Both obesity and low BMI are associated with increased morbidity in patients with COPD. Obesity increases the work of breathing and is associated with sleep apnoea, hypoventilation and cor pulmonale, as well as metabolic complications. Malnutrition is an independent predictor of mortality and use of healthcare services in patients with COPD. Energy intake is often reduced due to dyspnoea, medications and lung hyperinflation whereas expenditure is increased due to the metabolic demands of breathing, infections and systemic inflammation. Low BMI and low fat-free mass are inversely associated with respiratory and peripheral muscle function, exercise capacity and health status. Importantly, those with poor nutrition are most likely to benefit from nutrition therapy before an under-nutrition state is established.37 Nutritional supplementation in malnourished patients can improve walking distance and respiratory muscle strength. High-calorie nutritional supplements should be considered in patients with COPD and a low BMI, particularly those who are malnourished and/or have severe disease.
Self-management and action plans
COPD self-management programs may lead to improved health-related quality of life, with reduced exacerbations being a positive outcome of some studies. Other studies have not shown benefit. Trials to date have used a wide range of study designs and interventions, thus no recommendations as to the essential elements of a COPD self-management program can be made.10
Interventions targeting mental health, an active lifestyle, relaxation therapy, use of action plans, correct medication use and facilitated access to services have been found to reduce exacerbations and visits to the emergency department. Written action plans have been shown to reduce emergency department visits and hospital admissions. Action plans should be completed by the clinician and patient together, with the aim of assisting the patient to identify symptoms of an exacerbation and know what actions they should take. A sample action plan is shown in Figure 2.
Anxiety and depression are common in patients with COPD and are associated with reduced quality of life, poor self-management and medical symptoms. There is also some evidence that mood disorders are independent risk factors for exacerbations and hospitalisations. Elderly patients with COPD prescribed benzodiazepines may be at increased risk of exacerbations; caution with use of these medications, or avoidance, is warranted in all patients with COPD due to their potential for depression of respiratory drive. Behavioural therapy and selective serotonin receptor inhibitors (SSRIs) may be better management options, along with referral to clinical psychologists and psychiatrists.
In patients with debilitating breathlessness despite optimal COPD management, referral for specialist advice, consideration of judicious use of low-dose opiates and palliative care involvement can be considered. Use of a handheld fan can also be of considerable help
Many regions now have specialist multidisciplinary outreach teams to assist in the co-ordination of home care. For example, in Victoria, the Hospital Admission Risk Program aims to reduce avoidable hospital admissions and emergency department presentations (www.health.vic.gov.au/harp-cdm).