COPD

Definition

Chronic obstructive pulmonary disease = chronic obstructive airway disease where the obstruction if not fully reversible.
Includes chronic bronchitis, emphysema, and asthma with incomplete reversibility of airway obstruction.

Risk factors

Cigarette smoking is the leading cause of COPD.

There is a dose–response relationship between tobacco exposure and decline in FEV1.

Individual susceptibility varies: about half of smokers develop some airflow limitation, and around 15–20% develop clinically significant COPD disability.

Even smokers without spirometric COPD can still have respiratory symptoms, reduced exercise tolerance, and subtle lung function abnormalities.

Smokers with COPD are also at increased risk of lung cancer, ischaemic heart disease, and peripheral vascular disease.

In susceptible smokers, COPD usually causes a progressive decline in lung function, with FEV1 falling by about 25–100 mL/year.

COPD often develops slowly and insidiously, so impairment may go unrecognised until disease is advanced.

Smoking cessation is the most important intervention:

may only slightly improve lung function,
but importantly slows further FEV1 decline,
and delays disability.

COPD usually reflects a gene–environment interaction.

The best recognised genetic factor is alpha-1 antitrypsin deficiency.

Other genetic factors likely contribute smaller effects.

Second-hand smoke increases COPD risk.

Risk is higher with longer duration of exposure, especially >5 years.

Hookah/water-pipe smoking is also associated with COPD, especially with:

older age,
longer smoking duration,
male sex,
heavier use,
chronic cough, sputum, and dyspnoea.

Occupational exposure is a major non-smoking cause of COPD and may account for 20–30% of cases.

Important occupational risks include exposure to:

dusts (mineral, organic, biological),
vapours, gases, fumes,
diesel exhaust,
pesticides,
respirable quartz.

Higher-risk occupations include:

agriculture/farming,
fishing,
warehouse work,
plastics processing,
food/drink/tobacco processing,
gardening/grounds work,
artistic restoration and engraving-related work.

Occupational risks are also seen in never-smokers.

Combined exposure to smoking plus occupational hazards markedly increases COPD risk.

Biomass smoke exposure from indoor cooking/heating is an important global COPD risk factor.

In Australia/NZ this is less common, but indoor pollutants such as PM2.5 and NO2 can worsen symptoms and exacerbation risk.

Outdoor air pollution, including coal fire smoke and landscape fire smoke, is also a recognised risk.

Poor lung growth or reduced maximal lung function early in life increases later COPD risk.

Important early-life risks include:

premature birth,
impaired lung development,
childhood respiratory infections.

Asthma is an important risk factor for later COPD.

Risk is particularly high with:

early-onset persistent asthma with allergy,
late-onset asthma with allergy,
childhood asthma history.

This supports the concept of treatable traits and early airway disease management to reduce future COPD risk.

Other recognised COPD risk factors include:

age and sex,
lower socioeconomic status,
chronic bronchitis,
airway hyper-reactivity,
tuberculosis,
childhood respiratory infection.

Tuberculosis can cause permanent lung damage and is associated with a higher later risk of COPD, likely through airway fibrosis and scarring.

There is some evidence that women may be more susceptible to tobacco smoke effects, with faster FEV1 decline after midlife.

Symptoms and Signs

Symptoms: dyspnoea on exertion; chronic cough (esp productive); decreased exercise tolerance. Always consider other comorbidities (eg coronary).
Signs: chest hyperinflation; wheeze; prolonged expiratory phase; Barrel shaped chest; Hoover’s sign; features of right HF / pulm HTN

Investigations

(https://www.safetyandquality.gov.au/standards/clinical-care-standards/chronic-obstructive-pulmonary-disease-clinical-care-standard/information-clinicians)

