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Table 1: Risk factors for COPD (World Health Organization, 2014)Smoking

Occupational-related exposure

Air pollution, indoor and outdoor

Genetic factors

Chronic obstructive pulmonary disease (COPD) is the term given to progressive airflow

obstructive conditions, namely chronic bronchitis and emphysema (National Institute for Health and Care Excellence [NICE], 2010). It is a serious, long-term, irreversible disease which obstructs airflow to the lungs due to inflammation of the air passages and lung tissue damage (British Lung Foundation [BLF], 2014).

It is estimated that three million people in the UK are affected by COPD — 900,000 having been diagnosed, with around two million being undiagnosed due to initial

Community management of chronic obstructive pulmonary disease (COPD)

symptoms being ignored (Healthcare Commission, 2006). COPD has been the cause of between 25,000 and 30,000 deaths each year for the last 25 years (Health and Safety Executive, 2013).

is breathlessness (BLF, 2014). This can affect an individual's ability to walk, exercise, work, socialise, sleep and eat, thus having a major impact on all their activities of daily living.

NICE (2010) suggests that due to the lifestyle changes required, the development of anxiety and depression is also common. The physical, psychological and social impact to each individual affected can be huge. Although COPD cannot be cured, the earlier it is diagnosed and a management plan implemented, the sooner symptoms can be improved and progression slowed, and thus fewer lifestyle restrictions will be necessary (BLF, 2014).

Early identificationCommunity nurses have an important role to play in the early identification of COPD and Jones et al’s (2014) study highlights the 'opportunities lost' for early diagnosis, both in primary and secondary care.

The study reveals that of the participating 38,859 people diagnosed with COPD, opportunities to diagnose 85% of these in the five years preceding their diagnosis had been missed. There were many reasons for this, including education.

However, there are now clinical guidelines and pathways in place to support practitioners, as well as enhanced knowledge surrounding COPD and many opportunities to

Annette Bades, district nursing specialist practitioner and clinical lead cardio-respiratory, Lancashire Care NHS Foundation Trust

Chronic obstructive pulmonary disease (COPD) is a serious, long-term and irreversible disease, which obstructs airflow to the lungs due to inflammation of the air passages and lung tissue damage. The most debilitating and frightening symptom is breathlessness, which can affect an individual's ability to walk, exercise, work, socialise, sleep and eat, thus having a major impact on all activities of daily living. This article aims to provide an overview of COPD to facilitate a general understanding of the disease, assist community nurses with early identification for prompt detection and highlight the pathways and management options available. Due to its complexity, COPD can be challenging for both patients and healthcare professionals, thus the earlier it is diagnosed and management plans started, the sooner its progression can be slowed and any impact reduced.

KEYWORDS:COPD Self-management Assessment Screening

Annette Bades

'Community nurses have an important role to play in the early identification of COPD'

COPD costs the NHS more than £800 million each year and results in an estimated £2.7 billion of costs in lost working days (Department of Health [DH], 2010). However, there is no real price that can be attached to the changes people have to make to their lifestyles, due primarily to the restrictions enforced by ongoing disease progression and the potentially disabling effects COPD can have.

SYMPTOMS

As COPD progresses the most debilitating and frightening symptom

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educate patients. Community nurses have a definitive role in assisting with the early identification of COPD and Csikesz and Gartman (2014) suggest primary care staff have the potential to make a real difference to the high number of hospital admissions and deaths caused by the disease.

However, management of COPD, including the essential techniques of self-management and positive behavioural change, is complex and difficult, therefore, a good understanding of this chronic disease is vital for community nurses (Rennard et al, 2013).

COPD RISK FACTORS

COPD is, in the main, a preventable disease. The predominant cause of COPD is smoking, including passive smoking (Table 1; World Health Organization, 2014). Smoking causes inflammation of the lining of the airways, resulting in permanent, irreversible damage.

Over the past 10 years there have been dramatic public health measures taken to promote health and to reduce deaths by assisting people to stop smoking, including:Increased spending on stop

smoking campaignsMore smoking cessation servicesBanning smoking in public placesEnhanced education in relation to

smoking (DH, 2004)

All community nurses have a role in the area of health promotion and a responsibility to recommend services within their area to support their patients.

Occupational-related exposure to fumes, dust and chemicals can also be a contributory factor to COPD. Workplaces are now educated and more aware of these dangers than they were in the past, so it is vital that protective clothing is worn and exposure regulations are in place and followed (Health and Safety Executive, 2013).

