Not only is COPD a considerable drain on NHS resources, it also has a significant negative impact on quality of life and places a major burden on patients and their families.

COPD affects an estimated 3.7 million people, is the fifth biggest killer in the UK¹ and is predicted by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) to become the third-highest cause of death worldwide by 2020.²

Each year in the UK, more than 30,000 people die from COPD3 - more than from bowel cancer, breast cancer or prostate cancer.¹ COPD was the twelfth highest cause of years lost due to premature death and disability in 1990; forecasts suggest it will become the fifth highest by 2020, behind heart disease, depression, traffic accidents and cerebrovascular disease.²

Therefore, COPD has implications globally and nationally, but also for primary and secondary care and, more importantly, for patients' lives.

Impact of exacerbations
A report from the British Lung Foundation highlighted COPD as the second most common cause of emergency admission to hospital.¹ According to another report, from the Healthcare Commission, nearly one in three people discharged from hospital following their first admission for COPD are readmitted within three months.⁴

On average, 15 per cent of those admitted to hospital with COPD die within three months and up to a quarter die within a year.⁴ It is therefore imperative that we, as a healthcare community, are prepared to care for patients by optimising their treatments, to help prevent exacerbations and their impact on day-to-day activities.

COPD is a progressive disease resulting in permanent lung damage; the symptoms of breathlessness can be improved but not fully relieved. Further damage is caused by exacerbations.

An exacerbation is defined as a sudden-onset, sustained worsening of a patient's usual stable state beyond day-to-day variations. Typically, patients experience worsening breathlessness, cough, increased sputum production and change in sputum colour.⁵

Most patients experiencing an exacerbation can be managed at home but in the case of severe exacerbations, hospital treatment is generally required, with courses of antibiotics and/or oral steroids, oxygen, high-dose bronchodilators or, in extreme cases, non-invasive ventilation.⁵

Exacerbations can also affect mortality and lung function. Research has shown that risk of mortality increases with the frequency of severe acute exacerbations.⁶ In addition, lung function has been shown to decline faster with more frequent exacerbations.⁷ It is therefore vital to be able to manage COPD in a consistent, evidence-based way.

In the UK, management of COPD is conducted in line with guidance developed by the National Collaborating Centre for Chronic Conditions, on behalf of NICE.⁵ Treatment aims to reduce exacerbation rates, slow decline in health status and improve lung function, thereby optimising patients' ability to undertake simple activities of day-to-day living (see box).

Impaired quality of life
It follows, therefore, that quality of life is particularly impaired in people who have frequent exacerbations. Research has demonstrated that patients who have between three and eight exacerbations in a year have a significantly worse quality of life than those who have up to two exacerbations per year.⁸

These individuals had more symptoms, were less able to perform usual activities and reported a greater impact of COPD on everyday life.8 However, it can be difficult to use a health-related quality of life questionnaire in everyday practice.

One suggestion is to use the MRC dyspnoea scale to help ascertain broadly the impact of the disease on day-to-day life and the potential treatment options, and this approach is supported by current guidelines (see top box).5 Subjective measurement needs to be taken into account, as many patients still suffer unnecessarily.

One measure of quality of life is how people with COPD describe the impact it has on daily activities. A survey of 326 people with COPD, entitled 'Unleash the life within... ' was carried out in April this year by Astra-Zeneca in collaboration with Taylor-Nelson Sofres Healthcare. The survey revealed that COPD has a major negative impact on simple, everyday activities that people not affected by the disease may take for granted.

Being unable to walk a short distance was cited as having the most negative impact on everyday life, by 46 per cent of respondents, while feeling chronically tired (26 per cent), depressed and frustrated (28 per cent) also made patients' lives less enjoyable. Being unable to take part in hobbies or play with grandchildren was ranked by 24 per cent of participants as having the worst effect on day-to-day life.

The survey also found that although patients used a wide range of medicines to relieve symptoms and control the disease, a quarter thought symptoms were getting worse, and 21 per cent felt that their COPD was not well controlled.

It is hoped that highlighting the shortfalls of current care, as well as the strengths, will focus attention on the goals of treatment that matter most to those who have COPD, and that this will help identify the most effective strategies and tools for achieving these goals.

