Chronic obstructive pulmonary disease
Page highlights:
- Chronic obstructive pulmonary disease (COPD) is a preventable and treatable lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.
- An estimated 4.8% or 464,000 people aged 45 and over had COPD in 2017–18.
- Indigenous Australians were 2.3 times as likely as non-Indigenous Australians to have COPD.
- COPD was more common in people living in the lowest socioeconomic group compared with the highest group (men: 7.5% and 3.1%, women: 6.6% and 4.0%).
- 7,018 people died due to COPD in 2021.
- COPD accounted for over half (51%) of the disease burden due to respiratory conditions and 3.7% of the total disease burden in 2022.
- It cost the Australian health system an estimated $994.8 million in 2019–20, representing 21% of disease expenditure on respiratory conditions and 0.7% of total disease expenditure.
- There were 53,600 hospitalisations with a principal diagnosis of COPD for people 45 and over in 2020–21.
- 86% of people who had COPD also had one or more other chronic conditions.
- People who reported having COPD were more likely to be current daily smokers compared with those without COPD.
What is COPD?
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The symptoms of COPD include cough, sputum production, and dyspnoea (difficult or labored breathing). COPD symptoms often don't appear until significant lung damage has occurred, which usually worsens over time (WHO 2020).
It is worth noting that it can be difficult to distinguish COPD from asthma because the symptoms of both conditions can be similar – both have obstruction to the airways, both are chronic inflammatory diseases that involve the small airways (Buist 2003). Although the current definitions of asthma and COPD overlap, there are some important features that distinguish typical COPD from typical asthma. For more information, see Asthma .
Additionally, COPD and bronchiectasis share common symptoms of cough with sputum production and susceptibility to recurrent exacerbations (Hurst et al. 2015). Although these two diseases present several common characteristics, they have different clinical outcomes. Therefore, it is very important to differentiate them at early stages of diagnosis, so appropriate therapeutic measures can be adopted (Athanazio 2012). For more information, see Bronchiectasis.
What causes COPD?
COPD results from a complex interaction between genes and the environment. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), there are many causes of COPD, which may include:
- Tobacco smoking: both active smoking and passive exposure to smoking. Although cigarette smoking is the most well studied COPD risk factor, it is not the only risk factor and there is consistent evidence from epidemiologic studies that non-smokers may also develop chronic airflow limitation.
- Genetic factors: a small number of people have a form of emphysema caused by a protein disorder called alpha-1 antitrypsin deficiency (AATD). This is where the body finds it difficult to produce one of the proteins (Alpha-1 antitrypsin) which usually protects the lungs. The lack of this protein can make a person more susceptible to lung diseases such as COPD.
- Lung growth and development factors: any factors that affect lung growth during gestation and childhood have the potential for increasing an individual’s risk of developing COPD, such as low birthweight, early childhood lung infections, abnormal lung growth and development (with normal decline in lung function over time) (Lange et al. 2015).
- Environmental factors: working or living in areas where there is dust, gas, chemical agents and fumes, smoke or air pollution.
- Other chronic conditions: such as asthma and chronic bronchitis, which are associated with an increased likelihood of developing COPD (GOLD 2020).
How common is COPD?
The development of COPD occurs over many years and therefore affects mainly middle aged and older people while asthma affects people of all ages. The prevalence of COPD increases with age, mostly occurring in people aged 45 and over.
In the 2017–18 ABS National Health Survey (NHS), the prevalence of COPD (captured here as self-reported emphysema and/or bronchitis) in Australians aged 45 and over was 4.8%, or an estimated 464,000 people (ABS 2018). Overall, the prevalence did not differ significantly between men and women (4.5% and 5.1% respectively), however for those aged 55–64, COPD was more prevalent in women compared with men (6.2% and 3.6%, respectively) (Figure 1).
However, it should be noted that the prevalence of COPD is difficult to determine from routine health surveys. This is because COPD is formally defined in terms of an abnormality of lung function and clinical testing is required to accurately estimate the prevalence of the disease.
In a large international study called the Burden of Obstructive Lung Disease (BOLD) study, the lung function of nearly 10,000 people were tested (Buist et al. 2007). The BOLD study estimated the prevalence of COPD using spirometry testing in addition to questionnaires about respiratory symptoms, health status, and exposure to COPD risk factors. BOLD estimated the overall prevalence of COPD in 12 countries (including Australia, China, Turkey, Iceland, Germany, USA and Canada) to be 10% for people aged 40 and over. In a later study conducted in Australia using a protocol that closely followed that used in the global BOLD study, the prevalence of COPD was estimated to be 7.5% for people aged 40 years and over and 30% for people aged 75 and over (Toelle et al. 2013).
Figure 1: Prevalence of COPD among people aged 45 and over, by sex and age group, 2017–18
Notes
COPD here refers to self-reported current and long-term bronchitis and/or emphysema.
COPD occurs mostly in people aged 45 and over. While it is occasionally reported in younger age groups, in those aged 45 and over there is more certainty that the condition is COPD and not another respiratory condition. For this reason only people aged 45 and over are included in this graph.
Source: ABS 2019 (Data table).
