Chronic obstructive pulmonary disease (COPD)

The BTS describes COPD as a chronic, slowly progressive disorder with airflow obstruction that does not return to normal with treatment. The patient will have a history of cough and/or wheeze, fatigue and/or breathlessness. This results in the loss of support for the airways and early closure on expiration (Fehrenbach, 2002). Most COPD patients have a history of cigarette smoking of at least 20 pack-years (one pack year = one pack of 20 per day for one year (Brewin, 1997).

Current research has revealed that inflammation plays a significant role in the COPD disease process. The premise that tobacco smoking is a major cause for lung disease is well documented as per literature reviewed by the author. However, it is not the only significant cause of COPD as not only smokers develop COPD (Mackay, 1996). Other causes include occupational exposure, air pollution and genetic factors. As can be seen from the definitions above, whatever descriptive title is used the condition is associated with a progressive reduction of airflow in the lungs. COPD is an encompassing term that includes emphysema, chronic bronchitis and airflow limitation. The disease is slowly progressive and is characterised by airflow obstruction manifested by reduced pulmonary function that does not change markedly over several months (Margereson, Heslop, Esmond, & Dunn, 1997)). Lung function impairment is fixed in patients with COPD, although some impairment can be reversed using bronchodilators or other forms of treatment (BTS 1997). The spirometry test is gold standard to measure lung volumes. As pulmonary function deteriorates the lungs’ vital capacity (FVC) and forced expiratory volume per second (FEV1)decreases.

All patients with COPD suffer from some degree of airflow obstruction; further more the obstruction is largely irreversible. Most patients with COPD are smokers (Petty, (1999). Tobacco smoking generally underlies the development of COPD. Passive inhalation of cigarette smoke, air pollution, and occupational exposure to known lung irritants and also initiate small airway damage.

From the afore going descriptions is it evident that COPD does meet the criteria of a chronic illness, namely, it is long term by nature (permanency); has uncertainty; has residual and irreversible damage on lungs; has a profound effect on lifestyle; it is multiple disease, expensive and requires ancillary services. This will be show in the case of George below.

George is a 70-year old gentleman with a long history of severe COPD . He has been admitted from the accident and emergency (A&E) department with yet another acute infective exacerbation of his COPD. The patient’s baseline pulmonary disease is important in the severity assessment of the current exacerbation (Trudea, 1999). This information on George was supplied by his daughter and also by medical records retrieval.  He has been getting increasingly short of breath over the last few days with a cough productive of purulent green sputum. He can only walk a few yards now and is short of breath on minimal exertion. The progressive course of COPD is often associated with increased frequency of acute exacerbation. The most common causes of an exacerbation are tracheobronchial tree infection and environmental factors, such as air pollution and temperature. Bacterial infections are also commonly associated to play a significant role due to increased production and purulence of sputum. However, Chojnowski (2003) disputed this and puts forward the notion that these are due to viral infections or non-infectious.

On examination, George was cyanosed breathing room air, barely able to complete his sentences. His arterial oxygen saturation, by pulse oximeter, of 86% was indicative of someone experiencing acute respiratory failure. Shortness of breath is one of the most common reasons patients seek help from health professionals (GOLD 2001).  George also had other signs of the condition – has respiratory rate of 36 with prolonged expiration, and pursed lip breathing; using his accessory muscles of respiration, wheeze, inability to lie flat, and tachycardia (Bennett, 2000). Realising that George could deteriorate quickly, the nurse immediately notified the doctor of our findings. The doctor prescribed supplementary oxygen to improve George’s oxygen saturation, ordered pulmonary function tests, chest X-ray and ECG. The arterial blood gases (ABG) were meant to give a more accurate oxygenation status.  The pulmonary examination will evaluate the respiratory pattern, accessory muscle use, evidence of paradoxical chest wall motion and adventitious breath sounds. The cardiovascular examination will note any presence of central cyanosis, peripheral oedema and haemodynamic instability such as hypotension, tachycardia or arrhythmias. Management of the hospitalised patient should initially include providing controlled oxygen therapy and prompt determination if the situation is life threatening, requiring monitoring. Oxygen therapy is the basis for hospital treatment of COPD exacerbations and the goal is adequate levels of oxygenation achieving an oxygen partial pressure, PaO2>60mmHg or SaO2>90% in uncomplicated exacerbation (Chojnowski, 2003).  

