Chronic Obstructive Pulmonary Disease Clinical Care Standard

COPD is a serious chronic condition, affecting an estimated 1 in 13 Australians over the age of 40.^[i] It is a leading cause of potentially preventable hospitalisations (PPHs) in Australia,^[ii] and is associated with significant costs to the healthcare system. In 2020-21, an estimated $832 million was spent on COPD, and in 2023, it accounted for 50% of the total disease burden due to respiratory conditions in Australia.^[iii]

Tobacco smoking is the most common risk factor for COPD - 47% of people with COPD are past smokers and 25% currently smoke.^{[iv], [v]} Smoking cessation is one of the most effective ways to slow disease progression, reduce symptom severity and the risk of exacerbations.^[iv]

Despite the availability of clinical guidelines to support the management of this condition, there is significant variation in health care for COPD in Australia. The Fourth Australian Atlas of Healthcare Variation identified up to 18-fold variation in hospitalisation rates for COPD between local areas.^[vi] The rate for Aboriginal and Torres Strait Islander people was 4.8 times as high as the rate of other Australians. In addition, the Fifth Australian Report on Antimicrobial Use and Resistance in Human Health highlighted that almost 50% of all antimicrobial prescriptions for COPD in admitted patients are inappropriate.^[vii]

The goal of this clinical care standard is to reduce potentially preventable hospitalisations and improve overall outcomes for people with COPD by supporting best practice in the assessment and management of COPD, including exacerbations.

It also aims to increase consideration of the palliative care needs of people with COPD to support symptom management and improve quality of life.

The standard covers key aspects of care relating to the diagnosis and management of COPD, including exacerbations. 

What is not covered 

This clinical care standard does not specifically address:

• Screening for genetic disorders (for example, alpha-1 antitrypsin deficiency)
• Assessment and management of other respiratory conditions (for example, asthma or bronchiectasis)
• Surgical interventions for COPD management (for example, lung volume reduction surgery or lung transplantation)
• Long-term oxygen therapy (for example, home oxygen therapy). 

The standard was developed in consultation with a topic working group of clinicians, researchers and consumers. Public consultation of the clinical care standard was completed between November and December 2023. 

The standard has been endorsed by 20 key professional associations and consumer organisations, including the Thoracic Society of Australia and New Zealand and Lung Foundation Australia.

Promoting environmental sustainability not only serves to reduce the environmental risk factors that contribute to the inception and progression of disease in people with COPD, but also helps to minimise the impact of the disease and its management on the environment.

Respiratory medicine is recognised as a significant contributor to the carbon footprint of health care. This is largely attributed to the manufacture, distribution and use of inhaler devices. In particular, there are specific concerns relating to the greenhouse gas effects of the propellants used in pressurised metered-dose inhalers (pMDIs), which have 1,300–3,350 times the potency of carbon dioxide (CO2).

Unlike pMDIs, dry powder inhalers (DPIs) and soft mist inhalers (SMIs) do not contain propellant gases and therefore have a lower carbon footprint. Switching a person from regular pMDI use to DPI use, where clinically appropriate, can save an equivalent of approximately 420 kg of CO2 emissions annually. This is similar to the effect of a person switching from a petrol to a hybrid car (equivalent to approximately 500 kg CO2 annually).

There are ways to minimise the environmental impact of pMDIs until more climate-friendly propellants are developed. Initiatives in the United Kingdom encourage clinicians to offer DPIs or SMIs as a first choice when clinically appropriate, and to review frequency of inhaler use and inhaler technique to ensure the efficacy and efficiency of treatment.

Importantly, the most environmentally friendly inhaler is one used by the patient as prescribed and with the correct technique, as this minimises wastage and improves disease control.

While inhaler device selection is an important part, other opportunities to promote environmental sustainability along the trajectory of patient care for COPD include: 

• Establishing an accurate diagnosis of COPD (including exacerbations) to prevent incorrect or unnecessary treatment
• Supporting patients to recognise symptoms of a COPD exacerbation and understand what actions to take (for example, through establishing a COPD action plan) to reduce emergency department visits and hospital admissions
• Encouraging evidence-based preventive measures (for example, smoking cessation and vaccination) to reduce the risk of exacerbations and hospitalisation
• Optimising non‑pharmacological (for example, pulmonary rehabilitation) and pharmacological management to support disease control, including reviewing inhaler device technique and adherence
• Reducing inappropriate antibiotic use for COPD exacerbations 
• Encouraging patients to return used or unwanted inhalers to their community pharmacy for disposal.

Further information is available on the evidence sources underpinning the Chronic Obstructive Pulmonary Disease Clinical Care Standard (2024).

1. [i] Toelle BG, Xuan W, Bird TE, Abramson MJ, Atkinson DN, Burton DL, et al. Respiratory symptoms and illness in older Australians: the burden of obstructive lung disease (BOLD) study. Med J Aust. 2013 Feb 18;198(3):144–8.
2. [ii] Australian Institute of Health and Welfare. Potentially preventable hospitalisations in Australia by small geographic areas, 2020-21 to 2021-22: Data [Internet]. Canberra: AIHW; 2024. Available from: https://www.aihw.gov.au/reports/primary-health-care/potentially-preventable-hospitalisations-2020-22/data.
3. [iii] Australian Institute of Health and Welfare. Chronic obstructive pulmonary disease [Internet]. AIHW; 2024. Available from: https://www.aihw.gov.au/reports/chronic-respiratory-conditions/copd.
4. [iv] Yang I, George J, McDonald C, McDonald V, Ordman R, Goodwin A, et al. The COPD-X plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2024. Version 2.75. [Internet]. Brisbane: Lung Foundation Australia; 2024. Available from: https://copdx.org.au/copd-x-plan.
5. [v] Australian Institute of Health and Welfare. Chronic obstructive pulmonary disease (COPD). Canberra: Australian Government; 2020.
6. [vi] Australian Commission on Safety and Quality in Health Care. The fourth Australian atlas of healthcare variation. Sydney: ACSQHC, 2021.
7. [vii] Australian Commission on Safety and Quality in Health Care. AURA 2023: fifth Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC, 2023.