Lung Health Education Al and Preventative Health Event

Lung Health – Educational and Preventative Health Event Participant Guide

Introduction

Pharmacists are well-positioned to provide education and preventive health initiatives for the benefit of patients and the public.

This guide describes a Lung Health service that has been successfully prototyped by pharmacy students and pharmacists at the UBC Pharmacists Clinic. The clinical and procedural materials have been modified to enable any pharmacist to provide a similar service using equipment and materials routinely available in a community pharmacy.

The service includes the following components:

 Information on the structure and function of the lungs  Measurements of lung function: Respiratory rate and pattern, and peak expiratory flow  Information on factors that impact lung health and assessment of personal risk factors  A personalized plan for maintaining healthy lungs and managing lung conditions when present

To ensure accountability and compliance with regulatory requirements, all health care services should be provided by licensed pharmacists, pharmacy students supervised by a licensed pharmacist or other regulated health care professionals.

NOTE - This guide does not cover logistic and business aspects of organizing a health event such as: advertising, where to hold the event, identifying participants, booking appointments, charging fees, liability issues, offering service to local businesses, etc.

About the Pharmacists Clinic

The Pharmacists Clinic, located at the UBC Faculty of Pharmaceutical Sciences, is a university-affiliated, licensed, pharmacist-led patient care clinic with a mandate to:

 Be a model of patient care best-practices  Provide learning and skill development opportunities for health professionals and students  Be a living lab that contributes service models, systems, processes, research and program evaluation for the health care community.

More information about the Clinic is available here:

October 2017 1 https://pharmsci.ubc.ca/pharmacists-clinic

2 Service Approach

Participants are typically scheduled at 15 minute intervals with the total appointment time being about 20 minutes, although this may vary.

Two options for service delivery are:

 Participants move from station to station and receive part of the service at each station  Participants receive all services from one person  If enough pharmacists/students are available, 2 or 3 participants can receive service at the same time in parallel service streams.

Participants receive a Lung Health Passport where information about their health is recorded and they will take home. NOTE – the pharmacy needs to also keep a record of service provided. This can be done using an excel spreadsheet, taking a copy of the completed passport or using an electronic record.

The order of service is at your discretion, however, experience has shown that the following step-wise approach provides a logical flow.

Station* Step in Passport Service Description (if used) A Register participant in pharmacy record and give passport 1 Complete the “About Me” section B Explain the structure and function of the lungs 2 Check hMeasure height, weight, BMI, respiratory rate, breathing pattern, lung conditions and lung-related symptoms 2-53 Complete the “My Body”, “My Breathing”, My Lung Conditions” and My Symptoms sectionsNote breathing pattern C 74 Measure lung function (peak flow) Complete “Known Lung Conditions” section 8 Complete the “My Risk Factors” section 6 Complete the “Current Medications” section 5 Complete “Lung Related Symptoms” section 6 Measurement of lung function (peak flow) 7 Interview patient to determine risk factors for lung disease 8 Complete the “Current Medications” section D 9 Interpret results and establish “My Plan” with the

October 2017 3 patient 10 Pharmacist signs the passport Copy of information in the passport is retained at the pharmacy and patient takes the passport. *If service offered in stations, Station A can be manned by an administrative person. Stations B and C can be manned by pharmacy students with pharmacist supervision. Station D is for the licensed pharmacist.

4 Materials

In addition to this Guide, materials provided for use at a Lung Health event are:

 Lung Health Passport  Images (to print or load onto an iPad and have available at Station B)  Clinical Resources (to have available at Stations C and D)  Images (to print or load onto an iPad and have available at Station B)  Recommended list of supplies to have on-hand

Preparatory Readings

Clinical people (pharmacists/students) who will be providing service in the Lung Health event are encouraged to read the following materials so they are familiar with the elements of lung health being measured and discussed:

1. Overview of lung anatomy and physiology

The Lung Association – Respiratory System https://www.lung.ca/lung-health/lung-info/respiratory-system

