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There are 500,000 people in the country living with chronic obstructive pulmonary disease (COPD), of whom approximately 200,000 have significant disease, according to the Department of Health. The Department also states that exacerbations of COPD are the most common medical cause of admission to our hospitals. We appear to have a particular problem with COPD in this country in that we have the highest rate of admissions in the OECD for exacerbations of COPD and have one of the highest mortality rates in Western Europe with the disorder. Clearly, in these circumstances, it is appropriate to review our management of this disorder.
There are four principal components to the managements of the disease. First of all, an accurate diagnosis is required. Secondly, the most appropriate therapy needs to be considered. As inhalers are central to the treatment of COPD, the patient will require instruction in their use. Finally, patients with COPD are at risk of exacerbations and in each patient the risk of exacerbations needs to be assessed and an action plan devised for that patient to act on in the event of a crisis.
Spirometry is essential for the diagnosis of COPD. Unfortunately, spirometry is not widely available in primary care in Ireland. Most patients with COPD initially present to their GPs and we know that only 20 per cent of GPs have access to a spirometer. The performance of spirometry takes time and the skill tends to wane with lack of use. Sending the patient to the hospital for confirmation of diagnosis of spirometry is not easy for the patient and should not be necessary. To try and address this, various initiatives have been promulgated over the last few years. In particular, a limited number of new respiratory integrated nurses and physiotherapists are carrying out spirometry in the community and such a service needs to be more widespread.
Once a diagnosis is made, the clinician is now faced with a plethora of new devices and inhalers for the patient to take. There are principally three classes of drugs used to treat COPD:
Long-acting muscarinic agents (LAMAs).
Long-acting beta agonists (LABAs).
Inhaled corticsteroids (ICS).
However, these medications are available both singly and in combinations, with combinations of LABA/LAMA and LABA/ICS being common. In the near future, there will be a combination of the three drugs available. Faced with such a confusing array of possibilities, the clinician often finds it difficult to make the ideal choice for a patient.
A further complication is that there has been much confusion between the asthmatic and the COPD patient. Differentiation between the two is important. In asthma clearly ICS are the cornerstone of treatment, whereas in COPD there is a very limited role for these drugs. There are obviously some patients who may have an overlap of asthma and COPD and the differentiation can be difficult. Factors that might support a diagnosis of asthma include a shorter smoking history, early onset of symptoms in life, marked variability in symptoms and obviously, if a patient has spirometry, the presence of reversibility would favour a diagnosis of asthma. If there is not an asthmatic component to the disorder, then inhaled ICS are unlikely to be of benefit and we are now increasingly aware of the risks of long-term use of these agents. There has been an increasing awareness of ICS producing pulmonary infections including pneumonia, but obviously they can accentuate the co-morbidities that go with COPD such as osteoporosis.
In starting off treatment, therefore, it is appropriate to commence with a LAMA or a LABA and at the moment, the burden of evidence would support commencing with the LAMA first. They have the most demonstrated efficacy in preventing exacerbations and improving dyspnoea in patients with COPD. If a LAMA on its own fails to provide enough improvement in dyspnoea it would be appropriate to add in a LABA, preferably using one of the new combination LABA/LAMA agents.
The question arises as to when ICS should be introduced. It is important to be aware that there is no evidence to date demonstrating that the addition of an ICS to a LABA/LAMA combination has been proven to reduce the risk of a patient with COPD getting an exacerbation. When this information is added to the fact that there are significantly increased costs, but more importantly, side effects to adding in ICS to the treatment regimen of a patient with COPD, it is important to make sure that this is not done lightly. Patients who should be considered for ICS would be those who are experiencing frequent exacerbations and have very significant reduction in lung function.
Consideration should also be given to stopping ICS when there does not appear to be any benefit. If a patient is on triple therapy with the LAMA/LABA and ICS, it is reasonable to consider stopping the ICS if the patient is stable and there are no features to suggest that the patient may have underlying asthma, such as mentioned above.
