O6.  Non-pharmacological interventions

06.1 Physical activity 

Regular physical activity is recommended for all individuals with COPD and has been shown to reduce the risk of COPD admissions and mortality (evidence level III-2). This recommendation is based on a population-based sample of 2,386 individuals with COPD who were followed for a mean of 12 years. Those who performed some level of regular physical activity had a significantly lower risk of COPD admissions or mortality than sedentary individuals.⁸⁴

O6.2 Exercise training

Exercise training is considered to be the mandatory component of pulmonary rehabilitation.^85,86 Numerous randomised controlled trials in patients with moderate to severe COPD have shown decreased symptoms (breathlessness and fatigue),increased exercise endurance and improved, health-related quality of life, emotional function and the patients’ self-control over their condition following exercise training alone⁸⁷ [evidence level I]. Improvements in muscle strength and self-efficacy have also been reported.[86] Exercise training also improves exercise tolerance in individuals with mild disease.⁸⁸

Inspiratory muscle training (IMT), performed in isolation using a threshold loading device or target-flow resistive device, has been demonstrated to increase inspiratory muscle strength and endurance and reduce dyspnoea in patients with COPD^89,90 [evidence level I]. It remains unclear whether IMT combined with a program of whole-body exercise training confers additional benefits in dyspnoea, exercise capacity or health-related quality of life. in subjects with COPD.⁹¹ At present, the evidence does not support the routine use of IMT as an essential component of pulmonary rehabilitation.⁸⁶

Some very disabled patients are shown how to reduce unnecessary energy expenditure during activities of daily living.⁸⁵ Some patients who experience marked oxygen desaturation on exertion may benefit from ambulatory oxygen during exercise training and activities of daily living. (see section P).

Maintenance of regular physical activity is essential for continuing the benefits from the initial training program.⁸⁶ Transfer of the exercise and education components of the initial pulmonary rehabilitation program into the home setting should be emphasised in an attempt to encourage long-term adherence. Exacerbations are reported by patients with COPD to be the commonest reason for non-adherence with exercise.⁹² Several strategies for maintaining regular exercise and self-management have been studied; however, there is no consensus as to the most effective strategy for maintaining the benefits of pulmonary rehabilitation.^85,86

O6.3 Education and self-management

There is limited evidence that education alone can improve self-management skills, mood and health-related quality of life^93-95[evidence level III-2]. Providing information and tools to enhance self-management in an interactive session is more effective than didactic teaching.^93,96

A systematic review of self-management education for COPD⁹⁷ concluded that self-management education is associated with a significant reduction in the probability of at least one hospital admission when compared with usual care (odds ratio 0.64 95% CI 0.47 to 0.89) [evidence level I]. This translates into a one-year Number Needed to Treat ranging from 10 (6 to 35) for individuals with a 51% risk of exacerbation to a Number Needed to Treat of 24 (16 to 80) for patients with a 13% risk of exacerbation. This review also showed a small but significant reduction in dyspnoea measured using the Borg 0-10 dyspnoea scale. However, the magnitude of this difference (weighted mean difference -0.53, 95% CI -0.96 to -0.10) is unlikely to be clinically significant. No significant effects were found in the number of exacerbations, emergency room visits, lung function, exercise capacity and days lost from work. Inconclusive results were observed in doctor and nurse visits, symptoms (other than dyspnoea), the use of courses of corticosteroids and antibiotics and the use of rescue medication. However, because of the heterogeneity in interventions, study populations, follow-up time and outcome measures, data are insufficient to formulate clear recommendations regarding the format and content of self-management education programs for individuals with COPD.

The single most important intervention is assistance with smoking cessation.⁷ Good nutrition; task optimisation for more severely disabled patients; access to community resources; help with control of anxiety, panic or depression; instruction on effective use of medications and therapeutic devices (including oxygen where necessary); relationships; end-of-life issues; continence; safety for flying; and other issues may be addressed.^7,85,98 

O6.3.1 Psychosocial support

Improved exercise tolerance, mood, self-efficacy and health-related quality of life have been reported from cognitive behavioural therapy alone^98,93 [evidence level III-2]. Depression, anxiety and panic are frequent complications of chronic disabling breathlessness, with dependence and social isolation being common.⁹⁹ General support, specific behavioural training and the use of appropriate antidepressant medications may enhance quality of life for the patient, and for the spouse or carer.

