respiratory inhaler check-up service what is the challenge?categorising inhaler devices aerosol...

1

Respiratory Inhaler Check-up Service

Dr Toby Capstick

Lead Respiratory Pharmacist

Leeds Teaching Hospitals NHS Trust

[email protected]

19th November 2019

What is the Challenge?

1. British Lung Foundation. The Battle for breath. 2016

2. Asthma UK (2014) http://www.asthma.org.uk/asthma-facts-and-statistics

3. Asthma UK. The Asthma UK Data Portal. https://www.asthma.org.uk/get-involved/campaigns/data-portal/ (accessed 27/10/17)

4. DH (2011). An outcomes strategy for COPD and Asthma in England

5. Public Health England. Inhale - INteractive Health Atlas of Lung conditions in England. 2015/16 data. https://fingertips.phe.org.uk/profile/inhale/data

6. Royal College of Physicians (2014). Why asthma still kills: The National Review of Asthma Deaths (NRAD)

ASTHMA COPD

The Burden of Disease in the UK

Inhaler Technique:

• 46% of people who died from asthma did not had inhaler technique checked

& recorded in the prior 12 months.6

1.2 million people in the UK diagnosed with

COPD.1

• 2/3 of people with COPD thought to

remain undiagnosed.1

There were 140,000 UK Hospital

admissions each year.1

COPD was responsible for 25,000 –

30,000 deaths annually.1,4

8 million people in the UK diagnosed with

asthma.1

• 5.4 million asthmatics in UK1-2

• (1.1 million children)2

There were 77,124 UK Hospital

admissions in 2016/173

75% of admissions are avoidable2

Asthma was responsible for 1,484 deathsin 2017.2

2/3 of deaths are preventable2

NHS Digital. Prescription Cost Analysis, England – 2018. Available at:

https://digital.nhs.uk/data-and-information/publications/statistical/prescription-cost-analysis/2018

Publication date: 28th March 2019

Prescription Cost Analysis - England, 2018

Overall, £931 million spent on inhalers in England in 2018

£12.65 million spent on inhalers in Leeds in 2018 (↓£14.65 in 2017)

BUT, are we getting value for money?

50% have not had inhaler technique checked & recorded in the

last 15 months.

Top 5 Brands Expenditure

1 Fostair 100/6 MDI £124,619,129

2Spriva 18mcg HandiHaler

refills£52,845,366

3 Braltus 10mcg Zonda £50,002,648

4 Seretide 250/25 MDI £48,765,022

5 Seretide 500 Accuhaler £41,875,352

Top 5 Generics Expenditure

1Beclometasone/formoterol 100/6

MDI£124,619,129

2Tiotropium

HandiHaler, Zonda£114,231,876

3Budesonide/formoterol 200/6 DPI

Turbohaler, Spiromax, Easyhaler£72,723,129

4Fluticasone/salmeterol 250/25

MDI£69,721,831

5Fluticasone/salmeterol 500/50 DPI Accuhaler, Forspiro, Spiromax, Easyhaler

£39,586,574

Asthma & COPD: Inhalers in 2010

Bronchodilators

SABAs

• Salbutamol (7+ devices)

• Terbutaline (1 device)

SAMAs

• Ipratropium (2 devices)

LABAs

• Formoterol (2 devices)

• Salmeterol (2 devices)

LAMAs

• Tiotropium (2 devices)

Corticosteroids

ICS

• Beclometasone (4 devices)

• Beclometasone extra-fine (3 devices)

• Budesonide (3 devices)

• Ciclesonide (1 device)

• Fluticasone propionate (2 devices)

• Mometasone (1 device)

ICS/LABA

• Fostair(beclometasone/formoterol)

(1 device)

• Seretide(fluticasone propionate/salmeterol)

(2 devices)

• Symbicort(budesonide/formoterol)

(1 device)

Asthma & COPD: Inhalers in 2019

†Not available as monotherapy

CorticosteroidsICS

• Beclometasone (Clenil Modulite) (2 devices)

