A multidisciplinary approach to the treatment and management of chronic obstructive pulmonary disease

Chronic obstructive pulmon­ary disease (COPD) is the only chronic disease with increasing mortality, which may mean that it will be the third leading cause of death worldwide by 2020.[1] A recent study showed that the prevalence of COPD in subjects over 40 years of age in Vancouver is 19.3%, and that in Canada the direct costs of treatment and management are estimated to be $2 billion a year.[2] 

COPD is associated with a significant systemic inflammatory response that results in adverse health effects later in life, such as cardiovascular morbidity and mortality, frailty from malnutrition and muscle weakness, osteoporosis with fractures, and depression. 

Patients with mild to moderate COPD can be adequately managed in the primary care setting by the family physician, whereas patients with more severe COPD and multiple comorbidities need a multidisciplinary approach to treatment.[3] Currently, there are gaps in care (Figure) that could be reduced by ensuring that allied health care workers assist the primary care physician and respirologist in managing more severe cases of COPD (Table 1). 

An ideal stepwise approach would involve family physicians and other health care providers, and would include early diagnosis, pulmonary rehabilitation, education in self-management, nutritional counseling, and appropriate use of bronchodilators.

Early diagnosis
Spirometry is the gold standard for diagnosing COPD and should be performed on all patients over 40 years of age with two or more of the following: 

• A history of smoking.
• Chronic cough.
• Shortness of breath.
• Frequent “chest colds.”

Family physicians often rely on symptoms and chest X-rays to make a COPD diagnosis because spirometry services are not available in the community. A recent study in 12 family practice groups demonstrated that spirometry testing can be incorporated into a family medicine practice with acceptable levels of technical adequacy and accurate interpretations, and that the results influence management of patients previously diagnosed with COPD.[4] 

Full pulmonary function tests, usually only available in a hospital setting, are important for those with moderate to severe COPD.

Smoking cessation
Smoking cessation remains the single most important factor in slowing the decline in lung function in patients with COPD. Eliminating this risk factor should be the highest priority in the management of COPD of all severities. In a multidisciplinary COPD clinic at St. Paul’s Hospital, smoking cessation was addressed in 76.2% of subjects, compared with 57.5% in a general respiratory clinic setting.[5] 

Helping patients address this addiction, whether through drug therapy, counseling, or a combination of the two, is key to the prevention and management of COPD. Referral to a structured smoking cessation program or direction to provincial programs is imperative if physician counseling in an office setting is unsuccessful.  Table 2 shows programs available in BC. 

Pulmonary rehabilitation
Pulmonary rehabilitation, a multi­disciplinary and structured intervention for patients with chronic pulmonary diseases, has been shown to improve exercise tolerance, reduce dyspnea, and improve health-related quality of life.[6,7] Pulmonary rehabilitation, combined with education and self-management, has been shown to result in a substantial reduction in hospital admissions. 

A recent randomized, controlled trial of a COPD self-management program that included education and exercise instruction showed that hospital admissions for exacerbations were reduced by 39.8% when patients in the study were compared with a control group receiving standard care.[8] Pulmonary rehabilitation also relieves dyspnea and fatigue, the two most debilitating symptoms in subjects with moderate to severe COPD.[9] 

Despite the overwhelming evidence of clinical and financial benefits of pulmonary rehabilitation, only a small fraction of Canadian and BC patients qualifying for pulmonary rehabilitation have access to this important mode of management.[10] Most of these programs are institutionally based and offer no form of maintenance exercise after the 6- to 8-week program is completed. 

The lack of community and home-based programs is currently being addressed, but it remains an important gap in ambulatory COPD management. In more remote regions without easy ac­cess to these programs, family physicians need to make simple exercise recommendations such as “walk daily at your own pace, gradually increasing your distance or time walked weekly.” 

Patients should also be en­couraged to utilize oxygen therapy when exercising if required. These simple recommendations will prevent deconditioning.  Table 3 lists pulmonary rehabilitation programs available across BC.

Education and self-management
Education and self-management are important components of a multidisciplinary approach to management of COPD. Programs for self-management consist of group or one-to-one educational sessions that explain the nature and course of the disease and teach pa­tients how to live with the consequences of the disease and integrate into their community. 

