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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Chronic obstructive pulmonary disease

Author Dr Penny Abbott 
Expert reviewer Professor Anne Chang

Background

Chronic obstructive pulmonary disease (COPD) is a serious, progressive and disabling disease and a major cause of hospital admission and premature death in Australia.3 Some 2 million Australians are estimated to have COPD.11 The death rate from COPD among Aboriginal and Torres Strait Islander people is five times that of non-Indigenous Australians.11,61 Tobacco smoking is the major cause of COPD.3 Half of Aboriginal and Torres Strait Islander people report that they smoke and daily smoking is twice as prevalent when compared with non-Indigenous Australians.61,82 Further, environmental tobacco smoke (ETS) exposure appears to be a risk factor for the development of COPD.83,84

COPD is characterised by airflow limitation that is not fully reversible and is usually progressive. A clinical diagnosis of COPD should be considered in any patient who has dyspnoea, chronic cough or sputum production, and a history of tobacco smoking. The diagnosis of COPD requires demonstration by spirometry of airflow limitation that is not fully reversible, in addition to symptoms of dyspnoea and cough and exposure to risk factors for the disease such as smoking. The presence of a postbronchodilator FEV1/FVC <0.70 and FEV1 <80% predicted confirms the presence of airflow limitation that is not fully reversible.11,22,23,85 

Spirometry in association with clinical symptoms can be used to classify COPD into:

  • mild disease (Stage I: FEV1/FVC <0.70 and FEV1 >80% predicted)
  • moderate disease (Stage II: FEV1/FVC <0.70 and FEV1 50–80% predicted)
  • severe disease (Stage III: FEV1/FVC <0.70 and FEV1 30–50% predicted), and
  • very severe disease (Stage IV: FEV1/FVC <0.70 and FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure).11,23

COPD is commonly associated with other diseases, including heart disease, obstructive sleep apnoea, lung cancer, stroke and depression, which should be actively identified and also carefully managed.23,86

Interventions

There is no evidence of an effective screening test for the early detection of COPD in asymptomatic individuals. Spirometry has not been demonstrated to improve health outcomes and there is no evidence that spirometry screening improves smoking cessation rates.87–90 Spirometry is therefore not recommended as a screening test but is required for diagnosis in symptomatic individuals.11,22,87,88,91–93 

The single most important intervention to prevent or reduce the progression of COPD for most people is smoking cessation and therefore strenuous efforts should be made to assist smokers with COPD to quit smoking.11 Similarly, other risk factors for COPD should be reduced such as occupational dusts and chemicals, and indoor and outdoor air pollutants.23

No medications have been shown to modify the steady decline of lung function, which is the hallmark of COPD.11,23 For people with an established diagnosis of COPD, much can be done, however, to improve quality of life, increase exercise capacity and reduce morbidity and mortality.11,85 The principal goals of other therapy, aside from smoking cessation, are to optimise function through symptom relief with medications and pulmonary rehabilitation and to prevent or treat aggravating factors and complications.11 Mild to moderate COPD is likely to be treated within primary care, but patients with more severe COPD require multidisciplinary team care including consideration of pulmonary rehabilitation.91 Pulmonary rehabilitation reduces dyspnoea, fatigue, anxiety and depression, improves exercise capacity, emotional function and health related quality of life and enhances patients’ sense of control over their condition.11,22,23,91

There is good evidence of benefit from annual influenza vaccination in people with COPD, with a demonstrable reduction in hospitalisations, complications and death.11,23,37 Influenza vaccination should therefore be given in early autumn to all patients with moderate to severe COPD.11 There is no direct evidence of the efficacy of pneumococcal vaccine in preventing pneumococcal exacerbations of COPD.24 There is however, evidence of benefit in elderly populations with or without chronic disease.22 Consequently pneumococcal vaccination (polyvalent covering 23 virulent serotypes) is recommended in this group.11

Despite the fact that medications cannot reverse or slow the deterioration in lung function in COPD, they have an important role in symptom control and management of complications. Both long acting anticholinergic agents and long acting beta agonists (LABAs) have proven effectiveness in symptom control for COPD. Evidence is insufficient to recommend one over the other.92 Inhaled corticosteroids (ICS) should be considered in patients with moderate to severe COPD and frequent exacerbations.11,85 While the long term adverse effects of ICS are unknown, caution is needed if treatment is stopped as abrupt withdrawal may be associated with worsening of symptoms.11 Combination inhaled therapies (ICS, LABA, long acting anticholinergics) may be appropriate in symptomatic people. The decision to use combination treatment and which agents to use should take into account the patient’s symptomatic response, personal preference and risk of side effects.91

Prophylactic antibiotics in chronic bronchitis/COPD have a small but statistically significant effect in reducing the days of illness due to exacerbations of chronic bronchitis. However, they do not have a place in routine treatment because of concerns about the development of antibiotic resistance and the possibility of adverse effects. Similarly, mucolytics may reduce the frequency and duration of exacerbations but are not indicated for routine use.11,91