• Beclometasone extra-fine (Qvar, Kelhale) (3 devices)

• Budesonide (3 devices)

• Ciclesonide (1 device)

• † Fluticasone furoate

• Fluticasone propionate (2 devices)

• Mometasone (1 device)

ICS/LABA

• Aerivio (fluticasone propionate/salmeterol) (1 device)

• AirFluSal (fluticasone propionate/salmeterol) (2 devices)

• Aloflute (fluticasone propionate/salmeterol) (1 device)

• Combisal (fluticasone propionate/salmeterol) (1 device)

• DuoResp (budesonide/formoterol) (1 device)

• Flutiform (fluticasone propionate/formoterol) (2 devices)

• Fobumix (budesonide/formoterol) (1 device)

• Fostair (beclometasone/formoterol) (2 devices)

• Fusacomb (fluticasone propionate/salmeterol) (1 device)

• Relvar (fluticasone fuorate/vilanterol) (1 device)

• Sereflo (fluticasone propionate/salmeterol) (1 device)

• Seretide (fluticasone propionate/salmeterol) (2 devices)

• Sirdupla (fluticasone propionate/salmeterol) (1 device)

• Stalpex (fluticasone propionate/salmeterol) (1 device)

• Symbicort (budesonide/formoterol) (2 devices)

ICS/LABA/LAMA

• Trelegy� (fluticasone fuorate/vilanterol/umeclidinium) (1 device)

• Trimbow�(beclometasone/formoterol/glycopyrronium) (1 device)

Bronchodilators

SABAs

• Salbutamol (6 devices)

• Terbutaline (1 device)

SAMAs

• Ipratropium (1 device)

LABAs

• Formoterol (4 devices)

• Salmeterol (2 devices)

• Indacaterol (1 device)

• Olodaterol� (1 device)

• † Vilanterol

LAMAs

• Aclidinium� (1 device)

• Glycopyrronium (1 device)

• Tiotropium (3 devices)

• Umeclidinium� (1 device)

LABA/LAMAs

• Anoro� (vilanterol/umeclidinium (1 device)

• Duaklir� (formoterol/aclidinium) (1 device)

• Spiolto� (olodaterol/tiotropium) (1 device)

• Ultibro� (indacaterol/glycopyrronium) (1 device)

1 2

3 4

5 6

2

Categorising Inhaler DevicesAerosol

Aerosol ± Spacer Soft Mist Breath Actuated Aerosol

MDI Small Vol. Spacer

Large Vol.

Spacer

Respimat Autohaler Easi-Breathe K-haler

Dry Powder Inhaler (DPI)

Single dose DPI - Blister Single dose DPI - Capsule

Accuhaler Ellipta Forspiro Orbicel Aeroliser Breezhaler HandiHaler Zonda

Reservoir Multidose DPI

Easyhaler Genuair NEXThaler Novolizer Spiromax Turbohaler Twisthaler

Generic Prescribing• Budesonide/formoterol ● Beclometasone/formoterol

• Fluticasone/salmeterol

• Formoterol

Symbicort

Turbohaler

DuoResp

Spiromax

Atimos Modulite

pMDI

NEXThalerpMDI

Formoterol

Easyhaler

Foradil

Aeroliser

Oxis

Turbohaler

Seretide

Accuhaler

AirFluSal

Forspiro

Fobumix

Easyhaler

Aerivio

Spiromax

BTS/SIGN Asthma Guidelines 2016

Stalpex

Orbicel

NICE COPD Guidelines 2019

Switching Inhaler Devices:

Effect of unconsented switch (Asthma)

Thomas et al. BMC Pulmonary Medicine 2009;9:1-10

Treatment Success OR: 0.29 [95% CI: 0.19, 0.44; p

3

Inhaler Technique: Has it Improved Over 40 Years?

