According to the British Lung Foundation (BLF), one in five people in the UK live with lung disease. Around two per cent of the UK population live with chronic obstructive pulmonary disease (COPD), and the prevalence has risen by 27 per cent in the last decade. Asthma affects around 12 per cent of people, with around 5.4 million receiving treatment for their condition. 

In 2020, the Taskforce for Lung Health (consisting of 35 member organisations, charities and individuals) conducted a survey of 2,157 people with lung disease, and carers of people with lung disease, who use community pharmacies as part of their usual care. While those asked believed community pharmacies play a valued and essential role, the survey also revealed missed opportunities. Vital services such as medication reviews, inhaler technique checks and flu vaccinations could be more widely used if they were effectively promoted and more people knew about them.

The survey followed on from the Taskforce for Lung Health’s launch of its five-year plan in December 2018, which highlighted common causes of lung disease – air pollution, smoking and occupational exposures – along with a lack of access to treatments and care. So, over two years after the launch of this five-year plan, what progress has been made, and how could community pharmacists expand their role in improving lung health in the UK?

In 2018, the Taskforce’s five-year plan recommendations included:

• Planning and funding for high quality, easily accessible stop smoking services
• Training all healthcare professionals to offer very brief advice (VBA) on smoking cessation
• Developing a formal referral system to enable community pharmacists to refer people directly to their GP or other appropriate services or organisations
• Helping people with lung disease to use their medication properly.

The Taskforce’s medicines optimisation working group was set up to drive forward recommendations around ensuring that people diagnosed with lung disease are getting the best medicines and getting the best use out of them. Its 2018 recommendations included:

• Making sure patients and healthcare professionals know how to use inhalers properly
• Increasing awareness of community pharmacists and their role of reviewing medicines, prescriptions and patient wellbeing
• Working to ensure the right people have access to the right medicines for their specific respiratory needs.

In 2020, the Taskforce’s two-year update revealed that progress in preventing lung disease since its initial report had been slow. The Government still hadn’t published its plan to make England smoke free within a decade, and the Environment Bill, with the potential to set world-leading new air quality targets, had been delayed.

The Covid-19 pandemic has of course disrupted all healthcare services, with a significant reduction in the diagnosis of lung conditions, yet lung health has become more important than ever. Some people with a long-term lung condition are at high risk of severe illness from coronavirus. Smokers seem to be more likely to experience more severe Covid-19 symptoms, and exposure to poor air quality can worsen the effects of the virus.

“The pandemic has placed exceptional demands on people living with lung disease and healthcare professionals,” says Taskforce chair Dr Alison Cook. “Frustratingly, the redeployment of personnel and the reallocation of resources has stalled much of the progress that was being made to improve services for people with respiratory disease. 

“In other areas, Covid-19 has accelerated some positive changes, such as the implementation of diagnostic hubs, which will be ‘one stop shops’ for diagnosing respiratory patients. We are committed to working with renewed focus and vigour to support the delivery of the NHS Long Term Plan and the Taskforce’s own recommendations for policy changes and service improvements.”

The pandemic has placed exceptional demands on people living with lung disease and healthcare professionals

Helga Mangion, policy manager at the National Pharmacy Association, says community pharmacies have an important role in helping the NHS make up ground lost due to the pandemic. “Covid has simultaneously raised the profile of respiratory conditions and set back routine care in this disease area,” she says. “Pharmacies can support people’s lung health through early identification of disease, flu vaccinations, support to quit smoking and optimising medicines use, including inhalers.”

In the Taskforce’s community pharmacy survey, most people were using pharmacies for collecting and ordering prescriptions, asking for advice and buying other medicines. Fewer people were using pharmacies for face to face medicine reviews, flu vaccinations, inhaler technique checks and recycling/returning old medicines. Services related to stop smoking services (medication and advice) were the least used.

Dr Anna Murphy, consultant respiratory pharmacist at University Hospitals of Leicester NHS Trust and honorary visiting professor at DeMontfort University, says many people with asthma don’t consider inhalers to be medicines. “This is an important message for pharmacies to address,” she says. “Patients are more likely to be hospitalised if their inhalers aren’t working properly. They should have an annual review, or be reassessed if their inhaler or inhaler dose is changed. Healthcare professionals need to check that patients are using their inhalers, and if not, find out why.”

Expanding on public health services

Community pharmacies are well placed to provide healthy living advice and identify customers who may have an underlying respiratory condition. “They could expand on public health services, such as stopping smoking programmes, encourage more exercise and inform customers about good lung health,” says Dr Murphy, who is co-chair of the Taskforce’s medicines optimisation working group and is working with the Royal Pharmaceutical Society. “They should be aware of which patients need to be referred to their GP surgery because they keep coughing and taking cough medicines, for example, and where to signpost patients for a quick diagnosis and assessment. Pharmacists should also be reviewing repeat prescribing of antibiotics and oral corticosteroids.”

The Taskforce for Lung Health is using the Respiratory Outcomes Tool ‘heat maps’ data, which shows geographical variation in prescriptions for SABAs (short-acting beta-agonists, also known as relievers). This demonstrates that in many areas there is worrying overprescribing and overreliance on these inhalers, which has been linked to asthma deaths.