Indoor air pollution from biomass fuels, used for heating and in cooking, is a risk factor, although these mainly affect women in developing countries

(World Health Organization, 2014). General outdoor air pollution has been shown to be a minimal risk, however, studies aimed at clarifying any links continue (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2014).

recommends that a diagnosis of COPD is considered for all adults, aged over 35, that present with one or more of the key indicators (Table 2), alongside a risk factor (for example, being a smoker or passive smoker; having occupational exposure; or family history of COPD).

In addition to the key indicators, COPD has other symptoms that may help with identification:Wheezing Weight loss Effort intolerance Waking at night Reduced exercise tolerance.

However, many symptoms are not exclusive to COPD and are common in other conditions. Spirometry is the only accurate method of measuring airflow obstruction in COPD, therefore, its use is fundamental in arriving at a COPD diagnosis (GOLD, 2014; NICE, 2010).

Spirometry This is a non-invasive procedure that involves the patient breathing into a spirometer. This measures the volume of air exhaled in one second, known as 'forced expiratory volume' (FEV1), and the total amount of air exhaled, known as 'forced vital capacity' (FVC).

In the author's experience, spirometry is widely performed in the community and provides instant information on the patient's breathing status. However, due to the number of conditions that can present in similar ways to

Table 2: Key indicators of COPD

Indicator Characteristics

Chronic cough May be intermittentMay be productive or unproductiveMay be worse in the morningOften categorised as a 'smoker's cough'

Chronic sputum production Regular sputum production — any pattern

Dyspnoea (shortness of breath) ProgressiveWorsens on exertionPersistentBecomes a cause of anxiety

Risk Factors Smoker — how many packs/yearsPassive smokerOccupational exposureFamily history of COPD

'The difficulty is that in its early stages COPD may show no, or minimal symptoms making it difficult to detect and diagnose'

There are also genetic risk factors for COPD — alpha1 antitrypsin deficiency being the most commonly known. Lung infections in childhood, low birth weight and general bacterial and viral infections can all increase an individual’s risk of developing the disease (GOLD, 2014).

Early diagnosis of COPD is vital to slow disease progression, facilitate positive behavioural change and develop individual management plans — these aim to improve symptoms and facilitate an active lifestyle (Lyngso et al, 2013).

Community nurses are ideally placed to recognise symptoms and act upon them accordingly. However, the difficulty is that in its early stages COPD may show no — or minimal — symptoms (NICE, 2010) making it difficult to detect and diagnose.

Table 2 lists the key indictors of COPD as determined by GOLD (2014) and NICE (2010). NICE (2010)

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Practical efficacy

®®

Practical effi cacy

Relvar Ellipta 92/22 mcg is indicated for the symptomatic treatment of patients with COPD with a FEV1 <70% predicted normal (post bronchodilator) and an exacerbation history despite regular bronchodilator therapy1

Because I just don’tBecause I just don’thave spacE forhave spacE for

more COPD

Relvar®▼Ellipta® (fl uticasone furoate/ vilanterol [as trifenatate]) Prescribing information(Please consult the full Summary of Product Characteristics (SmPC) before prescribing)Relvar® Ellipta® (fl uticasone furoate/vilanterol [as trifenatate]) inha-lation powder. Each single inhalation of fl uticasone furoate (FF) 100 micro-grams (mcg) and vilanterol (VI) 25mcg provides a delivered dose of 92mcg FF and 22mcg VI. Each single inhalation of FF 200mcg and VI 25mcg provides a delivered dose of 184mcg of FF and 22mcg of VI. Indications: Asthma: Regular treatment of asthma in patients ≥12 years and older not adequately controlled on inhaled corticosteroids and ‘’as needed” short-acting inhaled β2-agonists, where a long-acting β2-agonist and inhaled corticosteroid com-bination is appropriate. COPD: Symptomatic treatment of adults with COPD with a FEV1<70% predicted normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therapy. Dosage and administration: Inhalation only. Asthma: Adults and adolescents ≥12 years: one inhalation once daily of: Relvar 92/22mcg for patients who require a low to mid dose of in-haled corticosteroid in combination with a long-acting beta2-agonist. If patients are inadequately controlled then the dose can be increased to one inhalation once daily Relvar 184/22mcg. Relvar 184/22mcg can also be considered for patients who require a higher dose of inhaled corticosteroid in combination with a long-acting beta2-agonist. Regularly review patients and reduce dose to lowest that maintains effective symptom control. COPD: one inhalation once daily of Relvar 92/22mcg. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Pulmonary tuberculosis, severe cardiovascular disor-ders, chronic or untreated infections, diabetes mellitus. Paradoxical broncho-spasm – substitute alternative therapy if necessary. In patients with hepatic with moderate to severe impairment 92/22mcg dose should be used. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician su-pervision due to risk of symptom recurrence. Asthma-related adverse events and exacerbations may occur during treatment. Patients should continue

