Chronic obstructive pulmonary disease (COPD) is a common heterogeneous lung disease characterised by persistent respiratory symptoms, including breathlessness, cough, phlegm and exacerbations (Global Strategy for Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (GOLD), 2022). Symptoms are the result of airflow limitation and structural changes to the airways and alveoli, leading to chronic bronchitis/bronchiolitis and/or emphysema.
Direct exposure to tobacco smoke, noxious gases and air pollution are the main known causes of COPD in the UK. Furthermore, abnormal lung development, genetic factors and early life lung insults, including social determinants of health, are linked to increasing risk and development of COPD (Soriano et al, 2018; Lee et al, 2022).
The healthcare burden of COPD in the UK is substantial, with an estimated cost to the NHS of £1.8 billion per annum (Trueman et al, 2017). Approximately 1.2 million people are diagnosed with COPD in the UK and it is the second most common lung disease after asthma. In addition, it is the fourth and fifth most common cause of death for men and women respectively, and the UK has the third-highest mortality rate for COPD in the whole of Europe (Trueman et al, 2017).
The diagnosis of COPD should be based on:
- The presence of respiratory symptoms – breathlessness, wheeze, cough, phlegm – that are persistent and may be progressive in nature, and that may worsen with exertion
- The presence of associated risk factors – exposure to tobacco smoke, indoor and outdoor air pollution, lung developmental issues (e.g. low birth weight, parental smoking, frequent chest infections) and/or genetic factors
- A post bronchodilator forced spirometry result that demonstrates an obstructed ratio. The Association for Respiratory Technology and Physiology (ARTP) advocates using the ‘lower limits of normal’ when interpreting the ratio to minimise the potential of false positive results and over diagnosis of COPD, particularly in older people (Sylvester et al, 2020). Care should be taken to ensure spirometry is quality assured and performed and interpreted by appropriately trained and qualified health professions before assigning any diagnosis.
Individualised care
The main goals of COPD treatment include controlling symptoms, and improving exercise capacity and lung function, while preventing and reducing the occurrence of exacerbations, hospital admissions and mortality (Lemmens et al, 2009). An individualised approach considering health literacy, disease education, management and co-morbidities is necessary (Ogunbayo et al, 2017; Lenferink et al, 2017). This promotes self-management strategies to sustain effective behaviour change and lifestyle choices. Regular assessment and monitoring is necessary to help maintain quality of life, avoid unnecessary healthcare utilisation and, where appropriate, include advance decision making discussions (Lippiett et al, 2019).
Categorising COPD
The concept of endotypes in COPD is emerging, whereby sub-groups of patients share the same characteristics and underlying pathophysiology (Garudadri and Woodruff, 2018). Recognising treatable traits or phenotypes in clinical practice has progressed from the uncomfortable terms ‘blue bloaters’ and ‘pink puffers’ to identifying ‘exacerbators’ and ‘non-exacerbators’, the latter often experiencing dyspnoea as the symptom of burden (Agustí et al, 2022).
The former GOLD (2021) A, B, C, D framework used to support pharmacological and non-pharmacological therapy decision making for new and confirmed diagnosis of COPD has been replaced with an A, B, E framework (GOLD, 2022) (see Table 1). Categories A and B remain unchanged; both are non-exacerbators with either lesser (Group A) or greater (Group B) multifactorial symptom burden. Categories are determined by application of the validated COPD assessment Test (CAT) and Modified Medical Research Council Breathlessness Score (mMRC). Clinicians should take care to note that the mMRC (Mahler and Wells, 1988) uses the same statements as the original MRC score (MRC, 1960) but over a numerical range of 0–4 as opposed to 1–5 (see Table 2).
Table 1. GOLD ABE assessment tool
| ≥2 moderate exacerbations or 1≥ leading to a hospitalisation | Group ELABA + LAMAFactors to consider when adding an ICS to LAMA/LABA therapy. Peripheral blood eosinophil readings may fluctuate over timeUse stable state values (not during or soon after acute illness)Thresholds are estimates and not cut-off valuesAgainst ICS use <100 cells µLFavours ICS Use 100-300cells µLStrongly favours ICS use >300 cells µLThe above is not criteria for withdrawal of ICS | |
| 0 or 1 moderate exacerbations (not leading to hospital admission) | Group AA bronchodilator | Group BLABA + LAMA |
| mMRC 0-1, CAT <10 | mMRC ≥2, CAT ≥10 | |
Key: LABA=long-acting β2-adrenoceptor agonists; LAMA=long-acting muscarinic acetylcholine receptor antagonists; ICS=inhaled corticosteroids; µL=microlitre; mMRC=modified Medical Research Council dyspnoea scale; CAT=COPD Assessment TestTM
Table 2. MRC versus mMRC grade
| MRC | mMRC | |
|---|---|---|
| 1 | 0 | Not troubled by breathless except on strenuous exercise |
| 2 | 1 | Short of breath when hurrying on a level or when walking up a slight hill |
| 3 | 2 | Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace |
| 4 | 3 | Stops for breath after walking 100 yards, or after a few minutes on level ground |
| 5 | 4 | Too breathless to leave the house, or breathless when dressing/undressing |
Key: MRC=Medical Research Council dyspnoea scale; mMRC=modified Medical Research Council dyspnoea scale
One hospital admission for COPD exacerbation (AECOPD) or more than one community managed moderate exacerbation in the previous 12 months constitutes Category E, highlighting the profound significance of every exacerbation regardless of symptom burden (NICE, 2019; GOLD, 2022).
Bronchodilator therapy
Bronchodilators are globally recognised as the cornerstone of pharmacological treatment in COPD. In the UK, gone is the step approach to bronchodilation starting with short acting, then long-acting monotherapy and finally long-acting dual therapy. Instead, NICE recommends first-line maintenance therapy as dual bronchodilators for those newly diagnosed and as ongoing therapy for breathlessness in persons with confirmed COPD without asthma (NICE, 2019) (see Table 3). Short acting β2-adrenoceptor agonists (SABA) remains the pharmacological treatment for breakthrough breathlessness in addition to maintenance therapy.
Table 3. Treatment for AECOPD (NICE, 2019; GOLD, 2022)
| Mild | A temporary increase of short acting β2-adrenoceptor agonists (SABA) (eg. salbutamol and terbutaline) |
| Moderate | A course of oral prednisolone at 30 mg daily for 5 days for increased dyspnoea |
| Moderate | A course of antibiotics if there is evidence of an increase in the volume or in the presence of purulent phlegmFirst-line antibiotics include:
|
| Severe | Consider hospitalisation in patients with:
|
Combined long-acting β2-adrenoceptor agonists (LABAs) and long-acting muscarinic acetylcholine receptor antagonists (LAMAs) have a synergistic action on airway smooth muscle (Matera et al, 2020) and reduce occurrence of AECOPD (Suissa et al, 2022). Treating from diagnosis with a LAMA/LABA in a single device that the person can use, reduces day to day and exertional breathlessness and facilitates potential for activity-based undertakings, continued employment and social engagement, thus improving quality and experience of life (Anzueto and Miravitlles, 2018).
Crucially, long-acting bronchodilation augments individual potential to partake in vital non-pharmacological interventions, such as the activity-based component of the pulmonary rehabilitation programme and may support confidence in engaging with other therapies and activities such as singing. In moderate-to-severe COPD, sputum production and cough from the LAMA component maybe modified (Calzetta et al, 2022). Prescribers should be aware of special population guidance, namely renal impairment when selecting dual bronchodilator molecules. Oral mucolytics in either capsule (regimen varies) or effervescent (once daily) form can be considered to thin mucous and aid airway clearance alongside breathing techniques.
Central to the delivery of all inhaled therapy is the person's ability to use an inhaler device. Barriers to sub-optimal drug delivery are commonly non-intentional and include cognition, sight, dexterity, lip seal, inspiratory effort, and reliance on carer's understanding (Usmani et al, 2018). The prescriber and reviewing clinicians are responsible for ensuring device capability through observed assessment especially during and immediately after an exacerbation. Exploring health beliefs, expectations of treatment and dosing preferences (once or twice daily) facilitates concordance thereby decreasing risk of exacerbation and daily symptoms (Price et al, 2018; Usmani et al, 2018).
Once treatment is initiated, GOLD A, B or E categorisation is retired. The characteristics and experience of living with COPD has the potential to change over time. Revisiting symptom burden and identifying the COPD phenotype as exacerbator or non-exacerbator at annual, interim and at every post exacerbation review assists an ongoing individualised approach to pharmacological and non-pharmacological therapy. Switching molecules maybe required when adopting a person-centred approach to device selection, medicine side effect or dosing schedule.
