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# COPD-X

Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease

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## Pages

- [Home](https://copdx.org.au/) - The COPD-X Plan provides Australia's national clinical practice guidelines for managing chronic obstructive pulmonary disease (COPD), tailored for healthcare professionals. Access the latest evidence-based guidance, management strategies, and resources to improve patient outcomes
- [O4.4 Biologic therapies](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-4-biologic-therapies/) - This section is under review A comprehensive evidence review of biologic therapies for COPD is currently underway. This review will apply rigorous living evidence methodology to inform clinical practice recommendations for clinicians in Australia. The Committee will provide further updates as the evidence review progresses. O4.4 Biologic therapies Post hoc analyses of data from a
- [C2.6 Incidental findings (National Lung Cancer Screening Program)](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c2-diagnosis/c2-6-incidental-findings-national-lung-cancer-screening-program/) - C2.6 Incidental findings (National Lung Cancer Screening Program) The Australian National Lung Cancer Screening Program (NLCSP) launched in July 2025 introduces a new opportunity for early identification of COPD. The NLCSP is a government-funded initiative offering biennial low-dose CT (LDCT) scans to asymptomatic individuals aged 50–70 years with a ≥30 pack-year smoking history, including individual
- [COPD-X Plan Guidelines](https://copdx.org.au/copd-x-plan/) - The COPD-X Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease 2025 Download COPD-X V2.78 (published online December 2025) This document should be cited as: Yang I.A., George J., McDonald C.F., Disler R., Ordman R., Goodwin A., Smith B., McNamara R., Zwar N., Dabscheck E. 2025. The COPD-X Plan: Australian
- [X3.2 Non-invasive ventilation](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x32-niv/) - X3.2 Non-invasive positive pressure ventilation NIV is an effective and safe means of treatment of ventilatory failure. Its use allows preservation of cough, physiological air warming and humidification, and normal swallowing, feeding and speech. Applying NIV in addition to conven­tional therapy reduces the risk of mortality by 46% (risk ratio (RR) 0.54, 95% confidence interval
- [References S-Z](https://copdx.org.au/copd-x-plan/references/references-s-z/) - References S-Z SABIT, R., GRIFFITHS, T. L., WATKINS, A. J., EVANS, W., BOLTON, C. E., SHALE, D. J. & LEWIS, K. E. 2008. Predictors of poor attendance at an outpatient pulmonary rehabilitation programme. Respir Med, 102, 819-24. SAJKOV, D., WANG, T., FRITH, P. A., BUNE, A. J., ALPERS, J. A. & MCEVOY, R. D. 1997.
- [References H-R](https://copdx.org.au/copd-x-plan/references/references-h-r/) - References H-R HABTESLASSIE, D., KHORRAMNIA, S., MURUGANANDAN, S., ROMEO, N., SEE, K. & HANNAN, L. M. 2021. Missed diagnosis or misdiagnosis: How often do hospitalised patients with a diagnosis of chronic obstructive pulmonary disease (COPD) have spirometry that supports the diagnosis? . Intern Med J, 53, 510-6. HAJA MYDIN, H., MURPHY, S., CLAGUE, H., SRIDHARAN,
- [References A-G](https://copdx.org.au/copd-x-plan/references/references-a-g/) - References A-G AARON, S. D., TAN, W. C., BOURBEAU, J., SIN, D. D., LOVES, R. H., MACNEIL, J. & WHITMORE, G. A. 2017. Diagnostic Instability and Reversals of Chronic Obstructive Pulmonary Disease Diagnosis in Individuals with Mild to Moderate Airflow Obstruction. Am J Respir Crit Care Med, 196, 306-314. ABDALLAH, S. J., WILKINSON-MAITLAND, C., SAAD,
- [O10. Palliative and supportive care](https://copdx.org.au/copd-x-plan/o-optimise-function/o10-palliative-and-supportive-care/) - O10. Palliative and supportive care Palliative care - ideally from a multidisciplinary team which includes the primary care team - should be considered early, and should include symptom control and addressing psychosocial issues Patients with COPD experience many distressing symptoms including breathlessness, fatigue, depression, anxiety, cough and insomnia (Miravitlles 2017). However, these symptoms are often
- [C2. Diagnosis](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c2-diagnosis/) - C2. Diagnosis C2.1 History C2.2 Physical examination C2.3 Spirometry C2.4 Flow volume tests C2.5 COPD case finding C2.6 Incidental findings (National Lung Cancer Screening Program)
- [Register for PDF](https://copdx.org.au/register-for-pdf/) - The COPD-X Plan is updated regularly and the updates include a new PDF. By registering on the COPD-X website, you will be notified when updates occur. If you have already registered, please click here to download the full PDF.
- [P10. Oxygen therapy](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p10-oxygen-therapy/) - P10. Oxygen therapy [table-info id=46 show_rows= /] [table id=46 show_rows=6 /] Long term oxygen therapy (LTOT) reduces mortality in COPD (Medical Research Council Working Party 1981, Nocturnal Oxygen Therapy Trial Group 1980, Gorecka 1997, Zielinski 1998, American Thoracic Society 1995, Siafakas 1995, Tarpy 1995). It may also have a beneficial impact on haemodynamics, haematological status,
- [P: Prevent deterioration](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/) - P: Prevent deterioration [table id=46 /] REDUCING RISK FACTORS for COPD is a priority, and smoking is the most important of these. A systematic review of 47 studies with an average follow-up of 11 years found a significantly higher decline in FEV1 in people who continued to smoke compared to those who ceased (Lee 2010) [evidence
- [Appendix](https://copdx.org.au/copd-x-plan/appendices/) - Appendix Jump to Appendix 1: Use and doses of long-term inhaled bronchodilator and corticosteroids determined in response trials Appendix 2: Explanation of inhaler devices Appendix 3: Long term oxygen therapy (McDonald 2016) Appendix 4: Strategies that may assist in reminding people to reduce sedentary time Appendix 5: Table of Minimum Clinically Important Differences (MCID) (Cazzola
- [List of Boxes](https://copdx.org.au/copd-x-plan/list-of-boxes/) - List of Boxes Box 1: Levels of evidence Box 2: Risk factors for COPD (Global Initiative for Chronic Obstructive Lung Disease 2024) Box 3: Modified Medical Research Council (mMRC) Dyspnoea Scale for grading the severity of breathlessness during daily activities Box 4: Classification of severity of chronic obstructive pulmonary disease (COPD) Box 5: Assessment of
- [X3.9 Clinical review and follow-up](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x39-clinical-review-and-follow-up/) - X3.9 Clinical review and follow-up There are no randomised clinical trials that have addressed the best method for follow-up (Sin 2002). It is recommended that the first review after a hospital admission should be by the GP and within seven days of discharge (Box 17). Chronic cough and sputum production are associated with an increased risk
- [X3.7 Discharge planning](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x37-discharge-planning/) - X3.7 Discharge planning Discharge planning involves the patient, external lay and professional carers, the multidisciplinary hospital and com­munity team and the patient’s regular GP. It should com­mence on admission and be documented within 24–48 hours (see Box 16). Lung Foundation Australia has developed the Managing COPD Exacerbation Checklist available at: https://lungfoundation.com.au/resources/managing-copd-exacerbation-checklist/ which provides guidance on managing
- [X: Manage eXacerbations](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/) - X: Manage eXacerbations [table id=48 /] EXACERBATIONS of COPD which are more frequent in the winter months in temperate climates (Jenkins 2012) [evidence level II] often require hospital admission for treatment of respiratory failure. A record linkage study in WA (Geelhoed 2007) demonstrated that the rate of hospital admission for COPD has been declining. The
- [P5. Long-acting bronchodilators](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p5-long-acting-bronchodilators/) - P5. Long-acting bronchodilators P5.1 Antimuscarinics A Cochrane review of nine RCTs (6,584 patients) found that tiotropium reduced the odds of a COPD exacerbation (OR 0.74, 95% CI 0.66 to 0.83) and related hospitalisations (OR 0.64, 95% CI 0.51 to 0.82) compared to placebo or ipratropium. The number of patients who would need to be treated
- [D3. Self-management](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d3-self-management/) - D3. Self-management Chronic disease management can broadly be defined as a comprehensive strategy for improving overall health status and reducing healthcare costs (Hunter & Fairfield 1997). It is well suited to chronic conditions as it takes a holistic approach, treating patients as individuals throughout the clinical course of a disease rather than viewing their care
- [X3. Refer appropriately to prevent further deterioration (‘P’)](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/) - X3. Refer appropriately to prevent further deterioration (‘P’) The risk of death from exacerbations of COPD increases with acute carbon dioxide retention (respiratory acidosis), the presence of significant comorbid conditions (eg, ischae­mic heart disease) and complications (eg, pneumonia and empyema). Depending on the nature and severity of the exacerbation, the patient may require urgent specialist
- [Levels of evidence](https://copdx.org.au/copd-x-plan/key-recommendations-of-the-copd-x-guidelines-2/levels-of-evidence/) - Levels of evidence The key recommendations and levels of evidence incor­porated in the COPD-X guidelines were originally based largely on the Global Initiative for Chronic Obstructive Lung Disease (GOLD), which used the evidence ranking system of the US National Heart, Lung and Blood Institute (NHLBI) (NHLBI/WHO Workshop Report April 2001). The NHLBI scheme is shown in Box
- [D6. Referral to a support group](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d6-referral-to-a-support-group/) - D6. Referral to a support group Greater improvements in exercise performance and self-efficacy for exercise have been shown for people with COPD who received education and psychosocial support than for those who received education without support (Ries 1995). Patient support groups aim to empower participants to take a more active role in the management of their
- [List of Figures](https://copdx.org.au/copd-x-plan/list-of-figures/) - List of Figures Jump to Figure 1. Stepwise Management of Stable COPD Figure 2. Inhaler Device Chart Figure 3. COPD Phenotypes Figure 4.Time-course of COPD (Fletcher 1977) Figure 5. Risk of occupational exposures for COPD from selected studies Figure 6. Comparison of flow-volume curves for spirometry Figure 7. Important considerations for inhaler device prescription Figure
- [X2. COPD exacerbation management](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x2-copd-acute-exacerbation-plan/) - X2. COPD exacerbation management X2.1 Confirm exacerbation and categorise severity Assessment of severity of the exacerbation includes a medi­cal history, examination, spirometry and, in severe cases (FEV1 < 40% predicted), blood gas measurements, chest x- rays and electrocardiography. Patients should be provided with and bring a summary of their medical problems and treatment (eg, a
- [X2.2 Optimise treatment](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x2-copd-acute-exacerbation-plan/x22-optimise-treatment/) - X2.2 Optimise treatment Jump to section X2.2.1 Inhaled bronchodilators for treatment of exacerbations X2.2.2. Systemic corticosteroids for treatment of exacerbations X2.2.3. Antibiotics for treatment of exacerbations X2.2.4. Combined systemic corticosteroids and antibiotics for treatment of exacerbations An exacerbation of COPD may involve an increase in airflow limitation, excess sputum production, airway inflam­mation, infection, hypoxia, hypercarbia
- [D5. Assessment and management of anxiety and depression](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d5-treat-anxiety-and-depression/) - D5. Assessment and management of anxiety and depression Jump to D5.1 Loneliness D5.2 Treatment D5.2.1 Cognitive behavioural therapy D5.2.2 Pharmacotherapy Symptoms of anxiety and depression and associated disorders are common in people with COPD (Ng 2007, Xu 2008, Weiss 2022) and have a range of negative impacts [evidence level III]. A retrospective cohort study of
- [D1.9 Pharmacist](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d1-9-pharmacist/) - D1.9 Pharmacist Community pharmacists are medicines experts in the primary care setting and are well placed to engage in early detection/case finding of COPD, and COPD care programs due to their frequent interactions with patients during prescription refill. Monitoring and optimising COPD maintenance therapy in a community pharmacy has the potential to improve COPD management.