Systematic review. 144 studies, 54,354 patients

Sanchis et al. Chest 2016; 150(2):394-406

Association Between Inhaler Technique and

COPD exacerbations

45

36

80

71

38

29

70

63

0

10

20

30

40

50

60

70

80

90

Hospital admissions Emergency dept

visits

Antibiotic courses Corticosteroid

courses

% o

f p

ati

en

ts e

xace

rba

tin

g

At least 1 Critical Error No Errors

OR 1.47; p=0.001 OR 1.62; p

M3 Is there a clearer image that can be used ?Michaela, 26/09/2019

4

Effect of Multiple dosing into Spacers• Single actuations into spacers are recommended

Barry PW et O’Callaghan C. Eur Respir J., 1994, 7, 1707–1709

5

What do Guidelines Recommend?

BTS/SIGN Asthma Guidelines

2016

• Prescribe inhalers only after

patients have:• Received training in the use of the

device, and

• Have demonstrated satisfactory

technique

• Before initiating a new drug

therapy practitioners should

check:• Adherence with existing therapies

• Inhaler technique, and

• Eliminate trigger factors

NICE COPD Guidelines 2010

• Inhalers should be prescribed

only after patients have • received training in the use of the

device, and

• have demonstrated satisfactory

technique

• Patients should have their ability

to use an inhaler device regularly

assessed by a competent

healthcare professional and, if

necessary, should be re-taught

the correct technique

BTS/SIGN Asthma Guidelines 2016 NICE clinical guideline 101: Chronic

obstructive pulmonary disease. 2010

The Service

• Eligible Patients• Diagnosis of asthma / COPD, on inhaled therapy

• Registered with Leeds GP

• Speak & understand English (or translated by pharmacy team)

• Able to attend both consultations

• Service allowed once per patient

• Pharmacy requirements• Use consultation room

• Provided by Pharmacist or Registered Pharmacy Technician, • Must have completed CPPE Declaration of Competence for Improving Inhaler Technique.

• Must use In Check DIAL G16 with 1-way inspiratory mouthpieces, & placebos.• Initial supply provided.

• It is your responsibility to obtain more.• London Medicines Evaluation Network. Availability and supply of respiratory support devices to healthcare

professionals. http://www.medicinesresources.nhs.uk/upload/Availability%20of%20placebo%20inhalers%20FINAL_June13_LMEN.pdf

Service Outline

• Two appointments: baseline & 6-8 weeks later• Take telephone no. and/or email to use as a reminder

• Patient education:1. Assessment of Asthma Control (ACT) or COPD health status (CAT)

2. Inhaler technique:• Measure inspiratory flow using In-Check DIAL G16

• Assess, teach and optimise inhaler technique

3. Medicines use

4. Adherence

5. Smoking cessation

6. Data recorded on Pharmoutcomes within 48 hours

7. GP referral: e.g. if alternative device needed

• NB. If patient has (1) good control (ACT≥20 or CAT

5

• Patient education:

1. Assessment of Asthma Control (ACT) or COPD health status (CAT)

2. Inhaler technique:

• Measure inspiratory flow using In-Check DIAL G16

• Assess, teach and optimise inhaler technique

3. Medicines use

4. Adherence

5. Good Clinical Practice: Smoking cessation

6. Data recorded on Pharmoutcomes within 48 hours

7. GP referral: e.g. if alternative device needed

The Consultation

Resulting Symptoms:• Wheeze• Breathlessness at rest & during

activities

• Chest tightness• Cough• Increased mucous & phlegm

What is COPD?

Chronic Inflammation:

• Parenchymal

destruction

• Breakdown of

alveolar attachments

• Loss of bronchiole

elasticity

Narrowing

of airways

Chronic irritation by

tobacco smoke /

noxious agents:

• Increased no. of

goblet cells &

enlarged

submucosal glands

• Impaired mucociliary

clearance

• Mucous plugging

A common, preventable and treatable disease… characterised by persistent

respiratory symptoms and airflow limitation that is due to airway and/or alveolar

abnormalities usually caused by significant exposure to noxious particles or gases.

• Asthma is a chronic inflammatory disorder of the airways

• Involves a variety of cells and cellular mediators

• Airflow limitation is widespread, variable, and often reversible

• Chronic inflammation leads to an increase in airway hyperresponsiveness

with recurrent episodes of wheezing, coughing, and shortness of breath

What is Asthma?

