COPD - nursing care and implications for nursing
Some nurses will be actively involved in helping diagnose COPD by carrying out spirometry and reversibility testing, while others, particularly in secondary care, will be less involved in this diagnostic process.
VOL: 98, ISSUE: 37, PAGE NO: 43
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Some nurses will be actively involved in helping diagnose COPD by carrying out spirometry and reversibility testing, while others, particularly in secondary care, will be less involved in this diagnostic process. Good patient preparation is needed for accurate spirometry and, as it becomes a more routine test in both primary and secondary care, nurses working with COPD patients need to understand why and how it is carried out. Patients tend to dislike spirometry as it is very hard work and often induces coughing. A sympathetic approach is needed while ensuring that the patient blows to his/her maximum ability. Nurses who are carrying out reversibility tests should ensure that they have a patient group direction to cover the administration of any drugs they use (HSC, 2000).
Once the diagnosis has been established, nursing care is very much aimed at supporting the patient and his/her family, helping them to come to terms with the diagnosis and stay as well as possible. Some patients may feel that the disease is self-inflicted and be reluctant to seek help, fearing the disapproval of healthcare professionals, particularly if they have been unable to stop smoking. Those who have already stopped smoking may feel angry that, having ‘done the right thing’, they should not have to suffer now. A positive approach by the nurse is therefore needed, focused on maintaining day-to-day function while minimising symptoms as much as possible.
Much of the nurse’s role will be centred on helping patients adjust to their condition and teaching self-management skills. One of the most important tasks of the nurse is to teach patients how to use their inhaler devices correctly. Regular checking of the inhaler technique of patients in primary care and of those in secondary care before they are discharged is also vital. The importance of good inhaler technique should never be forgotten, even for patients who mostly use nebuliser therapy.
Helping patients help themselves
However severe the disease, smoking cessation will lengthen life (BTS, 1997), as cessation slows the accelerated decline in lung function. Unfortunately, lost lung function cannot be regained, so patients need to be aware that stopping smoking will not return them to health. Some patients may feel that the years gained may not be worth the effort, especially if they are already severely disabled.
Smoking cessation is difficult, and most smokers try several times before they succeed. Nicotine replacement therapy and bupropion do increase success rates (Silagy et al., 2002) and both are now readily available on prescription. Most nicotine replacement products are safe to use in COPD.
The inclusion of smoking cessation services as part of the National Service Framework for Coronary Heart Disease has benefited respiratory patients considerably (DoH, 2000). These services have developed over the past three years, and smoking cessation clinics and specialist advisers have now been established in every health authority. Smoking cessation guidelines (Raw et al., 1998; West et al., 2000) give clear and structured guidance for health professionals: all patients should be asked if they smoke, advised to quit if they do, offered help with quitting, and followed up.
Helping COPD patients to stop smoking is a vital part of the nurse’s role even if that help is referring the patient to specialist services. Many practice nurses have been trained in smoking cessation techniques and can offer patients a great deal of support. Similar skills are now developing in secondary care, although it may be more difficult to offer ongoing support in hospital.
Think Point: What smoking cessation services exist in your area of work? Are you comfortable with asking COPD patients about their smoking habits? You may wish to contact your local smoking cessation specialist and find out what services they offer. Do they visit housebound patients? Can they provide training for health professionals?
Many patients with advanced COPD are underweight, while some are overweight. Obesity increases the workload of breathing, and reducing weight will help patients cope with disability (BTS, 1997). Measuring body mass index (BMI) is simple and should be a routine part of assessing patients with COPD. A low BMI suggests a poorer prognosis (Landbo et al., 1999), especially in those whose disease is advanced, while an increase in BMI with treatment improves prognosis (Schols et al., 1998). Why patients lose weight is not clear, although it is widely accepted that weight loss occurs when energy demands exceed energy intake. Dietary supplementation may help, but this should not replace a normal diet. Patients with severe disease should be advised to eat little and often, particularly if eating increases the sensation of breathlessness.
Keeping active maintains general fitness and wellbeing. Breathlessness is very distressing, and the natural reaction is to stop the activity causing the breathlessness. Patients need to be reassured that, although it is distressing, breathlessness is not dangerous, and they should carry on with activities and interests (BTS, 1997). Many patients with moderate disease will be able to continue to work and should be encouraged to do so. Patients may need advice on pacing their activities, and housebound patients need to be encouraged to maintain upper and lower limb strength through simple exercise programmes so that simple but important tasks such as going to the toilet are manageable.
