Self-Care for Respiratory Health

Case 1 Asthma

Q: MR is a 33-year-old woman who is looking for a peak flow meter. She says she recently received a diagnosis of asthma from her physician and that he recommended this. He put MR on a few medications for her asthma and told her to monitor the progress using a peak flow. The physician mentioned green, red, and yellow zones. He instructed MR to pick up a meter from any pharmacy and read the instructions on use. She is concerned because she does not remember what his recommendations regarding the different zones were. What advice do you have for MR?

A: It is important to educate MR about the importance of using a peak flow meter, which is a portable device that measures the airflow or peak expiratory flow rate. It can help patients monitor progress and determine when to seek medical attention if they are having an attack or getting worse. As MR’s physician said, it can help patients monitor the progress of their chronic medications and how they are working. A patient should be instructed to make sure the device is reset and to take a deep breath in. Then MR should blow out as fast and as hard as she can. The best of 3 times is her normal airflow. Personal best is typically measured over 1 or 2 weeks. Make sure MR knows that her doctor should give her instructions on what to do in the red and yellow zones. If MR cannot recall the information, she should contact her doctor. The green zone is typically 80% to 100% of a person’s normal airflow. The yellow zone is 50% to 80%, and the red zone is below 50% of the personal best.¹ It is important for MR to know the numbers and what to do in each zone so that she can respond accordingly.

Case 2 Pneumococcal Disease

Q: LM is a 62-year-old woman who has a question about pneumococcal disease. She says that she had smoked for the past 30 years but recently quit. LM received a diagnosis of chronic obstructive pulmonary disease (COPD) 2 months ago and is taking 2 inhalers daily for her condition, though she does not remember the names of the medications. Her physician recommended that she go to the pharmacy and get a vaccination to prevent pneumococcal disease. LM says she has no allergies to medications and reports no other significant medical history. She is confused because there are 2 vaccines available and she wonders whether she should get both. What counseling can you provide regarding preventing pneumococcal disease?

A: Individuals with chronic lung disease are at an increased risk of pneumococcal infections. LM should receive 1 dose of pneumococcal polysaccharide vaccine (PPSV23) immediately, according to the Advisory Committee on Immunization Practices (ACIP). Because she has never received the vaccination, she would be eligible because of her newly diagnosed COPD. LM would not be eligible for the pneumococcal conjugate vaccine (PCV13) because she is not 65 or if she does not have any of the following conditions: anatomical of functional asplenia, cerebrospinal fluid leak, chronic renal failure, cochlear implants, HIV infection, immunodeficiency, or nephrotic syndrome. The ACIP recommends that patients with this group of conditions receive a PCV13 dose and 8 weeks later receive the PPSV23 vaccine to protect against invasive pneumococcal disease. When LM turns 65, she will be eligible for 1 dose of PCV13 and another dose of PPSV23 at age 67, which would be 5 years since her last dose. She will not need any more pneumococcal vaccines after that. PCV13 has an adult lifetime maximum of 1 vaccination, and PPSV23 has a lifetime maximum of 3 doses, 2 before 65 and 1 after 65. Two doses of PPSV23 before 65 are recommended only for patients with anatomical or functional asplenia, chronic renal failure, HIV infections, immunodeficiency disorders, or nephrotic syndrome.²

Case 3 Natural Remedies for Influenza

Q: GM is a 32-year-old woman who is seeking advice for self-treatment of influenza. She says she worries about getting the flu because many of her friends have gotten it. GM has avoided her friends and has no symptoms. She denies other medical problems and allergies to medications. GM has not yet discussed her concerns with her primary care provider. In lieu of prescription medications, she would like a recommendation for an herbal supplement to prevent the flu. GM’s friend recommended elderberry. What suggestions for self-care of influenza can you provide?

A: Influenza, or the flu, is a respiratory illness that is contagious. It can lead to chills, cough, fever, and weakness. Influenza is important to recognize because it can vary from a mild illness to something more severe that requires hospitalization. It is important to educate GM that the best way to prevent influenza is with the flu vaccine. In addition, the CDC recommends handwashing and staying away from sick people.³ Elderberry is a purple berry found typically in the warmer areas of Asia, Europe, and North America. The results of one study found a significant improvement in symptoms in 93.3% of cases including the elderberry extract within 2 days compared with 91.7% of patients showing improvement within 6 days in the placebo group (P<.001).⁴ The results of another study found that symptoms improved 4 days earlier.⁵ Let GM know that these results show a decrease in the number of days once a patient is exposed. Therefore, she should not use it as preventive medication. In addition, if LM does contract the flu, she should follow up with her health care provider. The studies that documented a benefit were relatively small (including <60 patients), so the results make it difficult to recommend elderberry to patients. Prescription antiretroviral agents are available and have demonstrated benefit in large, randomized trials.

Case 4 Cough

Q: HH is a 28-year-old woman who is looking for an OTC product to treat her cough. She says she has a productive cough that started about 2 weeks ago. HH’s symptoms had started to improve, but then she started feeling more congested a few days later. Her mucus is green. Over the past few days, HH has felt intermittent chills and shortness of breath. She says she did not have a fever, but she took acetaminophen because she had chills. HH says that she takes no regular medications but smokes 2 packs per day. She is a dancer and has a big show next week. HH wants to get rid of the cough before the show. What recommendations do you have for HH?

A: HH seems to be suffering from an acute cough, which can commonly be caused by postnasal drip or a respiratory infection. But because she has chills and dyspnea, she needs to visit her health care professional. It is important to educate patients about when to seek physician care, especially if symptoms are associated with dyspnea, hemoptysis, persistent fever, or weight loss or if the patient has HIV or tuberculosis.⁶ HH should also be educated about the dangers of smoking. She should be assessed for smoking cessation. Nonprescription nicotine products, such as the gum, lozenge, and patch, are available to help assist with smoking cessation. Prescription products could also be used, such as bupropion, inhalers, nasal sprays, and varenicline. If HH is interested in quitting, she should set a date to do so and plan on what do if a relapse occurs. Cessation groups are available and can help patients successfully kick the habit.

Mary Barna Bridgeman, PharmD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.Rupal Patel Mansukhani, PharmD, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

References

• Peak flow meter. American Academy of Allergy, Asthma, & Immunology website. aaaai.org/conditions-and-treatments/library/at-a-glance/peak-flow-meter. Accessed February 21, 2018.
• CDC. Recommended immunization schedule for adults age 19 years and older by medical conditions and other indications, United States, 2018. cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html#f7. Published February 6, 2018. Accessed February 21, 2018.
• Key facts about influenza (flu). CDC website. cdc.gov/flu/keyfacts.htm. Updated October 3, 2017. Accessed February 21, 2018.
• Zakay-Rones Z, Varsano N, Zlotnik M, et al. Inhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract (Sambucus nigra L.) during an outbreak of influenza B Panama. J Altern Complement Med. 1995;1(4):361-369. doi: 10.1089/acm.1995.1.361.
• Zakay-Rones Z, Thom E, Wollan T, Wadstein J. Randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections. J Int Med Res. 2004;32(2):132-140. doi: 10.1177/14732300040320020
• Lechtzin W. Cough in adults. In: Kaplan JL, Porter RS, eds. Merck Manual Professional Version. 19th ed. Kenilworth, NJ: Merck & Co; 2011.