Aboriginal and Torres Strait Islander people
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 Australian was 2.3 times as high as non-Indigenous Australians, after adjusting for difference in age structure (ABS 2020a; ABS 2020b).
Inequalities
The prevalence of COPD among Australians did not differ significantly according to remoteness area.
However, the prevalence of COPD was higher in the lowest socioeconomic area compared with those in the highest area (men: 7.5% and 3.1%, respectively; women: 6.6% and 4.0%, respectively) (Figure 2).
Figure 2: Prevalence of COPD among people aged 45 and over, by sex, remoteness area and socioeconomic group, 2017–18
Notes
Rates have been age-standardised to the 2001 Australian Standard Population as at 30 June 2001. Age groups: 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75+.
COPD occurs mostly in people aged 45 and over. While it is occasionally reported in younger age groups, in those aged 45 and over there is more certainty that the condition is COPD and not another respiratory condition. For this reason only people aged 45 and over are included in this graph.
Remoteness is classified according to the Australian Statistical Geography Standard (ASGS) 2016 Remoteness Areas structure based on area of residence.
Socioeconomic areas are classified according to using the Index of Relative Socio-Economic Disadvantage (IRSD) based on area of residence.
Source: ABS 2019 (Data table).
Impact of COPD
Burden of disease
What is burden of disease?
Burden of disease analysis is a way of measuring the impact of diseases and injuries on a population. It is the difference between a population’s actual health and its ideal health, where ideal health is living to old age in good health (without disease or disability). It combines health loss from living with illness and injury (non-fatal burden, or years lived with disability, or YLD) and dying prematurely (fatal burden, or years of life lost, or YLL) to estimate total health loss (total burden, or disability-adjusted life years, or DALY). One DALY is one year of 'healthy life' lost due to illness and/or death (AIHW 2022a).
In 2022, COPD was the fourth leading cause of burden and accounted for 3.7% of total disease burden (DALY); 3.3% of non-fatal burden (YLD), and 4.0% of fatal burden (YLL). Within the respiratory conditions disease group, COPD accounted for 51% of total burden (DALY); 38% of non-fatal burden (YLD); and 72% of fatal burden (YLL).
Variation by age and sex
- For both males and females, the rate of total burden (DALY) generally increased with age peaking at 75–79 years.
- Males have a higher proportion of fatal burden (YLL) than females (60% and 46% respectively).
- COPD is the leading cause of total burden in women aged 70–74 and 75–79 (31.8 and 40.5 DALYs per 1,000 population, respectively); and the second leading cause of total burden in men aged 70–74 and 75–79 (32.0 and 40.8 DALYs per 1,000 population, respectively).
Figure 3: Burden of disease due to COPD by age, sex and year
This bar chart shows the DALY, YLD and YLL due to COPD for different age groups by sex in selected years (2003, 2011, 2015, 2018 and 2022). For both males and females in 2022, the rate of total burden (DALY) generally increased with age peaking at 75–79 years. There were 36,731 DALY for total persons in the 75–79 age group.
In 2022 there were 107,836 YLL in persons due to COPD. Among females, YLL peaked in the 70–74 age group, while for males it peaked in the 75–79 age group.
In 2022 there were 95,737 YLD in persons due to COPD. Among females, YLD peaked in the 75–79 age group at 9,911, while for males it peaked in the 70–74 age group at 8,038.
This data visualisation includes 2 charts, the first presents DALY, YLD and YLL due to COPD by remoteness in selected years (2011, 2015 and 2018). In 2018, the DALY due to COPD was highest in Remote and very remote areas, and lowest in Major cities.
The second chart presents DALY, YLD and YLL due to COPD by socioeconomic group and year. In 2018, DALY was highest in the lowest socioeconomic group, and lowest in the highest socioeconomic group.
This icicle chart shows the health expenditure on COPD compared to total health expenditure by area of expenditure, in 2019–20. In total, COPD cost the Australian health system an estimated $990 million. This included $615.1 million for hospitals, $335.1 million for primary care services, and $44.6 million for referred services.
This bar chart shows the proportion of area expenditure for COPD by sex for 2019–20. The highest proportion of expenditure was spent on the Pharmaceutical Benefits Scheme (1.6%), and the least proportion of expenditure was on allied health and other services (0.1%).
Who is the money spent on?
In 2019–20:
- the health system expenditure distribution of spending on COPD reflects the prevalence distribution of the condition, with most spending being for older age groups (97% for people aged 45 and over).
- more COPD expenditure was attributed to males than females ($516.9 million and $466.4 million), respectively with a remainder $11.5 million (1.2%) not specified.
Further detail is available in Disease expenditure in Australia 2019–20.
In 2018–19, it was estimated that:
- COPD expenditure per case was 1.2 times greater for males than females ($1,700 and $1,400 per case, respectively).
- COPD expenditure per case was 67% higher than respiratory conditions as a group ($1,600 and $510 per case, respectively) (AIHW 2022c).
Further detail is available in Health system spending per case of disease and for certain risk factors.
Perceived health status
COPD can interrupt daily activities, sleep patterns and the ability to exercise. People with COPD rate their health worse than people without the condition. In 2017–18, 1 in 5 (20%) of those aged 45 years and over with COPD rated their health as poor, compared with 5.4% of those aged 45 years and over without it. At the same time, 17% of those with COPD rated their health as very good and 4.9% as excellent compared with 34% and 17% (respectively) of those without COPD (Figure 7).
