Primary care respiratory specialists Dr Steve Holmes and Carol Stonham offer their practical tips on how you can improve outcomes for your patients with COPD and related conditions
COPD is an incredibly common group of respiratory conditions that has a significant impact on patients’ everyday life. COPD is particularly related to health inequalities and affects many patients who face particular disadvantages, but both pharmacological and non-pharmacological treatments can improve their quality of life and overall symptom management, and reduce the frequency of exacerbations and their resulting complications. Here are our ten top tips to best applying this approach in practice to improve your patients’ outcomes.
 Ensure you get the diagnosis right
Getting the diagnosis right is crucial. NICE guidance recommends a number of steps to lead to diagnosis.1 These include taking a thorough history – patients have usually been smokers, although only 20% of smokers will develop COPD. Patients should also be examined, which should include tests to rule out other chest or cardiac problems, and taking full blood counts and chest X-rays.
It is particularly important to consider contributory or co-existing cardiac problems. If COPD is suspected in a young person, or an older person who has not smoked significantly, test for alpha-1 antitrypsin levels to check for an underlying cause.
Remember that the diagnosis is confirmed – not made – by good quality post-bronchodilator spirometry. If the patient’s presentations don’t clearly fit COPD, or your examination or investigations are conflicting, it is worth reviewing whether you are confident to make the diagnosis, or should involve a more specialist colleague.
 Reinforce advice on smoking cessation
The high Covid mortality amongst certain groups has raised the profile of health inequalities. This relates in large part to the huge legacy of tobacco dependence. The nicotine in cigarettes is of course highly addictive and so a difficult habit to break. There is strong evidence that the most effective method of smoking cessation is with professional support and appropriate medications.
If you are discussing smoking cessation with your patients, but suspect that you not making a difference to them, spend half an hour on the National Centre for Smoking Cessation and Training’s free online module. This will show you a rapid, evidence-based intervention that is more effective than most other similar discussions. The old acronym ‘Ask, advise and act’ should only take 30 seconds, is shown to be effective, and removes the difficult arguments that many of us have felt drawn into over the years.
When dealing with patients who smoke, especially if they have not been able to quit, many of us unfortunately still have some element of unconscious bias. This may be particularly towards those who do not exercise, are overweight and remain addicted to tobacco. It is important to challenge and overcome such attitudes, and give our full support to those who are potentially already disadvantaged, to treat their addiction.
 Take all exacerbations seriously
The National COPD Audit highlighted that mortality of COPD patients admitted to hospital with an exacerbation is considerably higher than that of patients admitted to hospital with a myocardial infarction, both immediately and at 90 days post-admission.2 Exacerbations are described as mild (if the patient increases their short-acting medication to resolve the exacerbation); moderate (requiring steroids, antibiotics or both, but not admission); or severe (requiring steroids, antibiotics or both, and admission). It is worth reflecting, however, that many of the moderate and severe exacerbations may well be of similar severity, and some people are admitted for less severe exacerbations but more complex social or psychological situations.
NICE, the Global Initiative for COPD (GOLD) and the Cochrane Review now all agree that the best treatment for exacerbations is steroids (30mg of prednisolone for five days), antibiotics (according to local recommendations, but since the Covid-19 pandemic, doxycycline for five days) or both.1,3 Some studies have found longer courses are related to worse outcomes and if a patient is improving, there is no need to repeat courses until their symptoms have resolved. This is true of other respiratory infections too, such as community-acquired pneumonia and bronchitis, and we have seen that many who have suffered from Covid pneumonia take a considerable time to recover.
What to review if a person has had an exacerbation:
- Was this really an exacerbation that warranted steroids or antibiotics, or was there another cause?
- Is there another co-morbidity making exacerbation symptoms more likely (such as bronchiectasis, carcinoma of the lung, or co-existing heart failure)?
- Should I be arranging a HRCT scan if thinking about bronchiectasis or asking for a specialist review?
- Did the patient’s delay in presenting result in worse outcomes?
- Has the patient been referred for pulmonary rehabilitation (like cardiac rehabilitation with equal or greater evidence of benefit) since admitted to hospital? It is important to discuss and encourage this, as benefits in terms of their quality of life and exacerbations is well-proven.
- Is the patient using their inhaler treatment appropriately via a good technique and by actually taking the medication? Many patients are using their inhalers ineffectively, or, as with other conditions, have made decisions to stop taking certain medications.
- Should the inhaled medication be changed to reduce the risk of further exacerbations (as per NICE guidelines)?
- Are there other factors that might increase the likelihood of exacerbations, such as tobacco dependency or not being immunised against influenza or pneumococcal disease?
- Is this patient suitable for a rescue pack to be prescribed in case of a further exacerbation? We believe that this should never be on a repeat prescription, and only prescribed after review, as many will have seen patients using large numbers – and there is plenty of evidence of the side effects of oral corticosteroids and antibiotics on the health of the population.
 Encourage activity and prevent deconditioning
We are in a situation where many people with chronic breathlessness find it difficult to motivate themselves to push their fitness, especially if it makes them feel more breathless and consequently concerned. We have also been through extended lockdowns with people staying at home to protect the NHS and lower their chances of contracting Covid. Unfortunately, this has led to a significant number of people finding they experience troublesome breathlessness when carrying out tasks they could previously perform fairly easily.