A diagnosis of COPD must rely on spirometry, as clinical features and imaging alone are insufficient.
Spirometry Indications:
- For individuals over 35 with recurrent respiratory symptoms and at least one risk factor.
- For patients with suspected COPD exacerbations where spirometry confirmation is lacking.
- Spirometry should be delayed in those with an active respiratory infection.
High-Quality Spirometry:
- Performed before and after administering a bronchodilator.
- Executed by trained and competent clinicians.
- Requires regular calibration and quality control of spirometers following ATS and ERS standards.
- If unavailable, referral to specialized centers is recommended.
Spirometry Results:
- A post-bronchodilator FEV1/FVC ratio of less than 0.7 is diagnostic of COPD, with insignificant improvement post bronchodilator = COPD
- FEV1 (% predicted) can be used to gauge disease severity.
- Trap:
  - significant air trapping can cause reduction in FVC.
  - Plethysmographic studies useful to differentiate between gas trapping and mixed obstructive-restrictive lung diseases.
- Near-threshold results warrant a repeat test for confirmation.
CXR:
- may show hyperinflation, flattened diaphragm, bullae.
- ABG: useful during acute exacerbations if concerned about respiratory acidosis; also require for home O2 therapy (if <55mmHg, or <60mmHg with RVF).
6 min walk test:
- functional capacity
- Can be used to monitor treatment.
If concerns about cor pulmonale, TTE and DLCO useful.
Investigations for comorbidities:
- eg ischaemic heart disease (cigarette common risk factor for both conditions).

Classification of severity of chronic obstructive pulmonary disease (COPD)
	MILD	MODERATE	SEVERE
Typical Symptoms	Few symptoms	Breathless walking on level ground	Breathless on minimal exertion
	Breathless on moderate exertion	Increasing limitation of daily activities	Daily activities severely curtailed
	Cough and sputum production	Recurrent chest infections	Exacerbations of increasing frequency and severity
	Little or no effect on daily activities	Exacerbations requiring oral corticosteroids and/or antibiotics
Typical Lung Function	FEV₁ ≈ 60-80% predicted	FEV₁ ≈ 40-59% predicted	FEV₁ < 40% predicted
FEV₁=forced expiratory volume in one second. PaO₂=partial pressure of oxygen, arterial. PaCO₂=partial pressure of carbon dioxide, arterial.

Pharmacological Management

Step 1: Reliever Therapy (All Patients)

Purpose: Immediate symptom relief

Medications:

SABA: salbutamol, terbutaline
SAMA: ipratropium

Use:

PRN for breathlessness

✔ Appropriate as initial therapy
✔ Can continue alongside all later steps

Step 2: Regular Long-Acting Bronchodilator (First-Line Maintenance)

Indication: Persistent dyspnoea or activity limitation

Options (choose ONE initially):

LAMA (preferred in COPD): tiotropium, umeclidinium, glycopyrronium
LABA: formoterol, salmeterol, indacaterol

Key points:

LAMA generally provides better exacerbation reduction
Continue SABA PRN
❌ Avoid LAMA + SAMA combination
- Same mechanism → no meaningful added benefit
  - Both LAMA (e.g. tiotropium) and SAMA (e.g. ipratropium) are:
    - Muscarinic (M3) receptor antagonists
    - Work via anticholinergic bronchodilation
  - Using both together = duplicate therapy
  - Minimal additional bronchodilation compared to LAMA alone
  - LAMA already provides long, sustained receptor blockade (24h)

Step 3: Dual Bronchodilator Therapy (LABA + LAMA)

Indication:

Ongoing breathlessness despite monotherapy

Examples:

indacaterol/glycopyrronium
umeclidinium/vilanterol
tiotropium/olodaterol

Action before escalation:

Check adherence
Check inhaler technique
Address non-pharmacological factors (deconditioning, anxiety)

✔ This is the mainstay for symptomatic COPD

Step 4: Add ICS (Selective Use – Not Routine)

Indication (important correction):

Frequent exacerbations (≥2/year or ≥1 hospitalisation)
AND features suggesting steroid responsiveness, e.g.:
- Blood eosinophils ≥300 cells/µL (or ≥100 with exacerbations)
- Co-existing asthma / ACO

Options:

ICS/LABA (e.g. budesonide/formoterol)
Triple therapy (ICS + LABA + LAMA) preferred if already on dual bronchodilator

⚠️ Key cautions:

↑ risk pneumonia
Avoid if low eosinophils + no exacerbations
Review regularly and consider de-escalation

Step 5: Advanced / Add-on Therapies (Specialist-guided)