Figure 7: Self-assessed health of people aged 45 and over with and without COPD, 2017–18
Notes
Rates have been age-standardised to the 2001 Australian Standard Population as at 30 June 2001. Age groups: 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75+.
COPD occurs mostly in people aged 45 and over. While it is occasionally reported in younger age groups, in those aged 45 and over there is more certainty that the condition is COPD and not another respiratory condition. For this reason only people aged 45 and over are included in this graph.
Source: ABS 2019 (Data table).
Psychological distress
In 2017–18, people with COPD were more likely to report high (19%) and very high (17%) levels of psychological distress compared with people without COPD (8.3% and 4.0%, respectively) (Figure 8).
Figure 8: Psychological distress experienced by people aged 45 and over with and without COPD, 2017–18
Notes
Rates have been age-standardised to the 2001 Australian Standard Population as at 30 June 2001. Age groups: 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75+.
COPD occurs mostly in people aged 45 and over. While it is occasionally reported in younger age groups, in those aged 45 and over there is more certainty that the condition is COPD and not another respiratory condition. For this reason only people aged 45 and over are included in this graph.
Psychological distress is measured using the Kessler Psychological Distress Scale (K10), which involves 10 questions about negative emotional states experienced in the previous 4 weeks. The scores are grouped into Low: K10 score 10–15, Moderate: 16–21, High: 22–29, Very high: 30–50.
Source: ABS 2019 (Data table).
Pain
In 2017–18, people with COPD were more likely to report moderate (36%) and severe (22%) bodily pain compared with people without COPD (23% and 7.8%, respectively) (Figure 9).
Figure 9: Pain experienced by people aged 45 and over with and without COPD, 2017–18
Notes
Rates have been age-standardised to the 2001 Australian Standard Population as at 30 June 2001. Age groups: 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75+.
COPD occurs mostly in people aged 45 and over. While it is occasionally reported in younger age groups, in those aged 45 and over there is more certainty that the condition is COPD and not another respiratory condition. For this reason only people aged 45 and over are included in this graph.
Bodily pain experienced in the 4 weeks prior to interview.
Source: ABS 2019 (Data table).
Deaths
How many deaths were due to COPD?
COPD is a major leading cause of death in Australia. In 2021, 7,018 people were recorded as having died from COPD (underlying cause of death), a mortality rate of 27.3 per 100,000 population, representing 4.1% of all deaths and 52% of all respiratory deaths.
COPD was more likely to be recorded as an associated cause of death (58% of COPD deaths). An additional 9,663 deaths were recorded as an associated cause equalling a total of 16,681 deaths in Australia due to or associated with COPD. This represented 9.7% of all deaths and 36% of respiratory deaths.
Variation by age and sex
In 2021, COPD mortality (as the underlying cause of death) was:
- more common in older people (69% aged 75 and over), which is similar to the proportion of people aged 75 and over for total deaths (67%).
- slightly higher in males (53% of COPD deaths were male which is similar to the proportion of males in total deaths (52%) (Figure 10).
Figure 10: Age profile of COPD mortality statistics, by sex
This line chart shows the death rate due to COPD in 2021, for COPD as the underlying condition, an associated-only cause of conditions and any cause of condition, by sex and age group. Mortality increased with increasing age for both males and females, with deaths being higher for males than females in most age groups.
This line chart shows the death rate for COPD as the underlying condition, an associated-only cause of conditions and any cause of condition from 2011 to 2021. COPD rates remained fairly stable between 2011 and 2021 with some minor fluctuation between 19 to 25 per 100,000 population.
Variation between population groups
Remote and very remote areas had 2.1 times more COPD deaths per population when compared with Major cities.
The lowest socioeconomic group (people living in areas with the highest level of disadvantage) had 2.9 times more COPD deaths per population than the highest socioeconomic group (people living in areas with the lowest level of disadvantage) in 2021.
The same patterns across population groups were seen for COPD deaths as an underlying cause or any cause (underlying or associated cause) of death.
Further detail on mortality data is available in the Chronic respiratory condition mortality data tables 2023.
COPD mortality and smoking trends
The main risk factor for the development and progression of COPD is smoking, with smokers being 12 to 13 times more likely to die from COPD than non-smokers (U.S. Department of Health and Human Services 2014).
Improvements in COPD mortality rates are expected to follow improvements in smoking rates, with a time-lag between smoking and COPD mortality. This is because chronic conditions, such as COPD, have a long latency period i.e. smoking early in life is involved in initiating disease processes prior to disease diagnosed (Lynch & Smith 2005). In Australia, the smoking rate of adults aged 18 and over decreased from 1980 to 2019 (men: 41% to 14%; women: 30% to 12%) (Greenhalgh et al. 2023).
As shown in Figure 12, smoking rates in Australia have decreased from 1980 onwards among both men and women, with men having consistently higher smoking rates than women (Greenhalgh et al. 2023).
