Primary Care: Respiratory Conditions in Pharmacy PDF

Primary Care: Respiratory Conditions in Pharmacy Objectives Describe the symptoms associated with upper and lower respiratory tract infections (URTI vs. LRTI) Compare signs & symptoms of respiratory system diseases: common cold, flu, rhinitis, sinusitis, cough, etc. Identify at-risk gro...

Primary Care: Respiratory Conditions in Pharmacy Objectives Describe the symptoms associated with upper and lower respiratory tract infections (URTI vs. LRTI) Compare signs & symptoms of respiratory system diseases: common cold, flu, rhinitis, sinusitis, cough, etc. Identify at-risk groups requiring vaccinations List relevant counselling points for patients with respiratory system conditions List the major causes of the respiratory system conditions Describe the treatment of common types of treatment, particularly OTC therapy Compare the signs and symptoms of viral and bacterial respiratory infections  Expanded history for respiratory tract Patient information: age, gender, health status, smoking status, etc. Complaint and duration Patient’s own story: asthma, eczema, allergies, exposure to infected contacts, etc. Occupational history Drug history: prescribed, non-prescribed, allergies, smoking, use of alcohol, etc. Family history  Expanded history for respiratory tract Symptoms: – URT  Nasal discharge/obstruction, post-nasal drip, sore throat, dysphagia, pain, fever, and earache. – LRT  Cough (nature: dry or wet), sputum (nature, colour, and odour), haemoptysis, pain, dyspnoea (shortness of breath, and wheeze), and fever (level and duration). Children: fever, appetite, and activity.  Upper Respiratory Tract (URT) conditions ORGAN PATHOLOGY SYMPTOMS Nose Mucosal swelling and Blocked nose, runny nose, and/or mucus secretion post-nasal drip. In children: feeding difficulties. Pharynx Inflammation Sore throat and/or ticklish cough. Tonsils Inflammation Sore throat, sore glands, dysphagia, and/or fever. Epiglottis Inflammation and swelling Respiratory difficulty. Larynx Swelling Altered voice and hoarseness. In children: cough, and respiratory difficulty. Trachea and Mucosal swelling and Pain, cough - dry and hacking, large bronchi mucus secretion and/or moist as secretions increase. Small bronchi Mucosal swelling, mucus Respiratory difficulty and and bronchioles secretion, and/or muscle obstruction, wheeze, cough, spasm and consolidation and/or pain on breathing.  Common cold The common cold or the cold is a viral infectious disease of the upper respiratory tract (URTIs) that primarily affects the respiratory mucosa of the nose, throat, sinuses, and larynx. The symptoms of the common cold usually last for 7–14 days. Some symptoms, such as a cough, may persist after the worst of the cold is over. Children are more susceptible to URTI than adults. Although colds are self-limiting, many people choose to buy OTC medicines for symptomatic relief. Some of the ingredients of OTC cold remedies may interact with prescribed therapy. Causes of the common cold It comprises a mixture of viral (URTIs). Rhinovirus 30 - 50% Coronavirus 15 - 20% Adenovirus 15 - 20%  Parainfluenza, or respiratory syncytial virus Enterovirus 5 - 10%  Varicella; Rubeola, Group A streptococci, Mycoplasma pneumoniae, or Herpes simplex Unknown 30%  Symptoms of the common cold Symptoms appear gradually over several hours Runny nose (rhinorrhea) Nasal obstruction Sneezing Summer colds General malaise The main symptoms are Headache nasal congestion, sneezing and irritant watery eyes; Conjunctivitis these are more likely to be Cough due to allergic rhinitis. Pharyngitis and/or laryngitis Usually those suffering from a cold often complain of feeling hot (no fever), however, fever is most common in children.  Earache is a common complication of colds, especially in children.  Flu …1 The flu is caused by an influenza virus (A, B, and C). Differentiating between colds and flu may be needed to decide about whether referral is needed. Patients in ‘at-risk’ groups might be considered for antiviral treatment. Flu is generally considered to be likely if  Temperature is 38ᵒC or higher (37.5ᵒC in the elderly).  A minimum of one respiratory symptom (cough, sore throat, nasal congestion or rhinorrhea) is present.  A minimum of one constitutional symptom (headache, malaise, myalgia, sweats/chills, and prostration) is present. Flu often starts abruptly (rapid onset of symptoms) with sweats and chills, muscular aches and pains in the limbs, a dry sore throat, cough and high temperature.  Flu …2 Someone with flu may be bedbound and unable to go about usual activities. A dry cough may persist for some time. Flu can be complicated by secondary lung infection (pneumonia). Complications are much more likely to occur in the very young, the very old and those who have pre-existing heart or lung disease (chronic bronchitis). Prevention of flu Pharmacists should encourage those in at-risk groups to have an annual flu vaccination. The vaccine provides to all patients over 65 and those below that age who have chronic respiratory disease (including asthma), chronic heart disease, chronic renal failure, diabetes mellitus or immunosuppression due to disease or treatment. Community pharmacists are in a good position to target patients each fall and remind them to have their vaccination.  