COPD clinical care standard stresses non-drug options

Pulmonary rehab is an effective but underutilised way to improve quality of life for the many people living with this disease.

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COPD is poorly understood for such a prevalent condition – around 8% of Australians over 40 have it, but half of them have no idea, according to the Australian Commission on Safety and Quality in Health Care.

Even that’s almost certainly a profound underestimate of the prevalence, Associate Professor Natasha Smallwood told TMR ahead of today’s launch of the ACSQHC’s first Australian clinical care standard for COPD.

The standard emphasises aspects of existing therapeutic guidelines – such as correct diagnosis through spirometry, non-pharmacological treatments such as pulmonary rehab, efficient inhaler use, communication between health professionals and culturally safe care – and sets out quality indicators for healthcare organisations.

Also this week, the Lung Foundation has put out an interactive COPD checklist for patients to make sure their treatment is on track.

Better known to the public as chronic bronchitis, COPD is defined as chronic airflow limitation due to inflammation, usually progressive over time and irreversible, with or without emphysema, as a result of exposures including smoking and other pollutants, such as cooking with biomass fuel.

“It’s a bit of a confusing term, and most patients don’t actually understand what they have,” said Professor Smallwood, a consultant respiratory physician at The Alfred and president-elect of the Thoracic Society of Australia and New Zealand.

“Because the symptoms develop insidiously over many years, people can normalise it – ‘oh well, it’s normal to be breathless, I’m older’, or ‘I’ve been a smoker, so it’s normal to cough’ – and actually don’t realise they’ve got significant illness.

“As a hospital specialist, many times I’ve seen people admitted to hospital profoundly unwell, and it’s the first time they’ve heard the diagnosis.”

Patients also commonly believe they have asthma because the inhalers can be the same, or the similarities with asthma are used to explain COPD.

Another reason for the prevalence underestimate is that spirometry is the only way to diagnose it, and the aerosol-generating procedure was largely stopped during the covid pandemic and has not recovered, at least not in primary care.

“That’s a huge problem – particularly if you live regionally, it means you can’t access the test that diagnoses your condition, and you don’t know the severity of the condition or have an accurate diagnosis,” Professor Smallwood said.

The appropriate order of pharmacological treatments is the reverse of what is for asthma, starting with bronchodilators – short- then long-acting beta agonists and long-acting muscarinic antagonists – and only adding inhaled corticosteroids when people have frequent exacerbations or are highly symptomatic on dual therapy.

But much treatment is non-pharmacological, and the earlier the diagnosis happens the sooner they can begin.

The first step is, of course, smoking cessation.

“If they are an active smoker, it’s absolutely critical that we help that person to stop smoking, because ongoing smoking will lead to progression,” Professor Smallwood said.

“We make sure people are up to date with their immunisations: having an annual flu vaccine, keeping their covid vaccines up to date, having a pneumococcal vaccine if they’re a wee bit older. Every time we prevent an infection, we can prevent further lung damage.”

Support is offered to lose weight and improve nutrition if necessary, and exercise and pulmonary rehabilitation programs are “absolutely critical”.

Pulmonary rehab is an effective, side effect-free and woefully underused resource for COPD patients, Professor Smallwood said, with only around 5% of eligible patients completing a program. It consists of a structured and supervised exercise regime over six to 12 weeks, delivered in groups in person or via telehealth, along with education about the disease. The aim is to make the exercise habitual beyond the duration of the formal program.

Choosing the right inhalers with the same mechanisms and ensuring proper use can help adherence while also, the care standard says, minimising waste from the devices, which use propellants thousands of times worse for the environment than carbon dioxide.

Another more global concern is the misuse of antibiotics to control exacerbations. The standard says around half of such antibiotic use in Australia is inappropriate.

Culturally appropriate care is a maxim in all the ACSQHC’s clinical care standards and is important for a condition that affects First Nations people at 2.5 times the rate of other Australians.

“We have to make sure the care we deliver is suitable for everyone and acceptable to everyone, and make sure that we’re not widening health gaps,” Professor Smallwood said.

Finally, another vastly underused resource is palliative or supportive care – a more acceptable term – for people with COPD to make their last few years as good as they can be.

“Their symptom burden can be worse than someone who has lung cancer, and yet they very rarely access any supportive care,” Professor Smallwood said.

“Part of the issue is that people often think palliative care is just end-of-life care, but it’s not. Palliative care is just really good holistic care that tries to improve symptoms and quality of life and psychosocial health over the last few years of life.”

The ACSQHC clinical care standard contains 10 quality statements:

1. Diagnosis with spirometry
2. Comprehensive assessment
3. Education and self‑management
4. Vaccination and tobacco-smoking cessation
5. Pulmonary rehabilitation
6. Pharmacological management of stable COPD
7. Pharmacological management of COPD exacerbations
8. Oxygen and ventilatory support for COPD exacerbations
9. Follow-up care after hospitalisation
10. Symptom support and palliative care

At a webcast panel discussion for the launch today, Dr Lee Fong, a GP and medical advisor to the ACSQHC, said COPD made up half the total respiratory disease burden in 2023 and directly caused 7500 deaths in 2022. It was also a leading cause of potentially preventable hospitalisations.

“What this tells us is that there’s a lot of people with COPD who are experiencing exacerbations, getting that ‘can’t breathe’ feeling, for whom that didn’t have to happen,” he said.

The Fourth Australian Atlas of Healthcare Variation showed an 18-fold variation in hospitalisation rates for COPD around the country, he said. Given this and the extent of inappropriate use of antibiotics, “we hope the standard will refocus attention on best practice care for the diagnosis and management of COPD across both community and hospital settings. If we can do that, then for people with COPD we will help reduce at an individual level that awful feeling of being unable to breathe, as well as improve outcomes and overall quality of life,” Dr Fong said.

Dr Kerry Hancock, chair of the RACGP Respiratory Medicine Specific Interests Group and of the Lung Foundation Australia Primary Care Clinical Council, said access to spirometry could be challenging. If GPs don’t have on-site spirometry, she said, they should check with their PHN for local hospitals, specialists’ rooms or mobile services.

“They could also consider training their own staff so that they do have it on site,” Dr Hancock said. “But even when that happens, they often do have to use other services as well.

“Getting that diagnosis by spirometry is absolutely critical, and the GP-based spirometry has certainly fallen off through the pandemic and has not come up again. So I think we need to activate all those other services that can offer spirometry to GPs.”

She said GPs also should be confident about checking patients’ inhaler technique or asking others, such as a community pharmacist or specialist pharmacist through a home medicines review.

“We know that many clinicians are actually not good at doing that themselves,” Dr Hancock said.

“We’ve seen some really weird stuff over the decades – people spraying [their inhalers] around and trying to catch it in their mouths.

“You’d certainly want to check inhaler technique before you escalate the same medications or other interventions … It’s absolutely critical, otherwise you’re wasting a lot of medication unnecessarily.”