has a) further exacerbations, treatment should be escalated to LABA+LAMA+ICS; b) major symptoms, switching to

LABA+LAMA should be considered.

NON-PHARMACOLOGICAL TREATMENT OF STABLE COPD

Non-pharmacological treatment is complementary to pharmacological treatment and should form part of the
comprehensive management of COPD.

After receiving a diagnosis of COPD a patient should be given further information about the condition. Physicians
should emphasize the importance of a smoke free environment, empower adherence to prescribed medication,
ensure proper inhaler technique, promote physical activity, prescribe vaccinations, and refer patients to pulmonary
rehabilitation.

Some relevant non-pharmacological measures based on the GOLD group AT DIAGNOSIS are summarized in Table 4.9.

Recommendations for FOLLOW UP non-pharmacological treatments are based on patient’s treatable traits e.g.,
symptoms and exacerbations (Table 4.10).

Education and self-management

Self-management education and coaching by healthcare professionals should be a major component of the “Chronic
Care Model” within the context of the healthcare delivery system.

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The aim of self-management interventions is to motivate, engage and coach patients to positively adapt their health
behavior(s) and develop skills to better manage their COPD on a day-to-day basis.(19) Physicians and healthcare
providers need to go beyond pure education/advice-giving (didactic) approaches to help patients learn and adopt
sustainable self-management skills. The basis of enabling patients to become active partners in their ongoing care is
to build knowledge and skills. It is important to recognize that patient education alone does not itself change behavior
or even motivate patients, and it has had no impact on improving exercise performance or lung function, (20,21) but it
can play a role in improving skills, ability to cope with illness, and health status.(22)

Patients may have individual and/or group education sessions. During group sessions, patients engage in active,
participatory-based learning of program content. During one-on-one interactions, a motivational communication style
should be used, as this approach empowers patients to take greater responsibility for their health and well-being,
where physicians and other healthcare professionals only serve as guides in the behavior change process.

Topics considered appropriate for an education program include: smoking cessation; basic information about COPD;
general approach to therapy and specific aspects of medical treatment (respiratory medications and inhalation
devices); strategies to help minimize dyspnea; advice about when to seek help; decision-making during exacerbations;
and advance directives and end-of-life issues. The intensity and content of these educational messages will vary
depending on the severity of the patient’s disease, although the specific contributions of education to the
improvements seen after pulmonary rehabilitation remain unclear.(23) Implicit in this description is the provision of
“self-management support/coaching”, which refers to the strategies, techniques and skills used by healthcare
providers to arm patients with the knowledge, confidence and skills required to self-manage their disease effectively.
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However, the individual patient’s evaluation and risk assessment with respect to exacerbations, patient’s needs,
preferences, and personal goals should inform the personalized design of the self-management education plan.

Physical activity
Pulmonary rehabilitation, including community and home-based, is an approach with clear evidence of benefits.
However, the challenge is promoting physical activity and maintaining it. There is evidence that physical activity is
decreased in COPD patients.(24) This leads to a downward spiral of inactivity which predisposes patients to reduced
quality of life, increased rates of hospitalization and mortality.(25-27) As such, there has been tremendous interest in
implementing behavior-targeted interventions with the aim of improving physical activity (28) and these should be
encouraged.(25) Technology-based interventions have the potential to provide convenient and accessible means to
enhance exercise self-efficacy, and to educate and motivate people in their efforts to make healthy lifestyle
changes.(29) The use of an internet-mediated intervention may benefit people with COPD with low baseline self-efficacy
to increase physical activity.(30) However, most published studies to date provide little guidance, being inconsistent in
the techniques, and lacking the necessary details (e.g., type, quantity, timing and method of delivery; tools used;
quality-assurance methods) to replicate the study or adapt the interventions for clinical care. One RCT that evaluated
the long-term effectiveness of a community-based physical activity coaching intervention in people with COPD
exacerbation history showed no benefits in acute care use or survival.(31) Another pedometer-based physical activity
interventional study (pedometer alone or pedometer plus a website with feedback) showed an association between
the intervention and reduced risk for acute exacerbations over 12-15 months of follow-up.(32) Non-pharmacological
interventions such as pursed lip breathing and diaphragmatic breathing have also been shown to improve pulmonary
function and increased exercise capacity in patients with COPD.(33)