For more information on the history of smoking and COPD, see Mortality from asthma and COPD in Australia (AIHW 2014), which presents detailed analysis of COPD mortality from 1965 to 2010.
Figure 12: COPD death rates of people aged 45 and over, 3-year moving average, and smoking rates, 1980 to 2020
Notes:
1. COPD deaths are shown as a 3-year moving average. For example, the 2020 data point represents the average of 2019, 2020 and 2021.
2. From 1979 to 1996, COPD classified according to ICD-9 codes 490, 491, 492, 496; from 1997 to 2021, COPD classified according to ICD-10 codes J40–J44. COPD occurs mostly in people aged 45 years and over. While it is occasionally reported in younger age groups, in those aged 45 years and over there is more certainty that the condition is COPD and not another respiratory condition. For this reason only people aged 45 years and over are included in this table.
3. Smoking refers to people those reporting that they smoke 'daily' or 'at least weekly', and smoking any combination of combustible cigarettes, cigars, pipes or waterpipes. It does not include use of electronic cigarettes/vapes or other personal vaporising devices where users inhale vapour rather than smoke.
4. Smoking data were calculated by the Cancer Council of Victoria. Smoking rates for 1980–1992 were sourced from surveys conducted by the Anti-Cancer Council of Victoria; smoking rates for 1995–2019 were sourced from the National Drug Strategy Household Survey. Blank cells mean that data was not available.
5. In this report, deaths registered in 2018 and earlier are based on the final version of cause of death data; deaths registered in 2019 are based on the revised version; and deaths registered in 2020 and 2021 are based on the preliminary version. Revised and preliminary versions are subject to further revision by the Australian Bureau of Statistics (ABS).
Sources: AIHW analysis of AIHW National Mortality Database, Scollo & Winstanley 2019.
Treatment and management of COPD
The Department of Health’s National Strategic Action Plan for Lung Conditions (the Action Plan) provides a detailed, person-centred roadmap for treating and managing COPD, among several other lung conditions (Department of Health 2019). The Action Plan outlines a comprehensive, collaborative and evidence-based approach to reducing the individual and societal burden of lung conditions and improving lung health (Department of Health 2019). The Action Plan can be found on the Lung Foundation Australia website.
Also, the COPD-X Plan: Australian and New Zealand Guidelines for the management of COPD (the COPD-X Guidelines) summarises current evidence around optimal management of people with COPD, and provides a decision support aid for general practitioners, other primary health care clinicians, hospital-based clinicians and specialists working in respiratory health. The evidence published in the COPD-X Guideline is systematically searched for, identified and reviewed on a regular basis (Yang et al. 2019).
COPD-X stands for:
- Case finding and confirm diagnosis
- Optimise function
- Prevent deterioration
- Develop a plan of care
- Manage eXacerbations (Yang et al. 2019).
The latest COPD-X Guidelines can be found on the Lung Foundation Australia website.
What role do GPs play in treating and managing COPD?
General practitioners (GPs) are often the first point of contact for people who develop COPD. According to the Bettering the Evaluation and Care of Health (BEACH) survey, in the ten-year period from 2006–07 to 2015–16, the estimated rate of COPD management in general practice was around 0.9 per 100 encounters (Figure 13) (Britt et al. 2016).
Figure 13: General practice encounters for COPD, all ages, 2006–07 to 2015–16
Notes
COPD classified according to International Classification of Primary Care, 2nd edition (ICPC-2) codes R79001, R79003 and R95.
The Bettering the Evaluation and Care of Health (BEACH) year is from April to March.
An encounter relates to a consultation between a patient and a GP.
Statistics on general practice activities based on BEACH data are derived from a random sample survey of GPs and their encounters with patients, and should be interpreted with caution.
Source: Britt et al. 2016 (Data table).
What interventions are used to treat and manage COPD?
Currently, the only intervention that has been shown to slow the long-term deterioration in lung function associated with COPD is assisting smokers to quit (Mosenifar 2022). Other interventions for COPD that can help maintain quality of life and reduce symptoms are: immunisations, pulmonary rehabilitation, medications, and, for people with very severe disease, long-term oxygen therapy.
Some information is available on use of medications by patients with COPD, however, there is currently a lack of nationally comparable information about access to and utilisation of pulmonary rehabilitation and oxygen therapy. Options for improving data about these interventions are discussed in the report Monitoring pulmonary rehabilitation and long-term oxygen therapy for people with chronic obstructive pulmonary disease (COPD) in Australia – a discussion paper.
Smoking cessation
The most beneficial step in any treatment plan for COPD patients is to stop smoking. Stopping smoking is the only intervention that has been shown to improve the natural progression of COPD. For example, it helps to improve a patient’s cough, ease breathlessness and slow down further lung damage (Yang et al. 2022).
Immunisation
Vaccination reduces the risks associated with influenza and pneumococcal infection, which are leading causes of exacerbations and healthcare visits. Therefore, influenza immunisation and pneumococcal immunisation is recommended for all patients with COPD (Yang et al. 2022).