The first priority intervention by the nurse is to ensure that the patient experiencing a respiratory failure is seen by a doctor as soon as possible (Alexander et al 2000). As George is agitated and constantly striving for breath the respiratory nurse was constantly giving him and his daughter support and reassurance. that the nurse’s immediate goals were to restore oxygenation. Maintaining  the head of George’s bed at 45° to helped to enlarge the thoracic space and assist in breathing.

George’s oxygen saturation level, 84%,  led us to suspect that he is experiencing acute respiratory failure. He has other signs of the condition – a respiratory rate greater than 35 per minute, use of accessory muscles to breathe, inability to lie flat, tachycardia. Realising that, like any patient with an airway emergency, George could deteriorate quickly the staff nurse immediately notified the doctor of my findings. The SHO ordered 24% oxygen by face mask to improve the patient’s oxygen saturation, pulmonary function tests, chest X-ray and ECG.  He ordered for arterial blood gases (ABGs), to determine a more accurate oxygenation status of the patient. The nurses’ immediate goal was to restore adequate oxygenation. The respiratory therapist administered a beta2 agonist, albuterol therapy by nebuliser to reverse bronchospasm. There was no improvement in George’s oxygen status and an anti-cholinergic bronchodilator (ipratropium bromide) was nebulised. In accordance with the BTS, 1997 guidelines, this acts by blocking the vagal stimulus to the bronchi, thus reducing muscle constriction and mucus production. As noted by Combivent (cited in Brewin, 1997), this practice of combining the stimulating effect of the beta2 stimulant with the blocking effect of anti-cholinergic drugs, has been found to be very effective in COPD   As oxygen therapy was being administered we continuously monitored the pulse oximeter to achieve an arterial saturation level of greater than 90%. (Chojnowski, 2003). An arterial blood gas was being constantly checked every 30 minutes of the oxygen therapy to assess for carbon dioxide retention. Antibiotics were prescribed and given to George as a prophylactic measure .Expectorants were also prescribed for mucous clearance.

Referrals were done to other healthcare professionals for George’s pulmonary rehabilitation comprising a combination of exercise and education. The physiotherapist was required to teach breathing exercises and optimise breathing, thereby arresting the downward spiral of breathlessness. The progressive course of COPD is often associated frequency of acute exacerbations. Prior to his admission George was having the services of a home help. George was persuaded to go and live with his daughter but he refused moving out his house to any alternative accommodation. Adjustment and social behaviour are important dimensions of social health and key indicators of life quality. Leidy (1996) asserts that  successful adjustment is defined by a sense of intrapersonal well-being in concert with a harmonious relationship with the environment, a balance between personal needs and environment demands. On the basis of this definition it is evident therefore George’s adjustment to his condition has bee negative as illustrated by his isolation, lack of intrapersonal growth, poor self upkeep and non-conformity to societal expectation and social roles His daughter raised concerns about her father’s deterioration in personal hygiene, eating habits- he has been losing weight and maintenance of his safe environment. George has been referred to the social welfare affairs in the hospital for them to arrange upgrading his care package to include provision of meals-on-wheels, a carer three times a day. The Occupational therapist an assessed George’s living conditions in his home with a view to making it one appropriate to his medical  condition.

A successful rehabilitation programme incorporates many of the skills of offered by the multi-disciplinary team (MDT), with accurate needs identification and agreed goals. A multidisciplinary approach to pulmonary rehabilitation is essential if a holistic approach is to be achieved using a range of expertise. Team members who contributed in the process included nursing and medical staff, physiotherapists, occupational therapists, social workers and dieticians. Effective communication skills, which aides to build rapport is instrumental in helping a nurse to determine what the patient is thinking and feeling about the situation and what their hopes and aspirations in learning to live with a chronic condition (Dluhy, 1995). The intention of the rehabilitative programme is to enhance self-esteem and self-confidence and to promote a sense of mastery over the situation.

According to Levin (2002) the initial functional ability of the patient provides the MDT with a basis for charting progress or deterioration enabling flexibility in care planning. Failure to progress may require an alternative approach or the reassessment of circumstances, or of a previously undetected problem. Other aspects such as mental acuity and depression will affect the outcome of rehabilitation. Social support is also a key factor in a person’s ability to cope with a stressful situation. Emotional support is most received from family and friends. This social support engenders a positive effect on physical and mental health. Rehabilitation staff need knowledge of how different interventions affect an individual’s well being so as to be able to draw up clear strategies for supporting patients and their relatives in everyday life. High quality rehabilitation presupposes close co-operation between health-care professionals and their patients and their families (Margereson et al, 1997).

