Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the world (World Health Organization (WHO), 2020), accounting for 6% of total deaths, followed by lower respiratory tract infections, which are the fourth leading cause of death and are associated with the highest communicable disease mortality rate in the world. Approximately 3 million people in the UK have been diagnosed with COPD (British Thoracic Society, (BTS) (2018)), although over 1 million people have yet to be diagnosed. The Global Initiative for Lung Disease (GOLD) (2021) has implied that this figure is also set to rise in the coming decades due to risk factor exposure and population ageing. The WHO (2020) estimated that 65 million people have moderate to severe COPD worldwide.
COPD is defined as a preventable, treatable disease of the airways that causes persistent respiratory symptoms and airflow obstruction and an abnormal inflammatory response to noxious gases and particles (GOLD, 2021). Boland et al (2012) expanded this definition, adding that it is a life-limiting illness that may cause a significant burden for patients and carers, with an increasing cost to the NHS. The British Lung Foundation (2017) estimated that COPD costs the NHS £1.9 billion each year.
Prevalence of COPD
COPD prevalence is also associated with socioeconomic deprivation and high-risk occupational industrial areas, and environmental and metabolic risk factors have the highest impact on disease prevention (Murray et al, 2020). Targeting these modifiable risk factors through public health initiatives may reduce the global burden.
COPD is found to be more common in men than women; this could be because men working in high-risk industrial areas were more likely to smoke than women (GOLD, 2021). In 2019, tobacco consumption was still a leading risk factor associated with death among mostly men, but also women in all socio-economic groups and age ranges, despite public health targeting risk factors over the last few decades (Murray et al, 2020).
Burney et al (2014) reported that 10% of males and 11% of females in the UK aged between 16 and 65 years have an abnormal forced expiratory volume in the first second (FEV1) indicating a COPD diagnosis varying from mild to very severe. Recent evidence shows the diagnosis of COPD in men is now plateauing, and the diagnosis in women is on the rise, possibly linked to gender-related changes in smoking status and reduction in industrial-related diagnosis in men due to pit closures and reduction in steel working and power stations (Landis et al, 2014). The prevalence of this disease is projected to increase over the coming decades due to the continued exposure to COPD risk factors, including smoking and other noxious gas exposure (Mathers and Loncar, 2006). It will also be interesting to review the impact in the coming years from COVID-19 on chronic lung conditions and disease diagnosis.
It is estimated that over 30 000 deaths were attributed to COPD in 2015 (Office for National Statistics (ONS), 2017). Although, according to GOLD (2021), this value may be higher, caution should be sought when interpreting the data due to inconsistent use of COPD terminology and coding of disease (GOLD, 2021).
Devereux (2017) pointed out that emergency hospital admission for COPD is steadily increasing; in 1991, 0.5% of total admissions were for COPD, and this value increased to 1.5% in 2008-09, when it was the second most common cause for emergency admission to hospital in the UK and one of the costliest inpatient conditions treated in the NHS (British Lung Foundation, 2017). Hence, prevention of admission is of high priority in public guidance and policy.
Impact of COPD
The presenting symptoms of COPD are typically breathlessness, cough and sputum production (Bunker et al, 2012). COPD might be underdiagnosed because these symptoms are not significant to patients, and patients present only when their symptoms become troublesome. The most common cause of COPD is smoking, and non-smoking-related risk factors include indoor and outdoor air pollution, occupational exposures and early life factors, including genetics (Devereux, 2017).
There is no cure for COPD and, therefore, early interventions and disease management to delay disease progression and encourage self-management of the disease must be the focus. COPD not only has an impact on the individual's quality of life but carries a huge economic burden, costing the NHS billions of pounds each year (GOLD, 2021). A large proportion of this is inpatient costs for people with severe disease and acute exacerbations of COPD.
Exacerbation of COPD
The James Lind Alliance published research priorities in May 2021 concerning patient priorities for exacerbation of COPD (Alqahtani et al, 2021; James Lind Alliance, 2021). Patient perception of exacerbation of COPD is that it becomes a disruptive part of their life. Managing exacerbation is a goal in the COPD national guidelines, but no new treatment options have become available over recent years. The top 10 priorities include prevention, management and benefits of rescue medication in exacerbation. Exacerbation of COPD is an important factor in the trajectory of COPD in terms of health impact, mortality and morbidity, as well as the impact on the psychosocial wellbeing of the patient (Sapey and Stockley, 2006; GOLD, 2021).
