Patients with COPD often learn to cope with or “accommodate” their symptoms, which presents a challenge for nurses in terms of assessment and treatment.
Patients with COPD often learn to “accommodate” their symptoms, which makes it difficult for health professionals to assess the impact of the condition on their daily lives. This article explores the concept of accommodating COPD symptoms and gives advice to encourage optimal treatment.
Citation: Davies N (2012) Symptom “accommodation” in patients with COPD. Nursing Times [online]; 108: 34/35, 17-20.
Author: Nikki Davies is clinical manager and community respiratory nurse specialist, Croydon Respiratory Team
- This article has been double-blind peer reviewed
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Disease severity and quality of life can be poorly correlated. While some patients classed as having severe chronic obstructive pulmonary disease (COPD) may report having good quality of life, they may have learned to “accommodate” their symptoms and therefore do not feel the disease has made a significant impact on their everyday lives. On the other hand, those defined as having mild COPD may report having poor quality of life and feel the condition has taken over their lives.
Although spirometry is an important tool in managing COPD, the measurement of FEV1 should not be used in isolation, as it is not always linked to patients’ reported quality of life (Jones, 2001). Regular reassessment is a vital part of managing this disease; this article explores the impact that accommodating symptoms can have on patients’ condition and offers practical advice to encourage optimal treatment with the aim of improving quality of life and reducing hospital admissions.
The main symptoms of COPD include progressive breathlessness on exertion, chronic cough, regular sputum production, frequent episodes of “winter bronchitis” or “chest infections”, and wheeze. Many people have not heard of COPD and those who have the condition in the mild or early stage often dismiss symptoms as an inevitable sign of being unfit, or do not seek help for fear of being stigmatised (Healthcare Commission, 2006). By the time patients seek help, it is often because their breathlessness has become intolerable and has a major impact on their quality of life.
Early on in the disease pathway, breathlessness may only occur during strenuous exercise. As the disease progresses, exertional breathlessness can become so severe it becomes disabling, leading to further inactivity. Patients’ consequent inability to perform the simplest of daily tasks without exhaustion can lead to social isolation and depression (British Lung Foundation, 2007). However, avoiding exercise leads to physical deconditioning, which means that even simple household chores can precipitate breathlessness. As a result, patients choose to do less which, in turn, means they are able to do less. Eventually, even activities of daily living (such as washing or dressing) can cause severe symptoms, limiting what people can do in their everyday lives. This leads to their becoming more reliant on partners and families (Fletcher et al, 2011).
As the rate of COPD decline is slow, patients often accept and learn to accommodate their symptoms (for example, by walking more slowly and avoiding activities they know worsen their level of breathlessness); consequently, they accept their symptoms as a way of life. As a result, patients are often diagnosed much later in the disease progression as having “moderate” or “severe” disease.
The problem of people accommodating symptoms is not solely restricted to the diagnosis phase, but also presents a challenge for nurses in the continued management of those with COPD and in ensuring their treatment is optimised. The case study in Box 1 shows how practice nurse support helped a patient to quit smoking and pulmonary rehabilitation improved her COPD.
Tools for assessment
During consultations it can be difficult to assess whether a patient’s condition has deteriorated; simple questions such as “how do you feel?” or “are you feeling more breathless?” may be difficult for patients to put into context and answer due to the slow progressive decline of the disease.
Severity of disease and its impact can be measured using multidimensional tools that not only measure lung function, but also other parameters such as breathlessness. Two examples of such tools that are useful in primary care are given below.
Medical Research Council dyspnoea scale
The Medical Research Council dyspnoea scale is commonly used to measure breathlessness (Fletcher et al, 1959) (Table 1). It can provide a simple way to quantify the impact of breathlessness for patients with COPD as well as information on how much or how little they are able to do. Patients rate their level of breathlessness using a five-point scale, choosing the grade that represents their symptoms most closely; the higher the grade, the greater the limitations imposed by their disease. However, the use of the scale can be limited, due to the restricted choice between the grades.
