FEATURE: NON-PHARMACOLOGICAL MANAGEMENT OF COPD

The Non-pharmacological management of COPD

Written by Ms. Joan Johnston, National Co-ordinator COPD Support Ireland Email: nationalcoordinator@copd.ie | Professor J.J.Gilmartin, Chair COPD Support Ireland. Email: chair@copd.ie

Chronic Obstructive Pulmonary Disease (COPD) has a prevalence of approximately 380,000 patients in Ireland. With the iterations of the GOLD (Global Initiative for Obstructive Lung Disease 2020) the pharmacological management of COPD by severity class has been well established. Additionally, there is now significant evidence-based literature on non-pharmacological interventions showing improvements in dyspnoea, quality of life and even life expectancy. COPD Support Ireland (COPDSI ) is a national patient oriented charity with over 30 patient support groups around the country.

Nationally we have an advocacy role with links to the National Respiratory Programme, the ICGP, HSE and most recently on the Vulnerable people subgroup of NPHET. As per public health guidance we stood down our support groups and exercise programmes in March 2020, however we have been actively working with our members and health care professionals across Ireland to deliver alternative supports during COVID. COPDSI in conjunction with the National Clinical Programme have updated the “COPD & Me” information booklet, outlining many of the non-pharmacological options for patients with COPD. In this article we will review some of these interventions and the potential benefits in the management of COPD even during COVID-19: • Pulmonary Rehabilitation • Physical Activity • Peer Support • Breathlessness management • Anxiety management • Breathing Pattern Disorders

Where do non-pharmacological interventions fit in?

Declining activity levels in this patient demographic often happen long before diagnosis, the symptoms either go unnoticed or are easily explained away by progressing age, smoking history, weight gain etc. Initiation of Non-pharmacological management of COPD is just as important from diagnosis as the Joan Johnston, COPD Support Ireland

pharmacological management. Enabling patients to manage their symptoms when well, provides a broad ranging ‘toolbox’ to draw upon during times of exacerbation or disease progression.

Pulmonary rehabilitation

This is the gold standard for improving quality of life, decreasing dyspnoea, and increasing life expectancy in COPD patients. These programmes are a one stop shop for the individually tailored, holistic management of COPD and commencing early after a COPD hospitalisation in now becoming the norm.

They include a supervised exercise programme two to three times a week for 6-8 weeks with clear guidance on progressing exercise tolerance and understanding safe levels of exertional dyspnoea. The Borg scale of breathlessness is used with optimum exercise intensity resulting in moderate dyspnoea equivalent to a 3-4 on the Borg scale. In lay terms they should be able to “talk but not sing” during physical activity. Key to any pulmonary rehabilitation (PR) programme is to effect a lifestyle change that lasts beyond the 6–8-week programme, it is only with ongoing activity and self-management that the enduring benefit of PR can be found at 12-24 months post intervention. PR also provides education sessions covering topics such as pathophysiology of COPD, Inhaler technique, airway clearance, breathlessness management, anxiety, dietary advice, and smoking cessation delivered by the multidisciplinary team, and the interactive nature of these sessions can help cement those lifestyle changes. Unfortunately, PR programmes, while improving in number and capacity, can still have service gaps and waiting lists dependant on geography. COPDSI has used its group network to deliver key elements of PR where these gaps exist and recruits new members, for ongoing PR and peer support. During COVID-19 we have been rolling out the use of virtual solutions such as Zoom to deliver ongoing exercise, education, peer support and a singing for lung health programme for people living with COPD.

Physical Activity & Peer Support

20-30 minutes of moderate intensity exercise 3-4 times per week maintains both physical and mental wellbeing in the general population and this is more important when living with COPD. People are conditioned to “listen” to their bodies and if something does not feel right, then avoid it so it’s unsurprising that a person with COPD limits their activity levels. This leads to a vicious cycle of breathlessness with reduced activity causing deconditioning and subsequent increased respiratory rate and oxygen demand during any future physical activity. Education on the benefits of physical activity specific to COPD using the basic premise of “use it or lose it” can resonate in this population. This is especially important during the current COVID-19 pandemic with advice for people at high risk to stay home. As an organisation we have maintained contact with our 33 support group exercise classes around the country and they have all strongly attributed their physical and mental well being to that exercise. The loss of this support is the single biggest challenge they currently face, in response to this we launched a “Living Well with COPD during COVID” information pack which includes an updated COPD & Me book detailing the self-management of COPD including simple exercises to be done at home and our Top Tips to Protect your Physical and Mental Health during COVID.

