Do people with mild COPD benefit from early pulmonary rehabilitation programmes?
Pulmonary rehabilitation is seen as a gold standard intervention for moderate to severe COPD. A pilot project tested its effectiveness in the early stages of disease
Ram Gulrajani, BSc, Asthma Dip, COPD Dip, RSCN, RGN, is respiratory nurse consultant, West Essex PCT.
Gulrajani R (2010) Do people with mild COPD benefit from early pulmonary rehabilitation programmes? Nursing Times; 106: 17, early online publication
People with mild to moderate COPD usually receive information about their condition from GPs or practice nurses, while those with moderate to severe disease have access to pulmonary rehabilitation programmes. This article describes a pilot of a pre-pulmonary rehabilitation course that aimed to standardise information for people with mild disease.
Keywords Pulmonary rehabilitation, Patient education, COPD, Quality of life
- This article has been double-blind peer reviewed
- GPs and practice nurses usually deliver education for people with mild to moderate chronic obstructive pulmonary disease (COPD), but it is not standardised.
- There is limited time to educate people with long term conditions such as COPD during a GP or practice nurse consultation.
- Pulmonary rehabilitation programmes are not available to those with mild COPD.
Exacerbations of chronic obstructive pulmonary disease (COPD) account for nearly 16% of all medical emergency admissions (British Thoracic Society, 2006). A small sub-group of people with COPD are prone to frequent exacerbations and hospital admission and this has considerable implications for healthcare costs (Garcia-Aymerich et al, 2003).
Prompt presentation for treatment has been shown to improve outcomes in COPD (Wilkinson et al, 2004) and it is important that people who develop exacerbations, together with their carers, are able to understand and recognise symptoms early.
Patient views on services
Our PCT held a consultation meeting with people with COPD and local stakeholder groups to elicit their views on services. The group included the local community respiratory specialist team, local GPs, practice nurses and commissioners. At the meeting patients gave extremely positive feedback on pulmonary rehabilitation programmes (PRP).
NICE (2004) supported the use of PRP as a gold standard intervention for moderate to severe COPD. One patient representative asked why this was only available to people who are moderately to severely unwell. It is assumed that people with mild COPD are given information about managing their condition by a GP, practice nurse and the multidisciplinary team involved in their care.
However, feedback from our practice nurses suggests they spend much of their time trying to meet the Quality and Outcomes Framework (QOF) targets for chronic disease management. Those involved in monitoring COPD as part of the targets are required to carry out spirometry, take a smoking history and check inhaler technique, which are important in preventing deterioration and monitoring patients’ condition. However, the short time slot for consultations, usually 15 minutes, may not allow for additional educational input.
While literature is available for people with COPD, it is difficult to assess whether this is effective in helping them to manage their condition.
Pre-pulmonary rehabilitation programme
Following the stakeholder meeting we agreed to pilot a pre–pulmonary rehabilitation programme (pre-PRP) for people with mild to moderateCOPD. The aim was to try to prevent deteriorating lung function rather than wait until patients had moderate to severe disease and could attend PRP. The programme was funded through innovation funds from the PCT’s practice based commissioning group and commissioning arm.
A pilot was carried out in one large surgery in the Harlow area, within the West Essex PCT as the nurse practitioner from the surgery was present at the stakeholder event and was keen to take part.
Thirteen people with mild to moderate COPD were randomly selected and invited to take part in the pilot and eight accepted the invitation. An additional patient from another surgery heard about the programme and also attended. None had previously attended PRP but had received information about their condition from practice nurses during consultations.
Patients were invited to six two-hour sessions, held twice a week for three weeks. They ran from 7pm-9pm to accommodate people who were working during the day, and were held in a community clinic in Harlow.
The programme was delivered by the multidisciplinary team including a respiratory nurse consultant, senior respiratory physiotherapist and a nurse practitioner from the surgery involved in the pilot.
The Chronic Respiratory Questionnaire (CRQ-SR) was used as an outcome measure at the beginning and end of the course (Williams et al, 2001). This was selected because it is a reproducible, reliable and stable measure of health status. It is also quick to administer, and therefore cost -effective (Williams et al, 2001). Box 1 outlines the programme content.
Box 1. Outline of programme content
- An overview of COPD and lung function testing with CRQ-SR questionnaire;
- Relaxation techniques, breathing techniques and sputum clearance;
- Exercise and breathlessness;
- Inhalers, medications and immunisations;
- Smoking cessation and nutrition;
- Exacerbation management, CRQ-SR questionnaire and feedback.
Patients were also given supporting literature.
The programme was evaluated with a questionnaire to allow patients to comment freely on their perception of the programme, its use and effect.
Patients received group learning that was standardised and reproducible. The programme was well received by them and attendance was very good. One patient missed the initial session due to work commitments and three missed one session due to other reasons.
The results of the CRQ-SR questionnaire demonstrated that the course had an impact on patients’ symptoms and function.
Four patients reported a decrease in dyspnoea; two said they felt less fatigue and two felt their emotional function had improved. Four said they had more control over their condition.
Patients commented that they understood more about their condition and felt more able to manage it. They also benefited from engaging with other patients in a group setting and sharing experiences. Fig 1 outlines patient feedback.
The cost of the programme was approximately £1,800, compared with one hospital admission based on health related group (HRG) costs of £2,000.
Following the pilot, the commissioners have decided to fund three more programmes. These will be open to other surgeries in the PCT and will involve larger numbers of patients to improve cost effectiveness. We will evaluate whether larger numbers change the group dynamics.
We do not have evidence that the intervention will have an impact on future admissions and this issue could be addressed by formal research in the future.
We are in the process of producing a curriculum and teaching package so that the pre-PRP can be delivered by primary care nurses and other COPD teams supported by PCT specialist COPD services and health coaches. It could also be run entirely by the practice based commissioning cluster.
The quality of life outcomes were an unexpected advantage from the pilot, which initially aimed to test whether education could be successfully delivered in a standardised format such as a group setting. These quality of life measures will be included in the course as standard.
All newly diagnosed people with COPD should attend a pre-PRP, which appears to be a valuable way to disseminate information to patients.
Further research is needed to identify whether such initiatives can not only reduce demands on and costs of services but also, more importantly, improve quality of life and increase self management outcomes.
British Thoracic Society (2006) Burden of Lung Disease. London: BTS.
Department of Health (2008) High Quality Care For All: NHS Next Stage Review Final Report. London: DH.
Garcia-Aymerich et al (2003) Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax; 58: 2, 100–105.
Williams JEA et al (2001) Development of a self-reported Chronic Respiratory Questionnaire (CRQ-SR). Thorax; 56: 954-959.
Wilkinson TMA et al (2004) Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. American Journal ofRespiratory and Critical Care Medicine; 169: 1298-1303.