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|Key Components of the COPDX plan
- Confirm diagnosis and assess severity by the use of spirometry and
measurements of functional impairment
- Optimise function by relief of symptoms, increasing wellbeing and
reducing the number and severity of exacerbations and complications
- Prevent deterioration by smoking cessation and reduction of exposure
to other harmful inhaled fumes and particles
- Develop support network and self management plan
- Manage eXacerbations promptly and appropriately
Managing COPD continues to be a major feature of primary care, particularly in practices with a high
proportion of Māori and Pacific peoples.
COPDX clinical practice guidelines provide a useful framework for the diagnosis and management of COPD.1,2 Here
is a reminder of the COPDX framework and an update of recent evidence on COPD management based on a 2007 report by the
Canadian Thoracic Association.3
Smoking cessation is still the only intervention that slows deterioration in lung function. However, the roles of other
interventions, such as long acting beta-2 agonists (LABAs), aminophylline, inhaled steroids and tiotropium, are evolving
as new evidence becomes available.
Confirm diagnosis and address severity
Table 1 Canadian Lung Association suggestions for selection
Offer spirometry to current or ex-smokers who are aged over 40 years and answer yes to any of the following questions.
- Do you cough regularly?
- Do you cough up phlegm regularly?
- Do even simple chores make you short of breath?
- Do you wheeze when you exert yourself or at night?
- Do you get frequent colds that persist longer than those of other people?
Spirometry remains key to confirming the diagnosis and assessing the severity of COPD. There are no evidence-based criteria
on which to select people for spirometry but the Canadian Lung Association’s suggestions seem reasonable (Table 1).
Bronchodilators are useful for people with moderate to severe COPD
Bronchodilators currently form the mainstay of pharmacological therapy for people with moderate to severe COPD. They
improve expiratory flow and lung emptying thereby reducing air trapping and hyperinflation. However there is little information
available on their efficacy for people with mild COPD (FEV1 > 65% of predicted).
Short acting bronchodilators
Short acting bronchodilators, both the beta-2 agonists such as salbutamol and anti-cholinergics such as ipratropium,
improve pulmonary function, dyspnoea and exercise performance in moderate to severe COPD. Individual responses to different
classes are variable. Using both classes together often produces a superior response.
Special Authority Criteria for Tiotroprium
In New Zealand, for special authority for subsidy of tiotropium, ALL of the following criteria must
- To be used for the long-term maintenance treatment of bronchospasm and dyspnoea associated with COPD
- In addition to standard treatment, the patient has trialled a dose of at least 40 micrograms ipratropium q.i.d
for one month
- Any of the following:
The patient’s breathlessness according to the Medical Research Council (UK) dyspnoea scale is
- Grade 4 (stops for breath after walking about 100 metres or after a few minutes on the level) or;
- Grade 5 (too breathless to leave the house, or breathless when dressing or undressing)
- Actual FEV1 (litres) < 0.6 × predicted FEV1 (litres)
- The patient is not a smoker (for reporting purposes only) or;
- The patient is a smoker and has been offered smoking cessation counselling
- The patient has been offered annual influenza immunisation.
The effects of daily tiotropium on pulmonary function, chronic activity-related dyspnoea and quality of life is more
sustained than four times per day ipratropium and adherence may be better. Short-term studies have shown it to be as effective,
or more effective than LABAs, but long-term comparisons are not yet available.
N.B. Patients perscribed tiotropium should have their ipratropium discontinued. Combinations such as Combivent include
Combivent is no longer funded; it has been replaced by Duolin HFA. See "News in brief", BPJ 34 (February, 2011).
Long acting beta-2 agonists.
LABAs produce more sustained improvements in pulmonary function, chronic dyspnoea and quality of life than short acting
bronchodilators in moderate to severe COPD. Their effect on exercise performance has not yet been consistently demonstrated.
LABA / tiotropium combinations
Combination of these two classes of long acting bronchodilators may improve pulmonary function in severe COPD.
Oral theophyllines are relatively weak bronchodilators; they may offer some additional effects when added to inhaled
bronchodilators in chronic COPD management. However, theophylline has significant adverse effects and drug interactions
and changes in smoking habits can alter blood concentrations of theophylline.
Inhaled corticosteroids may reduce exacerbation rates
Inhaled corticosteroids (ICS) do not reduce the decline of lung function in COPD but may reduce the severity or frequency
The place of ICS in combination with LABAs is still not clear. Salmeterol plus fluticasone does not appear to reduce
mortality rates compared to placebo but the combination does appear to reduce exacerbation rates and improve lung function.
Addition of this combination to tiotropium does not appear to reduce exacerbation rates but may improve lung function,
quality of life and exacerbation rates.
Opioids may help relieve severe intractable dyspnoea and are the most effective dyspnoea relieving medication in end
of life care.
Long-term oral corticosteroids not appropriate
Long-term treatment with oral corticosteroids is not appropriate for COPD as there is little evidence of benefit and
substantial risk of systemic adverse effects.