Think Point: A patient with COPD tells you that his wife wants him to stop playing bowls as he gets very breathless and tired. However, he enjoys his bowls but doesn’t want his wife to worry. What advice could you give?
Prevention and management of exacerbations of the disease
Exacerbations are common, particularly in the wintertime, and it is sensible to recommend an annual influenza vaccination (Calman, 1993). Many COPD patients are offered pneumoccocal immunisation despite the lack of evidence of its effectiveness in COPD (BTS, 1997).
Teaching patients how to recognise exacerbations and to seek help early may reduce the need for hospital admission. The symptoms of an exacerbation of COPD are listed in Fig 1. Treatment should be aimed at maximising bronchodilation, treating any underlying infection and reducing inflammation. Although most exacerbations are not bacterial in origin, antibiotics are commonly used. Short courses of oral steroids reduce recovery times and improve lung function during an exacerbation, and are recommended for all patients with an acute exacerbation who do not have significant contraindications (MacNee, 2002).
Some patients may wish to have a supply of antibiotics and oral steroids at home. In such cases, clear written guidance must be given on how and when to start treatment and whom to contact if advice is wanted at any time. Patients with worsening symptoms and signs may need to be admitted to hospital, so the importance of seeking advice needs to be explained.
In-patient management is similar, but allows assessment of blood gases and closer monitoring and support. Pulse oximetry can provide a useful means of monitoring oxygen levels but it will not detect hypercapnia. The question of providing ventilatory support may arise for some patients, and it can be helpful to know if they have any views on this aspect of their care. Patients with end-stage disease may not wish to be ventilated, although the development of non-invasive ventilation provides a less frightening alternative.
It may become apparent during admission of a patient to hospital that he/she needs to be considered for long-term oxygen therapy. Assessment for this treatment, which involves having supplemental oxygen for a minimum of 15 hours a day (Medical Research Council Working Party, 1981) should be carried out on two separate occasions when the patient is stable, usually four to six weeks post-admission. The criteria for long-term oxygen therapy are listed in Fig 2.
Patients who use long- or short-term oxygen therapy should not smoke, as this negates any treatment benefit and, moreover, is a fire hazard. Oxygen concentrators rather than oxygen cylinders should be used if possible, as these offer a much cheaper and more convenient means of providing oxygen.
While many patients with moderate COPD are able to continue working, those with more severe disease may not. Financial hardship is not uncommon, although many patients may be reluctant to ask for help. The burden of caring often falls on the spouse, who is likely to be of a similar age and may have his/her own health problems. Tactful inquiry about ability to cope is needed. Financial help may be available, and simple modifications to the home may make life easier for both the patient and the carer. Referral to social services can be offered both in hospital and at home.
Living with COPD can be an isolating experience for both patient and carer. Some patients will enjoy the opportunity to meet others with the same disease. The British Lung Foundation has groups all over the country (Breathe Easy groups) which meet regularly. Support from a number of organisations is available for people suffering from all types of lung disease (see Fig 3 for a list of addresses and websites).
Think Point: Is there a local Breathe Easy group in your area?
Familial risk - Advice to families
COPD appears to run in families, and patients will often report a family history of chest problems. Alpha-1-antitrypsin deficiency is the only known genetic risk factor, causing 1% of COPD, yet most of those with a family history of COPD do not have this abnormality. Silverman et al. (1998) found that relatives of patients with early onset COPD were found to have reduced lung function if they had a history of current or past smoking, suggesting some genetic risk. Barnes (1999) has suggested that many genes are likely to be involved. However, the most important environmental insult to the lungs comes from smoking, and advice to families should be to stop smoking or never start.
Where alpha-1-antitrypsin deficiency is identified, families should be screened and offered genetic counselling, as they are likely to develop severe emphysema at an early age even if they do not smoke. Smoking greatly intensifies the disease and all family members should be advised not to smoke. Patients who have alpha-1-antitrypsin deficiency which leads to severe disease in early life may be suitable for lung transplantation (BTS, 1997). Continuing to smoke may reduce the likelihood of being accepted onto a transplant programme.