Consider the role of social prescribers, who can signpost to healthy activity programmes in the local area, or pulmonary rehabilitation. Simply trying to increase medication is not going to work.
You can also point digitally literate patients to use of apps, to encourage activity. However, many will struggle or lose momentum without prolonged motivation from a coach or healthcare professional. It is surprising how little emphasis we have traditionally placed on encouraging activity, despite firm knowledge of better outcomes in it.
 Treat breathlessness with adequate inhaled medication
NICE and GOLD say to use short-acting beta agonists (SABA) initially, but these only last up to four hours.1,3 So, it may be more beneficial to use long-acting bronchodilators to help motivate patients to exercise, to try to avoid deconditioning. Breathlessness is controlled for longer so patients feel more confident when exerting themselves.
NICE is more aggressive than GOLD, in that it recommends moving to dual long-acting bronchodilation with both a long-acting beta agonist (LABA) and a long-acting muscarinic agonist (LAMA), whereas GOLD recommends initially moving to single long-acting therapy (usually a LAMA). Essentially NICE advises that this dual LABA and LAMA therapy approach is more cost-effective as a result of preventing exacerbations as well as improving symptoms.
Either way, patients do not want to experience limiting breathlessness, so longer-acting bronchodilators may be more acceptable and appropriate. Once you have made this change, you can top up occasionally with SABA.
Remember to trust patients’ experiences of breathlessness, rather than solely medical assessments. Spirometry results might not correlate with the degree of breathlessness a patient experiences – they may have a reasonable FEV1, but in reality feel very limited by their breathlessness.
Be aware that oxygen is only beneficial long-term in people with COPD if they are hypoxic. It is important to consider psychological causes for disabling breathlessness – especially in patients who are anxious when they become breathless. Breathing pattern disorders such as hyperventilation, which may ease symptoms but make things worse long term, should be addressed through breathing training. Also encourage patients to understand that if they maintain fitness they are less likely to become breathless, even if their lung function hasn’t changed.
 Make sure to treat asthma or allergic airways disease
With COPD, don’t assume that spirometry confirmed impairment of lung function is the end of the story. Instead, think more towards conditions like allergies and interstitial lung disease.
Asthma is not resolved if the patient also develops COPD – be mindful that they are different diseases with different pathologies, so asthma treatment should remain a priority here, as long as you are confident that there has been a sound historical diagnosis. A combined approach may be required, incorporating single or combination long-acting bronchodilation to treat the breathlessness associated with the COPD diagnosis.
 Remind of the importance of immunisation
The pneumococcal, influenza and Covid vaccines are all particularly important for patients with long-term respiratory conditions like COPD, reducing their risk of serious complications from these infections.
Do reiterate this to your patients and encourage take-up, at whatever stage of the pandemic. It is never too late to receive a booster, or even the first or second dose.
 Keep up to date with inhaler knowledge
You will find that certain issues with inhaler technique and compliance crop up regularly.
You can complete the literature available on sites like The UK Inhaler Group (UKIG) to update your knowledge and we would recommend the RightBreathe (rightbreathe.com) or the Asthma and Lung UK (asthmaandlung.org.uk) websites with inhaler technique demonstrations to help quickly review patients’ technique.
It’s also helpful to use inhalers that you and your locality are familiar with – there are so many inhalers available that no clinician will demonstrate the whole selection to a patient, but rather concentrate on a limited number.
Use of soft mist inhalers (SMIs) and dry power inhaler (DPIs) is being encouraged to protect the environment, but only consider these if appropriate for the individual, remembering the roles of personalised care and shared decision-making when doing so.
 Do not neglect co-morbidities
Cardiovascular disease and COPD often co-exist, so it is important to look out for this, as we do in diabetes care. Also look out for other risk factors such as smoking and erectile dysfunction, and check for accompanying osteoporosis – we know the risk of osteoporosis is higher among those who smoke, are less active and on high-dose inhaled or oral steroids, but COPD is also thought to be a risk factor on its own. Consider cumulative risk, and doing a FRAX score every year. Every osteoporotic fracture in COPD that was not anticipated should warrant a case-based review.
 Deprescribe where possible
Regular review of medication and the positive effects is essential. Inhaled medication that is ineffective or has unacceptable side effects should not be continued. As patients age there may be associated frailty, activity and exercise limitation and interactions with other medicines. A person who becomes more frail is likely to limit their activity and therefore may not be bothered by their breathlessness – and the medicine may have avoidable side effects, for example an inhaled LAMA can cause a dry mouth.4
Dr Steve Holmes is a GP partner and Carol Stonham is a Queen’s Nurse with special interests in respiratory health
Sources and further reading
- NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115 2019
- National COPD audit https://www.nacap.org.uk/
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD. 2021
- Keeley D, Gruffyd-Jones K. Frailty and respiratory disease in primary care. Primary Care Respiratory Update 2021 Available from https://www.pcrs-uk.org/sites/pcrs-uk.org/files/pcru/articles/2021-July-Issue-22-Frailty.pdf