The COPD Action Plan

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is the most common cause of medical visits, hospital admissions, and death among patients with COPD.¹ Frequent exacerbations result in accelerated decline in lung function.¹ It is therefore vital that COPD be treated appropriately, prevention strategies adopted, and exacerbations identified and treated early.

The 2008 Canadian Thoracic Society (CTS) COPD update defines acute exacerbations of chronic obstructive pulmonary disease (AECOPD) as sustained (≥ 48 hours) worsening of dyspnea, cough, or sputum production leading to increased use of maintenance medications or supplementation with additional medications.¹ Patients with COPD experience approximately 2 exacerbations per year on average, but the rate is highly variable. Patients reporting exacerbations earlier have more hospital emergency visits and experience decreased quality of life.²

Self-management

Self-management education holds promise for positive economic benefits in the context of increased patient case-loads and rising costs of hospitalization.³ In Canada, with occasionally limited access to specialist care and sometimes great distances between centres, self-management education is an important component of health care improvement programs. By reviewing and incorporating current best practice into standardized patient self-management tools and resources, general practitioners can contribute to progress in evaluation and ensure tools are designed to reflect the realities of practice.

The Canadian Respiratory Guideline Consortium struck a committee to create and refine currently available action plans for use in primary care. Such plans comprise written information with specific instructions about management when symptoms deteriorate. Studies investigating effects of written self-management plans for COPD patients showed several positive effects.^4,5 Authors of a New Zealand study of a nationally adopted COPD action plan in primary care concluded that patients who had plans reported increases in early intervention with oral corticosteroids and antibiotics and more confidence in their self-management ability.⁶ European studies report that using action plans during consultations resulted in overall improvement in patient-GP communication.⁷ A Cochrane review⁸ showed that action plans helped people with COPD to recognize and react appropriately to exacerbations through self-initiation of antibiotics or steroids; and work in Canada by Bourbeau and colleagues has shown improved morbidity and mortality.³ Bourbeau’s work includes an excellent detailed action plan administered in COPD clinics by trained educators and nurses who are then available for telephone follow-up and to give advice (www.livingwellwithcopd.com). This has been shown to decrease severity of exacerbations, hospitalizations, and the cost of health care for those with COPD.³ In its current form, however, the plan is not applicable in primary care owing to its length.

Action plan

A short COPD Action Plan was created by Family Physician Airways Group of Canada executive members, and a validation trial is currently under way. Two respirologists and 2 family physicians worked on adapting existing tools into the new COPD Action Plan, which is available on CFPlus,* at the CTS website, www.copdguidelines.ca, or at the Family Physician Airways Group website, www.fpagc.com.

This plan is a 2-sided sheet with 3 copies: 1 for the patient, 1 for the physician, and 1 for the pharmacist. The copy for the pharmacist also acts as a prescription. The forms have been colour-coded into green, yellow, and red zones (modeled after the Asthma Action Plan). The green zone describes the patient’s normal situation. In asthma we aim for no symptoms, but in COPD regular symptoms are normal for people with persistent airway obstruction.

The yellow zone is for times of change, when symptoms worsen, including dyspnea and changes in sputum colour and quantity. Although more than half of AECOPD cases are caused by infection (many are initially viral), additional triggers include exposure to allergens and irritants. Other causes, such as congestive heart failure and pulmonary embolism, will require different management.

The yellow zone contains advice to use routine COPD medications, to use breathing exercises and relaxation techniques, to change the environment if it is causing the flare-up, and to increase oxygen. If the exacerbation is infective and the dyspnea is accompanied by increased or coloured sputum, antibiotics and systemic steroids are suggested. If the condition worsens, patients are advised to visit their physicians or the emergency department. Follow-up with their physicians after the attack is also recommended.

The back of each copy provides instructions as well. The patient copy has instructions about what AECOPD means and explains that rapid identification and action are helpful. The back of the physician and pharmacist copies include current guideline advice for choice of appropriate antibiotics. Further advice includes reminders to adjust antibiotic therapy to decrease antibiotic resistance if exacerbations occur within 3 months and to use preventative strategies, including influenza and pneumococcal vaccination and appropriate pharmacotherapy.

Treatment choices

Patients with COPD do not have a lot of respiratory reserve. As such, the initial choice of antibiotic is important, as patients often end up in the emergency department (or worse) if symptoms do not improve. Antibiotic choice is based on which organisms are likely to be colonizing patients’ airways. In those with reasonable lung function (forced expiratory volume in 1 second > 50%) and 3 or fewer exacerbations per year, the likely organisms include Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenza. First-line antibiotics are appropriate for these patients. In those with more severe reduction in lung function, more frequent exacerbations, and numerous comorbidities, the presence of other bacteria, including Gram-positive and Gram-negative β-lactam–resistant bacteria, is more likely; respiratory fluoroquinolones or amoxicillin-clavulanate are appropriate. For those with chronic suppurative disease (eg, bronchiectasis), the presence of other organisms such as Pseudomonas aeruginosa and resistant Enterobacteriaceae entail treatment with ciprofloxacin or parenteral agents.

In addition to antibiotics, inhaled bronchodilators (combinations of short-acting β₂-agonist and anticholinergic inhaled therapies) are indicated to improve lung function and dyspnea symptoms. Oral or parenteral corticosteroids are indicated in most patients with moderate to severe AECOPD. Treatment for 7 to 14 days is recommended, with dose and duration individualized so that patients receive the lowest effective dose. Recommended doses are 25 to 50 mg daily of prednisone or equivalent in patients with moderate to severe COPD.

Hospitalizations account for more than 50% of the total direct cost of COPD,⁹ and short-acting β-agonists are responsible for 49% to 55% of the cost of all inhalers.¹⁰ Long-acting bronchodilators are associated with substantially lower rates of hospitalization (and therefore lower total cost) than short-acting agents are. Clearly prevention of exacerbations and early intervention have huge cost implications.

Barriers to use

Despite the clear benefits of the COPD Action Plan, there are certainly barriers to its use. Physicians need time to teach patients, to review patients’ use of the plans, and to ensure that antibiotics are appropriately prescribed. Systemic steroids do have side effects, and the risk-benefit ratio must be reviewed in the context of patients’ other diseases. Providing only a single repeat on medications helps to ensure follow-up appointments occur. Support resources include the BreathWorks program, Certified Respiratory Educators, and the Lung Association.

Longitudinal research examining self-management behaviour in response to exacerbations in a larger population is needed to improve this tool. Further improvements will occur after the validation studies are complete, and we are working on creating an interactive electronic version for inclusion in electronic medical records.

Early identification and treatment of AECOPD improves outcomes for patients and reduces the costs associated with COPD. The COPD Action Plan provides patients and primary care providers with a tool to facilitate management of these exacerbations when they occur.

Strategies for prevention of AECOPD as recommended by the 2008 CTS COPD update include the following:

• smoking cessation,

• annual influenza vaccination,

• pneumococcal vaccination every 5 to 10 years,

• self-management education,

• regular long-acting bronchodilator therapy for moderate to severe COPD,

• regular therapy with an inhaled corticosteroid and long-acting β-agonist combination for moderate to severe COPD with an average of at least 1 AECOPD per year,

• oral corticosteroid therapy for AECOPD, and

• pulmonary rehabilitation.