The ABC of COPD

Today is World COPD Day, and Lung Foundation Australia has released updated guidelines on diagnosis and management and resources for patients.

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Chronic obstructive pulmonary disease is a preventable and treatable disease characterised by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities.

It is usually caused by significant exposure to noxious particles or gases and influenced by host factors including abnormal lung development. Significant comorbidities may have an impact on morbidity and mortality^[i].

COPD – the umbrella term for emphysema and chronic bronchitis – is the fifth leading cause of death in Australia. In a 2013 Australian study, the prevalence of COPD based on spirometric testing was estimated to be 7.5% for people aged 40 years and over and 30% for people aged 75 and over; however, studies have shown that around half of people living with symptoms don’t know they have the condition^[ii].

Based on self-reported data, in 2018–19, 10% of Aboriginal and Torres Strait Islander people aged 45 and over had COPD (an estimated 17,800 people), with a higher rate among females (13%) compared with males (6.7%). The prevalence of COPD among Indigenous Australians was 2.3 times that of non-Indigenous Australians, after adjusting for difference in age structure^[iii]. The prevalence of COPD across all age groups among Indigenous Australians is 2.5 times as high as the prevalence for non-Indigenous^[iv].

Despite its prevalence, COPD is usually not diagnosed until it is moderately advanced and symptoms begin to impair quality of life or hospital admission is required^[v]. Too often, early COPD symptoms are mistaken for signs of ageing, a lack of fitness or asthma. Women seem to be more susceptible to the effects of COPD than men, with respect to symptom burden. Overall people with COPD rate their health worse than people without the condition. In 2017–18, 20% of people aged 45 years and over with COPD rated their health as poor, compared with 5.4% of those aged 45 years and over without COPD^[vi].

Primary healthcare professionals play a vital role in the early diagnosis and appropriate management of COPD to ensure patients have the best quality of life possible. The Lung Foundation Australia COPD-X Plan, the Australian and New Zealand Guidelines for management of COPD^[vii], first published in 2003, summarises the current evidence around optimal management of people with COPD. Published evidence is systematically searched for, identified, and reviewed on a regular basis (four times a year) by the Guidelines Evaluation Committee and determines whether the reviewed evidence needs incorporation into the guideline.

The 2020 edition of the COPD-X Concise Guide^[viii] is an evidence-based clinical resource that provides practical recommendations to support all healthcare professionals, including GPs, in the diagnosis and management of COPD.

Risk factors and symptoms

Risk factors for COPD include:

• Environmental factors – long-term exposure to harmful pollutants such as dust, gas, chemical fumes, smoke or air pollution. Other airway disease risk factors include chronic asthma, prematurity and childhood respiratory diseaseviii.
• Smoking – current and former smokers, or exposure to significant passive smoking.
• Genetics – a small number of people have a form of emphysema caused by alpha-1 antitrypsin deficiency (AATD), an inherited gene mutation. The low levels of alpha-1 antitrypsin allow proteases to damage the lungs, resulting in emphysema which is more common (and worse) in people who smoke. Emphysema in non-smokers can be caused by alpha-1 antitrypsin deficiency.

The main symptoms of COPD include:

• Shortness of breath
• A persistent cough, typically worse in the mornings, with mucoid sputum
• Increased mucus production
• Fatigue
• Frequent chest infections
• Longer recovery from cold or chest infections
• Chest tight­ness, wheezing and airway irritability.

In more advanced disease, physical features com­monly found are hyperinflation of the chest, reduced chest expansion, hyperresonance to percussion, soft breath sounds and a prolonged expiratory phase.

Diagnosis

In clinical practice, diagnosis is usually based on:

• Symptoms of exertional breathlessness, cough and sputum
• A history of smoking, or exposure to other noxious agents
• Airflow limitation (FEV1/FVC<0.7 post-bronchodilator).

The COPD-X Guidelines and Concise Guide recommend a thorough patient history documenting any history of prematurity or childhood respiratory problems including asthma, age of onset of symptoms, triggers, occupational and environmental exposures, smoking history, and family history. Asthma is a known risk factor for COPD.

As the presence and severity of airflow limitation are impos­sible to determine by clinical signs alone, objective measure­ments such as spirometry are also essential.

Spirometry is the gold standard for measurement of airway obstruction and determining bronchodilator responsiveness^[ix] and is essential for the early diagnosis and staging of COPD and differentiation from asthma. Identification of the severity of COPD by spirometry allows progression of the disease to be monitored objectively and the most appropriate interventions to be identified for each patient.

Severity of COPD should take into account lung function, effect of COPD symptoms on daily activities, level of breathlessness, and the presence of complications and/or comorbidities such as exacerbations, hypoxaemia, pulmonary hypertension, heart failure, or polycythaemia.

The COPD Assessment Test (CAT)^[x] is useful for determining the impact of COPD symptoms on wellbeing and daily life. Symptom severity may not correlate with spirometry criteria for severity. History of previous exacerbations may be the strongest predictor of future exacerbations and possible decline in lung function^[xi].