COPD Assessment Test
The COPD Assessment Test (CAT) is a simple tool that patients complete to measure their health status in (www.catestonline.co.uk). It contains eight items, which cover cough, phlegm, chest tightness, exertion, level of activity at home, confidence, sleep and level of reported energy, and can provide a more holistic assessment of the impact of COPD on patients. Each scenario is marked 0-5, with the best having a low rating and the worst having a high rating. This provides a total score of 0-40; patients with a CAT score of >30 may need input from a respiratory specialist to optimise treatment and improve health outcomes (Jones et al, 2009).
Each individual statement can also provide information about patients that may need to be addressed further. The statements in the confidence scenario, “I am confident leaving my home despite my lung condition” or “I am not at all confident leaving my home because of my lung condition” could be used as an opportunity to explore any potential concerns, and referral to a member of the multidisciplinary team, such as a physiotherapist, psychologist or occupational therapist, could be made.
Encouraging patients to stop smoking is one of the most important aspects of managing COPD (National Institute for Health and Clinical Excellence, 2010). Although lost lung function cannot be restored, those who do give up smoking are likely to experience lung function deterioration at a slower rate (Fletcher et al, 1976). In addition, continuing to smoke can complicate further treatment such as oxygen therapy due to the potential dangers associated with smoking and oxygen use (Lacasse et al, 2006).
The British Thoracic Society and the Primary Care Respiratory Society clearly state oxygen should be used to treat hypoxia and not breathlessness (IMPRESS, 2010); health professionals need to be confident in reinforcing this message with their patients. Patients need to be properly assessed for long-term oxygen therapy, it must be appropriately prescribed and patients should be followed up.
Pulmonary rehabilitation is defined as a multidisciplinary programme of care for patients with chronic respiratory impairment; it is individually tailored and designed to optimise the individual’s physical and social performance (NICE, 2010). This intervention can produce significant improvements in exercise tolerance, activities of daily living and health status, and can subsequently reduce the number of days spent in hospital by patients admitted with an acute exacerbation of COPD (NICE, 2010). Pulmonary rehabilitation should be offered to all appropriate patients who consider themselves to be functionally disabled by COPD (MRC dyspnoea scale score of ≥3), including those who have recently been admitted to hospital for an exacerbation (NICE, 2010).
Treatment focuses on symptom control and reducing the frequency and severity of exacerbations. This is vital for managing exacerbations, breathlessness and resulting exercise limitation as these are the most distressing symptoms for many patients.
Despite the wealth of inhaled therapy available, many patients are on suboptimal treatment. NICE (2010) guidance contains an algorithm on using inhaled therapies that provides a guide to optimising treatment according to disease severity, especially in patients with persistent symptoms. However, as with all medication, its effectiveness needs to be assessed along with checking inhaler technique and concordance, not only to prevent waste and reduce costs, but also to allow patients to report whether the therapy has helped to relieve symptoms.
Box 1. Case study
Janice Woodward*, aged 56, is an office worker who lives with her husband. Mrs Woodward was diagnosed with moderate COPD two years ago after being admitted to hospital with a chest infection.
Before she was diagnosed, Mrs Woodward had become increasingly breathless and was no longer able to walk up a flight of stairs. She recalled being embarrassed when her breathlessness caused her to stop for breaks walking to meetings. She also felt guilty about taking time off work, as she had already taken sick leave on two or three occasions with chest infections.
Mrs Woodward had smoked on average 20 cigarettes a day for 35 years - equating to 35 pack years - and had been advised to stop smoking when she was diagnosed with COPD. However, the stress of her son’s divorce made it difficult for her to quit. As her symptoms progressed she knew she needed help and made an appointment to see her practice nurse. With the support of her husband and the nurse she succeeded in quitting.