Smooth muscle

Mucus plug

Basementmembrane

Epithelium

Mucous glands

Adapted from Jeffery PK. Am J Respir Crit Care Med. 2001;164:S28-S38.

44

Normal

airway

Asthmatic

airway

1. Assessment of Asthma Control (ACT)

or COPD Health Status (CAT)

25 26

27 28

29 30

6

COPD Assessment Test (CAT)

(http://catestonline.org).

• 8 Questions (max score 40)

• Score ≤5: normal healthy

non-smokers

• 20: high impact

• >30: very high impact

• A change of 2 is clinically

meaningful.

• Influenza vaccination can reduce hospital admissions for both

pneumonia and influenza, and reduce mortality risk.

ACTION

• Ask whether patient had a flu vaccination during the most recent

winter

• If patient did not have their most recent vaccination when due

• Advise of the benefits and encourage to have it annually

• During ‘flu season’: offer annual flu vaccination

• From community pharmacy or GP

Vaccination

2. Inhaler Technique

How Should We Teach Inhaler Technique?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pren=8

Postn=7

Pren=9

Postn=8

Pren=9

Postn=9

Tu

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hale

r Tech

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ue S

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re

Unsatisfactory

Satisfactory

Optimal

VerbalAugmented

Verbal

Augmented

Verbal + PhysicalBasheti IA et al. Respir

Care 2005;50:617-23.

• Assess Technique using Placebos

• “Show and Tell” training method

• Re-assess technique

• Complete Inhaler Technique Labels

• Repeat at frequent intervals

Impact of “Show and Tell” Inhaler Technique

Counselling Service

Basheti IA et al. Patient Education and counseling 2008;72:26-33

Community Pharmacy Service:Teaching Inhaler Technique Improves Asthma Outcomes

Basheti IA et al. Patient Education and counseling 2008;72:26-33

Inhaler Technique

Asthma Severity

31 32

33 34

35 36

7

Leeds Community Pharmacy Inhaler Technique

Service 2018-19

Capstick T., Burnley M, Higgins H. Data on file.

Inhaler Technique ResourcesAsthma UK / UK Inhaler Group Videos

https://www.asthma.org.uk/advice/inhaler-videos/

Written Resources

Right Breathe https://www.rightbreathe.com/

ACTION: Assess & improve inhaler technique• Step 1 - Check inspiratory flow

• Use In-Check DIAL G16 inspiratory flow meter to measure inspiratory flow through the

inhaler device(s).

• Step 2 - Check inhaler technique • Patient should demonstrate how they use their own inhaler (unless newly prescribed).

• Assess Inhaler technique as

• ‘Optimal’ (all steps completed correctly),

• ‘Satisfactory’ (some minor errors, but all critical steps completed correctly), or

• ‘Unsatisfactory’ (at least one critical error made).

• Step 3 - Teach correct inhaler technique

• Pharmacist/Tech should demonstrate correct inhaler technique to the patient.

• Issue Aerochamber where appropriate

• Step 4 – Re-check inhaler technique and check understanding

• After teaching correct technique, the patient should demonstrate how they would use it

again.

• This allows Pharmacist/Technician to check understanding & reinforce any difficulties.

Inhaler Technique Assessment

Categorising Inhaler DevicesAerosol

Aerosol ± Spacer Soft Mist Breath Actuated Aerosol

MDI Small Vol. Spacer

Large Vol.

