D3. Self-management plans

A distinction can be made between 'self management' and 'self-management support'. ‘Self-management’ is a normal part of daily living, and involves the actions individuals take for themselves and their families to stay healthy and to care for minor, acute and long-term conditions. ‘Self management support’ is the facility that healthcare and social-care services provide to enable individuals to take better care of themselves. The onus in recent times has been on delivering training for self-management skills to individuals through a range of interventions.²²⁷

Patients with chronic illness who participate in self-management have better outcomes, including reduced healthcare costs, than those who do not.¹⁰¹ This study included some people with COPD. In COPD, behavioural education alone is effective, although less effective than integrated pulmonary rehabilitation programs that include an exercise component.¹⁰⁴

The concept of written action plans for patients with COPD is derived from their success in asthma management indicating doses and medications to take for maintenance therapy and for exacerbations. Instructions for crises are often also included. A systematic review by Turnock et al²²⁸ found that the use of action plans results in an increased ability to recognise and react appropriately to an exacerbation by individuals. However, there was no evidence these behavioural changes alter health-care utilisation. However, pharmacological treatment of COPD is generally less effective, as the condition is, by definition, non-reversible. Some interventions have strong support (eg, use of bronchodilators and systemic glucocorticoids for exacerbations and antibiotics if there is purulent sputum). They might be more effective if instituted early in an exacerbation, thereby preventing crisis and hospital admission. The primary care team needs to develop systems to identify those with more severe COPD who might benefit from more intensive education and training in self-management skills.

GP involvement in review of self-management plans (including medications) may be undertaken in the context of Domiciliary Medication Management/Review (DMMR), for which a Medicare Benefits Schedule fee is applicable (EPC Item 900). This requires the involvement of an accredited pharmacist and patient consent.

The plan should be reviewed after any exacerbation to make adjustments as appropriate. Patients should be encouraged to start additional treatment at the earliest sign of an impending exacerbation.

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 glucocorticoids have been given for an acute exacerbation. There is at present no evidence for back titration and further clinical trials are required.

D3.2 Exacerbations and crises

Detailed discussion of the management of exacerbations is found in Section X.

For severe exacerbations there is evidence for the use of bronchodilators, antibiotics, systemic glucocorticoids and supplemental oxygen (if patients are hypoxaemic). Selected patients may benefit from early intervention with these agents according to a predetermined plan developed by a GP or respiratory specialist. Some patients can be instructed to start using a "crisis medication pack" while awaiting medical review. They may also be instructed to contact a particular member of the multidisciplinary care team as part of their overall care plan.

Controlled trials are required to document the efficacy of self-management plans in patients with stable COPD, but, drawing on the success of asthma action plans, education of patients with COPD in self-management is recommended. Written plans are usually required to complement such interventions (see examples at http://www.lungnet.com.au/content/view/165/164/).