Optimising COPD Management: The Integrated Care Paradigm

Introduction: The updated 2024 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines define Chronic Obstructive Pulmonary Disease (COPD) as a heterogeneous lung condition characterized by chronic respiratory symptoms due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction. In this article, we review the aetiology, clinical features, diagnosis, and management of COPD, including both non-pharmacological & pharmacological interventions. We will also describe the role of Integrated Care in the management of COPD, with a paradigm shift away from hospital centred care to person-centred care.

Causes of COPD

• Tobacco smoke
• Marijuana smoking
• Indoor (household air pollution from burning solid fuels for cooking or heating) and outdoor air pollution (particulate matter)
• Occupational exposures, including dusts, chemical agents and fumes
• Genetic factors such as alpha-1antitrypsin deficiency
• Females are more susceptible than males to the harmful effects of cigarette smoke, women who smoke are 50% more likely to develop COPD than men
• Abnormal lung growth and development
• Lower socioeconomic status
• Asthma and Airway Hyper-reactivity
• Recurrent Respiratory infections

Clinical Features of COPD

The three main symptoms of COPD are dyspnoea, chronic cough, and spectum production.

The most common symptom reported by patients is dyspnoea on exertion. Dyspnoea that is persistent, progressive over time and worse with exercise is characteristic of COPD. The modified Medical Research Council (mMRC) scale is a useful dyspnoea scoring system that forms part of the GOLD COPD classification system. Dyspnoea is multi-factorial in COPD. Contributing factors include airway obstruction, parenchymal destruction, dynamic hyper inflation leading to air trapping, and systemic effects including sarcopenia.

Cough and sputum occur in 30% of COPD patients. Less commonly, patients describe symptoms of wheeze, fatigue and anorexia. Comorbidities may contribute to restriction of activity. These include heart disease, osteoporosis, malignancy, musculoskeletal disorders, anxiety and depression.

The key findings on clinical examination of a patient with COPD are usually absent until significant impairments of lung function has occurred. Tachypnoea occurs with activity, with increasing respiratory rate in proportion to disease severity. Use of accessory respiratory muscles and paradoxical indrawing of the lower intercostal spaces (Hoover sign) indicates airway hyperinflation and a flattened diaphragm. Other findings on thoracic examination include a barrel chest, hyperresonance on percussion, diffusely decreased breath sounds, and prolonged expiration.

Diagnosis

Diagnosis of COPD is based on a triad of causative exposure, symptoms and spirometry. Spirometry is the most reproducible and objective measurement of airflow limitation. It measures the volume of air that a patient can forcibly exhale from the point of maximal inspiration (Forced Vital Capacity, FVC) and the volume of air that is exhaled during the first second of this manoeuvre (Forced Expiratory Volume in one second, FEV1). The ratio of the FEV1/FVC is calculated. Airflow obstruction is a post-bronchodilator FEV1/FVC ratio less than 70%.

 

At diagnosis, patients should have the severity of their airflow limitation classified according to the GOLD guidelines. This classifies patients with a FEV1/ FVC ratio less than 70% into four categories (GOLD 1 – 4), based on their FEV1 value. . Symptom burden is assessed using the mMRC dyspnoea score or the CAT (COPD Assessment test). An assessment of exacerbation risk should also occur. A COPD exacerbation is an acute worsening of respiratory symptoms that results in additional therapy. Exacerbations can be classified as mild, moderate or severe. The best predictor of having frequent exacerbations (defined as two or more exacerbations in one year) is a history of previous exacerbations. Using these variables, individuals may be classified as GOLD 1-4 A, B or E (Figure 1).

In our practice, we obtain a chest radiograph in all new suspected COPD patients. While it does not diagnose COPD, it can be useful in excluding alternative diagnoses and establishing the presence of comorbidities including pulmonary fibrosis, pleural disease, kyphoscoliosis and cardiomegaly. We obtain routine laboratory investigations, including FBC to check for eosinophilia. Blood eosinophil counts may predict the magnitude of the effect of inhaled corticosteroid therapy as an addition to regular maintenance bronchodilator treatment in preventing future COPD exacerbations. We screen for alpha one antitrypsin deficiency in concordance with WHO recommendations. For those with recurring exacerbations, we check an immunoglobulin level to screen for hypogammaglobinaemia.

Management

Addressing COPD treatment necessitates a comprehensive approach encompassing non pharmacological, pharmacological, and interventional therapies (Table 1). The aim of COPD management is to reduce symptoms and future risk.

A particular emphasis needs to be placed on smoking cessation. Healthcare providers are pivotal in delivering smoking cessation messages and interventions. Approximately 40% of those diagnosed with COPD are active smokers, who continue to smoke despite being aware of their diagnosis. Stopping smoking is the single biggest intervention to influence the natural history of COPD. It also improves symptoms and reduces the frequency of exacerbations. Nicotine replacement therapy (NRT) is effective in promoting long-term smoking abstinence.

People with COPD should be up to date with their vaccines. Current recommendations include vaccination against Influenza, SARS-CoV-2 (COVID), and pneumococcal infection.