The nurse also referred Mrs Woodward to a local pulmonary rehabilitation programme at the local gym. As well as increasing her exercise tolerance, Mrs Woodward felt it raised her confidence. After each class, she received information from health professionals on inhaler technique, chest clearance, relaxation and self-management tips, including how to recognise the early signs of a COPD exacerbation.
She was prescribed a “rescue pack” containing oral steroids and antibiotics, which she was advised to start if she became symptomatic - that is, if she was more breathless than usual, coughing up copious amounts of phlegm and her inhaled bronchodilator was ineffective in relieving the symptoms. Mrs Woodward was advised to keep the surgery informed about when she started the pack and continued to see the nurse for annual COPD reviews, which included spirometry, inhaler technique and assessing the effectiveness of her medication.
After completing pulmonary rehabilitation, Mrs Woodward now attends the gym for regular exercise and has joined the local Breathe Easy group (a UK-wide network of British Lung Foundation support groups). She now feels back in control and, as she no longer relies on her husband, their relationship has improved. She now looks forward to a healthy retirement.
*The case study is fictitious
Exacerbations of COPD are common and have serious implications. They are distressing and disruptive for patients, often under-reported and account for a significant proportion of the total NHS cost of caring for those with COPD (Healthcare Commission, 2006). Acute exacerbations of COPD are the second most common cause of emergency admissions and make up a total of one million hospital bed days each year in the UK (Department of Health, 2005).
Patients at risk of an exacerbation should be encouraged to be vigilant for symptoms and respond quickly by:
- Adjusting their bronchodilator therapy by increasing the frequency of short-acting bronchodilator as prescribed;
- Starting oral corticosteroids if their increased breathlessness interferes with activities of daily living (unless contraindicated);
- Starting oral antibiotics if sputum is purulent (NICE, 2010)
As with all medication, possible contraindications and further differential diagnoses need to be considered (DH, 2011). Patients should be assessed at the end of each exacerbation and referred for specialist advice if there is little or no improvement in symptoms.
When treatment is suboptimal, it can lead to exacerbations and hospital admission, which can result in further deterioration (NICE, 2010). Nurses can be proactive in regularly re-evaluating their patients to assess whether they are still breathless or receiving suboptimal treatment by using tools in their consultations.
- Patients’ coping with the limitations of COPD can make identifying the optimal time to intervene difficult
- Practitioners need to be proactive in encouraging patients to discuss symptoms, as early identification can slow the decline of lung function
- Optimal COPD management can improve quality of life, reduce likelihood of exacerbations and keep patients out of hospital
- Practitioners can use assessment tools in consultation to assess a patient’s breathlessness and disease severity
- Encouraging patients to stop smoking is vital in managing COPD
British Lung Foundation (2007) Invisible Lives: Chronic Obstructive Pulmonary Disease (COPD): Finding the Missing Millions. London: BLF.
Department of Health (2011) An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England. London: DH.
Department of Health (2005) On the State of the Public Health: Annual Report of the Chief Medical Officer 2004. DH.
Fletcher M et al (2011) COPD Uncovered: The New Workplace Epidemic.
Fletcher CM (1976) An 8-year follow-up of FEV and respiratory symptoms in middle aged men (proceedings). Scandinavian Journal of Respiratory Disease; 57: 6, 318-321.
Fletcher CM et al (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal; 2: 257-266.
Healthcare Commission (2006) Clearing the Air: A National Study of Chronic Obstructive Pulmonary Disease. London: Commission for Healthcare Audit and Inspection.
IMPRESS (2010) More for Less. British Thoracic Society & Primary Care Respiratory Society.
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Jones PW et al (2009) The COPD Assessment Test: Expert Guidance on Frequently Asked Questions. Healthcare Professional User Guide.
Lacasse Y et al (2006) Got a match? Home oxygen in current smokers. Thorax; 61: 5, 374-375.
National Institute for Health and Clinical Excellence (2010) Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care (Partial Update). London: NICE.