🫁 COPD Guidelines & Education

Recognize Your Zones - Symptom Action Plan

My Regular Medicines

Keep this section filled with your personal medication details:

Inhaler 1: _________________      Dose/Frequency: _________________

Inhaler 2: _________________      Dose/Frequency: _________________

Rescue Pack (if prescribed): _________________________________________________

Avoid & Protect

• Avoid smoking, biomass, and dust exposure
• Stay active - walk, stretch, or follow your PR exercise plan
• Keep vaccinations up to date - influenza yearly and pneumococcal as advised
• Maintain healthy weight and nutrition
• Attend all follow-up visits even if you feel well

A. Breathing Techniques

1. Pursed-Lip Breathing (PLB)

• Breathe in through nose (2 counts)
• Purse lips as if blowing a candle
• Breathe out slowly through pursed lips (4 counts)
• Use during breathlessness or exercise

2. Diaphragmatic Breathing

• Sit or lie comfortably
• Place one hand on chest, one on belly
• Breathe in through nose - belly should rise, chest stays still
• Breathe out slowly through pursed lips
• Practice 5-10 minutes, 2-3 times daily

3. Paced Breathing During Activity

• Coordinate breathing with movement
• Example: Walking - breathe in for 2 steps, out for 3-4 steps
• Use PLB if breathless

B. Home Exercise Program

Warm-Up (5 minutes)

• Gentle arm circles, shoulder rolls
• March in place slowly
• Neck and ankle rotations

Aerobic Exercise (20-30 minutes daily)

Choose activities you enjoy:

• Walking: Start with 10 minutes, gradually increase to 30 minutes
• Stair climbing: Start with 5-10 steps, increase gradually
• Stationary cycling: If available, 15-20 minutes at comfortable pace

Intensity Guide:

• You should be able to talk but not sing
• Breathlessness should settle within 5 minutes of stopping
• Use modified Borg scale: aim for 3-4/10 breathlessness

Strength Training (3 times per week)

Upper Body (using water bottles or light weights 0.5-1 kg):

1. Bicep curls - 10 repetitions × 2 sets
2. Shoulder press - 10 repetitions × 2 sets
3. Arm raises to side - 10 repetitions × 2 sets

Lower Body:

1. Sit-to-stand from chair - 10 repetitions × 2 sets
2. Heel raises (holding chair for balance) - 10 repetitions × 2 sets
3. Knee lifts (marching) - 10 each leg × 2 sets
4. Wall squats (if able) - 5-10 repetitions × 2 sets

Core Stability:

1. Seated trunk rotations - 10 each side
2. Pelvic tilts (lying down) - 10 repetitions

Cool-Down (5 minutes)

• Slow walking
• Gentle stretching of arms, legs, back
• Deep breathing exercises

Weekly Exercise Schedule Template

Day	Activity	Duration	Notes
Monday	Walking + Upper body strength	30 min + 15 min
Tuesday	Walking + Breathing exercises	20 min + 10 min
Wednesday	Walking + Lower body strength	30 min + 15 min
Thursday	Walking + Breathing exercises	20 min + 10 min
Friday	Walking + Full body strength	30 min + 15 min
Saturday	Walking (longer)	30-40 min
Sunday	Light activity or rest	As comfortable

C. Nutritional Support

For Underweight COPD Patients (BMI <18.5):

• Eat small, frequent meals (5-6 per day)
• High-protein foods: eggs, dhal, fish, chicken, milk, yogurt
• Energy-dense snacks: nuts, dried fruits, three poshe/samaposha
• Nutritional supplements if recommended
• Avoid filling up on fluids before meals

For Overweight COPD Patients (BMI >25):

• Balanced portion control
• Focus on vegetables, lean proteins, whole grains
• Limit sugar-sweetened drinks and fried foods
• Maintain muscle mass while losing fat

General Nutrition Tips:

• Stay hydrated (6-8 glasses water daily)
• Reduce salt if swelling present
• Eat fruits and vegetables for vitamins
• Avoid gas-producing foods if bloating is a problem

D. Managing Daily Activities

Energy Conservation Techniques:

• Plan activities during your best time of day
• Take rest breaks before getting too tired
• Sit instead of standing when possible (e.g., while cooking, bathing)
• Organize frequently used items within easy reach
• Use assistive devices if needed (shower chair, long-handled tools)

Activity Pacing:

• Break tasks into smaller steps
• Alternate heavy and light activities
• Don't rush - slow and steady
• Ask for help when needed

E. Psychological Wellbeing

COPD can affect mood and mental health:

• Stay socially connected with family and friends
• Join COPD support groups if available
• Practice relaxation techniques (meditation, gentle music)
• Set realistic goals and celebrate small achievements
• Speak to healthcare provider if feeling depressed or anxious

F. When to Seek Help

Contact your healthcare provider if:

• Increased breathlessness not relieved by usual medicines
• Change in sputum color, amount, or thickness
• Fever or chest pain
• Swelling in ankles or legs
• Increased fatigue or confusion
• Unable to perform usual home exercises

1. Pneumococcal Vaccination

COPD patients are at increased risk of pneumococcal pneumonia and exacerbations. Pneumococcal vaccination is strongly recommended in adults with COPD.

Recommended approach:

• Adults ≥50 years or younger adults with chronic lung disease should receive a conjugate pneumococcal vaccine (PCV15 or PCV20).
• Give 1 dose of PCV20 or PPSV23 at least 8 weeks after last PCV dose.
• For those who have received PPSV23 previously, a conjugate vaccine (PCV20/21) may still be given if available.
• Revaccination with PPSV23 after 5 years may be considered in very high-risk patients.

2. Influenza Vaccination

Annual influenza vaccination is essential for COPD patients to prevent exacerbations and hospitalizations.

Sri Lanka experiences two influenza peaks: April-June and November-February. Vaccinate before the main peak (March-April).

• Annual vaccination is recommended for all COPD patients, especially those ≥65 years or with frequent exacerbations.
• Twice-yearly vaccination may be considered in very high-risk patients (e.g., severe COPD, immunocompromised) if feasible.
• Either Northern or Southern Hemisphere vaccine formulation may be used based on availability.

3. COVID-19 Vaccination

COPD patients are at higher risk for severe COVID-19 outcomes. All patients should be up to date with the national schedule, including boosters.

• Record date and type of last COVID-19 vaccine and ensure booster doses as per Ministry of Health guidance.
• Strongly advise vaccination for those on inhaled corticosteroids or with multiple comorbidities.

4. Varicella (Chickenpox) Vaccination

Varicella vaccine is not part of the routine national schedule in Sri Lanka but is available privately.

• Consider vaccination for adults with COPD who have no prior history of chickenpox or are seronegative.
• Schedule: Two doses 4-8 weeks apart for those aged ≥13 years.
• Recommended mainly for high-risk adults (e.g., healthcare workers, caregivers).

1. Why Quitting Matters in COPD

Immediate Benefits (within days-weeks):

• Breathing becomes easier
• Cough and sputum improve
• Energy levels increase
• Sense of smell and taste return

Long-term Benefits:

• Slows lung function decline
• Reduces exacerbations by 30-40%
• Decreases risk of lung cancer
• Improves response to medications
• Increases survival

2. The 5 A's Approach to Smoking Cessation

ASK - Identify tobacco users at every visit

"Do you currently use tobacco - cigarettes, beedis, cigars, chewing?"

Document: Type, amount (cigarettes/beedis per day), years of use

ADVISE - Strongly urge all tobacco users to quit

"Quitting smoking is the most important thing you can do for your lungs and your health. I strongly recommend you quit now."

• Be clear, strong, and personalized
• Link advice to COPD symptoms and test results
• Avoid being judgmental

ASSESS - Determine willingness to quit

"Are you willing to try to quit smoking now?"

