Ensuring Safe Transitions of Care in Patients with
Chronic Obstructive Pulmonary Disease

Global Initiative for Chronic Obstructive Lung Disease (GOLD) Strategies defines COPD as a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

• The common symptoms include shortness of breath, cough and/or sputum production.
• Tobacco smoking is the most common exposure that causes COPD.
• A patient with COPD must have a Forced Expiratory Volume during the first second (FEV1) to Forced Vital Capacity (FVC) ratio less than 0.70 measured by spirometry.

For Patients

• Inpatient Education Worksheet
• COPD Follow-up Checklist
• Global Initiative for Chronic Obstructive Lung Disease Patient Resources
• COPD Foundation Patient Resources
• American Lung Association COPD Patient Resources
• Learn About COPD (Chest Foundation)
• COPD Patient Resources (American Thoracic Society)
• Pulmonary Rehabilitation Patient Information (American Thoracic Society)

For Providers

• Global Initiative for Chronic Obstructive Lung Disease (GOLD) Resources
• The COPD Pocket Consultant Guide Mobile App (COPD Foundation)
• American Thoracic Society COPD Official Documents

There are many different COPD Action Plans available. Most follow the Stop Light format. Action Plans are helpful for patients to self-assess their normal symptoms to help identify early warning signs of worsening symptoms and appropriate actions.

• Green days: normal day, continue normal activity and medications
• Yellow days: bad day, ask how many puffs of rescue medicine a day does patient use, call provider for possible steroids and/or antibiotics if needed
• Red days: urgent medical attention needed; call 911

• My COPD Action Plan (PDF) (American Lung Association)
• COPD 360 action It’s My COPD Action Plan (COPD Foundation -- Must register to access resources)

The goal is to improve symptoms and prevent exacerbations. Proper selection of medication and delivery devices is essential and should take into account the patients cognitive and physical functioning.

Medications: generally categorized according to if used as needed for symptoms or if used everyday regardless of how patient feels to help prevent worsening of symptoms.

• Quick acting/rescue: All patients should have a quick acting or rescue medication (albuterol or levalbuterol) available to use as needed for shortness of breath, difficulty breathing, or wheezing.
• Controller/maintenance: Most patients are initiated on mono-bronchodilator (long-acting muscarinic antagonist (LAMA)) or dual bronchodilator (LAMA/long-acting beta agonist (LABA) therapy when diagnosed. An Inhaled corticosteroid (ICS) may be considered for patients with more moderate to severe exacerbations, with high eosinophil counts (>300 cells/microliter) or history of asthma. Choice of therapy is usually based on the severity of the patient’s symptoms (using mMRC or CAT score) and number of exacerbations.
• Do not use more than one LAMA, LABA, or ICS

Devices
The device delivers the medications to the lungs and are generally categorized according to their power source.

• Metered Dose Inhaler (MDI) medications are delivered with a propellant. Spacers are recommended for use with MDIs for better lung deposition.
• Soft Mist Inhalers (SMI) are a spring loaded system producing a fine mist.
• Dry Powder Inhaler (DPI) are dependent on a patient’s inspiratory flow rate for adequate delivery.
• Nebulizer delivery uses electricity or a battery operated compressor to aerosolize the medication for inhalation.

Inhalers
Proper inhaler technique cannot be over emphasized. Review product specific prescribing information instructions prior to use. Teach proper technique upon initial prescribing and reassess at every visit. Review quick videos or printed material. Provide demonstration and written instructions. Ask the patient to show you how they are using the device. Repeat until mastered or consider changing devices. Encourage patients to bring all inhalers to appointments for proper inhaler technique education.

• Prime MDI and SMI prior to first use and if not used in several days
• Shake MDI for 5 seconds
• Use a spacer with MDI to get more medication to the lungs
• Breathe out fully away from mouthpiece
• Form a good seal with mouthpiece
• Breathe in SLOW and deep for MDI/SMI, breath in FAST and deep for DPI
• Hold breath up to 10 seconds or as long as possible
• Rinse and spit after use if inhaler contains corticosteroid

Clean according to manufacturer specific instructions:

• MDI: Once weekly remove canister and wash casing. Shake off extra water and air dry. Re-prime as directed. Some exclusions apply.
• SMI: Once weekly wipe mouthpiece with damp cloth.
• DPI: Occasionally wipe with dry cloth.
• Spacer: Once weekly disassemble and soak in warm soapy water, rinse, and air dry.