Long term domiciliary oxygen therapy
Long-term continuous oxygen is beneficial for patients with stable COPD with severe hypoxaemia. However, there is no
evidence to justify the widespread use of ambulatory oxygen or support the use of nocturnal oxygen to improve survival,
sleep quality or quality of life for patient with isolated nocturnal desaturation.
Exercise and pulmonary rehabilitation
Pulmonary rehabilitation programmes are the most effective interventions for improving dyspnoea, exercise capacity and
quality of life. These improvements are largely attributed to the exercise components of the programmes. Aerobic exercise
of the lower limbs and strength training are both beneficial.
In 2006, Māori aged 45 years or over had a COPD hospitalisation rate four
times that of non- Māori from the same age group. In addition, for this age group COPD mortality rates were over
three times higher for Māori than for non-Māori. The relative risk increase was greatest for females for
both hospitalisation and mortality rates. Māori females had a COPD hospitalisation rate almost five times that
of non-Māori females.4
Māori have an increased smoking prevalence rate compared to non-Māori. See Update
of New Zealand smoking cessation guideline in this issue
All people with COPD should be encouraged to maintain an active lifestyle and whenever possible, stable patients who
remain dyspnoeic despite optimal medication, should be referred for pulmonary rehabilitation.
Smoking cessation and reducing exposure to other inhaled noxious substances remain the only interventions which will
slow the rate of deterioration of lung function in COPD (see here for smoking cessation update).
Influenza immunisation reduces the risk of hospitalisation by approximately 40% in people with chronic respiratory disease.
The evidence for pneumococcal immunisation is less well established but is likely to be beneficial.
Develop support network and self management plan
Quality of life is improved for people with COPD who get good psychosocial support. Components of a COPD self-management
plan should include:
- Reminder of day to day medications
- Nutritional advice with supplementation for some people
- Lifestyle tips to improve functional status and avoid exacerbations
- Early recognition of exacerbations
- Prompt response to exacerbations, including self-medication
Management of exacerbations
A wide range of comorbidities may confuse the diagnosis of exacerbations of COPD. Once a confident diagnosis has been
made, most exacerbations can be managed at home.
Giving short acting inhaled beta-2 agonists plus ipratropium is recommended in an acute exacerbation to relieve dyspnoea
by improving airway function and reducing hyperinflation.
Oral prednisone at an individualised dose of approximately 40mg daily for seven to 14 days has good evidence of efficacy
in moderate to severe acute exacerbations of COPD. They are more effective if given early and people who have exacerbations
should maintain a home supply.
| Table 2 Risk factors in COPD exacerbation
- FEV1 <50% predicted
- Greater than four exacerbations per year
- Ischaemic heart disease
- Use of home oxygen
- Chronic oral corticosteroid use
- Antibiotic use in previous three months
Oral antibiotics are beneficial in acute exacerbations of COPD and, as with prednisone, people who have exacerbations
should maintain a home supply.
For simple exacerbations (increased cough, sputum, purulence and dyspnoea) in people without risk factors, first choice
antibiotics are amoxycillin, doxycycline or erythromycin.
If the exacerbation is complicated by risk factors (see Table 2), amoxycillin/clavulanic acid or another suitable antibiotic,
such as a fluoroquinolone, are more appropriate.
Aminophylline is no longer recommended for acute COPD exacerbations. It produces no clinically significant benefit and
significantly increases nausea.2
COPD is likely to remain a major problem in primary care for some years to come. Tobacco smoking is the most common
cause of COPD and around 23% of New Zealanders smoke tobacco. The prevalence is higher among Māori (46%) and Pacific
Primary care clinicians can help by focusing on the framework of the COPDX plan, initiating therapy using Table 3 as
a guide and tailoring care for individual patients based on their response to treatment, the number and severity of any
exacerbations and any degree of reversibility. The evidence is often confusing and is continually evolving. However, the
message that smoking cessation confers a greater health benefit than any other intervention for people with, or at risk
of COPD is a message we should never tire of promoting.
Table 3 Guide to initial therapy for COPD*
||Oxygen therapy may be indicated
|Trial of inhaled steroids
|Regular short acting beta agonist or ipratropium or both
Tiotropium if not responding to short acting bronchodilators
LABA if not responding to or intolerant of tiotropium
|Intermittent short acting beta agonist or ipratropium
Exercise and lifestyle modification
|Smoking cessation (NRT ± support )
Regular questions about coughs, colds, sputum, dyspnoea and wheeze
*Tailor therapy to response and number and severity of exacerbations.
- McKenzie D, Frith P, Burdon J, Town G. The COPDX Plan: Australian and New Zealand guidelines for the management of
chronic obstructive pulmonary disease 22003 Med J Aust 2003; 178 (6 suppl): S1-S40
- Abramson J, Crockett A, Frith P, McDonald C. COPDX: an update of guidelines for the management of chronic pulmonary
disease with a review of recent evidence. Med J Aust 2006; 184: 342-345
- O’Donnell D, Aaron S, Bourbeau J et al. Canadian Thoracic Society recommendations for management of chronic obstructive
pulmonary disease – 2007 update. Can Respir J 2007;14(Suppl B):5B-32B
- Tatau kahukura - Māori Health Chart Book 2006. Available from