Pulmonary rehabilitation
Pulmonary rehabilitation is one of the most effective interventions for COPD and is recommended for all patients with COPD who are short of breath on exertion, including in the period following an acute exacerbation (Spruit et al. 2013; Alison et al. 2017). According to Spruit, pulmonary rehabilitation is a comprehensive intervention, mainly involving exercise training, education, and behaviour change. It is designed based on a thorough patient assessment followed by patient-tailored therapies (Spruit et al. 2013). Strong evidence supports pulmonary rehabilitation is effective for COPD patients to improve their physical and emotional condition, long-term adherence to health behaviours, quality of life and reduce hospitalisations, thus helping them improve their independence and functioning in the community (Gordon et al. 2019; McCarthy et al. 2015; Puhan et al. 2016).
Pulmonary rehabilitation is commonly delivered by an interdisciplinary team of therapists and may comprise various associated supportive strategies (Alison et al. 2017). It mainly includes the following components:
- Exercise training – the cornerstone foundation of pulmonary rehabilitation. This aims to build patient confidence, maximise skeletal muscle function, optimise cardiovascular fitness and promote self-sustaining healthy physical activity behaviours.
- Education – involves the provision of tailored advice to improve people’s understanding of their lung disease, awareness of self-management strategies, how to exercise safely, how to use medicines, how treatment works, and when to ask for help. Education may be provided in various formats such as group discussions or resources. Identifying individual support needs (e.g. assistance to quit smoking) is an essential goal of education.
- Nutrition counselling – the provision of individually tailored dietary support to optimise nutritional intake and control weight loss or gain. In people with COPD, both excess weight and low weight are associated with increased morbidity. Obesity increases the work of breathing, while poor nutritional status and insufficient energy intake may lead to impaired muscle function, which can accelerate deconditioning and worsen symptoms such as breathlessness.
- Psychosocial support – People with COPD are vulnerable to developing symptoms of anxiety and depression, which can worsen quality of life and disability. Support is often provided by peer participants, support groups, social workers or external organisations. This may involve emotional support, social support, or the development of coping strategies to help people better manage COPD. Mental health specialists may provide additional expert support, if required, for clinically significant symptoms of anxiety or depression (Alison et al. 2017; Yang et al. 2022).
Pulmonary rehabilitation may be provided in hospital outpatient departments, in community facilities or at home. Hospital-based programs are often considered ‘usual care’, however community-based programs of equivalent frequency and intensity can be offered to people with COPD as a suitable alternative (Alison et al. 2017). Home-based pulmonary rehabilitation programs should include regular contact with an exercise specialist to facilitate appropriate participation and progression.
Medications
Medications are used in COPD treatment to prevent and control symptoms, reduce the frequency and severity of exacerbations and improve exercise tolerance. Some drugs used to treat COPD are also used to treat other respiratory conditions such as asthma. For more information, see Respiratory medication use in Australia 2003–2013: treatment of asthma and COPD.
Several medications are available for treatment of COPD in Australia, including long-acting bronchodilators used both separately and in combination with inhaled corticosteroids or other bronchodilators. Bronchodilators are drugs that can relax and dilate the bronchial passageways and therefore improve the passages of air into the lungs. It is worth mentioning that the majority of the medications used in COPD treatment are delivered via inhalers, so good inhaler technique and adherence to treatment are important for optimal treatment outcome (George & Bender 2019).
Oxygen therapy
Long term oxygen therapy (LTOT) – the provision of supplemental oxygen therapy for 15 hours per day or more – can be prescribed for people with persistently low levels of oxygen in the blood, including from chronic lung disease, most commonly advanced COPD. LTOT reduces mortality in COPD and may also have a beneficial impact on aspects of quality of life (Yang et al. 2022). Although effective, it is a potentially expensive and cumbersome therapy that should only be prescribed for those in whom there is evidence of benefit (Yang et al. 2022). In Australia, LTOT is mostly delivered in the home using an oxygen concentrator, a device that removes nitrogen from room air, thereby increasing the concentration of oxygen. Sometimes oxygen cylinders are provided for short-term or portable use.
Non-invasive ventilation
Non-invasive ventilation (NIV) refers to the administration of ventilatory support using a face mask, nasal mask, or a helmet, rather than an invasive artificial airway (such as a tube). Air, usually with added oxygen, is given to patient through the mask under positive pressure, where the amount is altered depending on whether the patient is breathing in or out. NIV has now become an integral tool in the management of acute and chronic respiratory failure, in both the home setting and in the critical care unit.
The current evidence shows that NIV is effective in preventing respiratory failure after extubation (removal of a tube previously inserted into a patient's body) (Ferrer et al. 2009) and treating patients with an acute exacerbation of COPD and other disorders characterised by hypoventilation (Ram et al. 2004; Osadnik 2017).
What role do hospitals play in treating COPD?
Patients may require admission to hospital for severe acute exacerbations of COPD. Acute exacerbations of COPD (flare-ups) are frequently due to respiratory tract infections. They have also been associated with increases in exposure to air pollution and changes in ambient temperature. Episodes that are life threatening sometimes require temporary assistance with breathing.
Data from the AIHW National Hospital Morbidity Database (NHMD) show that in 2020–21 there were 53,600 hospitalisations of people 45 and over where COPD was the principal diagnosis. The rate of hospitalisation for COPD among those aged 45 and over was 510 per 100,000 population. Both the rate of hospitalisations and the average length of stay in hospital tended to increase with increasing age (Figure 14).