Comparison of symptoms and signs in adults common cold and flu SYMPTOMS Common COLD FLU Nasal Severe Mild Sneezing Mild-moderate Mild Sore throat Mild-moderate Moderate-severe Malaise Mild Severe Headache Mild Severe Hoarseness Mild-moderate Mild Cough Mild-moderate Severe Fever and Chills Mild Severe Myalgias Mild Moderate-severe Ocular Mild Moderate-severe Patients should be advised to see their doctor in 10 – 14 days if the cold has not improved.  Respiratory Viral Vs. Bacterial infection FACTORS FAVOURING VIRAL FACTORS FAVOURING INFECTION BACTERIAL INFECTION Exudate only in adenoviral infection Exudate on tonsil or posterior pharyngeal wall Erythema of pharyngeal mucosa or soft palate Temperature less than 37.70C Pyrexia (fever) - over 37.70C Posterior lymph nodes may be Anterior lymph nodes often enlarged, enlarged. If anterior nodes enlarged, usually tender tenderness not marked Patient presents picture of mild Patient presents picture of severe illness illness Hoarseness and cough common Hoarseness and cough uncommon Sputum clear or white Sputum yellow-green Watery nasal discharge common Nasal discharge (if present) mucopurulent Conjunctivitis common Conjunctivitis rare  Nasal conditions  Acute rhinitis  Chronic rhinitis - atrophic rhinitis and vasomotor rhinitis.  Seasonal allergic rhinitis is sometimes called “hay fever”.  Allergic rhinitis - acute seasonal rhinitis, and perennial allergic rhinitis.  Drug-induced rhinitis - side effects: rhinitis medicamentosa (‘rebound congestion’).  Acute rhinitis  Acute Rhinitis (short-lived).  Causes  Usually viral, allergies and sometimes bacterial.  Symptoms  Oedema and vasodilatation of the mucous membrane, nasal discharge (rhinorrhoea), and obstruction (blocked / ‘stuffy’).  Treatment  Steam inhalation, saline drops/spray, and/or systemic or topical nasal decongestants.  Management and Treatment Steam inhalation (inhalation of water vapor)  To soothe and open the nasal passages and get relief from the symptoms of a cold or sinus infection.  It can help to loosen mucus and decrease irritation in the sinuses (NOT directly treat an illness). Saline drops/spray help relieve blocked nose in infants and kids, keeping their noses clean and healthy. For drops, recommended for children 2 weeks of age and older: 1-2 drops into each nostril as needed. For spray, recommended for children > 2 years: 1-2 spray per nostril as needed. The usual frequency of use is 2 to 4 times a day per nostril.  Topical and Systemic Nasal Decongestants  Decongestants are a type of medicine that can provide short- term relief for a blocked or stuffy nose, by constricting the dilated blood vessels in the nasal mucosa.  Sympathomimetics (vasoconstrictor): such as pseudoephedrine, oxymetazoline, and phenylephrine are effective in reducing nasal congestion.  These medicines can be given orally (tablets and syrups) or applied topically directly to the nasal cavity (nasal sprays and drops).  MECHANISM OF ACTION: Stimulation of alpha and beta receptors, either directly or indirectly.  Alpha stimulation: vasoconstriction of nasal mucosa and a reduction of nasal blood supply to the sinusoids.  Beta-2 stimulation: bronchodilatation  SYSTEMIC NASAL DECONGESTANTS DRUGS IN GROUP  Phenylephrine HCl  Pseudoephedrine HCl Indications  Relief of nasal congestion in acute and chronic rhinitis.  Hay fever (in combination with antihistamines).  Otitis media with eustachian tube congestion. Therapeutic doses individual properties Phenylephrine Pseudoephedrine  Adults 10 mg q4h. Adults 60 mg every 4 – 6  Onset of action 15 - 20 hours (max. 240 mg / 24 mins. hours).  Maximum effect 30 to 90  Onset of action 15 - 30 mins. mins.  Time to peak effect 30 to 60  Duration of action 2 to 4 mins. hrs.  Duration of action 4 - 6 hrs.  Sustained release (12 hours). SIDE EFFECTS Serious (less frequent)  Cardiac effects (chest pain, irregular or slow heartbeat).  CNS effects (hallucinations, and convulsions). Less serious (more frequent at higher doses)  Insomnia and sleep disturbances.  Hallucinations have been reported.  Other ephedrine-like symptoms may occur: nervousness, trembling, dizziness, headache, tachycardia, palpitations, sweating or flushing.  Difficult or painful urination. Decongestants – Adverse effects  Sympathomimetics can cause stimulation of the heart, an increase in blood pressure, and blood glucose levels; therefore, a caution should be taken in people with diabetes, heart disease, hypertension, and hyperthyroidism (Nasal drops and sprays is safer for these people).  