Diagnosis and management of COPD in Māori and Pacific peoples

Chronic Obstructive Pulmonary Disease (COPD) is estimated to affect 15% of all New Zealanders aged over 45 years.¹ It is the fourth leading cause of death in New Zealand behind cancer, heart disease and stroke.¹ COPD is permanent, disabling and frequently progressive. Over 85% of cases of COPD are caused by inhalation of tobacco smoke.¹

COPD in Māori and Pacific peoples

Amongst New Zealanders aged 50 – 64 years, Māori are approximately five times more likely to die from COPD-related causes than non-Māori and are affected by COPD up to 20 years earlier.^2,3 COPD is ranked as the third highest health priority for Pacific peoples in the Auckland DHB region.⁴

There is also evidence that COPD may be under-diagnosed in New Zealand, especially among Māori. In a study of 3500 randomly selected people aged over 25 years in the greater Wellington area, 736 people were referred for pulmonary testing. Overall, 16% of those tested had COPD, and 23% of Māori in the group had COPD.⁵

Hospital discharge rates (Figure 1) show that Māori and Pacific peoples are three to four times more likely to be admitted to hospital for COPD than people in other ethnic groups in New Zealand.⁶

Promoting awareness may encourage Māori and Pacific peoples with COPD to contact their general practice earlier. Some patients may delay visiting their doctor due to the slowly progressive nature of the disease, while others may be dismissive of their symptoms, e.g. just a "smoker's cough" or "just being older and unfit". Financial barriers to accessing services are also likely to contribute.⁷

Every Māori or Pacific person who is a current, or ex-smoker, or has household members that smoke should be made aware of the:

• Support that is available to help them stop smoking
• Symptoms of COPD and the need to visit a health professional if a family member displays symptoms
• High impact COPD has on Māori and Pacific communities

Once a person has symptoms of COPD, lung damage has already occurred. This damage cannot be reversed, but can be substantially slowed through smoking cessation and prevention of exacerbations.

"Support not blame" is an important approach for health professionals engaging with people who have COPD. A feeling of judgement or blame, because of the association between smoking and COPD, may cause people to present to their general practice later than they otherwise would have. General practice staff need to be seen as welcoming and supportive.

Spirometry

Spirometry is the recommended method for diagnosing COPD.⁸ Ideally this should be performed with a device that allows electronic analysis of results (see "Spirometry devices"). International guidelines recommend that spirometry should be offered to any person aged over 40 years with any of the following characteristics:²

• Chronic cough (may be sporadic and unproductive)
• Chronic sputum production (phlegm)
• Dyspnoea that is persistent or progressive and worse with exercise
• History of exposure to tobacco, occupational smoke, dust or chemicals
• Family history of COPD

Due to the earlier age of onset and increased burden of COPD in Māori and Pacific peoples, testing for COPD in selected people who are at increased risk should begin at a younger age, e.g. Māori or Pacific peoples who are heavy smokers and have a family history of COPD may benefit from being offered testing from age 30 years.

It is important that normal spirometry results are not interpreted by the patient as a disincentive to stop smoking. Conversely, early detection and the "shock" of a diagnosis of COPD often helps to motivate people to stop smoking.⁹

Asthma Societies throughout New Zealand provide spirometry and support services for people with COPD. A list of local branches of Asthma Societies is available from:
www.asthmafoundation.org.nz/asthma_societies.php

If spirometry is unavailable, questionnaires, such as the clinical COPD questionnaire (CCQ), may be used as an indication of the likelihood of COPD.

The clinical COPD questionnaire is available from: http://ccq.nl/

Spirometry testing should be performed when the patient is clinically stable and without infection. Patients should be advised not to use a short-acting bronchodilator in the six hours prior to testing, or a long-acting bronchodilator in the 12 hours prior to testing.

Values should be measured:

• Before and 10 – 15 minutes after administering a short-acting beta-2 agonist, e.g. salbutamol 400 micrograms (four puffs) via a spacer
• or
• Before and 30 – 45 minutes after administering a short-acting anticholinergic, e.g. ipratropium 160 micrograms (eight puffs) via a spacer

A diagnosis of COPD is defined as a post-bronchodilator forced expiratory volume (in one second) to forced vital capacity ratio (FEV1/FVC) of < 0.7.¹⁰

The peak expiratory flow rate (PEFR) should not be used in the diagnosis or management of COPD as it is a measure of airflow in large airways.

