Chronic obstructive pulmonary disease (COPD) is a largely preventable and treatable—but not fully reversible—lung disease, characterised by a chronic obstruction of lung airflow that interferes with normal breathing. 

In Australia it affects 638,000 people, accounting for 3.6 per cent of the total disease burden and half of the disease burden due to respiratory conditions. 

In 2021–22, the disease was responsible for 53,000 hospitalisations (Australian Institute of Health and Welfare 2024). 

Importantly, 87 per cent of people with COPD live with additional chronic conditions, including arthritis (45 per cent) and back problems (42 per cent), and hence may be seen by physiotherapists in private practice. 

Late last year the Australian Commission on Safety and Quality in Health Care (‘the Commission’) published the first national quality standard for COPD, the COPD Clinical Care Standard. 

The Standard aims to reduce hospitalisations and improve overall outcomes for people with COPD by supporting best practice in assessment and management of the disease (Australian Commission on Safety and Quality in Health Care 2024). 

‘It sets up what patients should expect to receive if they have COPD, what clinicians should do and what health services should provide to enable that to happen,’ says Professor Jennifer Alison APAM, who was a member of the Commission’s COPD Topic Working Group, which advised on the development of the Standard. 

Jennifer points out that the COPD Clinical Care Standard is not the same as the COPD-X Guidelines, which are updated quarterly to provide clinicians with the current best evidence-based practice in assessing and managing COPD. 

Rather, the COPD Clinical Care Standard is focused on high priority areas where there is significant potential to improve clinical outcomes by increasing adherence to COPD-X guidelines. 

Priority areas for quality improvement are presented as 10 quality statements (see below), accompanied by measurable quality indicators that can be used by clinicians and health services to assess and monitor care. 

Not just for respiratory physiotherapists 

Ultimately, Jennifer believes that the COPD Clinical Care Standard will help to clarify best practice for COPD care and management, both for those who work in respiratory physiotherapy and more broadly. 

Jennifer says that several of the 10 quality statements are directly relevant to physiotherapists working in the cardiorespiratory space, most importantly the ones about pulmonary rehabilitation (Quality statement 5), education and self-management (Quality statement 3) and spirometry (Quality statement 1). 

‘My view is that if you work in the respiratory area, you need to know about all these things. 

‘As a physiotherapist, you would have an essential role in bringing several of these quality statements to life in clinical practice. 

‘The biggest one for physiotherapy is pulmonary rehabilitation and everything that goes with it—exercise training, symptom review, self-management education and teaching patients how to use their inhalers,’ she says. 

‘There are a lot of resources out there, but I think knowing where to find those resources and being knowledgeable about these aspects of care means that physios can step up and be part of a number of the quality statements, not just the one about pulmonary rehabilitation.’ 

From Jennifer’s perspective, it is valuable for all physiotherapists to have at least a basic understanding of the COPD Clinical Care Standard, especially given the high rate of musculoskeletal comorbidities in people with COPD. 

‘If you’re in private practice and your patient with an osteoarthritic knee comes in breathless that is going to stand in the way of them getting back to being physically active. 

‘If you know they have a diagnosis of COPD, your role as a health professional is to use the Clinical Standard to figure out whether you can provide additional help and what referrals or alternative measures you could take,’ Jennifer says. 

If they don’t have a COPD diagnosis, this might mean identifying risk factors for COPD such as smoking or working in a polluted environment, and suggesting that they talk to a GP about being assessed. 

‘I think raising awareness is important, and if we do that for the patients we see in private practice, that will just help to raise the tide in managing something as pervasive as COPD. 

‘In general, there hasn’t been the same focus on chronic lung disease as there has been on conditions like heart disease and diabetes. 

‘Sometimes people with COPD feel marginalised due to stigma around smoking. 

‘If they receive timely care they can live very well with their chronic lung condition, but so many have a late diagnosis because either they think breathlessness is a natural part of ageing or they stop doing things that make them breathless and nobody bothers to ask why.’ 

She notes that the earlier patients with COPD are referred to pulmonary rehabilitation and start on a self-management plan, the better. 

‘We can improve their fitness within the limitation of their lung condition—if they’re fitter they’re more likely to be able to continue to do activities with less breathlessness—and that will hold them in good stead. 

‘We all decline in lung function as we age, but good care can make a big difference.’ 

The Clinical Care Standard in practice 

Professor Jennifer Alison was a member of the Topic Working Group for the COPD Clinical Care Standard

Jennifer says it’s a reflection of the important role played by respiratory physiotherapists that Quality statement 5: Pulmonary rehabilitation literally holds a central position, being fifth of the ten statements that comprise the Clinical Care Standard. 

‘It was recognised that getting people to pulmonary rehab was important, and this should be highlighted early in the Standard, before pharmacology, which is the more recognised treatment,’ she says. 

Quality Statement 5 states that all patients with COPD should be referred for pulmonary rehabilitation, and that if someone has been hospitalised for a COPD exacerbation, they should commence pulmonary rehabilitation within four weeks. 

The two indicators for Quality statement 5 relate to monitoring the proportion of patients with COPD who are referred to a pulmonary rehabilitation program, and the number of people who have been hospitalised due to an exacerbation of COPD who start pulmonary rehabilitation within four weeks of hospital discharge. 

‘That’s based on the evidence from randomised control trials of people admitted to hospital with an exacerbation of COPD. 

‘Those who commenced pulmonary rehab in the first four weeks after hospital discharge had a 52 per cent reduction in hospital readmissions—which is huge,’ Jennifer says. 

‘COPD has a high incidence of potentially preventable hospitalisations, and the Standard is really aiming to reduce those preventable admissions through better management in primary care. 

‘It will be challenging to meet that indicator within four weeks of hospital discharge, but it’s there because that’s best practice and it would make a difference to health costs and to patients,’ Jennifer says. 

