National Guide

Chapter 14 | Respiratory health

Chronic Obstructive Pulmonary Disease







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      2. Chronic Obstructive Pulmonary Disease

Respiratory health | Chronic Obstructive Pulmonary Disease

Dr Sarah Cush 

Key messages

  • Chronic obstructive pulmonary disease (COPD) is a significant burden on the Aboriginal and Torres Strait Islander population.1,2
  • Smoking is the single greatest cause of high rates of respiratory disease, including COPD, in the Aboriginal and Torres Strait Islander population.
  • Smoking prevention and cessation programs could significantly reduce COPD incidence, morbidity and mortality for Aboriginal and Torres Strait Islander people.
  • Targeted screening tools for COPD include formal questionnaires and simple lung function testing devices. Positive results from any method should be followed with diagnostic spirometry.
  • Early detection and management, as per COPD-X (Case finding and confirm diagnosis; Optimise function; Prevent deterioration; Develop a plan of care; Manage eXacerbations) clinical guidelines, are key in optimising health and wellbeing and reducing mortality for people with COPD.3
Type of preventive activity - Immunisation
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People with an established diagnosis of COPD Encourage vaccination against:
  • influenza
  • pneumococcus
  • COVID-19
 As per National Immunisation Program Strong National and international guidelines3,4 Vaccinations are highly effective in reducing the risk of exacerbations and reducing the risk of pneumococcal pneumonia, as well as significant illness from each respective infection
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged over 35 years who currently smoke or are ex-smokers Check for symptoms of COPD as part of a targeted, active case-finding approach

Consider the use of a symptom questionnaire to help with case finding (refer to Useful resources)		 Opportunistically Strong National guideline3 Early diagnosis enables education and pharmacological treatment
All adults with symptoms, especially shortness of breath, chronic bronchitis (cough and sputum) and recurrent acute bronchitis If symptoms of COPD are present, spirometry is indicated to determine the presence of airflow obstruction and to assess its severity As clinically indicated Strong National guideline3 Early diagnosis enables education and pharmacological treatment
Healthy adults who do not report respiratory symptoms Do not routinely use spirometry to screen healthy adults without symptoms N/A Strong National guideline3 No evidence of benefit
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people Advise of the importance of not smoking to prevent COPD (see Chapter 2: Healthy living and health risks, Smoking) Opportunistically Strong National and international guidelines5,6
Aboriginal and Torres Strait Islander-specific evidence7		 Smoking prevention/cessation is the single greatest factor in preventing the onset and reducing the progression of COPD
People who currently smoke Offer counselling and treatment for nicotine dependence to all people who smoke (see Chapter 2: Healthy living and health risks, Smoking) Opportunistically Strong National and international guidelines3,4,8,9 Smoking prevention/cessation is the single greatest factor in preventing the onset and reducing the progression of COPD
People with an established diagnosis of COPD who currently smoke Offer counselling and treatment for nicotine dependence to all people who smoke, regardless of the degree of airflow obstruction (see Chapter 2: Healthy living and health risks, Smoking) Opportunistically and at regular review Strong National and international guidelines3,4,8 Smoking cessation reduces the rate of lung function decline
People with an established diagnosis of COPD Offer referral to pulmonary rehabilitation when available

Access to and the safety of pulmonary rehabilitation programs need to be considered for each individual		 As clinically indicated Strong National and international guidelines3,4 Pulmonary rehabilitation has been shown to reduce COPD exacerbations and improve quality of life
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People with an established diagnosis of COPD Implement Stepwise management plan as per COPD-X guidelines (see Useful resources)

