Summary of the major changes

The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease, Version 2.56, December 2018

COPD-X Summary of Changes V2.56, December 2018

The latest update of The COPD-X Plan: Australian and New Zealand Guidelines for the Management of COPD has been provided by Lung Foundation Australia in conjunction with the Thoracic Society of Australia and New Zealand following the December 2018 meeting of the COPD-X Guidelines Committee.

Implications for Clinical Practice

All changes made to the document are outlined below and those highlighted in yellow in the PDF document are differentiated as the most significant and likely to have an impact on clinical practice.

C: Confirm diagnosis and assess severity

C2.3 Spirometry

Inclusion of new Figure 4: Comparison of flow-volume curves for spirometry.

C2.5 COPD case finding 

Inclusion of wording from a study by DeMeo discussing the potential for under diagnosis and under treatment of COPD in women (DeMeo 2018).  An analysis of 4,484 COPD subjects in the ‘Genetic Epidemiology of COPD cohort’ demonstrated that females are more susceptible to the effects of COPD than males with respect to symptom burden, including severity of dyspnoea, and exacerbation risk, especially in younger females.

O: Optimise Function

O2.1 Methylxanthines

Review and update of section discussing theophylline.  A 2018 study by Devereux et al randomised 1,567 UK-based COPD patients with a history of exacerbations to theophylline or placebo.  All patients were receiving inhaled corticosteroids and 80% of patients were on ‘triple-therapy’ (Devereux 2018).   Patients were permitted to continue with their usual COPD medications.  There was no difference in exacerbation rates at 12 months.  Based on the available evidence, theophylline cannot be recommended in COPD in the Australasian context [evidence level II].

O4.2.1 Eosinophil count and inhaled corticosteroids

Inclusion of wording from the GLUCOLD (Groningen and Leiden Universities Corticosteroids in Obstructive Lung Disease) study of patients using ICS or placebo during 30 months of follow up which showed neither baseline blood eosinophil levels nor baseline levels in sputum, bronchoalveolar lavage or bronchial biopsy predicted longitudinal changes in FEV1 with or without ICS (Hartjes 2018). 

O6.1 Pulmonary rehabilitation

Addition of wording discussing a meta-analysis (Jenkins 2018) of data from 5 studies comparing supervised maintenance pulmonary rehabilitation programs with usual care. The study showed a significant reduction in the risk of experiencing at least one respiratory-related hospital admission, although these findings were heavily influenced by one study (Guell 2017).

O6.5 Physical activity and sedentary behaviour

Inclusion of a paragraph discussing the effect of a multicomponent training intervention on physical activity.  A randomised controlled trial (Arbillaga-Etxarri 2018) carried out in Spain in people with moderate COPD (predominantly male) showed a significant increase in physical activity at the 12-month follow-up in a group that received a multicomponent Urban Training intervention compared to a group that received usual care.  Key components of the intervention included behavioural techniques and motivational interviewing, maps of validated walking trails of different intensities, pedometer and calendar to record physical activity, text messages every 2 weeks and option to participate in a monthly supervised walking group.  No between-group differences were seen in any of the secondary outcomes that included 6-minute walk distance, quality of life and severe exacerbations.

O7.1 Increased risks from comorbidities in the presence of COPD

Addition of a sentence based on a retrospective cohort study of COPD admissions in over 2,000 male US army veterans which found that comorbidity was associated with a higher 30 day readmission and mortality rate and with lower rates of corticosteroid and antibiotic use whilst in hospital (Spece 2018).

O7.4 Frailty in COPD

New section added discussing how frailty particularly affects older people with chronic conditions such as COPD.  Overall, patients with COPD have double the risk of becoming frail. Frailty has been associated with poorer lung function and reduced health status, increased length of stay following exacerbations (Bernabeu-Mora 2017) and increased mortality (Galizia 2011). Although frailty can be difficult to manage, there is evidence from systematic reviews that exercise can be beneficial for physical functioning, cognitive and psychological wellbeing in frail older adults (Silva 2017).  In addition, in older adults with frailty, multifactorial interventions including exercise and nutritional support can minimise physical decline and can be cost effective for health care providers (Apostolo 2018). In frail patients with COPD hospitalised for an acute exacerbation, exercise resulted in improvements in strength and balance (Torres-Sanchez 2017). Frail patients with COPD have also been shown to benefit from pulmonary rehabilitation with improvements in breathlessness, exercise performance, physical activity level and health status (Maddocks 2016). However, frail patients were twice as likely to not complete pulmonary rehabilitation. Given that smoking is a predictor of frailty (Kojima 2015) and patients with frequent exacerbations have increased risk of frailty (Lahousse 2016), smoking cessation as well as minimisation of exacerbations are additional key therapeutic targets in COPD.

