Copyright EMAP Publishing 2020

This article is not for distribution

except for journal club use

Clinical Practice Keywords Chronic obstructive

pulmonary disease/Respiratory disease
Review
Respiratory disease This article has been
double-blind peer reviewed

In this article...
● S
 afe and effective use of inhaled and oral pharmacological therapies
● The value of pulmonary rehabilitation
● Supporting patients to self manage

COPD 2:
management and nursing care
Key points
Author Stephen Gundry is COPD nurse, Newcastle Hospitals NHS Foundation Trust.
Nurses have a
central role in Abstract Most nurses, not just specialist nurses, will routinely encounter people with
the care and chronic obstructive pulmonary disease in their care. Although there is no cure for this
management of progressive respiratory disease, nurses have a crucial role in its treatment and
people with chronic management, including helping patients to minimise and control their symptoms, and
obstructive improve the quality of their lives. This article, the second in a two-part series,
pulmonary disease describes treatment and management options when patients are stable and during
events, such as exacerbations, when their condition deteriorates. It describes the safe,
Inhaled effective use of inhaled and oral drug treatments and oxygen therapy, as well as
bronchodilators are non-pharmacological interventions – such as smoking cessation, pulmonary
the mainstay of rehabilitation – support for mental health and helping patients to self manage.
drug therapy
Citation Gundry S (2019) COPD 2: management and nursing care. Nursing Times
Support for smoking [online]; 116: 5, 48-51.
cessation can be

M
important in slowing
the progression ost nurses – not just those
of the disease who are specialist chronic
obstructive pulmonary dis-
Too few patients ease (COPD) or respiratory
are referred for nurses – will routinely care for people who
pulmonary have COPD. As described in part one of
rehabilitation this series, COPD is a long-term, progres-
despite evidence sive respiratory disease, which imposes a
of its effectiveness significant health-related burden on the
individual. Although COPD cannot be
Use of self- cured, nurses have a crucial role in the
management plans care and management of people living
has been shown to with it, including helping them to mini-
improve patients’ mise and control their symptoms, and
quality of life, while improve the quality of their lives.
also reducing
breathlessness and Inhaled drug therapies
hospitalisation Inhaled medication is the mainstay of
pharmacological treatment for patients
with COPD, inhalers need to be selected on
the basis of the medication prescribed and
patients’ ability to use them with a compe-
tent technique. Most patients can learn to
use inhalers effectively with coaching and
regular review; nurses and other practi-
tioners should use each consultation as an
opportunity to offer inhaler technique
coaching (National Institute for Health and
Care Excellence, 2018a). If patients have dif-
ficulty with an inhaler, they should be
offered an alternative.
Patients using pressurised metered-
dose inhalers (pMDI inhalers) should be
given a spacer device; this helps to:
l I ncrease lung deposition of medication;
l R educe local oropharyngeal deposition;
l R educe local side-effects.
They should be advised to inhale a single
dose at a time using tidal breathing or a
single breath – tidal breathing technique
may be more suitable during episodes of
breathlessness, when it is easier to take sev-
eral (usually five) ordinary-sized breaths
without the need for a breath hold. It is
helpful to use combination devices where
appropriate to minimise the number of
inhalers a patient needs (NICE, 2018a).
Medication in dry-powder inhalers
(DPIs) is either built into the device itself or
in capsule form and inserted into the
inhaler. DPIs tend to require a greater
inspiratory effort to inhale the medication

Nursing Times [online] May 2020 / Vol 116 Issue 5 48 www.nursingtimes.net


Clinical Practice
Review
into the airways and should be selected on
the basis of patients’ ability to use them
competently.
Short-acting beta-2 agonists (SABAs),
such as salbutamol and terbutaline, are
used to relieve breathlessness (dyspnoea)
and associated exertional limitation. Long-
acting beta-2 agonists (LABAs), such as for-
moterol and salmeterol, and long-acting
muscarinic antagonists (LAMAs), such as
tiotropium, umeclidinium and acli-
dinium, provide ongoing maintenance
therapy to help control COPD symptoms.
They are frequently used in combination.
LAMA/LABA inhalers are suitable for
patients who have no asthmatic features in
their signs and symptoms.
Inhaled corticosteroids (ICS) are helpful
in patients who demonstrate some degree
of steroid responsiveness and asthmatic
features, and those who have frequent
exacerbations (more than two in a
12-month period) or hospitalisations. They
are generally used in combination inhalers
alongside LABA medication, but are asso-
ciated with increased risk of pneumonia in
patients with COPD, (Kew and Seniuko-
vich, 2014). They should be used with cau-
tion and withdrawn in patients who do not
experience frequent exacerbations.
Triple therapy – comprising LABA,
LAMA and ICS – can be considered for
patients who remain symptomatic despite
treatment (NICE, 2018a) (Fig 1).
Patients should be informed about, and
understand:
l T
 he possible side-effects of oral
inhalers (for example, oral candidiasis,
hoarse voice, dry mouth);
l H
 ow to reduce their risk of developing
these side-effects (D’Ancona, 2015);
l T
 he role of their inhalers and spacer
devices;
l A
 ppropriate storage and cleaning
instructions.
Oral therapy
Oral corticosteroids are not recommended
for routine maintenance treatment;
patients who cannot be weaned off ster-
oids should have their dose reduced to as
low as possible and be started on osteopo-
rosis prophylaxis, to counter side-effect of
steroid use (NICE, 2018a). However, oral
corticosteroids have an important role
during acute exacerbations, patients can
be given a short course of tablets lasting
for 7-14 days (NICE, 2018a).
Antibiotics may be necessary during an
exacerbation where infection is suspected,
for example, in the presence of increased
volume of sputum or darker sputum colour.
Nursing Times [online] May 2020 / Vol 116 Issue 5
Copyright EMAP Publishing 2020
This article is not for distribution
except for journal club use
Fig 1. Inhaled therapies
Offer SABA or SAMA to use if needed
Person still breathless or has exacerbations despite treatments?
No asthmatic features/features Asthmatic features/features
suggesting steroid responsiveness* suggesting steroid responsiveness*
Offer LABA + LAMA Offer LABA + ICS
Person still breathless or has
For ALL inhaled therapies further exacerbations
Train people in correct inhaler technique despite further treatment?
Review medication, and assess inhaler
technique and adherence regularly
Offer LAMA, LABA and ICS
Explore further treatment options if needed (see NICE, 2018a)
*Any previous secure diagnosis of asthma or atopy, a raised blood eosinophil count, substantial
variation in forced expiratory volume per second (FEV1) over time (at least 400ml) or substantial
diurnal variation in peak expiratory flow (at least 20%)
ICS = inhaled corticosteroids; LABA = long-acting beta-2 agonist; LAMA =long-acting muscarinic
antagonist; SABA = short-acting beta-2 agonist
NICE (2018b) recommends first-line oral exacerbations per year, prolonged exacer-
antibiotic treatment with amoxicillin, dox- bations or exacerbations leading to hos-
ycycline or clarithromycin; options for pital admission (NICE, 2018a).
intravenous antibiotics include amoxi-
cillin, co-amoxiclav, clarithromycin, co-tri- Oxygen therapy
moxazole and piperacillin with tazobactam. Oxygen therapy is used to correct hypox-
Although routine sputum testing is not aemia, rather than prevent or treat breath-
recommended, poor response to treatment lessness; it should be prescribed with cau-
should prompt a change of antibiotic. tion in patients with COPD after arterial
Oral slow-release theophylline can be blood-gas assessment. An indication to
used in patients who are unable to manage refer a patient for long-term oxygen
inhalers, although there is lower con- therapy assessment is a reliable pulse oxi-
sensus over its efficacy in COPD (The Lancet metry reading <92%.
Respiratory Medicine, 2018). This requires Long-term oxygen therapy is indicated
monitoring plasma levels to titrate the in patients with an arterial partial pressure
dose correctly, and monitoring patients for of oxygen (PaO2) when stable of <7.3kPa, or
the medication effects and any adverse <8kPa with comorbid symptoms of periph-
effects. A reduced dose may be needed for eral oedema, pulmonary hypertension or
patients with comorbidities, or when secondary polycythaemia – high concen-
starting antibiotics in the macrolide or tration of red blood cells in blood – (NICE
fluoroquinolone groups due to possible 2018a). Nurses need to be alert to the safety
reduced drug clearance (NICE, 2018a). issues associated with oxygen therapy,
Mucolytic therapy may be helpful in particularly the risk of burns and fire, and
patients with a productive cough who falls and trips.
struggle to expectorate effectively (NICE, NICE (2018a) recommends that patients
2018a). Prophylactic antibiotic treatment who still smoke after being offered smoking
with optimised inhaled therapy can be cessation support and referral to specialist
considered in patients with ongoing smoking cessation services (discussed later
sputum production who do not smoke but in this article) should not be offered home
experience frequent (four or more) oxygen therapy routinely. However,
49 www.nursingtimes.net

Clinical Practice
Review
Box 1. Ask, Advise Act:
a three-step approach to
smoking cessation
l ASK and record smoking status – is
the patient a smoker, ex-smoker or
non-smoker?
l ADVISE on the best way of quitting
– the best way of stopping smoking is
with a combination of medication
and specialist support
l ACT on patient response – build
confidence, give information, refer
and prescribe. Patients are up to four
times more likely to quit successfully
with NHS support
Source: Wright (2013)
practice varies and British Thoracic Society
guidelines recommend patients are:
l I nformed of the reduced benefits of
oxygen if they smoke;
l G iven written safety instructions and
alerted, along with their relatives, to
the fire risk (Hardinge et al, 2015).
Ambulatory oxygen offers improved
exertional endurance to patients who
desaturate on exercise and demonstrate
improved exercise capacity while
breathing supplementary oxygen (NICE,
2018a), but it should only be prescribed fol-
lowing a structured assessment under-
taken by a specialist.
Emergency oxygen in patients at risk of
hypercapnic respiratory failure, including
those with COPD, should be prescribed
and administered to maintain an oxygen
saturation of 88-92% (O’Driscoll et al, 2017).
Smoking cessation
For patients who smoke, smoking cessa-
tion is probably the most important
measure they can take to improve their
long-term prospects and slow the progres-
sion of the disease. Nurses can help by pro-
moting smoking cessation, offering treat-
ment and/or signposting to smoking
cessation services. Two starting points are:
l A
 simple three-step approach – Ask,
Advise, Act (Box 1);
l  Very Brief Advice on Smoking,
developed by the National Centre for
Smoking Cessation and Training
(Bit.ly/SmokingAAA), and
recommended by the Department of
Health (Wright, 2013).
The NHS Long Term Plan demonstrates a
clear commitment to promoting smoking
cessation, with the intention of creating a
‘smoke-free society’ (NHS England, 2019).
As an example, it highlights evidence
Nursing Times [online] May 2020 / Vol 116 Issue 5
demonstrating improved quit rates using
brief personalised counselling, timely pro-
vision of nicotine replacement or medica-
tion, and follow up. Nurses are well placed
to play a central role in this smoking cessa-
tion strategy, which will deliver consider-
able health benefits across the population.
Pulmonary rehabilitation
Pulmonary rehabilitation (PR) for COPD is a
structured exercise and education pro-
gramme shown to improve exercise
capacity, quality of life, symptoms, and
levels of anxiety and depression (NICE 2016);
it has long been recognised as a valuable
and important intervention in COPD man-
agement (BTS, 2014). Nurses should actively
promote, screen and refer patients to PR
and can also support educational compo-
nents of rehabilitation programmes.
The NHS Long Term Plan states that only
13% of eligible patients are offered PR,
despite evidence that 90% will benefit
from improved quality of life and exercise
tolerance (NHS England, 2019). Although
the reasons for this low uptake are unclear,
it may be caused by low awareness of both
the availability of PR and the strength of
supporting evidence.
13%
QUICK Patients offered pulmonary
FACT rehabilitation out of all
those who are eligible
Anxiety and depression
Generalised anxiety, phobias and panic
attacks are more common in people with
COPD compared with the wider popula-
