How difficult is it to manage people with COPD?

I’ve previously looked at how difficult it is to diagnose people with chronic obstructive pulmonary disease (COPD), covering some of the more common areas of diagnosis with a slightly different perspective. This second article on perceptions of COPD is aimed at challenging some of our conscious and unconscious views about COPD and the patients with COPD we care for.

It will look at some of the more typical areas of care with a slightly different perspective. I hope it will allow you to reflect on your own practice and those of your colleagues, and think about challenging our current system.

Of course, this piece will also be grounded in the major English guidelines from the National Institute for Clinical Excellence (NICE)^[1] and the strategy and report produced on behalf of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).^[2]

COPD interventions

At the beginning of my career (but thankfully less so over time), those lecturing on COPD would traditionally highlight that the only effective intervention for COPD was smoking cessation.^[3] Thankfully, we have much more that has proven beneficial for people, including smoking cessation support,^[4] and immunisation for protection against influenza,^[5] pneumococcal,^[6] COVID-19 and respiratory syncytial virus (RSV).^[7]

This, combined with pulmonary rehabilitation,^[8] the inhaled medications available as well as management of acute exacerbations with steroids and antibiotics,^[1],[2] demonstrate the wealth of valuable interventions available.

Reducing assumptions

How often do we feel, when a patient returns and is smoking still, that it is not worthwhile asking them again? We know that smoking cessation support is effective^[9] – but less well known is that 73% of smokers wish to stop and would value help in stopping.^[10] And as the PCRS Pragmatic guide suggests,^[9] we should not give up either.

It is also possible to be lured into thinking that people with COPD will not be good with new technology. This may be linked with our assumptions that all people with lung disease fit in with the health inequalities agenda linked to poorer outcomes^[11] – despite evidence that many people with COPD may benefit from using technology.^[12] It would be good to ensure that at an individual level, we promote genuine personalised care and don’t assume but ask our patients about their knowledge and skills.^[13]

Comorbidities in COPD

When managing the person with COPD (not just looking at their lungs), perhaps it would be sensible to consider effective interventions for managing cardiovascular risk (including QRISK2 or ideally QRISK3 routinely)^[14] as part of their annual review.^[15] It may also be worth thinking about, assessing and managing the osteoporosis risk in our COPD population – the risk factors are well recognised with less activity, smoking history, and high corticosteroid intake leaving people more prone.^[16] There are simple assessment methods that should become a routine part of care for our COPD patients.^[17]

Whilst reviewing our patient, how many of us routinely advise on skin care and protection (again, in a group who are prone to aging skin with loss of collagen linked to smoking and both oral and inhaled corticosteroids)?^[18] It is worth reflecting on whether skin tears and ulceration could potentially be prevented with our early professional advice.

It is also always important to remember erectile dysfunction, which is well recognised as one of the earliest symptoms of vascular disease, and should alert us to cardiovascular assessment as well as clinical management.^[19]

Let us not forget mental health – how confident are you at assessing the mental health of those with COPD? It is probably expected that many will be living with the psychological consequences of disability linked to their condition that may benefit from many forms of ‘talking therapy’, however is this pathological and how can we get our patients fitter?^[20] We should be using the breathing, thinking functioning model regularly to improve our patients lives.^[21]

Thinking forward

There are still plenty of things to think of in a good review. We must look at the evidence that suggests our patients are just as poor using their inhalers now as they were 30+ years ago – especially with all our targets and drive towards addressing inhaler technique. ^[22]

This may just be the time to move towards more holistic patient reviews that address our patients concerns, and assesses and manages commonly associated conditions associated with COPD. However, it is hoped this will trigger some learning areas to explore in the next year to improve clinical care for your patients.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi).  All content in this article is for informational and educational purposes only.  Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.

[1] National Institute for Clinical Excellence. NG 115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE; 2019. Available at: https://www.nice.org.uk/guidance/ng115

[2] Global Initiative for Chronic Obstructive Lung Disease. 2024 Gold Report. Available at: https://goldcopd.org/2024-gold-report/

[3] van Eerd EA, van der Meer RM, van Schayck OC, et al. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016; 2016(8): CD010744

[4] Lei S, Li M, Duan W, et al. The long-term outcomes of tobacco control strategies based on the cognitive intervention for smoking cessation in COPD patients. Respir Med. 2020; 172: 106155

[5] Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018; 6(6): CD002733

[6] Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017; 1(1): CD001390

[7] Simon S, Joean O, Welte T, et al. The role of vaccination in COPD: influenza, SARS-CoV-2, pneumococcus, pertussis, RSV and varicella zoster virus. Eur Respir Rev. 2023; 32(169): 230034

[8] Puhan MA, Gimeno-Santos E, Cates CJ, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016; 12(12): CD005305

[9] PCRS Pragmatic Guides for Clinicians. Diagnosis and Management of Tobacco Dependency. Available at: https://www.pcrs-uk.org/sites/default/files/tobacco_dependency_pragmatic_guide_2.pdf

[10] Joly B, Perriot J, d’Athis P, et al. Success rates in smoking cessation: Psychological preparation plays a critical role and interacts with other factors such as psychoactive substances. PLoS One. 2017; 12(10): e0184800

[11] The Lancet Respiratory Medicine. COVID-19 casts light on respiratory health inequalities. Lancet Respir Med. 2020; 8(8): 743

[12] Shaw G, Whelan ME, Armitage LC, et al. Are COPD self-management mobile applications effective? A systematic review and meta-analysis. NPJ Prim Care Respir Med. 2020; 30(1): 11

[13] Cravo A, Attar D, Freeman D, et al. The Importance of Self-Management in the Context of Personalized Care in COPD. Int J Chron Obstruct Pulmon Dis. 2022; 17: 231-243

[14] Hippisley-Cox J, Coupland C, Brindle P. Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study. BMJ. 2017; 357: j2099

[15] Morgan AD, Zakeri R, Quint JK. Defining the relationship between COPD and CVD: what are the implications for clinical practice?. Ther Adv Respir Dis. 2018; 12: 1753465817750524

[16] Li Y, Gao H, Zhao L, Wang J. Osteoporosis in COPD patients: Risk factors and pulmonary rehabilitation. Clin Respir J. 2022; 16(7): 487-496

[17] Gupta A, Jayes LR, Holmes S, et al. Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement. Int J Chron Obstruct Pulmon Dis. 2020; 15: 1377-1390

[18] O’Brien ME, Chandra D, Wilson RC, et al. Loss of skin elasticity is associated with pulmonary emphysema, biomarkers of inflammation, and matrix metalloproteinase activity in smokers. Respir Res. 2019; 20(1): 128

[19] Yannas D, Frizza F, Vignozzi L, Corona G, et al. Erectile Dysfunction Is a Hallmark of Cardiovascular Disease: Unavoidable Matter of Fact or Opportunity to Improve Men’s Health?. J Clin Med. 2021; 10(10): 2221

[20] Pumar MI, Gray CR, Walsh JR, Yang IA, et al. Anxiety and depression-Important psychological comorbidities of COPD. J Thorac Dis. 2014; 6(11): 1615-1631

[21] Spathis A, Booth S, Moffat C, et al. The Breathing, Thinking, Functioning clinical model: a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease. NPJ Prim Care Respir Med. 2017; 27(1): 27

[22] Sanchis J, Gich I, Pedersen S. Aerosol Drug Management Improvement Team (ADMIT). Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time?. Chest. 2016; 150(2): 394-406