Figure 14: Age profile of COPD hospitalisation statistics, by sex
This line chart shows the number of COPD separations per 100,000 persons in 2020–21. COPD hospitalisations were higher in women compared with men until the 60–64 age group. In those aged 65-69 and higher, the rate of COPD separations was higher in men.
The line chart shows COPD hospitalisation rates among people aged 45 and over from 2010─11 to 2020─21. The hospitalisation rate for both men and women has declined annually from its peak in 2016-17.
This line chart shows the hospitalisations per 100,000 population for acute respiratory infections and chronic pulmonary obstructive disease from 2016 to 2020.
Comorbidities of COPD
People with COPD often have other chronic and long-term conditions. This is called ‘comorbidity’, which describes any additional disease that is experienced by a person with a disease of interest (the index disease). Comorbidities often share common risk factors, and are increasingly seen as acting together to determine the health outcome.
Australians diagnosed with one or more chronic conditions often have complex health needs, die prematurely and have poorer overall quality of life (AIHW 2018). In terms of comorbidities, in 2017─18 one in five Australians (20%) had two or more chronic conditions (ABS 2018). As people age, they are more likely to have more than one chronic condition. Because COPD is more likely to occur in older people, people with COPD also commonly experience a range of other chronic conditions (Chatlia et al. 2008; Divo et al. 2012). These comorbidities contribute to ill health and risk of death in all stages of COPD, and the incidence of hospitalisation for non-respiratory causes is increased in patients with COPD (Franssen & Rochester 2014). As well, when people are admitted for non-respiratory causes, they have a longer length of hospital stay and are more likely to die if they also have COPD (Holguin et al. 2005).
The chronic conditions that have been selected for this COPD comorbidity analysis are: arthritis, asthma, back problems, cancer, diabetes, heart, stroke and vascular disease, kidney disease, mental and behavioural conditions and osteoporosis. They have been selected because they are common in the general community and cause significant burden. Other chronic conditions that are found commonly in people with COPD, and that can impact COPD, include bronchiectasis and obstructive sleep apnoea (Yang et al. 2019). COPD is also associated with an increased risk of lung cancer and gastro-oesophageal reflux disease (GORD) (Yang et al. 2019).
In February 2019, the Department of Health released the National Strategic Action Plan for Lung Conditions (the Action Plan), which includes COPD in its scope. The Action Plan ‘provides a detailed, person-centred roadmap for addressing one of the most urgent chronic conditions facing Australians’ (Department of Health 2019). The Action Plan ‘outlines a comprehensive, collaborative and evidence-based approach to reducing the individual and societal burden of lung conditions and improving lung health’ (Department of Health 2019). The Action Plan acknowledges as with most chronic conditions, lung disease may co-exist with other common chronic conditions. The Action Plan addresses these comorbidities when clinically relevant to a patient living with lung condition(s) (Department of Health 2019). For more information, see National Strategic Action Plan for Lung Conditions- external site opens in new window.
Comorbidities can complicate management options and multiply the effects of chronic conditions (van der Molen 2010). Physicians may need to prescribe medications for one condition that may exacerbate another existing comorbid condition. For example, some bronchodilator medications prescribed for COPD may worsen glaucoma (increased pressure in the eyes), or can cause urinary problems in men with an enlarged prostate. Use of steroid tablets for COPD exacerbations (or flare-ups) may contribute to weakening of the bones (osteoporosis) (AIHW 2020).
COPD has a high rate of comorbidity with cardiovascular disease (CVD) (Bhatt et al. 2014). Beta‑blocker medications are recommended for management of acute coronary syndromes, cardiac failure and sometimes for irregular heartbeat and hypertension. However, these medications can cause severe flare-ups in people with asthma and so have frequently been withheld from people with COPD (AIHW 2020). Despite this, recent evidence suggests that beta-blockers may be safe and helpful for managing COPD (Bhatt et al. 2016), though the COPD-X Plan states that despite a paucity of evidence to suggest harm, beta-blockers are still under-utilised in COPD for guideline-based indications such as systolic heart failure (Yang et al. 2019).
Establishing a better understanding of the common comorbidities of COPD may help with the diagnosis of comorbid conditions. For example, coronary artery disease is common in patients with COPD and is underdiagnosed (Reed et al. 2012). Optimal management of any individual patient with COPD should include identification and management of comorbidities and anticipation of increased risks associated with those comorbidities in the presence of COPD (Yang et al. 2019).
Prevention and diagnosis can be improved by a better understanding of risk factors for the development of COPD. Tobacco smoking, air pollution, poor nutrition and serious childhood lung infections are all known risk factors for developing COPD (Yang et al. 2019). More information on risk factors can be found in the section Risk factors associated with COPD.
Treatment strategies that target modifiable behaviours can be used to manage various chronic diseases, for example, diet, exercise, weight control, and smoking cessation or reduction (Bauer et al. 2014). Smoking cessation is the most important intervention to prevent the worsening of COPD (Yang et al. 2019).
