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

Background

Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic obstruction of lung airflow that is not fully reversible. It is a serious, progressive and disabling disease and a major cause of hospital admission and premature death in Australia. The mortality rate from COPD among Aboriginal and Torres Strait Islander peoples is 2.6 times that of other Australians.¹ Given that cigarette smoking remains the most important cause of COPD,² high rates of smoking among Aboriginal and Torres Strait Islander peoples is the major driver in disparity from COPD-related disease burden.³ Importantly, however, COPD also occurs in people who have never smoked. Other important risk factors are exposure to environmental smoke, occupational dusts and fumes, air pollution and individual susceptibilities, including genetic factors and damaged airways due to childhood infections.^4,5 Longstanding or poorly controlled asthma can lead to chronic irreversible airways obstruction, and it is also recognised that some people have co-existing asthma and COPD.²

The accurate diagnosis of COPD is vital and rests on the demonstration of airflow limitation that is not fully reversible.² This requires the use of spirometry. The presence of forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) less than 70% and FEV₁ less than 80% of the predicted value after the use of a bronchodilator confirms the diagnosis of COPD.² In people with suspected COPD and no evidence of airflow limitation, an alternative diagnosis should be sought. Other conditions to consider would include bronchiectasis, heart failure, chronic infections (including tuberculosis) and interstitial lung disease.

COPD is commonly associated with other diseases, including heart disease, obstructive sleep apnoea, lung cancer, stroke, anxiety and depression. These conditions should also be actively identified and carefully managed in a holistic approach for Aboriginal and Torres Strait Islander people who have COPD.⁶

Early detection

The possibility of COPD should be actively considered in all people who smoke or are ex-smokers aged >35 years. Given the lack of evidence of population-level screening for COPD, widespread screening of asymptomatic individuals is not recommended.⁷ However, targeted early case finding in primary care appears to be beneficial in finding people with COPD, thus avoiding late diagnosis.⁸ Australian guidelines recommend that people who are clinically suspected to have COPD should be opportunistically checked for symptoms, followed by spirometry if warranted, as part of a targeted case-finding approach.² COPD symptom questionnaires have been shown to be successful in practice-led case finding.⁹ The Lung Foundation Australia has developed an ‘Indigenous Lung Health Checklist’ that may also assist in identifying people who have COPD (refer to ‘Resources’).

Interventions

The single most important intervention to prevent or reduce the progression of COPD for most people is smoking avoidance and smoking cessation, and therefore strenuous efforts should be made to assist people with COPD who smoke to quit.² Similarly, environmental risk factors for COPD, such as fumes, gases, occupational dusts and chemicals, and indoor and outdoor air pollutants, should be avoided.¹⁰

There is good evidence of benefit from annual influenza vaccination in people with moderate to severe COPD, with reduction in hospitalisations, complications and death. Influenza vaccination should therefore be given in early autumn to all such patients.^2,10 Pneumococcal vaccine prevents lower respiratory tract infections in people with severe COPD and people aged >65 years with or without chronic disease, consequently pneumococcal vaccine is recommended in these groups.¹⁰ Australian guidelines for Aboriginal and Torres Strait Islander peoples also recommend offering influenza immunisation for all people from six months of age. The greatest clinical benefit is found in the following Aboriginal and Torres Strait Islander groups: children with a chronic disease, children aged six months to <5 years, and those aged ≥15 years. Pneumococcal vaccination (polyvalent covering 23 virulent serotypes) is also recommended for all Aboriginal and Torres Strait Islander people at significant risk of pneumococcal infection, which includes people with chronic lung disease regardless of their age or severity.^10,11

While inhaled medicines have not been shown to modify the steady decline of lung function, which is the hallmark of COPD, they do provide symptom relief, an initial increase in lung function, improvement in quality of life, and prevention of exacerbations of COPD.^2,10 The principal goals of non-pharmacological and pharmacological therapy for COPD are to optimise function through symptom relief with medications, regular exercise and pulmonary rehabilitation, and to reduce future risk of complications.^2,10 Patients with more severe COPD require multidisciplinary team care, including strategies to support chronic disease self-management and social and emotional wellbeing, including carer wellbeing.² Pulmonary rehabilitation reduces dyspnoea, fatigue, anxiety and depression, improves exercise capacity and health‐related quality of life, enhances patients’ sense of control over their condition and reduces exacerbation rates.¹¹ A COPD written action plan, with education, reduces hospitalisations.¹²