Assessing the severity of COPD

Assessment of COPD severity should take into account the following:²

• Level of breathlessness (Table 1)
• Spirometry results (Table 2)
• Exacerbation risk – calculated from the number of exacerbations experienced in the previous 12 months: less than two exacerbations is low risk, two or more is high risk
• Presence of co-morbidities – influences risk of hospitalisation and overall mortality risk

Once a diagnosis of COPD has been made, there is strong evidence that smoking cessation reduces the rate of lung function decline.10 People with COPD who smoke, typically smoke more cigarettes per day than other smokers and have a comparatively higher physical dependence to nicotine.15 Motivating a person with COPD to stop smoking (i.e. using "ABC" – ask, brief advice, cessation support) should be the primary management focus, followed by pharmacological treatment, pulmonary rehabilitation and management of exacerbations.

For further information on smoking cessation see: "Update on smoking cessation", BPJ 33 (Dec, 2010).

Pharmacological treatment of COPD

Medicines for COPD are used to improve patient comfort and exercise tolerance while reducing the frequency of exacerbations. No medicine currently available has been conclusively shown to modify the long-term decline in lung function associated with COPD.2 Medicine choice should be based upon severity of symptoms and patient-specific response (Table 3). It is important that patients and their whānau monitor symptoms in order to discuss management with their healthcare team. If inhaled medicines are used, training in inhaler technique is essential and inhaler technique should be regularly assessed.

The Asthma Foundation website has printable booklets which provide instructions on correct inhaler use, storage and cleaning. Available from: www.asthmafoundation.org.nz/resources.php

Choosing a treatment regimen

The following points are generally applicable when selecting medicines for the management of stable COPD:²

• Inhaled bronchodilators are preferable to oral bronchodilators
• When symptoms are mild, short-acting bronchodilators are preferable to long-acting formulations
• When symptoms are more severe, long-acting bronchodilators are superior due to increased duration of action and a reduction in the risk of exacerbations. There is no strong evidence to recommend one long-acting formulation over another and treatment choice should be based on patient perception of symptom relief
• When COPD is severe and the risk of exacerbations is high, the addition of inhaled corticosteroids is indicated
• Suggested starting doses of medicines are listed in Table 4

MDI = metered dose inhaler, DPI = dry powder inhaler

Short-acting beta-2 agonists (SABA), e.g. salbutamol, terbutaline, are usually prescribed as "rescue" medicine (as required) for the relief of breathlessness.

Short-acting anticholinergics, e.g. ipratropium, have been shown to improve quality of life and decrease the need for oral corticosteroid treatment, while decreasing the risk of adverse effects compared to SABA.¹⁰

Short-acting combinations, e.g. salbutamol and ipratropium, have been shown to improve spirometry results and reduce the need for oral corticosteroids, compared to ipratropium alone.¹⁰

Long-acting beta-2 agonists (LABA), e.g. salmeterol, reduce exacerbations and improve symptoms, and are more effective at maintaining symptom relief than SABAs. They are effective for at least 12 hours and can be administered twice daily.

Long-acting anticholinergics, e.g. tiotropium, reduce exacerbations and have an effect over 24 hours and are therefore administered once daily. There is an increased risk of dry mouth and urinary retention. Tiotropium is fully subsidised under Special Authority.

Inhaled corticosteroids (ICS), e.g. budesonide, fluticasone, decrease the exacerbation rate compared to placebo, and increase quality of life,² but do not appear to prevent lung function deterioration and may increase the risk of pneumonia.12 Systemic absorption does occur and long-term use must be balanced against the risk of adverse effects. Beclomethasone is also available but there is less evidence for its use in COPD.

Combination inhaled corticosteroids with long-acting beta-2 agonists, e.g. budesonide with eformoterol and fluticasone with salmeterol (fully subsidised under Special Authority), can be taken twice daily.

Theophylline, available in long-acting tablets or oral liquid, is used as a third-line treatment for people with COPD when other bronchodilators are either ineffective or unavailable for long-term treatment.

Long-term continuous oxygen therapy (16 – 24 hours per day) may be of benefit in selected patients with COPD who have a PaO2 consistently less than 55 mm Hg. Home oxygen is usually initiated by a respiratory physician. The patient must be clinically stable and have stopped smoking for at least one month.

Managing exacerbations

A COPD exacerbation is an acute event where symptoms deteriorate beyond normal day-to-day variation to the point where a change in the medicine regimen is required.² This is characterised by an increase in dyspnoea, cough or sputum production, most commonly caused by a respiratory tract infection. COPD exacerbations are known to increase the rate of lung function decline and are associated with increased rates of mortality.17 The higher rate of hospitalisation amongst Māori and Pacific peoples due to COPD suggests that COPD exacerbations affect these groups more significantly than other groups. People with COPD need to be able to identify exacerbations and seek treatment early.

Strategies to reduce the risk of exacerbations include:

• Improving exercise capacity
• Influenza vaccination (annually – funded for people with COPD) and pneumococcal vaccination (five-yearly) for people with COPD and their families
• Reducing the risk of infection by avoiding people who have symptoms of an upper respiratory tract infection, e.g. cough, rhinitis, nasal congestion, sneezing
• Avoiding smoke and other environmental pollutants, e.g. smog
• Optimised control of co-morbidities
• Warm and well ventilated homes

Treatment options for exacerbations include bronchodilation with SABA, either alone or in combination with short-acting anticholinergics; doubling the dose or increasing the frequency of use, e.g. from four times to six times per day, if necessary. If the patient is using a long-acting bronchodilator then this should also be continued during the exacerbation. A short course of oral corticosteroids, e.g. 20 – 40 mg, once daily, for 7 – 14 days, may also reduce recovery time, improve lung function and reduce the risk of a relapse.¹⁰

Antibiotics should only be used to treat exacerbations when there is an increase in cough, dyspnoea, sputum volume or purulence. First-line treatment choice is amoxicillin 500 mg, three times a day, for five days. Second-line is doxycycline 100 mg, twice daily, for five days if the patient is penicillin allergic or has had a recent course of amoxicillin.

When a patient has a history of exacerbations, or may have difficulty accessing a general practice, a step-wise self-management plan, including optimising bronchodilator use, oral corticosteroids and indications for antibiotic use may be useful.¹⁰

Referral to secondary care should be considered when:

• A previously mobile patient can no longer walk short distances
• Dyspnoea prevents eating or sleeping
• There is an inability to manage at home due to exhaustion
• A high-risk co-morbidity is present, e.g. heart failure or ischaemic heart disease
• There are sign of hypercapnia (CO2 retention) present, such as altered mental state
• There is an inadequate response to treatment or uncertain diagnosis

Pulmonary rehabilitation may improve symptoms of COPD

Pulmonary rehabilitation refers to programmes which combine multiple approaches to attempt to break the cycle of COPD, where decreased physical activity due to dyspnoea leads to further loss of fitness and eventual immobility. There is strong evidence that rehabilitation programmes improve the symptoms of COPD and reduce hospitalisations.¹⁰ Pulmonary rehabilitation also reduces muscle wasting and weight loss, and programmes that include psychosocial support have been associated with significant reductions in anxiety and depression.^10,21 The minimum time-frame for a rehabilitation programme to be beneficial appears to be six weeks,¹⁰ and the longer the programme lasts, the greater its effectiveness.² Family members play an important role in motivating a person with COPD to remain compliant with their rehabilitation programme.

Weight loss is common in people with COPD as the added effort to breathe can increase energy requirements by 15–20%.²² People with COPD who are underweight have increased mortality rates.²² Pulmocare is a high fat, low carbohydrate dietary supplement, designed to minimise CO2 production. It is available under Special Authority for people with hypercapnia as a result of COPD.

For further information see: "The nutritional management of unintentional weight loss in people with COPD", Prescription Foods (May, 2011).

Psychosocial support is particularly important for Māori and Pacific peoples with COPD. People with COPD have an increased risk of developing symptoms of anxiety and depression, both of which are linked to poor health outcomes.^10,23 In addition, Māori and Pacific adults have a higher prevalence of mental health disorders in general than other ethnic groups.²⁴ Cognitive behavioural approaches have been shown to significantly reduce depression and improve the health status of people with severe COPD.²⁵ Strategies include relaxation, breathing techniques, positioning and chest clearing techniques and modification of negative thoughts.²⁵

For further information on pulmonary rehabilitation programmes contact the respiratory department at your local DHB. The Asthma Foundation's "Breathe easier with COPD" booklets provide a list of suggested exercises that can be performed at home and practical ways of dealing with the stress and limitations of COPD.