D2. Support team

In advanced disease, the many comorbidities, social isolation and disability mean that a multidisciplinary approach to coordinated care may be appropriate. The multidisciplinary team, depending on local resources, may include the members listed below. The role of respiratory specialists is outlined in Section C.

D2.1 General

As the primary healthcare provider, the GP is uniquely placed to identify smokers and help them quit, diagnose COPD in its early stages and coordinate care as the disease progresses.

Smoking cessation: A doctor's advice is an important motivator for smoking cessation, especially if the doctor is the family physician. The GP can help initiate the cycle of change by repeated brief interventions. Since relapse to smoking is common, GPs should make enquiries about smoking status routinely at each visit. There are several smoking cessation programs that have been developed for use in general practice (outlined in the RACGP "Green Book"²¹⁹). The GP is also the appropriate health professional to recommend or prescribe nicotine replacement therapy and pharmacological treatment of nicotine addiction (for a detailed discussion of smoking cessation interventions, see Section P).

Early diagnosis: Most people visit a GP about once a year. Simple questions relating to smoking history, daily cough and degree of breathlessness should lead to lung function testing.

Coordinate investigation and management: GPs will manage patients with mild to moderate COPD. Referral to a respiratory physician may be indicated to confirm the diagnosis, exclude complications and aggravating factors, and to help develop a self-management plan (Section C, Box 8).

Coordinate care in advanced disease: GPs play a crucial role coordinating services provided by a range of healthcare professionals and care agencies (the "multidisciplinary team").

D2.2 Nurse/respiratory educator

Specific aspects of care provided by nurses in COPD may include:

• respiratory assessment, including spirometry and pulse oximetry;

• implementation of, or referral for, interventions such as smoking cessation, sputum clearance strategies, oxygen therapy;

• skills training with inhalation devices;

• education to promote better self-management (eg, medications and response to worsening of symptoms);

• organisation of multidisciplinary case conferences and participation in care-plan development; and

• assessment of the home environment.

D2.3 Physiotherapist

Physiotherapists are involved in a broad range of areas, including exercise training, sputum clearance, breathing retraining, mobility, non-invasive positive pressure ventilation, postoperative respiratory care (eg, after LVRS), and assessment and treatment of musculoskeletal disorders commonly associated with COPD.

D2.4 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.

D2.5 Social worker

Social workers can provide counselling for patients and their carers, organisation of support services, respite and long-term care.

D2.6 Clinical psychologist

Anxiety and depression are common comorbidities in patients with COPD.²⁰² Panic disorder is also frequent, and can be disabling and out of proportion to the impairment of lung function. Clinical psychologists can use techniques such as counselling and cognitive behavioural therapy to help address anxiety and depression. They may also advise whether pharmacological treatment may be appropriate.

D2.7 Speech pathologist/therapist

Speech pathologists can be involved in the assessment and management of recurrent aspiration, swallowing and eating difficulties caused by shortness of breath, and dry mouth associated with some pharmaceuticals, age and mouth breathing.

D2.8 Pharmacist

Pharmacists are involved in education about medications and supply of medications. They can help smokers quit by advising about nicotine replacement and can counsel patients requesting over-the-counter salbutamol. They are well placed to monitor for medication problems and complications and suggest solutions (eg, individual dosing dispensers).²⁰⁷ This is particularly important where multiple comorbid conditions require treatment with multiple medications that have potential interactions, or when confusion exists about timing of medication administration.

D2.9 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.

D2.10 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, nebulisers, etc;

• Homecare;

• government-supported assistance with activities of daily living (showering, cleaning, shopping, etc);

• home maintenance;

• Meals on Wheels;

• exercise programs; and

• support groups.