Spacer

Respimat Autohaler Easi-Breathe K-haler

Dry Powder Inhaler (DPI)

Single dose DPI - Blister Single dose DPI - Capsule

Accuhaler Ellipta Forspiro Orbicel Aeroliser Breezhaler HandiHaler Zonda

Reservoir Multidose DPI

Easyhaler Genuair NEXThaler Novolizer Spiromax Turbohaler Twisthaler

Choosing an Inhaler

Usmani, Capstick, Chowhan & Scullion. Choosing an appropriate inhaler device for the treatment of adults

with asthma or COPD. www.guidelines.co.uk/wpg/inhaler-choice [Accessed: November 2017]42

37 38

39 40

41 42

8

Measuring Inspiratory Flow:

In-Check DIAL Comparison of Inspiratory Resistance &

Inspiratory Flow

Kruger P et al. on behalf of Almirall. ERS Poster 2014

1. Preparation• Check dose counter• Shake inhaler (where applicable)

2. Priming• Before first use (where applicable)• Open inhaler / remove cap

3. Exhaling• Fully and away from mouthpiece

4. Mouth• Tilt head so that chin is lightly upwards• Place mouthpiece in mouth & close lips for tight seal

5. Inhalation• DPI: quick and deep inhalation (within 2–3 seconds)• pMDI/SMI: slow and steady inhalation (over 4–5 seconds)

6. Breath holding• Remove from mouth, hold breath for 5 seconds

7. Closing and repeating• Close inhaler / replace cap• Repeat as necessary

For individual devices patients should refer to the Patient Information Leaflet that accompanies the inhaler

Inhaler Technique: 7 Steps to Success

Usmani, Capstick, Chowhan & Scullion. Choosing an appropriate inhaler device for the treatment

of adults with asthma or COPD. Guidelines.co.uk . In Press.

(adapted from Anna Murphy (simplestepseducation) Seven Step approach)

Aerosol InhalersMDI SMI

Respimat

BA-MDIAutohaler/Easi-Breathe /

K-haler

Range of

Drugs

• Wide range of

drugs/classes

• Compatibility with

Spacer (needed for many)

• Long-acting

bronchodilators

• SABA (AH / EB)

• ICS (AH / EB)

• ICS/LABA

Dose

Delivery

• Low IFR needed

• Many inhale too fast

• Low IFR needed

• Efficient dose delivery

• Low IFR needed

Ease of Use • Moderate dexterity

• Coordination required

• Many use incorrectly

• Haleraid available

• High dexterity

• Complex

loading/priming

• Locks when empty

• Low dexterity

Dose

Counter

• Dose counter: ICS/LABA

(not SABA or ICS)

• Dose indicator • None

Feedback • Taste / sound • Taste / click • Taste / click

Single Dose DPI - BlistersAccuhaler Ellipta Forspiro

Range of

Drugs

• SABA

• LABA

• ICS; ICS/LABA

• ICS/LABA

• LAMA

• LAMA/LABA

• FP/Salm only (1

strength)

Dose

Delivery

• Medium-low airflow

resistance

• Relatively consistent

across IFR 30-90L/min

• Do not invert


resistance

• Consistent across IFR

43-130L/min

• Do not invert


resistance



• Do not invert

Ease of Use • Low-moderate dexterity

• Gritty if not used

correctly

• Low dexterity

• Simple device

• Moderate-high

dexterity

Dose

Counter

• Small dose counter • Large dose counter • Dose counter

Feedback • Taste • Taste • Taste

• Visual: loading of doses

& used blisters

Single Dose DPI - CapsuleBreezhaler HandiHaler Zonda

Range of

Drugs

• LABA

• LAMA

• LAMA/LABA

• LAMA • LAMA

Dose

Delivery

• Low airflow resistance



• Do not invert

• Risk of inhaling capsule

fragments

• High airflow resistance



• Do not invert

• Risk of inhaling capsule

fragments


• No data on drug

delivery?

• Do not invert

• ? Risk of inhaling

capsule fragments ?

