Individualizing COPD treatment

Key challenges1

An expert panel of post-acute/long-term care (PA/LTC) professionals convened to identify challenges of chronic obstructive pulmonary disease (COPD) management within PA/LTC settings. The two key issues of focus were the:

  • Underuse of long-acting bronchodilator maintenance therapy, including lack of standardized method for device selection based on the individual needs of patients 
  • Need to reduce hospitalizations and readmissions from exacerbations of COPD

New, optional tools were developed for assessing individual patient abilities and choosing an appropriate device for maintenance treatment. Recommendations aim to align current practices with emerging value-based, person-centered, accountable care models.

These recommendations are not a substitute for your medical judgment.

Developing an appropriate treatment plan1

According to Patel et al, assessment of disease severity is a critical first step in developing an appropriate treatment plan. The use of objective and subjective measures helps to individualize approaches to treatment. Considerations may be guided by the results of the assessments below. 

Patient assessment following hospitalization for an exacerbation includes transitional care planning and an individualized therapeutic plan. Consider the following algorithm:

Reprinted from Patel M, et al. Chronic obstructive pulmonary disease in post-acute/long-term care settings: seizing opportunities to individualize treatment and device selection. J Am Med Dir Assoc. 2017;18(6): 553.e17-553.e22. With permission from Elsevier.

*Physical assessments: neuromuscular evaluation for conditions limiting inspiratory force, identification of arthritis, or other condition limiting ability to use a handheld device;
Cognitive assessment: brief interview for mental status;
Respiratory assessments: recent change in dyspnea, cough, mucus production, or short-acting beta2-agonist (SABA) use; recent exacerbation or upper respiratory infection; and check inspiratory force/flow.

 

Treatment should be guided by:

  • Assessment of disease severity
  • Patient symptoms
  • Symptom frequency
  • Activity limitation, exacerbation risk
  • Compliance with chosen device

In the PA/LTC setting, patients are most often in GOLD categories B, C, and D. For these patient categories, GOLD states that regular treatment with long-acting beta2-adrenergic agonist (LABA) therapy is more effective than SABA therapy for maintenance therapy1


GOLD does not endorse any specific treatments.

GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Device selection in patients with COPD1

According to Patel et al, the next step in individualizing treatment is to select the type of device aligned with each patient’s physical and cognitive abilities. Patients with physical or cognitive limitations may require caregiver assistance regardless of device selected.

Developing a facility-based COPD action plan1

Top priorities for facilities are to prevent or reduce shortness of breath and exacerbations. Protocol development may be guided by the following:

  • Categorize COPD severity and history of exacerbations at admission
  • Align facility staff goals with goals of patients
  • Recognize “red flags” for potential or incipient exacerbations
  • Monitor patients for anxiety and depression caused by shortness of breath or other symptoms, acute exacerbations of COPD, hospital transfers and readmissions for acute exacerbations of COPD, sleep disturbances, and viral and bacterial infections
  • Monitor changes in patient activity, overall health, breathing status, and rescue medication use

Increased need for oxygen therapy; escalating daily symptom burden; respiratory infection; increased antitussive medication use; reduced peak expiratory flow rate; increased rescue SABA or SABA/short-acting muscarinic antagonist (SAMA) use, or use of SABA/SAMA treatments as daily maintenance therapy; nighttime awakenings; nonadherence (patient does not accept or complete his or her breathing treatments); declining ability to perform activities of daily living; increase in dyspnea, fatigue, tachypnea, tachycardia; increase in amount or character of sputum production, and confusion; and/or absence of scheduled long-acting bronchodilator therapy.


 

Reference:

  1. Patel M, Steinberg K, Suarez-Barcelo M, Saffel D, Foley R, Worz C. Chronic obstructive pulmonary disease in post-acute/long-term care settings: seizing opportunities to individualize treatment and device selection. J Am Med Dir Assoc. 2017;18(6):553.e17-553.e22.