Green prescribing
There has been a recent drive on green prescribing because of government commitments to cutting 78% of the UK's greenhouse gas emissions by 2035 (NHS Sustainable Development Unit, 2018). Inhalers reflect 3% of all NHS carbon emissions, Pressurised metered dose inhalers (pMDIs) have a higher estimated carbon footprint compared to dry powder inhalers (DPIs) (500 g v 20 g CO2eq per dose). In addition, pMDI use in the UK is far higher than other European countries (Lavorini et al, 2011). While environmental factors are important, prescribing should be individualised as the consequences of device error may lead to unnecessary healthcare usage resulting in a higher carbon footprint. Switching to lower carbon footprint devices should involve communication, consent, and education. Indeed, it may be better to start new patients on DPIs with support and education rather than focussing on switching.
Inhaled corticosteroids in COPD
There is a lack of biomarkers in COPD to differentiate inflammatory profiles (GOLD, 2022). Regional UK guidelines, in line with GOLD (2022) recommend using stable state peripheral blood eosinophil (PBE) trends retrievable in previous full blood counts (taken when the person is stable and well). As part of an exacerbation prevention strategy, stable PBE values support a process to identify those at increased risk of future exacerbations and those most likely to benefit from inhaled corticosteroids (ICS) (Suissa et al, 2020; Calzetta et al, 2021; GOLD, 2022).
Exacerbators, be they identified at diagnosis (GOLD category E) or at review, with evidence of stable state PBE ≥ 300 cells/μL (cells/microlitre), or at least > 100 cells/μL are at increased risk of future exacerbations and most likely to benefit from this triple therapy preventive strategy (ICS/LAMA/LABA) preferably in one device, that they have been assessed as able to use (David et al, 2018; Garudadri and Woodruff, 2018; Kaplan and van Boven, 2020; Pavord et al, 2016). For non-exacerbators with PBE ≥ 300 cells/μL it can be reasonable to prescribe a dual bronchodilator (Calzetta et al, 2021), local guidelines are available to support this assessment and decision making. In all cases, device assessment and shared decision making will support concordance and positive outcomes.
Historical over-prescribing of ICS in COPD is recognised (Price et al, 2014; Brusselle et al, 2015; Gruffydd-Jones et al, 2016). Published literature recommends a risk–benefit approach, not only to initiation of ICS but also continuation of ICS therapy (Ashdown et al, 2022; Singh et al, 2022; Wright et al, 2022). In practice, this requires time and shared decision making.
The clinician will have to identify and discuss why ICS was initiated and assess current symptoms, past and present exacerbation rates. There is little consensus and ongoing debate on stepping away from ICS (Dalin et al, 2022). If uncertain, requesting advice and guidance from specialist respiratory services is appropriate. Where asthma was a previously confirmed diagnosis but consequential exposure, symptoms and persisting airway obstruction is evident, i.e. the person is identified as having co-existing asthma and COPD, the inclusion of ICS remains critical (NICE, 2019; GOLD, 2022). There is often uncertainty about responsibility for assessing accumulative steroid exposure and issuing a steroid card. Guidance can be found on the Specialist Pharmacy website (https://www.medicinesresources.nhs.uk/guidance-on-issuing-the-steroid-emergency-card.html).
Exacerbations
Currently there are no formal tests to confirm an AECOPD (Vogelmeier et al, 2017). Instead, diagnosis is based on a change in baseline (day to day) respiratory symptoms, such as increased dyspnoea or cough, an increase in volume or a change in colour of phlegm or difficulty in completing activities of daily living (NICE, 2019; GOLD, 2022). GOLD (2022) has produced a process of assessing AECOPD through objective tests and observation alongside visual analogue scales (Celli et al, 2021) but it is not yet validated. Exacerbations are commonly caused by bacterial or viral infections as well as environmental factors such as air pollution. Treatments for AECOPD include a temporary increase of SABA (e.g. salbutamol and terbutaline) which may be enough to resolve symptoms and return the patient to their usual health status (see Table 3).