Pseudoephedrine when taken orally, have the potential to keep patient awake because of their stimulating effects on the CNS. It is reasonable to suggest that the patient avoids taking a dose of the medicine near bedtime.  Hypertension Heart disease Diabetes PRECAUTIONS Hyperthyroidism Closed-angle glaucoma - elevated intraocular pressure Prostatic enlargement – urinary retention Severe hepatic or renal dysfunction Elderly/infants - more sensitive to side effects Breast feeding: excreted in breast milk Pharmacy Practice IV A  TOPICAL NASAL DECONGESTANTS INDICATIONS FOR USE Relief of nasal congestion in acute rhinitis. Otitis media with eustachian tube congestion. Drugs in group Sympathomimetic agents (phenylephrine) Imidazoles: oxymetazoline, tramazoline, and xylometazoline, naphazoline. Mechanism of action: adrenergic stimulants cause constriction of dilated arteriolar network.  TOPICAL NASAL DECONGESTANTS The decongestant effects of topical products containing oxymetazoline or xylometazoline are longer lasting (up to 6 hrs) than those of some other preparations such as ephedrine. The pharmacist should advise the patient not to use nasal sprays/drops product for longer than 7 days (usually 5 days). Rebound congestion (rhinitis medicamentosa) can occur with topically applied but not oral form.  Phenylephrine: 2-3 drops not more than 4 hourly Adults and Children above 12 years: 0.25 - 1% Children 6 – 12 years: 0.25% Children 2 - 6 years: 0.125% Oxymetazoline: 2-3 drops/sprays BID 6+ years: 0.05% THERAPEUTIC 2 - 6 years: 0.025% DOSES Tramazoline: for 6 + years: 0.1% 1-2 sprays up to QID Xylometazoline: Birth to 6 months: 0.05% 1 drop up to TDS 6 months - 6 years: 0.05% 1 spray BID - QID 7-12 years: 0.05% 2-3 drops/sprays BID - QID 12 + years: 0.1% 2-3 drops/sprays BID - QID ONSET & DURATION OF ACTION Onset  Phenylephrine within 30 minutes (5-10 mins?)  Imidazoles 5-10 mins Duration  Phenylephrine up to 3 - 4 hours  Imidazoles 5 - 6 hours; declining in activity up to 10 hours (xylometazoline), and 12 hours (oxymetazoline)  ADMINISTRATION – Sprays  Clear nose by gently blowing.  Shake container before each use.  Insert spray nozzle into nostril.  Block other nostril, and while sniffing gently, spray once with head and canister vertical and then, if a second spray is indicated, with head tilted forward and canister vertical.  Repeat for other nostril.  ADMINISTRATION – Drops  Clear nose by gently blowing.  Lie down with head lower than shoulders.  Insert the appropriate number of drops into each nostril.  Remain in the same position for several minutes to allow drops to penetrate. For babies (trouble feeding) do not use sprays  Dropper should be used use cotton bud, touch by only one person and inside nostril rinsed after use. alternate nostrils 15 minutes before feeds  Chronic rhinitis  Chronic rhinitis (long-standing) usually occurs with chronic sinusitis (chronic rhinosinusitis).  Medical assessment for exclusion of serious causes.  Symptoms: nasal obstruction, purulent nasal discharge, and/or sometimes epistaxis (nose bleeding). Treatment: antihistamines, decongestants, and/or nasal sprays. Atrophic rhinitis Vasomotor rhinitis  Symptoms: crust formation,  Symptoms: recurrent, foul (stinky) odour, frequent vasodilatation of the membrane, epistaxis, and/or anosmia sneezing, and/or watery (loss of smell). rhinorrhoea.  Cause:? no allergic component;  Treatment: topical antibiotics. exacerbated by dry air.  Antihistamines (H1 antagonists)… 1  They can reduce some of the symptoms: runny nose (rhinorrhea) and sneezing.  These effects are due to the anticholinergic action of antihistamines.  The older drugs (e.g., chlorpheniramine, and promethazine) have more pronounced anticholinergic actions than do the non-sedating antihistamines (e.g., loratadine, and cetirizine).  Antihistamines are not so effective at reducing nasal congestion.  First Generation Second Generation  ACTIONS  H1 antagonists act by competing with histamine for H1 receptor sites, prevent response mediated by histamine.  They are not effective once histamine has been released.  Sedating antihistamines:  Anticholinergic effect – Rhinitis  Central effects - use in motion sickness, and sedation. It helps the patient to sleep (included in combination products intended to be taken at night).  Antitussive (diphenhydramine) - depression of cough reflex by direct effect on cough centre. It may include in cold remedies for their supposed antitussive action.  Antihistamines … 2  Dose: commonly 1 - 2 tablets per day.  Sedating antihistamines (1st generation) are contraindicated in children less than six years of age for cough and cold symptoms. After 2 to 3 days, tolerance to sedative effects may occur  Histamine is not released in common cold, therefore, antihistamine is not a specific treatment.  OTC combinations with nasal decongestants, analgesics, cough suppressants, etc.  Antihistamines … 3  Side effect: drowsiness, sedation, and dizziness; avoid for anyone who is driving, or in whom an impaired level of consciousness may be dangerous (e.g., operators of machinery at work).  