Nebulizers
Nebulizers are available as jet, mesh, and ultrasonic. Cleaning is very important because it helps prevent buildup of medicine and contamination with bacteria, fungus, or virus. Review product specific cleaning instructions prior to use

• Jet nebulizers are the most commonly used, and least expensive, but have the longest administration times, can be noisy, and may be heavier than other nebulizers.
• Rinse nebulizer cup after each use
• Wash nightly
• Disinfect weekly
• Mesh or vibrating mesh nebulizers are more expensive but administrations times are shorter, virtually silent, lightweight, and more portable.
• Ultrasonic nebulizers are not used often due to incompatibility with heat sensitive medications and lack of advantage over the other types of nebulizers.

• Guide to Device Selection
• Respiratory Medication Summary Chart (PDF)
• Proper Inhaler Technique Brochure (PDF) (Northside Hospital)
• Proper Inhaler Technique Poster (PDF) (Northside Hospital)
• Inhaler Training Videos (National Jewish Health Center)
• Inhaler Training Video (COPD Foundation)
• Photos of Various Devices (PDF)
• How To Use Inhalers Interactive Guide (website)
• COPD Patient Education Series (American Thoracic Society Medicines)
• Review of COPD Treatments and Medications (COPD Foundation)
• Global Initiative for Chronic Obstructive Lung Disease (GOLD) Resources (website)
• Mixing and compatibility guide for commonly used aerosolized medications (AJHP article)

• CDC Recommended Adult Immunization Schedule (2020) (PDF)
• Vaccinations for Adults with Lung Disease (PDF)

Nicotine dependence is a chronic disease that most often requires multiple quit attempts to be successful. A quick assessment is to ask every patient every time about current tobacco product use (cigarettes, e-cigarettes, chewable tobacco, etc), ask how important quitting is and offer assistance. Provide a list of local programs, state tobacco quit line, and online resources. Consider medications, nicotine replacement or other therapies to improve cessation rates.

Resources for patients to help stop smoking

• Quit Line (North Carolina Department of Health and Human Services)
• Become an Ex (Truth Initiative)
• Smoke Free (National Cancer Institute)

Clinical Resources

• Rx for Change (UCSF School of Pharmacy)

Alpha-1 antitrypsin deficiency (A1AT) is a genetic cause of emphysema and COPD. A1AT screening is indicated for any patient with fixed airflow obstruction by spirometry or evidence of emphysema seen on CT scan. Free testing kits are available through the alpha-1 foundation.

• alpha-1 Foundation

Low dose computed tomography (LDCT) screening should be done in patients 55-80 years old with a ≥ 30 pack year history of smoking and who currently smoke or quit within the past 15 years. Pack years = (packs smoked per day) x (years as a smoker)

• U.S. Preventive Services Task Force Lung Cancer Screening
• CDC Lung Cancer Screening Recommendations

Instruct Patients to: Maintain healthy weight and well balanced diet. Drink at least 6-8 glasses of water throughout the day. Eat 4-6 small meals a day allows your diaphragm to move more easily and for you to breathe better. Eat complex carbohydrates, good sources of protein, and mono- and poly-unsaturated fats. Eat a variety of fruits and vegetables. Limit simple carbohydrates and sodium.

• Nutrition and COPD (American Lung Association)
• Nutrition for Someone with COPD (COPD Foundation)

COPD is a disease of expiratory airflow limitation. Special breathing techniques can help patients empty their lung to prepare for their next breath in. Some of the most common breathing techniques are pursed-lip breathing and diaphragmatic breathing.

Some patients may produce more mucous than others. Cough techniques may help remove mucous from airways.

• Coughing and Huffing (Cystic Fibrosis Foundation)

Pulmonary rehabilitation is just as important as medication therapy to improve symptoms, health status, and exercise tolerance. Pulmonary rehabilitation requires a provider’s referral.

• Pulmonary Rehabilitation Patient Information (American Thoracic Society)
• What is Pulmonary Rehabilitation? (COPD Foundation)
• The Basics of Pulmonary Rehabilitation (American Lung Association)
• Live Better with Pulmonary Rehabilitation

Exertional oxygen assessment will determine the patient’s oxygen need. A pulse oximeter can be used to monitor oxygen levels at rest and with ambulation. Patients may have oxygen delivered via concentrators at home. There are portable tanks and bags available for transportation and easy ambulation.

• Oxygen Therapy (American Lung Association)
• Oxygen Therapy (COPD Foundation)
• Optimizing Home Oxygen Therapy An Official American Thoracic Society Workshop Report

Instruct patients to practice the 4 Ps (Prioritize, Plan, Pace, and Position) to help you use your energy for what you want to do.

• 10 Ways to Conserve Your Energy if You Have COPD
• Energy Conservation (PDF)

Counsel patients to join COPD support communities and advocacy groups where they can find the tools and connections to stay active, healthy, and engaged in their treatment and care.

• Better Breathers Club (American Lung Association)
• COPD360social (COPD Foundation)
• Alpha-1 Foundation
• GOLD COPD
• The Care Transitions Program