treatment but seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation of Relvar. Systemic effects: Systemic effects of inhaled corticosteroids may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Possible Systemic effects include: Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, growth retardation in children and adolescents, cataract, glaucoma. More rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). Increased incidence of pneumonia has been observed in patients with COPD receiving Relvar. Risk factors for pneumonia include: cur-rent smokers, patients with a history of prior pneumonia, patients with a body mass index <25 kg/m2 and patients with a FEV1<50% predicted. If pneumonia occurs with Relvar treatment should be re-evaluated. Patients with rare heredi-tary problems of galactose intolerance, the Lapp lactase defi ciency or glucose-galactose malabsorption should not take Relvar. Interactions with oth-er medicinal products: Interaction studies have only been performed in adults. Avoid β-blockers. Caution is advised when co-administering with strong CYP 3A4 inhibitors (e.g. ketoconazole, ritonavir). Concomitant admin-istration of other sympathomimetic medicinal products may potentiate the adverse reactions of FF/VI. Relvar should not be used in conjunction with other long-acting β2-adrenergic agonists or medicinal products containing long-acting β2-adrenergic agonists. Pregnancy and breast-feeding: Ex-perience limited. Balance risks against benefi ts. Side effects: Very Common (≥1/10): Headache, nasopharyngitis. Common (≥1/100 to <1/10): Can-didiasis of the mouth and throat, dysphonia, pneumonia, bronchitis, upper respiratory tract infection, infl uenza, oropharyngeal pain, sinusitis, pharyngi-tis, rhinitis, cough, abdominal pain, arthralgia, back pain, fractures, pyrexia. Uncommon (≥1/1,000 to <1/100): Extrasystoles. Legal category: POM. Presentation and Basic NHS cost: Relvar® Ellipta®. 1 inhaler x 30 doses. Relvar Ellipta 92/22 - £27.80. Relvar Ellipta 184/22 - £38.87. Marketing authorisation (MA) nos. 92/22mcg 1x30 doses [EU/1/13/886/002]; 184/22mcg 1x30 doses [EU/1/13/886/005]. MA holder: Glaxo Group Ltd, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK. Last date of revision: November 2013. Relvar® and Ellipta® are registered trademarks

of the GlaxoSmithKline group of companies. All rights reserved. Relvar® Ellipta® was developed in collaboration with Theravance,Inc.

Adverse events should be reported. For the UK, reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, adverse events should be reported directly to the IMB; Pharmacovigi-lance Section, Irish Medicines Board, Kevin O’Malley House, Earlsfort

Centre, Earlsfort Terrace, Dublin 2, Tel: +353 1 6764971. Adverse events should also be reported to GlaxoSmithKline

on 0800 221 441 in the UK or 1800 244 255 in Ireland.

References: 1. Relvar Ellipta Summary of Product Characteristics. GlaxoSmithKline; 2014. 2. Boscia JA et al. Effect of Once Daily Fluticasone Furoate/Vilanterol on 24 Hour Pulmonary Function in Patients With Chronic Obstructive Pulmonary Disease: A Randomized, Three Way, Incomplete Block, Crossover Study. Clin Ther. 2012; 34(8):1655 66. 3. Riley JH et al. Delivery of umeclidinum/vilanterol using a new twin strip device (ELLIPTA®) to COPD pa-tients. Presented at the Annual Congress of the European Respiratory Society (ERS), Barcelona, Spain, 7–11 September, 2013. Poster No. P4145. 4. Ser-etide Summary of Product Characteristics. GlaxoSmithKline, 2012 (accessed 24.01.14). 5. Symbicort Turbohaler 400/12 Summary of Product Character-istics. AstraZeneca Ltd; 2013 (accessed 24.01.14). 6. Dransfi eld MT et al. A once daily inhaled fl uticasone furoate and vilanterol versus vilanterol only for prevention of exacerbations of COPD: two replicate double-blind, paral-lel-group, randomised controlled trials. Lancet Respir Med 2013;1:210-23.

