Management of stable chronic obstructive pulmonary disease Karen Grindrod

Service Manager and Specialist Respiratory Nurse, Croydon Respiratory Team, Croydon Health Services NHS Trust   Email: [email protected]


Chronic obstructive pulmonary disease (COPD) is a common condition. There are an estimated 3 million cases in the UK. Of these, 2 million have not got a formal diagnosis. Community nurses meet patients with COPD frequently, although COPD may not be the primary reason for the encounter, or the COPD may be present but undiagnosed. The number of patients with COPD is believed to be increasing and, with increased awareness of the condition and an emphasis on improving diagnosis, the number of cases is expected to rise. Community nurses are well placed to raise concerns that a patient in their care may have undiagnosed COPD; if the condition is subsequently diagnosed and appropriate treatment is given, outcomes will improve for that individual. Community nurses can also support patients and their families to manage the condition through all stages of the disease trajectory, from diagnosis to the end-of-life phase.


w COPD w Pathophysiology w Symptoms w Diagnosis w Comorbidities


Background COPD is an umbrella term that includes emphysema, chronic bronchitis and chronic asthma. COPD is characterised by airflow obstruction caused by a narrowing of the airways that is not fully reversible. The disease is usually progressive. It gets worse over time, especially if exposure to noxious agents (usually tobacco smoking) continues (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2014) (see Table  1). Exacerbations or ‘flare-ups’ can occur; during these episodes, there is a rapid and significant deterioration of symptoms beyond the normal variation that can occur from day to day (GOLD, 2014). Flare-ups are important because they require extra treatment and possibly admission to hospital. Recovery time after an exacerbation can be up to 6  weeks and a full recovery may never be achieved—exacerbations can contribute to a more rapid decline in lung function and lead to death.

Pathophysiology The airflow obstruction seen in COPD is due to a combination of damage to the small airways and the lung parenchyma (NICE, 2010; GOLD, 2014). Narrowing of the small airways occurs as a result of chronic inflammation: the bronchiole walls become oedematous, there is increased mucus production and a reduction in the number of cilia, which usually help clear the airways of mucus resulting in pooling of secretions. The supporting tissues within the lungs are destroyed; there is a loss of elastic lung recoil, leading to collapse of the airways during expiration, which results in air being trapped in the alveoli. The alveoli are destroyed, resulting in air spaces (bullae) forming in the lungs. There is a loss of surface area and the alveolar capillary interface is damaged, leading to a reduction in gas exchange. In rare cases, COPD is caused by alpha-1-antitrypsin deficiency (see Box 1).

Diagnosis Accurate diagnosis of COPD is essential if correct and timely treatment is to be implemented. Suspicion of COPD is aroused by presence of symptoms, history of smoking or exposure to another risk factor, and diagnosis is made by a combination of physical examination, history and postbronchodilator spirometry. The symptoms of COPD are progressive breathlessness

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ome studies have suggested that the district nursing workforce has little contact with patients in the latter stages of non-malignant diseases, such as chronic obstructive pulmonary disease (COPD), if the patients do not have any other specific nursing needs (Disler and Jones, 2010a). However, with an increasing amount of care taking place in the home and patients with increasing comorbidities, it is now likely that many district nurses provide care for people living with COPD (including the end stages of the disease) and other conditions. This is particularly true for end-of-life care if patients wish to stay at home. There is research evidence that community nurses may lack confidence in their ability to interact with people living with advanced COPD (Disler and Jones, 2010b). As a result, there is a need for support and training to help community nurses feel more confident caring for patients with COPD in order to improve outcomes (Disler and Jones, 2010a). Furthermore, the majority of nurses lack professional confidence in facilitating self-management in patients with chronic conditions (Wilson et al, 2006). The aim of this article is to aid the understanding of COPD and to give an overview of the treatments available. The article provides an update on managing stable COPD, as underpinned by guidance from the National Institute for Health and Care Excellence (NICE) (2010).

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Occupational or environmental


Primary care treatment

Genetic: alpha-1-antitrypsin deficiency or similar


COPD and its comorbidities cannot be cured; however, if it is diagnosed early, and appropriate treatment is commenced, progression can be prevented or slowed. Treatment is ongoing and can be effective in relieving symptoms, reducing exacerbations, improving exercise tolerance and enhancing quality of life (GOLD, 2014). Stopping smoking is beneficial at any point during the disease trajectory, even when disease is advanced. Support to stop smoking is available through GP surgeries, community pharmacies and specialist services. It is important to know what is available in your area so that patients can be signposted for this important intervention. Continuing to smoke causes further damage to the lungs and may render some treatments less effective. Individuals who continue to smoke should be encouraged to stop and offered help to do so at every opportunity (NICE, 2010).

Source: Fletcher (2010)

Box 1. Alpha-1-antitrypsin deficiency Alpha-1-antitrypsin deficiency (A1AD) is a rare genetic cause of COPD. A1AD is an enzyme that has a protective effect on the lungs; in patients with a deficiency of the enzyme, the lungs are much more susceptible to the damaging effects of tobacco smoke. Individuals with A1AD who smoke are more likely to develop severe emphysema at an early age. Emphysema can also occur in non-smokers with A1AD. Source: Kenny (2012)

(initially on exertion or during a respiratory infection), cough, chronic sputum production, frequent winter bronchitis and wheezing (NICE, 2010).

