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The editorial content below has been developed solely between Guidelines in Practice and the expert author.

sapey

Guest Editor—Dr Elizabeth Sapey

Honorary Respiratory Consultant, Queen Elizabeth Hospital, Birmingham
Senior Lecturer in Respiratory Medicine, University of Birmingham

In this series, Dr Elizabeth Sapey presents a series of articles to support best practice in the primary care management of COPD. Topics covered include medications for the management of COPD, breathlessness, exacerbations, COPD and co-morbidities, and end-of-life conversations.

Background

Chronic Obstructive Pulmonary Disease (COPD) is a common and debilitating lung disease.1,2 Predominantly caused by smoking, COPD is characterised by the presence of airflow obstruction that is not fully reversible following inhaled bronchodilation. Most patients with COPD complain of symptoms that steadily worsen over time, including breathlessness and a cough, which may or may not be productive of sputum. Many patients with COPD experience exacerbations; intermittent flare ups of their symptoms that require a change in medication.2

There are 1.2 million people in the UK who have been diagnosed with COPD,1 however screening studies suggest that 3 million people have the condition,3 meaning that there are millions of people in the UK who have COPD but have not been diagnosed.

There is no single diagnostic test for COPD. Making a diagnosis relies on clinical judgement about the patient’s symptoms and history, findings on physical examination, and the presence of airflow obstruction tested using spirometry after bronchodilation.2

This series will consider how to look after a patient with COPD once the diagnosis has been made.

Getting the basics right

There are four things that should be discussed with all patients with COPD at every contact:

  • smoking cessation
  • vaccination
  • exercise
  • inhaler technique.

Smoking cessation

Patients with COPD who continue to smoke experience worse symptoms and have poorer health outcomes compared with those who stop smoking, who have improved survival rates and better lung function, whatever their age or disease severity.4 Smoking cessation is vital, and it is never too late—individualised plans should be made to support patients in their efforts to quit.

Vaccination 

Vaccines work—seasonal influenza and pneumococcal immunisations reduce exacerbation frequency and severity, hospital admissions, and death rates in people with COPD.5,6 Influenza immunisation is not associated with COPD exacerbations but transient and mild side effects are common.6,7 Vaccination should be championed for people with COPD.

Exercise

Exercise is important for people with COPD, and pulmonary rehabilitation has been shown to reduce symptoms of breathlessness and fatigue; improve quality of life, exercise tolerance, and confidence; and reduce healthcare utilisation.8 In spite of this, referral and uptake rates for pulmonary rehabilitation are poor.8 We need to discuss these very real benefits with patients and make referrals for pulmonary rehabilitation more often.

Drugs do not work if they are not taken effectively

Inhaler technique is often poor in people with COPD and many patients have never received inhaler technique instruction.9 Treatment decisions should include the device as well as the drug, and inhaler technique and compliance should be assessed at every meeting.10

Next: medications for the management of COPD—breathlessness

References

  1. British Lung Foundation. Chronic obstructive pulmonary disease (COPD) statistics. statistics.blf.org.uk/copd (Accessed 9 November 2017).
  2. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Clinical Guideline 101. NICE, 2010. Available at: www.nice.org.uk/guidance/cg101
  3. Buist A, McBurnie M, Vollmer W, et al. International variation in the prevalence of COPD (the BOLD study): a population-based prevalence study. Lancet 2007; 370: 741–750.
  4. Tønnesen P. Smoking cessation and COPD. Eur Respir Rev 2013; 22 (127): 37–43.
  5. Varkey J, Varkey A, Varkey B. Prophylactic vaccinations in chronic obstructive pulmonary disease: current status. Curr Opin Pulm Med 2009; 15 (2): 90–99.
  6. Bekkat-Berkani R, Wilkinson T, Buchy P, et al. Seasonal influenza vaccination in patients with COPD: a systematic literature review. BMC Pulm Med 2017; 17: 79.
  7. Poole P, Chacko E, Wood-Baker R, Cates C. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006; 25 (1): CD002733.
  8. Corhay J, Dang D, Van Cauwenberge H, Louis R. Pulmonary rehabilitation and COPD: providing patients a good environment for optimizing therapy. Int J Chron Obstruct Pulmon Dis 2014; 9: 27–39.
  9. Lavorini F, Magnan A, Dubus J, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med 2008; 102 (4): 593–604.
  10. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD, 2017. Available at: goldcopd.org