tion (Abebaw and Alexopoulos, 2014).
Holistic nursing assessment has a key role
in identifying anxiety and depression, and
there is evidence to support the role of
nurses in delivering a cognitive behav-
ioural therapy approach to help patients
with COPD manage the two conditions
(Heslop-Marshall et al, 2018).
Education and self-management
Nurses have a central role in educating
patients on disease management and equip-
ping them to understand their condition
and live as well as they can. Patients need to
understand the long-term nature of their
condition and that, although there is no
cure, much can be done to mitigate symp-
toms and optimise their quality of life.
COPD self-management plans are typi-
cally patient-held documents containing
information and advice to support people
on their COPD journey. This can include
factors such as managing shortness of
50
Copyright EMAP Publishing 2020
This article is not for distribution
except for journal club use
breath, staying active, eating well and
inhaler medication, along with possible
side-effects and goal setting. Self-manage-
ment plans should be patient specific, so
they reflect individual needs and priori-
ties. There is evidence to support the use of
self-management plans for patients with
COPD – a Cochrane meta-analysis found
improved health-related quality-of-life
scores, reduced self-described breathless-
ness (dyspnoea) and lower respiratory and
all-cause hospitalisation as a result of self-
management plans (Lenferink et al, 2017).
Nurses have a critical role in ensuring
patients can self-manage in terms of rec-
ognising symptoms and dealing with
exacerbations appropriately, with steroids
and/or antibiotics where necessary. There
is scope to draw up self-management plans
with patients, support self-management
and help patients work towards health-
related goals.
When patients deteriorate and become
more dependent on family, friends, and
health and social care staff, nurses have an
important role to play in providing sup-
port, information and education for formal
and informal carers. This may include staff
education and training – specialist nurses
are particularly well equipped to deliver
this because of their specialist knowledge
of COPD management.
Resources to support patient education
are available from a number of organisa-
tions; as an example, the British Lung
Foundation (www.blf.org.uk) provides
clear and accessible patient information,
available in print and online.
Preventing hospital admission
In secondary care, widespread adoption of
hospital-at-home and early-discharge
schemes have succeeded in reducing
length of hospital stay (Echevarria et al,
2018). There are also numerous examples
of integrated care and multidisciplinary
teams engaged in managing COPD that
successfully bridge the gap between pri-
mary and secondary care; the Respiratory
Action Network for the Benefit of Wolver-
hampton (RAINBOW) group (Bit.ly/Rain-
bowCOPD) is one example.
In primary care, nurses are key in man-
aging and monitoring stable patients, and
supporting patients’ ability to self-manage
their condition.
Nursing care
Many nursing roles are ideally placed to
support patients to live well with COPD. As
discussed in part one, COPD has no cure
and, although medication can help to
www.nursingtimes.net
 Copyright EMAP Publishing 2020
This article is not for distribution
except for journal club use

