Professor Tim McDonnell speaks to Dawn O’Shea about optimising the management of COPD
A 2019 study by University College, Dublin and Cambridge University showed the level of frustration and distress patients experience with the traditional model of COPD care. In one-to-one discussions, patients made comments such as “I don’t think the right hand knows what the left hand is doing”, “I’m confused by conflicting advice”, and “I haven’t had enough physiotherapy”. These responses underline the need for patient-centred holistic approaches to COPD care – which is what the new the ambulatory specialist care hubs hope to do.
This model of care brings with it the need for a new type of consultant – the Integrated Care Consultant. In a new approach to the management of chronic diseases, these consultants will spend 50 per cent of their time holding specialist clinics in the community.
Eighteen ambulatory hubs are being developed and will be associated with 11 hospitals. Each hospital has been resourced for at least one integrated care consultant, and it is expected that additional consultants will be recruited as the hubs develop.
Professor Tim McDonnell, former consultant respiratory physician at St Vincent’s University Hospital, has been involved in the development of these hubs, and he said this new model of care is an important development.
There are a number of core elements to COPD care, he said – reaching a diagnosis, picking a suitable inhaler for the patient and teaching them how to use it appropriately, and what to do in the event of an exacerbation.
“You’ve got the diagnosis to make. Then you have to pick an inhaler for the patient. You’ve got to make sure the patient knows how to use the inhaler appropriately, and knows what to do when they have problems – like steroids and antibiotics. A lot of that is very time-consuming and has to be done in a structured way. GPs are just too busy to do a lot of that. They’re up to their gills putting out fires,” Prof. McDonnell said.
“While most COPD care can be delivered in the primary care setting, GPs need to be resourced and supported to do that”, he said.
“The first thing you need to treat COPD is spirometry. If a GP can’t access that, they’re basically doing a best guess as to what the diagnosis is,” he said.
The new hubs will allow GPs to access spirometry directly within the community, which will be carried out by a respiratory physiologist. Accurate testing is essential given the overlap of COPD symptoms with those of other conditions, particularly asthma and heart failure.
Prof. McDonnell shares his approach to diagnosis.
“There are a few things you have to look at. I always ask the patient when they first started having chest problems. If they had chest problems as a child, that would certainly suggest that they have an asthmatic tendency. Obviously, a history of smoking would push you towards COPD.
“The finding of eosinophilia would push you more towards asthma. It certainly would be a sign that inhaled steroids would be useful, which is a key point in trying to distinguish asthma from COPD. And obviously, if you can get spirometry and check for reversibility.”
“But sometimes we do get caught out,” he said. “I’ve had patients that I thought were pure COPD and they turned out to have an asthma component, and it took a while for the penny to drop with me.”
Non-respiratory conditions should also be considered, Prof. McDonnell said. “There’s always a chance that the patient has heart disease. They have similar risk factors. Both are common, particularly in the elderly. Brain natriuretic peptide (BNP) is often useful but there’s nothing stopping a patient from having both COPD and heart failure. You have to keep that in mind.”
Treatment of COPD
“The two problems COPD patients have is one, shortness of breath (SOB) and exacerbations. For SOB, whether you use a long-acting anticholinergic or a long-acting beta-agonist or a combination of both, that’s your initial approach to SOB,” Prof. McDonnell advised.
“If they’re still SOB, the next step would be an inhaled corticosteroid (ICS) but if that doesn’t work you should probably stop it after six months. Factors that might promote using ICS is if the patient had a slight eosinophilia and if they’re getting exacerbations.”
“The thing to prevent exacerbations is long-acting azithromycin. The trouble with using azithromycin is that it can produce cardiac arrhythmias, so you need an ECG at the beginning that doesn’t show a prolonged QRS interval. There is also the possibility that it will cause some deafness. That might be something you need to talk to the patient about in advance.”
The national COPD guidelines published by the National Clinical Effectiveness Committee in November 2021 recommend azithromycin for one year in patients with severe COPD with two treated exacerbations. First-line antibiotic choices include doxycycline, amoxicillin, or a macrolide.
While there have been little or no major developments in the pharmaceutical arena of late, there has been much more activity in relation to non-pharmacological treatments.
Targeted lung denervation (TLD) is one promising option. The goal of denervation is to disrupt pulmonary nerve input to achieve sustained bronchodilation and reduce mucous secretion, simulating the effect of anticholinergic drugs.
The AIRFLOW-1 study analysed the long-term impact of TLD. Trial results published earlier this year show that the therapy was associated with a stabilisation of exacerbations, lung function and quality of life over a three-year period.
Another emerging treatment is metered cryospray (MCS), which delivers liquid nitrogen to the tracheobronchial airways, ablates abnormal epithelium and facilitates mucosal regeneration.
In a prospective study involving patients with FEV1 30-80 per cent predicted who were taking optimal medication, 34 patients completed three treatments, lasting an average of 34.3 minutes 4-6 weeks apart.
Clinically meaningful improvements in patient-reported outcomes were observed at three months.
Bronchial rheoplasty has also been attracting attention. The procedure uses an endobronchial catheter to apply nonthermal pulsed electrical fields to the airways.
Preclinical studies have demonstrated epithelial ablation followed by regeneration of normalised epithelium.
The first clinical evidence for bronchial rheoplasty was published in 2020. The findings showed significant changes from baseline in COPD Assessment Test (mean, -7.9; median, -8.0; P = 0.0002) and St. George’s Respiratory Questionnaire (SGRQ) at six and 12 months.
It appears we are a long way from finding the Holy Grail of COPD care – a disease-modifying treatment. In the meantime, Prof. McDonnell stresses, that while pharmacological treatments have an important role, patient education, repeated inhaler training, treatment adherence and pulmonary rehabilitation are essential components to optimise symptom control and quality of life.
National Clinical Effectiveness Committee guidelines on the management of COPD
Pharmacological Management of COPD
- Prescribe inhaled SABAs or SAMAs where rescue therapy is needed.
- Offer inhaled LAMAs and LABAs for stable patients with ongoing symptoms.
- LAMAs have a greater impact on exacerbation frequency than LABAs.
- LAMA/LABA combination has a greater impact than monotherapy.
- First-line inhaled corticosteroid (ICS) are not routinely recommended.
- ICS should be considered for asthma-COPD overlap syndrome (ACOS).
- Patients with blood eosinophils <0.1 x109 are unlikely to benefit from ICS.
- ICS with LABA is more effective than the individual components in reducing exacerbations in moderate to very severe COPD.
- Triple inhaled therapy with ICS/LAMA/LABA delivers added benefit.
- Roflumilast can be used in selected patients with chronic bronchitic phenotype of COPD with severe to very severe air flow obstruction and history of exacerbations.
- Theophylline can be used in selected patients.
- In patients with severe COPD with two treated exacerbations, the addition of azithromycin may be considered for one year.
- Routine mucolytic and antioxidants is not recommended.
- Leukotriene receptor antagonists are not recommended.
- Provide nutrition support to malnourished patients.
- Lung volume reduction surgery is recommended for carefully selected patients with upper lobe emphysema and low post-rehabilitation exercise capacity.
- Bullectomy is recommended for selected patients.
- In selected patients with advanced emphysema, bronchoscopic interventions are recommended.
Management of Exacerbations
- Initiate short-acting acute bronchodilator therapy.
- Systemic steroids (prednisolone recommended dose of 40mgs) once daily for five days.
- First-line antibiotic choices include doxycycline, amoxicillin, or a macrolide.