“Pharmacists can check that patients are using their preventer inhalers, which helps to reduce hospitalisations, and that they are not over-relying on their emergency treatments,” says Darush Attar-Zadeh, respiratory lead pharmacist and community pharmacist in Barnet, London, and co-chair of the medicines optimisation working group. “This can help to identify patients at a higher risk of respiratory attacks and those in need of a treatment review. Many people with a metered dose inhaler (MDI) aren’t being prescribed a spacer device. In some boroughs, pharmacies can become ‘Spacer Guardians’ – identifying which patients would benefit from having a spacer device with their MDI and whether the spacer has been changed in the last 12 months.”

Inhaler checks

Inhaler technique checks are a crucial part of basic care for people with lung disease, but are often missed or not carried out properly. In the Taskforce’s community pharmacy survey, 46 per cent of respondents believed they don’t need this pharmacy service, 38 per cent were receiving it elsewhere and 15 per cent said they weren’t aware it could be done at a community pharmacy.

Over the last two years, the Taskforce’s medicines optimisation working group has been working to improve training for all healthcare professionals who deliver inhaler checks to patients, and making the case for an enhanced role for community pharmacists in managing respiratory patients and their medicines. 

“People who are started on inhalers should, at a minimum, be told how to use them and be signposted to the Asthma UK videos,” says Dr Murphy. “There are subtle differences in how each inhaler is used and how to breathe in when using them. We are pushing to change the pharmacy contract so that community pharmacies can be paid to check patients’ inhaler techniques. Pharmacies are already doing so under the NMS, but we want to enhance the quality and quantity of inhaler checks.” 

Pharmacies can support...through early identification of disease, flu vaccinations, support to quit smoking and optimising medicines use

In 2020, the Taskforce reviewed and revised the UK Inhaler Group (UKIG)’s Seven Steps to Success competency document for teaching patients correct inhaler technique. “According to the UKIG, there are seven steps to using an inhaler properly; errors can occur at each step,” says Mr Attar-Zadeh. “Some inhaler devices are easier to use than others. With MDIs, for example, patients often struggle with the coordination required, or find the speed at which they need to inhale challenging. Some research has shown that around 90 per cent of healthcare professionals may make a mistake when using an MDI alone, so it’s not surprising that patients do so as well.”

In response to the practical issues associated with healthcare provision during the pandemic, the medicines optimisation working group has produced a position paper on how to optimise inhaler technique remotely. “Inhaler technique coaching shouldn’t just be a one-off event,” says Mr Attar-Zadeh. “It should be given at every possible opportunity, including respiratory reviews. Face to face is the optimal way to teach someone how to use an inhaler, but remote video consultations can also be effective – this is much more difficult over the telephone.”

Smart inhaler technology

Smart inhalers and apps for asthma are becoming increasingly available, to help track, monitor and prompt medicine use. However, according to the Taskforce’s five-year plan, barriers to the adoption of smart inhalers must be removed. For example, there is currently no universal funding mechanism for this technology to be readily provided to patients within the NHS.

Since December 2020, Berry Global Healthcare’s RS01X single dose dry powder inhaler (DPI) has been available with built-in sensors and digital capabilities – it connects to the Respiro app. According to Mauro Citterio and Marco Franza from Berry Healthcare, inhaler data can be downloaded to the app to give patients real time feedback. “Patients can choose to share this information with healthcare providers,” they say. “This enables professionals to offer advice on improved usage of the device and adjustments to the treatment programme. The app technology and data can act as companions to the inhaler, reminding patients when it is time to inhale a dose and providing personalised insights and tips to help them self manage more effectively.”

Research presented by Clement Clarke International and Clin-e-cal at the Respiratory Drug Delivery 2021 conference suggests inhalers using acoustic technology could provide a viable, cheaper alternative to smart inhalers. Clement Clarke International is developing the In-Tone actuator, which creates an acoustic signal when the inhaler is used correctly. 

The company’s acoustic technology is already available in its Clip-Tone device, which clips to the top of an inhaler and makes a whistling sound when the patient inhales at the correct speed to propel the drug into their lungs. It can be used alongside the Clip-Tone Buddy app (developed by Clin-e-cal), which uses the same technology as the Rafi-Tone app (designed for children and recommended by the NHS App Library).

Patients can also use standalone mobile apps to improve their respiratory health and inhaler usage. “Digital apps can be used alongside personalised asthma action plans to improve asthma control,” says Darush Attar-Zadeh. “The RightBreathe website (www.rightbreathe.com) and mobile app, for example, include dose reminders and videos on using different inhalers.”

Asthma nurse Karyn McBride recommends the MySpira app. “It helps children understand their condition,” she says. “This means they are visually able to learn how to use inhalers. They connect with a character, which leaves them with an image to recall.”

Digital technology has its place, but Dr Murphy stresses that respiratory patients still need regular one-to-one advice from a healthcare professional. “Smart inhalers may be a useful way to identify patients who are struggling to use their inhalers as prescribed, as some measure clicking of the device and how patients breathe in,” she says. “But while these can identify there’s a problem, these don’t solve the problem. Healthcare professionals need the right skillset in place to change patient behaviour.”