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.[133]Lenferink A, Brusse-Keizer M, van der Valk PD, et al. Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Aug 4;(8):CD011682.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011682.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/28777450?tool=bestpractice.com
Self-management plans should include personalized 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]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report [internet publication].
https://goldcopd.org/2023-gold-report-2
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 die from suicide than those without COPD, and symptoms of anxiety, depression, and frustration are common.[135]Sampaio MS, Vieira WA, Bernardino ÍM, et al. Chronic obstructive pulmonary disease as a risk factor for suicide: A systematic review and meta-analysis. Respir Med. 2019 May;151:11-18.
https://www.doi.org/10.1016/j.rmed.2019.03.018
http://www.ncbi.nlm.nih.gov/pubmed/31047105?tool=bestpractice.com
[136]Russell S, Ogunbayo OJ, Newham JJ, et al. Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals. NPJ Prim Care Respir Med. 2018 Jan 17;28(1):2.
https://www.doi.org/10.1038/s41533-017-0069-z
http://www.ncbi.nlm.nih.gov/pubmed/29343739?tool=bestpractice.com
Studies have found a beneficial effect of cognitive behavioral therapy (CBT) on outcomes including symptoms of depression and anxiety, quality of life, and frequency of emergency department visits.[137]Pollok J, van Agteren JE, Esterman AJ, et al. Psychological therapies for the treatment of depression in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2019 Mar 6;3:CD012347.
https://www.doi.org/10.1002/14651858.CD012347.pub2
http://www.ncbi.nlm.nih.gov/pubmed/30838649?tool=bestpractice.com
[138]Ma RC, Yin YY, Wang YQ, et al. Effectiveness of cognitive behavioural therapy for chronic obstructive pulmonary disease patients: a systematic review and meta-analysis. Complement Ther Clin Pract. 2020 Feb;38:101071.
http://www.ncbi.nlm.nih.gov/pubmed/31743870?tool=bestpractice.com
[139]Williams MT, Johnston KN, Paquet C. Cognitive behavioral therapy for people with chronic obstructive pulmonary disease: rapid review. Int J Chron Obstruct Pulmon Dis. 2020;15:903-19.
https://www.doi.org/10.2147/COPD.S178049
http://www.ncbi.nlm.nih.gov/pubmed/32425516?tool=bestpractice.com
Further research is warranted into the effects of high-resource-intensive versus low-resource-intensive CBT.[139]Williams MT, Johnston KN, Paquet C. Cognitive behavioral therapy for people with chronic obstructive pulmonary disease: rapid review. Int J Chron Obstruct Pulmon Dis. 2020;15:903-19.
https://www.doi.org/10.2147/COPD.S178049
http://www.ncbi.nlm.nih.gov/pubmed/32425516?tool=bestpractice.com
One randomized controlled trial found that a telephone health coaching intervention to promote behavior 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.[140]Jolly K, Sidhu MS, Hewitt CA, et al. Self management of patients with mild COPD in primary care: randomised controlled trial. BMJ. 2018 Jun 13;361:k2241.
https://www.bmj.com/content/361/bmj.k2241.long
http://www.ncbi.nlm.nih.gov/pubmed/29899047?tool=bestpractice.com
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.[141]Long H, Howells K, Peters S, et al. Does health coaching improve health-related quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease? A systematic review and meta-analysis. Br J Health Psychol. 2019 Sep;24(3):515-46.
https://www.doi.org/10.1111/bjhp.12366
http://www.ncbi.nlm.nih.gov/pubmed/31033121?tool=bestpractice.com
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.
Regular medical follow-up is necessary to optimize the treatment. If there is any worsening of symptoms, immediate medical attention is required.
