Take a Deep Breath

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Take a Deep Breath: Understanding Respiratory Illnesses

Respiratory illnesses, from the common cold to chronic diseases such as asthma and chronic obstructive pulmonary disease (COPD), are among the most common health issues. Steve Titmarsh explains…

Pharmacists on the frontline

Community pharmacists can play their part in educating people about these diseases and how to prevent them or minimise their impact on health.

The NHS Long Term Plan says respiratory disease affects one in five people in England and is the third biggest cause of death.¹

• Acute respiratory infections such as influenza, pneumonia and bronchitis often result from viral or bacterial infections
• Some of the most common chronic respiratory diseases include COPD, asthma and occupational lung diseases

🚩Key risk factors

According to the World Health Organization (WHO) common risk factors include:

• Tobacco smoke
• Air pollution
• Occupational chemicals and dust
• Frequent lower respiratory infections during childhood ²

**Asthma alone affects 5.4 million people in the UK.

Asthma: updated guidelines

The updated NICE guidelines³, published in November 2024, represent a collaboration between NICE, the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN). It highlights the importance of patient history in the diagnosis, partly as there is no accurate test yet for the disease.

Shift in diagnosis & treatment

• Testing for eosinophils (via blood test or fractional exhaled nitric oxide (FeNO) test) is recommended as a first-line approach: most people with asthma have high levels of eosinophilic inflammation thought to be associated with symptoms.⁴

Treatment

• NICE no longer recommends using a short-acting bronchodilator agonist (SABA) alone
• Excessive or exclusive use of these drugs is linked to increased risk of asthma attacks and death
• Patients prescribed a SABA must also receive an inhaled corticosteroid to use regularly
• The use of SABAs is generally decreasing⁴

Monitoring & inhaler technique

Monitoring is especially important and should be done at least once a year for people whose asthma is controlled, and more often if it is not. Seeing patients after an asthma attack is also key because attacks signal that treatment is not working.

NICE also recommends that inhaler technique should be checked at every opportunity – something pharmacists could do when dispensing inhalers.⁴

📊Study findings from Thorax:

A 2019 study of 380 patients with COPD or asthma recruited by 35 community pharmacies found:

• 104 patients had never been shown how to use their inhalers
• After training by pharmacists and pharmacy technicians, inhaler technique improved significantly:
  a) Before training: 60.2% of inhaler techniques were rated as good
  b) After training: 96.2% of inhaler techniques were rated as good ⁵

➡️ Pharmacists play a key role in ensuring patients use inhalers correctly: Educating patients about their asthma and its treatment is important to equip them to deal with attacks and strategies to reduce the risk of attack by, for example, avoiding common triggers such as pollution.

Strengthening the community workforce

In its submission to the government on healthcare workforce pressures, the British Thoracic Society (BTS) emphasised:

• An increase in the NHS workforce is the single most effective intervention to address current health system pressures
• A well-resourced, multi-professional workforce can meet day-to-day demands for care and more easily absorb seasonal surges any extraordinary and seasonal surges in demand without impacting the delivery of their services  
• Crucial for future sustainability is the expansion of the role of community pharmacy in supporting patients managing their health and avoiding the need for hospitalisation⁶

Averting respiratory illnesses

In its report A respiratory workforce for the future, the British Thoracic Society says: 

“Exacerbations and frequent admissions to hospital are common to many respiratory diseases, for example COPD and asthma. Shifting the focus from reactive to proactive care has enormous benefit to patients and the healthcare system.”

“Supported self-management is a key part of the NHS Long Term Plan’s commitment to make personalised care the norm for patients. The narrative needs to change from admission avoidance to admission prevention.”

"To help deliver that part of the plan we will need to support community pharmacists in building confidence in advising patients with respiratory symptoms."

Darush Attar-Zadeh, a community pharmacist and Executive Committee member of the Primary Care Respiratory Society, wrote in 2019 a blog endorsing the role his colleagues can play in helping people with asthma. This included:

✅ Promoting good inhaler techniques
✅ Educating patients about medicines and what to expect from them
✅ Community pharmacists’ knowledge and skills can complement those of GPs managing people with respiratory diseases’, he said.⁷

In its handbook on chronic respiratory disease for pharmacists the International Pharmaceutical Federation (FIP) notes: as healthcare delivery undergoes a paradigm shift towards a people-centred care approach to optimising therapy and health outcomes, pharmacists are well positioned to play a unique and complementary role in an interprofessional collaborative care model to manage chronic respiratory diseases.⁸

Prevention

Community pharmacists can play a key role in helping to reduce the spread of respiratory infections by:

• Promoting healthy lifestyles
• Providing stop smoking advice
• Administering vaccinations
  
  AND adopting hygiene measures like:

• Handwashing regularly
• Covering the mouth when coughing/sneezing
• Throwing away used tissues immediately⁹
• Physical distancing
• Wearing masks

📊 Impact of the COVID-19 pandemic: In 2020, there was a 36% reduction in emergency asthma admissions. This was partly due to hygiene measures adopted during the peak of the pandemic, including encouraging people to stay home if they have a cold or the flu, and wearing a mask if they are with others.

New developments: a breakthrough in treatment

Described by some as the first breakthrough in 50 years for treating asthma and COPD, a monoclonal antibody –benralizumab – made headlines in November 2024 following the results of a trial in people with severe asthma or COPD.¹⁰

What is benralizumab?

• Recommended by NICE as an add-on therapy for adults with uncontrolled severe eosinophilic asthma
• Targets eosinophilic inflammation, which is involved in about half of asthma attacks and 30% of COPD exacerbations

A trial published in November 2024 in The Lancet involved 158 patients who were randomly assigned to receive an injection of benralizumab or a five-day course of prednisolone or a combination of both. 90 days later:

• Patients who received prednisolone showed 74% failure rate
• Patients who received benralizumab showed 47% failure rate
• Combination therapy showed 42% failure rate

🌟Benralizumab may offer a more effective alternative to steroids for managing eosinophilic asthma attacks

References

1. NHS Long Term Plan
2. World Health Organization
3. National Institute for Health and Care Excellence (NICE). Asthma: diagnosis, monitoring and chronic asthma management
4. Whittamore A. Implementing the new joint NICE asthma guidelines
5. Capstick T, Burnley M, Higgins H. P234 Improving in inhaler technique: a community pharmacy service Thorax 2019;74:A217–A218
6. British Thoracic Society: A respiratory workforce for the future
7. Attar-Zadeh D. BLOG SERIES – Asthma outcomes: Community pharmacy perspective
8. FIP. Chronic respiratory diseases: a handbook for pharmacists
9. NHS. Respiratory tract infections (RTIs)
10. Gregory A. Doctors hail first breakthrough in asthma and COPD treatment in 50 years
11. Ramakrishnan S, Russell REK, Mahmood HR, et al. Treating eosinophilic exacerbations of asthma and COPD with benralizumab (ABRA): a double-blind, double-dummy, active placebo-controlled randomised trial