UK/FFT/0264/14 Date of preparation May 2014

The fi rst ICS/LABA combination to deliver continuous 24-hour effi cacy in a practical, once-daily dose1,2

Delivered in a straightforward device3

That offers value to the NHS

Relvar is generally well-tolerated in COPD1. The risk of pneumonia in COPD patients with Relvar 92/22 mcg is similar to that reported within the Summary of Product Characteristics of commonly used ICS/LABAs1,4-6

www.relvar.co.uk

COPD

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COPD, such as asthma, congestive heart failure and carcinoma of the bronchus, further investigations should be undertaken to ensure differential diagnoses have been considered before a final diagnosis of COPD is made (NICE, 2010).

In addition — as with all conditions — it is essential that a patient’s full history is taken and considered, as this might reveal vital information that could assist the community nurse in arriving at an accurate diagnosis.

The effects of COPD can vary greatly and impact people differently. Also, its symptoms are easily attributed to other diseases or conditions, which can make COPD difficult to identify at first. Community nurses are ideally placed — partly due to the sheer numbers of people they come into contact with and the range of experience they accrue — to be alert for the possibility that a patient has COPD symptoms and, with the patient’s consent, seek further investigations.

TREATMENT

COPD affects individuals in different ways, therefore, its management should be guided by the symptoms experienced. However, management plans for people with COPD should include the following components: Assessment and monitoring Reduction of risk factorsManagement of stable COPD Management of exacerbations.

The aim is to (NICE, 2010; GOLD, 2014): Prevent disease progressionRelieve symptomsImprove exercise toleranceImprove health statusPrevent and treat complicationsPrevent and treat exacerbationsReduce mortality.

An essential element of the management plan is to reduce any known risk factors, which have the potential to cause an exacerbation. As discussed above, smoking is the primary cause of COPD, thus the most significant intervention is to encourage smoking cessation

Inhaled corticosteroids can also be used in combination with bronchodilators (NICE, 2010). Due to the importance of inhaled therapy in the management of COPD, an effective inhalation technique is vital and patients must be supported and their techniques regularly reviewed (Bades, 2012). Nebulisers and oral medication are also available and normally used for patients undergoing a severe exacerbation.

In addition, the use of oxygen therapy can be considered. However, as some patient’s respiratory drive (respiration is primarily controlled, or 'driven', by the level of carbon dioxide dissolved in the blood) is dependent upon their degree of hypoxia, a specialised assessment must be undertaken to avoid respiratory depression (NICE, 2010).

Education is vital if people are to take responsibility for their own health and wellbeing (DH, 2013). Pulmonary rehabilitation requires a multidisciplinary approach, involving numerous health professionals including nurses, physiotherapists and occupational therapists to facilitate education and an individualised exercise programme (BLF, 2014). This aims to increase patients'

KEY POINTS COPD is a progressive,

debilitating disease that cannot be cured, but can be managed with early diagnosis.

Individuals living with COPD may suffer from depression due to the impact upon their quality of life.

Management of COPD, including self-management and positive behavioural change, is complex and difficult.

Education is vital to facilitate individuals in taking responsibility for their own health and wellbeing.

COPD affects individuals in different ways, therefore, its management should always be guided by the symptoms experienced by the patient.

Pulmonary rehabilitation is a vital stage in the management of COPD, as are the specialist respiratory nurses who are available to offer advice, support and management plans.

The predominant cause of COPD is smoking, including passive smoking.

Occupational-related exposure to fumes, dust and chemicals can also be a contributory factor to COPD.

Indoor air pollution from biomass fuels, used for heating and in cooking, is a risk factor, but mainly affects women in developing countries.

General outdoor air pollution has been shown to be a minimal risk, however, studies aimed at clarifying any links continue.

Inhaled drug therapy is central to the management of COPD and is used to prevent and/or reduce symptoms.

Community nurses are ideally placed to be alert to the possible symptoms and, with their patient's consent, seek further investigations.

'Smoking is the primary cause of COPD, thus the most significant intervention is to encourage smoking cessation therapy'

therapy. Both Van der Meer et al (2003) and Kanner et al‘s (1999) studies demonstrate that — if identified and acted upon early — eliminating smoking will reduce the symptoms of COPD.