Recommendations: Chronic obstructive pulmonary disease
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Immunisation People with an established diagnosis of COPD Offer influenza vaccine in the pre-flu season months for the prevention of influenza (March to April) Annually IIB 11,91
Pneumococcal vaccine (23vPPV) is recommended for the prevention of invasive pneumococcal disease See section on pneumococcal vaccination for recommendations on frequency IIC2,11,23,91
Screening Current smokers
Ex-smokers over 35 years of age
Screen for symptoms of COPD (persistent cough/sputum production, wheezing, dyspnoea) Opportunistic IIB11
If symptoms are present spirometry is indicated to assess for COPD
Spirometry is not recommended to screen healthy adults who do not report respiratory symptoms
Opportunistic IA11,22,87,88,91–93
Chest X-ray is not recommended for the diagnosis or screening of COPD
Chest X-ray may be of value to rule out other diagnoses and for later use as a baseline
Opportunistic GPP22,91
Behavioural All people Advise of the importance of not smoking as the most effective strategy to prevent COPD (see Chapter 1: Lifestyle, smoking) Opportunistic 1A11
People with an established diagnosis of COPD Smoking cessation reduces the rate of decline of lung function. Counselling and treatment of nicotine dependence should be offered to all smokers regardless of the presence or absence of airflow obstruction (see Chapter 1: Lifestyle, smoking) Opportunistic IA11,23,87
Chemoprophylaxis People with an established diagnosis of COPD Pharmacotherapy (bronchodilator treatment, inhaled corticosteroids, long term antibiotic treatment) does not modify decline in lung function
Pharmacotherapy is useful in decreasing symptoms and/or complications and improving quality of life
Opportunistic IA11,23
Environmental All people Advise that risk factors for COPD should be minimised (eg. occupational exposure, ETS and indoor/outdoor air pollution and irritants). This may include strategies such as adequate ventilation when cooking with solid fuels and avoidance of irritants and reduction of emissions in the workplace N/A IIIC23,84

Resources

Screening for chronic obstructive pulmonary disease using spirometry
www.uspreventiveservicestaskforce.org/ uspstf/uspscopd.htm

The COPD-X Plan. Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease
www.copdx.org.au

Inhaler technique in adults with asthma or COPD
www.clinicalguidelines.gov.au/ search.php?pageType=2&fldglrID=1564&

Chronic obstructive pulmonary disease: diagnosis and management of acute exacerbations
www.guideline.gov/ syntheses/synthesis.aspx?id=16404

Diagnosis and management of stable chronic obstructive pulmonary disease
www.guideline.gov/ syntheses/synthesis.aspx?id=16403

Chronic obstructive pulmonary disease: pulmonary rehabilitation
www.guideline.gov/ syntheses/synthesis.aspx?id=16423

Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update)
www.guideline.gov/ content.aspx?id=23860&search=asthma+and+prevention

Chronic obstructive pulmonary disease
http://guidance.nice.org.uk/CG101.

References

  1. National Health and Medical Research Council. The Australian immunisation handbook, 9th edn. Canberra: Commonwealth of Australia, 2008. Cited October 2011. Available at www.health.gov.au/ internet/immunise/publishing.nsf/ content/handbook-home.
  2. Australian Institute of Health and Welfare. Asthma, chronic obstructive pulmonary disease and other respiratory diseases in Australia. Canberra: AIHW, 2010.
  3. McKenzie DK, Abramson M, Crockett AJ, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2011. COPDX, 2011. Cited October 2011. Available at www.copdx.org.au.
  4. Management of COPD Working Group. VA/DoD clinical practice guideline for the management of outpatient chronic obstructive pulmonary disease. Washington: Department of Veterans Affairs, Department of Defense, 2007.
  5. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda: Global Initiative for Chronic Obstructive Lung Disease, 2009. Cited October 2011. Available at www.guideline.gov/content.aspx?id=25648.
  6. Granger R, Walters J, Poole PJ, et al. Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006;Oct 18;(4):CD001390.
  7. Poole P, Chacko EE, Wood-Baker R, Cates CJ. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006;Jan 25;(1):CD002733.
  8. Thomson N, MacRae A, Burns J, et al. Overview of Australian Indigenous health status. HealthInfoNet, April 2010. Cited October 2011. Available at www.healthinfonet.ecu.edu.au/ health-facts/overviews.
  9. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey, cat. no. 4714.0. Canberra: ABS, 2008. Cited October 2011. Available at www.abs.gov.au/ ausstats/abs@.nsf/mf/4714.0.
  10. Yin P, Jiang CQ, Cheng KK, et al. Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study. Lancet 2007;370:751–7.
  11. Eisner MD, Anthonisen N, Coultas D, et al. An official American Thoracic Society public policy statement: novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010;182(5):693–718.
  12. University of Michigan Health System. Chronic obstructive pulmonary disease. Ann Arbor: University of Michigan Health System, 2010.
  13. Pierce R, Antic R, Chang A, et al. Respiratory and sleep health in Indigenous Australians. Sydney: Thoracic Society of Australia and New Zealand, 2009.
  14. US Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry, topic page. Rockville: US Preventive Services Task Force, 2008. Cited October 2011. Available at www.uspreventiveservicestaskforce.org/ uspstf/uspscopd.htm.
  15. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2008;148(7):535–43.
  16. Wilt TJ, Niewoehner D, Kane RL, MacDonald R, Joseph AM. Spirometry as a motivational tool to improve smoking cessation rates: a systematic review of the literature. Nicotine Tob Res 2007;9:21–32.
  17. Buffels J, Degryse J, Decramer M, Heyrman J. Spirometry and smoking cessation advice in general practice: a randomised clinical trial. Respir Med 2006;100(11):2012–7.
  18. National Institute for Health and Clinical Excellence. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Institute for Health and Clinical Excellence, 2010. Cited October 2011. Available at http://guidance.nice.org.uk/CG101.
  19. Qaseem A, Snow V, Shekelle P, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007;147(9):633–8.
  20. US Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: US Preventive Services Task Force Recommendation Statement. Rockville: US Preventive Services Task Force, 2008. Cited October 2011. Available at www.uspreventiveservicestaskforce.org/ uspstf08/copd/copdrs.htm.
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