Optimize the patient's condition prior to air travel and assess their need for inflight oxygen. Advise patients to carry all medications and spacer devices in their hand luggage and have any emergency medications immediately accessible during the flight. Venous thromboembolism prophylaxis may be required, especially for longer flights. Patients on continuous oxygen therapy may need an increase in oxygen flow during air travel.[190]British Thoracic Society. Air travel. March 2022 [internet publication].
https://www.brit-thoracic.org.uk/quality-improvement/clinical-statements/air-travel
Physical activity is recommended for all patients with COPD and they should be encouraged to maintain it.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report [internet publication].
https://goldcopd.org/2023-gold-report-2
One systematic review and meta-analysis of randomized 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 counseling.[151]Lahham A, McDonald CF, Holland AE. Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials. Int J Chron Obstruct Pulmon Dis. 2016 Dec 8;11:3121-36.
https://www.dovepress.com/exercise-training-alone-or-with-the-addition-of-activity-counseling-im-peer-reviewed-fulltext-article-COPD
http://www.ncbi.nlm.nih.gov/pubmed/27994451?tool=bestpractice.com
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.[254]Iepsen UW, Jørgensen KJ, Ringbæk T, et al. A combination of resistance and endurance training increases leg muscle strength in COPD: An evidence-based recommendation based on systematic review with meta-analyses. Chron Respir Dis. 2015 May;12(2):132-45.
https://www.doi.org/10.1177/1479972315575318
http://www.ncbi.nlm.nih.gov/pubmed/25767138?tool=bestpractice.com
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.[153]Ward TJC, Plumptre CD, Dolmage TE, et al. Change in VO2peak in response to aerobic exercise training and the relationship with exercise prescription in people with COPD: a systematic review and meta-analysis. Chest. 2020 Jul;158(1):131-14.
https://www.doi.org/10.1016/j.chest.2020.01.053
http://www.ncbi.nlm.nih.gov/pubmed/32173489?tool=bestpractice.com
[154]Paneroni M, Vitacca M, Venturelli M, et al. The impact of exercise training on fatigue in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Pulmonology. 2020 Sep - Oct;26(5):304-13.
http://www.ncbi.nlm.nih.gov/pubmed/32184070?tool=bestpractice.com
[155]Taylor D, Jenkins AR, Parrott K, et al. Efficacy of unsupervised exercise in adults with obstructive lung disease: a systematic review and meta-analysis. Thorax. 2021 Jun;76(6):591-600.
http://www.ncbi.nlm.nih.gov/pubmed/33685962?tool=bestpractice.com
A Cochrane review found limited evidence for improvement in physical activity with physical activity counseling, exercise training, and pharmacologic management of COPD. The authors commented that assessment of quality had been limited by lack of methodologic detail and the diverse range of interventions had primarily been assessed in single studies.[156]Burge AT, Cox NS, Abramson MJ, et al. Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2020 Apr 16;4:CD012626.
https://www.doi.org/10.1002/14651858.CD012626.pub2
http://www.ncbi.nlm.nih.gov/pubmed/32297320?tool=bestpractice.com
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Which interventions lead to increased regular physical activity for people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.3155/fullShow me the answer 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.[157]Cramer H, Haller H, Klose P, et al. The risks and benefits of yoga for patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Clin Rehabil. 2019 Dec;33(12):1847-62.
http://www.ncbi.nlm.nih.gov/pubmed/31353959?tool=bestpractice.com
[158]Tong H, Liu Y, Zhu Y, et al. The therapeutic effects of qigong in patients with chronic obstructive pulmonary disease in the stable stage: a meta-analysis. BMC Complement Altern Med. 2019 Sep 4;19(1):239.
https://www.doi.org/10.1186/s12906-019-2639-9
http://www.ncbi.nlm.nih.gov/pubmed/31484521?tool=bestpractice.com
[159]Lu Y, Li P, Li N, et al. Effects of home-based breathing exercises in subjects with COPD. Respir Care. 2020 Mar;65(3):377-87.
https://www.doi.org/10.4187/respcare.07121
http://www.ncbi.nlm.nih.gov/pubmed/31719191?tool=bestpractice.com
Tai Chi has been shown to improve exercise capacity compared to usual care.[160]Liu X, Fu C, Hu W, et al. The effect of Tai Chi on the pulmonary rehabilitation of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Ann Palliat Med. 2021 Apr;10(4):3763-82.
https://www.doi.org/10.21037/apm-20-940
http://www.ncbi.nlm.nih.gov/pubmed/33894710?tool=bestpractice.com
Dietary advice and oral supplements have been found to improve body weight, quality of life, respiratory muscle strength and 6-minute walk distance.[161]Collins PF, Elia M, Stratton RJ. Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology. 2013 May;18(4):616-29.