Other side effects: dry mouth, blurred vison, increased appetite, constipation, and urinary retention.  These side effects occur more frequently with first- generation antihistamines.  PRECAUTIONS  Asthma – drying/thickening effect on mucus if respiratory tract infection present; therefore, it not recommended for asthma patients due to thickening of bronchial secretions.  Glaucoma  Prostatic hypertrophy  Geriatric: More sensitive - dizziness, mental confusion, and fainting.  Paediatric o Paradoxical reaction – hyperexcitability o Caution: pregnancy: category B or C. It is not recommended to use in pregnancy, and breast feeding.  Contraindication: Neonates  Acute Seasonal allergic rhinitis Abrupt onset  Symptoms Sneezing Nasal symptoms - itching; discharge (profuse, watery, clear), and congestion. Ocular symptoms – itching and watering. Pharyngitis - itching of throat (& roof of mouth). Others: frontal headaches, irritability, loss of appetite, depression, insomnia, coughing, and wheezing  Acute Seasonal allergic rhinitis History Exposure to allergens Seasonal occurrence Other atopic allergic symptoms Family history Treatment Avoidance of allergens Antihistamines (+ sympathomimetics) Intra-nasal corticosteroids Prescription : Oral corticosteroids (desensitisation)  Intra-nasal corticosteroids …1  It helps relieve the stuffy nose, irritation, and discomfort of hay fever, other allergies, and other nasal problems through reduces inflammation.  Sodium cromoglycate  Fluticasone (Avamys ®)  Beclomethasone  Triamcinolone (Nasocort ®)  Mematasone (Nasonex ®)  Intra-nasal corticosteroids …2  Intra-nasal corticosteroids (INSs) may begin to give relief to allergy symptoms after about 3 to 10 hours, although optimal control may take several days of use.  The most common side effects include nasal irritation, sneezing, throat irritation, headaches, and nose blood, which are usually mild.  When used appropriately at recommended doses, INSs are generally not associated with substantial systemic adverse effects (AEs).  Perennial allergic rhinitis  An inflammatory condition of the nose characterized by nasal obstruction, sneezing, itching, and/or rhinorrhea, occurring for an hour or more on most days throughout the year.  The most common allergen is the house dust mite, cats and dogs.  Symptoms: nasal symptoms - chronic obstruction, as sometimes Eustachian tube blockage leading to hearing problem.  History: hypersensitivity, and positive reaction to skin patch tests  Treatment: symptomatic relief from oral antihistamines (+sympathomimetics), and intranasal corticosteroids.  Drug-induced rhinitis  Drug-induced rhinitis is a type of non-allergic rhinitis that is caused by a range of reported drug classes (e.g., NSAIDS, aspirin, alpha- blockers (e.g., alfuzosin and prazosin) and beta-adrenergic blockers, and local decongestant).  This will result in rhinitis related symptoms such as nasal congestion, itching, or runny nose.  Also, can be side effects of using some medications: o Rhinorrhoea with enalapril with methyldopa o Nasal stuffiness Pharmacy Practice IV A Drug-induced rhinitis Rhinitis medicamentosa (rebound congestion) … 1  Cause: prolonged or use of topical nasal decongestant.  Effect: nasal passages feel congested because of vasodilatation; patients continue to use in false hope of relief.  Mechanism? prolonged vascular constriction causes fatigue or failure of the constrictor mechanism resulting in reactive vasodilatation.  Symptoms/signs: chronically blocked nasal passages, nasal mucosa is red, chronically swollen, with fragile areas prone to bleeding. Pharmacy Practice IV A Drug-induced rhinitis Rhinitis medicamentosa (rebound congestion) … 2  Treatment:  Discontinuation of topical therapy (cessation of all drops/spray).  Substitution of saline drops/spray.  Replacing topical medication with systemic medication (sympathomimetic or antihistamine).  Assessment  Severity: if severe, may need steroid treatment or surgery  Underlying conditions; anatomical causes e.g. deviated septum, or disease states such as allergy or bacterial sinusitis. Pharmacy Practice IV A Ear Problems  Ear Problems in pharmacy Although the treatment of common ear problems is straightforward, it is not easy to make an accurate diagnosis at the pharmacy. It is not always possible to determine the problem from the story (symptoms). A key issue for the pharmacist is the potential risk from not examining the inside of the ear and seeing how the ear looks. Diagnosis is thus best made by the doctor, who can examine the ear with an auriscope or otoscope. Referral to the doctor is therefore advisable for ear problems. Ear problems – signs and symptoms Site Signs & Symptoms External ear Itch, pain, discharge, and hear problem and deafness Middle ear Pain, discharge, and deafness Inner ear Deafness, dizziness, tinnitus  Otitis Externa Otitis externa (OE) involves inflammation and infection of the skin in the ear canal. OE may be localized or diffuse. In the diffuse, a combination of some or all of pain, itching, hearing CONDITION SYMPTOMS loss and discharge. Otitis Pruritus Localized is due to a furuncle (boil), externa Pain the main symptom is ear pain. Discharge Sometimes it is a site of eczema, Scaliness which may become secondarily Mild deafness? Furuncles Localised infected. (Boils) Pain It is also known as 'swimmer's ear’; Deafness? it is five times more common in Discharge Wax Deafness swimmers than in non-swimmers.  