Number of comorbid chronic conditions in people with COPD
Based on self-reported data from the 2017–18 National Health Survey (NHS), an estimated 599,000 Australians (2.5% of the population) have COPD (ABS 2018). While COPD is occasionally reported in younger age groups, in those aged 45 and over there is more certainty that the condition is COPD and not another respiratory condition. The 2017–18 NHS estimates that 464,000 (4.8%) Australians aged 45 and over had COPD (ABS 2019). Eighty six per cent of people who had COPD also had one or more of the following selected chronic conditions (ABS 2018):
- arthritis
- asthma
- back problems
- cancer
- diabetes
- heart, stroke and vascular disease
- kidney disease
- mental and behavioural conditions
- osteoporosis.
These 9 chronic conditions have been selected because they are common in the general community, pose significant health problems, have been the focus of ongoing national surveillance efforts, and action can be taken to prevent their occurrence (AIHW 2012; AIHW 2015).
Additional chronic conditions that are commonly found in people with COPD, and that can impact on COPD, include bronchiectasis (a condition in which the airway walls are damaged and the person has excessive mucus production and frequent chest infections) and obstructive sleep apnoea (Yang et al. 2019)).
Of those aged 45 and over who had COPD, 90% had at least one other chronic condition while just 10% had COPD and no other selected chronic conditions (Figure 17). Nearly 1 in 5 (18%) had one other selected chronic condition and over 2 in 3 (72%) had two or more other selected chronic conditions.
Figure 17: Comorbidity of selected chronic conditions in people aged 45 and over with COPD, 2017–18
Note: The 9 other selected chronic conditions include arthritis, asthma, back problems, cancer, diabetes, heart, stroke and vascular disease, kidney disease, mental and behavioural conditions and osteoporosis.
Source: ABS 2019 (Data table).
Types of comorbid chronic conditions in people with COPD
Among people aged 45 and over with COPD:
- 55% had arthritis (compared with 33% for people without COPD)
- 43% had asthma (compared with 11% for people without COPD)
- 41% had mental and behavioural conditions (compared with 21% of people without COPD)
- 40% had back problems (compared with 25% for people without COPD)
- 26% had heart, stroke and vascular disease (compared with 10% of people without COPD) (Figure 18).
Figure 18: Prevalence of other chronic conditions in people aged 45 and over with and without COPD, 2017–18
Notes
COPD here refers to self-reported current and long-term bronchitis and/or emphysema.
Proportions may not add to 100% as a person may have more than one additional diagnosis.
Source: ABS 2019 (Data table).
Risk factors associated with COPD
COPD shares a number of risk factors with other chronic conditions, such as:
- Non-modifiable risk factors
- age (COPD is more common as people age)
- genetic predisposition
- Modifiable risk factors
- smoking or exposure to environmental tobacco smoke (including in childhood)
- exposure to fumes and smoke from carbon-based cooking and heating fuels, such as charcoal and gas
- occupational hazards (for example, exposure to pollutants and chemicals)
- poor nutrition
- pneumonia or childhood respiratory infection (AIHW 2017).
In people with COPD, risk factors for poor health outcomes such as worsening symptoms, exacerbations (flare-ups) and increased risk of death include (Yang et al. 2019):
- smoking and exposure to environmental tobacco smoke
- influenza and pneumococcal infection
- malnutrition/ obesity
- insufficient physical activity
- presence of comorbidities
For COPD, as for many other chronic conditions, there are two types of risk factors: those that increase the chance of developing COPD in the first place, and those that increase the chance that a person who already has COPD will develop additional health problems. Risk factors also vary according to the person's age.
Finding a factor that is associated with an increased risk of developing COPD, or an increased risk of poor health outcomes in COPD, does not necessarily mean that the risk factor caused these problems, or that they can be prevented. However, there is overwhelming evidence that smoking and exposure to biomass fuels are major causes of COPD (AIHW 2017).
Common risk factors
Based on the 2017–18 National Health Survey (NHS), people with self‑reported COPD aged 45 and over were more likely to be current daily smokers and insufficiently physically active, compared with those without COPD aged 45 and over (see Figure 19). Risk factor definitions are included in Box 1 (under data notes). These risk factors are also common among other chronic conditions (ABS 2018).
Figure 19: Prevalence of selected risk factors in people aged 45 and over with and without COPD, 2017–18
Note: Obese is based on body mass index (BMI) for persons whose height and weight was measured and imputed. In 2017–18, 33.8% of respondents aged 18 years and over did not have a measured BMI. For these respondents, imputation was used to obtain BMI. For more information, see Appendix 2: Physical measurements in the 2017–18 National Health Survey (ABS 2018).
Source: ABS 2019 (Data table).
Selected risk factors
Smoker status
People with COPD aged 45 and over were more likely to be current daily or ex-smokers, with:
- 25% being a current daily smoker (compared with 12% without COPD aged 45 and over)
- 47% being an ex-smoker (compared with 38% without COPD aged 45 and over) (Figure 19).
It is worth noting that one quarter (26%) of people aged 45 and over with COPD had never smoked cigarettes.
Tobacco smoking is one of the leading behavioural risk factors for death from all causes and contributes significantly to deaths from a range of chronic conditions (including CVD, COPD, and lung cancer) (AIHW 2017). Tobacco smoking is the predominant cause of COPD and is associated with a majority of COPD cases (Yawn & Kaplan 2008). Lifelong smokers have a 50% probability of developing COPD during their lifetime (Laniado-Laborin 2009).