- [D: Develop a plan of care](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/) - D: Develop a plan of care [table id=47 /] IN THE EARLY STAGES OF DISEASE, patients with COPD will often ignore mild symptoms, and this contributes to delay in diagnosis. As the disease progresses, impairment and disability increase. As a health state, severe COPD has the third-highest perceived “severity” rating, on a par with paraplegia and
- [P7. Mucolytic agents](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p7-mucolytic-agents/) - P7. Mucolytic agents Mucolytics, including N-acetylcysteine (NAC), ambroxol (3), sobrerol, carbocysteine, sobrerol, letosteine, cithiolone, iodinated glycerol, N-isobutyrylcysteine (NIC), myrtol and erdosteine have multiple possible actions in COPD including decreasing sputum viscosity, and antioxidant, anti-inflammatory or antibacterial activity. A 2019 Cochrane Review (Poole 2019) [evidence level I] included 38 trials involving 10,377 participants with COPD or
- [P2.4 Respiratory syncytial virus immunisation](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p2-immunisations/p2-4-respiratory-syncytial-virus-immunisation/) - P2.4 Respiratory syncytial virus immunisation The Australian Immunisation Handbook recommends a single dose of respiratory syncytial virus (RSV) vaccine in the following adult populations. Adults aged ≥75 years Adults aged ≥60 years who have medical risk condition that increase their risk of severe RSV disease (including chronic respiratory conditions such as COPD) Aboriginal and Torres
- [O7.2 Cardiac disease](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/072-cardiac-disease/) - O7.2 Cardiac disease COPD patients possess an increased burden of cardiovascular disease (CVD), cardiac arrhythmia and heart failure when compared to the normal population. Chen’s systematic review and meta-analysis pooled the results from 29 datasets and reported that COPD patients were more likely to be diagnosed with cardiovascular disease (ischaemic heart disease, dysrhythmia, heart failure,
- [O6.1 Pulmonary rehabilitation](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o6-1-pulmonary-rehabilitation/) - O6.1 Pulmonary rehabilitation Pulmonary rehabilitation programs involve patient assessment, supervised exercise training, education, behaviour change, nutritional intervention and psychosocial support (Spruit 2013). The aim of pulmonary rehabilitation is to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviours (Spruit 2013). Exercise training is
- [O5. Inhaler use](https://copdx.org.au/copd-x-plan/o-optimise-function/o5-inhaler-use/) - O5. Inhaler use Jump to O5.1 Inhaler technique O5.2 Inhaler adherence O5.3 Environmental impacts of inhaled medicines O5.1 Inhaler technique Incorrect inhaler technique is common and is associated with worse outcomes. A systematic review of articles reporting direct observation of inhaler technique in COPD and asthma reported that the overall prevalence of optimal inhaler technique
- [C1. Aetiology and natural history](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c1-aetiology-and-natural-history/) - C1. Aetiology and natural history Cigarette smoking is the most important cause of COPD (Fletcher 1977, Burrows 1977, Matheson 2018). There is a close relationship between the amount of tobacco smoked and the rate of decline in forced expiratory flow in one second (FEV1), although individuals vary greatly in susceptibility (Fletcher 1977). Around half of all smokers
- [Clinical Summary Tools](https://copdx.org.au/copd-x-plan/clinical-summary-tools/) - Clinical summary tools Stepwise Management of Stable COPD (Figure 1) is a brief clinical tool summarising the stepped care approach to the evidence-based recommendations (non-pharmacological and pharmacological interventions) in the COPD-X Plan. [table id=Fig1 /] The inhaler device chart (Figure 2) illustrates the medicine classes and inhalers approved for use in Chronic Obstructive Pulmonary Disease
- [C2.3 Spirometry](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c2-diagnosis/c2-3-spirometry/) - C2.3 Spirometry Confirm COPD with spirometry (post-bronchodilator FEV1/FVC
- [C: Case finding and confirm diagnosis](https://copdx.org.au/copd-x-plan/confirm-diagnosis/) - C: Case finding and confirm diagnosis [table id=44 /] CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterised by airflow limitation which is not fully reversible. The airflow limitation is usually progressive and associated
- [C6. Specialist referral](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c6-specialist-referral/) - C6. Specialist referral Consider referral to specialist respiratory services if needed [evidence level III-2, strong recommendation] Referral to a respiratory medicine specialist may be considered for the indications outlined in Box 6. Box 6: Indication for referral to specialist respiratory outpatient services Reason Purpose Diagnostic uncertainty and exclusion of asthma Establish diagnosis and optimise treatment.
- [C5. Further investigations](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c5-further-investigations/) - C5. Further investigations Further investigations may be necessary to confirm or exclude other conditions and assess COPD severity [evidence level III-2, strong recommendation] Further investigations are often required to confirm a COPD diagnosis. Some common investigations may be required to identify differential or co-existing causes of airway narrowing or hyper- responsiveness, or both, such as
- [C3. Assessing the severity of COPD](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c3-assessing-the-severity-of-copd/) - C3. Assessing the severity of COPD Airflow limitation, COPD symptoms, and exacerbation risk should be assessed regularly, as they relate to prognosis and can guide COPD management strategies and treatment decisions. Spirometry is the most reproducible, standardised and objective way of measuring airflow limitation, and FEV1 is the variable most strongly associated with prognosis (Peto
- [Introduction](https://copdx.org.au/copd-x-plan/introduction/) - Introduction Jump to section Forward The origins of the COPD-X Guidelines COPD-X Methodology Acknowledgement of Country Foreword Chronic Obstructive Pulmonary Disease (COPD) places an enormous burden on people living with this lung condition and on the Australian healthcare system. COPD was the 5th leading cause of death in Australia in 2017 (AIHW 2021). In 2015–16, COPD cost
- [O1.2.2 Long-acting beta2-agonists (LABA)](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o12-long-acting-bronchodilators/o122-long-acting-beta2-agonists-laba/) - O1.2.2 Long-acting beta2-agonists (LABA) Long-acting beta2-agonists cause prolonged bronchodilatation with a duration of action of 12 to 24 hours. Indacaterol is available in Australia on PBS as a monocomponent LABA inhaler for the management of COPD. This and other LABAs (salmeterol, formoterol, vilanterol, olodaterol) are also available as combination LAMA/LABA, ICS/LABA or ICS/LABA/LAMA inhalers. Indacaterol
- [O7.2.2 Safety of beta-blockers](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/072-cardiac-disease/o712-safety-of-beta-blockers/) - O7.2.2 Safety of beta-blockers Beta blockers have well established survival benefits in heart failure and after myocardial infarction and have been long used in coronary artery disease and hypertension but have been considered contra-indicated in patients with COPD. A Cochrane systematic review identified 20 RCTs of cardio-selective beta blockers which examined lung function and respiratory
- [O1.2.3 Long-acting bronchodilator combinations (LAMA/LABA)](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o12-long-acting-bronchodilators/o1-2-3-long-acting-bronchodilator-combinations-lama-laba/) - O1.2.3 Long-acting bronchodilator combinations (LAMA/LABA) A number of LAMA/LABA fixed dose combinations in a single inhaler are available in Australia, which are delivered via a range of devices: aclidinium/formoterol (Genuair) glycopyrronium/indacaterol (Breezhaler) tiotropium/olodaterol (Respimat) umeclidinium/vilanterol (Ellipta) Aclidinium/formoterol: Twice daily aclidinium/formoterol had greater bronchodilation over placebo (mean FEV1 up to 143 ml greater), and to a
- [O1.2 Long-acting bronchodilators](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o12-long-acting-bronchodilators/) - O1.2 Long-acting bronchodilators Long-acting bronchodilators produce significant improvements in lung function, symptoms and quality of life (Braido 2013), as well as decreasing exacerbations. These benefits come at a cost of increased adverse effects, which are generally of mild to moderate severity. O1.2.1 Long-acting muscarinic antagonists (LAMA) Long-acting muscarinic antagonists (LAMAs) result in bronchodilation with a
- [P1. Risk factor reduction](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/) - P1. Risk factor reduction P1.1 Smoking cessation Australia has made substantial progress in reducing the prevalence of tobacco smoking. In 2017-18 the prevalence of daily smoking in adults (people aged 18 and over) was 13.8% compared to 16.1% in 2011-12 and 23.8% in 1995. The proportion of First Nations people aged 15 years and over
- [O6.2 Exercise training](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o6-2-exercise-training/) - O6.2 Exercise training Exercise is defined as physical activity that is planned, structured and repetitive, and undertaken with the aim of improving or maintaining physical fitness and for health benefits (Garber 2011). Exercise training (whole body endurance training and strength training) is considered to be the essential component of pulmonary rehabilitation (Alison 2017, Spruit 2013, Ries 2007).
