From Ms S. Greene, MRPharmS and Ms V. Wallroth, MRPharmS
SIR,—We welcome the recent publication of practice guidance on the care
of people with asthma and chronic obstructive pulmonary disease (PJ, September
16, p390). However, we would
like to highlight an issue regarding nebulised drug therapy that should be addressed
by pharmacists in both primary and secondary care.
Education of patients with regard to domiciliary nebuliser use is vital in the
appropriate management of severe asthma and COPD. The incorrect perceptions
that some asthmatic and COPD patients have of their need for nebulised therapy
may lead to irrational prescribing and, in some cases, dangerous practice. Unfortunately,
the practice guidance omits making recommendations on how to deal with patients’
requests for obtaining a nebuliser.
The British Thoracic Society guidelines for nebulised therapy clearly state
that nebulisers should only be prescribed for asthma or COPD after assessment
by a respiratory specialist (defined as a chest physician, paediatrician or
general medical practitioner who has undergone specific training). They also
state that patients should not be advised to buy such equipment themselves.
However, we hear anecdotal reports of neighbours borrowing compressors, devices
turning up at car boot sales and patients being sold nebulisers in the community,
without formal assessment.
The selling of a nebuliser to a patient who has had no formal assessment could
lead to a GP being pressured into prescribing nebules, whether appropriate or
not, at the demand of the patient. Nebulised therapy can be beneficial when
used in the correct circumstances, but equipment is not cost-effective when
over or inappropriately used. Overreliance on nebulisers at home may delay patients
from consulting their GP or a casualty department. As a result, their condition
can become more difficult to treat, often requiring admission.
Supplying patients with a nebuliser is not always the best intervention we can
make. Recommending a large volume spacer with a bronchodilator in a metered
dose inhaler is endorsed by the BTS, and is just one option that may offer the
patient more freedom and allow them to maintain a better quality of life. Perhaps
the inclusion of a nebuliser referral form in the practice guidance might enable
a formal mechanism for effective liaison between GP and community pharmacists
to be established and, ultimately, improve patient care.
The issuing of practice guidance for specific clinical areas is a positive approach.
If, in the future, a National Service Framework is developed for lung disease,
we hope it will further stimulate pharmacists to work with GPs and others to
minimise inappropriate patient pressure and, in addition, optimise the use of
nebulised therapy.
Sally Greene
Clinical Pharmacist, Respiratory Medicine,
Whiston Hospital,
Merseyside
Verna Wallroth
Associate Editor, Merec Publications,
National Prescribing Centre,
Liverpool