Otitis Externa … Causes Dermatological conditions such as eczema; contact dermatitis (e.g. chlorine in pools). Bacterial or fungal infection; heat and moisture (e.g. when swimming) encourage growth, disturbance of normal acid environment by water, soap or debris also encourages infection. It is more frequent in hot and humid environments and is ten times more common in summer than winter. Inflammation of external auditory canal or auricle; often follows water maceration.  Otitis Externa - Signs and Symptoms – Scaling: dermatitis of the ear canal is characterized by pruritis, scaling, flaking, and erythema of the skin of the external auditory meatus and ear canal. – Itch / irritation Skin may become red and swollen - swelling in narrow opening may cause pain - pain on pulling the earlobe is diagnostic for infection or inflammation of the outer ear. If condition becomes infected, pus may block canal and cause deafness, pus or blood may be visible in the canal. Dry scales in the canal or outer ear usually indicate fungal infection - itch is also greater.  Referral to a doctor Referral to the doctor may be necessary for accurate diagnosis. It is possible that the same symptoms can arise from a middle ear infection (otitis media) with a perforated eardrum. Antibiotics or antifungals, often in conjunction with topical corticosteroids. Systemic antibiotics needed if fever, spread of inflammation to pinna, or folliculitis.  Otitis Externa - Treatment Acidic alcohol-based ear drops to dry ear canal and restore normal pH, e.g. acetic acid + isopropyl alcohol (Aquaear®, or Ear Clear®). Acetic acid 2% solution is effective, as it has both antibacterial and antifungal effects and works by increasing the acidity of the ear canal, making it more difficult for pathogens to grow. The spray must be primed before use by pressing the actuator up and down until a fine mist is seen. The nozzle is then placed into the ear and pressed once to deliver the correct dose.  Prevention of recurrent otitis externa: People who are prone to recurrent OE  Water exclusion with ear plugs.  Instil acidic alcohol-based ear drops after shaking water out; regular use is essential – susceptible individuals must use EVERY time after swimming  Try not to let soap or shampoo get into the ear canal. While having a shower, placing a piece of cotton wool coated in soft white paraffin (e.g. Vaseline) in the outer ear or silicone rubber earplugs.  Let it dry naturally, and do not use cotton buds to dry any water that does get in the ear canal.  Try not to scratch or poke the ear canal with fingers, cotton wool buds, etc.  Furuncles (boil); (acute localised otitis externa) Localised condition associated with hair follicle. Produces significant pain. If large, may block canal and cause deafness. Relief when ‘boil’ bursts – discharge. Treatment Simple analgesics; local heat? Systemic antibiotics usually effective. Surgical drainage?  Earwax Wax blocking the ear is one of the commonest causes of temporary deafness. It may also cause discomfort and a sensation that the ear is blocked. Wax is present to prevent build-up of foreign particles in ear. Some individuals are prone to excessive secretion. If wax becomes impacted, patient will complain of deafness.  Earwax - Treatment Do not use a cotton bud – increases impaction and risks perforation of ear drum. Ear drops to soften wax e.g. – Docusate sodium (Waxol®) – Arachis oil (Cerumol®) o Warm drops (ideally to body temperature). o Lie on the side to increase contact. o Treatment may need to be repeated - may take several days. Stubborn cases may require syringing - refer  Middle ear - Otitis media Inflammation of the middle ear; may be due to viral or bacterial infection. Most common cause of earache in children, usually accompanying a viral respiratory tract infection. Acute otitis media Otitis media with effusion (Glue ear) – Refer Chronic otitis media – Refer  Acute otitis media - Signs and Symptoms  Mild inflammation of the middle ear – Reddening, dullness and possibly bulging of the tympanic membrane. – + fluid in middle ear – + fever – Hearing loss, ear fullness, and headache. – Rapidly increasing pain - may be evident in a young child by irritability and pulling at the ear. Self-limiting (60% resolve within 24 hours)  Acute otitis media - Treatment Simple analgesics – paracetamol. NOT ear drops