Despite commonly advising an early increase in SABA dosing at onset of acute worsening symptoms, most UK regional exacerbation guidelines do not detail a SABA dosing schedule. GOLD (2022) suggests one to two doses of salbutamol 100 mcg every 1–2 hours for 2–3 occasions, then every 2–4 hours based on response. LAMA/LABA or ICS/LAMA/LABA maintenance therapy should continue as prescribed in a fixed dose regimen. Inspiratory effort and technique in exacerbation may change. Some individuals may require a spacer and pMDI for their therapy during this time despite good technique with DPI when stable.
Moderate AECOPDs may require a course of gluco-corticosteroids (e.g. prednisolone) where there is an increase in dyspnoea, and antibiotics where there is an increase in the volume or change in colour of phlegm and suspected infected exacerbation of COPD (IECOPD). While most AECOPDs are treated in the community, approximately a third of all patients will experience a moderate or severe AECOPD which are responsible for at least one in eight hospital admissions in the UK (Gayle et al, 2017; Vogelmeier et al, 2017).
Repeated AECOPDs can lead to terminal lung function decline, repeated admissions, reduced quality of life and increased mortality (Hurst et al, 2010; Mathioudakis et al, 2020). It is worth noting that in AECOPD systemic impact, presence of co-morbidities, access to services and socio-economic factors often determine where or how the crisis event is treated (Kim and Aaron, 2018; Celli et al, 2021).
Rapidly identifying and treating AECOPDs is, therefore, essential to help preserve health status. This relies on educating people with COPD to correctly recognise a change in character from their normal baseline respiratory symptoms. Self-management plans tailored to individual needs can support this process and should be offered at annual COPD reviews (NICE, 2019). Visual aids and talk back methods may be more appropriate for patients with lower levels of health literacy (Ogunbayo et el, 2017). If a written plan is appropriate, Asthma Lung UK (a national charity supporting patients with lung disease) has a good downloadable plan alongside other educational resources available on their website which is used frequently in the NHS and available from: https://www.blf.org.uk/sites/default/files/COPD_self-management_plan_2021_V3_interactive.pdf (Figure 1). Other self-management plans may be available locally.
Rescue packs
People with COPD maybe offered a rescue pack of antibiotics and steroids to commence in AECOPD and prevent delays in accessing and obtaining treatment. While this can be more convenient for the patient, it may lead to overuse and potentially harmful short and long-term side effects and the risk of antibiotic resistance (Hutchinson et al, 2022). Rescue packs should not be on repeat medication lists. Careful selection of eligible persons is important, taking into consideration whether they are willing and able to use a rescue pack correctly and whether other high-impact interventions have already been attempted (Rodman, 2021).
NICE (2019) suggests considering a rescue pack in those who have experienced at least two or more AECOPDs in the past 12-month period. People with confirmed co-exisiting bronchiectasis will usually require a longer course of antibiotics and and ideally a sputum culture before starting emperic or previously recommended or guided antibiotic treatment. Clinicians need to provide education with appropriate self-management tools and ensure the person is aware to inform their primary care provider when use is initiated and be booked for a priority review during or soon after the rescue therapy (NICE, 2019) and certainly before another pack is issued.
Vaccination
As respiratory infections are a common cause of exacerbation, hospitalisation and death, the World Health Organization (WHO) and all major COPD clinical guidelines recommend influenza, pneumonia, and SARS-Covid-19 vaccination (Bekkat-Berkani et al, 2017). Despite this and relatively mild side effects, flu vaccination uptake among people with lung disease rates remain low in the UK, approximately 56% during 2021/2022 (UK Health Security Agency, 2022). Vaccination should be encouraged at every clinical contact, discussing benefits and possible side effects.
Pulmonary rehabilitation
Dyspnoea and fatigue on exertion are commonly reported symptoms in COPD, which can be distressing for the individual. This may lead to avoiding occasions when symptoms are triggered, resulting in deconditioning and reduced exercise capacity. Pulmonary rehabilitation (PR) is a person-centred treatment for people with COPD involving a programme of exercise and disease education, nutritional, psychological, and behavioural interventions run by expert multidisciplinary teams (Spruit et al, 2013). The recognised benefits of PR include reduced symptoms, exacerbations, and health care usage plus increased quality of life and improved exercise capacity (McCarthy et al, 2015). PR is a key element of COPD management and was included as a clinical priority in the NHS Long Term Plan (NHS, 2019). Discussions about and referral to PR are now incentivised in the Quality Outcomes Framework COPD templates in GP practices and other initiatives and investment aim to improve access and increase capacity in the service.