Ease of Use • High dexterity

• Significant manipulation

• Redesigned blisters

easier to open

• High dexterity


• Blisters difficult to open

• High dexterity


• Capsules in bottle

Dose

Counter

• Capsule count (in

blister)


blister)


blister)

Feedback • Taste

• Whirring/vibration

• Visual: transparent caps

• Taste


• Visual: open caps

• Taste


• Visual: transparent caps

43 44

45 46

47 48

9

Reservoir Multidose DPI (1)Easyhaler Spiromax Turbohaler

Range of

Drugs

• SABA

• LABA

• ICS

• ICS/LABA (due 2017)

• ICS/LABA • SABA

• LABA

• ICS

• ICS/LABA

Dose

Delivery


• Consistent across IFR 30-

60L/min

• Do not invert

• Medium airflow

resistance

• Higher dose delivery at

faster IFRs (90 vs 40 L/min)

• Do not invert

• Medium-high airflow

resistance

• Higher dose delivery at

faster IFRs (90 vs 40 L/min)

• Do not invert

Ease of Use • Low dexterity

• Prime in vertical position

• Low dexterity

• Simple device

• Prime in vertical-

horizontal position

• Moderate dexterity

• Prime in vertical position

• Turn aid available

Dose

Counter

• Dose counter (steps of

10)

• Dose counter (steps of

2)

• Dose counter (Symbicort –

steps of 20) or indicator

Feedback • Taste

• Window shows unused

doses

• Taste • Generally no taste

Reservoir Multidose DPI (2)Genuair NEXThaler

Range of

Drugs

• LAMA

• LAMA/LABA

• ICS/LABA

Dose

Delivery

• Medium airflow

resistance

• Consistent

• No delivery

10

Evidence for the Side Effects of ICS

Price et al. Prim Care Respir J 2013; 22(1): 92‐100

• MHRA May 2006:• Prolonged use of high doses of ICS…carries a risk of systemic side effects...• Corticosteroid treatment cards should be routinely provided for…high doses of ICS.

• MHRA, September 2010:• Inhaled (and intranasal) corticosteroids...

• High Dose Inhaled Corticosteroid Warning Cards, 2014• For all patients Rxed high doses of ICS (≥1000mcg BDP/day).• Consider for medium doses of ICS (e.g. 800mcg BDP/day) + Intranasal steroids

• Further information:• https://www.networks.nhs.uk/nhs-networks/london-lungs/documents/inhaled-

corticosteroids-in-adults/view

• https://www.networks.nhs.uk/nhs-networks/london-lungs/documents/high-dose-inhaled-corticosteroid-alert-card-order-form

Risks of High Dose Inhaled Corticosteroids

MHRA. Current Problems in Pharmacovigilance 2006

MHRA. Drug Safety Update 2010.

4. Adherence

What is Non-adherence?

• Unintentional Non˗adherence:

• The patient wants to follow the agreed treatment but is prevented from doing so by barriers that are beyond their control:

• Poor recall / forgetfulness

• Have difficulties in understanding the instructions

• Problems with using the treatment

• Inability to pay for the treatment

• These should be relatively straight forward to address

NICE CG76. Medicines adherence… 2009

What is Non-adherence?

• Intentional Non˗adherence

• The patient decides not to follow the treatment recommendations:

– Beliefs: Views about prescribed medications

Necessity: Beliefs about the necessity of medication to maintain health

Concerns: Beliefs about potential consequences of using medicines

• These are potentially more difficult to address

Menckeberg TT et al. J Psychosomatic Research 2008

NICE CG76. Medicines adherence… 2009

55 56

57 58

59 60

11

ACTION:

• EXPLORE and identify reasons for reported non-

adherence

• (e.g. due to beliefs, device, medicine, or side-effects).

• ASK the patient how they feel about using their COPD

inhalers.

• Do they have any concerns about using these medicines?

• DISCUSS and agree strategies and solutions to

improve adherence with the patient.

• A patient-centred approach should be used at all times

Medication Adherence• How are you getting on with this medicine / inhaler?

• An open question to get the patient talking about issues that are important

to them

• When and how often do you use this medicine / inhaler?

• Are you having any problems with this medicine/ inhaler, or concerns

about taking or using it?

• It may be important to assure the patient that it is normal to have concerns

about taking any medicine

• Do you think this medicine / inhaler is working?

(Prompt- is this different from what you were expecting?)

• Patients should understand their medicines & benefits in COPD

• Do you think you are getting any side effects or unexpected effects?