Self-management involves preparing an “Action Plan” for prompt treatment of acute exacerbations in order to improve quality of life and reduce the use of health care resources. Although pa­tient self-management through an individualized Action Plan can help with early initiation of therapy, its use depends on the patient being able to recognize the features of an exacerbation.[11] 

Patients reporting fear and anxiety may benefit from psychosocial support, and the integration of occupational therapy or social services support into these programs may im­prove independence in activity. Family physicians should refer patients to local programs with either peer or professionally led self-management groups.

Nutritional counseling
Nutritional status is an important determinant of symptoms, disability, and prognosis in COPD. Nutritional intervention should be considered for patients who are underweight, overweight, or have body composition abnormalities. For example, patients with marginal ventilatory reserve might benefit from a dietary regimen in which a high percentage of calories are supplied by fat.[12] 

In addition, adequate fluids, calories, protein, calcium, and potassium can ease breathing and improve immunity. Adequate hydration can thin respiratory mucus and help prevent drying of the mucous membranes if oxygen is used. Dietary protein is required to maintain good visceral protein status and immune function. 

Calcium is involved in the regulation of blood pressure, muscle contraction, and maintenance of healthy bones. Normal serum potassium levels are beneficial for muscle contraction to aid breathing. All COPD patients should maintain a healthy weight and obtain adequate nutrients to decrease risk of infection and ease breathing.

Bronchodilators
Inhaled bronchodilators (ß2 agonists and anticholinergic agents) are the preferred option for symptomatic management in stable COPD, either for regular treatment or for use on an as-needed basis.[13] Recent evidence showed that long-acting ß2 agonists and anticholinergic agents improve compliance and are more efficacious than their shorter-acting equivalents. 

Although inhaled corticosteroids do not affect declines in FEV1, they do reduce the exacerbation rate in pa­tients with moderate to severe COPD, and there is some evidence for their role in reducing overall mortality.[14] Patients who have difficulty mas­tering inhaler technique with the metered-dose inhaler should use a spacer with the device. 

Different types of spacers and inhaler devices should be experimented with in an attempt to identify a device that the patient can use easily and effectively. As with inhaler technique, patients require training in how to use a spacer effectively. This approach is more convenient than recommending treatment with a nebulizer.

End-of-life care
The family physician has an important role to play in discussing end-of-life care and addressing the patient’s concerns and fears. This discussion should not be left until the patient is moribund. A discussion of advanced care issues, including the use of biPAP and mechanical ventilation, is a vital component of overall management. 

Summary
Multidisciplinary team programs are available to assist family physicians in Vancouver (St. Paul’s Hospital, Royal Columbian Hospital, Vancouver General Hospital, and Richmond Hospital) and Kelowna. These programs can help physicians provide stepwise management of COPD at all stages of severity, as summarized in Table 4. 

In this approach, the family physician is the pivotal health care provider at all stages of the disease and ensures that the patient has access to the following:

• Spirometry testing. Spirometry is essential for both diagnosis and for determining the severity of disease. 

• Patient education: A respiratory therapist, either in the community or at a regional hospital, can assist with inhaler device technique and smoking cessation. A self-management program can help patients develop an Action Plan and learn to live with their disease.

• Pulmonary rehabilitation. Patients should be referred to a pulmonary rehabilitation program or, alternatively, a healthy heart program. If there are no programs available, physicians should encourage their patients to walk every day at their own pace, gradually increasing their distance or time walked per week. Patients should be advised to utilize oxygen therapy when exercising if required. A physiotherapist can also assist with a home exercise program to build strength and help with overall conditioning.

• Nutritional advice. Nutritional intervention should be considered for patients who are underweight or overweight.

• End-of-life care. The family physician should discuss end-of-life and palliative care issues with their patients or provide them with materials about advanced care planning.

Competing interests
The Pacific Lung Health Centre’s COPD program is part of the PRIISME chronic disease management program supported by GlaxoSmithKline.

Dr van Eeden is a professor in medicine at the James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Re­search, University of British Columbia, St Paul's Hospital, Vancouver, Canada. Jane Burns is a physiotherapist and the PRIISME project coordinator with the Pacific Lung Health Centre at St. Paul’s Hospital.