Effective and appropriate management of patients with chronic obstructive pulmonary disease (COPD) includes immunisation against influenza and pneumococcus, encouraging smoking cessation, regular exercise and a healthy diet, and treating exacerbations early. These measures can help prevent hospitalisations due to COPD exacerbations.
- A patient’s usual management of chronic obstructive pulmonary disease (COPD) should be reviewed in early winter, ensuring they have an appropriate treatment plan, including both pharmacological and nonpharmacological therapies.
- Pulmonary rehabilitation is an effective intervention in COPD and can improve quality of life, fitness and self-confidence, and reduce hospitalisations.
- Influenza and pneumococcal vaccinations should be kept up to date; use patient recall systems if needed.
- Patients should be encouraged to have a COPD self-management plan.
- Patients should be reviewed early and regularly after an exacerbation, whether they are treated at home or in hospital; readmission risk is highest within three months of discharge.
- The involvement of outreach and community home services in the management of patients with COPD should be considered.
- Early treatment of patients with exacerbations of COPD may reduce hospitalisations.
Chronic obstructive pulmonary disease (COPD) is currently the fifth leading cause of death in Australia with many deaths occurring as a result of an exacerbation.1 COPD is a common clinical problem encountered in general practice, with about one million Australians being significantly affected by long-term lung conditions characterised by shortness of breath, such as chronic bronchitis and emphysema.2 Exacerbations of COPD can significantly impair a patient’s quality of life, contribute to progressive decline in lung function and are frequently under-recognised by both the patient and medical staff. A considerable increase in the number of COPD exacerbations and hospital admissions is seen during the winter months, and deaths from COPD tend to be highest in the late winter months (July to August).3
This article reviews current recommendations for the care of patients with COPD and the management of exacerbations in the general practice setting, with the aim of reducing the number of exacerbations and hospitalisations this winter. Advanced treatment measures for exacerbations of COPD are beyond the scope of this review and are not discussed in detail here.
What is COPD in 2019?
Our understanding of COPD has evolved dramatically over the past two decades, with the past 10 years in particular seeing an exponential increase in research in COPD. Successful new options for treatment have been developed and new evidence has informed the use of older drugs in certain types of patients with COPD. There has been a shift from an airflow limitation (forced expiratory volume in one second [FEV1]) and ‘one size fits all’ approach to diagnosis and management towards recognition of COPD as a very complex and heterogeneous condition. This recognition is leading to increased individualisation of COPD management.4
International guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend that COPD be considered as a whole condition, not just by the degree of airflow obstruction.5 Severity of airflow limitation (based on postbronchodilator FEV1) remains a core feature, but symptoms experienced by the patient and history of moderate or severe exacerbations should now be included in the assessment. Dyspnoea is a better prognostic indicator of mortality in COPD than FEV1, and previous history of exacerbations is the best surrogate marker of the risk of future exacerbations.
Precision medicine is defined as ‘treatments targeted to the needs of individual patients on the basis of genetic, biomarker, phenotypic or psychosocial characteristics that distinguish a given patient from other patients with similar clinical presentations’.6 The ultimate aim of precision, or individualised, medicine is to provide the most appropriate treatment for individual patients while avoiding unnecessary medications and minimising side effects. COPD is well suited to an individualised medicine approach because it likely represents not a single disease but a continuum of different diseases that may share biological mechanisms and present similar clinical features, but which have varying treatment responses.
A patient’s phenotype is composed of traits or characteristics produced by the interaction between their genes and the environment.7 Some of these traits will be amenable to treatment, others will not. COPD phenotypes were traditionally defined as chronic bronchitis (‘blue bloater’) and emphysema (‘pink puffer’). In the past the limited alternatives for pharmacological treatment made it unnecessary to clinically identify different types of patients. However, the number of treatments now available for COPD treatment has increased considerably over the past decades. Phenotyping can help clinicians identify patients who share clinical characteristics and outcomes and, more importantly, similar responses to existing treatments. It has become increasingly evident that not all patients respond equally to all drugs, and the need to identify ‘responders’ is crucial.