- [O6.5 Physical activity and sedentary behaviour](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o64-physical-activity-2/) - O6.5 Physical activity and sedentary behaviour Physical activity is defined as any bodily movement generated by skeletal muscle that results in energy expenditure above resting levels and is often classified as light, moderate or vigorous intensity according to the energy level required (Garber 2011). In its broadest form, physical activity encompasses exercise (physical activity) that
- [D1.1 General Practitioner](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d11-general-practitioner/) - D1.1 General Practitioner As the primary healthcare provider, the general practitioner (GP) is uniquely placed to identify smokers and help them quit, diagnose COPD in its early stages and coordinate care as the disease progresses (Johnston 2011). Improving GP uptake of spirometry for COPD diagnosis and recommendation of evidence-based behavioural treatments, including smoking cessation and
- [C2.5 COPD case finding](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c2-diagnosis/c2-5-copd-case-finding/) - C2.5 COPD case finding The US Preventive Services Task Force reviewed the evidence on population-based screening of asymptomatic adults for COPD using questionnaires or office-based screening pulmonary function testing from January 2000 to January 2015. The review found no direct evidence to determine the benefits and harms of screening or treatment in screen-detected populations. On
- [P2.1 Influenza immunisation](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p2-immunisations/p21-influenza-vaccination/) - P2. Immunisations P2.1 Influenza immunisation Influenza immunisation reduces the risk of exacerbations, hospitalisation and death (Nichol 1994, Poole 2006) [evidence level I]. Annual influenza immunisation reduces by about 50% the development of severe respiratory complications and hospi­talisation or death from both respiratory disease and all causes (Nichol 1994, Poole 2006) [evidence level I]. The vaccine used in
- [O3.1 Oral corticosteroids](https://copdx.org.au/copd-x-plan/o-optimise-function/o3-corticosteroids/o3-1-oral-corticosteroids/) - O3.1 Oral corticosteroids Long term use of systemic corticosteroids is not recommended (Postma 1988, Postma 1985, Decramer 1996, Decramer 1994, Decramer 1992) [evidence level I]. Indeed, caution in the long term use of systemic corticosteroids is necessary because of limited efficacy and potential toxicity in elderly patients. Some patients with stable COPD show a significant
- [O7.4 Frailty in COPD](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-4-frailty-in-copd/) - O7.4 Frailty in COPD Frailty is a loss of resilience which means people affected may be physically or mentally vulnerable and less able to recover quickly after illness or a stressful event (Clegg 2013). A consequence is that frail persons have decreased function, health status and require additional health and social care (Roe 2017). Frailty
- [O3. Corticosteroids](https://copdx.org.au/copd-x-plan/o-optimise-function/o3-corticosteroids/) - O3. Corticosteroids O3.1 Oral corticosteroids Long term use of systemic corticosteroids is not recommended (Postma 1988, Postma 1985, Decramer 1996, Decramer 1994, Decramer 1992) [evidence level I]. Indeed, caution in the long-term use of systemic corticosteroids is necessary because of limited efficacy and potential toxicity in elderly patients. Some patients with stable COPD show a
- [Acknowledgements](https://copdx.org.au/copd-x-plan/copd-guidelines-committee-past-and-present/) - COPD-X Guidelines Committee Current COPD-X Guidelines Committee Professor Ian Yang, MBBS(Hons), PhD, FRACP, Grad Dip Clin Epid, FAPSR, FThorSoc, Thoracic Physician, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD (Co-Chair) Associate Professor Eli Dabscheck, MBBS, M Clin Epi, FRACP, Respiratory and Sleep Physician, Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC (Co-Chair)
- [O4.3 Eosinophils](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-3-eosinophils/) - O4.3 Eosinophils There is significant interest in the use of blood eosinophil count as both a prognostic marker and to guide the use of inhaled corticosteroids in COPD. In a US cohort study (Zeiger 2018), elevated blood eosinophils at baseline were independently associated with COPD exacerbations and COPD-related ED visits or hospitalisations during a year
- [O4.2.4 Prescribing and availability](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-2-inhaled-corticosteroids/o4-2-4-prescribing-and-availability/) - O4.2.4 Prescribing and availability Triple therapy prescribing has been increasing since 2016. Retrospective analysis of de-identified administrative data from the US between 2013 and 2018 found that almost three-quarters of patients with COPD who were prescribed triple therapy did not meet guideline recommendations pertaining to prior maintenance therapy and/or exacerbations. Relative to patients prescribed open
- [O4.2.3 Fixed vs open triple therapy](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-2-inhaled-corticosteroids/o4-2-3-fixed-vs-open-triple-therapy/) - O4.2.3 Fixed vs open triple therapy More data are becoming available on different drug combinations and regimens, including open triple therapy (multiple inhalers collectively containing ICS, LAMA, and LABA) and fixed triple therapy (a fixed-dose single triple therapy inhaler containing ICS/LABA/LAMA). The TRINITY study evaluated the fixed triple therapy (extra-fine beclomethasone dipropionate, formoterol fumarate and
- [O4.2.1 ICS/LABA/LAMA vs LABA/LAMA](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-2-inhaled-corticosteroids/o4-2-1-eosinophil-count-and-inhaled-corticosteroids-2/) - O4.2.1 ICS/LABA/LAMA vs LABA/LAMA In a meta-analysis of 21 trials, triple therapy reduced moderate or severe exacerbations compared to LABA/LAMA (RR 0.78, 95% CI 0.70 to 0.88) (Zheng 2018) [evidence level I]. Similar findings were seen in a network meta-analysis of 14 trials, which indicated that ICS/LABA/LAMA combination therapy significantly reduced the risk of moderate
- [O4.2.2 ICS/LABA/LAMA vs ICS/LAMA](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-2-inhaled-corticosteroids/o4-2-2-ics-laba-lama-vs-ics-lama/) - O4.2.2 ICS/LABA/LAMA vs ICS/LABA In a meta-analysis of 21 trials, triple therapy reduced moderate or severe exacerbations compared to ICS/LABA (RR 0.77, 95% CI 0.66 to 0.91) (Zheng 2018) [evidence level I]. Similar findings were observed in a meta-analysis of 13 RCTs including 15,519 patients with COPD, where the number needed to treat to protect
- [O4.2 Inhaled corticosteroids and long-acting beta2-agonists and long-acting antimuscarinics in combination](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-2-inhaled-corticosteroids/) - O4.2 Inhaled corticosteroids and long-acting beta₂-agonists and long-acting antimuscarinics in combination (ICS/LABA/LAMA) Triple therapy may be suitable for patients with moderate to severe COPD and frequent exacerbations, with benefits to outcomes including exacerbation risk, lung function, mortality, and quality of life. However, only some COPD subgroups may achieve a reduction in all-cause mortality from ICS-containing
- [O4. Combination therapies and biologic therapies](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/) - O4. Combination therapies and biologic therapies O4.1 Inhaled corticosteroids and long-acting beta2-agonists in combination (ICS/LABA) A systematic review of 19 randomised controlled trials involving 10,400 COPD patients of combined corticosteroids and long-acting beta2-agonists in one inhaler (Nannini 2013a) [evidence level I] found that, compared with placebo, both fluticasone/salmeterol and budesonide/formoterol reduced the rate of exacerbations
- [O4.1 Inhaled corticosteroids and long-acting beta2-agonists in combination (ICS/LABA)](https://copdx.org.au/copd-x-plan/o-optimise-function/o4-inhaled-combination-therapy/o4-1-inhaled-corticosteroids-and-long-acting-beta2-agonists-in-combination-icslaba/) - O4. Combination therapies and biologic therapies O4.1 Inhaled corticosteroids and long-acting beta2-agonists in combination (ICS/LABA) A systematic review of 19 randomised controlled trials involving 10,400 COPD patients of combined corticosteroids and long-acting beta2-agonists in one inhaler (Nannini 2013a) [evidence level I] found that, compared with placebo, both fluticasone/salmeterol and budesonide/formoterol reduced the rate of exacerbations
- [O3.2 Inhaled corticosteroids (ICS)](https://copdx.org.au/copd-x-plan/o-optimise-function/o3-corticosteroids/o32-inhaled-corticosteroids/) - O3.2 Inhaled corticosteroids (ICS) Exacerbations have a detrimental effect on quality of life, and patients with severe disease and frequent exacerbations have an accelerated decline in their quality of life (Miravitlles 2004). A Cochrane systematic review (Yang 2023a) of studies of long-term (more than 6 months) ICS monotherapy compared to placebo, in people with stable COPD
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- [test](https://copdx.org.au/test/) - The COPD-X Plan is updated regularly and the updates include a new PDF. By registering on the COPD-X website, you will be notified when updates occur. If you have already registered, please click here to download the full PDF. COPDX Sign up Personal Details Title First Name Last Name Email Health Professional TypePlease select... Aboriginal
- [Accredited education and training](https://copdx.org.au/education-and-training/) - Accredited education and training World COPD Day 2020 - COPD-X Concise Guide and quality improvement activities for COPD in primary care webinar RACGP Activity Number: 228689 This webinar is accredited for 4 CPD points for the RACGP 2020-2022 Triennium. Click here to view webinar slides. To watch the webinar, click here. The guest panel included:
- [The COPD-X Plan Version Archives](https://copdx.org.au/copd-x-plan/version-archives/) - #The COPD-X Plan Version Archives [table id=60 /] These PDF are searchable documents. Download the document/s. Enter your search term in the Find box located on the Toolbar after download. For COPD-X Plan versions published earlier than June 2021, contact Robyn Ordman at robyno@lungfoundation.com.au.
