9.2 Asthma & COPD

9.2 Asthma & COPD

Quick Answer: Separate reliever (quick symptom relief) from preventer (anti-inflammatory control, usually inhaled corticosteroid). Fix device technique and adherence before assuming the medicine “does not work.” Support written action plans, short-course oral steroids only for prescribed exacerbations, smoking cessation in COPD and asthma, and emergency referral for life-threatening features. Confirm regimens and stepwise choices in AMH/Australian asthma and COPD pathways.

Respiratory medicines are high-frequency Intern Written content because they combine pharmacology, device skill, monitoring of control, and acute safety-netting (Competencies 3.1–3.3 and health promotion overlaps).

Asthma — pathophysiology framing for pharmacists

Asthma involves variable airflow limitation, airway inflammation, and hyper-responsiveness. Symptoms include wheeze, dyspnoea, chest tightness, and cough — often worse at night or with triggers (viral infection, allergens, exercise, smoke). Pharmacotherapy aims to:

1. Control inflammation (prevent exacerbations and remodelling risk)
2. Relieve acute bronchoconstriction safely
3. Minimise adverse effects and over-reliance on short-acting bronchodilators alone

Reliever versus preventer

Critical counselling point: Feeling well does not mean stop the preventer. Patients commonly abandon ICS when asymptomatic, then present with preventable exacerbations. Explain that preventers work on inflammation over days to weeks; relievers do not replace anti-inflammatory therapy.

ICS adherence and safety

Inhaled corticosteroids are the cornerstone of persistent asthma preventer therapy. Counselling:

• Use every day as prescribed, even when well
• Rinse mouth / spit after ICS (and ICS–LABA) to reduce oral candidiasis and dysphonia
• Spacer use with pMDI can improve lung deposition and reduce oropharyngeal side effects
• Do not escalate to oral corticosteroids for mild day-to-day symptoms without a plan — oral steroids have systemic toxicity

Local adverse effects (thrush, hoarse voice) are common and manageable; systemic effects are less at standard inhaled doses but still relevant at high doses long-term (bone, adrenal, skin) — monitor step-down when control allows.

MART concepts (high-level)

Maintenance and reliever therapy (MART) uses a single ICS–formoterol inhaler for both regular maintenance doses and as-needed relief, within approved stepwise asthma regimens. Formoterol’s onset supports reliever use; the ICS component delivers anti-inflammatory treatment with each relief actuation — addressing the problem of SABA-only overuse without steroid coverage.

Pharmacist counselling for MART:

• Which inhaler is the MART device (do not mix with a separate SABA plan unless the written plan says so)
• How many maintenance actuations daily
• How to use extra actuations for symptoms and the maximum daily actuations before seeking urgent review
• That MART is not “use only when wheezy” if a maintenance dose is prescribed

If a patient on MART still carries an old SABA and dual-uses chaotically, reconcile the plan — confusion causes both under-treatment and toxicity risk.

Device technique — the counselling that saves lives

Wrong technique is a leading cause of “treatment failure.” Always check technique at initiation, when control is poor, and at regular reviews.

Pressurised metered-dose inhaler (pMDI) essentials:

1. Shake (if required for product)
2. Exhale gently away from device
3. Seal lips; start slow deep inhalation as you actuate
4. Continue inhaling; hold breath ~5–10 seconds if able
5. Wait between actuations as directed
6. Prefer a spacer for most adults and children using pMDI for asthma/COPD rescue or ICS — reduces coordination demand and oropharyngeal deposition

Dry powder inhalers (DPI): require adequate inspiratory flow; counsel forceful deep inhalation, device-specific priming/loading, and moisture protection.

Soft mist inhalers: follow device-specific actuation and slow inhalation technique.

Never assume a patient “has been on this for years” means technique is correct. Ask them to demonstrate.

