A new focus for COPD patients

In 2018, Chronic Obstructive Pulmonary Disease (COPD) was the fifth leading cause of death in Australia.¹

Exacerbations contribute substantially to the progressive decline of COPD patients; every new exacerbation worsens lung function and quality of life, and increases the risk of a subsequent exacerbation, and premature death (see Figure 1).^2, 3

The 2020 Lung Foundation Australia, Australian and New Zealand COPD-X Guidelines emphasise a range of interventions to reduce symptoms, prevent exacerbations and improve quality of life including smoking cessation, pulmonary rehabilitation, daily physical activity, influenza and pneumococcal immunisation and patient education for self-management.⁴

The guidelines recommend medicines be used in a step-wise approach in conjunction with these interventions rather than predominantly relying on medicines alone.⁴

Emphasise to patients that pulmonary rehabilitation is highly effective

More than 300 pulmonary rehabilitation programs and 70 Lungs in Action Programs are registered with Lung Foundation Australia.¹¹

Offer to refer all symptomatic patients with COPD to a pulmonary rehabilitation program.^9, 12

To find a program near your patient, contact Lung Foundation Australia on 1800 654 301 or go to: https://pulmonaryrehab.com.au/national-program-map/

If there is no pulmonary rehabilitation program near your patient, find an exercise physiologist (Exercise & Sports Science Australia) at: www.essa.org.au/find or a physiotherapist (Australian Physiotherapy Association) at: https://choose.physio/find-a-physio

See insert ‘Providing pulmonary rehabilitation for veterans: useful resources for physiotherapists and exercise physiologists’ if you are interested in setting up your own program to treat veterans and their families.

An appropriate follow-on program such as the Lungs in Action Program helps patients to maintain benefits gained through pulmonary rehabilitation and to find like people for emotional support and social interaction.¹³ To find a class near your patient, go to: https://lungfoundation.com.au/patients-carers/support-services/lung-disease-and-exercise/exercise-classes/

Due to COVID-19, some programs may not be conducting face-to-face sessions; contact the facility directly to see if they deliver telerehabilitation or have resumed as COVID-19 restrictions change.

Promote ongoing physical activity that includes 30 minutes a day for at least five days a week to maintain fitness.¹⁴

Individualise choice of medicines using a step-wise approach

Inhaled bronchodilators play an important role in improving the patient’s ability to build their exercise capacity and fitness, by improving lung function and reducing breathlessness and exacerbations.^14, 15

Assess severity of symptoms, exacerbation risk and comorbidities to guide medicines use, and adjust depending on benefits, adverse effects and the patient’s ability to manage their inhaler device.¹⁴

• Use the COPD Assessment Test (CAT) to assess severity of symptoms and impact of COPD on daily life,^14, 16 at: www.catestonline.org/hcp-homepage.html
• Consider spirometry to assess severity of airflow obstruction and help guide therapeutic decisions.^5, 14
• For further information about using spirometry in primary care in COPD patients (NPS MedicineWise), go to: www.nps.org.au/news/the-value-of-spirometry-in-clinical-practice#spirometry-%E2%80%93-the-right-tool-for-the-job
• or ‘Overview of pulmonary function testing’ (Therapeutic Guidelines) at: www.tg.org.au

If the response to an inhaled medicine is insufficient, check your patient’s inhaler technique and adherence before changing medicines.^5, 14, 17 If there is no improvement following an adequate trial of the medicine, consider other causes of breathlessness or refer to a specialist for advice.¹⁷

To reduce confusion, avoid using different inhaler types where possible.^5, 18

• If combination therapy is indicated, a fixed-dose combination inhaler may improve adherence and be more manageable than separate single-drug inhalers.¹⁷
• Instruct your patient to stop all previous inhalers containing medicines from the same class when starting a fixed-dose combination inhaler.¹⁸

An update on corticosteroid use in COPD

Review stable patients using inhaled corticosteroids long-term

In general, the addition of an inhaled corticosteroid (ICS) can be considered in frequent exacerbators (at least one exacerbation requiring hospitalisation or two or more moderate exacerbations in the last year), if a long-acting muscarinic antagonist (LAMA) and long-acting beta₂ agonist (LABA) combination inhaler has not been sufficient to control symptoms or exacerbations.^14, 17, 18