PR should be offered to people who are functionally impaired by their COPD or identify as MRC 3 and above (see Table 2) and those who have been hospitalised with an exacerbation. Eligibility needs to include evidence of obstructed spirometry and the person must be physically and mentally capable of completing the programme and able to attend. It is the responsibility of health professionals to ensure patients are aware of the benefits of PR so that maximum uptake is achieved. They also need to explain the level of commitment needed to improve the chance the person will complete the programme so that it is worthwhile to their health and to help reduce drop-out rates. Where post-PR maintenance or volunteer-led classes are not available, patients should be encouraged to continue regular exercise to maintain strength and fitness.
Specialist management and treatment in COPD
Management of COPD requires a holistic and often multidisciplinary approach. Smoking cessation, multi-morbidity management, nutrition, mental wellbeing, oxygen assessment and prescribing, breathing techniques and disease support networks may intermittently or continually be part of COPD management. Referral criteria to respiratory specialist community or secondary care teams will differ region to region and likely will include frequent exacerbations (>2 per year), suspected corpulmonale, rapid decline in lung function and/or progressive or disproportionate breathlessness not responding to interventions (see Table 4). Depending on the concern individual pathophysiology, pheno or endotype, specialist treatments may include prophylactic antibiotic, theophylline, Roflumilast and lung surgery (see Table 4).
Table 4. Potential referral criteria
| Criteria | Reason |
|---|---|
| There is diagnostic uncertaintySuspected severe COPDOnset of cor pulmonale | Confirm diagnosis and optimise therapy |
| Assessment for oxygen therapy | Optimise therapy and measure blood gases |
| Assessment for long-term nebuliser therapy | Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace |
| A rapid decline in FEV1 | Stops for breath after walking 100 yards, or after a few minutes on level ground |
| Assessment for lung volume reduction surgery or lung transplantation | Too breathless to leave the house, or breathless when dressing/undressing |
| Dysfunctional breathing | Confirm diagnosis and access physiotherapy |
| Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiency | Identify alpha-1 antitrypsin deficiency, consider therapy and screen family |
| Symptoms disproportionate to lung function deficit | Look for other explanations including cardiac impairment, pulmonary hypertension, and hyperventilation |
| Frequent infective exacerbations | To exclude bronchiectasis and to access treatments that include azithromyin and roflumilast (phosphodiesterase 4 inhibitor) |
| Haemoptysis | Exclude carcinoma of the bronchus |
| End stage COPD | Access to palliative care |
Key FEV1: Forced expiratory volume in 1 second
Conclusions
Social determinants of health, inequalities, mental health, complex disease and co-existing morbidities all modify the lived experience of COPD and potential for support. Successful therapeutic relationships are crucial and need to take into consideration these factors as well as health beliefs, physical attributes, and goals. People with COPD are likely to have multiple clinical contacts with differing health professionals with variable experience or knowledge. Having a good understanding of the key clinical guidelines, teams and specialisms that exist is key to enhance COPD care that supports self-management.
Key Points
- Bronchodilation is the cornerstone treatment for COPD
- In exacerbation COPD phenotype, triple therapy is preferable in the presence of relevant peripheral eosinophil counts
- Acute exacerbations of COPD are characterised by a change in baseline symptoms, vary in intensity and are treated with an increase in short acting bronchodilation and sometimes with gluco-corticosteroids and antibiotics
- Viruses, including Influenza and COVID-19 are known to impact COPD. Vaccination against these and other diseases as well as Pneumonia should be offered to all people with COPD as per current recommendations
- Pulmonary rehabilitation is a key non-pharmacological treatment in the management of COPD and dyspnoea and should be offered to all people with COPD experiencing functional limitation due to breathlessness or as per local service criteria
- Referral to a respiratory specialist should be considered in patients who would benefit from additional treatment and management of their COPD on a case-by-case basis
CPD reflective questions
- What patients would benefit from inhaled corticosteroids and what key measures would you check before you start them?
- Before prescribing inhalers to your patient, how would you assess that they are able to use them effectively?
- How would you broach a discussion with a patient who is sceptical about vaccination?
- What do you need to learn more about to discuss the benefits and outcomes of engaging with pulmonary rehabilitation?
- Do you know the criteria set by your local specialist respiratory service and/or current national recommendations for referral into respiratory specialist service(s)?