Treatment & management

What role do GPs play in treating 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 2006–07 to 2015–16 the estimated rate of COPD management in general practice was around 0.9 per 100 encounters (Figure 1) [1].

Figure 1: General practice encounters for COPD, all ages, 2006–07 to 2015–16

The line chart shows the general practice encounters for COPD remained steady from 2006─07 to 2009─1 at 0.8 per 100 encounters, and then fluctuated slightly up to 2015─16. The peak appeared in 2013–14, at 1.0 per 100 encounters.

Notes

  1. The Bettering the Evaluation and Care of Health (BEACH) year is April to March.
  2. An encounter relates to a consultation between a patient and a GP.
  3. COPD classified according to International Classification of Primary Care, 2nd edition (ICPC-2) codes R79001, R79003 and R95.
  4. 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: [1] (Data table).

What interventions are used to treat COPD?

Management of COPD is mainly focused on preventing further deterioration and maintaining lung function and quality of life. The only intervention that has been shown to slow the long term deterioration in lung function associated with COPD is assisting smokers to quit [2,3]. Three other interventions for COPD that can help maintain quality of life and reduce symptoms are pulmonary rehabilitation, medications, and, for people with very severe disease, long-term oxygen therapy.

Some statistical information is available about supply of medications for 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 [4].

Medications

Medications are used in COPD 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 [5].

Several new medications have recently been approved for treatment of COPD in Australia, including new long-acting bronchodilators both separately and in combination with inhaled corticosteroids or other bronchodilators.

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 [6]. Although effective, it is a potentially expensive and cumbersome therapy that should only be prescribed for those in whom there is evidence of benefit [6]. 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.

Pulmonary rehabilitation 

Pulmonary rehabilitation is one of the most effective interventions for COPD, and it is recommended for all patients with COPD who are short of breath on exertion. It is a system of care that includes education, exercise training and psychosocial support delivered by an interdisciplinary team of therapists. 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. It has favourable interactions with other interventions, such as nutritional counselling and pharmacotherapy [7].

Pulmonary rehabilitation may include [6,7,8]:

  • Exercise training—which aims to build patient confidence, maximise skeletal muscle, improve breathing techniques, optimise cardiovascular fitness, and encourage regular, ongoing exercise. Pulmonary rehabilitation that includes exercise training is considered to be a key component of the management of people with COPD.
  • Education—explains the disease progression, how to use medicines, how treatment works, and when to ask for help. A primary component of education advice is assisting smokers to quit and sustain quitting.
  • Nutrition counselling—the provision of individually tailored dietary guidance to optimise nutritional intake and control weight loss or gain. In patients 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 functions causing breathing difficulties.
  • Psychosocial support—provided by support groups and other organisations. It may include emotional support, social support, and new knowledge and coping strategies to help people with COPD and their carers better manage the condition. People with COPD are vulnerable to developing symptoms of anxiety and depression, which then worsen quality of life and disability. Additional intervention by mental health specialists may be required for clinically significant symptoms of anxiety or depression.

Pulmonary rehabilitation can be provided in hospital outpatient departments, in community facilities or at home. Home-based Pulmonary Rehabilitation programs that include regular contact to facilitate exercise participation and progression, or community-based Pulmonary rehabilitation of equivalent frequency and intensity as hospital-based programs, can be offered to people with COPD as an alternative to usual care [8].

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 2016–17 there were 78,100 hospitalisations of people 45 years and over where COPD was the principal diagnosis. The rate of hospitalisation for COPD among those aged 45 and over was 757 per 100,000 population—the highest recorded over the previous 10 years.

The hospitalisation rate for men aged 45 years and over declined 6% in the ten years from 2007–08 to 2016–17, from 885 to 831 per 100,000 population (Figure 2).

In contrast, the hospitalisation rate for women increased by 17% from 599 in 2007–08 to 703 per 100,000 population in 2016−17. The rate of hospitalisation for women in 2016–17 was the highest recorded over the previous 10 years.

Hospitalisation rates for both men and women aged 45 years and over have been increasing since 2013−14.

Figure 2: COPD hospitalisations of people aged 45 and over, 2007–08 to 2016–17

The line chart shows COPD hospitalisation rates among people aged 45 and over from 2007─08 to 2016─17. The hospitalisation rate for men in this age group declined from 2007–08 (885 per 100,000 population) to 2016–17 (831 per 100,000 population). In contrast, the hospitalisation rate for women increased from 2007– 08 (599 per 100,000 population) to 2016−17 (703 per 100,000 population).

Note: Age-standardised to the 2001 Australian Standard Population.

Source: AIHW National Hospital Morbidity Database (Data table).

There is a strong seasonal driver of COPD exacerbations

Admissions to hospital for COPD are highest in winter and early spring. This matches and is related to the trend for acute respiratory infections (e.g. rhinovirus (common cold), influenza, pneumonia and acute bronchitis) (Figure 3). 

Figure 3: Hospitalisations for acute respiratory infection (ARI) or COPD of people aged 45 and over, by month, 2012–16

The line chart shows hospitalisation rates of ARI and COPD among people aged 45 and over in different seasons from 2012 to 2016. The admissions to hospital for acute respiratory infection and COPD are highest in both winter and early spring, and lowest in late summer.

Note: Data obtained from records of hospitalisations, reported by period of hospital admission.

Source: AIHW National Hospital Morbidity Database (Data table).

References

  1. Britt H, Miller GC, Bayram C, Henderson J, Valenti L, Harrison C et al. 2016. A decade of Australian general practice activity 2006-07 to 2015-16. General practice series no. 41. Sydney: Sydney University Press.
  2. Anthonisen NR, Connett JE, Kiley JP, Altose MD, Bailey WC, Buist AS et al. 1994. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. Journal of American Medical Association 272:1497–505.
  3. Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE & Connett JE 2005. The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial. Annals of Internal Medicine 142:233–9.
  4. Australian Institute of Health and Welfare (AIHW): Marks G, Reddel H, Guevara-Rattray E, Poulos L & Ampon R 2013. Monitoring pulmonary rehabilitation and long term oxygen therapy for people with chronic obstructive pulmonary disease (COPD) in Australia: a discussion paper. Canberra: AIHW.
  5. AIHW: Correll PK, Poulos LM, Ampon R, Reddel HK & Marks GB 2015. Respiratory medication use in Australia 2003-2013: treatment of asthma and COPD. Cat. no. ACM 31. Canberra: AIHW.
  6. Yang IA, Brown JL, George J, Jenkins S, McDonald CF, McDonald V, Smith B, Zwar N, Dabscheck E. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2018. Version 2.55, August 2018. Viewed 30 April 2019.
  7. Lung Foundation Australia 2008. A manual for pulmonary rehabilitation in Australia: Evidence base and standards (PDF). Milton: Lung Foundation Australia.
  8. Lung Foundation Australia 2017. The Australia and New Zealand Pulmonary Rehabilitation Guidelines. Milton: Lung Foundation Australia.