All patients should be well educated about the disease course and symptoms of exacerbation or decompensation. Their expectation of the disease, treatment, and prognosis should be realistic. It is important to remember that no medicine has been shown to modify the long-term decline in lung function, and the primary goal of pharmacotherapy is to control symptoms and prevent complications.
One Cochrane review found that self-management interventions that include an action plan for acute exacerbations of COPD are associated with improvements in health-related quality of life and fewer admissions to hospital for respiratory problems. An exploratory analysis found a small, but significantly higher, respiratory-related mortality rate for self-management compared to usual care, although no excess risk of all-cause mortality was seen. Self-management plans should include personalised advice on: breathlessness and stress management techniques, energy conservation, avoiding aggravating factors, how to monitor symptoms, how to manage worsening symptoms, and contact information to use in the event of an exacerbation.
Helping patients to self-manage should ideally address psychosocial concerns and patients’ personal beliefs about COPD and its management. Many patients report losses and limitations on their lifestyle and social interaction after a diagnosis of COPD. Symptoms of anxiety, depression, and frustration are common. A systematic review found a small beneficial effect of cognitive behavioural therapy-based psychological treatment and symptoms of depression, compared with education or no intervention, although the evidence was limited by heterogeneity between trials and inability to blind participants and researchers to the intervention.
One randomised controlled trial found that a telephone health coaching intervention to promote behaviour change in patients with mild COPD in primary care led to improvements in self-management activities, but did not improve health-related quality of life. A meta-analysis found that health coaching that included goal setting, motivational interviewing, and COPD-related health education significantly improved health-related quality of life and reduced hospital admissions for an exacerbation of COPD, but did not decrease all-cause hospital admissions.
Patients should stay as healthy and active as possible. It is necessary to stop active or passive smoking and avoid environmental exposure to toxic fumes.
Motivational interviewing overview
Motivational interviewing: smoking cessation part 1
Motivational interviewing: smoking cessation part 2
Regular medical follow-up is necessary to optimise the treatment. If there is any worsening of symptoms, immediate medical attention is required. Patients on continuous oxygen therapy may need increase in oxygen flow during air travel.
Physical activity is recommended for all patients with COPD and they should be encouraged to maintain it. One systematic review and meta-analysis of randomised controlled trials found that exercise training on its own can improve physical activity in COPD, and greater improvements can be made with the addition of physical activity counselling. Another systematic review and meta-analysis found that a combination of aerobic exercise and strength training was more effective than aerobic exercise alone in increasing leg muscle strength, but there was no difference between the groups in health-related quality of life, walking distance, or exercise capacity. A Cochrane review found limited evidence for improvement in physical activity with physical activity counselling, exercise training, and pharmacological management of COPD. The authors commented that assessment of quality had been limited by lack of methodological detail and the diverse range of interventions had primarily been assessed in single studies. The optimal timing, components, duration, and models for improving physical activity remain unclear. Meta-analyses suggest that yoga and Qigong can improve exercise capacity and pulmonary function in patients with COPD.
Patients who use inhaled therapies should receive training on inhaler device technique. The majority of patients make at least one error in using their inhaler and incorrect inhaler use is associated with worse disease control. Poor technique is more likely when patients are using multiple devices or have never received inhaler technique training. Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique. Demonstration using a placebo device may be most effective for teaching inhaler technique to adults aged ≥65 years. Patients should be asked to bring their inhalers to clinic to facilitate a review of inhaler use. Pharmacist-led interventions and lay health coaching can improve inhaler technique and adherence in patients with COPD.
Metered dose inhaler
Metered dose inhaler plus spacer
Dry powder inhalers
Soft mist inhaler
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