- [Glossary of Terms](https://copdx.org.au/copd-x-plan/glossary-of-terms/) - [table id=57 /]
- [X1. Home management](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x1-home-management/) - X1. Home management The shortage of hospital beds, especially in winter, has prompted interest in home care for management of COPD exacerbations, with involvement of multidisciplinary teams assisting GPs. Such “Hospital in the Home” schemes were studied in a systematic review by Jeppesen (Jeppesen 2012) that included 8 randomised controlled trials which entered patients into
- [P2. Immunisations](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p2-immunisations/) - P2. Immunisations P2.1 Influenza immunisation In people aged 65 years and older, annual influenza immunisation may lower the risk of influenza and probably lowers the risk of influenza-like illness (Demicheli 2018). A Cochrane systematic review has shown that in people with COPD, inactivated influenza vaccine reduced the total number of exacerbations per vaccinated person, compared
- [D1. Support team](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/) - D1. Support team Patients and their family and friends should be actively involved in a therapeutic partnership with a range of health professionals (Celli 1995, Spruit 2013, Ries 1995, Lorig 1999). In advanced disease, the many comorbidities, social isola­tion and disability mean that a multidisciplinary approach to coordinated care may be appropriate. Studies have demonstrated the
- [Key Recommendations](https://copdx.org.au/copd-x-plan/key-recommendations-of-the-copd-x-guidelines-2/) - Key Recommendations of the COPD-X Guidelines [table id=44 /] [table id=45 /] [table id=46 /] [table id=47 /] [table id=48 /]
- [X3.6 Pulmonary rehabilitation](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x36-pulmonary-rehabilitation/) - X3.6 Pulmonary rehabilitation Exacerbations of COPD are characterised by worsening dyspnoea and fatigue, decreased exercise tolerance and a reduction in health-related quality of life (HRQoL) (Seemungal 2000, Spencer 2003). Individuals are typically less active following hospitalisation for an exacerbation of COPD and this low level of activity may persist for several weeks (Pitta 2006). Quadriceps
- [X3.4 Clearance of secretions](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x34-clearance-of-secretions/) - X3.4 Clearance of secretions and exercise training during hospitalisaton Jump to section X3.4.1 Clearance of secretions X3.4.2 Exercise training during hospitalisation X3.4.1 Clearance of secretions Patients who regularly expectorate sputum or those with tenacious sputum may benefit from airway clearance techniques (ACTs) during an exacerbation. However, the choice of ACTs during exacerbations requires careful consideration
- [X3.1 Controlled oxygen delivery](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x31-controlled-oxygen-delivery/) - X3.1 Controlled oxygen delivery In the emergency setting, supplemental oxygen may be required to relieve hypoxaemia. Oxygen flow should be carefully titrated to achieve a target SpO2 range of 88 to 92%. Nasal cannulae deliver a variable concentration of oxygen, but a flow of 0.5–2.0 L per minute is usually sufficient. The TSANZ position paper
- [P8. Humidification therapy and nasal high flow (NHF) therapy](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p8-humidification-therapy/) - P8. Humidification and nasal high flow (NHF) therapy Several trials have shown that nasal high flow (NHF) humidified air in stable COPD patients reduces transcutaneous CO₂ (PtCO₂) and respiratory rate (Fraser 2016, Biselli 2017, McKinstry 2018, 2019). A randomised trial by Rea et al (Rea 2010) found that NHF for up to 2 hours daily reduced annual
- [P9. Regular review](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p9-regular-review/) - P9. Regular review Regular review, with objective measures of lung function, health status (COPD Assessment Test [CAT]), consideration of referral to pulmonary rehabilitation and medication review, is recommended. This may reduce complications and the frequency or the severity (or both) of exacerbations and admissions to hospital. An English RCT block randomised 18 general practices to
- [O7.11 Combined pulmonary fibrosis and emphysema](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-11-combined-pulmonary-fibrosis-and-emphysema/) - O7.11 Combined Pulmonary Fibrosis and Emphysema Combined pulmonary fibrosis and emphysema (CPFE) is a syndrome defined by clustering of pulmonary fibrosis and emphysema in a patient (Cottin 2022). Spirometry is frequently normal due to opposing effects of hyperinflation from emphysema and restriction from fibrosis. Gas transfer, however, is usually severely impaired due to the additive
- [O7. Comorbidities](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/) - O7. Comorbidities Optimal management of any individual patient with COPD should include identification and management of comorbidities and anticipation of increased risks associated with those comorbidities in the presence of COPD (Gershon 2016). An American population based, nationally representative survey of almost 15,000 people demonstrated that patients with self reported COPD have significantly higher prevalence of important
- [O6.10 Nutrition](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o610-nutrition/) - O6.10 Nutrition Nutritional management of COPD is complex, as both malnutrition and obesity are highly prevalent and both contribute to patient morbidity and mortality risk. In addition, poor eating habits, sedentary lifestyle, smoking and corticosteroid use can lead to poor nutritional status in COPD, with deficiencies in various nutrients such as vitamins and minerals, fatty
- [O1.2.1 Long-acting muscarinic antagonists (LAMA)](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o12-long-acting-bronchodilators/o121-long-acting-muscarinic-antagonists-lama/) - O1.2 Long-acting bronchodilators Long-acting bronchodilators produce significant improvements in lung function, symptoms and quality of life (Braido 2013), as well as decreasing exacerbations. These benefits come at a cost of increased adverse effects, which are generally of mild to moderate severity. O1.2.1 Long-acting muscarinic antagonists (LAMA) Long-acting muscarinic antagonists (LAMAs) result in bronchodilation with a
- [Conflicts of Interest](https://copdx.org.au/copd-x-plan/copd-guidelines-committee-past-and-present/conflicts-of-interest/) - Conflicts of Interests Correct at June 2024 COPD-X Committee The COPD-X Guidelines Committee is responsible for updating the COPD-X Guidelines. All below-named members of the COPD-X Guidelines Committee are required to lodge declarations of potential conflicts of interest with Lung Foundation Australia on an annual basis. Such disclosures include the receipt of unrestricted educational grants,
- [Support for COPD-X](https://copdx.org.au/copd-x-plan/copd-guidelines-committee-past-and-present/conflicts-of-interest/support-for-copd-x-2/) - Support for COPD-X Ongoing logistical and financial support for the development of the COPD-X Guidelines is provided by Lung Foundation Australia as part of its national COPD program. This program receives sponsorship funding from a number of industry partners. Industry partners of Lung Foundation Australia have no direct or indirect influence over the content of
- [Other contributors - Past and Present](https://copdx.org.au/copd-x-plan/copd-guidelines-committee-past-and-present/other-contributors-past-and-present/) - Other contributors – Past and Present Associate Professor Jenny Alison, Physiotherapist Dr Guy Bannink, Staff Specialist Palliative Medicine Ms Kate Baumwol, Senior Speech Pathologist Mr Paul Cafarella, Psychologist Associate Professor Donald Campbell, Respiratory Physician Ms Nola Cecins, Physiotherapist Dr Belinda Cochrane, Staff Specialist Respiratory and Sleep Physician Dr Karen Detering, Respiratory Physician Dr Tanja Effing,
- [COPD-X Handbook Conflicts of Interest](https://copdx.org.au/copd-x-plan/copd-guidelines-committee-past-and-present/conflicts-of-interest/copd-x-handbook/) - COPD-X Handbook Conflicts of Interests Correct at June 2024 COPD-X Handbook Working Group The COPD-X Handbook Working Group was responsible for a major upgrade of the COPD-X Handbook, which had not been updated since the 2018 resource (then called the COPD-X Concise Guide). The multidisciplinary working group was convened from 2023 to 2024. All below-named
- [D1.7 Clinical psychologist/psychiatrist](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d17-clinical-psychologistpsychiatrist/) - D1.7 Clinical psychologist/psychiatrist Anxiety and depression are common disorders in patients with COPD, which worsen quality of life and add to disability (Weiss 2022, O'Toole 2022) [evidence level III]. There is promising evidence that anxiety and depression can be treated by clinical psychologists and psychiatrists using approaches such as cognitive behaviour therapy (Hynninen 2010, Yohannes 2017)