There has been much recent research assessing whether mildly elevated eosinophils may predict patients with COPD who respond to steroids, but no further conclusions can be taken from this data yet. There is no doubt that a LABA/LAMA combination is superior to a LABA/ICS combination in protecting a patient against exacerbations.
Once a particular inhaler drug is chosen for a patient, the issue of drug delivery and compliance arises. We know that patients who are on medication in many chronic diseases have poor compliance with ongoing therapy. Some studies have demonstrated a compliance rate as low as 50 per cent in patients taking medication for cardiac disorders.
In COPD we have the added problem that not alone does the patient have to take the medication, but they have to use the delivery device effectively. This is especially the case as many patients with COPD are elderly or may find certain devices difficult to operate. There are many potential devices offering different delivery solutions, but metered dose inhalers (MDI) are probably the most inefficient. The clinician in conjunction with the patient must make the best assessment of which device suits a particular patient. Ease of use together with patient preference are important factors. The device needs to be demonstrated to the patient and the patient needs to be supervised in its use, both in the initial visit and follow-up visits. Again, this is an onerous part of the care of a COPD patient. Nonetheless, it is an important part and one that would benefit from the input of nurse colleagues to ensure it is adequately delivered.
As mentioned, exacerbations are an important complication of COPD. Patients who experience exacerbations have a greater reduction in lung function, poorer quality-of-life and obviously more need for interaction with healthcare services. Exacerbations are also a significant predictor of mortality in patients with COPD, with one study showing that 50 per cent of patients admitted to hospital following a first exacerbation were dead at 3.6 years, a figure comparable to many cancers.
The patient with COPD who is at risk from exacerbation needs to know what to do when they get one. It is reasonable to give such patients prescriptions for steroids and antibiotics to take in the event of such a crisis occurring. A five-day course of prednisone at a 30-40mg dose depending on weight is reasonable for such patients. The majority – 70 per cent – of exacerbations are associated with infection and some of these infections may well be viral. Extrapolating from this, it suggests that exacerbations do not always need to be treated with antibiotics, but it can be difficult to determine which ones are infective and which ones are not. In those circumstances, it is more important than ever to ensure that over usage of antibiotics does not take place. It is reasonable to allow the patient to take an antibiotic with a limited spectrum, such as a macrolide, doxycycline or amoxicillin. More broad-spectrum antibiotics should certainly be kept in reserve for treating exacerbations that have failed to resolve.
Other aspects of the management of COPD that are also very important
Smoking is clearly a major cause of COPD, but 10 per cent of COPD patients have never smoked and 30 per cent are ex-smokers. For those that are still smoking it is important that they be aware that they should try and stop, and support is given in the way of nicotine replacement therapy or other pharmacological support to those that are attempting to quit. It is important to remind patients to get their annual flu shot and it is also reasonable for them to get pneumococcal vaccination.
Patients and their relatives are often very enthusiastic to obtain oxygen for patients with COPD. Under certain criteria oxygen can certainly prolong life, but there has been no proven benefit for patients who are prescribed oxygen for COPD who have only got mild hypoxaemia, nocturnal desaturation or desaturation on exercise. Oxygen in these circumstances can often inhibit a patient from exercising. Exercise itself is an important component in the treatment of COPD, both on its own and in combination with a formal pulmonary rehabilitation programme. It is known, for instance, that patients who are discharged from hospital, who exercise more than a control group, will have less likelihood of being readmitted to hospital with exacerbations. Pulmonary rehabilitation is well documented to improve the exercise capacity of patients, together with quality-of-life, and reduce the risk of being re-admitted following an exacerbation.
However, the capacity available for pulmonary rehab in Ireland is very poor and taking all the capacity in the system for patients who would require pulmonary rehabilitation post-exacerbation would only provide access for 10 per cent of such patients and of course do nothing for the vast numbers of patients who are experiencing ongoing dyspnoea from their COPD.