Ensure the correct use of devices at each visit		 As clinically indicated Strong National guideline3 Pharmacotherapy plays an important role in improving quality of life by reducing symptoms, preventing exacerbations and treating exacerbations early to prevent deterioration
People with an established diagnosis of COPD Develop a COPD action plan, including the management of exacerbations (see Useful resources Strong National guideline3 Support a prompt response to exacerbations and reduce hospitalisation
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people Discuss risk factors for COPD (eg occupational exposures, environmental tobacco smoke and indoor and outdoor air pollution and irritants) Opportunistically Conditional National guideline3 This discussion may include strategies such as ensuring adequate ventilation when cooking with solid fuels, avoiding irritants and reducing emissions in the workplace
  • Each client contact should include questions around smoking status and a brief intervention encouraging smoking cessation at the time, as appropriate.
  • Risk factors and symptoms can be explored opportunistically or systematically through health checks or recalls.
  • Provide clear health promotion messages through posters, flyers and during community events.
  • Onsite spirometry with appropriately trained Aboriginal and Torres Strait Islander health practitioners/heath workers could increase the uptake of the test and enable earlier diagnosis of COPD.
  • Use recalls to identify those at risk of COPD (age over 35 years and smoking/past history of smoking) and invite them to complete the Lung Foundation questionnaire, or post out the Indigenous Lung Health Checklist (see Useful resources). Offer spirometry for diagnosis.
  • A clinical audit could include up-to-date recording of smoking status or a review of people with a recorded diagnosis of COPD as a medical history item to ensure spirometry has been performed to confirm diagnosis and that medication use is appropriate.

Background

COPD is a progressive and persistent lung condition that affects daily quality of life and function. It is characterised by chronic respiratory symptoms (shortness of breath, cough, sputum production and exacerbations) due to damage to the airways and alveoli.10 

COPD was the fifth leading cause of death in Australia in 2017,10 and disproportionately affects Aboriginal and Torres Strait Islander people, with a prevalence rate 2.3-fold higher,2 a mortality rate 2.7-fold higher1 and a hospitalisation rate 4.8-fold higher5,6 than for non-Indigenous Australians. 

Cigarette smoking continues to be the biggest risk factor for developing COPD in Australia, and the high rates of smoking among Aboriginal and Torres Strait Islander people is the major driver in the disparity of COPD prevalence. Smoking increases the risk of both developing and dying from COPD. The rates of smoking among Aboriginal and Torres Strait Islander adults aged over 15 years are steadily decreasing: from 51% in 2001 to 44% in 2012–13 and further down to 37% in 2018–19.10 However, this rate remains significantly higher than the daily smoking rate of 11% for all Australians aged over 15 years.11 

Other risk factors for COPD include: 

  • asthma, especially if poorly controlled
  • factors in childhood, including low birth weight and recurrent respiratory infections
  • environmental pollution
  • second-hand smoke
  • exposure to occupational dust, fumes and chemicals
  • rarely, a genetic disorder (α1-antitrypsin deficiency).4

There is ongoing research into predisposing risk factors and how they are affected by epigenetics (eg exposure to cigarette smoke in utero and whether this increases the risk of developing COPD later in life when exposed to toxic agents and/or affects lung volume and development).4

Behavioural

Smoking prevention and cessation have the greatest capacity to change the development and progression of COPD by slowing the rate of decline in lung function and delaying the onset of disability (Figure 1).3,4,12 Smoking prevention and cessation can be achieved through individual counselling and pharmacotherapy (eg nicotine replacement therapy) and through public health and legislative changes (eg taxes and banning smoking in public places). The potential harms of vaping are not yet fully known, nor is there evidence to support the safety of e-cigarettes as a cessation tool.4 Furthermore, e-cigarettes may independently increase an individuals’ risk of developing COPD and other chronic respiratory conditions13 (see Chapter 2: Healthy living and health risks, Smoking and Vaping).

Figure 1. The Fletcher and Peto curve.
†Death from underlying chronic obstructive lung disease.
FEV1, forced expiratory volume in one second.
Reproduced from Fletcher and Peto (1977).12


This figure shows the risks of disability and death in men according to whether they have ever smoked and the age when they quit. The figure clearly demonstrates the reduction in lung function in smokers over time, and how smoking cessation at any age reduces the rate of decline in lung function.

Screening

Although primary prevention is critical, early detection of COPD through opportunistic and/or targeted screening and active management is key in optimising health and wellbeing and reducing mortality for people with COPD. 

Targeted screening aims to identify people with or at risk of COPD. Available targeted screening tools include formal questionnaires, validated risk calculators (in development for use in those aged 40–49 years)14 and simple lung function testing using devices such as the Piko-6 or COPD-6. Positive results from either method indicate higher risk and should be followed by diagnostic spirometry. 

