A better quality of life for respiratory patients

A look at some of the most common respiratory conditions and their treatment pathways

Introduction

Respiratory diseases encompass a wide range of conditions that affect the lungs and airways, making gas exchange difficult. These include conditions involving the trachea, bronchi, bronchioles, and alveoli. Respiratory illnesses can range from mild and self-limiting conditions to more severe and life-threatening diseases. Several factors contribute to respiratory diseases, including genetic predisposition, nutritional deficiencies, environmental exposures, tobacco smoking, infections, and occupational hazards.

Respiratory diseases represent one of the most significant public health challenges in Ireland, being among the primary causes of morbidity and mortality. Respiratory disease causes approximately one in five deaths in Ireland with respiratory disease death rates in Ireland 38 per cent higher than the European Union average. Pharmacists are ideally placed in the community to play a crucial role in the management of respiratory conditions. They can provide support to patients to optimise medication use, improve disease outcomes, and reduce the burden on the healthcare system.¹

Background

Respiratory diseases can generally be categorised into chronic and acute diseases. Chronic respiratory diseases affect the airways and structures of the lungs and include chronic obstructive pulmonary disease (COPD), asthma, cystic fibrosis, idiopathic pulmonary fibrosis, lung cancers, and sarcoidosis. These conditions are either incurable or difficult to cure, but medications can help control symptoms and improve quality of life. Tobacco smoke is the main risk factor associated with chronic respiratory diseases, with other risk factors including air pollution, occupational chemicals, and frequent lower respiratory infections during childhood. Acute respiratory diseases can be caused by respiratory viruses, including respiratory syncytial virus, influenza, and coronaviruses, and include conditions such as pneumonia and bronchitis. These may be self-limiting or may require short-term medical intervention.^2,3

Non-pharmacological interventions

Non-pharmacological approaches are very important in the management of respiratory conditions. These interventions can be used to complement pharmacological therapies by addressing lifestyle and environmental factors that worsen respiratory symptoms. Non-pharmacological interventions can improve symptoms, enhance quality of life, and prolong life expectancy. These interventions include smoking cessation, pulmonary rehabilitation, vaccination, long-term oxygen, environmental control, and nutritional support.

Smoking is the major risk factor for COPD and lung cancer, as well as exacerbating asthma symptoms. Smoking cessation is critically important in preventing lung function decline after diagnosis of COPD, with early cessation being particularly important. Smoking cessation has also been shown to reduce the risk of mortality in COPD patients. Counselling from a healthcare professional can increase the chances of success. Pharmacological interventions, including nicotine replacement therapy, bupropion, and varenicline, can be effective in improving cessation rates when compared to placebo.^4,5

Respiratory infections can lead to exacerbations of respiratory diseases, increasing morbidity and mortality. Prevention is crucial due to the limited treatment options available for respiratory infections. Vaccination is a key strategy to prevent infection and reduce exacerbations. Influenza, pneumococcal, and Covid-19 vaccinations are all important interventions in the non-pharmacological management of respiratory diseases.⁴

Reducing exposure to triggers such as pollen and dust is important in the management of asthma and allergic conditions. Allergen control measures, including the use of air purifiers and hypoallergenic bedding, can help achieve this goal. Pulmonary rehabilitation is another essential intervention as it maintains physical activity and muscle strength in patients with COPD. It is an effective approach that can reduce symptoms and improve lung function. Nutritional support is also crucial since malnutrition can be a concern for patients with advanced chronic respiratory conditions. Additionally, breathing techniques, long-term oxygen therapy, and lung transplantation may be considered depending on individual cases.⁴

Conditions

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a respiratory disease characterised by progressive airflow limitation and tissue damage, typically resulting from exposure to harmful substances. Structural lung changes occur due to chronic inflammation from prolonged exposure to noxious gases, with cigarette smoke being the primary cause of COPD. It usually presents in adulthood, most commonly in individuals older than 40, and is primarily seen in smokers, although cases can occur in non-smokers.

