Stable COPD: assessment and teaching

Chronic obstructive pulmonary disease is a preventable and treatable but largely irreversible narrowing of the airways and destruction of the alveoli, caused above all by tobacco smoke and also by biomass and occupational exposure, that goes undiagnosed because its chronic cough, sputum and breathlessness on exertion are written off as a smoker's cough, ageing or being unfit, so the nurse recognizes the exposed patient with those symptoms as one who needs spirometry -- the only test that confirms the disease, by an airflow limitation that persists after a bronchodilator -- rather than a chest film or a normal oximeter reading to exclude it; assesses the stable patient by how the disease is lived rather than by the spirometry grade alone -- the breathlessness graded against activity, the symptom burden scored, the exacerbations of the past year counted because even one predicts the next, the pattern of cough and sputum, the barrel chest, prolonged expiration, pursed lips and accessory muscles that mean air trapping, the activity tolerance, the sleep, the weight and muscle that the work of breathing consumes, the mood, the oximetry, and the inhaler technique and adherence at every contact -- because it is symptoms and exacerbation history, not the lung function number, that decide the treatment group and whether the plan is working; and teaches a plan whose aim is to slow the disease and keep the patient out of exacerbation rather than to cure it: stopping smoking as the single measure that changes the course of the disease, offered at every contact with counselling and pharmacotherapy together, however long the patient has smoked, and with the same weight given to vaping and to second-hand, biomass and occupational smoke; the maintenance long-acting bronchodilator taken every day whether or not the patient feels breathless, the short-acting reliever kept for symptoms and not used as the main treatment, and the inhaled corticosteroid, where it is prescribed for the patient who keeps exacerbating, taken with the mouth rinsed afterwards and never used as a reliever, with the tremor, racing heart, dry mouth and hoarseness the drugs bring named as effects to report rather than reasons to stop; pursed-lip and diaphragmatic breathing, energy conservation and a paced daily programme of walking and exercise or pulmonary rehabilitation, because breathlessness on exertion is treated by activity and not by rest; small frequent meals and an adequate protein intake, because the work of breathing wastes the patient and a wasted patient breathes worse; influenza, pneumococcal and the other recommended vaccinations; avoiding irritants, crowds in the respiratory season and extremes of air; a written action plan naming the early signs of an exacerbation -- breathlessness, sputum volume or purulence beyond the patient's usual -- and the medicine to take and the person to call when they appear; and long-term oxygen, prescribed only for the patient whose resting hypoxemia is severe, worn for as many hours of the day as prescribed rather than reserved for breathlessness -- while the nurse recognizes that stable is a state to be maintained and not a reason to do nothing, that a patient who is losing weight, sleeping badly, giving up activity or reaching for the reliever more often is deteriorating however normal the oximeter reads, and that the plan is judged by symptoms, exacerbations and what the patient can do.