Pulmonary rehabilitation programs

Patients with high symptom burden and risk of exacerbations (Groups B and E), should be encouraged to take part in
a formal rehabilitation program that includes setting patient goals and is designed and delivered in a structured
manner, taking into account the individual’s COPD characteristics and comorbidities.(22,34,35) This includes patients who
are older, female, more deprived, or have a comorbidity of diabetes, asthma, or painful condition and currently appear
less likely to be referred for pulmonary rehabilitation.(36)

Exercise training
A meta-analysis of RCTs found that exercise training alone, or with the addition of activity counseling, significantly
improved physical activity levels in COPD patients.(37) A combination of constant load or interval training with strength
training provides better outcomes than either method alone. (38)

Where possible, endurance exercise training to 60-80% of the symptom-limited maximum work or heart rate is
preferred,(39) or to a Borg-rated dyspnea or fatigue score of 4 to 6 (moderate to severe).(40) Endurance training can be
accomplished through either continuous or interval exercise programs. The latter involves the patient doing the same
total work but divided into briefer periods of high-intensity exercise, a useful strategy when performance is limited by
other comorbidities.(41,42)

In some cultures, other alternatives such as Tai Chi practice, emphasizing the use of ‘mind’ or concentration for control
of breathing and circular body movement, has been shown to improve exercise capacity in comparison to usual care
in COPD patients.(43) However from this meta-analysis, the effects of Tai Chi in reducing dyspnea level and improving
quality of life remain inconclusive. Future studies addressing these topics and the most beneficial protocols for Tai Chi
practice are warranted.

Exercise training can be enhanced by optimizing bronchodilators,(44) since both LAMA and LABA have shown reduced

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resting and dynamic hyperinflation. These changes contribute to better training effects.(45,46) Adding strength training
to aerobic training is effective in improving strength, but does not improve health status or exercise tolerance. (47)
Upper extremities exercise training improves arm strength and endurance, and results in improved functional capacity
for upper extremity activities.(48) Exercise capacity may also be improved by whole-body vibration training.(49)

Inspiratory muscle training increases strength of inspiratory muscles,(50) but this not consistently translate to better
performance, reduced dyspnea or improved health related quality of life when added to a comprehensive pulmonary
rehabilitation program.(51-53)

Assessment and follow-up

Baseline and outcome assessments of each participant in a pulmonary rehabilitation program should be made to
specify individual maladaptive behaviors (including motivation), physical and mental health impediments to training,
goals, barriers and capabilities and to quantify gains and to target areas for improvement.

Assessments should include:

► Detailed history and physical examination.

► Measurement of post-bronchodilator spirometry.
► Assessment of exercise capacity.
► Measurement of health status and impact of breathlessness.
► Assessment of inspiratory and expiratory muscle strength and lower limb strength in patients who suffer
from muscle wasting.
► Discussion about individual patient goals and expectations

The first two assessments are important for establishing entry suitability and baseline status but are not used in
outcome assessment.

Exercise tolerance can be assessed by cycle ergometry or treadmill exercise with the measurement of a number of
physiological variables, including maximum oxygen consumption, maximum heart rate, and maximum work
performed. Standardized self-paced, timed walking tests (e.g., 6-minute walking distance) are useful in clinical practice
as they require minimal facilities and are relevant to routine functioning. Shuttle walking tests provide more complete
information than an entirely self-paced test, and are simpler to perform than a treadmill test.(54) Walking tests do
require at least one practice session before data can be interpreted.
It is important not to limit assessment only to these outcome measures but gather information on each patient’s
ultimate goal (relevant or valued outcomes), such as their desired achievements in work, home and leisure by the end
of the program.

Several detailed questionnaires for assessing health status are available, including some specifically designed for
patients with respiratory disease. Health status can also be assessed by generic instruments, although these are less
sensitive to change than the disease specific questionnaires such as the CAT™, CRQ or SGRQ. The Hospital Anxiety and
Depression Scale (HADS)(55) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Questionnaire(56)
have been used to improve identification and treatment of anxious and depressed patients.

End-of-life and palliative care

Clinicians should develop and implement methods to help patients and their families to make informed choices that
are consistent with patients’ values. Simple, structured approaches to facilitate these conversations may help to
improve the occurrence and quality of communication from the patients’ perspective.(57)

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