containing analgesic/ anaesthetic. (may mask symptoms – perforation of ear drum may result). Refer after 24 hours (6 months – 2 years) or 2 days (> 2 years) if pain/fever persist. NOTE: Antibiotics have only moderate benefit. NO evidence of benefit from decongestants or antihistamines. Otitis media with effusion (‘glue’ ear); serous otitis media In ‘glue’ ear’, the middle ear becomes filled with non-infected mucus. Common in children. Causes hearing impairment, and persistent deafness must be referred. Diagnosis requires persistence for more than 3 months (90% of cases are spontaneously resolved in 3 months). NO evidence of benefit from decongestants or antihistamines. Bacterial infection may contribute. Those with persistent problems may benefit from 10-30 day course of antibiotics.  Negative middle ear pressure If passage of air is impeded (e.g., due to oedema from URTI), negative pressure may build up in the middle ear, leading to pain. Over time, negative pressure can build up in the ear, causing pain, ear fullness, and muffled hearing. Less common in adults (except when flying) because the Eustachian tube is larger. Swallowing or crying can help to open the Eustachian tube and even up the pressure. Systemic or topical decongestants can help. Simple systemic analgesics and local heat can relieve pain.  Barotrauma “Airplane Ear” When flying, as the plane descends the air pressure in the cabin increases. If the Eustachian tube is blocked, pressure differences cause pain. Can be relieved by forcing air up the Eustachian tube to correct the negative pressure: – Sucking a sweet. – Valsalva technique is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon.  Other ear symptoms: Tinnitus Tinnitus is the perception of sound that does not have an external source. Tinnitus is a common problem; it affects about 15% to 20% of people and is especially common in older adults. Tinnitus is commonly described as a ringing sound, but some people hear other types of sounds, such as roaring or buzzing. The noises of tinnitus may hear in one or both ears. Sometimes, tinnitus is a sign of high blood pressure, an allergy, or anemia. Causes: ageing, changes in pressure (e.g., flying), using some drugs e.g., quinine, or aspirin (high doses), and wax? If it bothers the patient, see a doctor to find out the underlying cause, because there is usually no treatment available.  COUGH Functionof cough reflex is to remove foreign matter and debris to protect lung function. Cough - rapid expulsion of air from lungs (voluntary or involuntary). Respiratory tract and other areas contain chemical and mechanical receptors. Cough involves complex reflex arc that begins with stimulation of these receptors. Afferent (sensory) impulses pass along nerve fibres to the cough centre in the medulla. Efferent (motor) impulses to the diaphragm, intercostal and abdominal muscles.  Cough - classification This cough is usually caused by viral infection and self-limiting. Unproductive No abnormal production of LRT (dry, ‘tickly’) secretions. Results from: pharyngitis; irritation of cough cough receptors. Coughing ineffective and unnecessary. Excess bronchial secretion and cell debris impair mucociliary clearance. Productive Cough is a mechanism to loosen and expectorate excess secretions. (wet/moist) Over secretion may be caused by irritation cough of the airways due to infection, allergy, etc. or when the cilia are not working properly (e.g. in smokers).  Cough Suppressants - ANTITUSSIVES  Antitussives: agents that reduce coughing.  Where there is no identifiable cause (underlying disorder), cough suppressants may be useful. A. Centrally acting – produce cough suppression by acting on the medullary cough centre or associated higher centres 1. Narcotic (prescribed): codeine, dihydrocodeine, and pholcodine. 2. Non-narcotic (available without a prescription): dextromethorphan, and butamirate.  Non-specific depression of higher centres in the CNS.  Interruption of transmission of nerve impulses from bronchial tract to the brain or to muscles involved in act of coughing. Centrally acting cough suppressants – Narcotic INDICATIONS FOR USE Suppression of unproductive cough (check for underlying cause) THERAPEUTIC DOSES Codeine phosphate/sulphate (prescribed) Adult 10-20 mg every 4-6 hours – Analgesic levels 30 mg – Narcotic, thus potential for abuse – Side effects: GI effects – nausea, vomiting, appetite loss, and constipation (especially in elderly); Central – headache, light-headedness; and has drying effect, caution in asthma (secretions difficult to expel). Dihydrocodeine tartrate/bitartrate – Antitussive action equal to codeine, similar analgesic action and abuse potential to codeine. Pholcodine 20 mg equivalent to 15 mg codeine – Less dependence potential than codeine. – Little analgesic effect. – Side effects – mild (drowsiness, nausea), and equal to codeine in respiratory depression.  