The incidence of adverse effects associated with inhaled corticosteroids is related to dose and duration of treatment and include:

• hoarseness and oropharyngeal candidiasis^19, 20
• diabetes, osteoporosis and fracture,²¹ thinning and bruising of the skin and cataracts²⁰
• pneumonia.^5, 18-20

When making clinical management decisions, consider the individual needs of your patient and all corticosteroids prescribed to balance potential benefits and risks, and quality of life, especially in older patients with frailty and comorbidities.^4, 5, 19

Review stable patients using long-term ICS, and consider withdrawing gradually when:

• the adverse effects outweigh the benefits, (there is no improvement in symptom control, functional capacity or quality of life)⁴
• pneumonia develops⁴
• there is no evidence of asthma and no history of frequent exacerbations in the last year.^4, 22

After withdrawing ICS, optimise bronchodilation with a LABA or LAMA or a LABA and LAMA combination and monitor symptoms and exacerbation risk fortnightly initially, or as clinically needed, then three monthly for six months.^4, 23, 24

Limit oral corticosteroids to a maximum of two weeks

Oral corticosteroids reduce the severity of exacerbations, lower the rate of relapse and shorten recovery time.²⁵ There is an increase in adverse drug effects with their use.²⁵ Hence, use for longer than two weeks is not recommended.^4, 5

Consider oral prednisolone 30 mg to 50 mg or equivalent for five days (given in the morning) for the treatment of an acute exacerbation, and then cease.¹⁴ There is generally no need to taper the dose after five days of treatment.¹⁴

Chronic use of inhaled or oral corticosteroids can lead to adrenal insufficiency

• Patients taking prednisolone 5 mg per day or equivalent for four weeks or longer, patients taking inhaled beclomethasone greater than 1000 mcg per day, or inhaled fluticasone greater than 500 mcg per day are at risk of steroid dependence and adrenal insufficiency.²⁶
• Consider the need for withdrawing corticosteroids gradually as abrupt cessation can result in adrenal crisis; a medical emergency which if left untreated, can be fatal.^18, 26
• The adrenal response can remain depressed for a year or more after long-term corticosteroid use is ceased; corticosteroids may be needed in times of physiological stress such as intercurrent illness, infection, trauma or surgery, due to an inadequate adrenal response.¹⁸ Consider specialist review for advice as needed.¹⁸

Talk with your patients about maximising other key interventions

Providing pulmonary rehabilitation for veterans: useful resources for physiotherapists and exercise physiologists

Providing pulmonary rehabilitation for veterans: useful resources for physiotherapists and exercise physiologists

Pulmonary rehabilitation is highly beneficial and strongly recommended for people with Chronic Obstructive Pulmonary Disease (COPD).^9, 14 The core components of a program include individualised patient assessment, exercise training, education, evaluation and maintenance. The structure and delivery can vary, depending on resources available, especially in rural and remote areas. Even a pulmonary rehabilitation program with limited resources has been shown to be effective.⁹

If you are interested in setting up your own program to treat veterans and their families using local resources available, the following information may be of help to you.

Providing services to Veteran Card holders

Understanding the experiences of veterans and their families

Veterans and their families face unique experiences and significant challenges during a military career, making them different from other patients. Seeking to understand their experiences and developing an alliance with them can help to engage them and enhance the effectiveness of treatments provided.³⁶

Learn more about veterans and their families at Open Arms Veterans & Families Counselling: www.openarms.gov.au/health-professionals/about-veterans-and- their-families

