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Patient Education and Counseling

A key objective for patients with COPD is the prevention of exacerbations and hospital readmissions. Educating and counseling patients and their caregivers about their disease state and symptom management strategies plays a critical role in achieving this objective.

  • After understanding the COPD basics, the Action Plan is the foundation to empower patients and caregivers to identify signs and symptoms of worsening COPD and actions to take. All patient education materials relate to the Action Plan. It may be preventative care, maintenance therapy, or treating an exacerbation.
  • A good way to start the conversation is by asking patient open-ended questions (e.g, questions that start with what, how, and why) to determine what the patient already knows and identify their concerns. After addressing all concerns provide new information to the patient to build on what the patient already knows by filling in the gaps.

Every respiratory device requires special training to ensure that the recommended dose of medication is delivered to the patient's lungs and outcomes are optimized. Visit the Guide to Device Selection section of this website to learn more about the appropriate use of inhaled therapies and get tips to help patients get the most out of their medications.

  • Review the proper inhaler technique videos, brochure and/or poster with patients. The most effective way of ensuring proper inhaler technique is to physically demonstrate it to patients and provide written instructions that explain proper technique.
  • Ask the patient to show you how they use their device, correct their technique as appropriate, and repeat until proper inhaler technique is mastered. If the patient is unable to use one device properly it may be necessary to try another. There are many different inhalers and nebulizers available to allow for personalization of device selection.
Topic Discussion/Counseling Points Related Resources
COPD Basics

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

For Providers

Topic Discussion/Counseling Points Related Resources
Action Plan

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
Patients should bring their COPD Action Plan to their provider appointment and discuss specific recommendations.

Topic Discussion/Counseling Points Related Resources
Inhaled Therapies

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.

Topic Discussion/Counseling Points Related Resources
Vaccination schedules GOLD Strategy and CDC recommends all COPD patients receive pneumonia vaccines (PPSV23 and PCV13) and annual Influenza vaccination (some possible exclusions apply).

Smoking cessation

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

Clinical Resources

Screen for Alpha-1 antitrypsin deficiency

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.

Lung cancer screening

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)

Nutrition

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.

Breathing techniques

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.

Breathing Exercises and Techniques for COPD
Airway clearance techniques

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

Pulmonary rehabilitation

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

Oxygen therapy

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.

Energy conservation

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

Patient advocacy groups

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.

COVID-19 Resources

ASHP COVID-19 Resource Center

ASHP is committed to supporting you in the response to the COVID-19 pandemic. We have opened access to our evidence-based online resources and tools, making them widely available to all pharmacists and healthcare professionals, and our COVID-19 Resource Center is updated frequently.

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