In summary, frailty is common in COPD and associated with poorer health outcomes, hospital admissions and failure to complete pulmonary rehabilitation. Measuring frailty is useful in COPD and may identify vulnerable patients and allow earlier interventions such as pulmonary rehabilitation to minimise the development and impact of frailty on patients and carers as well as health and social care services.

P: Prevent deterioration

P8. Humidification and nasal high flow (NHF) therapy

Section wording condensed

D: Develop a plan of care

D3 Self-management

Discussion of a 2018 RCT evaluating the effect of a program combining transitional care and long-term self-management support on outcomes of hospitalised COPD patients (Aboumatar 2018). The study recruited patients admitted to hospital with an exacerbation of COPD, or patients who had a previous diagnosis of COPD who were hospitalised and were receiving treatment for an increase in symptoms. They were randomised to a three month intervention delivered by nurses that involved:

  1. A transition support aimed at preparing patients and caregivers for discharge and ensuring they understood the post discharge plan of care,
  2. Individualised COPD self-management support to help patients take medications correctly, recognise exacerbation signs and follow action plans, practise breathing exercises and energy conservation techniques, maintain an active lifestyle, seek help as needed, and stop smoking
  3. Facilitated access to community programs and treatment services.

Usual care involved a general transition coach to follow the patient for 30 days after discharge, with a focus on adherence to the discharge plan, and connecting to outpatient care. The intervention resulted in fewer exacerbations at 6 months compared to usual care and improvement in health status. COPD self-management programs overwhelmingly lead to improved health related quality of life, with reduced exacerbations being a positive outcome of many studies. However, due to the heterogeneity of the study designs, setting and outcomes, recommendations regarding the essential elements of a COPD self-management program cannot be made.

X: Manage eXacerbations

Hospital admissions are indicators or failed prevention and are highly expensive to health care systems.  Hospitalisations are being included increasingly as an outcome measure in   randomised controlled trials of a range of interventions.  Inclusion of a table Reducing hospital utilisation: current level I and II evidence from COPD-X which summarises the interventions that have been demonstrated, in such randomised control trials to statistically significantly reduce hospitalisations.


ABOUMATAR, H., NAQIBUDDIN, M., CHUNG, S., CHAUDHRY, H., KIM, S. W., SAUNDERS, J., BONE, L., GURSES, A. P., KNOWLTON, A., PRONOVOST, P., PUTCHA, N., RAND, C., ROTER, D., SYLVESTER, C., THOMPSON, C., WOLFF, J. L., HIBBARD, J. & WISE, R. A. 2018. Effect of a Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Hospitalized Patients With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial. JAMA, 320, 2335-2343.

APOSTOLO, J., COOKE, R., BOBROWICZ-CAMPOS, E., SANTANA, S., MARCUCCI, M., CANO, A., VOLLENBROEK-HUTTEN, M., GERMINI, F., D’AVANZO, B., GWYTHER, H. & HOLLAND, C. 2018. Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: a systematic review. JBI Database System Rev Implement Rep, 16, 140-232.

ARBILLAGA-ETXARRI, A., GIMENO-SANTOS, E., BARBERAN-GARCIA, A., BALCELLS, E., BENET, M., BORRELL, E., CELORRIO, N., DELGADO, A., JANE, C., MARIN, A., MARTIN-CANTERA, C., MONTEAGUDO, M., MONTELLA, N., MUNOZ, L., ORTEGA, P., RODRIGUEZ, D. A., RODRIGUEZ-ROISIN, R., SIMONET, P., TORAN-MONSERRAT, P., TORRENT-PALLICER, J., VALL-CASAS, P., VILARO, J. & GARCIA-AYMERICH, J. 2018. Long-term efficacy and effectiveness of a behavioural and community-based exercise intervention (Urban Training) to increase physical activity in patients with COPD: a randomised controlled trial. Eur Respir J, 52.

BERNABEU-MORA, R., GARCIA-GUILLAMON, G., VALERA-NOVELLA, E., GIMENEZ-GIMENEZ, L. M., ESCOLAR-REINA, P. & MEDINA-MIRAPEIX, F. 2017. Frailty is a predictive factor of readmission within 90 days of hospitalization for acute exacerbations of chronic obstructive pulmonary disease: a longitudinal study. Ther Adv Respir Dis, 11, 383-392.

