically >4 per year) with sputum production, prolonged exacerbations with sputum production or exacerbations resulting in hospitalisation. Note this is unlicensed therapy requiring monitoring before and during therapy • ‘As required’, low dose lorazepam (0.5mg) and morphine sulphate liquid (2.5mg) for anxiety and breathlessness respectively, are useful in more end stage disease where patients may suffer panic attacks. 2,14,15 Quality standards and outcomes NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the three dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from highquality guidance from, for example, NICE or other sources accredited by NICE. The COPD quality standard (last updated in 2016), in conjunction with the guidance, should contribute to the improvements outlined in the following three outcomes frameworks published by the Department of Health: 20 NHS Outcomes Framework 2015–16 Reducing premature mortality, enhancing quality of life for people with long term conditions, helping people to recover from episodes of ill health or following injury and ensuring that people have a positive experience of care. Public Health Outcomes Framework 2013–16 Health improvement/healthcare public health and preventing premature mortality. Adult Social Care Outcomes Framework 2015–16 Delaying and reducing the need for care and support. The quality standard is expected to contribute to improvements in the following outcomes: • COPD diagnosis • morbidity • mortality • acute exacerbations • hospital admissions Other considerations • Medication adherence – understanding barriers 17 HHE 2019 | hospitalhealthcare.com