Macrolides

Indication:

Severe COPD with frequent exacerbations despite optimal inhaled therapy

Regimen:

Azithromycin 250 mg daily or 3x/week

Risks:

QT prolongation → ECG required
Hearing impairment
Antimicrobial resistance

Other options (often overlooked in COPD-X)

Roflumilast (chronic bronchitis + FEV1 <50%)
Mucolytics (e.g. carbocisteine in selected patients)
Long-term oxygen therapy (if hypoxic)

https://files.nationalasthma.org.au/resources/NAC055-Asthma-COPD-Medications-Chart-2025_A4_WEB.pdf

Class	Medication (Brand)	Drug(s)	Typical Adult Dose	Notes
SABA	Ventolin, Airomir	Salbutamol	1–2 puffs (100 mcg) PRN (up to q4h)	First-line reliever
	Bricanyl	Terbutaline	500 mcg inhalation PRN	Alternative reliever
SAMA	Atrovent	Ipratropium	2 puffs (20 mcg) QID	COPD / acute asthma adjunct
ICS	Flixotide	Fluticasone propionate	100–500 mcg BD	Preventer
	Pulmicort	Budesonide	200–400 mcg BD (↑ to 800 BD)	Preventer
	QVAR	Beclometasone	100–200 mcg BD	Fine particle
	Alvesco	Ciclesonide	80–160 mcg daily (max 320)	Lower SE profile
	Arnuity Ellipta	Fluticasone furoate	100–200 mcg OD	Once daily
LABA	Serevent	Salmeterol	50 mcg BD	❌ Not alone in asthma
	Oxis	Formoterol	6–12 mcg BD	Fast onset
	Onbrez Breezhaler	Indacaterol	150–300 mcg OD	COPD only
LAMA	Spiriva Respimat	Tiotropium	2 puffs OD (5 mcg total)	COPD / severe asthma add-on
	Spiriva Handihaler	Tiotropium	18 mcg OD	Capsule device
	Incruse Ellipta	Umeclidinium	62.5 mcg OD	COPD
	Seebri Breezhaler	Glycopyrronium	50 mcg OD	COPD
	Bretaris Genuair	Aclidinium	400 mcg BD	COPD
ICS/LABA	Symbicort	Budesonide + Formoterol	1–2 BD ± PRN (MART, max ~12/day)	Preferred asthma
	Seretide	Fluticasone + Salmeterol	1 inhalation BD	No PRN use
	Breo Ellipta	Fluticasone furoate + Vilanterol	1 OD	Once daily
	Flutiform	Fluticasone + Formoterol	BD
	Fostair	Beclometasone + Formoterol	1–2 puffs BD	Fine particle
LABA/LAMA	Anoro Ellipta	Umeclidinium + Vilanterol	1 OD	COPD
	Spiolto Respimat	Tiotropium + Olodaterol	2 puffs OD	COPD
	Ultibro Breezhaler	Indacaterol + Glycopyrronium	1 OD	COPD
	Brimica Genuair	Aclidinium + Formoterol	BD	COPD
Triple Therapy	Trelegy Ellipta	Fluticasone + Umeclidinium + Vilanterol	1 OD	Severe COPD/asthma
	Trimbow	Beclometasone + Glycopyrronium + Formoterol	2 puffs BD
	Breztri Aerosphere	Budesonide + Glycopyrronium + Formoterol	2 puffs BD
	Enerzair Breezhaler	Mometasone + Indacaterol + Glycopyrronium	1 OD
LTRA	Montelukast	Montelukast	10 mg nocte	Add-on asthma

Inhaler and Spacer Technique

Clinician Preparation:
- Ensure all healthcare providers have a solid understanding of the correct inhaler techniques.
- Misuse is common; up to 90% of patients may not use inhalers correctly, leading to suboptimal drug delivery.
Education and Demonstration:
- Demonstrate proper inhaler use, including:
  - Breath-Actuated Inhalers: Ensure slow, steady inhalation.
  - Pressurized Metered-Dose Inhalers (pMDIs): Use a spacer device for optimal drug delivery.
  - Dry Powder Inhalers (DPIs): Ensure fast and deep inhalation.
- Educate on cleaning, maintenance, and storage.
Regular Technique Checks:
- Evaluate technique:
  - Before escalating treatment.
  - After any change in therapy.
  - Following an exacerbation.
- Consider a
  - Home Medicines Review (HMR) or
  - Residential Medication Management Review (RMMR) to assess adherence and technique.
Simplification Strategies:
- Use familiar devices or combination inhalers when possible.
- Educate on the environmental impact of inhalers and recommend greener alternatives if suitable.