Patients who present with respiratory symptoms and/or risk factors but show normal results on lung function assessments may be at risk of other lung disease or of developing COPD in later life. These individuals should be monitored over time and supported to undertake preventative strategies, such as mitigating exposure to environmental hazards and smoking cessation^[xii].

Management

The key principles of management in COPD are:

• smoking cessation
• optimising function to provide symptom relief and improve exercise capacity via
  • non-pharmacological interventions (such as exercise training, regular physical activity and pulmonary rehabilitation)
  • appropriate pharmacotherapy
• management of comorbidities (such as hyperglycaemia, heart disease, osteoporosis, mood disorders and anxiety)
• preventing exacerbations (appropriate pharmacotherapy, early recognition and treatment of exacerbations, vaccination, avoiding or reducing triggers such as viral infections, heart failure, psychosocial factors).

While there is no cure for COPD, the primary healthcare team, which includes general practitioners (GP), nurses, physiotherapists, pharmacists, dieticians and mental health clinicians play a critical role in the management of COPD and supporting patients in appropriate self-management.

Inhaler technique and pharmacological management

In combination with non-pharmacological approaches, inhaled COPD medicines can improve symptoms, therefore improving quality of life for people with COPD. Up to 90% of patients with a respiratory condition are not using their inhaler devices correctly^[xiii] and therefore are not receiving the dose of medicine they need to adequately control symptoms. As patient self-management skills can wane over time, GPs and other qualified members of the healthcare team should check regularly that the patient has the correct inhaler technique. Common errors include improper device preparation, poor coordination during use, inadequate speed and/or depth of inspiration as well as absence of a post-inhalation breath hold.

Elderly patients, especially those with cognitive impairment, may have difficulty with some devices. Lung Foundation Australia has developed a series of inhaler device technique videos^[xiv] and factsheets for patients which provide step-by-step instructions on correct inhaler technique.

To help GPs and healthcare teams consider the appropriate pharmacological approach to COPD, Lung Foundation Australia’s Stepwise Management of Stable COPD – a brief two-page guide – outlines the sequence of medicines to prescribe, depending on severity, as well as a pictorial display of all the available inhaled medicines for COPD and a “ready reckoner” so as to avoid duplication of classes of inhaled medicines.

Pulmonary rehabilitation

In addition to pharmacological management, there is strong evidence for the benefits of regular exercise in COPD management. The COPD-X Guidelines recommend that all patients with COPD should be encouraged to engage in physical activity consistent with the recommendations for healthy adults (ie 150 minutes per week). Referral to pulmonary rehabilitation should also be considered since it improves exercise tolerance and quality of life, and reduces COPD-related hospital admissions and mortality in the short-term^[xv],[xvi].

During the COVID-19 pandemic some pulmonary rehabilitation programs are delivering services by telehealth and primary healthcare teams are encouraged to continue referring their patients wherever possible. To assist patients Lung Foundation Australia has developed a free, 18-part home-based exercise video series hosted by a qualified exercise physiologist accessible via the Lung Foundation Australia website.

Written COPD Action Plans

COPD?is the leading cause of preventable hospitalisations?in Australia^[xvii]. Use of written COPD action plans, when combined with proper education and self-management support, reduce in-hospital health care utilisation and reduce the duration of COPD exacerbations^[xviii] through increased timely initiation of corticosteroids and antibiotic treatment^[xix].

A delay of 24 hours or more in seeking treatment for a COPD exacerbation doubles the chance of hospital admission^[xx]. A history of previous exacerbations may be the strongest predictor of future exacerbations and possible decline in lung function.

Lung Foundation Australia’s COPD Action Plan template is a ready-to-use resource which can be completed by the GP and patient together. The plan guides the patient in recognising when their symptoms change and what action they should take.

Managing Exacerbations

The COPD-X Guidelines define a COPD exacerbation as being characterised by an acute change in the patient’s baseline dyspnoea, cough, and/or sputum that is beyond normal day-to-day variations. Exacerbations of COPD are more frequent in the winter months in temperate climates and often require hospital admission for treatment of respiratory failure.

Exacerbations become more frequent as severity of COPD worsens. The single best predictor of exacerbations across all severity stages is prior exacerbations^[xxi]. Primary healthcare teams can help prevent COPD exacerbations by following the exacerbation algorithm in the COPD-X Concise Guide.

Summary points:

• Send reminders and recalls
• Re-assess smoking status
• Review COPD flare-up symptoms
• Send vaccinations reminders
• Review medication
• Develop a COPD action plan
• Refer patients to pulmonary rehabilitation
• Manage co-morbidities.

COPD resources for GPs

The recently updated 2020 edition of the COPD-X Concise Guide translates the extensive evidence on the diagnosis and management of COPD from the comprehensive COPD-X Plan Guidelines into clinical practice. The evidence is presented in a compact and easily digestible format and includes recommendations and practice tips which is important for busy clinicians who work across many disease areas.