Clinical Practice For more articles

on respiratory nursing, go to
Review nursingtimes.net/respiratory

mitigate some of the symptoms, it cannot
alter the inevitable course of the disease –
exacerbations can feature, particularly as
COPD becomes more severe. The need for
ongoing routine surveillance, and the pos-
sibility of escalating treatment regimes,
brings patients into frequent contact with
nurses, and the alignment of the nurse’s
role with the notion of enablement and
health promotion means many interven-
tions they deliver and support can improve
patients’ lives and wellbeing.
NICE endorses the role of specialist
COPD or respiratory nurses in the multi-
disciplinary team, and the specialist nurse
role sits easily with many of the elements of
care and treatment recommended by the
organisation. The specialist nurse role
varies between primary and secondary care
and acute treatment, chronic management
and surveillance (NICE, 2018a).
Conclusion
COPD is a complex disease that places a
considerable burden on individuals in
terms of physical symptoms, and reduced
mental and social wellbeing. The chronic
nature of the disease, and occurrence of
exacerbations, will cause patients to access
health services multiple times for routine
and acute assessments in the course of their
COPD journey. Nurses in both primary care
and acute-care settings will encounter
COPD patients on a regular, even frequent,
basis and have a central role to play in
meeting their health and social needs. NT
References
Abebaw MY, Alexopoulos GS (2014) Depression
and anxiety in patients with COPD. European
Respiratory Review; 23: 345-349.
British Thoracic Society (2014) Quality Standards
for Pulmonary Rehabilitation in Adults. BTS.
D’Ancona G (2015) Inhaled corticosteroids:
managing side effects. The Pharmaceutical
Journal; 294: 7851, 247-249.
Echevarria C et al (2018) Home treatment of
COPD exacerbation selected by DECAF score: a
non-inferiority, randomised controlled trial and
economic evaluation. Thorax; 73: 713-722.
Hardinge M et al (2015) British Thoracic Society
guidelines for home oxygen use in adults:
accredited by NICE. Thorax; 70: i1-i43.
Heslop-Marshall K et al (2018) Randomised
controlled trial of cognitive behavioural therapy in
COPD. ERJ Open Research; DOI:
10.1183/23120541.00094-2018.
Kew KM, Seniukovich A (2014) Inhaled steroids
and risk of pneumonia for chronic obstructive
pulmonary disease. Cochrane Database of
Systematic Reviews; 3: CD010115.
The Lancet Respiratory Medicine (2018) The death
of low-dose oral theophylline for COPD? The
Lancet Respiratory Medicine; 6: 7, 479.
Lenferink A et al (2017) Self-management
interventions including action plans for
exacerbations versus usual care in patients with
chronic obstructive pulmonary disease. Cochrane
Database of Systematic Reviews; 8: CD011682.
National Institute for Health and Care Excellence
(2018a) Chronic Obstructive Pulmonary Disease in
Over 16s: Diagnosis and Management. NICE.
National Institute for Health and Clinical
Excellence (2018b) Chronic Obstructive Pulmonary
Disease (Acute Exacerbation): Antimicrobial
Prescribing. NICE
National Institute for Health and Care Excellence
(2016) Chronic Obstructive Pulmonary Disease
in Adults. NICE.
NHS England (2019) The NHS Long Term Plan. NHS.
O’Driscoll BR et al (2017) BTS guideline for oxygen
use in adults in healthcare and emergency settings.
Thorax; 72: ii1-ii90.
Wright J (2013) Very Brief Advice can be effective
in Encouraging Smokers to Quit.
guidelinesinpractice.co.uk; 1 January.
CLINICAL
SERIES Chronic obstructive
pulmonary disease series
Part 1: Pathophysiology, diagnosis Apr
and prognosis 
Part 2: Management and nursing care May

Support your nurses and improve patient CPD

safety and care with a group subscription
Nursing Times Group Subscriptions help organisations support their nurses’
development by providing:
Flexible, user-friendly online learning units and an e-portfolio in which to
easily store CPD and revalidation evidence
A clinical archive of 6,000+ double-blind, peer reviewed articles to help
nurses stay up to date and safe to care
A Manager Dashboard to help managers keep track of staff progress, and
quickly identify address problems if they arise.
Nursing Times Group Subscriptions also help drive retention and recruitment,
providing an additional staff benefit and helping staff feel valued and supported.

To find out more visit www.nursingtimes.net/groupsubscriptions or to book a demo call 020 3953 2977

Some of our current clients:

NT Print Advert V2 U3 - 195x125.indd 1 10/03/2020 14:49

Nursing Times [online] May 2020 / Vol 116 Issue 5 51 www.nursingtimes.net