Resources for providing pulmonary rehabilitation

References

1. Australian Government Australian Institute of Health and Welfare. Chronic obstructive-pulmonary disease (COPD). Cat. no. ACM 35. Canberra: AIHW. Viewed 25 August 2020. Available at: www.aihw.gov.au/reports/chronic-respiratory-conditions/copd/contents/copd [Accessed November 2020].
2. Suissa S, Dell'Aniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality. Thorax. 2012; 67: 957-63.
3. Hurst J et al. Understanding the impact of chronic obstructive pulmonary disease exacerbations on patient health and quality of life. Eur J Intern Med. 2020; 73: 1-6.
4. Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. 2020.
5. Global Initiative for Chronic Obstructive Pulmonary Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2020 Report. Available at: https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf [Accessed November 2020].
6. National COVID-19 Clinical Evidence Taskforce. Caring for people with COVID-19. Available at: https://covid19evidence.net.au/#living-guidelines [Accessed February 2021].
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9. Alison J et al. On behalf of the Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. Australian and New Zealand Pulmonary Rehabilitation Guidelines. Respirology. 2017; 22: 800-819.
10. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015; 2. Art. No.: CD003793.
11. Lung Foundation, Australia. Exercise classes. Available at: https://lungfoundation.com.au/patients-carers/support-services/lung-disease-and-exercise/exercise-classes/?event_category=127&condition=9 [Accessed October 2020].
12. Puhan M, Scharplatz M, Troosters T, Steurer J. Respiratory rehabilitation after acute exacerbation of COPD may reduce risk for readmission and mortality - a systematic review. Respir Res. 2005; 6: 54.
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17. Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited March 2020. Available at: http://online.tg.org.au/lp/desktop/index.htm [Accessed November 2020].
18. Australian Medicines Handbook. Adelaide. Australian Medicines Handbook Pty Ltd. 2020.
19. Yang I, Clarke M, Sim E, Fong K. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012; 7. Art. No.: CD002991.
20. Williams D. Clinical Pharmacology of Corticosteroids. Respir Care. 2018; 63: 655-670.
21. Moon J, Sin D. Inhaled corticosteroids and fractures in chronic obstructive pulmonary disease: current understanding and recommendations. Curr Opin Pulm Med. 2019; 25: 165-172.
22. Yawn B, Suissa S, Rossi A. Appropriate use of inhaled corticosteroids in COPD: the candidates for safe withdrawal. NPJ Prim Care Respir Med. 2016; 26: 16068; doi: 10.1038/npjpcrm.2016.68
23. Avdeev S et al. Withdrawal of inhaled corticosteroids in COPD patients: rationale and algorithms. Int J Chron Obstruct Pulmon Dis. 2019; 14: 1267-1280.
24. Chalmers J et al. Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline. Eur Respir J. 2020; 55: 2000351.
25. Walters J et al. Systematic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014; CD001288.
26. Simpson H, Tomlinson J, Wass J, Dean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine. 2020; 20(4): 371-378.
27. United States Department of Health and Human Services. The Health Consequences of Smoking - 50 Years of Progress. Office of the Surgeon General. Rockville, MD. United States. 2014.
28. Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018; 6 Art. No.: CD002733.
29. Walters J, Tang J, Poole P, Wood-Baker R. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017; 1 Art. No.:CD001390.
30. Pfizer Australia Pty Ltd. Australian Product Information - Comirnaty™ (BNT162b2 [mRNA]) COVID-19 Vaccine. Sydney, NSW. 2021.
31. Sanchis J, Gich I, Pedersen S on behalf of the Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has patient technique improved over time? Chest. 2016; 150: 394-406.
32. Bosnic-Anticevich S et al. The use of multiple respiratory inhalers requiring different inhalation techniques has an adverse effect on COPD outcomes. Int J Chron Obstruct Pulmon Dis. 2017; 12: 59-71.
33. Howcroft M, Walters E, Wood-Baker R, Walters J. Action plans with brief patient education for exacerbations in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;12. Art. No.: CD005074.
34. Guo Y et al. Body mass index and mortality in chronic obstructive pulmonary disease: a dose-response meta-analysis. Medicine. 2016; 95: e4225.
35. Alqahtani J et al. Risk factors for all-cause hospital readmission following exacerbation of COPD: a systematic review and meta-analysis. Eur Respir Rev. 2020; 29: 190166.
36. Open Arms Veterans & Families Counselling. About veterans and their families. Available at: www.openarms.gov.au/health-professionals/about-veterans-and-their-families [Accessed February 2021].
37. Cox N et al. Telerehabilitation compared to centre-based pulmonary rehabilitation: a randomised controlled equivalence trial. Eur Respir J. 2020; 56: Doi: 10.1183/13993003.congress-2020.4354

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