Questionnaires can be self-administered, delivered by health workers and/or integrated into annual health checks (see Box 1). Lung Foundation Australia and the Queensland government have developed an Indigenous Lung Health Checklist for Aboriginal and Torres Strait Islander people.15 

Microspirometry devices such as Piko-6 and COPD-6, which measure forced expiratory volume in one (FEV1) or six (FEV6) seconds, can be used in the primary care setting for targeted screening.14 However, these devices should not be used to diagnose COPD because they can result in an overestimation of airflow obstruction.16 

There is insufficient evidence to recommend screening asymptomatic individuals with spirometry because this is likely to identify many individuals with clinically insignificant airflow obstruction who will not benefit from treatment. 16

Box 1. Lung Foundation Australia criteria for identifying individuals at risk of chronic obstructive pulmonary disease
Individuals aged 35 years or older who meet at least one of the following criteria may be at risk of COPD and should undergo further assessment and spirometry:
  • Smoker or ex-smoker
  • Work or worked in a job where [they] were exposed to dust, gas or fumes
  • Cough several times most days
  • Cough up phlegm or mucus most days
  • Out of breath more easily than others of a similar age
  • Experience chest tightness or wheeze
  • Have frequent chest infections
Reproduced with permission from the Australian Lung Foundation position paper on the use of chronic obstructive pulmonary disease (COPD) screening devices for targeted case finding in the community.17

Diagnosing COPD

For individuals identified at risk of COPD, spirometry is important to make an accurate diagnosis in order to optimise management and secondary prevention. A diagnosis of COPD is made when there is a persistent airflow limitation that is not fully reversible; that is, a post-bronchodilator FEV1/forced vital capacity ratio <0.7 and an FEV1 <80% of predicted.3,4 However, it should be noted that this criterion can result in the overdiagnosis of COPD in older people and the underdiagnosis of COPD in young adults; therefore, in practice, a lower limit of normal is often used. The lower limit of normal can be affected by the reference ranges chosen when performing spirometry. Spirometry reference ranges are adjusted for birth sex, age, height and ethnicity. The Global Lung Initiative 2012 recommends the use of the ‘other/mixed’ reference range for Aboriginal and Torres Strait Islander people.18 

Spirometry is underutilised in primary care settings, and access to spirometry can be even more difficult in rural or remote settings.19 The National Asthma Council Australia provides training in general practice to perform spirometry onsite, which may reduce barriers for Aboriginal and Torres Strait Islander peoples in attending hospital clinics (see Useful resources). 

Pulmonary rehabilitation

Pulmonary rehabilitation is a program of education and supervised exercise sessions designed for people with COPD to empower them with knowledge of the disease and ways to manage their symptoms, improve exercise capacity, reduce symptoms and improve quality of life.3 Aboriginal and Torres Strait Islander people have limited access to culturally safe pulmonary rehabilitation programs. It has been proposed there would be greater uptake of pulmonary rehabilitation programs if they were provided by Aboriginal Community Controlled Health Organisations (ACCHOs).7 Such programs could be funded, in part, through the Medicare Benefits Schedule team care arrangements and My Aged Care packages for those aged over 50 years.

Medication

The aim of prescribing in COPD is two-fold: 

  1. To reduce symptoms (shortness of breath, cough, mucous production
  2. To prevent exacerbations or deteriorations.

It is recommended a stepwise approach is followed to achieve adequate control of symptoms.3 This involves developing an exacerbation action plan to empower individuals to treat their exacerbations early and to prevent hospitalisations and deterioration.3 Each patient should have a management plan guided by their symptoms, comorbidities, preferences and ability to use the various drug-delivery devices.3 It is important to check and correct inhaler use and technique regularly, ideally at each visit.

Immunisation

Influenza and pneumococcal vaccinations decrease the incidence of lower respiratory tract infections in people living with COPD. COVID-19 vaccines are highly effective in protecting against serious illness from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and people with COPD should have the COVID-19 vaccination in line with national recommendations3,4 (see Chapter 3: Immunisation across the life course). 

Environmental

Workplace safety and protective equipment should be used where occupational exposure to airway irritants, such as smoke, fumes and dust, occurs.