The Lung Association – - Breathing https://www.lung.ca/lung-health/lung-info/breathing

Animations of respiration: https://www.youtube.com/watch?v=k4uNapAUCQU https://www.youtube.com/watch?v=eGicIbMde2E

2. O2 Sat explanation http://www.pulseox.info/pulseox/what2.htm https://www.thoracic.org/patients/patient-resources/resources/pulse-oximetry.pdf

23. Peak flow meter overview http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with- asthma/managing-asthma/measuring-your-peak-flow-rate.html

34. Proper breathing techniques https://www.youtube.com/watch?v=JeDiS7MWXNk

45. Immunization Influenza: http://www.healthlinkbc.ca/healthfiles/hfile12d.stm Pneumococcal: http://www.healthlinkbc.ca/healthfiles/hfile62b.stm

October 2017 5 Service Delivery - Step-by-Step

Station A

“Welcome to our Lung Health event. You will be receiving information about your current health status and habits that impact on the overall health of your lungs. Information will be recorded in a passport for you to take with you. To start, we will record your name, year of birth, your gender and today’s date. Please proceed to the next station.”

6 Station B

“At this station, I will explain how lungs function, we will record information about you and your lung health and we will check the way you breathe measure your breathing and oxygen level in your blood. Do you have any questions before we start?”

Discuss kKey messages: (use images and pictures to facilitate discussion and provide context)

 Your Our lungs have an important role in keeping youus strong and well.  Most people take their lungs for granted until they experience problems with breathing. The reality is, like the rest of our body, our lungs need daily care and attention.  Lungs at rest and during most daily activities are working at only 50 percent of their capacity. This means we have some reserve if something goes wrong, but it also means we can have a serious lung disease, yet show no symptoms.  Chronic lower respiratory (lung) disease is in fact the 4th leading cause of death in Canada (2014 StatsCan)

 The lungs are part of a complex apparatus, expanding and relaxing thousands of times each day to bring in oxygen into the body and expel carbon dioxide out  Review diagram of respiratory system (you may elect to show an image for ) https://www.lung.ca/lung-health/lung-info/respiratory-system

Respiratory tract Function Pathology component Airways Conduct air -Asthma (chronic airway (Trachea/windpipe, Trachea branches into inflammation) bronchi and bronchi, which in turn -COPD (inability to exhale bronchioles) branch to normally) become progressively -Viral bronchitis smaller tubes throughout -Allergies the lungs -Cystic fibrosis: Cannot clear mucus -Sleep apnea (often upper part of airway due to neck anatomy)

Air sacs (Alveoli) At the end of the airways, Pneumonia, influenza, involved in gas exchange TBtuberculosis, emphysema, lung cancer Interstitium Microscopically thin, delicate Interstitial lung disease,

October 2017 7 lining between the air sacs. pneumonias Tiny blood vessels run through interstitium and allow gas exchange between alveoli and blood Blood vessels Ranges from sRange from Pulmonary embolism, smalmall ones in the pulmonary hypertension interstitium to the large ones that move blood both ways between the from the body and to the lungs and back again Pleura A thin lining of tissue Pleural effusion, pneumothorax, surrounding lungs and inside mesothelioma (post asbestos) the chest wall (rib cage). A tiny layer of fluid allows pleura on the lung’s surface to slide along the chest wall with each breath. Chest wall Muscles that connect ribs to Obesity: Extra weight on chest each other and help chest and abdomen hinders chest’s expand and ability to expand contract for breathing. Neuromusuclar disorders: paralysis, ALS, muscular dystrophies

Diaphragm A muscle between the lungs Neuromuscular disorders and abdomen that descends (Paralysis, ALS) with each breath in, also causing chest expansion to move air into and out of the lungs

Use videos to explain the physiology of breathing and gas exchange https://www.youtube.com/watch?v=eGicIbMde2E Gas exchange https://carolgiglioibbio2.files.wordpress.com/2012/11/gas_exchange_lungs1.jpg

