National Standard for Chronic Obstructive Pulmonary Disease

The Australian Commission on Safety and Quality in Healthcare recently released the Chronic Obstructive Pulmonary Disease Clinical Care Standard. This is the first national standard on chronic obstructive pulmonary disease (COPD), a common condition thought to affect around one in 13 Australians over the age of 40.

The new standard aims to reduce potentially preventable hospitalisations and improve overall outcomes for people with COPD. One of the main causes of preventable hospitalisations in this population is COPD exacerbations. An exacerbation is characterised by acute worsening of symptoms beyond what would be considered normal day-to-day variations. This may include increasing dyspnoea, worsening of chronic cough, and changes in sputum. Reducing exacerbations is a primary goal of COPD management.

Tobacco smoking is the most common risk factor for COPD. According to the Australian Burden of Disease Study 2024, tobacco contributed to 65% of the total burden from COPD. There has been a reduction in the rate of burden attributed to tobacco in Australia over the past few decades. This is likely due to the significant decrease in smoking prevalence. However, as there is a long lag time between smoking and developing disease, its contribution to disease burden is still high.

The evidence clearly demonstrates that smoking cessation is the most important intervention to prevent or minimise lung damage and reduce mortality in patients with COPD who smoke. Patients who currently smoke should be encouraged to quit smoking and offered evidence-based smoking cessation interventions.

Other interventions with evidence to support a reduction in exacerbations include:

• Optimisation of pharmacological therapies;
• Keeping up-to-date with recommended vaccinations; and
• Pulmonary rehabilitation.

Optimisation of pharmacological therapies.

Pharmacological therapies are an important part of COPD management as they can reduce symptoms and prevent exacerbations. The COPD-X Handbook provides information on a stepwise approach to therapy.

Therapy starts with a short-acting reliever that is used on an as-needed basis. This reliever may be a short-acting beta₂-agonist (SABA) or a short-acting muscarinic antagonist (SAMA). A long-acting bronchodilator, either a long-acting muscarinic antagonist (LAMA) or long-acting beta₂-agonist (LABA), may then be added. Depending on the response, a combination of LAMA + LABA may be considered. An inhaled corticosteroid may also be required for patients with moderate to severe COPD.

There are many different inhaler products and devices available. Some devices require the patient to load a capsule into the inhaler before each dose, while others are pre-loaded. Some devices, such as the metered dose inhaler, require a high level of coordination and manual dexterity. However, regardless of the type of device, optimal use of inhalers presents more challenges than most other dose forms. Therefore, patients must be trained on how to use each specific device correctly. The Lung Foundation Australia provides instructional videos for various inhaler devices.

Where possible, it is recommended to minimise the number of different inhaler devices used by a patient. Having multiple devices with different methods of use may increase the chances that the patient will not use their devices correctly. Incorrect inhaler technique is common, with reports that up to 90% of patients do not use their devices correctly. Poor inhaler technique can reduce drug delivery to the lungs, resulting in reduced efficacy and an increased risk of exacerbations. One study demonstrated a two-fold increase in the rate of severe exacerbations in the previous three months for patients with at least one critical device error compared to patients with no critical errors.

Inhaler technique should be regularly checked. In particular, it should be checked before considering an escalation of therapy, after a change in treatment, and after an exacerbation. The clinical care standard advises that all clinicians involved in a patient’s care can play a role in checking and correcting inhaler technique.

Reducing the complexity of therapy may also play a role in improving compliance with therapy. Many combination inhalers are now available, which have the potential to reduce the number of devices and doses that a patient needs to use.

Vaccinations

People with COPD are at higher risk of experiencing complications from many infections. Bacterial and viral infections are also known triggers for COPD exacerbations. Therefore, it is recommended that people with COPD are up-to-date with vaccinations for influenza, COVID-19, and pneumococcal disease.

Additional vaccines, such as a herpes zoster vaccine, may also be recommended. One meta-analysis found that people with COPD have a 41% higher risk of herpes zoster compared to healthy controls. The risk of complications may also be higher, with one study finding that COPD was associated with a 53% increased risk of post-herpetic neuralgia.

Shingrix® (varicella-zoster vaccine) is currently funded under the National Immunisation Program (NIP) for all adults 65 years of age and older, Aboriginal and Torres Strait Islander people from 50 years of age, and people 18 years of age or older with moderate to severe immunocompromise.

Pulmonary rehabilitation

Pulmonary rehabilitation has been shown to improve symptoms and reduce the risk of COPD exacerbations. These programs usually run over six to eight weeks and combine exercise, education, and self-management techniques. Patients who have completed a pulmonary rehabilitation program should be encouraged to continue with their exercise program to ensure the benefits are maintained.

The clinical care standard recommends that pulmonary rehabilitation be offered to all patients with COPD. For patients admitted to the hospital with a COPD exacerbation, the standard advises to begin within four weeks. This reduces the short-term risk of re-admission while also improving symptoms and quality of life following the exacerbation.