Once COPD has developed, continued smoking increases the risk of exacerbations (flare-ups) and the risk of death, not only from COPD but also from other causes, such as cancer and cardiovascular disease (AIHW 2017). While the damage from past smoking is not fully reversible, the rate of progression of COPD can be reduced through smoking cessation (Laniado-Laborin 2009). Quitting smoking also reduces the risk of exacerbations and mortality in patients with COPD (Anthonisen et al. 2005; Au et al. 2009).
General Practitioners play an important role in encouraging and supporting people to quit smoking, especially when they have health problems caused or exacerbated by smoking, which are more common with age (RACGP 2021). In Australia, smoking rates have been falling amongst males since the 1950s (1970s in women) (Greenhalgh et al. 2019), and recent studies have shown that smoke free laws, tobacco price increases and mass media campaigns have all contributed to a continuing decline in smoking rates, including among young people (Wakefield et al. 2014).
Figure 20: Smoker status of people aged 45 and over with and without COPD, 2017–18
Source: ABS 2019 (Data table).
Physical activity
People with self-reported COPD aged 45 and over were more likely than people without COPD aged 45 and over to be insufficiently physically active (76% compared with 60% for people without COPD) (Figure 21).
One of the main features of COPD is shortness of breath on exertion. As the condition progresses, shortness of breath can worsen and even minor physical activities, such as dressing or showering can become very difficult. People with COPD therefore are often unable to exercise as much as those without COPD, or they may limit their physical activity to avoid becoming short of breath. However, low physical activity in turn leads to lack of cardiovascular fitness, increased risk of cardiovascular disease, and obesity, each of which may further worsen shortness of breath (AIHW 2019b).
Exercise-based pulmonary rehabilitation is an important part of management of COPD, as it improves quality of life and exercise capacity and reduces hospitalisations (Alison et al. 2017). It is a system of care that includes education, exercise training and psychosocial support delivered by an interdisciplinary team of therapists (Alison et al. 2017). Pulmonary rehabilitation reduces symptoms, disability and handicap, reduces hospitalisation and improves physical and emotional function. It can help people achieve and maintain an optimal level of independence and functioning in the community (Alison et al. 2017). For more information regarding pulmonary rehabilitation, refer to Monitoring pulmonary rehabilitation and long-term oxygen therapy for people with chronic obstructive pulmonary disease (COPD).
Figure 21: Physical activity in people aged 45 and over with and without COPD, 2017–18
Source: ABS 2019 (Data table).
Body mass
People with self-reported COPD aged 45 and over were not significantly more likely to be obese compared with people without COPD (43% with COPD compared with 38% without COPD) (Figure 22).
Several studies have shown strong associations between overweight and obesity, as measured by body mass index (BMI), and increased prevalence of COPD (Fuller-Thomson et al. 2018). This is not surprising, as the prevalence of both COPD and obesity increase with increasing age. There is little evidence that high BMI increases the risk of developing COPD. However, obesity is a risk factor for dyspnoea (or shortness of breath), which may contribute to symptoms of COPD and may also reduce lung function (AIHW 2019b).
For patients who already have COPD, many studies have shown that mild obesity appears to be protective from risk of death, unlike many other chronic diseases in which increased body weight is associated with worse outcomes (Hanson et al. 2014; Spelta et al. 2018). Being underweight or average weight is associated with increased risk of dying for people with COPD (Hanson et al. 2014). The relationship between low BMI and increased mortality is particularly seen in patients with more severe COPD, of whom around 14% experience substantial weight loss and reduced fat-free mass (van der Molen 2010). This may be due to systemic inflammation associated with COPD, leading to muscle wasting (van der Molen 2010). Reduced micronutrient intake may also contribute to increased risk (Hanson et al. 2014).
Figure 22: Body mass index (BMI) distribution in people aged 45 and over with and without COPD, 2017–18
Note: Based on body mass index (BMI) for persons whose height and weight was measured and imputed. In 2017–18, 33.8% of respondents aged 18 years and over did not have a measured BMI. For these respondents, imputation was used to obtain BMI. For more information, see Appendix 2: Physical measurements in the 2017–18 National Health Survey (ABS 2018).
Source: ABS 2019 (Data table).
Age differences in risk factors in people with COPD
People with COPD aged 45–64 were more likely to be a current daily smoker (38%) compared with those aged 65 and over (14%) and were less likely to be insufficiently physically active (68%) compared with people with COPD ages 65 years and over (82%). The difference in obesity between the two age groups was not statistically significant (Figure 23).
Figure 23: Prevalence of selected risk factors in people aged 45 and over with COPD, by age group, 2017–18
Note: Overweight and obese are based on body mass index (BMI) for persons whose height and weight was measured and imputed. In 2017–18, 33.8% of respondents aged 18 years and over did not have a measured BMI. For these respondents, imputation was used to obtain BMI. For more information, see Appendix 2: Physical measurements in the 2017–18 National Health Survey (ABS 2018).
Source: ABS 2019 (Data table).