Keeping your COPD patients well this winter

Acute exacerbations in people with Chronic Obstructive Pulmonary Disease (COPD) contribute to long-term decline in lung function, exercise performance, quality of life and more frequent hospitalisation. For people living in temperate climates, exacerbations are almost twice as likely to occur during winter as in summer.^1-3

Analysis of DVA health claims data indicated, of the veteran hospitalisations between 2014 and 2015 for COPD, the majority occurred during the winter months of July and August.⁴ This therapeutic brief highlights interventions that can help to prevent exacerbations and improve the physical and mental well-being of COPD patients.

Reduce the risk of exacerbations by:

Arranging pulmonary rehabilitation

Pulmonary rehabilitation is an evidence-based, multidisciplinary intervention that promotes the adoption of healthy long-term behaviours to reduce the impact of COPD. It involves individualised therapies based on initial and ongoing assessments of the patient.⁵ Pulmonary rehabilitation is highly beneficial, strongly recommended and improves exercise tolerance and quality of life for patients, irrespective of the severity or stage of their disease.⁵ Pulmonary rehabilitation, initiated shortly after a hospitalisation for an exacerbation, reduces the risk of subsequent hospitalisations.^5,6

An established program typically involves six to eight weeks, two to three times a week, of being supervised and trained by a variety of qualified healthcare professionals. Programs can include:

• An initial assessment to review patients' medical history, usually provided by the GP, and to assess exercise capacity, quality of life, breathlessness and individual goals.⁷
• Education to provide patients with the knowledge, skills and confidence to better manage their condition.⁵ Topics might include smoking cessation, basic information about COPD and management of stress, depression and breathlessness.^7,8
• Exercise training to improve cardiorespiratory endurance, strength and flexibility. Specific training may include endurance, interval, or resistance training, neuromuscular electrical stimulation or inspiratory muscle training and breathing techniques.⁵ Even if patients are not able to participate in the exercise training, they can join in the education sessions.⁷
• Behaviour change and self-management techniques including Cognitive Behavioural Therapy (CBT) to improve physical and mental well-being and quality of life. Behaviour change might include improving adherence to medicines, maintaining daily exercise or eating a healthier diet.⁵ CBT can be helpful in reducing symptoms of mild to moderate anxiety and depression often present in people with COPD.⁹
• Evaluation based on patient feedback and improvement in exercise capacity and quality of life.⁷

When referring your patients to a pulmonary rehabilitation program provide information about:¹⁰

• relevant investigations, including recent lung function test or arterial blood gas results
• conditions that might restrict or impact on their ability to exercise
• comorbidities (COPD patients often have comorbidities related to treatments, long-term smoking, ageing or the disease itself).^8,11

Refer to the Coordinated Veterans’ Care Program: a Guide for General Practice to enhance the management of your veteran patients with chronic diseases at: www.dva.gov.au/sites/default/files/files/providers/cvc/cvc-a-guide-for-general-practice-booklet.pdf

In areas where established pulmonary rehabilitation programs are not available:

• Encourage your patients to access COPD Online Patient Education (C.O.P.E.) to undertake the educational component at home, available at: www.cope.lungfoundation.com.au
• Refer your patients to a supervised exercise program or an established cardiac exercise program conducted at a hospital. Established cardiac exercise programs conducted at hospitals are often similar to pulmonary rehabilitation programs.
• See the section Setting up a pulmonary rehabilitation program for information about establishing a pulmonary rehabilitation program.

Encourage people to continue regular exercise after completion of a pulmonary rehabilitation program to maintain improvements.⁸ Exercise programs alone can have clear benefits; 20 to 30 minutes of brisk walking each day is beneficial.^8,12,13 A randomised controlled trial found brisk walking two to three times a week for eight to ten weeks significantly improved people’s quality of life and endurance exercise capacity.¹³

Refer your patients who have completed a pulmonary rehabilitation program to a maintenance program, such as ‘Lungs in Action’. It is a community based exercise program that helps to maintain a person’s fitness and social support after a pulmonary rehabilitation program. For further information and class locations, access the website at: www.lungsinaction.com.au

Prioritising smoking cessation

Reinforce the importance of quitting smoking. It is the single most effective intervention to prevent deterioration.^8,11,14

To increase your patients’ chances of successfully quitting:

• offer a combination of pharmacological and non-pharmacological interventions.¹¹ Under the Repatriation Pharmaceutical Benefits Scheme, eligible veterans, war widows and widowers have access to medicines for nicotine dependence
• encourage contact with Quitline on: 13 7848 or at: www.quitnow.gov.au
• offer counselling with a healthcare professional and suggest they join a social support group⁸
• show your patients a graphic illustration of their estimated lung age before and after they quit smoking, on the Lung Age Estimator, available at: https://lungfoundation.com.au/primary-care-respiratory-toolkit/
• refer to the RACGP’s Smoking Cessation Guidelines for Australian General Practice available at: www.racgp.org.au/your-practice/guidelines/smoking-cessation

The benefits of guideline-directed care for your COPD patients^5,11,14,15

Immunising against influenza and pneumococcal pneumonia

Review immunisation status and offer the influenza vaccination to your patients each year in early autumn, and consider vaccinating against pneumococcal disease if appropriate.¹¹

Refer to the Australian Immunisation Handbook online for detailed information at: https://immunisationhandbook.health.gov.au/vaccines

Supporting self-management and developing care plans

Develop a GP Management Plan (GPMP) and if eligible, a Team Care Arrangement (TCA) with your patients, their family and carers to anticipate and plan for their long-term care needs.¹¹

