Managing COPD

This section focusses on six key aspects of COPD management, in order of greatest impact on your patient.   

Quitting smoking is the most effective intervention for preventing COPD progression and improving patient outcomes. Watch this video from PCRS to find out why quitting is so important and what you can do to help your patient. 

Very Brief Advice (VBA) is a simple and effective approach used in smoking cessation to help individuals quit smoking. It involves healthcare professionals delivering concise advice to patients, typically within 30 seconds. The VBA model follows a three-step process:

• Ask about smoking status.
• Advise on the benefits of quitting and the best ways to do so.
• Act by offering support and resources to help the patient quit.

This method aims to quickly and efficiently prompt smokers to consider quitting and take action toward cessation. Free online training is available from the National Centre for Smoking Cessation and Training (NCST)
There are a variety of methods available to stop smoking, from nicotine replacement therapy, to fast acting oral and nasal products, to rescription only stop smoking medications and e-ciagrettes. See NCST's guide for more information.
Make sure you know about your local smoking cessation services and the options available to help your patient quit.  Share the A+LUK booklet How to Stop Smoking with your patient.
Remember to revisit smoking habits every time you review your patient so they know that help is there when the time is right for them. 

Lack of physical exercise and deconditioning are associated with a worse prognosis for patients with COPD.  So it’s vitally important that you help your patient to prioritise physical activity by referring them to rehabilitation – just as you would for patients who have had a heart attack.

Patients who have completed a Pulmonary Rehabilitation (PR) course experience less breathlessness and less fatigue. They will have greater exercise tolerance, better quality of life and have fewer exacerbations.

Pulmonary rehabilitation courses include:

• Structured education 
• Lifestyle support  
• Personalised exercises so that people with COPD can be confident to live well with their condition.

Watch this video for more information

A Cochrane review of patients who completed a PR course following an exacerbation of COPD, showed PR prevented further deterioration and exacerbations, and reduced admissions for 90% of participants. The benefits of PR can last at least 2 years.

However, patient uptake of PR is low so it is important that you are able to inspire your patients to attend.  Read this quick guide to find out how to explain to your patients what PR is and how it will help them.
There are significant waiting times in some regions.  To bridge this gap, signpost your patient to:

The A+LUK Keep Active Programme

From the point of diagnosis or whilst waiting for PR, the Keep Active Programme gives your patients everything they need to start moving more with their lung condition. It includes:

• Advice to help them move safely with their lung condition 
• Breathing techniques to help during activity
• Gentle warm up
• Step-by-step exercises to help them feel stronger and more energetic 
• Cool down and stretch
• Stories from people with lung conditions to inspire them to move more

Keep Active has been created by specialist respiratory physiotherapists for anyone living with a lung condition and includes three levels for your patient to choose from.  

The videos are supported by the My Keep Active Handbook, which can be downloaded or ordered.

Patients with COPD are more susceptible to infections such as influenza and pneumonia, which can also trigger COPD exacerbations.  
Ensure your patient receives vaccines as per the UK immunisation schedule for:

Pneumococcal disease

This vaccine protects against streptococcus pneumoniae, which is the most frequent cause of community acquired pneumonias in people with COPD.  People with COPD are at year round risk from pneumococcal disease.  Most adults just need 1 dose.

Influenza

You can send this video to patients to explain why the flu vaccine is important if you have COPD.

Inhaled therapies

Inhaled therapies can be determined by the GOLD ABE assessment tool grouping. 

Group A patients should be prescribed either a short-acting (SABA) or a long-acting bronchodilator (LABA). The choice between a SABA and LABA can depend on the patient's preference, symptom relief, and response to the medication. 

LABAs are often preferred for their convenience and sustained symptom control, but SABAs can be useful for immediate relief. Pressurised metered dose inhalers must always be prescribed with a spacer.

Group B and E should be started on a LABA (Long-Acting Beta-2 Agonist) and LAMA (Long-Acting Muscarinic Antagonist).  Evidence suggests that LABA/LAMA combination inhalers are more effective because they act on different receptors, causing greater relaxation of the airways.

In group E patients with eosinophils over 0.3, triple therapy of LABA, LAMA and inhaled corticosteroid (ICS) can be used.

All patients should have a short acting bronchodilator (SABA) and spacer for immediate symptom relief. It’s essential that patients are shown how to use their inhalers and are prescribed a device that is suitable for them. Use our guide to choosing the right inhaler for your patient. 

