What are the Most Important Steps for Effective COPD Management?

Chronic Obstructive Pulmonary Disease, commonly known as COPD, refers to a group of respiratory diseases that cause airflow blockage and breathing problems in affected patients. While COPD is a chronic, gradually progressing lung disease that is not entirely curable, there are several effective options to help patients manage and treat this illness. As technology, medicine, and methods for chronic disease management have advanced dramatically over the last decade, the ways in which healthcare providers can help COPD patients improve outcomes and their overall quality of life are continuously expanding.

Steps to Effectively Manage and Treat COPD in Patients

Treatment and continuous monitoring are essential when it comes to managing COPD. By effectively treating COPD in the early stages of advancement, patients can typically see improvements in their breathing, reduce coughing, and slow the progression of this disease. While there are a number of things patients can do themselves to reduce symptoms significantly, such as quitting smoking and making healthier lifestyle choices, healthcare providers can further improve health outcomes for patients by providing suitable treatment options. Here, we will provide information on the steps healthcare providers can take to effectively manage patients with COPD and discuss their benefits.

Provide COPD Patients With Educational Resources

There are several programs available to patients living with COPD which provide educational resources. These programs help patients manage aspects of their disease themselves and are vital in building a connection with their healthcare providers. Educational resources can include information about quitting smoking, avoiding triggers such as fumes or particles that can be inhaled, medications to keep on hand, breathing techniques, and much more. 

Studies show that there are distinct benefits to providing patients with educational resources. In a study done by Elsevier Science Ireland where patients were provided educational resources about COPD self-management, the need for general practitioner visits was reduced by 85%, and the need for reliever medication was also reduced.

Regular check-ups are important to ensure the patient’s condition is not worsening.

Assess Patients’ Symptoms and Progress Regularly

Healthcare providers must be regularly updated on COPD patients’ symptoms to identify concerning changes and track improvements. To do so, patients may choose to schedule in-person checkups or meet with their providers virtually. In either case, patients must be equipped with the right tools and knowledge to identify changing symptoms and know when to report them. 

By providing patients with an at-home monitoring device, healthcare providers can track symptoms in real-time and reduce the need for in-person visits at their clinic or facility. Solutions such as Aetonix’s aTouchAway Platform can help connect providers with patients to monitor their condition and adjust their care plans accordingly. In connecting this way, patients can take action towards managing their symptoms in very little time, thus reducing the progression of their respiratory illness and the need for hospitalizations or in-person checkups.

Ensure Patients Are Regularly Checking In if Their Symptoms Worsen

COPD symptoms may worsen or become more severe intermittently. This is known as an exacerbation or “flare-up” and should be addressed by patients and healthcare providers promptly. In many cases, warning signs are present and can include excessive coughing, wheezing, shortness of breath, feeling tired for more than one day, trouble sleeping, and more.

By having patients continuously monitor their symptoms, they are more likely to recognize a flare-up before it worsens, and can inform their healthcare provider so that the appropriate measures can be taken. Fortunately, there are several ways patients can go about sharing their symptoms, one of which being remote patient monitoring.

Remote patient monitoring is one of the efficient ways of receiving patient updates as it allows providers to stay up-to-date on changing symptoms without the need for in-person visits. With this method, providers can instruct patients to input their symptoms on their remote monitoring platform as soon as they occur. This can give providers instant notifications for any concerning changes, and allows them to quickly respond to their patients’ needs.

Coordinate Effective Support for Patients

Some COPD patients’ health conditions make travelling to in-person appointments inconvenient. Additionally, many patients live in remote communities or are located far away from loved ones or healthcare providers. This can bring challenges such as difficulties travelling to and from medical appointments and feelings of isolation.

A critical factor in successfully treating and managing COPD in patients is providing them with a robust support system. Virtual care pathways are one method that can be used to help patients keep in touch with their healthcare providers, families, and other members who can help improve patient support. On platforms such as aTouchAway, patients and authorized members can view a snapshot of their care journey, remotely coordinate care, and communicate effectively through messaging and video features. This helps patients connect in a more convenient way, and reduces the need for unnecessary hospitalizations or in-person visits.

Benefits of Properly Treating and Managing COPD

Effective treatment and management of COPD can significantly enrich the lives of patients and their loved ones. Patients can improve their quality of life by breathing better, having more energy to do things they love, and slowing the progression of the disease. 

Proper treatment of COPD in patients can also have positive effects on health care systems. Hospitalizations cost the Canadian healthcare system $68 Billion yearly, a number that is expected to increase due to the COVID-19 pandemic. As patients are able to gain more control over their symptoms and avoid problematic flare-ups, hospitalizations decrease which results in less funds needed to support these visits.

Consequences of Inadequate COPD Treatment and Management

If COPD is not managed or treated properly, a patient’s symptoms will likely worsen over time. This can lead to several health issues that can negatively impact their quality of life, including extreme difficulty breathing, trouble doing daily activities, increased fatigue, and more. Inadequate treatment also increases the likelihood of hospitalizations and in-person checkups that are burdensome to patients.

Healthcare inefficiencies can also occur if chronic diseases such as COPD are not treated and managed effectively. These inefficiencies can lead to a number of consequences including facilities not having adequate resources to treat patients, excessive workloads for physicians and other medical personnel, and other issues that put a strain on healthcare practices.

Providing patients with the right resources can drastically help their condition.

Improving Treatment and Management for COPD Patients

Effectively treating and managing COPD as a patient requires lifelong chronic disease management. By providing patients with the right resources and knowledge, medication, and encouraging acts of self-management, healthcare providers can have a tremendous impact on their patients’ success.

As more research is conducted and treatment options continue to expand for patients living with COPD, it is likely health outcomes for those living with this disease will continue to improve over time with the right care. 

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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