Treatment & management

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 Chronic Obstructive Pulmonary Disease (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 Guidelines is systematically searched for, identified and reviewed on a regular basis (Lung Foundation Australia 2019).

COPD-X stands for:

  • Case finding and confirm diagnosis
  • Optimise function
  • Prevent deterioration
  • Develop a plan of care
  • Manage eXacerbations (Lung Foundation Australia 2019).

The latest COPD-X Guidelines can be found 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 1) (Britt et al. 2016).

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. COPD classified according to International Classification of Primary Care, 2nd edition (ICPC-2) codes R79001, R79003 and R95.
  2. The Bettering the Evaluation and Care of Health (BEACH) year is from April to March.
  3. An encounter relates to a consultation between a patient and a GP.
  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: 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 2019). 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 (Lung Foundation Australia 2020).

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 (Lung Foundation Australia 2019).

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 and others (2013), 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 that 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 (Lung Foundation Australia 2008). 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 (Lung Foundation Australia 2017; Yang et al. 2018).

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 (Lung Foundation Australia 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. Bronchodulators are drugs that can relax and dilate the bronchial passage ways 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. 2018). 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. 2018). 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 alterated 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 exacberations 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 2017–18 there were 77,660 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 732 per 100,000 population.

The hospitalisation rate for men aged 45 years and over declined 8% in the ten years from 2008–09 to 2017–18, from 864 to 792 per 100,000 population (Figure 2). In contrast, the hospitalisation rate for women increased by 11% from 624 in 2008–09 to 690 per 100,000 population in 2017−18.

Figure 2: Age-standardised hospitalisation rate due to COPD, people aged 45 and over, by sex, 2008–09 to 2017–18

The line chart shows COPD hospitalisation rates among people aged 45 and over from 200809 to 201718. During the last decade, the hospitalisation rate for men aged 45 years and over declined from 864 per 100,000 population in 2008–09 to 792 per 100,000 population in 2017–18. In contrast, the hospitalisation rate for women increased from 624 per 100,000 population in 2008–09 to 690 per 100,000 population in 2017−18.

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COPD exacerbations are strongly driven by seasonality

Admissions to hospital for COPD are highest in winter and early spring and are consistent with the trend for acute respiratory infections, such as rhinovirus (common cold), influenza, pneumonia and acute bronchitis (Figure 3). 

Figure 3: Hospitalisations due to acute respiratory infection (ARI) and COPD, people aged 45 and over, by month, 2013–2017

The line chart shows hospitalisation rates of ARI and COPD among people aged 45 and over in different seasons from 2013 to 2017. The admissions to hospital for ARI and COPD are highest in both winter and early spring, and lowest in late summer.

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