Stages of Change:

Stage	Characteristics	Approach
Pre-contemplation	Not thinking about quitting	Provide information, plant seeds
Contemplation	Thinking about it	Explore ambivalence, discuss benefits
Preparation	Ready to quit soon	Set quit date, develop plan
Action	Currently quitting	Provide support, medication if needed
Maintenance	Quit for >6 months	Prevent relapse, reinforce success
Relapse	Returned to smoking	Non-judgmental, learn from attempt

ASSIST - Help patient with quit plan

Set a Quit Date:

• Within next 2-4 weeks
• Meaningful date (birthday, holiday, family event)
• Write it down, tell family and friends

Prepare for Quit Day:

• Remove all tobacco products from home, car, workplace
• Avoid triggers (alcohol, tea shops, smoking friends)
• Plan activities for urge management
• Stock healthy snacks (carrots, nuts, chewing gum)
• Plan first smoke-free day in detail

Get Support:

• Tell family, friends, coworkers
• Join support group if available
• Use telephone quitline if available
• Consider counselling

Consider Medication:

• Nicotine replacement therapy
• Prescription medications
• Discuss options with doctor

ARRANGE - Schedule follow-up contact

• Within 1 week of quit date
• Then at 1 month, 3 months, 6 months
• More frequent if needed
• Celebrate successes, address challenges

3. Pharmacotherapy for Smoking Cessation

A. Nicotine Replacement Therapy (NRT)

How it works:

• Provides nicotine without harmful tobacco chemicals
• Reduces withdrawal symptoms and cravings
• Doubles quit success rates

Forms available in Sri Lanka:

Type	Dose/Use	Pros	Cons
Patch	21 mg, 14 mg, 7 mg daily	Easy, steady level, once daily	Skin irritation, no hand-to-mouth
Gum	2 mg or 4 mg as needed	Controls acute cravings	Jaw fatigue, technique needed
Lozenge	2 mg or 4 mg as needed	Discreet, easy	Throat irritation, technique needed

How to choose:

• Heavy smokers (>20/day): Start with 21 mg patch + gum/lozenge for breakthrough cravings
• Moderate smokers (10-20/day): 14 mg patch or gum/lozenge alone
• Light smokers (<10/day): 7 mg patch or gum/lozenge alone

Duration: Usually 8-12 weeks, then taper. Some may need longer.

Contraindications: Recent heart attack (within 2 weeks), unstable angina, severe arrhythmias

B. Prescription Medications

Varenicline:

• How it works: Blocks nicotine receptors, reduces cravings
• Dose: Start 0.5 mg daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily for 11-24 weeks
• Start: 1 week before quit date
• Effectiveness: Triples quit rates
• Side effects: Nausea (common, improves with time), vivid dreams, mood changes
• Monitoring: Assess mood at each visit, especially if history of depression
• Safety in COPD: Safe and effective; preferred choice for motivated patients

Bupropion:

• How it works: Antidepressant that reduces cravings and withdrawal
• Dose: 150 mg daily for 3 days, then 150 mg twice daily for 7-12 weeks
• Start: 1-2 weeks before quit date
• Effectiveness: Doubles quit rates
• Side effects: Insomnia, dry mouth, anxiety
• Contraindications: Seizure disorder, eating disorders, heavy alcohol use
• Safety in COPD: Safe; good option if depression also present

Combination Therapy:

• Varenicline + NRT patch may be more effective than either alone
• Consider for highly dependent smokers who have failed single therapy
• Requires specialist supervision

4. Biomass Exposure Reduction

Common Sources in Sri Lanka:

• Firewood cooking (kitchen smoke)
• Paddy drying (seasonal, intense exposure)
• Coconut husk burning
• Indoor open fires
• Incense and mosquito coils (minor contributors)
• Kerosene lamps

Health Impact:

• Similar lung damage to tobacco smoking
• Particularly affects women doing household cooking
• Children exposed also at risk
• Combined smoking + biomass exposure = worse outcomes

Harm Reduction Strategies:

A. Improve Kitchen Ventilation:

• Open windows and doors while cooking
• Install chimney or exhaust fan if possible
• Cook outside or in separate kitchen building when feasible
• Use improved cookstoves with chimneys (Anagi Lipa programs)