- [O7.1 Increased risks from comorbidities in the presence of COPD](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-1-increased-risks-from-comorbidities-in-the-presence-of-copd/) - O7.1 Increased risks from comorbidities in the presence of COPD Using a large dataset generated from 311 general practices in the UK, Feary et al (Feary 2010) found COPD was associated with increased risks of cardiovascular disease (OR 4.98, 95% CI 4.85 to 5.81), stroke (OR 3.34, 95% CI 3.21 to 3.48) and diabetes mellitus (OR
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- [P4. Macrolides](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p4-macrolides/) - P4. Macrolides For patients with moderate-severe COPD and recurrent exacerbations, trials have found that long-term low-dose oral macrolides reduce the number of patients experiencing an exacerbation and the frequency of exacerbations. The number needed to treat to prevent one exacerbation (NNT) was 8 (95% CI 5 to 18) (Herath 2018). A systematic review of prophylactic
- [P3. Immuno-modulatory agents](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p3-immuno-modulatory-agents/) - P3. Immunomodulatory agents A Cochrane review of 36 studies published between 1981 and 2015 and involved 6192 participants with chronic bronchitis or COPD treated with either immunostimulants or placebo over a mean treatment period of 6 months (Fraser 2022) [evidence level I]. Participants treated with immunostimulants were slightly more likely to be free of exacerbations
- [P1.2.5 Electronic cigarettes (e-cigarettes)](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p12-treatment-of-nicotine-dependence/p125-electronic-cigarettes-e-cigarettes/) - P1.2.5 Electronic cigarettes (e-cigarettes) E-cigarettes are battery-powered devices that may deliver nicotine in a vapour without tobacco or smoke. Nicotine e-cigarettes can relieve cravings and symptoms of nicotine withdrawal as well as simulating the behavioural and sensory aspects of smoking. Concerns about e-cigarettes include limited evidence for short-term efficacy and short-and long-term safety, particularly in
- [O7.3 Osteoporosis](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o73-osteoporosis/) - O7.3 Osteoporosis Patients with COPD are at increases risk for fracture due to the disease itself, the use of high dose corticosteroids and coexisting risk factors such as hypogonadism (induced by corticosteroid therapy itself in high doses in men and women), immobilisation reduced muscle mass and other factors. These patients may have reduced bonemineral density
- [O6.11 Complementary therapies](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o610-complementary-and-alternative-therapies/) - O6.11 Complementary therapies A systematic review by Guo (Guo 2006) concluded there was no clear evidence supporting the effectiveness of herbal medicines for treating COPD. Tai Chi is a systematic callisthenic exercise that involves a series of slow and rhythmic circular motions moving from one form to another. The styles of Tai Chi are differentiated
- [C1.1 Natural history](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c1-aetiology-and-natural-history/c1-1-natural-history/) - C1.1 Natural History Although FEV1 has long been accepted as the single best predictor of mortality in population studies in COPD (Fletcher 1977, Peto 1983) studies have suggested various other indices, which may also predict mortality. In patients with established COPD, degree of hyperinflation as measured by inspiratory capacity/ total lung capacity (IC/TLC) ratio was
- [P1.1 Smoking cessation](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p11-smoking-cessation/) - P1.1 Smoking cessation Smoking cessation is the most important intervention to prevent the worsening of COPD [evidence level II, strong recommendation] Australia has made substantial progress in reducing the prevalence of tobacco smoking. In 2017-18 the prevalence of daily smoking in adults (people aged 18 and over) was 13.8% compared to 16.1% in 2011-12 and
- [O2. Oral bronchodilators](https://copdx.org.au/copd-x-plan/o-optimise-function/o2-oral-bronchodilators/) - O2. Oral bronchodilators O2.1 Methylxanthines Theophylline is rarely used for COPD in Australia. A small randomised placebo controlled trial in China demonstrated that doses of 100mg twice daily reduced exacerbations compared with placebo (Zhou 2006). In this study, patients were not on inhaled corticosteroids or long-acting bronchodilators which limits the generalisability of the study findings.
- [O3.3 Inhaled corticosteroids versus long-acting beta2-agonists](https://copdx.org.au/copd-x-plan/o-optimise-function/o3-corticosteroids/o33-inhaled-corticosteroids-versus-long-acting-beta-agonists/) - O3.3 Inhaled corticosteroids (ICS) versus long-acting beta2-agonists (LABA) A systematic review of inhaled corticosteroids versus long-acting beta-agonists in COPD found similar benefits in exacerbation rates and mortality when comparing these treatments, but there was a higher rate of pneumonia with inhaled corticosteroids (Spencer 2011) [evidence level I]. There were small benefits in FEV₁ (for long-acting
- [O2.1 Methylxanthines](https://copdx.org.au/copd-x-plan/o-optimise-function/o2-oral-bronchodilators/o2-1-methylxanthines/) - O2.1 Methylxanthines Theophylline is rarely used for COPD in Australia. A small randomised placebo controlled trial in China demonstrated that doses of 100mg twice daily reduced exacerbations compared with placebo (Zhou 2006). In this study, patients were not on inhaled corticosteroids or long-acting bronchodilators which limits the generalisability of the study findings. Devereux et al
- [O9.2 Lung volume reduction surgery and bronchoscopic interventions](https://copdx.org.au/copd-x-plan/o-optimise-function/o9-surgery/o92-lung-volume-reduction-surgery-and-other-techniques/) - O9.2 Lung volume reduction surgery and bronchoscopic interventions van Geffen et al performed a meta-analysis of data from randomised controlled trials across all modalities of lung volume reduction (surgical and endobronchial) (van Geffen 2019). The mean differences compared with the control were an increase in FEV1 of 15∙87% (95% CI 12∙27 to 19∙47), improvement in
- [O6.7 Breathing exercises](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o6-7-breathing-exercises/) - O6.7 Breathing exercises A variety of breathing exercises are used in people with COPD. The aim of these exercises is to reduce dyspnoea by altering respiratory muscle recruitment, reducing lung hyperinflation, improving the functioning of the respiratory muscles and optimising thoraco-abdominal motion. A Cochrane Review of 16 studies involving a total of 1233 individuals with
- [C2.1 History](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c2-diagnosis/c21-history/) - C2. Diagnosis C2.1 History A thorough history and examination is the first step in COPD diagnosis [evidence level III-2, strong recommendation]. The main symptoms of COPD are breathlessness, cough and sputum production. Patients often attribute breath­lessness to ageing or lack of fitness. A persistent cough, typically worse in the mornings with mucoid sputum, is common in
- [P1.2.2 Nicotine Receptor Partial Agonists](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p12-treatment-of-nicotine-dependence/p123-nicotine-receptor-partial-agonists/) - P1.2.2 Nicotine receptor partial agonists The addictive properties of nicotine are considered to be mediated through its action as an agonist at alpha4beta2 nAnti-Cholinergic Receptors (α4β2 nAChR), which stimulate the release of dopamine (Coe 2005). Varenicline was developed to counteract the effects of nicotine on the nAChRs, and its efficacy in smoking cessation has been
- [P1.2.1 Nicotine replacement therapy](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p12-treatment-of-nicotine-dependence/p121-nicotine-replacement-therapy/) - P1.2.1 Nicotine replacement therapy All forms of nicotine replacement therapy (NRT) appear to be useful in aiding smoking cessation and increase the rate of quitting by 50 to 70% (Stead 2012) [evidence level I]. NRT is most suitable for nicotine dependent smokers who are motivated to quit. All forms of NRT (at equivalent doses) are similarly effective
- [P2.2 Pneumococcal immunisation](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p2-immunisations/p22-pneumococcal-immunisation/) - P2.2 Pneumococcal immunisation Pneumococcal immunisation is recommended for all patients with COPD. Pneumococcal immunisation with conjugated vaccines covering 13 virulent serotypes (13vPCV) is highly effective in preventing community-acquired pneumococcal pneumonia in older adults (Bonten 2015). In contrast, the pneumococcal polysaccharide vaccine covering 23 virulent serotypes (23vPPV) is less effective in elderly or immunosuppressed patients (Simberkoff 1986).