An exacerbation of COPD can be defined as a sustained worsening of respiratory symptoms that is acute in onset; it is often associated with increased neutrophilic inflammation in the airways (Sapey and Stockley, 2006). This leads to airway obstruction, hyperinflation of the lung, increased oxygen demands, increase in pulmonary artery pressure and a mismatch in ventilation/perfusion (Currie, 2017). The presence of worsening symptoms may be associated with concurrent deterioration in pulmonary function, increasing both local and systemic inflammation and becoming more frequent as severity of disease progresses (Hurst and Wedzicha, 2007).
Periods of worsening symptoms vary in severity and frequency over the course of COPD illness; people who have more frequent exacerbations have a higher mortality rate and rate of emergency admission to hospital (Trappenburg et al, 2011).
Newman et al (2017) suggested that COPD patients have, on average, three exacerbations per year and are the leading cause of unplanned admission to hospital. Some patients are more prone to exacerbations, and this can worsen their prognosis (GOLD, 2021).
Exacerbations can be infectious in origin or as a result of irritation to the airways (Kim and Aaron, 2018). Severe exacerbations may enhance disease progression by accelerating decline in lung function and quality of life (QoL), preventing patients from returning to their baseline normal day-to-day activities (Donaldson et al, 2002).
Exacerbation of COPD remains a clinical diagnosis, although Government guidelines, including those from the National Institute for Health and Care Excellence (NICE) (2018), highlighted a drive for self-management of exacerbations. Hurst and Wedzicha (2007) also stated that, during a clinical diagnosis, it is important to consider other causes for breathlessness; self-management of exacerbation may lead to misdiagnosis or delay appropriate treatment. However, early treatment of exacerbations may lead to earlier recovery. Both GOLD (2021) and NICE (2018) guidelines have been published regarding the use of ‘rescue medication’ in the home that patients are given to start if they note an onset of exacerbation. The use of rescue medication as part of a self-management plan also raises concerns over appropriate use of these medications, and these need to be monitored to prevent overuse. In more recent guidance, repeat prescribing of rescue medication in COPD has been stopped to prevent antibiotic resistance (GOLD, 2021).
The chronic nature of this disease requires that individuals learn to manage their disease in order to optimise their QoL, reduce or prevent exacerbations, and limit effects on activities of daily living (Becker, 2018). It is essential to manage disease progression and prevent exacerbations through both pharmacological and non-pharmacological methods. Jones et al (2010) pointed out that managing acute exacerbations for patients at high risk of admissions with COPD in the community setting may reduce the cost burden of inpatient care and prevent decline in the patients' QOL.
Reducing the risk of exacerbation through pharmacological optimisation of treatment for COPD, including inhaled corticosteroids, inhaled long acting anti-muscarinics and long-acting bronchodilators, is essential in effective self-management. The need to optimise all COPD medication, including oral mucolytic medication, may reduce mortality associated with repeated exacerbations. Non-pharmacological treatment is part of the NICE (2018) recommendations for self-management, including the annual vaccination programme for influenza and the pneumococcal vaccine, smoking cessation, dietary intake and pulmonary rehabilitation, which include a focus on maintaining physical activity to prevent deconditioning and dysfunctional breathing.
Self-management
Coulter et al (2013) focused on the need to support patients to self-manage their chronic conditions due to the high prevalence and long-term nature of their conditions. Motivation to change behaviours has been linked to patients with a severe COPD diagnosis. A self-management approach aims to reduce healthcare burden and improve self-belief, awareness and ownership of health, and using self-management interventions has been evidenced in reducing the number of admissions for COPD patients (Newman et al, 2017). Jolly et al (2018) suggested that self-management interventions applied at an early stage may reduce risk in more severe stages of disease and improve patient self-efficacy.