COPD is the third most common cause of morbidity and mortality worldwide. Patients typically present with chronic and progressive dyspnoea, cough, sputum production, wheezing, and chest tightness, with symptoms often worsening during the winter months. COPD is evaluated in patients with relevant symptoms and risk factors. Diagnosis is confirmed through spirometry, performed before and after the administration of an inhaled bronchodilator. Additional diagnostic tests may include a six-minute walk test, laboratory tests, and radiographic imaging.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a program initiated by the World Health Organisation, provides guidelines for the diagnosis and management of COPD. These guidelines are used to assess disease severity and inform treatment options. Treatment choices should be individualised and tailored to each patient.⁶

The primary objectives of treatment are to control symptoms, improve quality of life, reduce exacerbations, and improve life expectancy. Commonly used medications to treat COPD include bronchodilators (beta2-agonists, antimuscarinics, methylxanthines), inhaled corticosteroids (ICS), systemic corticosteroids, phosphodiesterase-4 (PDE4) inhibitors, and antibiotics.

Beta2-agonists act on beta-adrenergic receptors, causing relaxation of smooth muscle in the lungs and dilation of the airways. They are classified as short-acting beta2-agonists (SABAs) and long-acting beta2-agonists (LABAs). SABAs, such as salbutamol and terbutaline, are used as required to provide immediate relief. LABAs, including formoterol, vilanterol, and salmeterol, are generally used for maintenance therapy. Antimuscarinic agents are administered via inhalation. They exert their mechanism of action by blocking M3 muscarinic receptors in smooth muscle and therefore preventing bronchoconstriction.

Short-acting antimuscarinic agents (SAMAs), such as ipratropium, are used on an as-needed basis for rapid bronchodilation. Long-acting antimuscarinic agents (LAMAs), such as tiotropium, umeclidinium, and aclidinium, are used for maintenance therapy. Methylxanthines relax smooth muscle by inhibiting phosphodiesterase, leading to bronchodilation. Theophylline is a methylxanthine administered orally and is effective in treating COPD. Methylxanthines are generally used as add-on treatment in maintenance therapy, offering additional relief after LABA or LAMA treatment.⁶

ICS are commonly used to decrease inflammation in the airways and are often combined with LABAs and LAMAs for effective COPD treatment. Examples of ICS include fluticasone, beclomethasone, and budesonide. However, the use of inhaled ICS may be associated with an increased risk of pneumonia and oral candidiasis if used incorrectly. Oral corticosteroids are not indicated for long-term use but can be useful in treating acute exacerbations of COPD. Long-term use is not advised due to potential adverse effects, including mood changes, weight gain, adrenal insufficiency, and gastrointestinal upset.

Azithromycin, a macrolide antibiotic, may reduce the number of exacerbations in COPD patients. Azithromycin is generally administered orally, either as 250mg per day or 500mg three times per week. It should be used with caution as it can promote antibiotic resistance, QT prolongation, and hearing problems. Mucolytics, such as carbocisteine, may also be used as add-on therapy to reduce mucus viscosity and improve symptoms in COPD patients.⁶

Asthma

Asthma is a chronic inflammatory respiratory condition that presents significant challenges in both diagnosis and management. It is characterised by airway inflammation, resulting in reversible airflow obstruction and bronchial hyperresponsiveness. The prevalence and severity of asthma are influenced by a complex interplay of genetic and environmental factors. Asthma often develops during childhood and is frequently associated with other atopic conditions, such as eczema and hay fever. The primary symptoms of asthma include coughing, wheezing, chest tightness, and shortness of breath, which can be triggered by allergens, infections, exercise, or exposure to cold air. These symptoms generally occur intermittently, lasting from hours to days, and resolve when the trigger is removed, or appropriate medication is administered. However, in some cases, symptoms may become life-threatening. Diagnosing asthma typically involves excluding alternative diagnoses and demonstrating variable airflow limitation, usually through spirometry.⁷           

The primary objectives of asthma therapy are to achieve and maintain control of symptoms, prevent exacerbations, and reduce limitations on quality of life. Effective treatment improves lung function, enhances quality of life for the patient, and reduces the burden on healthcare services. Similar to COPD treatment, pharmacological treatment of asthma involves beta-2 agonists, muscarinic antagonists, ICS, and methylxanthines. Leukotriene receptor antagonists (LTRAs), such as montelukast, can also be used as add-on treatment. The best practice in asthma management involves incorporating these different classes of drugs and applying a stepwise approach. In this method, patients adjust treatment by stepping up or down as necessary to maintain asthma control. This stepwise approach is outlined below, along with potential add-on options for uncontrolled asthma.^7,8

Step 1 – is recommended for patients with symptoms occurring less than twice per month. The recommended controller options are low-dose ICS whenever SABA is required (in adults and children) or a low-dose combination ICS/LABA as needed (in adults). Formoterol is the LABA of choice due to its quicker onset of action. SABA-only therapy is no longer recommended and can lead to worse clinical outcomes.^7,8