8  3. I’m now going to gather some general information about youGather general information regarding the patient  Record age and gender  Measure hHeight and , weight  C, calculate BMI using any calculator (BMI = kg/m2).  Check respiratory rate (RR) by watching and counting how many breaths a person takes in 10 or 15 seconds and then calculate the breaths/minuteat this time

 4. Pre-existing lung disease screen  Review lung diseases checklist and (CCircle Y/N based on known conditions/diagnoses:) o -Asthma o -COPD o -Allergies (environmental) o -Sleep apnea o -Lung infection in last 12 months o -Other (note manually on the passport)

 Specific questions about signs and symptoms that can indicate a problem with the lungs:  Review symptom checklist and circle all that apply: o Shortness of breath o Wheeziness o Pain with breathing o Persistent cough o Voice hoarseness o Loss of appetite/weight loss o Snoring o Daytime fatigue o Waking up from sleep choking/gasping o Morning headaches

“You are ready to move on to Station C where we will assess for any lung related symptoms you may be experiencing, do a measure to assess lung capacity and ask about lifestyle factors and health conditions that can influence lung health. Then you will meet with the pharmacist for a consultation on your results.”

October 2017 9 10 Station C

“At this station we are going to check for any lung related symptoms you may be experiencing, measure your lung capacity, assess lifestyle factors that contribute to life- long healthy lungs and briefly review any medications you are currently taking. Do you have any questions before we start?”

 1. Specific questions about signs and symptoms that can indicate a problem with the lungs:

Review symptom checklist (circle):  -Shortness of breath  -Wheeziness  -Pain with breathing  -Persistent cough  -Voice hoarseness  -Loss of appetite/weight loss  -Snoring  -Daytime fatigue  -Waking up from sleep choking/gasping  -Morning headaches

 Measure Peak expiratory flow

Discuss Key messages:

 -Peak flow measures your ability to push air out of your lungs in liters per minute. Lung conditions that cause airway damage or inflammation may affect this measurement  -A "normal" peak flow rate is based on a person's age, height, sex, race and physical health. Peak flow generally increases from childhood to adulthood, with height and is generally higher in males due to increased lung size. Caucasians typically have greater peak flows vs. other races. Directions for using Peak Flow Meter:  Ensure a disposable mouthpiece is used for each patient and that the mouthpiece of the peak flow meter is sanitized with an alcohol swab  Step 1: Before each use, shake the meter vertically to make sure the sliding yellow marker is at the bottom of the numbered scale  Step 2: Have patient stand up straight (may sit if unable to stand). Remove gum or any food from mouth. Instruct them to take a deep breath (as deep as they can). Ask them to put the mouthpiece of the peak flow meter into their mouth forming a tight seal with their lips and ensuring tongue is away from the mouthpiece. In one breath, have them blow out as hard and as

October 2017 11 quickly as possible: “blow a fast, hard blast until you have emptied out nearly all of the air from your lungs”.  Step 3: Note the PEFR in L/min in the Passport.  Step 4: Repeat the entire routine three times. (You know you have done the routine correctly when the numbers from all three tries are very close together.)  Step 5: Use their best reading as compared to expected value to determine where they fall (80-100%, 50-79%, <50%) and note in passport.

 Assessment of risk factors that can aeffect for optimization of lung health

Complete risk factor checklist:  Smoking (current or recent) and pack year history i. Describe what smoking does to the lungs and the good news that no matter how long someone has smoked, the lungs can heal themselves when smoking stops i.1. “15 years post smoking” diagram http://www.dailytimesgazette.com/heart-failure-risk-for- smokers-return-to-normal-15-years-after-quitting/14257/ i.2. Healthy lung vs. smoker’s lung picture  Risk factors for lung infections: Age≥65, chronic disease, weakened immunity  Occupational/environmental exposures i. http://www.healthlinkbc.ca/healthtopics/content.asp? hwid=hw161562  Sedentary (<30 min of physical activity - where the heart rate goes up and some sweat forms -- most days/week)  Obesity/overweight – BMI >24.9 i. Note limitations of BMI  Chest breather or use of accessory muscles (as self identified during station 2)  Immunization status i. Influenza (yearly) ii. PneumoccoalPneumococcal

