COPD - do the right thing

Abstract

A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.

Keywords: Chronic obstructive; Primary health care; Pulmonary disease; Referral and consultation general practice.

Fig. 1

The pathophysiological background to dyspnoea. Alveolar wall destruction leads to loss of elastic ‘passive’ recoil of the alveoli and support for the bronchiole is lost, leading to bronchiole collapse, which in turn results in air trapping, static hyperinflation and increased functional residual capacity [, –43]

Fig. 2

The pathophysiology of COPD exacerbations. Reproduced with permission from: Wedzicha JA, Seemungal TAR. COPD exacerbations: defining their cause and prevention. Lancet. 2007;370(9589):786–96. Copyright © Elsevier 2007. COPD chronic obstructive pulmonary disease

Fig. 3

Proportion of exacerbations under-reported in different studies. From references [, –100]

Fig. 4

Disease characteristics and initial pharmacological treatment algorithm. ^aConsider if highly symptomatic (e.g. CAT > 20). ^bConsider if EOS ≥0.3 × 10⁹ cells/L (≥300 cells/mm³). Reproduced with permission from: Global Initiative for Chronic Obstructive Lung Disease 2021 Report; Figure 4.2. Available from https://goldcopd.org/wp-content/uploads/2020/11/GOLD-REPORT-2021-v1.0-16Nov20_WMV.pdf, accessed 18 November 2020. CAT COPD assessment test, COPD chronic obstructive pulmonary disease, EOS eosinophil count, ICS inhaled corticosteroids, LABA long-acting β₂-agonist, LAMA long-acting muscarinic antagonist, mMRC modified Medical Research Council dyspnoea scale

Fig. 5

Treatment algorithm for patients with a) dyspnoea or b) exacerbations at review. ^aConsider if EOS ≥0.3 × 10⁹ cells/L (≥300 cells/mm³) or EOS ≥0.1 × 10⁹ cells/L (≥100 cells/mm³) AND ≥ 2 moderate exacerbations/1 hospitalisation. ^bConsider de-escalation of ICS or switch in response to pneumonia, inappropriate original indication or lack of response to ICS. Reproduced with permission from: Global Initiative for Chronic Obstructive Lung Disease 2021 Report; Figure 4.4. Available from https://goldcopd.org/wp-content/uploads/2020/11/GOLD-REPORT-2021-v1.0-16Nov20_WMV.pdf, accessed 18 November 2020. EOS eosinophil count, FEV₁ forced expiratory volume in 1 s, ICS inhaled corticosteroid, LABA long-acting β₂-agonist, LAMA long-acting muscarinic antagonist