Step 2 – is recommended for patients with symptoms occurring more than twice per month but less than daily. The preferred controller option is daily low-dose ICS plus as required SABA (in adults and children) or as required low-dose ICS/LABA combination. Other options include an LTRA for patients who do not tolerate ICS or those with concomitant allergic rhinitis.^7,8

Step 3 – is recommended for patients who have symptoms most days. In adults, the recommended treatments are low-dose ICS/LABA maintenance plus as-required SABA or low-dose ICS/LABA maintenance and reliever therapy (MART). In children, the recommendation is medium-dose ICS plus as required SABA or low-dose combination ICS/LABA plus as required SABA.^1,3

A MART treatment is recommended for adults with moderate-to-severe asthma. MART offers several benefits, including flexible dosing to address symptoms, reduces the chance of SABA reliever overuse, lowering overall steroid dose, and decreasing the rate of exacerbations.^7,8

Step 4 – is recommended for patients who have symptoms on most days or have low lung function. The recommended treatment is low-to-medium-dose ICS/LABA MART (in adults) or medium-dose ICS/LABA maintenance plus as required SABA (in adults and children).^7,8

Step 5 – is for patients who have persistent symptoms and exacerbations despite correct inhaler technique and adherence to step 4 treatment. These patients should be referred for phenotypic investigations and add-on treatment options explored.^7,8

LAMA therapy is indicated as an add-on bronchodilator therapy for patients with severe asthma who have experienced one or more exacerbations in the preceding 12 months, despite using high-dose ICS and LABA. Tiotropium is an example of a LAMA used for this purpose. Other medications that may be considered as add-on treatment after specialist review include high-dose ICS, oral theophylline, and oral corticosteroids.^7,8

Respiratory infections

Respiratory tract infections can involve either the upper or lower respiratory tract and are classified as upper respiratory tract infections (URTIs) or lower respiratory tract infections (LRTIs). An URTI is generally caused by an acute infection that involves the nose, sinuses, larynx, pharynx, or large airways, with common conditions including tonsillitis, laryngitis, pharyngitis, sinusitis, otitis media, and the common cold. URTIs are most often caused by viruses, such as rhinovirus, influenza, adenovirus, enterovirus, and respiratory syncytial virus. Less commonly, they may result from bacterial infections, while fungal infections are rare but still possible. Symptoms of URTIs include cough, sore throat, runny nose, nasal congestion, low-grade fever, headache, sneezing, and malaise. Onset of symptoms is typically one to three days after exposure and persists for seven to 10 days. URTIs are generally self-limiting, with treatment aimed at symptom relief. Decongestants, antihistamines, and analgesics can be used to treat symptoms including cough, congestion, and aches.⁹

A LRTI is an infection of the lower airways, including the bronchial tubes, bronchioles, and lungs. LRTIs are typically much more severe than URTIs. Common LRTIs include pneumonia, bronchitis, and influenza. These conditions are generally treatable but can become severe or life-threatening in certain populations, such as the elderly, young children, and individuals with chronic illnesses.

Pneumonia is an inflammatory respiratory condition affecting the lungs, primarily the alveoli. It is caused by bacterial or viral infection, with other microorganisms less commonly responsible. It can be classified as hospital-acquired or community-acquired. The severity of the condition varies, and it may become life-threatening in elderly or immunocompromised patients. Symptoms of pneumonia can include cough, difficulty breathing, chest pain, and fever. Diagnosis is often based on clinical symptoms and physical examination, with additional tools such as cultures, chest X-rays, and blood tests being useful for confirmation. Treatment depends on the underlying cause. Antibiotic therapy is vital for bacterial pneumonia, with amoxicillin, doxycycline, and clarithromycin commonly used agents.^10,11

Role of the pharmacist

Pharmacists play an integral role in respiratory medicine and the management of respiratory conditions. Pharmacists are ideally placed in the community to assess and optimise treatment regimens, ensuring clinical outcomes are achieved. Pharmacists can counsel and educate patients on correct inhaler techniques, the importance of adherence, and strategies to manage adverse effects.

Furthermore, pharmacists contribute to public health efforts by administering vaccinations and offering smoking cessation programmes, thereby reducing the burden of respiratory diseases. They also collaborate with other healthcare professionals to address the challenges posed by respiratory conditions, enhance patients’ quality of life, and promote overall public health.