Acute Exacerbations

Recognizing Exacerbations:

Key Symptoms:
- Increased breathlessness beyond normal day-to-day variation.
- Reduced exercise tolerance and increased fatigue.
- Tachypnea, increased cough, and sputum production (especially if purulent).
- Fever may indicate an infectious trigger.
Differential Diagnoses: Consider heart failure, pulmonary embolism, pneumonia, and sepsis.

General Treatment Approach:

An exacerbation of COPD can involve increased airflow limitation, excess sputum production, airway inflammation, infection, hypoxia, hypercarbia, and acidosis.
Treatment is directed at addressing each of these problems.

Confirm Exacerbation and Categorize Severity:

Medical History & Examination: Essential to gather a detailed history and conduct a thorough physical examination.
Spirometry: Used to confirm COPD diagnosis, especially useful prior to discharge.
Oxygenation Assessment:
- Pulse Oximetry: Routine measurement alongside other vital signs.
- Arterial Blood Gases (ABGs): Indicated if:
  - FEV1 < 1.0 L or < 40% predicted.
  - SpO2 < 92% with adequate perfusion.
  - Falling SpO2 and increased FiO2 needed.
  - Risk of hypercapnia.

Spirometry:

Purpose: Confirms diagnosis of COPD by demonstrating airflow limitation.
Timing: Can be performed prior to discharge to verify diagnosis.

Assess Oxygenation:

Pulse Oximetry: Should be recorded routinely.
Arterial Blood Gases: Crucial for:
- FEV1 < 1.0 L or < 40% predicted.
- SpO2 < 92%.
- Declining SpO2 with increased FiO2.
- Risk of hypercapnia.
- Hypoxaemic respiratory failure: PaO2 < 60 mmHg.
- Ventilatory failure: PaCO2 > 45 mmHg.
- Respiratory acidosis: Indicates need for assisted ventilation.

Venous Blood Gases (VBG):

Study by McKeever et al (2016):
- VBG pH ≤7.34 had high sensitivity (88.9%) and specificity (95.6%) for ABG pH ≤7.35.
- VBGs suggested for initial assessment, ABGs for further assessment if VBG pH ≤7.34.
- Caution due to lesser precision with VBGs.

Chest X-ray and ECG:

Purpose: Identify alternative diagnoses and complications (e.g., pulmonary oedema, pneumothorax, pneumonia, empyema, arrhythmias, myocardial ischaemia).

Clinical Prediction Score – BAP-65:

Parameters: Age, basal urea nitrogen, acute mental status change, pulse.
Utility: Predicts in-hospital mortality.
- Mortality increases with higher score classification (from 1 to 5).
- Highest class mortality: 14.1% to >25%.

CXR and Pneumonia:

Study (2012): 920 patients with COPD exacerbation.
- Higher mortality with CXR-confirmed pneumonia (20.1% vs. 5.8%, p<0.001).
Dyspnoea Severity: Associated with in-hospital mortality and early readmission.

Medications

1. Bronchodilators:

Inhaled Beta-Agonists:
- Salbutamol: 400–800 mcg
- Terbutaline: 500–1000 mcg
Antimuscarinic Agents:
- Ipratropium: 80 mcg
Administration Methods:
- Pressurised metered dose inhaler (pMDI) with spacer
- Jet nebulisation:
  - Salbutamol: 2.5–5 mg
  - Terbutaline: 5 mg
  - Ipratropium: 500 mcg
Dosing Interval: Titrate based on response, ranging from hourly to six-hourly.
Delivery Method Efficacy: No significant difference between nebulisers and pMDI with spacer regarding FEV1 at one hour and serious adverse events (van Geffen 2016) [evidence level I].