2. Record medications  Collect medication (Rx, OTC and NHP) information from the patient (what you take, why you take it, how you take it)

12  You are not expected to perform a detailed medication history, simply ask if they are taking any regular medications and make note of the drug name

“You are ready to move on to Station D where the pharmacist will go over all the information we’ve gathered, discuss your results and answer your questions.”

October 2017 13 14 October 2017 15 16 October 2017 17 18 Station D (Pharmacist) “At this station, we will review your measurement results, risk factors and go over any questions you have. We will then will talk about a plan for you to maintain optimal lung health.”  For all participants: Emphasize ways to optimize lung health, educate on meaning of Peak flow measurements, answer questions, assess if influenza or pneumococcal vaccines appropriate, refer if required. Pharmacist will take oneOne of the following 3 approaches can be taken tofor this consultation, depending on the patient’s status. Alternatively, focus could be on smoking cessation if patient identifies as being ready to quit and is seeking information. 1. Healthy lungs: all measurements normal, no risk factors a. Positive reinforcement of lifestyle measures for optimal lung health (exercise, hydration, posture, healthy breathing, infection prevention) a.i. Review diaphragm or “belly” breathing using AHS pictogram (print out) a.ii. Additional resource: Healthy Breathing Handout, adapted from: http://liveboldandbloom.com/10/health/breathe-deeply-live-longer b. Influenza or pneumococcal vaccination assessment c. If patient is a smoker, assess readiness to quit and provide info regarding BC’s smoking cessation service and products 2. Asthma: Create asthma action plan, puffer techniques a. Materials: Placebo puffers, asthma action plan, BC Health Link on asthma b. Influenza or pneumococcal vaccination assessment c. If patient is a smoker, assess readiness to quit and provide info regarding BC’s smoking cessation service and products

3. COPD: Create COPD action plan, puffer techniques a. Materials: Placebo puffers, COPD action plan, BC Health Link on COPD b. Influenza or pneumococcal vaccination assessment c. If patient is a smoker, assess readiness to quit and provide info regarding BC’s smoking cessation service and products  (For all) Smokers: -5A’s and provide patient-Info re. BC smoking cessation services/products Discuss key messages:  Emphasize ways to optimize lung health  Educate on meaning of Peak flow measurements

October 2017 19 Final steps:  Document the plan in the passport “My Plan”  If the participant has more questions, wants information on supplements or has issues for the pharmacist, suggest they follow-up at another time.  If the participant has risk or issues that warrant a medical visit, ask them to follow-up with their family doctor or GP o Occupational health and safety o Suspected sleep apnea o Spirometry o Lung cancer screening Possible Referrals -BC smoking services -Occupational health and safety -MD for spirometry or lung CA screening or if sleep apnea suspected  Indications for spirometry: o -Evaluation of symptoms such as chronic persistent cough, wheezing, dyspnea, and exertional cough or chest pain o -Objective assessment of bronchodilator therapy o -Evaluation of effects of exposure to dusts or chemicals at work o -Risk evaluation of patients prior to thoracic or upper abdominal surgery o -Objective assessment of impairment or disability o Monitoring disease course and response to therapy o -Monitoring disease course and response to therapy

 Indications for lung CA screening (CTFPHC): o -Have a history of heavy smoking (30 pack years+, or 15 2pack years), o -Smoke now or have quit within the past 15 years,

20 o -Are between 50 and 74 years old

PC referrals -Poorly managed lung condition -Indication for immunization -Smoker wanting to quit “Thank you for participating in this event. We hope you found it useful. Do you have any feedback that we can use to make this event better in the future?“

 Make note of the feedback

October 2017 21