Managing COPD in primary care
Chronic obstructive pulmonary disease (COPD) is currently the 10th commonest cause of death in Singapore, with a disease burden of 5.9 percent according to a 2015 population-based survey (EPIC-Asia survey) in Singapore. Pearl Toh spoke with Dr Augustine Tee, chief and senior consultant of the Department of Respiratory and Critical Care Medicine at Changi General Hospital (CGH) in Singapore, on how COPD is often underdetected in the primary care population as symptoms are not specific and diagnosis requires a combination of clinical risk factors, symptoms and spirometry testing.
COPD can be suspected by taking a patient’s history of risk factors (in particular, smoking) and related symptoms. Some of the key symptoms that a clinician should look out for are chronic cough and sputum, which are often ascribed to the “smoker’s cough”, and are commonly present during the early phase of COPD.
Additionally, many patients may start to reduce their physical activities due to exertional dyspnoea and fatigue. Eventually, many progress to weight loss, low mood, and sleep complaints, which can all affect their activities of daily living.
Most patients consult doctors for frequent coughs, seeking quick remedies, while others are worried about being infectious or having undiagnosed lung cancer. In fact, patients who are diagnosed at a late stage (eg, requiring long-term oxygen at home) have a prognosis of median 2–3 years survival, which is not too different from some cancers.
To confirm diagnosis, however, a spirometry is required. Standard diagnosis refers to the postbronchodilator spirometry values, essentially the FEV1* and FEV1/FVC** after administering a bronchodilator. Of note, a lack of bronchodilator reversibility is not a criterion for diagnosing COPD.
Typically, general practitioners (GPs) may face challenge related to diagnosis of COPD and patient support. GPs should maintain a high index of suspicion when seeing adult smokers/ex-smokers of >40 years old who present with symptoms.
A major challenge is ensuring spirometry is performed during diagnosis. I would advise primary care givers to engage their patients in the diagnosis of COPD, so that they understand the importance of spirometry. Many hospitals, including CGH, offer spirometry services for GPs to order without needing a referral to specialists.
Another challenge relates to ensuring a patients’ adherence to treatment even after they have felt better. Some of the common reasons of noncompliance to maintenance inhalers include fear of “addiction” and being ignorant to the role of inhalers as an actual preventive medication.
The key aims of COPD management are to reduce symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance, which can partly be achieved with (but not limited to) drug therapy. Ideally, these should be achieved with minimal medication side effects.
The backbone of COPD treatment is to achieve maximal bronchodilation. Although GPs are familiar with short-acting beta agonist (SABA) and short-acting muscarinic antagonist (SAMA), these are suitable for patients with minimal airflow obstruction and intermittent mild symptoms. Once symptoms become frequent and have an impact on the patients, long acting bronchodilators (LABA, LAMA or a combination LABA+LAMA) should be considered.
GPs should also be aware of the implications associated with overuse of inhaled corticosteroids (ICSs), as these often are available as ICS+LABA combination. Evidence has shown that only certain subgroups of COPD patients benefit from ICS, although the patients’ characteristics associated with clinical benefit remain unclear. One example of such a group is the asthma-COPD overlap syndrome (ACOS). However, prolonged use of high doses of ICS has been linked to increased incidence of pneumonia.
GPs may also need support, such as educational materials from hospitals or health promotion board, in providing patient education and demonstration of the correct technique for using an inhaler. Importantly, all healthcare professionals have a part to play in creating more awareness of COPD, so that more individuals with COPD can be detected and compliance to treatment is ensured.
Most restructured hospitals in Singapore have COPD programmes to support patients and reduce re-admissions to hospitals. CGH in collaboration with the Eastern Health Alliance engage GPs in the nation’s eastern region to support their care of COPD patients by providing access to medications within a continuing care programme; in addition to providing regular continuing medical education and awareness activities, such as public lung function screening.
Quitting smoking is one of the major challenges in COPD management. Smoking is an addiction condition that requires a multipronged approach of screening, counseling (including some form of cognitive behavioural approach), and pharmacological therapy (eg, nicotine replacement therapy, bupropion, varenicline). Smoking cessation is the key to COPD management, as it is one of the few interventions that can improve survival. GPs can also advise smokers to call the Health Promotion Board’s quitline. Even a brief intervention by a doctor can impact a patient’s effort to quit smoking.
Another challenge relates to effective pharmacological management of mild and moderate COPD. Evidence shows that the most rapid decline in lung function of COPD patients occurs during Stage 2 airflow obstruction (FEV1 50–80 percent predicted). Hence, this is when more intensive treatment with long-acting bronchodilators may benefit most. However, patients often do not feel impacted by the disease at this stage, and may refrain from accepting the more expensive LABA or LAMA.
Patients should be referred to a specialist if they have: severe COPD (FEV1 < 50% predicted), frequent exacerbations (≥2 a year) despite compliance to treatment, rapidly progressing disease, new symptoms (eg, haemoptysis), or new physical signs (eg, cyanosis, peripheral oedema).
COPD is a chronic disease, very much prevalent but underdetected in primary care. We need to re-emphasize COPD in the list of chronic conditions that primary care practitioners can play a vital role in improving the health of the community. [Singapore Med J 2013;54:673-677]
COPD is also part of the wide range of comorbidities that many elderly patients present with. For example, cardiovascular patients can have undiagnosed COPD, while COPD patients may be commonly affected by cardiovascular disease, osteoporosis, anxiety, depression, and metabolic conditions. Comorbidities worsen the impact of COPD on the patients and increase the complexity of symptom presentation.
Management strategies should not be limited to pharmacological approach, and should be complemented by relevant nonpharmacological interventions. Particularly, smokers should be strongly encouraged to quit.
Additionally, GPs should develop a therapeutic relationship with COPD patients and their caregivers as they require clinical, emotional, social, and financial support through the challenging disease journey.
Global Initiative for Chronic Obstructive Lung Disease
National Institute for Health and Care Excellence
Lung Foundation Australia