B. Fuel Switching (in order of preference):

1. Best: Electricity or LPG (liquid petroleum gas)
   • Cleanest options
   • Government subsidies available for low-income families
   • Long-term cost savings despite higher initial cost
2. Better: Biogas from home digesters
   • Renewable, clean
   • Initial investment required
   • Suitable if have livestock
3. Good: Improved biomass stoves
   • 50-70% reduction in smoke exposure
   • Much less expensive than fuel switching
   • Programs available through government and NGOs
4. Minimal improvement: Dry, seasoned wood instead of wet wood
   • Reduces smoke but still significant exposure

C. Behavior Modification:

• Light fire outdoors, bring inside once established (less smoke)
• Avoid bending over fire while cooking
• Take breaks during cooking to breathe fresh air
• Assign cooking tasks to family members without COPD
• Batch cook to reduce total cooking time
• Use pressure cookers and covered pots (shorter cooking time)

D. Personal Protection:

• Well-fitted N95 mask while cooking (not cloth masks)
• Change position to stay out of smoke plume
• Tie back hair and wear long sleeves (reduces smoke absorption)

1. Concept Overview

Term	Definition	Why It Matters
Pre-COPD	Respiratory symptoms ± imaging or physiological abnormalities suggestive of early airway disease but post-BD FEV₁/FVC ≥0.7	Indicates incipient COPD - target for prevention through lifestyle, exposure, and vaccination
PRISm (Preserved Ratio Impaired Spirometry)	FEV₁ <80% predicted with FEV₁/FVC ≥0.7	Transitional state - some progress to COPD, some revert to normal. Common in obesity, post-TB, biomass exposure

2. Spectrum of Progression

Risk Factors → Pre-COPD → PRISm → Established COPD

Stage	Pathology/Function	Imaging/Tests	Clinical Clues
Pre-COPD	Small-airway inflammation, early air-trapping	↓ FEF₂₅₋₇₅%, ↑ RV/TLC, IOS: ↑R5-R20	Cough, exertional breathlessness, normal FEV₁/FVC
PRISm	Hyperinflation, dysanapsis, early emphysema	FEV₁ <80%, normal ratio, HRCT air-trapping	Often obese/metabolic, post-TB changes
COPD	Fixed airflow obstruction	FEV₁/FVC <0.7 post-BD	Chronic dyspnoea, productive cough

3. Management Framework

Goal	Pre-COPD	PRISm
Exposure Control	Stop smoking, remove biomass, improve ventilation	Same as Pre-COPD
Vaccination	Influenza, Pneumococcal, Pertussis, COVID	Same
Physical Activity/PR	Daily walking, breathing exercises	Early pulmonary rehab if symptomatic
Nutrition	Maintain BMI 20-25; treat sarcopenia	Weight reduction if obese; control metabolic syndrome
Pharmacologic	No routine bronchodilators unless reversible	LABA/LAMA trial if symptomatic with low FEV₁
Monitoring	Spirometry every 12-18 months	Every 6-12 months
Referral	Worsening symptoms or FEV₁ decline >100 mL/yr	Same + HRCT if decline persists

4. Sri Lanka-Specific Notes

• Biomass-PRISm common in rural women; often mislabelled as asthma
• Post-TB airflow patterns mimic PRISm due to airway distortion without obstruction
• Childhood undernutrition + infection leads to early small-airway disease
• Integrate detection into NCD and Chest Clinics using handheld spirometry and a short exposure questionnaire

5. Follow-Up Algorithm

Comprehensive Device Comparison

Attribute	pMDI	Single-Dose DPI	Multi-Dose DPI	BA-MDI	SMI
Propellant/Activation	HFA propellant (manual press)	No propellant; capsule punctured per use	No propellant; built-in reservoir or blister strip	HFA-based; inhalation triggers actuation	No propellant; spring-driven liquid mist
Inspiratory Flow	Low; suitable for all	High (≥40-60 L/min)	Moderate (~30-50 L/min)	Low-moderate	Low (slow, gentle)
Coordination	Required (major error source)	Not required	Not required	Not required	Not required
Spacer	Strongly recommended; improves deposition, reduces side effects	Not compatible	Not compatible	Usually not required	Not required
Ease of Use	Moderate; requires training	Moderate; capsule loading	High; dose counter	High; minimal coordination	Very high; easy slow inhalation
Dose Counter	Common on newer models	Not typical	Standard	Available on some	Integrated on most

