Rapid Responses to:

PRACTICE: Daryl Freeman and David Price Primary care and palliative care BMJ 2006; 333: 188-190 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Palliative Care in COPD (Chronic Obstructive Pulmonary Disease)

Stephen Head   (23 July 2006)

recording smoking load on clinical summaries

Nigel J Masters, Catherine Tutt Specialist Pratitioner Practice Nursing : Respiratory Trainer   (27 July 2006)

Palliative Care in COPD (Chronic Obstructive Pulmonary Disease) 23 July 2006
Stephen Head, General Practice Performer Middleton Lodge, New Ollerton, Newark, Nottinghamshire, NG22 9SZ. Send response to journal: Re: Palliative Care in COPD (Chronic Obstructive Pulmonary Disease)	The review of this by Freeman and Price is most welcome as palliative care for respiratory disease is poorly researched (as the vintage of the referances illustrate) and poorly taught, with much unmet patient need. Besides morphine and benzodiazepines (which can precipitate CO2 narcosis and so are not without risk) there is evidence for sedative antihistamines (notably promethazine) and dihydrocodeine in releiving subjective dyspnoea. These drugs can be used in earlier disease and can greatly improve the quality of life of patients who are still ambulant. I often use these, but seem to be in a small minority of current practitoners. They are far cheaper and I suspect much more effective than short burst oxygen. The authors also mention parenteral hyoscine for patients who cannot clear their secretions. There is a trans-dermal preparation available which can be especially useful in Primary Care - Scopaderm. This is licensed for motion sickness but can be used off-label - avoiding the need for sub-cutaneous infusions which are otherwise rarely needed in end-stage COPD. Referances Huttemann U, Kunkel G, Lode H, Hass E. The influence of laevomepromazine and prometazine on respiration in healthy subjects and patients with pulmonary emphysema. Arzneimittelforschung. 1971 Oct;21(10):1594-8 Johnson MA, Woodcock AA, Geddes DM. Dihydrocodeine for breathlessness in "pink puffers". Br Med J (Clin Res Ed). 1983 Feb 26;286(6366):675-7. Woodcock AA, Gross ER, Gellert A, Shah S, Johnson M, Geddes DM. Effects of dihydrocodeine, alcohol, and caffeine on breathlessness and exercise tolerance in patients with chronic obstructive lung disease and normal blood gases. N Engl J Med. 1981 Dec 31;305(27):1611-6. Competing interests: None declared
recording smoking load on clinical summaries 27 July 2006
Nigel J Masters, General Medical Practitioner Highfield Surgery Highfield Way Hazlemere High Wycombe Bucks HP9 1TR, Catherine Tutt Specialist Pratitioner Practice Nursing : Respiratory Trainer Send response to journal: Re: recording smoking load on clinical summaries	We read the excellent primary care management of COPD but wished to share a new initiative at our surgery in the way we record smoking on the computerised clinical record . This change was introduced to target smokers at risk of COPD during surgeries and refer them to in house spirometry and in the process possibly trigger a quit attempt if indicated. We have avoided pack years as a measure of smoking dose as we believe it is difficult for healthstaff to grasp its meaning and simplified it to years smoked and cigarettes per day.This is listed on the clinical summary either under read code term date ceased smoking or if over 40 years amount smoked. All those who have smoked have this smoking load recorded and spirometry is offered to those with a calculated smoking dose greater than 300 (Cigarettes per day multiplied by years smoked). This smoking load recording is then easily transmitted on patient referrals to secondary care.We believe this simple change in recording smoking load or dose is a significant advance and should be built into practice computer software so that its use across the healthcare sector becomes routine. Competing interests: None declared