https://www.doi.org/10.1111/resp.12070
http://www.ncbi.nlm.nih.gov/pubmed/23432923?tool=bestpractice.com
[162]Ferreira IM, Brooks D, White J, et al. Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD000998.
https://www.doi.org/10.1002/14651858.CD000998.pub3
http://www.ncbi.nlm.nih.gov/pubmed/23235577?tool=bestpractice.com
However, nutritional support has not been consistently found to improve lung function.[162]Ferreira IM, Brooks D, White J, et al. Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD000998.
https://www.doi.org/10.1002/14651858.CD000998.pub3
http://www.ncbi.nlm.nih.gov/pubmed/23235577?tool=bestpractice.com
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.[142]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80.
https://www.doi.org/10.15326/jcopdf.6.3.2018.0168
http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com
[143]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8.
https://www.doi.org/10.1016/j.rmed.2011.01.005
http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com
Poor technique is more likely when patients are using multiple devices or have never received inhaler technique training.[144]Rootmensen GN, van Keimpema AR, Jansen HM, et al. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv. 2010 Oct;23(5):323-8.
http://www.ncbi.nlm.nih.gov/pubmed/20804428?tool=bestpractice.com
Demonstration of inhaler use by a clinician, device selection, and reviewing technique at subsequent appointments can improve inhaler technique.[145]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018;13:695-702.
https://www.doi.org/10.2147/COPD.S149404
http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com
Demonstration using a placebo device may be most effective for teaching inhaler technique to adults ages ≥65 years.[146]Maricoto T, Monteiro L, Gama JMR, et al. Inhaler technique education and exacerbation risk in older adults with asthma or chronic obstructive pulmonary disease: a meta-analysis. J Am Geriatr Soc. 2019 Jan;67(1):57-66.
http://www.ncbi.nlm.nih.gov/pubmed/30291745?tool=bestpractice.com
Patients should be asked to bring their inhalers to clinic to facilitate a review of inhaler use.[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report [internet publication].
https://goldcopd.org/2023-gold-report-2
Pharmacist-led interventions and lay health coaching can improve inhaler technique and adherence in patients with COPD.[147]Jia X, Zhou S, Luo D, et al. Effect of pharmacist-led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: a systematic review and meta-analysis. J Clin Pharm Ther. 2020 Oct;45(5):904-17.
https://www.doi.org/10.1111/jcpt.13126
http://www.ncbi.nlm.nih.gov/pubmed/32107837?tool=bestpractice.com
[148]Willard-Grace R, Chirinos C, Wolf J, et al. Lay health coaching to increase appropriate inhaler use in COPD: a randomized controlled trial. Ann Fam Med. 2020 Jan;18(1):5-14.
https://www.doi.org/10.1370/afm.2461
http://www.ncbi.nlm.nih.gov/pubmed/31937527?tool=bestpractice.com
Inhaler device attributes such as rapid onset of symptom relief and small size have been recorded in patient preference studies.[149]Navaie M, Dembek C, Cho-Reyes S, et al. Inhaler device feature preferences among patients with obstructive lung diseases: A systematic review and meta-analysis. Medicine (Baltimore). 2020 Jun 19;99(25):e20718.
https://www.doi.org/10.1097/MD.0000000000020718
http://www.ncbi.nlm.nih.gov/pubmed/32569208?tool=bestpractice.com
[150]Tervonen T, Hawken N, Hanania NA, et al. Maintenance inhaler therapy preferences of patients with asthma or chronic obstructive pulmonary disease: a discrete choice experiment. Thorax. 2020 Sep;75(9):735-43.
https://www.doi.org/10.1136/thoraxjnl-2019-213974
http://www.ncbi.nlm.nih.gov/pubmed/32631932?tool=bestpractice.com
Metered dose inhalerA principal pharmacist shows a patient how to use a metered dose inhaler and discusses ways of improving inhaler technique.
Metered dose inhaler plus spacerA principal pharmacist shows a patient how to use a metered dose inhaler plus a spacer and discusses ways of improving inhaler technique.
Dry powder inhalersA principal pharmacist shows a patient how to use dry powder devices and discusses ways of improving inhaler technique.
Soft mist inhalerA principal pharmacist shows a patient how to use a soft mist inhaler and discusses ways of improving inhaler technique.