3. Corticosteroids:

Oral Corticosteroids: Hastens resolution and reduces relapse likelihood.
Typical Regimen: Prednisolone 40–50 mg daily for up to two weeks.
Longer Courses: Do not add benefit and increase risk of side effects.
Recommended Regimen as per COPDx:
- 5-day course of oral prednisolone at 30mg to 50mg.
- Tapering may be necessary for patients on corticosteroids for longer than 14 days.
- Long-term corticosteroid therapy (>7.5 mg prednisolone daily for more than 6 months) increases the risk of osteoporosis.
- Prevention and treatment of corticosteroid-induced osteoporosis should be considered.
- Longer courses of prednisolone may increase mortality and pneumonia risk (Sivapalan 2019).

4. Antibiotics:

Indication: Clinical Features of Infection: Increased sputum volume, change in sputum color, and/or fever warrant antibiotic therapy (evidence level II, strong recommendation).
Common Pathogens:
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
First-Line Antibiotics:
- Amoxicillin 500 mg three times daily.
- Doxycycline 100 mg daily.
- Avoid Broad-Spectrum Antibiotics unless specific indications exist; they do not offer superior outcomes and may increase harm.
- Intravenous Antibiotics: Reserved for patients unable to take oral medications.

5. Controlled Oxygen Therapy:

Indication: For patients with hypoxia, aiming to improve oxygen saturation to 88-92%.
Delivery Methods:
- Nasal prongs: 0.5–2.0 L/min
- Venturi mask: 24% or 28%
Caution: Minimize excessive oxygen to avoid worsening hypercapnia.

6. Ventilatory Assistance:

Indication: For increasing hypercapnia and acidosis.
Preferred Method: Non-invasive ventilation (NIV) via mask.

Summary

Antibiotics are beneficial in COPD exacerbations with signs of bacterial infection.
Diagnostic indicators like sputum purulence, CRP, and procalcitonin levels can guide antibiotic use.
Short courses of antibiotics are generally as effective as longer courses and have fewer adverse effects.
Combination therapy with corticosteroids and antibiotics is effective, particularly in the early stages of treatment.

Chronic Management

1. Smoking Cessation

Cease Smoking:
- Smoking cessation is the most critical intervention for all COPD patients.
- Use a combination of behavioral support and pharmacotherapy as recommended by Australian guidelines:
  - Nicotine Replacement Therapy (NRT): patches, gum, lozenges, sprays.
  - Prescription Medications: Varenicline (Champix) or bupropion (Zyban).
- Access local Quitline services and utilize the ‘Ask, Advise, Help’ approach for smoking cessation.

2. Inhaler Therapy – Regularly assess and educate on correct inhaler technique and spacer use.

3. Vaccination Recommendations

Annual Influenza Vaccine: Recommended for all COPD patients to prevent flu-related complications.
Pneumococcal Vaccine:
- 13-valent Pneumococcal Conjugate Vaccine (Prevenar 13) and 23-valent Pneumococcal Polysaccharide Vaccine (Pneumovax 23) based on age and risk factors.
COVID-19 Vaccine: Ensure COPD patients are up to date with COVID-19 vaccinations.

4. Pulmonary Rehabilitation

Multidisciplinary Pulmonary Rehabilitation Programs:
- Strongly recommended for all symptomatic COPD patients.
- Includes exercise training, education, and behavior change support.
- Refer to local programs using resources like the Lung Foundation Australia’s Pulmonary Rehabilitation Finder.
- Benefits include reduced breathlessness, improved quality of life, and fewer hospitalizations.

5. Long-Term Oxygen Therapy (LTOT)

Indications for LTOT:
- Resting PaO₂ < 55 mmHg, or 55–60 mmHg with evidence of right heart failure or polycythemia.
- Must be non-smoker due to fire hazard.
- Requires specialist referral for assessment and initiation.
Duration: Minimum of 15 hours/day to improve survival in hypoxaemic patients.
Intermittent Oxygen:
- Consider for use during exertion if oxygen saturation falls below 88%.