SIDE EFFECTS – Codeine and derivatives Serious – Codeine & derivatives may depress respiratory centre – caution in patients with respiratory problems. – Allergy – skin rash, hives, facial oedema, and bronchospasm. – CNS stimulation – paradoxical reaction, especially in children – unusual excitement, and restlessness. – CNS depression – confusion. – Paralytic ileus – severe constipation, bloating, nausea, stomach cramps/pain, and vomiting (patients with inflammatory bowel conditions). – Histamine release – decreased BP, fast heart rate, increased sweating, redness or flushing of face, and wheezing. Less serious – Drying effects – decreased urination, blurred vision, constipation, and dry mouth. – Central effects - dizziness, and drowsiness (common). Centrally acting cough suppressants – Non-Narcotic Dextromethorphan hydrobromide (available without a prescription) INDICATIONS FOR USE Suppression of unproductive cough. It is less potent than codeine and derivatives Adult 10-20 mg q4h or 30 mg every 6-8 hours Low abuse potential Comparable to codeine on a mg/mg basis Side effects - mild drowsiness, and mild GI upsets  Centrally acting cough suppressants CONTRAINDICATIONS & DRUG INTERACTIONS CONTRAINDICATIONS Do not give to children < 2 years – more prone to complications. Nocturnal cough in children – refer (must exclude asthma). DRUG INTERACTIONS Centrally acting drugs: other central acting drugs may cause respiratory depression. Anticholinergic antitussives (diphenhydramine): may get dry mouth and constipation. Antihistamines: sedation; and should avoid alcohol.  Butamirate - Centrally acting cough suppressants Antitussive structurally unrelated to opioids. It works by binding to the cough center in the brain. It is indicated to treat dry cough. It also has peripheral anti-inflammatory and broncho spasmolytic activity. Dose: 15 ml (7.5mg/5ml) up to 4 times daily S/E: may cause drowsiness or dizziness (caution: do not drive or operate machinery). Also, may cause nausea, vomiting, diarrhea, somnolence, dizziness, hypotension.  ANTITUSSIVES - Peripherally acting B. Peripherally acting – produce effect by action on cough receptors of pharynx, trachea and bronchi. 1. Local analgesic effect on respiratory tract (e.g. camphor, and menthol). 2. Enhance drainage of bronchial secretions by reducing viscosity of sputum (expectorants, and hydrating agents). 3. Demulcent or soothing effect on irritated throat and bronchial airways (honey, syrup, and expectorants). 4. Relaxation of smooth muscle of bronchial tract when bronchospasm present (bronchodilators).  EXPECTORANTS INDICATIONS To promote or facilitate evacuation of secretions in the bronchial tract. Achieved by: a) Reducing the thickness of mucus. b) Augmenting formation of more fluid secretions; through stimulating bronchial mucus secretion, leading to increased liquefying of sputum, and making it easier to cough up. c) Alternatively, they may act indirectly via irritation of the gastrointestinal (GI) tract, which has a subsequent action on the respiratory system resulting in increased mucus secretion. Additionally, expectorants may indirectly diminish tendency to cough by: a) Facilitating evacuation of the irritants. b) Soothing ‘demulcent’ effect on inflamed membranes. c) Physical barrier against irritants. Weak activity; limited evidence of effectiveness.  EXPECTORANTS - MoA: Guaiphenesin - gastric reflex and direct action on bronchial secretions. Bromhexine – mucolytic; acts on the mucus at the formative stages in the glands, within the mucus-secreting cells. Ambroxol – mucolytic; breaks down the acid mucopolysaccharide fibers which makes the sputum thinner and less viscous. Sodium Citrate - mucolytic Potassium Iodide – mucolytic; may cause enzymatic hydrolysis of protein in sputum and thus break down integrity. Ammonium chloride - gastric reflex action Ipecac - gastric reflex action [Not available] Squill - gastric reflex action [Not available]  THERAPEUTIC DOSES Adult (+ Children Children 6 - 12 Children 4 - 6 Children 2 - 5 over 12 years) years old years old years old Guaiphenesin 200 - 400 mg 100 to 200 mg 50 to 100 mg Not every 4 hours every 4 hours every 4 hours recommended Bromhexine 8 -16 mg 3 - 4 4 mg 2 times 4 mg 4 times daily times daily daily Ambroxol 30 - 120 mg 2 – 3 30 mg 2 – 3 15 mg 3 times 15 mg 2 times times daily times daily daily daily  SIDE EFFECTS Most have a good safety record Guaiphenesin: mild effects (rare) – nausea, vomiting, and diarrhoea. Bromhexine: GI effects, headache, and dizziness. Ammonium Chloride: acidosis may occur, esp. with high doses or in patients with hepatic, renal, or pulmonary insufficiency. Acid urine may affect excretion of other drugs. Ipecac: alkaloids toxic to heart, liver, kidney, GI tract, and muscle (Not recommended). Potassium Iodide: SEs high in long term use due to iodine. Squill: higher doses cause nausea, vomiting, violent purging; and glycosides may be toxic to heart. Sodium Citrate: high sodium content may exacerbate disease states; mild diuretic, laxative in larger doses, and GI irritant if undiluted. CONTRAINDICATIONS Generally, no absolute contraindications to taking expectorants Ammonium Chloride: – Patients with renal, hepatic, and pulmonary insufficiency who cannot cope with acidosis. – Patients on drugs affected by acid urine. PATIENT COUNSELLING Get plenty of rest and keep warm. Try to breathe moist air, use a humidifier. Drink plenty of fluids, consume warm fluids, and avoid cold drink.  