Device Selection Algorithm

Step 1: Assess Patient Capability

Inspiratory Flow Capacity:

• Measure peak inspiratory flow (PIF) if available
• Single-dose DPI requires ≥40-60 L/min
• Multi-dose DPI requires ~30-50 L/min
• pMDI, BA-MDI, SMI suitable for all flow rates

Coordination Ability:

• Poor hand-breath coordination → DPI, BA-MDI, or SMI preferred
• Children <5 years → pMDI + spacer with face mask
• Children 5-12 years → pMDI + spacer OR multi-dose DPI
• Adults/adolescents → Any device based on preference and flow

Step 2: Match Device to Clinical Context

Acute Exacerbations/Emergency:

• pMDI + spacer (nebulizer if severe)
• Reliable delivery regardless of inspiratory effort
• SMI acceptable if patient familiar with device

Maintenance Therapy:

• Multi-dose DPI preferred for stable patients (dose counter, no propellant)
• BA-MDI for transitional patients learning technique
• SMI for patients requiring low-carbon footprint and reliable delivery

Step 3: Consider Environmental and Cost Factors

Environmental Impact: Next-generation HFA-152a propellants offer ~90-95% reduction in global warming potential compared to standard HFA-134a.

Cost and Availability:

• Multi-dose DPI may have higher upfront cost but better adherence
• pMDI + spacer remains most cost-effective in resource-limited settings

Spacer Technique & Maintenance

Benefits of Spacers with pMDI

Spacer Types

Valved Holding Chamber (VHC):

• One-way valve allows inhalation timing flexibility
• Preferred for children and elderly
• Most common type available

Non-Valved Spacer:

• Simple tube design
• Requires immediate inhalation after actuation
• Cost-effective but less forgiving

Correct Spacer Technique

1. Assemble spacer and attach pMDI
2. Shake pMDI 5 times
3. Breathe out gently (away from spacer)
4. Place mouthpiece between lips (tight seal)
5. Actuate pMDI ONCE into spacer
6. Breathe in slowly and deeply (5-10 seconds for VHC)
7. Hold breath for 10 seconds
8. Wait 30-60 seconds before second puff if needed
9. Rinse mouth after ICS use

Spacer Maintenance

• Wash weekly with warm soapy water
• Air dry (do not wipe - creates static charge)
• Replace every 6-12 months or if damaged/cracked
• Avoid detergents with surfactants (increases static)

6MWT - 6-Minute Walk Test

ABG - Arterial Blood Gas

ACO - Asthma-COPD Overlap

AECOPD - Acute Exacerbation of COPD

BD/BDR - Bronchodilator/Bronchodilator Reversibility

BIA - Bioelectrical Impedance Analysis

BiPAP - Bilevel Positive Airway Pressure

BMI - Body Mass Index

CAT - COPD Assessment Test

COPD - Chronic Obstructive Pulmonary Disease

CXR - Chest X-Ray

DLco - Diffusing Capacity for Carbon Monoxide

DPI - Dry Powder Inhaler

FEV₁ - Forced Expiratory Volume in 1 second

FVC - Forced Vital Capacity

GOLD - Global Initiative for Chronic Obstructive Lung Disease

HRCT - High-Resolution Computed Tomography

ICS - Inhaled Corticosteroid

LABA - Long-Acting Beta-Agonist

LAMA - Long-Acting Muscarinic Antagonist

mMRC - Modified Medical Research Council (dyspnea scale)

MOH - Ministry of Health

NIV - Non-Invasive Ventilation

NIP - National Immunization Program

pMDI - Pressurized Metered Dose Inhaler

PCV - Pneumococcal Conjugate Vaccine

PR - Pulmonary Rehabilitation

PPSV23 - Pneumococcal Polysaccharide Vaccine 23

RV/TLC - Residual Volume/Total Lung Capacity

SMI - Soft-Mist Inhaler

SpO₂ - Oxygen Saturation