• Consider filling in a Yellow Card if severe or ▼ drugs

• Allows discussion about managing/preventing side effects

Framework for discussions

How can we improve adherence?

• Explore reasons for non-adherence– Unintentional: Rx charges, inhaler technique, memory, understanding

– Intentional: Understand the patient (beliefs)

• Involve the patients– Good communication

– Shared decision making

– Non-judgemental questioning

• Possible Solutions– Education, education, education

• Understanding medicine & condition

• Inhaler technique

– Address factors & concerns

– Link to personal goals

– Alter regimen, e.g. device(s), OD / BD inhaler

– Consider daily routine (daily prompts to take remind patient)

Possible Causes of Non-Adherence

Beliefs Device Medicine

• Denial of condition

• Concern about quantity

• Misunderstand

condition

• Misunderstand

treatment

• Fear of side-effects

• Embarrassment

• Dexterity problems

• Incorrect technique

• Incorrect cleaning of

spacer

• Frequency of dosing

• Several different

medicines

• Actual side-effects

• Forgetfulness

• Cost of prescription

• Information and education about COPD & medicines to address

beliefs & concerns

• Set realistic expectations (e.g. ICS do not have an immediate effect

on symptoms)

• Advice on use and care of inhaler devices & spacers

• Addressing forgetfulness: reminders, location etc.

• Managing and avoiding ADRs

Adherence Interventions

5. Smoking Cessation

61 62

63 64

65 66

12

FEV1 (% of value at age 25)

COPD & smoking

Fletcher CM, Peto R. The natural history of chronic airflow obstruction. BMJ 1977; 1(6077):1645-1648

100

75

50

25

025 50 75

Never smoked or notsusceptible to smoke

Smoked regularlyand susceptibleto its effects

Stopped at 45

Stopped at 65

Disability

Death

Age (in years)

• Stopping smoking is the most important & cost-effective

intervention in COPD

ACTION:

• Give very brief advice (30 seconds)

• Ask / Advise / Act

• Refer to local NHS stop smoking service:

• Web: https://oneyouleeds.co.uk/be-smoke-free/

• CPPE/NCSCT Training:

• Stop smoking NCSCT practitioners

assessment: knowledge and skills

• Learning about stop smoking support

Smoking History

Very Brief Advice

‘Do you or anyone else in your

household smoke?’

www.ncsct.co.uk

Very Brief Advice

‘Do you know that stopping smoking

can improve breathlessness, reduce

hospital admissions, help prevent

disease progression and increase life

expectancy?’

‘It’s never too late to stop.’

‘Have you ever thought of stopping or

tried to stop before? I can tell you

where to get the best help.’www.ncsct.co.uk

Very Brief Advice

‘The Local NHS Stop Smoking Service

can offer you support and advice on

quitting. You are up to 4 times more

likely to stop with the support from the

service’

‘The Stop Smoking Service can make

this much easier for you.’

‘Shall I refer you? It really is the best

thing you can do right now.’

‘It’s a free advice service’

www.ncsct.co.uk

• Signpost patients to patient resources on the internet, e.g.

• British Lung Foundation (https://www.blf.org.uk/)

• Asthma UK (https://www.asthma.org.uk/)

• Inhaler technique videos e.g.

• Asthma UK (https://www.asthma.org.uk/advice/inhaler-videos/#Videos)

• Right Breathe (https://www.rightbreathe.com/)

• BLF Breathe Easy support groups (https://www.blf.org.uk/support-

for-you/breathe-easy)

• Bradford (Undercliffe Cricket Club)

• West Leeds (St James’s Church, Pudsey)

• ‘Yeadon’ (Guiseley Theatre)

Further support for patients

67 68

69 70

71 72

13

• Summarise key points:

• Smoking cessation, inhaler technique & adherence,

vaccination, healthy lifestyle

• Confirm issues being referred to their GP

• And send it to the GP!

• Ask if they have any final questions.

• Arrange follow-up appointment.

• Record consultation on PharmOutcomes – within 48hrs

End of Consultation

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