Spacers

Spacers (valved holding chambers) improve pMDI delivery. Key points:

• Compatible mouthpiece/mask fit
• One actuation into spacer at a time (unless specific product advice differs)
• Tidal breathing or single breath-hold methods as taught
• Regular cleaning per manufacturer to reduce electrostatic drug loss (avoid rough drying that increases static for some devices)
• Replace when valves fail or device is damaged

Supplying a preventer without assessing spacer need for a poorly coordinated pMDI user is incomplete care.

Asthma action plans and oral corticosteroids

Written asthma action plans define green/yellow/red zones: usual medicines, how to step up, when to start oral corticosteroids if prescribed for home use, and when to call emergency services. Pharmacists reinforce the plan at dispensing and after exacerbations.

Oral corticosteroids (e.g. prednisolone short courses) are for acute exacerbations under a clinician plan — not daily maintenance for typical asthma. Counsel:

• Exact dose and duration (often several days — confirm prescription)
• Take in the morning with food if GI upset
• Mood, sleep, glucose rises (especially diabetes), and infection risk awareness
• Do not stop abruptly after longer courses without advice (adrenal suppression risk with prolonged therapy)

Severe asthma exacerbation — red flags

Urgent/emergency care (call emergency services / hospital), not “wait and see at home”:

• Severe breathlessness, inability to complete sentences, exhaustion
• Cyanosis, confusion, drowsiness
• Silent chest, collapsing, oxygen desaturation if measured
• Little or no response to reliever as directed
• Parental concern in children with marked work of breathing, feeding refusal, or lethargy

While awaiting help, patients use reliever as per emergency plan (often via spacer) — but pharmacy delay must not replace ambulance activation.

COPD — community therapeutic concepts

Chronic obstructive pulmonary disease features persistent airflow limitation, usually from smoking or other exposures. Goals: reduce symptoms (dyspnoea, cough, sputum), prevent exacerbations, improve function, and address comorbidities.

Foundations before “more inhalers”

1. Smoking cessation — single most important disease-modifying intervention; offer brief advice, behavioural support, and pharmacotherapy (NRT, varenicline, bupropion as appropriate) every opportunity
2. Vaccination — influenza, COVID-19 per current schedules, and pneumococcal vaccination concepts for chronic lung disease (see Section 9.4)
3. Pulmonary rehabilitation and activity — refer when available
4. Inhaler technique and adherence — same critical counselling as asthma

Dual and triple therapy concepts (high-level)

COPD stepwise inhaled therapy commonly includes:

• Bronchodilators: LABA and/or LAMA for symptom and exacerbation reduction
• ICS-containing regimens in selected patients with higher exacerbation risk or asthma–COPD overlap features — not every COPD patient needs ICS
• Triple therapy (ICS + LABA + LAMA) for patients who continue to exacerbate or remain highly symptomatic despite dual long-acting bronchodilation, per guideline criteria

Pharmacist role: ensure the patient understands which inhaler is for daily maintenance versus any short-acting reliever, check technique, watch for ICS thrush risk, and flag duplicate same-class inhalers from multiple prescribers.

COPD exacerbations

Exacerbations may need increased bronchodilators, short-course oral corticosteroids, and antibiotics only when bacterial infection criteria are met (purulent sputum with increased dyspnoea/volume patterns — follow clinical guidelines). Stewardship still applies: not every “bad day” is bacterial.

Red flags: severe dyspnoea, cyanosis, confusion, drowsiness, chest pain, haemoptysis, or failure to respond — emergency care.

Monitoring control

For asthma, ask about night waking, reliever frequency, activity limitation, and exacerbations. Frequent SABA refill without preventer use is a control failure signal — open a clinical conversation and recommend medical review. For COPD, track exacerbation frequency, dyspnoea, and inhaler possession ratios.

Exam mindset

Intern items often hinge on technique, preventer adherence, MART dual-role clarity, spacer use, short-course oral steroid limits, smoking cessation, and emergency red flags. Drug names matter, but process skills pass the exam.