It’s an area that Jennifer believes private practice physiotherapists should upskill in, to provide extra services to patients who need them. 

Currently, pulmonary rehabilitation programs are hospital-based and there are long waiting lists for existing programs as many were shut down during the COVID-19 pandemic and have not been re-established. 

The Medicare Chronic Disease Management plan currently limits patients to five allied health visits per calendar year. 

This makes privately run pulmonary rehabilitation programs not financially viable for patients who are not privately insured, as these programs typically involve 16 sessions of exercise and education. 

Jennifer highlights Quality statement 3: Education and self-management as another area of key importance for physiotherapists. 

‘In all our university courses physiotherapists learn about this, so they should be able to provide information and self-management education to patients. 

‘For COPD that education involves managing breathlessness, staying physically active, quitting smoking, talking to people about appropriate vaccinations, et cetera. 

‘We should also be ensuring they have an action plan from their GP about what to do if they’re less well,’ Jennifer says. 

Next on the list is spirometry (Quality statement 1), which is used as the primary diagnostic for COPD. 

‘COPD is not able to be diagnosed without spirometry. 

‘We teach students how to do spirometry, but physios could step up and do more in this area, and help private practices or local GP clinics that need spirometry services but don’t have a qualified practice nurse. 

‘Otherwise the patient has to go to a respiratory lab, and that’s another big effort to get a diagnosis,’ Jennifer explains. 

Inhaler technique (Quality statement 6) is another one that physiotherapists working with patients with COPD should be across. 

‘That’s everybody’s business really, the doctor who prescribes it, the pharmacist who gives it out and the physios who see the patient in pulmonary rehab should always check their inhaler technique,’ Jennifer says. 

Physiotherapists also play a role in providing oxygen therapy and ventilatory support for patients who are severely unwell in hospital due to an exacerbation of their COPD—in many hospitals physiotherapists are involved with assessment and treatment via oxygen therapy and non-invasive ventilation. 

Oxygen and ventilatory support are covered by Quality statement 8. 

Jennifer says an important aspect of the Clinical Care Standard is that it also presents information on how to provide culturally safe and equitable care for Aboriginal and Torres Strait Islander Peoples and communities. 

This includes recognising some of the barriers to accessing care and rehabilitation programs, and making programs and services available through local Aboriginal Community Controlled Health Organisations. 

‘For Aboriginal and Torres Strait Islander people the prevalence of COPD is two and a half times higher. 

‘They go to hospital five times more and their mortality rate is three times higher than other Australians, so it’s a big gap,’ Jennifer says. 

Chronic obstructive pulmonary disease Clinical Care Standard 

The Chronic Obstructive Pulmonary Disease (COPD) Clinical Care Standard aims 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. 

Quality Statement 1: Diagnosis with spirometry 

A person over 35 years of age with a risk factor and one or more symptoms of chronic obstructive pulmonary disease (COPD) receives high-quality spirometry to enable diagnosis. Spirometry is also performed for a person with a recorded diagnosis of COPD that has not yet been confirmed with spirometry. 

Quality Statement 2: Comprehensive assessment 

A person with a confirmed COPD diagnosis receives a comprehensive assessment to determine their individual care needs. This includes assessing their symptoms and disease severity using a validated assessment tool, history and risk of exacerbations, and comorbidities. Follow-up assessment occurs at least annually. 

Quality Statement 3: Education and self-management 

A person with COPD is supported to learn about their condition and treatment options. They participate in developing an individualised self-management plan that addresses their needs and treatment goals and includes an action plan for COPD exacerbations. 

Quality Statement 4: Vaccination and tobacco-smoking cessation 

A person with COPD is offered recommended vaccinations for respiratory and other infections including influenza, pneumococcal disease and COVID-19. They are asked about their tobacco-smoking status and, if currently smoking, offered evidence-based tobacco-smoking cessation interventions. 

Quality Statement 5: Pulmonary rehabilitation 

A person with COPD is referred for pulmonary rehabilitation. If the person has been hospitalised for a COPD exacerbation, they are referred to a pulmonary rehabilitation program on discharge and commence the program within four weeks. 

Quality Statement 6: Pharmacological management of stable COPD 

A person with a confirmed COPD diagnosis is offered individualised pharmacotherapy in line with the COPD-X stepwise approach. Inhaler technique is demonstrated, assessed and corrected when starting treatment and regularly thereafter, including after any change in treatment or a COPD exacerbation. 

Quality Statement 7: Pharmacological management of COPD exacerbations 

A person having a COPD exacerbation receives short-acting bronchodilator therapy at the onset of symptoms and, if indicated, oral corticosteroids in line with the current COPD-X Guidelines. Antibiotics are only considered if criteria for prescribing are met, and they are prescribed according to evidence-based guidelines. 

Quality Statement 8: Oxygen and ventilatory support for COPD exacerbations 

A person experiencing hypoxaemia during a COPD exacerbation receives controlled oxygen therapy, ensuring that oxygen saturation levels are maintained between 88 per cent and 92 per cent. Non-invasive ventilation is considered in anyone with hypercapnic respiratory failure with acidosis. 

Quality Statement 9: Follow-up care after hospitalisation 

A person who has been hospitalised for a COPD exacerbation is offered a followup assessment within seven days of discharge, facilitated by timely and effective communication between their hospital and primary care providers. 

Quality Statement 10: Symptom support and palliative care 

A person with COPD is offered symptom support and palliative care that meets their individual needs and preferences. 

Click here for more information about the COPD Clinical Care Standard, including related measurement indicators and a suite of resources for clinicians, patients and healthcare services.  

The PRF has developed an infographic for the COPD Clinical Care Standard.

Quick links: 

• references