Nebulised treatment should be not be routinely used as evidence suggests inhaled medication is as effective.  It can be considered for patients experiencing significant or disabling breathlessness despite optimal inhaler use. It should be continued if there is observed improvement in symptoms, daily activity performance, exercise capacity, or lung function.

If your patient is on nebulised therapy, they will need support and advice in looking after their nebuliser, including servicing, cleaning and using it safely.  NARA Breathing Charity supports patients using nebulisers.

Mucolytics

Mucolytics such as Carbocisteine and Acetylcysteine can be given to patients with excessive mucous production. They work by breaking down the mucus structure, making it thinner and easier for your patient to cough up.   In some patients mucolytics can also reduce the volume of sputum produced.

Before thinking about prescribing mucolytics, ensure that your patient has been:

• Shown how to clear their chest using the Active Cycle of Breathing
• Offered smoking cessation advice if appropriate
• Referred to pulmonary rehabilitation. 

It’s not always easy to predict whether your patient will respond to mucolytic therapy so a 4-8 week trial of treatment should be undertaken.

Stop treatment if it has been taken for more than one month and if it doesn't seem to be helping symptoms. 

For more information on prescribing mucolytics, see this guide.

Oral bronchodilators

Roflumiltast is not a first-line treatment but can be used add-on treatment to bronchodilator therapy in patients with severe COPD with chronic bronchitis.  It is usually initiated by a specialist in respiratory medicine.

Theophylline can be effective in some patients with COPD, but requires careful monitoring due to potential toxicity and drug interactions.  It is also usually initiated by a specialist in respiratory medicine.

Prophylactic antibiotics

Azithromycin is a macrolide antibiotic that can be used preventatively for patients who:

• Do not smoke and 
  • Have optimised their non-pharmacological management, inhaled therapies, and received relevant vaccinations. 
  • Have been referred for pulmonary rehabilitation if appropriate. 
  • Are experiencing frequent exacerbations (typically four or more per year) with sputum production
  • Prolonged exacerbations with sputum production, or 
  • Exacerbations resulting in hospitalisation.

Patients need an ECG, blood and sputum tests prior to commencing Azithromycin, and must be advised about the small risk of hearing loss. They should be reviewed 3 months after starting and 6 monthly thereafter.  They should not stop taking Azithromycin during exacerbations if they are taking other antibiotics.

Oxygen

Some patients with COPD require long-term oxygen therapy (LTOT) due to chronic hypoxemia.  LTOT improves survival rates in with severe resting hypoxemia. It increases quality of life by reducing symptoms such as fatigue and confusion, enabling patients to perform daily activities more easily. 

LTOT can reduce complications such as pulmonary hypertension, right-sided heart failure (cor pulmonale), and polycythemia. Additionally, evidence suggests that it reduces the frequency of exacerbations and hospital admissions in this group of patients.

The criteria for referral to oxygen assessment can be found here.  See our patient guide for living with home oxygen.

Malnutrition and obesity are both common among COPD patients. 

Malnutrition often starts in the community, so it is essential that it is identified and treated early.  This involves screening for malnutrition using a validated tool at diagnosis, and at post-exacerbation and annual reviews. Patients need to be aware that any unintentional weight loss should be reported in case it needs further investigation such an a chest x-ray to exclude lung cancer.

Malnutrition depletes skeletal muscles, including the muscles that support breathing. This in turn causes increased breathlessness and fatigue, both of which make eating and the preparation of food challenging. Malnutrition decreases immunity, which can make your patient more susceptible to exacerbations, which also decrease appetite.  

The Malnutrition in COPD Pathway recommends the LEARN acronym for assessment:

Look at the individual – what do you see? Have they got muscle wasting, are they thin or frail looking?
Eating – ask about what they are eating, are they consuming foods from all food groups, missing meals?
Appetite – ask about appetite, has it changed?
Relatives – family members can be a source of information and support; do they have any concerns?
Nutrition – give appropriate nutritional advice. If you are not skilled or confident to do so, seek advice from someone qualified e.g. your local dietitian.

Find out more about nutrition in COPD from this article.

Patients aged over 65 should take vitamin D supplements.

Obesity in COPD patients often results from inactivity and an increased appetite due to oral steroid use. Even minor obesity can lead to increased respiratory effort in those with COPD, causing:

• Greater breathlessness during physical activity
• Decreased exercise capacity and activity levels
• Worsening of overall symptoms

Significant weight loss can be difficult to achieve and should be approached with sensitivity. Exercise programs like pulmonary rehabilitation can be beneficial. Patients with a BMI over 30 should be referred to a dietitian for expert guidance.

Our leaflet Eating Well for Healthier Lungs is full of information to support your patient.