- [O6.3 Inspiratory Muscle Training](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o6-3-inspiratory-muscle-training/) - O6.3 Inspiratory Muscle Training Inspiratory muscle training (IMT), performed in isolation using a threshold loading device or target-flow resistive device at loads equal to or greater than 30% of an individual’s maximum inspiratory pressure generated against an occluded airway (PImax) has been shown to produce short-term gains in inspiratory muscle strength and endurance, reduce dyspnoea,
- [D3.1 Maintenance therapy](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d3-self-management/d31-maintenance-therapy/) - D3.1 Maintenance therapy Detailed discussion of the maintenance therapy for COPD appears in section O. In general, the use of drugs in COPD does not involve back-titration, which is a core principle in asthma management. The exception is when oral corticosteroids have been given for an exacerba­tion. There is at present no evidence for back
- [D3.2 Exacerbation prevention](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d3-self-management/d32-exacerbation-prevention/) - D3.2 Exacerbation prevention Detailed discussion of the management of exacerbations is found in section X. Committee Commentary: COPD Exacerbation Terminology In patient education and for effective patient-clinician partnerships, the words we use as clinicians’ matter. This is particularly important when discussing COPD exacerbations. COPD exacerbations are common and have deleterious impacts on patients at the
- [P11 Long-term home non-invasive ventilation](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p11-long-term-home-non-invasive-ventilation/) - P11 Long-term home non-invasive ventilation Raveling et al (2021) performed a meta-analysis of chronic non-invasive ventilation use in patients with COPD and hypercapnia compared to usual care. The analysis was separated into studies where NIV was commenced in a stable phase and studies where NIV was commenced after an exacerbation. Data was included from 13
- [O9.3 Lung Transplantation](https://copdx.org.au/copd-x-plan/o-optimise-function/o9-surgery/o93-lung-transplantation-2/) - O9.3 Lung Transplantation Lung transplantation is a complex therapy for selected patients with severe COPD and it is indicated to improve quality-of-life and most likely improve survival. International guidelines (Weill 2015) and national consensus guidelines from the Australian Organ and Tissue Donation and Transplantation Authority https://www.tsanz.com.au/organallocationprotocols and NHRMC Ethical Guidelines for Organ Donation from Deceased
- [O6.6.1 Psychosocial support](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o6-6-education-and-self-management/o661-psychosocial-support/) - O6.6.1 Psychosocial support Support groups may provide people with COPD and their carers with emotional support, social interaction, and new knowledge and coping strategies, although studies specifically evaluating the benefits of these groups for improving quality of life and psychological well-being are yet to be conducted. Pulmonary rehabilitation provides a good opportunity to initiate support
- [O6.6 Education and self-management](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o6-6-education-and-self-management/) - O6.6 Education and self-management There is limited evidence that education alone can improve self-management skills, mood or health-related quality of life (HRQoL). Education is often included with exercise training as part of a comprehensive pulmonary rehabilitation program (Ries 2007) [evidence level III-2]. Delivering COPD-specific information in a didactic style is unlikely to be beneficial and
- [X3.5 Develop post-discharge plan and follow-up](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x3-5-develop-post-discharge-plan-and-follow-up/) - X3.5 Develop post-discharge plan and follow-up The aim is to relieve hypoxaemia and obtain improvement in clinical signs and symptoms. Clinical examination: Reduction in wheeze, accessory muscle use, respiratory rate, distress. Gas exchange: Arterial blood gas levels and/or pulse oximetry levels should be monitored until the patient’s condition is stable (SpO2 88 to 92%). Respiratory
- [D4. Telehealth](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d4-telehealth/) - D4. Telehealth Telemonitoring interventions ranging from simple telephone follow-up to daily telemonitoring of physiological or symptom scores, to more complex telemonitoring interventions with greatly enhanced clinical support; have been evaluated in patients with COPD. A Cochrane Review found that telehealth may have an impact on quality of life and emergency attendances in COPD, however, further
- [O6.8 Chest physiotherapy (Airway clearance techniques)](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o67-chest-physiotherapy-airway-clearance-techniques/) - O6.8 Chest physiotherapy (Airway clearance techniques) Airway clearance techniques (ACTs) are only indicated for patients with COPD who have evidence of sputum. This is likely to include individuals who have the clinical features of chronic bronchitis, those with co-existent bronchiectasis and some patients during an exacerbation. The aims of ACTs in patients with COPD are
- [O7.5 Falls in COPD](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-4-falls-in-copd/) - O7.5 Falls in COPD Accidental falls are an important and underestimated problem in people with COPD. As in older adult populations, falls in people with COPD are associated with increased injury-related mortality and risk for hip fractures, which impose a substantial economic burden on health care systems worldwide (Berry 2008). Chronic obstructive pulmonary disease was
- [X4. Uptake and impact of guidelines for exacerbations](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x4-uptake-and-impact-of-guidelines-for-exacerbations/) - X4. Uptake and impact of guidelines for exacerbations Although there are many COPD guidelines around the world, there has been little evaluation of their uptake into clinical practice, or their impact on clinical outcomes. A study of the compliance to COPD-X (Gerber 2018) recommendations in 381 COPD patients attending the EDs of two hospitals within
- [D2. Multidisciplinary care plans](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d2-multidisciplinary-care-plans/) - D2. Multidisciplinary care plans A multidisciplinary care plan involves documentation of the various medical, paramedical and non-medical services required to keep a patient functioning in the community. Various generic and disease-specific proformas are available. The care plan may be initiated in the context of a multidisci­plinary case conference involving the GP and at least two other
- [D1.3 GP practice nurse/ nurse practitioner/ respiratory educator/ respiratory nurse](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d13-gp-practice-nurse-nurse-practitioner-respiratory-educator-respiratory-nurse/) - D1.3 GP practice nurse/ nurse practitioner/ respiratory educator/ respiratory nurse Nurses play an integral role in the assessment and delivery of education and management for people living with COPD. The training, expert knowledge and skills of respiratory nurses allow them to undertake multidimensional assessments and to work with patients to tailor specific therapeutic interventions and
- [D1.2 Other specialist physicians](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d12-other-specialist-physicians/) - D1.2 Other specialist physicians COPD is an important morbidity in older people which impacts on comprehensive medical management and quality of life. It is important to note that the support team involved in the management of COPD patients may include a geriatrician, cardiologist, endocrinologist and psychiatrist amongst others.
- [P12 Alpha1-antitrypsin deficiency](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p11-alpha1-antitrypsin-deficiency/) - P12 Alpha1-antitrypsin deficiency Alpha1-antitrypsin deficiency (AATD) is an inherited condition that increases the risk of developing pulmonary emphysema. Evidence for the diagnosis and treatment of patients with AATD-related lung disease has been comprehensively reviewed in a position statement endorsed by the Thoracic Society of Australia and New Zealand (TSANZ) (Dummer 2020).
- [P1.2 Treatment of nicotine dependence](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p12-treatment-of-nicotine-dependence/) - P1.2 Treatment of nicotine dependence Pharmacotherapies for nicotine dependence are effective and should be offered to all nicotine dependent smokers who express an interest in quitting, except when contraindicated (Tobacco Use and Dependence Guideline Panel 2008, Cahill 2013) [evidence level I]. Caution is recommended in people with medical contraindications, pregnant women and adolescent smokers. Nicotine patches, varenicline
- [O7.2.4 Statins](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/072-cardiac-disease/o7-2-4-statins/) - O7.2.4 Statins Despite historic cohort studies suggesting a potential benefit of statins in COPD, a meta-analysis of eight randomised controlled trials including 1,323 predominantly male patients with COPD showed no change to mortality, exacerbation rates, lung function or quality of life with statin therapy compared to placebo [evidence level I] (Walsh 2019). Several of the
- [C4.1 Confirm or exclude asthma](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c4-assessing-acute-response-to-bronchodilators/c41-confirm-or-exclude-asthma/) - C4.1 Confirm or exclude asthma If airflow limitation is fully or substantially reversible, (FEV1 response to bronchodilator>400 ml), the patient should be treated as for asthma (British Thoracic Society 2008a, Hunter 2002) Some patients may have coexisting COPD and asthma (Global Initiative for Asthma 2019). Asthma usually runs a more variable course and dates back
- [O7.2.1  Heart failure](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/072-cardiac-disease/o721-heart-failure/) - O7.2.1 Heart failure The diagnosis of heart failure coexisting with COPD is complicated by symptom overlap and the technical challenges of echocardiography in COPD. The natriuretic peptides, including BNP and NT-proBNP, can assist in identifying heart failure in the setting of acute breathlessness, but do not exclude comorbid COPD, and currently have an unclear diagnostic
- [O: Optimise function](https://copdx.org.au/copd-x-plan/o-optimise-function/) - O: Optimise function [table id=45 /] THE PRINCIPAL GOALS OF THERAPY are to stop smoking, to optimise function through symptom relief with medica­tions and pulmonary rehabilitation, and to prevent or treat aggravating factors and complications. Adherence to inhaled medications regimes is associated with reduced risk of death and admissions to hospital due to exacerbations in
- [O8. Hypoxaemia and pulmonary hypertension](https://copdx.org.au/copd-x-plan/o-optimise-function/o8-hypoxaemia-and-pulmonary-hypertension/) - O8. Hypoxaemia and pulmonary hypertension Hypoxaemia Hypoxaemia in patients with COPD should be identified and corrected with long term oxygen therapy as this has been shown to improve survival and quality of life (Nocturnal Oxygen Therapy Trial Group 1980, Medical Research Council Working Party 1981 (see O8.1). Hypoxaemia is best screened for using pulse oximetry,
- [O7.8 Gastro-oesophageal reflux disease (GORD)](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-7-gastro-oesophageal-reflux-disease-gord/) - O7.8 Gastro-oesophageal reflux disease (GORD) In patients with COPD, hyperinflation, coughing and the increased negative intrathoracic pressures of inspiration may predispose to reflux, especially during recumbency and sleep. Microaspiration of oesophageal secretions (possible including refluxed gastric content) is a risk, especially with coexistent snoring or OSA. Reflux and microaspiration exacerbate cough, bronchial inflammation and airway
- [X2.1 Confirm exacerbation and categorise severity](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x2-copd-acute-exacerbation-plan/x21-confirm-exacerbation-and-categorise-severity/) - X2.1 Confirm exacerbation and categorise severity Assessment of severity of the exacerbation includes a medi­cal history, examination, spirometry and, in severe cases (FEV1 < 40% predicted), blood gas measurements, chest x- rays and electrocardiography. Patients should be provided with and bring a summary of their medical problems and treatment (eg, a personal health record). If
- [C4. Assessing acute response to bronchodilators](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c4-assessing-acute-response-to-bronchodilators/) - C4. Assessing acute response to bronchodilators The response to bronchodilators is determined to: assign a level of severity of airflow limitation (post- bronchodilator); and help confirm asthma. The details for this assessment are outlined in Box 5. The change in FEV1 after an acute bronchodilator revers­ibility test indicates the degree of reversibility of airflow limitation.