Becker (2018) pointed out that, when asked about their condition, most patients have poor knowledge and understanding of disease effects, progression and symptom management, and they often do not know what medication they take and why. Highlighting this gap in knowledge is crucial in aiding in the management and prevention of disease progression with individuals in both primary and secondary care. Barlow et al (2002) defined self-management as the ability to deal with all that a chronic disease entails, including symptoms, treatment and physical consequences. However, Effing et al (2016) reported the need for patients to have significant knowledge of COPD to enable them to effectively self-manage their disease, including recognition of symptoms, correct use of inhalers and inhaler technique, management of breathlessness and smoking cessation. Self-efficacy is also an imperative when managing chronic disease, allowing patients to execute an appropriate course of action when they recognise early signs and symptoms. This is a major driving force in self-management behaviours (Guo et al, 2017), enabling the patient to overcome barriers that may challenge their motivation. A systematic review by Hosseinzadeh and Shnaigat (2019) considered the evidence surrounding self-management interventions in primary care, and the authors found that most COPD interventions have been focused in and around secondary and tertiary care following admission and that minimal data was available in the research around primary care interventions. Robb and Shedon (2006) argued that self-management should be scrutinised, and professionals need to have a clear understanding of patients' knowledge of the disease and what method of self-management would best support them.
Case management of COPD
Hosseinzadeh and Shnaigat (2019) pointed out that the primary care setting, including GP practices and community nursing, is the first contact between patient and health professionals, placing professionals working in primary care at the forefront of implementing education and intervention for patients with COPD. Intervention at an early stage can reduce the burden of managing advancing stages of disease, although Mitchell et al (2014) suggested that the effectiveness of self-management in the primary care setting is still uncertain.
Up until the early 21st century, COPD and other long-term conditions were managed under the primary care teams in GP practices and via hospital specialists. The NHS plan (Department of Health and Social Care (DHSC), 2000) highlighted the need for case management of people with long-term conditions by highly skilled health professionals. Primary care appointments focus on the diagnosis of COPD and management of mild disease. The DHSC (2005a) recommended that as the disease progresses through the stages, case management should be used to manage both health and social needs of patients with complex needs, through self-management plans, which can be implemented in a patient's home rather than a GP surgery. The DHSC (2005b) also provided a framework for improving care for patients, grouping patients into three categories depending on their level of need: level 1 accounts for 70-80% of patients with a long-term condition and they would be managed in general practice, requiring support to self-manage their condition. Levels 2 and 3 include patients with more complex health needs/comorbidities and fall under the case-management domain. Considerable early research around case management in the UK was adopted from the US. The Evercare model (2004) for case management was introduced as a tool in the community. Primary care trusts identified their at-risk populations through admission data and GP practice data to find patients who would be suitable for case management by highly skilled community matrons. However, Ross et al (2011) suggested that, although the Evercare model did improve quality of care, it had no impact on the admission rate or mortality, linking this to how patients were targeted and engaged in the programme. Consensus throughout this research has been that reduction in admissions or statistical significance is minimal when using a self-management plan. The difficulty in comparing data from numerous studies due to the heterogeneous nature of the content is a challenge, but can be achieved (Bootland et al, 2017).
Government policy (DHSC, 2005a) is central to leading on publication and employment of case managers in the community, with the aim of preventing unnecessary admission to hospital and supporting patients to manage their own condition with the aid of a self-management plan. People with long-term conditions have a varying intensity of need, and care provided should be individualised and targeted according to these needs and not on a generic basis. Ross et al (2011) stated that, although self-management is mostly offered to individuals with lower-intensity needs, it has a part to play in the package of care offered to those with a long-term condition who have more intense needs. Research around use of self-management plans in COPD is variable: some of the research focuses on mild or moderate COPD, while other research looks at moderate and severe disease.
The National Service Framework (NSF) (DHSC, 2005c) focused on putting the patient at the centre of care; although this NSF had a focus on neurological conditions, the core principles can be applied to all long-term conditions. The core principles include person-centred care, support for family and carers and providing high-quality efficient and supportive services in the community. Devereux (2017) reported that a reduction in exacerbations of COPD and hospitalisation would result in significant cost saving for both the health service and patients.
Mental health
The importance of mental and emotional wellbeing is a crucial part of self-management and case-management in COPD (Newman et al, 2017). The prevalence of anxiety and depression is high among COPD patients, and teaching self-management techniques is a key factor in helping manage both physical and psychological aspects of the disease.
The comorbid symptoms of anxiety and breathlessness in COPD patients are often a difficult cycle for patients to handle, and mismanagement of anxiety and breathlessness can often lead to admission to hospital, while the physical symptom of breathlessness can lead to an increase in anxiety and vice versa (Baker and Fatoye, 2019).
NICE (2018) and GOLD (2021) both highlighted the importance of reinforcing good mental health management in patients with COPD due to the high prevalence of associated depression and anxiety diagnosis. Encouraging exercise through pulmonary rehabilitation will improve pulmonary function techniques in managing breathlessness. Effective tools to enable patients to calm their breathing through controlled breathing techniques, relaxation and mindfulness may also help reduce anxiety. Finally, increasing exercise in a controlled environment is also linked to improved mental wellbeing (GOLD, 2021).
Research
The focus on early research in COPD is around lifestyle changes. The role of the community matron in practice is to provide highly skilled nursing intervention and case management, providing support, education, knowledge and complex disease management, incorporating both pharmacological and non-pharmacological factors. GOLD (2021) recognised the need to prevent disease progression to prevent/treat exacerbations and reduce mortality. McHugh et al (2007) suggested that community matrons are a cornerstone in implementing these guidelines.
A systematic review was undertaken on the topic of patients with COPD, focusing on the support needs of this patient group (Hosseinzadeh and Shnaigat, 2010). It found that 11 studies in this review identified patients needing support in managing their condition. A number of these studies reported that patients want a more dynamic support network, particularly when managing exacerbations. Partridge et al (2011) and Philips et al (2012) both found that patients valued guidance on when to take standby medication rather than making a decision autonomously. In addition, providing feedback as to whether patients have managed a situation effectively was high on the agenda. The range of research covered in this systematic review was mostly qualitative in nature, reporting on the perspectives of patients with COPD and the importance/value of support to enable them to manage life with COPD.
The view of the patients was a key component rather than that of a health professional. The review identified a comprehensive set of domains in which patients felt they needed support to manage their COPD, thus influencing future practice to enable clinicians to enhance patient support using evidence-based person-centred care. The question is how do self-management plans and their use in COPD support the emerging evidence? Arguably, the view of the patient is seen as more influential than that of health professionals in terms of meeting the needs of the patients, but research around patient views is limited.
Pinnock et al (2016) suggested that research around COPD ranges widely in terms of methodology. Quantitative and qualitative data and research projects are available. The quantitative research focuses on drug intervention and pharmacological management of COPD.
Conclusion
The management of long-term conditions, particularly COPD, is highlighted in several national guidelines. COPD has high prevalence in those aged over 65 years, and many of those diagnosed have comorbidities. Self-management plans are used to support these patients in managing their conditions and, with support from case managers to address exacerbations, detecting symptoms of early exacerbation is an important component of these management plans. It is important to include not only physical but also psychological aspects in these case management and self-management plans to facilitate a holistic approach to supporting COPD patients.
Useful resources
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention ofchronic obstructive pulmonary disease. 2021 report. https://tinyurl.com/2p5xap7f
- National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. https://tinyurl.com/hnjdjbfy
- British Lung Foundation. https://www.blf.org.uk
- British Thoracic Society. https://tinyurl.com/8ypsdy3k
- The James Lind Alliance. https://www.jla.nihr.ac.uk/
KEY POINTS:
- The number of people with chronic obstructive pulmonary disease (COPD) is on the rise, due to population ageing and exposure to risk factors, such as air pollution and cigarette smoke
- Case management is a recommended tool in supporting patients with long-term conditions, including COPD
- Primary care appointments focus on the diagnosis of COPD and management of mild disease, while case management is recommended for later disease stages
- Self-management plans are varied in their content, but the main aspects are supportive guidance on identifying early symptoms of exacerbations and how prompt treatment may reduce a delayed response, in turn reducing the long-term impact on disease progression
CPD reflective practice:
- How are self-management plans used in your work area when dealing with patients with a diagnosis of chronic obstructive pulmonary disease (COPD)?
- What is the prevalence of COPD among your patient population? Are there any links to industry in your area?