Breathlessness, Anxiety and Breathing Pattern Disorders

The symptoms of these often coincide, overlap, or mimic each other and attempting to address one without considering the others can result in incomplete or futile interventions. Anxiety and depression are common comorbidities in COPD and can be associated with higher morbidity and mortality, increased disability, and increased healthcare service use. Where dyspnoea appears to be poorly controlled despite optimal bronchodilation and activity levels, anxiety is often the first consideration. While there are pharmacological interventions available to us, there are also proven non-pharmacological interventions. Cognitive behavioural therapy (CBT) has been shown to alleviate symptoms of anxiety in COPD through exploration of the link between a

patient’s situation, their symptoms, belief system and emotions. Retraining people with COPD to recognise that breathlessness is not always harmful can be a slow process. Patients may have had years of experiential and iatrogenic reinforcement of the negative thinking, that dyspnoea is directly correlated with oxygenation and that low oxygen levels are something to be avoided. Addressing this anxiety around breathlessness requires a change in the patients thinking but also in that of the healthcare professional. Brief interventions in CBT have been shown to improve the HADSAnxiety subscale scores with statistical significance in an RCT performed by Heslop-Marshall et al (2018). To deliver CBT to a wider group of COPD patients several Respiratory Nurse specialists were trained to deliver such interventions which also found that these interventions were in fact more cost effective than provision of information leaflets alone at 12 months post intervention. Breathing pattern disorders are the second comorbidity to consider in the persistently dyspnoeic patient. They have been well described in the literature particularly in relation to exercise induced bronchospasm or asthma, however they can also be present in COPD. In a COPD patient with poor bronchodilator relief a Nijmeigan questionnaire may be helpful in identifying non somatic causes of breathlessness. The interventions for breathing pattern disorders with or without anxiety can be as simple as retraining the breathing pattern, anxiety management, inspiratory muscle training and sinus rinsing. The following are common interventions used by physiotherapists in the management of the breathless patient. Breathing control where the patient is encouraged to breathe gently, with arms supported and hands and shoulders relaxed and is particularly helpful to regain control of breathing. This, when combined with a position of ease such as forward lean in sitting, resting elbows on knees or a table; or in standing, leaning against a wall, helps to optimise the length tension relationship of the diaphragm and increase its efficacy during each breath. Purse lip breathing helps maintain control of the breath during activity and has been shown to result in lower VO2 and respiratory rate and an increased recovery rate in patients with COPD (Jones et al, 2003 as cited in Bott et al, 2009). “Blow as you go”, where the patient is told to blow out during exertion, like the instruction given in the gym when lifting weights, patients are instructed to blow out through pursed lips during the exertional part of the activity such as standing up from sitting. Diaphragmatic breathing, where the abdominal wall is encouraged to excurse outwards against a hand resting on the abdomen during inspiration can also reduce VO2 and respiratory rate in COPD patients. Describing how a small child breathes with their tummy after running around is a helpful analogy to draw when teaching this technique. It is important to note here that patients with Severe COPD found this technique increased their experience of dyspnoea despite there being improvements in oxygenation and thus is not recommended for those with severe disease (Bott et al, 2009).

Conclusion

The GOLD guidelines (2020) provide an algorithm for the initiation of non-pharmacological interventions alongside pharmacological management from diagnosis with a follow-on algorithm for the review of these

Professor JJ Gilmartin interventions and continuation if benefit is demonstrated. The overall message is clear, nonpharmacological management of COPD is key to its successful management or more accurately its self-management. “COPD & Me” details a number of these non-pharmacological interventions and is a great first step in addressing their optimisation in the COPD patient. “Living well with COPD during COVID” information pack can be downloaded from www.copd. ie, alternatively patients can text the word “COPD” plus their name and address to 51444 to receive a free pack in the post. (standard network charges apply) The “COPD & Me” book can be downloaded from www.copd.ie alternatively email info@copd.ie to order copies for your service. The “Living Well with COPD in a COVID world” conference can be viewed on our website homepage www.copd.ie.

References

Bott J, Blumenthal S, Buxton M, et al Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient Thorax 2009;64:i1-i52. Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2020 global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease, 2020 report. Heslop-Marshall K, Baker C, CarrickSen D, et al. Randomised controlled trial of cognitive behavioural therapy in COPD. ERJ Open Res. 2018;4(4):000942018. Published 2018 Nov 23. doi:10.1183/23120541.00094-2018