- [D1.8 Speech pathologist/therapist](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d18-speech-pathologisttherapist/) - D1.8 Speech pathologist/therapist Speech pathologists are involved in the assessment and management of dysphagia (difficulty swallowing) in individuals with COPD and can be accessed in the community or in a hospital setting (inpatient or outpatient). Early identification of dysphagia in those with COPD and adequate management can minimise COPD exacerbations and hospital admissions (Kobayashi 2007,
- [O7.15 Anaemia](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-13-anaemia/) - O7.15 Anaemia Anaemia is a relatively uncommon comorbidity of COPD (Schnell 2012, Barnes 2009, Yohannes 2011a, Almagro 2012) either attributable to erythropoietin resistance (Markoulaki 2011) or inflammation (Markoulaki 2011, Rutten 2013, Boutou 2012), which may impair functional performance (Cote 2007a, Krishnan 2006, Boutou 2011) and health status (Krishnan 2006, Boutou 2011), contribute to worse survival (Haja
- [O7.13 Testosterone deficiencies and supplementation](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-11-testosterone-deficiencies-and-supplementation/) - O7.13 Testosterone deficiencies and supplementation Observational studies in COPD patients have revealed reduced total testosterone levels compared with matched controls [WMD -3.21nmol/L (95% CI -5.18 to -1.23)] (Atlantis 2013). The clinical significance of this finding is unclear. Although testosterone supplementation therapy has been shown to increase peak muscle strength and peak work load achieved in patients
- [O7.14 Cognitive Impairment](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-12-cognitive-impairment/) - O7.14 Cognitive Impairment Cognitive dysfunction has been described in people with COPD as in other chronic diseases such as cardiac failure and diabetes. The frequency of cognitive dysfunction varies depending upon the battery of neuropsychological tests used, with the domains most influenced being memory and attention. In a population cohort of community dwelling elderly (age
- [O7.12 Alcohol and sedatives](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-10-alcohol-and-sedatives/) - O7.12 Alcohol and sedatives Patients with COPD have impaired gas exchange and an exaggerated fall in Po2 with recumbency and sleep onset (Meecham Jones 1995, Chaouat 1995). Excessive use of alcohol and sedatives exacerbates this and predisposes to sleep-disordered breathing. Heavy cigarette smoking is associated with misuse of other substances in many individuals. Nicotine, caffeine and alcohol
- [O7.9 Lung Cancer](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-8-lung-cancer/) - O7.9 Lung cancer Lung cancer is a serious health problem in Australia (Cancer Council Australia 2004). In 2007, in Australia, lung cancer was the fourth most commonly diagnosed cancer in both males and females (excluding basal and squamous cell carcinoma of the skin), with a total of 9,703 diagnosed (AIHW & Cancer Australia 2011).Lung cancer is the
- [O7.7 Aspiration](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-6-aspiration/) - O7.7 Aspiration Aspiration of food and liquid is common in those with COPD, up to 70% of adults with COPD and dysphagia (difficulty swallowing) aspirate (Good-Fratturelli 2000). Aspiration in those with COPD is thought to be due to the disrupted coordination of the exhale-swallow-exhale respiratory cycle during swallowing, cricopharyngeal muscle dysfunction, and changes in lung
- [O7.2.3 Stroke](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/072-cardiac-disease/o7-2-3-stroke/) - O7.2.3 Stroke The Rotterdam cohort study of 13,115 participants, studied for up to 22 years, included 1,566 patients with COPD, who had a 20% higher incidence of stroke during the study, particularly following an exacerbation of COPD. However, this association was no longer significant after adjusting for smoking, which indicates that smoking is a common
- [O6.9 Smoking cessation](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o68-smoking-cessation/) - O6.9 Smoking cessation While smoking cessation has long been known to reduce the rate of decline of lung function (see section P1.1), there is evidence it also has short-term benefits on lung function and quality of life. In a randomised controlled trial of varenicline (Tashkin 2011b) participants who continuously abstained from smoking compared to those who
- [O6.4 Neuromuscular Electrical Stimulation](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o64-physical-activity/) - O6.4 Neuromuscular electrical stimulation Neuromuscular electrical stimulation (NMES) uses an intermittent electrical current to elicit a contraction of a superficial peripheral muscle. The main aim of NMES is to improve muscle power or endurance. In people with COPD, NMES is generally applied to the thigh muscles. NMES is associated with a very low ventilatory load and
- [O1.1.2 Short-acting muscarinic antagonist (SAMA)](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o11-short-acting-bronchodilators/o112-short-acting-muscarinic-antagonist-sama/) - O1.1.2 Short-acting muscarinic antagonist (SAMA) Bronchodilators such as ipratropium, tiotropium, glycopyrronium, aclidinium and umeclidinium are not ‘anticholinergics’ since they are unable to antagonize the effects of acetylcholine on nicotinic receptors. They only block the muscarinic effects of acetylcholine. The word ‘anticholinergic’ suffers from pharmacodynamic approximation and should be replaced by ‘antimuscarinic’ (if we consider the
- [O1.1.1 Short-acting beta2-agonists (SABA)](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o11-short-acting-bronchodilators/o111-short-acting-beta-agonists/) - O1.1.1 Short-acting beta2-agonists (SABA) Regular short-acting beta2-agonists improve lung function and daily breathlessness scores. A systematic review of randomised controlled trials (Ram 2003) found a significant increase in post-bronchodilator spirometry when compared to placebo; weighted mean difference = 140mls (95% CI 40 to 250) for FEV1 and 300mls (95% CI 20 to 580) for forced
- [References](https://copdx.org.au/copd-x-plan/references/) - References The COPD Evaluation Committee continually reviews the published evidence on COPD. Papers that have been reviewed but not cited are included for information purposes. References A-G References H-R References S-Z All Papers considered for citation in COPD-X
- [O2.2 Phosphodiesterase type-4 inhibitors](https://copdx.org.au/copd-x-plan/o-optimise-function/o2-oral-bronchodilators/o22-phosphodiesterase-type-4-inhibitors/) - O2.2 Phosphodiesterase type-4 inhibitors Phosphodiesterase type-4 (PDE-4) inhibitors act by increasing intracellular concentrations of cyclic adenosine monophosphate (cAMP) to suppress inflammation and bronchoconstriction. A Cochrane Review analysed results from RCTs of roflumilast (20 trials, 17,627 patients) and cilomilast (14 trials, 6,457 patients) (Chong 2017) [evidence level I]. Compared to placebo, PDE-4 inhibitors improved FEV1 (mean
- [P1.2.4 Other agents](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p12-treatment-of-nicotine-dependence/p124-other-agents/) - P1.2.4 Other agents A number of other agents have been shown to be effective in smoking cessation but are not commonly used in clinical practice. Clonidine, an antihypertensive agent, increased smoking cessation 12 weeks following the end of treatment compared to placebo, although abstinence was not objectively confirmed in all studies (NNT = 12, 95%
- [P1.2.3 Antidepressants](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p12-treatment-of-nicotine-dependence/p122-antidepressants/) - P1.2.3 Antidepressants Antidepressants for smoking cessation have been shown to be effective in a number of trials which have been pooled in a Cochrane systematic review (Hughes 2014). This review included a total of 90 trials, 404 of which assessed the effect of bupropion and 10 nortriptyline. Pooling six available trials using nortriptyline as the only pharmacotherapy
- [O7.10 Bronchiectasis](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-9-bronchiectasis/) - O7.10 Bronchiectasis Bronchiectasis is characterised by dilated, thick-walled bronchi that fail to clear airway secretions, leading to a chronic productive cough, persistent bacterial infection and infective exacerbations. In milder COPD patients, bronchiectasis may be an incidental, subclinical finding on CT chest, as observed in the ECLIPSE study where the prevalence of bronchiectasis was 4% (Agusti
- [O7.6 Sleep related breathing disorders](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/o7-5-sleep-related-breathing-disorders/) - O7.6 Sleep-related breathing disorders COPD has adverse effects on sleep quality, resulting in poor sleep efficiency, delayed sleep onset, multiple waken­ings with fragmentation of sleep architecture, and a high arousal index. Arousals are caused by hypoxia, hypercap­nia, nocturnal cough and the pharmacological effects of methylxanthines and b-adrenergic agents (Phillipson 1986). Intranasal oxy­gen administration has been shown
- [O1.3 Assessment of response and continuation of bronchodilator therapy](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o13-assessment-of-response-and-continuation-of-bronchodilator-therapy/) - O1.3 Assessment of response and continuation of bronchodilator therapy In some patients a response to bronchodilator therapy may require treatment for up to two months. Symptomatic and functional benefits can often be demon­strated in the absence of an increase in FEV1. Other objective measurements, such as an increase in exercise capacity (e.g. as measured using
- [O1. Inhaled bronchodilators](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/) - O1. Inhaled bronchodilators See Appendix 1. Use and doses of long-term inhaled bronchodilator and corticosteroids determined in response trials. O1.1 Short-acting bronchodilators O1.1.1 Short-acting beta2-agonists (SABA) Regular short-acting beta2-agonists improve lung function and daily breathlessness scores. A systematic review of randomised controlled trials (Ram 2003) found a significant increase in post-bronchodilator spirometry when compared to
- [Links](https://copdx.org.au/links/) - COPD Algorithm The COPD algorithm is available from the following location: https://lungfoundation.com.au/health-professionals/clinical-resources/copd/primary-care-respiratory-toolkit/ Websites Lung Foundation Australia Australian Lung Cancer Conference Australasian Lung cancer Trials Group Lung Cancer Network Lung Health Checklist Pulmonary Rehabilitation Toolkit
- [X3.8 Support after discharge](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x38-support-after-discharge/) - X3.8 Support after discharge Follow-up at home after discharge from hospital may extend the continuum-of-care process begun within the acute envi­ronment and supported discharge programs are now well established. Such programs are generally short term in nature and have clear criteria for which patients are suitable. Compared to more traditional in-patient management, supported discharge programs
- [D1.10 Dietitian/Nutritionist](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d110-dietitiannutritionist/) - D1.10 Dietitian/Nutritionist Excessive weight-loss is a common problem in patients with end-stage COPD. Conversely, obesity in patients with COPD is associated with sleep apnoea, CO2 retention and cor pulmonale. Dietitians play a central role in managing these problems. A Cochrane Review of 17 studies (632 participants) that provided nutritional supplementation for patients with COPD for
- [O7.2.5 Coronary revascularisation procedures](https://copdx.org.au/copd-x-plan/o-optimise-function/o7-comorbidities/072-cardiac-disease/o7-2-5-coronary-revascularisation-procedures/) - O7.2.5 Coronary revascularisation procedures Patients with COPD are at increased risk of death and complications following cardiac surgery [evidence level III-2]. A study identified 1169 patients undergoing coronary artery bypass grafts and / or valve replacement at one US centre who had preoperative lung function tests (Adabag 2010). Operative mortality was 2% in those with no
- [O6. Non-pharmacological interventions](https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/) - O6. Non-pharmacological interventions There is strong evidence for the benefits of regular exercise in individuals with COPD (McCarthy 2015, Ries 2003, Spruit 2013, Alison 2017) [evidence level I]. All individuals with COPD should be encouraged to engage in physical activity consistent with the recommendations for ‘healthy’ adults. The current Australian and New Zealand guidelines for
- [O1.1.3 Short-acting bronchodilator combinations](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o11-short-acting-bronchodilators/o113-short-acting-bronchodilator-combinations/) - O1.1.3 Short-acting bronchodilator combinations For combination therapy with ipratropium bromide and short-acting beta2-agonists, there was no significant difference in pre-drug spirometry compared to ipratropium bromide alone (Appleton 2006a). There was a significant benefit for the combination in post-drug spirometry measurements; weighted mean difference = 70 ml (95% CI 50 to 90) for FEV1 and 120 ml
- [D1.4 Physiotherapist](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d14-physiotherapist/) - D1.4 Physiotherapist Physiotherapists are involved in a broad range of areas, including exercise testing and training, assessment for oxygen therapy, patient education, airway clearance techniques, breathing retraining, mobility, non-invasive ventila­tion (NIV), postoperative respiratory care and assessment and treatment of musculoskeletal disorders com­monly associated with COPD. Please refer to section O6 for more detailed information.