6. Fitness to Fly

Pre-Flight Assessment:
- Assess the need for supplemental oxygen during air travel if SpO₂ < 92% at rest or during exertion.
- Refer to the Lung Foundation Australia’s resources on fitness to fly for further guidelines.

7. Management of Comorbidities

Cardiovascular Disease: Screen for and manage comorbidities like hypertension, ischemic heart disease, and heart failure.
Diabetes: Monitor blood glucose regularly in COPD patients with comorbid diabetes.
Osteoporosis: Consider bone density testing for patients on long-term corticosteroids.
Mental Health:
- Regularly assess for anxiety and depression. Refer to mental health professionals if needed.
- Address social isolation with referrals to community programs or support groups.

8. Surgical and Advanced Interventions

Lung Volume Reduction Surgery (LVRS):
- Consider for select patients with upper-lobe predominant emphysema and low exercise capacity after rehabilitation.
Bronchoscopic Interventions:
- Endobronchial Valves for lung volume reduction in emphysema patients not suitable for surgery.
- Requires specialist evaluation in tertiary centers.
Lung Transplant:
- Consider for end-stage COPD patients under 65 with severe disease not responsive to maximal medical therapy.

9. Multidisciplinary Team (MDT) Involvement

(multidisciplinary team approach; see http://lungfoundation.com.au/wp-content/uploads/2014/02/Pulmonary-Rehab-Fact-Sheet-Feb-2015.pdf)
Collaborate with a multidisciplinary team including:
- Respiratory specialists
- general practitioners
- pharmacists
- physiotherapists
- dietitians
- social workers
- mental health professionals.
- Ensure coordination between hospital and primary care for seamless follow-up post-hospitalization.

10. Regular Monitoring and Self-Management Education

Patient Education:
- Educate on COPD self-management, including recognizing symptoms of exacerbation and proper use of inhalers.
- Encourage adherence to medications and inhaler technique.
- Utilize tools like the COPD Action Plan to guide early management of exacerbations.
Exacerbation Management:
- Create a personalized action plan, including when to seek medical help.
- Teach patients breathing techniques, energy conservation methods, and airway clearance techniques.

11. Telehealth and Remote Support

Telehealth:
- Utilize telehealth for regular follow-up, particularly for patients in rural and remote areas.
- Leverage online education tools and apps endorsed by Lung Foundation Australia for self-management support.

(Controversial)

Long term prophylactic antibiotics (usually macrolide): shown to decrease exacerbations, but promotes resistance. Specialist initiated only.
Theophylline: reduced exacerbations, but multiple side effects.

Symptom Support and Palliative Care for COPD

Early Palliative Care Consideration:

Start a palliative approach from diagnosis, especially for those with significant comorbidities.
Address the misconception that palliative care is only for end-of-life patients

Factors Indicating Palliative Care Need:

Poor respiratory function (e.g., FEV1 < 25% predicted, hypoxaemia).
Need for advanced respiratory therapy (e.g., home oxygen).
Severe comorbidities (e.g., heart failure).
Unintended weight loss or cachexia.
Functional decline or increasing dependence.
Difficult physical or emotional symptoms.
Disease progression or frequent hospitalisations.

Holistic Approach:

Address all aspects of patient well-being.
Offer referrals to specialists (e.g., physiotherapists, psychologists) based on patient needs.

Advance Care Planning:

Discuss and establish an advance care plan if not already done.
Document and upload to the patient’s My Health Record if applicable.

Cultural Safety and Equity for Aboriginal and Torres Strait Islander People in COPD Care

from: https://www.safetyandquality.gov.au/standards/clinical-care-standards/chronic-obstructive-pulmonary-disease-clinical-care-standard/information-clinicians

nts:

Domain	Key Strategies
1. Culturally Safe Communication and Care	– Build trust through long-term engagement – Encourage self-identification as ATSI – Use clear, jargon-free language – Engage interpreters when needed – Be mindful of body language and non-verbal cues
2. Collaborative Approach to Care	– Involve patients in shared decision-making – Use culturally appropriate visual aids – Include family, carers, and Elders in consultations – Recognise and accommodate extended family structures
3. Inclusion of ATSI Health Professionals	– Integrate Aboriginal Health Workers into care team – Involve in education, discharge, and follow-up – Provide staff cultural safety training to address bias
4. Flexibility in Service Delivery	– Offer flexible appointments and outreach services – Consider home visits and telehealth – Partner with Aboriginal Medical Services (AMS)
5. Tailored COPD Management	– Respect traditional beliefs and healing practices – Use holistic language (physical, emotional, spiritual) – Provide culturally relevant diet and activity advice
6. Social and Environmental Considerations	– Assess housing, crowding, dust/smoke/mould exposure – Address barriers to medication access in remote areas – Provide education on reducing traditional and second-hand smoke exposure – Address social determinants (e.g. income, education, housing)
7. Preventative Measures and Early Diagnosis	– Implement early COPD screening in high-risk groups – Promote influenza and pneumococcal vaccination – Discuss smoking cessation respectfully – Use culturally adapted Quitline and support programs
8. End-of-Life Cultural Practices	– Initiate culturally sensitive palliative care discussions – Involve family and community in end-of-life planning – Support traditional and spiritual needs – Provide mental health and grief support
9. Quality Monitoring and Improvement	– Record ATSI status in health records – Audit services for cultural safety – Engage ATSI community in service and policy development
10. Community Empowerment	– Deliver community COPD education – Support ATSI-led health initiatives – Encourage culturally congruent self-management strategies

COPDX approach

C – confirm diagnosis and grade severity
- Suspect the diagnosis with a suggestive history of chronic cough, sputum production, exertional dyspnoea, wheeze and frequent exacerbations
- Confirm with Spirometry demonstrating FEV1/FVC<70% obstructive pattern.
- Classify the severity into mild, moderate and severe by symptom severity, functional impairment, frequency of exacerbation and spirometry values.
O – optimise function
- Education
  - Involves information on
    - disease management
    - its progression
    - treatment options
    - self-management strategies
    - proper inhaler technique
    - recognition of exacerbations
- Lifestyle measures
  - Exercise Training: Improves exercise tolerance, reduces dyspnea, and enhances quality of life. Recommended activities include aerobic exercises (walking, cycling) and resistance training.
- Nutritional Support
  - Malnutrition: High-calorie, high-protein diets to prevent muscle wasting.
  - Obesity: Weight management programs to reduce the work of breathing
- Medication measures
  - Step-wise management as per guidelines with SABA, SAMA, LABA, LAMA and ICS
  - Long-term oxygen therapy for patients with chronic respiratory failure (PaO₂ ≤ 55 mmHg or SaO₂ ≤ 88%).
  - Ambulatory oxygen therapy for those with significant desaturation during exercis
  - Chest Physiotherapy
    - Includes postural drainage, chest percussion, and vibration.
P – prevent deterioration
- Pulmonary rehabilitation
  - Refer all COPD patients, including those hospitalized for exacerbations, to pulmonary rehabilitation.
  - Ensure rehabilitation starts within four weeks after hospital discharge to prevent readmission and improve outcomes.
  - If hospital-based rehab is unavailable, consider telerehabilitation, local exercise programs, or specialists in pulmonary care.
    - Exercise
    - education
    - breathlessness management
    - medication guidance
    - nutrition
    - psychological support
- Immunisation (influenza, pneumococcal)
  - Influenza Vaccine: Annually to reduce the risk of respiratory infections.
  - Pneumococcal Vaccine: Both PPSV23 and PCV13 are recommended to prevent pneumococcal disease.
- Smoking cessation
  - Behavioural counselling.
  - Pharmacotherapy (e.g., nicotine replacement therapy, varenicline, bupropion).
  - Support groups and smoking cessation programs.
- Avoidance of Environmental Pollutants
  - Minimizing exposure to indoor and outdoor air pollutants, dust, and occupational irritants.
  - Use of air purifiers and proper ventilation at home.
- Psychosocial Support
  - Counseling or therapy for patients experiencing anxiety, depression, or social isolation.
  - Support groups for patients and caregivers.
D – develop a management plan
- GP management plan
- COPD action plan
- Advanced care directive
X – manage acute exacerbations
- Oxygen, NIV
- Bronchodilator
- Steroids
- Antibiotics