Chronic obstructive pulmonary disease (COPD) - Patient discussions

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.[135] 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.[1]

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. It is estimated that patients with COPD are 1.9 times more likely to commit suicide than those without COPD, and symptoms of anxiety, depression, and frustration are common.[137][138] Studies have found a beneficial effect of cognitive behavioural therapy (CBT) on outcomes including symptoms of depression and anxiety, quality of life, and frequency of emergency department visits.[139][140][141] Further research is warranted into the effects of high-resource-intensive versus low-resource-intensive CBT.[141]

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.[142] 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.[143]

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 an increase in oxygen flow during air travel.

Physical activity is recommended for all patients with COPD and they should be encouraged to maintain it.[1] 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.[153] 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.[251] Other studies have demonstrated improvements in peak oxygen uptake, perceived fatigue, and health-related quality of life following adherence to supervised and unsupervised exercise programmes.[155][156][157] 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.[158] The optimal timing, components, duration, and models for improving physical activity remain unclear. Meta-analyses suggest that yoga, Qigong, and other home-based breathing exercises can improve exercise capacity and pulmonary function in patients with COPD.[159][160][161] Tai Chi has been shown to improve exercise capacity compared to usual care.[162]

Dietary advice and oral supplements have been found to improve body weight, quality of life, respiratory muscle strength and 6-minute walk distance.[163][164] However, nutritional support has not been consistently found to improve lung function.[164]

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.[144][145] Poor technique is more likely when patients are using multiple devices or have never received inhaler technique training.[146] Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[147] Demonstration using a placebo device may be most effective for teaching inhaler technique to adults aged ≥65 years.[148] Patients should be asked to bring their inhalers to clinic to facilitate a review of inhaler use.[1] Pharmacist-led interventions and lay health coaching can improve inhaler technique and adherence in patients with COPD.[149][150] Inhaler device attributes such as rapid onset of symptom relief and small size have been recorded in patient preference studies.[151][152]

Metered dose inhaler

Metered dose inhaler plus spacer

Dry powder inhalers

Soft mist inhaler

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