More than 1.3m people in the UK have a diagnosis of COPD and it is estimated that at least a similar number of people have the condition but haven’t had a diagnosis. For a condition with a relatively high prevalence, and a significant impact on health services, COPD does not have the profile or prioritisation that it should.
COVID-19 has been difficult for many people with chronic conditions and especially those with COPD.
The British Lung Foundation this week revealed that the pandemic has had a dramatic impact on the number of people that are being diagnosed with the condition.
The charity estimates that 46,000 people in England missed out on a COPD diagnosis last year adding to the missing millions of people with the condition who are undiagnosed.
For patients that had a confirmed COPD diagnosis, the report found that most were not able to access the care they need – 75% of those surveyed by the report are missing out on the five key aspects of COPD care (as per NICE COPD guidelines):
- A written self-management plan
- Access to pulmonary rehabilitation
- Assistance to stop smoking
- Identification and management of coexisting medical conditions
- Flu and pneumonia vaccination.
It’s likely that this problem has been exacerbated by the pressures of the pandemic, with QOF reviews being suspended and some patients delaying accessing medical treatment because of fear of catching COVID-19.
As we head into winter, demand for appointments is increasing and a significant proportion are people with respiratory symptoms. We need to consider whether underlying conditions are contributing towards these symptoms whether already formally diagnosed or not.
It's also crucial that we make arrangements to follow up and investigate patients where we consider that there may be an underlying condition.
By optimising routine care of people with long-term conditions we can help reduce pressures on the NHS. Even with all the current pressures that we are facing, we can do five simple things to help patients with COPD.
1. Supporting patients to stop smoking
Although not everyone with COPD has a history of smoking, we know that the condition develops because of long-term damage to the lungs from breathing in a harmful substance, usually cigarette smoke.
It’s important to ensure from the moment someone presents at their GP practice with symptoms of COPD that they get support for smoking cessation if they smoke. Intervention doesn’t need to be time-consuming to be effective. The best way is to use the very brief advice (VBA) format.
This involves asking, advising and acting, and if done properly only takes 30 seconds. The VBA approach is NICE-recommended and known to be effective at triggering a quit attempt.
First you ask the person whether they smoke. If they do there’s no need to ask whether they want to quit, just move straight onto the advice section and tell them that the best way to quit is with a combination of medication and support.
Then comes the act. Signpost them to local stop smoking services and provide them with a prescription for smoking cessation medication. If there are no local Stop Smoking Services in your area, you can send them to the British Lung Foundation website where there are lots of resources.
If the person is not interested, just say ‘that’s okay’, but that you are here to help when they are ready to quit. The National Centre for Smoking Cessation and Training have free, online training courses on VBA here.
2. Ensuring vaccinations are up to date
As we head into winter, it is worth reminding patients with COPD that their symptoms could become worse if they get an infection, like flu or a cold. Checking whether they are up to date with their COVID-19 and flu vaccinations, and whether they have had their one-off pneumonia jab, will help to give them added protection as the colder months arrive.
3. Discussing the benefits of pulmonary rehabilitation
Encouraging patients with COPD to try to stay physically active is challenging when many have been isolating during the pandemic. But exercise is essential to not only staying well physically with COPD but also to support mental health.
Pulmonary rehabilitation is the best way to learn how to exercise at the right level for someone with COPD. Talk to your patients about the benefits of pulmonary rehab and help with access to a course if you can.
Pulmonary rehabilitation was suspended because of the pandemic so the British Lung Foundation has some online resources to help people carry on their pulmonary rehabilitation at home as well as help to exercise safely.
4. Helping with self-management
Supporting patients to self-manage their condition helps give them control. It's important for the patient to understand their COPD, their symptoms, their medication, and how to cope with flare-ups. The British Lung Foundation has self-management plans which can be downloaded for free and ordered in packs of 25 that can be given to patients with COPD.
Another useful resource to signpost to is the Asthma UK website, which has videos on how to use inhalers properly.
5. Identifying and managing coexisting medical conditions
Patients can have other medical conditions alongside their COPD. These might be related to a smoking history (cancer, arteriopathy, AF), related to the effects of COPD (mental health, obesity, deconditioning, weight changes, bronchiectasis) or related to the medications used to treat COPD (especially diabetes, osteoporosis and adrenal insufficiency with significant corticosteroid use).
It is important to assess the cumulative effect of different conditions on a person, and also not to presume that respiratory symptoms are solely due to the COPD. For example, breathlessness may have multiple contributing factors including COPD, deconditioning, obesity, gastric reflux, anxiety and dysfunctional breathing, even before lung cancer and heart conditions are considered.
- Dr Andrew Whittamore is clinical lead at the British Lung Foundation and a practising GP in Portsmouth
Healthcare professionals can order British Lung Foundation leaflets and booklets on COPD, including self-management plans, for free at their online shop.