Optimising treatment
Evidence suggests that tailoring COPD care to control the symptoms that most affect patients' everyday lives is crucial. The focus of patient care should be placed on helping improve breathlessness and hence the patient's ability to walk short distances (see box), reducing exacerbations, hospitalisation and possibly mortality.

This is supported by the GOLD guidelines, which emphasise the need to prevent exacerbations.² Both the GOLD and NICE guidelines back the use of combination bronchodilator treatment in patients who remain symptomatic on monotherapy.^2,5

Research has shown that combination therapies such as formoterol/budesonide and salmeterol/fluticasone can improve quality of life.9-12 For example, people with moderate to severe COPD (FEV1 <50 per cent) who used formoterol/budesonide had fewer severe exacerbations and needed fewer courses of oral steroids than those who used formoterol alone.^9,10

The long-acting anticholinergic drug tiotropium has also shown benefits in terms of reducing exacerbations and hospitalisations in a meta-analysis, and should be considered as an additional therapy.¹³

It may be worth considering how other interventions, in addition to pharmacological treatments, can benefit patients with COPD. For example, some patients may be particularly susceptible to seasonal variations in air temperature.

According to the Met Office, an increase in mortality and hospital admissions is frequently observed in the winter months in the UK.¹⁴ This may be due to cold air causing patients' airways to become narrower, making it more difficult for them to breathe.

Practical advice can include keeping homes warm (21 degsC in living rooms and 18 degsC in bedrooms), keeping physically active, and wrapping up warm when outside.¹⁴

In a similar vein, the British Lung Foundation recently produced a self-management plan for COPD¹⁵ that can be used to help patients manage their disease more effectively. The plan includes sections for recording medication, oxygen status and lung function, monitoring symptoms and preventing exacerbations. It also features helpful guidance on breathing techniques, healthy eating and weather conditions.

COPD - the future
The DoH is currently drafting an NSF for COPD - the first-ever national strategy for a respiratory disease in England.¹⁶ Scheduled for launch early in 2009, this long-awaited framework will provide a 10-year plan for reducing inequalities in COPD care and improving the delivery of services that are most needed by people living with this disease.

In advance of this, it is hoped that this article will provide useful insights into what can have the most significant impact on the lives of your patients, as well as help guide choice of treatment and highlight other sources of information on how to reduce exacerbations further.

Ultimately, it should help you to consider how initiating measures to improve breathlessness and reduce exacerbations and the risk of hospitalisation will have a positive impact on the lives of your COPD patients.

- David Long RGN, MSc is a senior respiratory nurse specialist, at Somerset Lung Centre, Musgrove Park Hospital, Taunton

References

1. British Lung Foundation. Invisible lives. November 2007.

2. GOLD. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Updated 2007.

3. DoH. On the state of the public health: annual report of the Chief Medical Officer 2004. London: HMSO; 2005.

4. Healthcare Commission. Clearing the air. 2006.

5. National Collaborating Centre for Chronic Conditions. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004; 59 (Suppl 1): i1-232.

6. Soler-Cataluna JJ, et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 2005; 60: 925-31.

7. Donaldson GC, et al. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002;57:847-52.

8. Seemungal TA, et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 157: 1,418-22.

9. Calverley PM, et al. Maintenance therapy with budesonide and formoterol in chronic obstructive pulmonary disease. Eur Respir J 2003; 22: 912-9.

10. Szafranski W, et al. Efficacy and safety of budesonide/formoterol in the management of chronic obstructive pulmonary disease. Eur Respir J 2003; 21: 74-81.

11. Calverley P, et al. Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease. Lancet 2003; 361: 449-56.

12. Kardos P, et al. Impact of salmeterol/fluticasone propionate versus salmeterol on exacerbations in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2007; 175: 144-9.

13. Barr RG, et al. Tiotropium for stable chronic obstructive pulmonary disease. Thorax 2006; 61: 854-62.

14. Met Office. Living with chronic obstructive pulmonary disease. Available at: www.metoffice.gov.uk/health/features/copd.html

15. British Lung Foundation. COPD self- management plan. Available at: www.lunguk.org/supporting-you/Publications.

16. DoH. Chronic obstructive pulmonary disease (COPD) national service framework. Available at: www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks.