World COPD Day – Never Too Early, Never Too Late!
Join Ms Mary Roberts as she examines COPD in Australia, and provides some quality advice on what you can do to control breathlessness and ensure the best possible quality of life for your patients, in alignment with World COPD Day 2018.
November 21st, 2018 is World COPD Day. I know, not another “Day”! Really??? We have days for everything. In January, there is National Hangover Day (1st), In February, Ground Hog Day (2nd), March has Plant a Flower Day (12th)! But there are some days that actually highlight important issues such as World MS Day (30th May), World Heart Day (29th September) and Breast Cancer Awareness Month (October).
World COPD Day highlights a disease that doesn’t get much press. It’s not sexy, but it is common - chronic obstructive pulmonary disease.
One in seven Australians over the age of 40 has COPD 1 and Aboriginal and Torres Strait Islander Australians have approximately 2.5 times the rate of COPD as other Australians 2. It is the second leading cause of avoidable hospital admissions and 6th leading cause of death in Australia 2.
Much can be done to improve symptoms, increase quality of life and reduce morbidity and mortality related to COPD. The Thoracic Society of Australia and New Zealand (TSANZ) and the Lung Foundation Australia (LFA) have developed the COPDX guidelines that summarise the evidence and provide key recommendations regarding the diagnosis and management of COPD that is updated quarterly. There is even a Concise Guide for Primary Care 3 so that you don’t have to troll through the whole 218 page document!
COPD is universally undiagnosed. Findings from several studies have shown that up to 75% of people with COPD remain undiagnosed4 and without diagnosis, treatment is delayed.
So on this World COPD Day, what are you going to do?
Smoking is the most important risk factor for COPD. COPD should be considered in anyone over 35 years old with a smoking history or occupational exposures to dust or fumes. Ensure you ask your patients about their smoking and occupational history. Conduct a risk assessment and refer patients on for formal spirometry if they are at risk of developing COPD.
COPD is confirmed by the presence of persistent airflow limitation (post bronchodilator FEV1/FVC<0.7). Spirometry is the gold standard for diagnosing COPD. Once a patient has a diagnosis of COPD, patients should have regular assessments of severity.
On World COPD Day, consider setting up a system where you can plan a regular review date for all your patients with COPD where you can assess lung function, in addition to symptoms and exacerbations over the last 12 months. This will enable you to plan care and modify treatment as required. If you have a Practice Nurse, they may be able to assist in the process by getting patients to complete a COPD Assessment Test. The CAT is a simple questionnaire for patients with COPD that can tell you the impact of the disease and can help you monitor their progress.
Other important factors to review include patients’ (not an exhaustive list):
- Smoking status (it can change!) – if your patient is a current smoker, offer smoking cessation support and referral to the QUITLINE (13 78 48).
- Medication technique – don’t assume just because your patient has been on puffers for 5 years, they are doing it right! Up to 92% of patients DO NOT know how to use their inhalers properly5,6 and up to 87% of trained health care professionals7 also don’t know how to use inhalers correctly. Take 10minutes and review an inhaler technique video and download a checklist so that you can assess your patients’ technique. Videos of correct inhaler technique for a range of devices can be found on the National Asthma Council website and on the NPS Medicinewise website.
- Physical activity level (the less you do, the less you are able to do). Sitting is the new smoking. Patients who get breathlessness on exertion tend to reduce physical activity, which in turn can worsen deconditioning and breathlessness. Encourage exercise. Better still, go to the Lung Foundation Australia website and look up your nearest pulmonary rehabilitation centre. Pulmonary rehabilitation has been proven to reduce breathlessness and improve quality of life8.
- Vaccination status – Influenza vaccination is recommended for patients with COPD10. It can reduce the risk of exacerbations and hospitalisations. I know all this takes time but you can get some reimbursement. Consider developing a GP Management Plan (GPMP, Item 721) and a Team Care Arrangement (TCA, Item 723). If you have a multidisciplinary team in your practice – engage them to help.
- Intensity of breathlessness – I know this is a hard one! I mean, what else can you do to help the patient who remains breathlessness despite all the best evidence-based bronchodilators? Well actually, lots!! As stated above, pulmonary rehabilitation reduces breathlessness but it’s a hard sell. The patient is breathless, and you ask them to do exercises!!! They will think you are mad but it’s important to explain that pulmonary rehabilitation is gold standard care for patients with COPD and that programs are individually prescribed. Other things that can assist your patient manage their breathlessness include using aids such as 4 wheeled walkers and shower chairs. Some patients will be reluctant to use aids but tell them it’s all about ‘outsmarting their breathlessness’, not giving in to it! Consider referral to an Occupational Therapist. The other aid that is gaining momentum is the hand-held fan! There is good evidence that the flow of cool air across the face decreases breathlessness9. Be a fan of the fan!
Live fan demonstrations at GPCE Melbourne over the weekend.
Looks like this delegate was a fan of the fan too!
This World COPD Day, don’t let the opportunity pass. Identify new patients with COPD and commence treatment. For your old patients, set up a review system so that you can offer extra evidence-based treatment to control their breathlessness so that breathlessness does not limit their dreams!
- Toelle BG, et al. Respiratory symptoms and illness in older Australians: The burden of obstructive lung disease (BOLD) study. Med J Aust 2013; 198(3):144-8.
- Australian Institute of Health and Welfare. Australia’s Health 2016: The 15 biennial health report of the Australian Institute of Health and Welfare. Available from http://www.aihw.gov.au/australia-health/2016/
- Lung Foundation Australia. COPDX concise guide for primary care. Available from ; https://copdx.org.au/wp-content/uploads/2015/08/LFA-COPD-X-doc_V3.02_0815_WEB.pdf
- Almagro P, Soriano J. Underdiagnosis in COPD: a battle worth fighting. The Lancet – Resp Med 2017; 5(5): 367-368
- Bryant L, Bang C, Chew C, Baik S, Wiseman D. Adequacy of inhaler technique used by people with asthma and COPD. J Prim Health Care 2013; 5(3): 191–86
- Lavorini F, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med2 008; 102: 593–604.
- Baverstock M, Woodhall N, Maarman V. Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? Thorax 2010; 65(4): A118.
- Alison JA et al. On behalf of the Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. Australian and New Zealand Pulmonary Rehabilitation Guidelines. Respirology 2017; doi: 10.1111/resp.13025
- Swan F, Booth S. The role of airflow for the relief of chronic refractory breathlessness. Curr Opin Support Palliat Care. 2015; 9(3):206-11.
- Wesseling G. Occasional review: Influenza in COPD: pathogenesis, prevention and treatment. Int J Chron Obstruct Pulmon Dis. 2007; 2(1): 5-10.
Ms Mary Roberts
Mary is the CNC for Respiratory Ambulatory Care at Westmead Hospital, Vice President of the Respiratory Nurses Interest Group of NSW Inc, and is an active member of the TSANZ. She has a research interest in COPD and has published over 50 abstracts, presenting nationally and internationally. She also has a keen interest in Breathlessness and is co-developing Australia’s first Breathlessness Clinic at Westmead Hospital.