  1. Pal A, Howarth TP, Rissel C, et al. COPD disease knowledge, self-awareness and reasons for hospital presentations among a predominately Indigenous Australian cohort: A study to explore preventable hospitalisation. BMJ Open Respir Res 2022;9(1):e001295. doi: 10.1136/bmjresp-2022-001295.
  2. Australian Institute of Health and Welfare (AIHW). Coronary heart disease and chronic obstructive pulmonary disease in Indigenous Australians. AIHW, 2014 [Accessed 12 May 2024].
  3. Dabscheck E, George J, Hermann K, et al. COPD‐X Australian guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2022 update. Med J Aust 2022;217(8):415–23. doi: 10.5694/mja2.51708.
  4. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for prevention, diagnosis and management of COPD: 2023 report. GOLD, 2023 [Accessed 12 May 2024].
  5. Australian Institute of Health and Welfare (AIHW). Disparities in potentially preventable hospitalisations across Australia, 2012–13 to 2017–18. AIHW, 2020 [Accessed 12 May 2024].
  6. Australian Commission on Safety and Quality in Health Care (ACSQHC), Australian Institute of Health and Welfare. The fourth Australian atlas of healthcare variation. ACSQHC, 2021 [Accessed 11 May 2024].
  7. Meharg DP, Jenkins CR, Maguire GP, et al. Implementing evidence into practice to improve chronic lung disease management in Indigenous Australians: The Breathe Easy, Walk Easy, Lungs for Life (BE WELL) project (protocol). BMC Pulm Med 2022;22(1):239. doi: 10.1186/s12890-022-02033-8.
  8. DiGiacomo M, Davidson PM, Abbott PA, Davison J, Moore L, Thompson SC. Smoking cessation in indigenous populations of Australia, New Zealand, Canada, and the United States: Elements of effective interventions. Int J Environ Res Public Health 2011;8(2):388–410. doi: 10.3390/ijerph8020388.
  9. Marley JV, Atkinson D, Kitaura T, et al. The Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote aboriginal Australian health care setting. BMC Public Health 2014;14(1):32. doi: 10.1186/1471-2458-14-32.
  10. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander health performance framework summary report 2020. AIHW, 2020 [Accessed 11 May 2024].
  11. Australian Institute of Health and Welfare (AIHW). Alcohol, tobacco & other drugs in Australia. AIHW, 2023 [Accessed 12 May 2024].
  12. Fletcher C, Peto R. The natural history of chronic airflow obstruction. BMJ 1977;1(6077):1645–48. doi: 10.1136/bmj.1.6077.1645.
  13. Xie W, Kathuria H, Galiatsatos P, et al. Association of electronic cigarette use with incident respiratory conditions among US adults from 2013 to 2018. JAMA Netw Open 2020;3(11):e2020816. doi: 10.1001/jamanetworkopen.2020.20816.
  14. Perret JL, Vicendese D, Simons K, et al. Ten-year prediction model for post-bronchodilator airflow obstruction and early detection of COPD: Development and validation in two middle-aged population-based cohorts. BMJ Open Respir Res 2021;8(1):e001138. doi: 10.1136/bmjresp-2021-001138.
  15. Lung Foundation Australia. Indigenous lung health checklist. Queensland Government, 2017 [Accessed 12 May 2024].
  16. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB; U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: Summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2008;148(7):535–43. doi: 10.7326/0003-4819-148-7-200804010-00213.
  17. Lung Foundation Australia. The Australian Lung Foundation position paper on the use of COPD screening devices for targeted COPD case finding in community settings. Lung Foundation Australia, 2019 [Accessed 12 May 2024].
  18. Blake TL, Chang AB, Chatfield MD, Marchant JM, McElrea MS. Global Lung Function Initiative-2012 ‘other/mixed’ spirometry reference equation provides the best overall fit for Australian Aboriginal and/or Torres Strait Islander children and young adults. Respirology 2020;25(3):281–88. doi: 10.1111/resp.13649.
  19. Zwar NA, Marks GB, Hermiz O, et al. Predictors of accuracy of diagnosis of chronic obstructive pulmonary disease in general practice. Med J Aust 2011;195(4):168–71. doi: 10.5694/j.1326-5377.2011.tb03271.x.




 

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