Physical activity is a strong predictor of mortality. People with COPD should be encouraged to increase their levels of physical activity. Pulmonary rehabilitation (PR), combining exercise training with disease-specific education, is recommended for GOLD B – D patients and for those discharged from hospital with a COPD exacerbation. It consists of an 8-week programme of supervised incremental exercise, where patients build up their muscle strength. PR improves dyspnoea, health status and exercise tolerance in stable patients. It leads to reduced symptoms of anxiety and depression. Patients are taught breathing exercises and the benefit of pacing. A reduction in further hospitalisations by 50% for patients who had PR initiated within 4 weeks of hospitalisation for COPD, compared to those who did not have PR, has been demonstrated. Pharmacological therapy for COPD is focused on symptoms and exacerbations. Individualised treatment regimens consider factors such as symptom severity, exacerbation risk, side effects, comorbidities, drug availability, cost, patient response, preference, and ability to use drug delivery devices. As per the 2024 GOLD guidelines, the commencement of bronchodilator agent(s) or a combination of bronchodilator agents with ICS (inhaled corticosteroid) is recommended, depending on the disease severity categorized into groups A, B or E (FIGURE 2).

Bronchodilator inhalers address airways obstruction, altering airway smooth muscle tone, leading to widening of the airways and improving dynamic hyperinflation. Available bronchodilators include short acting and long acting beta agonists (SABA/ LABA) and muscarinic agents (SAMA/LAMA). Rescue shortacting bronchodilators should be prescribed to all patients for immediate symptomatic relief. Bronchodilator therapy improves dyspnoea, improve exercise performance and decrease exacerbation frequency. Combination LABA/LAMA therapy in a single inhaler demonstrates improved patient reported outcomes, compared to monotherapies alone.

For Group E patients who are having frequent exacerbations combined LABA-LAMA inhaler therapy is the preferred choice for initial therapy. Use of LABA/ ICS is not encouraged. If there is an indication for the addition of an inhaled corticosteroid (ICS), then triple therapy in the form of LABA/LAMA/ICS has demonstrated superiority over LABA/ICS and should be the preferred choice. Triple therapy should be considered in Group E patients who have elevated blood eosinophil counts. If there is concomitant asthma, these patients should be treated accordingly. Under these circumstances, use of an ICS is mandatory. Regular assessment of inhaler technique is crucial.

Azithromycin is a macrolide antibiotic that has anti-inflammatory effects in the airway. It can be added on to therapy in former smokers who continue to exacerbate despite maximal inhaled therapy. Roflumilast is a phosphodiesterase inhibitor that reduces inflammation in the airway but has no immediate bronchodilator effect. It may be a reasonable add-on therapy in patients with a FEV1 < 50% predicted and chronic bronchitis, particularly if hospitalised with a COPD exacerbation in the past year. Roflumilast is not approved for reimbursement under the community drug schemes in Ireland.

Long-term oxygen therapy (LTOT) is recommended for patients with severe resting chronic hypoxemia, i.e. PaO2 ≤ 7.3kPa or PaO2 ≥ 7.3kPa to ≤ 8.0kPa with pulmonary hypertension, pedal oedema or raised haematocrit. Its routine prescription is not advised for stable COPD with moderate desaturation, emphasizing the need for individualised evaluation. Long-term non-invasive ventilation (NIV) may reduce mortality and prevent re-hospitalisation in patients with severe chronic hypercapnia and a history of acute respiratory failure. For select patients with advanced emphysema unresponsive to medical care, surgical or bronchoscopic interventions may offer benefits. Palliative approaches are effective in managing symptoms for individuals with advanced COPD.

Role of Integrated Care in COPD management

The population of Ireland is aging. People are living longer with increased levels of chronic disease. Often people with chronic disease access healthcare in a reactive, episodic manner, resulting in recurrent hospital admissions. Health services are now evolving to meet these changing population needs, with a paradigm shift away from hospital-centred care to person centred care. Integrated care for chronic disease, including COPD, is healthcare provided at the lowest level of complexity to meet patient needs. Patients are empowered to optimise their chronic condition and to minimise risk factors.

The National Clinical Programme (NCP) for Respiratory medicine, along with NCP Diabetes and NCP Heart Failure, form the main components of the Integrated Care Programme for Chronic Disease (ICPCD). The NCP Respiratory vision is for an end-to-end patientcentred integrated approach for persons living with COPD and asthma. COPD is included in the structured chronic disease treatment programme in primary care. Patients with COPD who have a medical card or GP visit card can avail of two free GP reviews in every 12-month period. A personalised care plan for patients with COPD is agreed between the patient and their GP or practice nurse, outlining steps to take to manage COPD and the supports available. An essential component of the Model of Care for COPD is early detection of disease and diagnosis, whereby GP’s have direct access to spirometry.

Integrated Respiratory Services, tailored to the individual needs of the patient, include COPD Outreach, Nurse-led clinics, Physiotherapy-led clinics, multidisciplinary team meetings to optimise management of patients with COPD, community-based pulmonary rehabilitation, oxygen clinics and Consultant-led clinics. The Integrated Respiratory Consultants provide a continuum of care across acute hospitals and specialist integrated care hubs. The Integrated Model of Care for COPD is very much aligned with the Sláintecare vision of the ‘Right Care, Right Place, and Right Time’. This new exciting way of working is optimising COPD patient care in Ireland, shifting care away from acute hospitals.

Written by Dr Dhiviya Ganesan, Respiratory Registrar, Galway University Hospital (GUH) and Dr Sinéad Walsh, Respiratory Integrated Care Consultant, GUH & Community Healthcare Organisation 2

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