Comorbidities that commonly present in COPD COPD is a multisystem disease and patients often have complex health issues and social needs (Fletcher and Dahl, 2013). One study showed that almost 97% of adults with COPD had at least one other condition that could complicate treatment of the COPD (Schnell et al, 2012). The study also found that nearly 52% of people with COPD over the age of 45 years were taking more than four medications (Schnell et al, 2012). The presence of comorbidities and polypharmacy presents a challenge for health professionals looking after patients with COPD who must determine the best treatment for an individual in the context of other medical conditions and medications. Among patients with COPD, it is suggested that (Fletcher, 2010): w Heart disease also affects 40% w Diabetes also affects 10% w Between 17% and 42% of people with COPD have high

Table 2. Medical Research Council dyspnoea scale 1

Not troubled by breathlessness except with strenuous exercise


Short of breath when hurrying or walking up a slight hill


Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace


Stops for breath after walking about 100 metres or after a few minutes on level ground


Too breathless to leave the house, or breathless when dressing or undressing

Source: Fletcher (1952); National Institute for Health and Care Excellence (2010)


blood pressure w Between 2% and 19% of people have osteoporosis w Between 18% and 22% of people have depression.

Exercise and pulmonary rehabilitation Pulmonary rehabilitation is a programme of exercise, education, psychosocial support and nutritional advice tailored to the individual’s needs. It encourages self-management and can help to improve exercise ability and reduce breathlessness. It also affects quality of life favourably and can lead to reduced use of health-care resources (Tidy, 2010). The Medical Research Council (MRC) dyspnoea scale (Table  2) can be used to assess the degree of disability caused by an individual’s breathlessness. Community nurses may find it useful to use the score to grade the level of breathlessness of patients they care for. It can be a useful tool to help monitor a patient’s condition, particularly in teams where it can be used to highlight deterioration in a patient’s condition. Individuals with an MRC score of 1 or 2 should be encouraged to exercise every day. Some areas have exercise prescription programmes that may be suitable.

Community nursing and pulmonary rehabilitation Pulmonary rehabilitation is recommended for patients with an MRC score of 3 or higher (NICE, 2010). Community nurses can refer patients into pulmonary rehabilitation classes; they are encouraged to find out the referral criteria for services available in their area. Patients with COPD are often reluctant to attend classes. They may have become used to staying at home and have lost confidence in going out. If they do attend, they often experience a significant improvement in their symptoms and self-confidence. A number of British Lung Foundation (BLF) ‘Singing for Health’ groups offer patients with respiratory conditions an opportunity to meet and sing together. These groups are a useful adjunct to conventional therapy, particularly when offered as part of pulmonary rehabilitation programmes. Singing classes have proved beneficial for patients with COPD by improving quality of life measures beyond those achieved by participating in a group activity (Lord et al, 2012); there is also evidence

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Table 1. Causes of COPD in the UK

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CLINICAL FOCUS of improvement in lung function (Morrison et al, 2013). BLF ‘Breathe Easy’ groups are run locally by members to provide support for patients with all respiratory conditions. Groups usually run monthly; the programme is designed by the members and may include talks from health professionals about local services and self-management and may also include visits to the theatre and places of interest. These groups also provide an opportunity for service users to engage with the commissioning and delivery of health services. District nurses can use this resource for their own patients and their carers by signposting them to the groups for support.

Influenza and pneumococcal vaccine Vaccinations to prevent influenza and pneumonia are recommended by the Chief Medical Officer to reduce the risk of chest infection leading to an exacerbation of COPD (Public Health England, 2014a; 2014b). District nurses are pivotal in promoting and delivering vaccines to housebound patients.

Inhalers Inhalers are prescribed according to national and local guidelines. The latest guidelines published by NICE (2010) recommend that treatment with inhaled medication follows a stepwise approach. Inhaled treatments are usually initiated by the patient’s GP. When choosing inhalers, factors to consider include the following: w Symptoms w Disease severity w Exacerbation history w Patient preference w Patient ability to use device w Side effects w Cost. District nurses are frequently required to administer medicines and inhalers for people living with COPD. This may mean supervising or direct administration of medications and inhalers. The community nurse’s role is to determine which inhalers have been prescribed and whether they are being used correctly. This includes checking inhaler technique and recognising when a change in a patient’s condition may mean they are unable to use an inhaler that they were previously able to use—for example, due to worsening lung function and a reduction in inspiratory flow. If a patient cannot use their inhaler or it is not working despite being used as prescribed, they should be referred back to their GP or to the specialist team for a review of their treatment. Table 3 explains how disease severity is graded in COPD.

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Stepwise approach The stepwise approach enables the community nurse to understand how treatment options for people living with COPD have been selected. This is summarised in Figure 1.

Step 1 A short-acting bronchodilator (either a short-acting beta agonist (SABA) or a muscarinic antagonist (SAMA)) is prescribed to be used when needed to relieve breathlessness associated with activity. A potential problem with this approach is that

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Table 3. COPD disease severity Post-bronchodilator FEV1/FVC ratio

FEV1% predicted

NICE (2010) clinical guideline

Management of stable chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a common condition. There are an estimated 3 million cases in the UK. Of these, 2 million have not got...
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