For a full list of resources and online training modules to support you in the diagnosis of COPD and management of patients living with the condition, visit the Lung Foundation Australia website.

Resources for your COPD patients

To mark World COPD Day (18 November), Lung Foundation Australia is encouraging patients with COPD to connect with support services and resources that can help them understand their condition and improve their wellbeing. The organisation has developed a free Live Your Best Life with COPD Resource Pack which enables patients to access self-management tools for their condition, manage their emotional and mental wellbeing, improve their physical health through a pulmonary rehabilitation program, and connect with services including peer support. Download a copy at the Lung Foundation Australia website.

Dr Kerry Hancock is a GP Principal at Chandlers Hill Surgery, Happy Valley, SA; member of Lung Foundation Australia’s COPD Advisory Committee and chair of the Lung Foundation Australia Primary Care Advisory Committee, and chair of the RACGP Specific Interests Respiratory Medicine Network. She is on the editorial board of The Medical Republic’s sister publication Allergy & Respiratory Republic.

References:

[i] Global Initiative for Chronic Obstructive Lung Disease. 2020. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. Accessed via: https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf
[ii] Toelle B, Xuan W, Bird T, Abramson M, Atkinson D, Burton D, James A, Jenkins C, Johns D, Maguire G, Musk A, Walters E, Wood-Baker R, Hunter M, Graham B, Southwell P, Vollmer W, Buist A, Marks G. Respiratory symptoms and illness in older Australians: The Burden of Obstructive Lung Disease (BOLD) study. Med J Aust 2013;198:144-148
[iii] Australian Institute of Health and Welfare. 2019. Chronic obstructive pulmonary disease. Accessed via: https://www.aihw.gov.au/reports/chronic-respiratory-conditions/copd/contents/copd
[iv] Australian Bureau of Statistics. 2013.?Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Australia, 2012–13. ABS cat. no. 4727.0.55.001. Canberra: ABS
[v] Haroon SM, Jordan RE, O’Beirne-Elliman J & Adab P. 2015. Effectiveness of case finding strategies for COPD in primary care: a systematic review and meta-analysis. NPJ Prim Care Respir Med, 25, 15056.
[vi] Australian Institute of Health and Welfare. 2019. Chronic obstructive pulmonary disease. Accessed via: https://www.aihw.gov.au/reports/chronic-respiratory-conditions/copd/contents/copd
[vii] Yang IA, Brown JL, George J, Jenkins S, McDonald CF, McDonald V, Smith B, Zwar N, Dabscheck E. 2020. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.61. Accessed via: https://copdx.org.au/copd-x-plan/
[viii] Yang IA, Dabscheck EJ, George J, Jenkins SC, McDonald CF, McDonald VM, Smith BJ, Zwar NA. 2019. COPD-X Concise Guide. Accessed via: https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-COPD-X-Concise-Guide-June2020.pdf
[ix] Graham BL, et al. Standardization of Spirometry 2019 Update. Am J Respir Crit Care Med 2019; 200 (8): e70-e88.
[x] COPD Assessment Test. 2018. Accessed via: catestonline.org
[xi] Agusti A, et al. 2010. Characterisation of COPD heterogeneity in the ECLIPSE cohort. Respir Res. 11: p. 122.
[xii] The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. 2nd edn. East Melbourne, Vic: RACGP, 2019
[xiii] National Health Performance Authority. 2015. Healthy Communities: Potentially preventable hospitalisations in 2013–14.
[xiv] Lung Foundation Australia. 2020. Inhaler device technique series. Accessed via: https://lungfoundation.com.au/resources/?user_category=32&search=inhaler%20device
[xv] Alison JA et al. 2017. Australian and New Zealand Pulmonary Rehabilitation Guidelines. Respirology. 22(4): p. 800-819.
[xvi] Ryrso CK et al. 2018. Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC Pulm Med. 18(1): p. 154.
[xvii] Australian Institute of Health and Welfare 2018. Admitted patient care 2016–17: Australian hospital statistics. Health services series no. 84. Cat. no. HSE 201. Canberra: AIHW.
[xviii] Lenferink A, Van Der Palen J, Cafarella P, Van Veen A, Quinn S, Groothuis-Oudshoorn CGM, Burt MG, Young MM, Frith PA, Effing TW. 2019. Exacerbation action plans for patients with COPD and comorbidities: a randomised controlled trial. Eur Respir J, 54(5).
[xix] Howcroft M, et al. 2016. Action plans with brief patient education for exacerbations in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 12: p. CD005074.
[xx] Walters JA, Tan DJ, White CJ, Gibson PG, Wood-Baker R, Walters EH. 2014. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 9, CD001288.
[xxi] Hurst JR, Vestbo J, Anzueto A, Locantore N, Mullerova H, Tal-Singer R, Miller B, Lomas DA, Agusti A, Macnee W, Calverley P, Rennard S, Wouters EF & Wedzicha JA. 2010. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med, 363, 1128-38.