Inhaled drug therapy (corticosteroids) is also central to the management of COPD and is used to prevent and/or reduce symptoms (GOLD, 2014). Inhaled bronchodilator medication relaxes the bronchial muscles, increasing the size of the airways and improving breathing — there are short and long-acting variations (British Medical Association/Royal Pharmaceutical Society [BMA/RPS], 2013).

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Stopped SmokingStarted rUnning

NICORETTE® Invisi Patch Prescribing Information:Presentation: Transdermal delivery system available in 3 sizes (22.5, 13.5 and 9cm2) releasing 25mg, 15mg and 10mg of nicotine respectively over 16 hours. Uses: NICORETTE® Invisi Patch relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. NICORETTE® Invisi Patch is indicated in pregnant and lactating women making a quit attempt. If possible, NICORETTE® Invisi Patch should be used in conjunction with a behavioural support programme. Dosage: It is intended that the patch is worn through the waking hours (approximately 16 hours) being applied on waking and removed at bedtime. Smoking Cessation: Adults (over 18 years of age): For best results, most smokers are recommended to start on 25mg/16 hours patch (Step 1) and use one patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10mg/16 hours patch (Step 3) daily for 2 weeks. Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) are recommended to start at Step 2 (15mg) for 8 weeks and decrease the dose to 10mg for the final 4 weeks. Those who experience excessive side effects with the 25mg patch (Step 1), which do not resolve within a few days, should change to a 15mg patch (Step 2). This should be continued for the remainder of the 8 week course, before stepping down to the 10mg patch

(Step 3) for 4 weeks. If symptoms persist the advice of a healthcare professional should be sought. Adolescents (12 to 18 years): Dose and method of use are as for adults however, recommended treatment duration is 12 weeks. If longer treatment is required, advice from a healthcare professional should be sought. Smoking Reduction/Pre-Quit: Smokers are recommended to use the patch to prolong smoke-free intervals and with the intention to reduce smoking as much as possible. Starting dose should follow the smoking cessation instructions above i.e. 25mg (Step 1) is suitable for those who smoke 10 or more cigarettes per day and for lighter smokers are recommended to start at Step 2 (15mg). Smokers starting on 25mg patch should transfer to 15mg patch as soon as cigarette consumption reduces to less than 10 cigarettes per day. A quit attempt should be made as soon as the smoker feels ready. When making a quit attempt smokers who have reduced to less than 10 cigarettes per day are recommended to continue at Step 2 (15mg) for 8 weeks and decrease the dose to 10mg (Step 3) for the final 4 weeks. Temporary Abstinence: Use a NICORETTE® Invisi Patch in those situations when you can’t or do not want to smoke for prolonged periods (greater than 16 hours). For shorter periods then an alternative intermittent dose form would be more suitable (e.g. NICORETTE® inhalator or gum). Smokers of 10 or more cigarettes per day are recommended to use 25mg patch and lighter smokers are recommended to use 15mg patch. Contraindications: Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, renal or hepatic impairment, phaeochromocytoma or uncontrolled hyperthyroidism, generalised

dermatological disorders. Angioedema and urticaria have been reported. Erythema may occur. If severe or persistent, discontinue treatment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response, to adenosine. Keep out of reach and sight of children and dispose of with care. Pregnancy and lactation: Only after consulting a healthcare professional. Side effects: Very common: itching. Common: headache, dizziness, nausea, vomiting, GI discomfort; Erythema. Uncommon: palpitations, urticaria. Very rare: reversible atrial fibrillation. See SPC for further details. NHS Cost: 25mg packs of 7: (£9.97); 25mg packs of 14: (£16.35); 15mg packs of 7: (£9.97); 10mg packs of 7: (£9.97). Legal category: GSL. PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL numbers: 15513/0161; 15513/0160; 15513/0159. Date of preparation: Feb 2012

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to McNeil Products Limited on 01344 864 042.

Date of preparation: January 2014 UK/NI/13-2374b

nicotine

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understanding, teach self-management techniques and coping strategies, and thereby enhance their quality of life. Pulmonary rehabilitation is a vital stage in the management of COPD, as are the specialist respiratory nurses who are available to offer advice, support and management plans.

Individuals living with the physical limitations caused by COPD can experience depression due to the impact on their quality of life (BLF, 2014). Pooler and Beech’s (2014) study indicates that individuals with depression and anxiety have a significantly increased risk of being hospitalised due to COPD exacerbations. It is, therefore, important that psychological aspects, such as anxiety, depression and feelings of wellbeing are considered and incorporated into any management/self-management strategies.