Demulcents Preparations such as glycerin, lemon and honey or simple Linctus are popular remedies and are useful for their soothing effect. They are common ingredients in cough mixtures and cough drops. They do not contain any active ingredient and are safe in children and pregnant women. Their pleasant taste makes them particularly suitable for children, but their high syrup content should be noted.  BRONCHODILATORS [Prescribed] INDICATION FOR USE For relief of bronchospasm involved with asthma or bronchitis. Overcome the spasm that causes narrowing of the bronchial air tubes. They achieve this by relaxing bronchial smooth muscle by:  Stimulation of the beta-2 receptors in the bronchial tree; salbutamol, and terbutaline (sympathomimetics)  Blocking cholinergic vagal nerve reflexes which mediate bronchoconstriction; theophylline (Xanthines) NOTE: Do not initiate therapy, breathing difficulty requires assessment Selecting combination products 1. Match active ingredients to symptoms. 2. Ensure active ingredients are safe (and effective). 3. Ensure all active ingredients are at therapeutic levels. 4. Ensure combination of active ingredients is rational. 5. Ensure active ingredients are not contraindicated by disease states or lifestyle. 6. Avoid or counsel on drug interactions.  Criteria of rational combinations Individual ingredients are at therapeutic levels. Dose spacing is appropriate for each ingredient. Indications for use are restricted to the indications of use for the active ingredients. Does NOT contain two (or more) active ingredients which work by the same mechanism for the same indication. Does NOT contain ingredients which have opposing pharmacological effects  Role of pharmacist in adult vaccination Three roles for pharmacists in immunization: - Pharmacists as facilitators (hosting others who vaccinate). - Pharmacists as advocates (educating and motivating patients). - Pharmacists as immunizers (vaccinating patients). Reference: ASHP Guidelines on the Pharmacist’s Role in Immunization. https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/pharmacists-role-immunization.ashx  Influenza vaccination Influenza vaccines, also known as flu shots, are vaccines that protect against infection by influenza viruses. New versions of the vaccines are developed twice a year, as the influenza virus rapidly changes. While their effectiveness varies from year to year, most provide modest to high protection against influenza. Routes of administration: Intramuscular, and intranasal (nasal spray flu vaccine).  Influenza vaccination – Risk groups Those potentially at risk of developing serious complications from influenza – Persons over 65 years of age. – Persons of all ages with chronic debilitating disease e.g., cardiac, pulmonary, renal and metabolic disorders. – Persons receiving immunosuppressive therapy – Persons residing in a nursing home or other long-term care facility. – Healthcare personnel if particularly at risk or working in a nursing home / long-term care facility. – Pregnant women. – Children (6 months and 5 years old).  Influenza vaccination - counselling Contra-indications: Anaphylactic hypersensitivity to eggs, neomycin, polymyxin, any other component. Acute feverish illness (fever > 38.5ºC). S/E the vaccines are generally safe. Main S/E is fever, and temporary muscle pains or feelings of tiredness. Dosage and Administration: Yearly vaccination – one dose.; normally taken in the fall. In children and the immunocompromised, two doses separated by an interval of at least 4 weeks.  Infants 6 months to 2 years 0.125 mL  Children 2 - 6 years 0.25 mL  Adults & children > 6 years 0.5 mL  Pneumococcal vaccination The Pneumococcal vaccine (PCV) can protect against pneumococcal disease, which is any type of infection caused by Streptococcus pneumoniae bacteria. It is recommended for adults who never received a PCV and are ages 65 years or older, and ages 19 through 64 years old with certain risk conditions. The vaccine should give once, and, if needed, the second dose can be given at least 5 years after that.  Pneumococcal vaccination - risk groups  Persons over 65 years of age  Immunocompromised individuals (e.g. those with HIV infection, nephrotic syndrome, multiple myeloma, lymphoma, Hodgkin’s disease, and organ transplantation).  Those at increased risk of complications because of chronic illness (e.g. diabetes; alcoholism; chronic cardiac, renal, and pulmonary disease).  Persons with cerebrospinal problem.