- [O9. Surgery](https://copdx.org.au/copd-x-plan/o-optimise-function/o9-surgery/) - O9. Surgery None of the current surgical approaches in patients with COPD provides a survival advantage (Benditt 1997). In view of the potential for serious morbidity and mortality, all surgical treatments require careful assessment by an experienced thoracic medical and surgical team.
- [O8.1 Treatment of hypoxaemia and pulmonary hypertension](https://copdx.org.au/copd-x-plan/o-optimise-function/o8-hypoxaemia-and-pulmonary-hypertension/o81-treatment/) - O8.1 Treatment of hypoxaemia and pulmonary hypertension Treat underlying lung disease: The logical first step is to optimise lung function and treat all potential aggravating conditions. Oxygen therapy: Long term, continuous (>18h/day) oxygen therapy to treat chronic hypoxaemia prolongs sur­vival of patients with COPD, presumably by reducing pulmonary hypertension (Medical Research Council Working Party 1981, Nocturnal Oxygen
- [P2.3 Haemophilus influenzae immunisation](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p2-immunisations/p23-haemophilus-influenzae-immunisation/) - P2.3 Haemophilus influenzae immunisation A Cochrane Review/meta-analysis of six placebo-controlled RCTs evaluating 557 patients, conducted to test the efficacy of enteric-coated, killed preparations of H. influenzae in populations prone to recurrent exacerbations of chronic bronchitis or COPD, concluded that there was no significant reduction in exacerbations in the vaccinated group when compared to the placebo
- [D1.5 Occupational therapist](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d15-occupational-therapist/) - D1.5 Occupational therapist Occupational therapists provide specific skills in task optimi­sation and prescription for those with severe disease of adaptive equipment and home modifications. Some therapists also teach energy conserva­tion for activities of daily living and can help in the set-up of home and portable oxygen. The effect of individualised occupational therapy in patients with
- [O1.1 Short-acting bronchodilators](https://copdx.org.au/copd-x-plan/o-optimise-function/o1-inhaled-bronchodilators/o11-short-acting-bronchodilators/) - O1.1 Short-acting bronchodilators O1.1.1 Short-acting beta2-agonists (SABA) Regular short-acting beta2-agonists improve lung function and daily breathlessness scores. A systematic review of randomised controlled trials (Ram 2003) found a significant increase in post-bronchodilator spirometry when compared to placebo; weighted mean difference = 140mls (95% CI 40 to 250) for FEV1 and 300mls (95% CI 20 to
- [O9.4 Pre-operative work-up surgery](https://copdx.org.au/copd-x-plan/o-optimise-function/o9-surgery/o93-lung-transplantation/) - O9.4 Pre-operative work-up surgery Patients with COPD are at increased risk of post-operative pulmonary complications after any thoracic or non-thoracic surgery. A US database analysis has shown that COPD is associated with increased post-operative mortality and morbidity with major surgical procedures (Gupta 2013), including abdominal operations (Fields 2016). Careful pre-operative work-up of patients with COPD
- [O9.1 Bullectomy](https://copdx.org.au/copd-x-plan/o-optimise-function/o9-surgery/o91-bullectomy/) - O9.1 Bullectomy This operation involves resection of large bullae (larger than 5cm). The procedure is most successful where there are very large cysts compressing adjacent apparently normal lung (Mehran 1995). Giant bullae can be defined as occupying more than 50% of the hemithorax with definite displacement of adjacent lung tissue (Laros 1986).
- [P10.1 Fitness to fly](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p10-oxygen-therapy/p101-fitness-to-fly/) - P10.1 Fitness to fly Commercial aircraft operate at altitudes of up to 12 500 metres, with the plane’s interior pressurised to 2100–2400 metres. At this “altitude” the alveolar PaO2 for healthy individuals decreases from 103 mmHg (13.7 kPa) to 64 mmHg (8.5 kPa) and oxygen saturation declines from 97% to 93%. As a general rule,
- [C2.2 Physical examination](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c2-diagnosis/c22-physical-examination/) - C2.2 Physical examination The sensitivity of physical examination for detecting mild to moderate COPD is poor (Badgett 1993). Wheezing is not an indicator of severity of disease and is often absent in stable, severe COPD. In more advanced disease, physical features com­monly found are hyperinflation of the chest, reduced chest expansion, hyperresonance to percussion, soft breath
- [X3.3 Invasive ventilation (intubation)](https://copdx.org.au/copd-x-plan/x-manage-exacerbations/x3-refer-appropriately-to-prevent-further-deterioration-p/x33-invasive-ventilation-intubation/) - X3.3 Invasive ventilation (intubation) NIV is contraindicated in patients who are unable to protect their airways, are not spontaneously breathing or who have severe facial injury or burns (Esteban 2000). Relative contrain­dications (situations where NIV may be less effective) include life-threatening refractory hypoxaemia (PaO2 < 60 mmHg, or 8 kPa on 100% inspired oxygen), bron­chiectasis with
- [P6. Corticosteroids](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p6-corticosteroids/) - P6. Corticosteroids The effect of inhaled corticosteroids on the disease progression in COPD has been the subject of a series of controlled trials and systematic reviews and the effect remains unclear. A Cochrane systematic review found benefits of inhaled corticosteroids in reducing exacerbations and reducing decline in quality of life, but no consistent benefit on
- [P1.3 Prevent smoking relapse](https://copdx.org.au/copd-x-plan/p-prevent-deterioration/p1-risk-factor-reduction/p13-prevent-smoking-relapse/) - P1.3 Prevent smoking relapse Family, friends and workmates should be advised of the intention to quit and asked to provide understanding and support. The relapse rate is increased if there are other smokers in the household. Success is more likely if all the smokers agree to quit together. Suggest the patient ring the Quit Line
- [C2.4 Flow volume tests](https://copdx.org.au/copd-x-plan/confirm-diagnosis/c2-diagnosis/c24-flow-volume-tests/) - C2.4 Flow volume tests Electronic spirometers allow for the simultaneous measure­ment of flow and volume during maximal expiration. Reduced expiratory flows at mid and low lung volumes are the earliest indicators of airflow limitation in COPD and may be abnormal even when FEV1 is within the normal range (>80%).
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- [D1.12 Non-medical care agencies](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d112-non-medical-care-agencies/) - D1.12 Non-medical care agencies Many patients with COPD have difficulties with activities of daily living and may require a range of non-medical support services, including governmental and non-governmental organisations. Availability of services varies between states and between areas within states (eg, urban, rural, remote). Some examples include: financial support and organisation of oxygen, CPAP machines,
- [D1.11 Exercise physiologist](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d111-exercise-physiologist/) - D1.11 Exercise physiologist Exercise physiologists are predominantly involved in exercise testing, exercise prescription and supervision of exercise rehabilitative programs. They also provide patient education on the importance of regular exercise and on activity/behavioural modification. They may also play a role in the assessment of exertional oxygen and the exercise rehabilitation of associated co morbidities.
- [D1.6 Social worker](https://copdx.org.au/copd-x-plan/d-develop-a-plan-of-care/d1-support-team/d16-social-worker/) - D1.6 Social worker Social workers can provide counselling for patients and their carers, organisation of support services, respite and long- term care.

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