CONCLUSION

COPD is a progressive, debilitating disease that cannot be cured, but can be effectively managed with early diagnosis, the removal of risk factors, education and regularly reviewed management/self-management plans.

COPD is complex, but if all community nurses have at least a basic understanding of the disease, are able to act upon an assessment of the symptoms, promote health and provide information about local services, many people with COPD will benefit from an enhanced quality of life. In addition, hospital admissions and deaths from COPD will be reduced. JCN

REFERENCES

Bades A (2012) Effective management of COPD. J Community Nurs 26(6): 4–8

BLF (2014) COPD. BLF, London. Available at: http://www.blf.org.uk/Page/chronic-obstructive-pulmonary-disease-COPD (accessed 10 March, 2014)

BLF (2014) What is Pulmonary Rehabilitation? BLF, London. Available at: http://www.blf.org.uk/Page/Pulmonary-rehab (accessed 02 April, 2014)

BMA/RPS (2013) British National Formulary. BMA/RPS, London

COPD Foundation (2014) What is COPD? Available at: http://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx (accessed 20 March, 2014)

Csikesz G, Gartman N (2014), New developments in the assessment of COPD: early diagnosis is key. Int J COPD 9: 277–86

DH (2004) Choosing Health: Making Healthy Choices Easier. DH, London

DH (2010) Health Facts about COPD 2010. DH, London. Available online at: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/COPD/DH_113006 (accessed 15 March, 2014)

DH (2013) Long-term Conditions Compendium of Information. DH, London. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216528/dh_134486.pdf (accessed 20 April, 2014)

GOLD (2014) Global Strategy for the Diagnosis, Management and Prevention of COPD. GOLD. Available at: http://www.goldcopd.org/uploads/users/files/GOLD_Pocket2014_Jan30.pdf (accessed 1 March, 2014)

Health and Safety Executive (2013) Chronic Obstructive Pulmonary Disease (COPD) in Great Britain 2013. Health and Safety

Executive, London. Available at: http://www.hse.gov.uk/STATISTICS/causdis/copd/copd.pdf (accessed 10 March, 2014)

Healthcare Commission (2006) Cleaning the Air: A National Study of Chronic Obstructive Pulmonary Disease. Healthcare Commission, London

Jones R, Price D, Ryan D, Sims E, et al (2014) Opportunities to diagnose COPD in routine care in the UK. Lancet 2(4): 267–76. Available at: http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(14)70008-6/fulltext (accessed 16 April, 2014)

Kanner R, Connett J, Williams D, et al (1999) Effects of randomized assignment to a smoking cessation intervention and changes in smoking habits on respiratory symptoms in smokers with early chronic obstructive pulmonary disease: the Lung Health Study. Am J Med 106: 410–16

Lyngso A, Gottleib V, Baker V, Nybo B, Frolick A (2013) Early detection of COPD in primary care. J COPD 10(13): 208–15

National Institute for Health and Care Excellence (2010) Chronic Obstructive Pulmonary Disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE, London

Pooler A, Beech R (2014) Examining the relationship between anxiety and depression and exacerbations of COPD which result in hospital admission: a systematic review. Int J COPD 9: 315–30. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974694/ (accessed 20 April, 2014)

Rennard S, Byrom T, Crapo J, et al (2013)Introducing the COPD guide for diagnosis and management of COPD, recommendations of the COPD Foundation. J COPD 10(3): 378–89. Available at: http://informahealthcare.com/doi/pdf/10.3109/15412555.2013.801309 (accessed 7 April, 2014)

Van der Meer R, Wagena E, Ostelo R (2003) Smoking Cessation for Chronic Obstructive Pulmonary Disease. The Cochrane Library. Available online at: http://www.ncsct.co.uk/usr/pub/smoking-cessation-for-chronic-obstructive-pulmonary-disease.pdf (accessed 10 April, 2014)

World Health Organization (2014) Causes of COPD. WHO, Geneva. Available online at: http://www.who.int/respiratory/copd/causes/en/ (accessed 1 April, 2014)

Answer the following questions about this article, either to test the

new knowledge you have gained or to form part of your ongoing practice

development portfolio.

1 – What are the causes of COPD?

2 – What are the key indicators of COPD?

3 – Can asthma be mistaken for COPD and, if so, what steps can be taken to ensure an accurate diagnosis?

4 – How can community nurses make a difference to the management of COPD?

5 – List the essential elements of pulmonary rehabilitation.

Five-minute test

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