The regular update of a patient’s functional ability by individual members of the MDT combined with MDT meetings ensures that the set goals are achieved. Focus on functional ability takes cognisance of the fact that although the disease process and prognosis are addressed, the emphasis is to assess the effects of the condition on daily living activities, the extent to which they might be limited by the condition. The goals that are then set and the interventions adopted are aimed towards enhancing the ability to live with the condition in a way that enables people a quality of life.  On the ward of clinical placement this was accomplished through the adherence to the BTS guidelines on COPD. Goals are set in consultation with the patient, with the immediate family and professionals involved in care. Contributions from all members of the MDT and any evidence of progress is both encouraging and stimulates motivation to realize other milestones in this rehabilitative process. Adaptation correlates with effective coping strategies. Problem focused strategies involve the individual in eliciting information and help them to make choices and also to ensure that the care planned reflects the most appropriate help for them (Alexander, Fawcett and Runciman, 2000).

Chronic obstructive pulmonary disease patients experience a myriad of symptoms. George is experiencing shortness of breath coupled with fatigue. One of the most distressing and prevalent symptoms of COPD is fatigue (Woo, 2000). The daughter informed the nurses that  as a result of the fatigue, George’s quality of life  in terms of physical, psychological and social functioning has been adversely affected. Margereson, Heslop, Esmond and Dunn (1997) argued that there exists a relationship between dyspnoea and fatigue. Since dyspnoea  has shown to be precipitated by various physical activities. COPD by definition is progressive in nature. This means that there is decreased pulmonary function due to progressive destruction of alveolar structure and inadequate alveolar gas exchange (Elkin et al). Consequently the poor oxygenation of locomotive muscles and impaired muscular energy producing  mechanism resulting from compromised pulmonary function predisposes COPD patients to fatigue. To avoid the distressing sensations of dyspnoea and other symptoms, the COPD patients reduce their physical activities. Edwards (1981) cited in Woo, 2000 attributes reduced muscle strength  and endurance to inactivity as a factor that may lead to fatigue with activity. This illustrates the importance of the nurse to have a wide base of knowledge over and above that of the particular clinical event at hand. In the care of George the MDT manage to link their respective knowledge to formulate an appropriate care plan for him.

The symptoms of COPD often impose serious limitation on the patient’s usual daily activities and as a disease increases in severity it takes away his ability to live independently (ref). Shortness of breath is one of the most common reasons  patients seek help from health professionals (GOLD 2001).  Tuck and Human (1998) (cited in Aylett and Fawcett, 2003) describe patients likening their existence to being held hostage to the illness as COPD causes them to miss out on so much of life. Hodges (2001) asserts that although the pathophysiology of chronic illness is increasingly understood, few studies explore the experience of living with chronicity from the patient and family’s perspectives. The symptoms of COPD  often impose serious limitations on the patient’s usual daily activities and as a disease increases in severity it takes away his ability to live independently (ref). Shortness of breath is one of the most common reasons  patients seek help from health professionals (GOLD 2001).   Understanding and intervening appropriately for the individual with chronic illness may contribute significantly to improving quality of life for this growing population (ref).Chronic health problems are not fixable with shiny new technology and do not promise the suspense, exhilarating hope and dramatic ending that acute medical crises often do (ref). They simply continue day after day, often invisible or misunderstood (Gullickson, 1993).Isolation, despair, frustration, fear, hope and change are all part of the unseen personal experience of long term illness for those with such conditions.  A study done by Hodges (2001) revealed nine distinct themes of experiences relating to chronic illness, namely, role change, sadness, isolation, decreased communication, adaptation, acceptance of self, fear, need for support and hope. According to information provided by George’s daughter it is evident that he expresses negative experience in social isolation, diminished communication with former social circles resulting in feelings of separation and distance. Social isolation occurs because of circumstances imposed on them individuals are unable to participate fully or meaningfully in social relationships (Somerson, Husted, & Somerson, 1996). For physical  or emotional reasons the individual is unable to make the contacts necessary for interpersonal involvement (Carpenito, 2000).

The nursing care provided to George is evidently evidence-based as members of the multidisciplinary team gave holistic care and correctly identified the common clinical presentation for COPD. They subsequently took the correct measures to save George’s life and resolved the critical life threatening events. Tests were adequately undertaken to examine the patient’s baseline pulmonary status to determine the severity of the current exacerbation. His information was obtained by interviewing his daughter along with medical records retrieval. This goes to show the importance of family and significant others in the holistic provision of quality patient care. Diagnostic studies were carried out to help the healthcare personnel to make informed and evidence-based decisions in the management of the acute exacerbation of COPD.

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