Patients able to self-manage well have improved quality of life and reduced hospital admissions.^16,17 A written action plan personalised for your patients, in addition to a GPMP and a TCA enables them to take action when symptoms are worsening to avoid or minimise an exacerbation. Routinely recall your patients when a review is due.¹¹

Access a COPD action plan template at: https://lungfoundation.com.au/resources/?search=COPD%20Action%20Plan&condition=9

Optimising medicines

Base medicine choice on your patients' treatment goals, symptoms, exacerbation history, response to treatment and risk of side effects.¹¹ Minimise use of different devices to reduce confusion and consider a spacer with a pressurised metered-dose inhaler (pMDI), particularly for your patients with poor inspiratory effort, or diminished coordination and dexterity.¹⁴ Review as needed to assess shortness of breath, quality of life and frequency of exacerbations.¹¹ Because many COPD medicines are combination products, take care not to duplicate classes when adding or changing medicines.^11,14

Refer to the ‘Stepwise Management of Stable COPD’ and other recent guidelines available at: https://lungfoundation.com.au/health-professionals/conditions/copd/overview/ The COPD-X guidelines are regularly updated at this website.

Reviewing your patients’ device management

Incorrect or poor use of devices and non-adherence is common among patients with COPD.^15,18 Before considering any change in inhaled medicines, check that your patients are taking them as directed and their inhaler device management, including technique is correct.¹¹

Talk with your patient about:

• when and how to prime or load their device
• how to clean and store their device
• when their device is empty
• when to replace their old device
• their susceptibility to dental and oral problems and the need for optimal oral care and regular check-ups, and
• what their medicines are for.

Consider referring your patients for an HMR or an RMMR if you suspect management or adherence issues or incorrect use of a device.¹¹

Ask the pharmacist to review your patients' inhaler device technique. Instructional videos and printable patient handouts for inhaler devices and their management can be viewed from https://lungfoundation.com.au/resources/?search=technique

Setting up a pulmonary rehabilitation program

Pulmonary rehabilitation is highly beneficial and strongly recommended for people with Chronic Obstructive Pulmonary Disease (COPD).^5,11 The core components of a program include individualised patient assessment, exercise training, education and evaluation. The structure and delivery can vary, depending on resources available, especially in rural and remote areas.¹⁰ Even a pulmonary rehabilitation program with limited resources has been shown to be effective. If you are interested in setting up your own program using local resources available, the following information will help you.

What personnel and equipment do I need?

The exercise component

The minimum requirements include knowing how to conduct an exercise program for people with lung disease and being trained in cardiopulmonary resuscitation.¹⁰

The education component

The team can include a doctor, nurse, dietician, psychologist, exercise physiologist, physiotherapist, pharmacist or social worker, depending on locally available healthcare professionals.¹⁰

The equipment component

A minimum requirements list is available at: www.pulmonaryrehab.com.au/wp-content/uploads/2016/08/What_Equipment_Will_I_Need.pdf

References

1. Jenkins C, et al. Seasonality and determinants of moderate and severe COPD exacerbations in the TORCH study. European Respiratory Journal. 2012; 39: 38-45.
2. Donaldson G, Seemungal T, Bhowmik A, Wedzicha J. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax. 2002; 57: 847-852.
3. Anzueto A. Impact of exacerbations on COPD. European Respiratory Review. 2010; 19 (116): 113-118.
4. DVA Health Claims Database, University of South Australia, QUMPRC. [Accessed October 2016].
5. Spruit M, et al. An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. American Journal of Respiratory and Critical Care Medicine. 2013; 188 (8): e13-64.
6. Puhan M, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease (review). The Cochrane Database of Systematic Reviews. 2011, Issue 10.
7. Lung Foundation Australia. Pulmonary rehabilitation toolkit. Available at: http://lungfoundation.com.au/health-professionals/clinical-resources/copd/pulmonary-rehabilitation-toolkit/ [Accessed July 2016].
8. Decramer M, et al. Global initiative for chronic obstructive lung disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Updated 2016. Available from: http://goldcopd.org/ [Accessed October 2016].
9. Hynninen M, et al. A randomised controlled trial of cognitive behavioural therapy for anxiety and depression in COPD. Respiratory Medicine. 2010; 104: 986-994.
10. Lung Foundation Australia. Primary care respiratory toolkit. Available at: http://lungfoundation.com.au/health-professionals/clinical-resources/copd/primary-care-respiratory-toolkit/ [Accessed July 2016].
11. Abramson M, et al. COPD-X Concise Guide for Primary Care. Brisbane. Lung Foundation Australia. 2016.
12. Miravitlles M, Cantoni J & Naberan K. Factors associated with a low level of physical activity in patients with chronic obstructive pulmonary disease. Lung. 2014; 192: 259-265.
13. Wootton S, et al. Ground-based walking training improves quality of life and exercise capacity in COPD. European Respiratory Journal. 2014; doi: 10:1183/09031936.00078014
14. Australian Medicines Handbook, Adelaide: Australian Medicines Handbook Pty Ltd. 2016.
15. Yang I, et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2016. Version 2.46, June 2016.
16. Effing T, et al. Self-management education for patients with chronic obstructive pulmonary disease (review). The Cochrane Database of Systematic Reviews. 2009; Issue 4: 1-62.
17. Zwerink M, et al. Self management for patients with chronic obstructive pulmonary disease (review). The Cochrane Database of Systematic Reviews. 2014; Issue 3: CD002990.
18. Sanchis J, Gich I & Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time? Chest. 2016; doi:10.1016/j.chest.2016.03.041

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