Pulmonary rehabilitation aims to reduce disability and improve the quality of life of patients with all types of lung disease. By improving physical fitness, breathlessness is reduced and the ability to function independently increases. Little improvement in terms of lung function can be achieved, but exercise tolerance and health status (quality of life) improves markedly, and is sustained at 12 months (BTS, 2001). Most programmes run from six to eight weeks, with twice-weekly group exercise and education sessions. The level of disability and health status is assessed before and after the programme. Exercises should be carried on at home between visits, and after the programme has been completed.
Many different formats for pulmonary rehabilitation have been developed, but at least some supervised sessions seem to be necessary. Education for patients and their family is generally included in the session, so that by the end of the programme patients will have developed their understanding of COPD and its treatment, and have acquired management skills such as relaxation techniques and being able to recognise exacerbations. Unfortunately, despite the success of rehabilitation, there are too few programmes to accommodate the number of patients who could benefit. Consequently, rehabilitation is offered late in the disease process. Most patients already have severe disease by the time they undergo rehabilitation and while these patients show marked benefits, those with less severe disease might show even greater improvements.
Think Point: Is there a pulmonary rehabilitation programme in your area? Is there open access? What difficulties might patients have in attending rehabilitation sessions?
The role of the nurse
The role of the nurse in caring for patients with COPD is, to a large extent, dependent on her area of work. Many nurses will have few contacts with these patients, while those in primary care and in respiratory wards will have frequent contacts. Although medical interventions are limited, nurses have a huge role in promoting healthy behaviour in patients with COPD. For example, they provide advice and support to patients and their families and, at the same time, educate and encourage patients to manage their disease proactively. Because change in lung function in response to interventions is minimal, nurses should be assessing response in terms of improvements in patients’ ability to mange their daily life.
Using simple assessments of disability such as the oxygen cost scale discussed in Part 2 lends a degree of objectivity to measuring the effectiveness of both pharmacological and non-pharmacological inter-ventions and provides evidence of benefits that are of considerable value to the patient.
A new, long-acting anticholinergic drug is awaiting licensing in the UK. The drug (tiotropium) has been shown to give benefit in terms of improvements in lung function when compared to ipratropium (van Noord et al., 2000) and, more importantly, in health status as well as lung function when compared with salmeterol (Donohue et al., 2002). Although tiotropium will not improve breathlessness dramatically, any intervention which offers benefit is welcome.
Despite the high prevalence of COPD and the huge healthcare cost, there is little prospect of this disease being given the priority it deserves through a national service framework. However, evidence-based guidelines for both pulmonary rehabilitation (BTS, 2001) and non-invasive ventilation (BTS, 2002) provide support for these newer interventions. The high cost of COPD hospital admission has led to the development of nurse-led early discharge schemes and acute respiratory assessment services which offer safe and cheaper means of managing exacerbations (Davies et al., 2000). Such services are highly acceptable to patients.
Most patients with COPD will be managed in primary care. One of the biggest challenges for primary care nurses is to be aware of the numbers of patients who will present with COPD and of the equipment and training that is available that makes diagnosis possible (Calverley and Bellamy, 2000). Although most COPD presents in patients in later life, those with undiagnosed COPD will be seen mostly in the winter. Referral of at-risk patients for spirometry would identify disease at an earlier stage, and provide an opportunity to intervene (Elkington and White, 2002).
When a diagnosis of COPD has been confirmed, management should follow the guidelines provided by the British Thoracic Society (BTS, 1997) (see Fig 4). Bronchodilator therapy can improve but not abolish symptoms, and the success of treatment needs to be measured in terms of improvements in disability and health status, rather than changes in lung function parameters. COPD is a progressive and disabling condition: nurses play a key role in educating and supporting patients and their families. While the disease is irreversible, it should never be viewed as hopeless.
Bellamy, D., Booker, R. (2000)Chronic Obstructive Pulmonary Disease in Primary Care. London: Class Publishing.
Esmond, G. (ed). (2001)Respiratory Nursing. London: Bailliere Tindall.
Morgan, M., Singh, S. (eds)Practical Pulmonary Rehabilitation. London: Chapman and Hall.