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Feature Article

COPD: reducing hospitalisations this winter

Belinda R. Miller
OPEN ACCESS

Pneumococcal immunisation is recommended for all patients with COPD. People with COPD vaccinated with injectable polyvalent pneumococcal vaccines are less likely to experience an exacerbation of COPD or episode of community-acquired pneumonia. At present, the 23-valent pneumococcal polysaccharide vaccine (23vPPV) given twice five years apart is recommended for adults aged 65 years and over. Expert opinion is divided about whether to continue to recommend 23vPPV or to replace its use with the more effective 13-valent pneumococcal conjugate vaccine (13vPCV). One small randomised, controlled trial found a significant additive effect of receiving both vaccines on exacerbations in patients with COPD.10

Physical activity and reducing sedentary behaviour

On average, people with COPD participate in 57% of the total duration of physical activity undertaken by healthy controls.33 Reductions in physical activity commence early in COPD and, over time, levels of physical activity substantially decline across all severities of COPD. This decline is accompanied by a deterioration in lung function and health status.34 Levels of physical activity are reduced further during hospitalisation for a COPD exacerbation. Recovery back to previous levels of activity often does not occur. 

Low levels of physical activity are associated with increased mortality and exacerbations in people with COPD.35 Regular physical activity is recommended for all individuals with COPD. People with COPD should be encouraged to be physically active and participate in activities of daily living that require the use of muscle strength, such as lifting or gardening as well as doing physical activities they enjoy, such as bowls, golf or swimming.10

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In addition to low levels of physical activity, there is growing recognition that people with COPD spend many of their waking hours in sedentary behaviours, defined as those behaviours that are undertaken in a sitting or reclined posture and have low energy requirements, such as watching television, reading and sitting at a computer. People with COPD with the greatest sedentary time during daily life are characterised by more frequent exacerbations, lower exercise capacity, long-term oxygen use, lower motivation for exercise and the presence of physical comorbidities including obesity and arthritis. Compared with the goal of increasing moderate- or high-intensity physical activity, the goal of reducing sedentary time by increasing light-intensity physical activity is likely to be more feasible in some patients with COPD. Of note, in people with COPD, greater participation in light-intensity physical activity has been reported to reduce the risk of respiratory-related hospitalisations.36Table 2 provides some strategies aimed at avoiding prolonged sedentary time.10

Pulmonary rehabilitation

The benefits of pulmonary rehabilitation in improving dyspnoea, quality of life, exercise capacity, anxiety and depression, fatigue and emotional function are well established.  Evidence also suggests that pulmonary rehabilitation is safe and highly effective in reducing hospital admissions and mortality and improving health-related quality of life in COPD patients after exacerbations.10

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Pulmonary rehabilitation programs consist of general assessment of the patient and specific assessment of exercise capacity and quality of life, followed by an exercise program and education sessions. Pulmonary rehabilitation programs are available at many community centres and hospitals, and usually welcome referrals from GPs.

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Associate Professor Miller is a Senior Specialist in Respiratory Medicine at The Alfred Hospital, Melbourne; and a Clinical Adjunct Associate Professor in the Department of Medicine, Monash University, Melbourne, Vic.