Lung support groups may provide patients and carers with emotional support, social interaction, and other social outlets, and help them gain new knowledge and coping strategies. More than 100 groups throughout Australia can be contacted via The Australian Lung Foundation’s LungNet Information & Support Centre and in New Zealand, contact the Asthma and Respiratory Foundation of New Zealand:

 

O6.4 Pulmonary rehabilitation

Pulmonary rehabilitation programs involve patient assessment, exercise training, education, nutritional intervention and psychosocial support.^85,100An online toolkit is available to assist health professionals to implement a Pulmonary Rehabilitation Program. See www.pulmonaryrehab.com.au

Pulmonary rehabilitation is one of the most effective interventions in COPD^87,86 and has been shown to reduce symptoms, disability and handicap, reduce hospitalisation[100, 101] and to improve function by:

• improving peripheral muscle function, cardiovascular fitness, muscle function and exercise endurance^86,87,102,
• enhancing the patient’s emotional function, self-confidence and coping strategies, and improving adherence with medications^87,98;
• improving mood by controlling anxiety and panic, decreasing depression, and reducing social impediments⁸⁶.

Pulmonary rehabilitation should be offered to patients with moderate to severe COPD, but can be relevant for people with any long-term respiratory disorder characterised by dyspnoea.^85,86 Exercise programs alone have clear benefits,⁸⁷ while the benefits of education or psychosocial support without exercise training are less well documented.^86,85 Comprehensive programs incorporating all three interventions have the greatest benefits (see below). Most research has been undertaken with hospital-based programs, but there is also evidence of benefit from rehabilitation provided to in-patients and in the community and home settings.^{85,103,104,86} The minimum length of an effective rehabilitation program that includes exercise training is six weeks; however, there is some evidence of dose response-effect with longer programs producing greater and more sustained benefits in exercise tolerance⁸⁶[evidence level II].

O6.5 Chest physiotherapy (Airway clearance techniques)

The aims of airway clearance techniques in patients with COPD are to assist sputum removal and improve lung ventilation in an attempt to slow the decline in lung function and relieve symptoms. Chest x-ray/ CT findings and auscultation help determine the regions of the lung to be treated. Short-acting inhaled bronchodilators prior to treatment may assist with sputum clearance in some patients.

A variety of techniques are available including conventional chest physiotherapy (defined as any combination of gravity-assisted drainage, percussion, vibrations and directed coughing), the Active Cycle of Breathing Techniques (ACBT), Positive Expiratory Pressure (PEP) therapy, oscillating devices (Flutter®, or Acapella®).

A systematic review of bronchopulmonary hygiene therapy in COPD and bronchiectasis showed a significant increase in sputum production and isotope clearance from the lung with no change in lung function or health status¹⁰⁵ [evidence level I]. However, the trials were all small and not generally of high quality. Further, the results could not be combined as the trials addressed different patient groups and outcomes.

Given the heterogeneity of lung disease in COPD it is unlikely that one technique is superior for all patients. The choice of technique depends on the patient’s condition (e.g. extent of airflow limitation, severity of dyspnoea); sputum volume; the effects of the different techniques on lung volumes, expiratory flow and dynamic airway compression; cognitive status of the patient and acceptability of the technique to the patient especially where long-term treatment is required.¹⁰⁶ Re-evaluation of the choice of airway clearance technique is necessary during an acute exacerbation of COPD when deterioration in lung function, increased sputum volume and increased work of breathing are likely to be present.

O6.6 Nutrition

In patients with COPD, both excess and low weight is associated with increased morbidity. Excessive weight increases the work of breathing and predisposes to sleep apnoea — both central hypoventilation and upper-airway obstruction. Progressive weight loss (body mass index < 20) is an important prognostic factor for poor survival^107,108,109 [evidence level I]. This may be the result of a relative catabolic state (related to high energy demands of increased work of breathing) added to disturbance of nutritional intake (related to breathlessness while eating). Deleterious consequences include combined protein–energy malnutrition,¹⁰⁸ and possibly mineral or essential vitamin and antioxidant deficiencies.¹⁰⁸

Randomised controlled trials of nutritional support in COPD have not shown significant improvements in nutrition, exercise capacity or other outcomes¹⁰⁹ [evidence level I]. Patients with COPD should not eat large meals, as this can increase dyspnoea. Several small nutritious (high energy, high protein) meals are better tolerated. Snacks may provide a useful addition to energy and nutrient intake. Referral to a dietitian for individual advice may be beneficial. Anabolic steroids in patients with COPD with weight loss increase body weight and lean body mass but have little or no effect on exercise capacity.^110,111