DEMEO, D. L., RAMAGOPALAN, S., KAVATI, A., VEGESNA, A., HAN, M. K., YADAO, A., WILCOX, T. K. & MAKE, B. J. 2018. Women manifest more severe COPD symptoms across the life course. Int J Chron Obstruct Pulmon Dis, 13, 3021-3029.

DEVEREUX, G., COTTON, S., FIELDING, S., MCMEEKIN, N., BARNES, P. J., BRIGGS, A., BURNS, G., CHAUDHURI, R., CHRYSTYN, H., DAVIES, L., DE SOYZA, A., GOMPERTZ, S., HAUGHNEY, J., INNES, K., KANIEWSKA, J., LEE, A., MORICE, A., NORRIE, J., SULLIVAN, A., WILSON, A. & PRICE, D. 2018. Effect of Theophylline as Adjunct to Inhaled Corticosteroids on Exacerbations in Patients With COPD: A Randomized Clinical Trial. Jama, 320, 1548-1559.

GALIZIA, G., CACCIATORE, F., TESTA, G., DELLA-MORTE, D., MAZZELLA, F., LANGELLOTTO, A., RAUCCI, C., GARGIULO, G., FERRARA, N., RENGO, F. & ABETE, P. 2011. Role of clinical frailty on long-term mortality of elderly subjects with and without chronic obstructive pulmonary disease. Aging Clin Exp Res, 23, 118-25.

GUELL, M. R., CEJUDO, P., ORTEGA, F., PUY, M. C., RODRIGUEZ-TRIGO, G., PIJOAN, J. I., MARTINEZ-INDART, L., GOROSTIZA, A., BDEIR, K., CELLI, B. & GALDIZ, J. B. 2017. Benefits of Long-Term Pulmonary Rehabilitation Maintenance Program in Patients with Severe Chronic Obstructive Pulmonary Disease. Three-Year Follow-up. Am J Respir Crit Care Med, 195, 622-629.

HARTJES, F. J., VONK, J. M., FAIZ, A., HIEMSTRA, P. S., LAPPERRE, T. S., KERSTJENS, H. A. M., POSTMA, D. S. & VAN DEN BERGE, M. 2018. Predictive value of eosinophils and neutrophils on clinical effects of ICS in COPD. Respirology, 23, 1023-1031.

JENKINS, A. R., GOWLER, H., CURTIS, F., HOLDEN, N. S., BRIDLE, C. & JONES, A. W. 2018. Efficacy of supervised maintenance exercise following pulmonary rehabilitation on health care use: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis, 13, 257-273.

KOJIMA, G., ILIFFE, S. & WALTERS, K. 2015. Smoking as a predictor of frailty: a systematic review. BMC Geriatr, 15, 131.

LAHOUSSE, L., ZIERE, G., VERLINDEN, V. J., ZILLIKENS, M. C., UITTERLINDEN, A. G., RIVADENEIRA, F., TIEMEIER, H., JOOS, G. F., HOFMAN, A., IKRAM, M. A., FRANCO, O. H., BRUSSELLE, G. G. & STRICKER, B. H. 2016. Risk of Frailty in Elderly With COPD: A Population-Based Study. J Gerontol A Biol Sci Med Sci, 71, 689-95.

MADDOCKS, M., KON, S. S., CANAVAN, J. L., JONES, S. E., NOLAN, C. M., LABEY, A., POLKEY, M. I. & MAN, W. D. 2016. Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study. Thorax, 71, 988-995.

SILVA, R. B., ALDORADIN-CABEZA, H., ESLICK, G. D., PHU, S. & DUQUE, G. 2017. The Effect of Physical Exercise on Frail Older Persons: A Systematic Review. J Frailty Aging, 6, 91-96.

SPECE, L. J., EPLER, E. M., DONOVAN, L. M., GRIFFITH, M. F., COLLINS, M. P., FEEMSTER, L. C. & AU, D. H. 2018. Role of Comorbidities in Treatment and Outcomes after Chronic Obstructive Pulmonary Disease Exacerbations. Ann Am Thorac Soc, 15, 1033-1038.

TORRES-SANCHEZ, I., VALENZA, M. C., CABRERA-MARTOS, I., LOPEZ-TORRES, I., BENITEZ-FELIPONI, A. & CONDE-VALERO, A. 2017. Effects of an Exercise Intervention in Frail Older Patients with Chronic Obstructive Pulmonary Disease Hospitalized due to an Exacerbation: A Randomized Controlled Trial. COPD, 14, 37-42.