Chronic obstructive pulmonary disease (COPD)

Answer

1. • Chronic Obstructive Pulmonary Disease

     Opening Statement

     Chronic Obstructive Pulmonary Disease (COPD) is a lung disease that causes an inadequate flow of air. Its main symptoms include loss of breath, sputum, and cough. The condition is caused by tobacco smoking and worsens with time. Prolonged exposure to smoke narrows air passages, and wears lung tissues, and can only be diagnosed through medical tests. In case the patient is a smoker, he or she should stop smoking to avoid further destruction of the lungs. This paper aims to establish the efficiency of self-management programs at home and at a rehabilitation center in managing COPD and propose alternative measures to improve patients’ quality of life.

     Introduction

     Chronic obstructive pulmonary disease, abbreviated as COPD, is a lung disease characterized by inflammation of air passage responsible for air transportation to and from the lungs, thickening them. It is characterized by coughing, production of sputum, shortness of breath, and wheezing. The wheezing sound is produced due to breathing difficulties caused by increased production of sticky mucus, which tightens the bronchiole muscles. This situation leads to swelling of muscle linings; thus, reducing the airway (Hansson, 2019). The bronchiole's swelling makes them sensitive to irritation and susceptible to an allergen, irritants, and other triggers.

     Chronic Obstructive Pulmonary Disease Symptoms

     COPD symptoms can be confused with asthma. For any symptom, it is recommendable for a patient to visit a doctor to rule out the condition and medicate appropriately. The disease reduces lung function, and with time, the situation deteriorates with age. It is not fully reversible, but it is manageable through regular checkups and following the treatment plan (Ng & Smith, 2017). Most important in the management of COPD is abstaining from tobacco smoking, which is the number one cause

     Emphysema and chronic bronchitis commonly contribute to COPD. Emphysema damages the lungs' air sacs, making air passage to the lungs difficult, which causes shortness of breath. As a result, the lungs do not get a sufficient oxygen supply and inhibit exhalation of the carbon dioxide produced in the lungs, which is dangerous. Chronic bronchitis is the swelling of the bronchial tubes responsible for air transportation to the lungs from the air sacs (Singh, Sagar & Varadharajulu, 2020). The swelling of the bronchial tubes leads to increased mucus production in the lungs, which makes the person to experience irritations in an attempt to clear the airway. They react by coughing; the cough produces mucus, referred to as sputum.

     COPD disease affects and limits the airflow in and out of the lungs, but, in most instances, it is preventable and manageable (Pedersen, Ersgard, Soerensen, & Larsen, 2017). The progression of COPD symptoms is often gradual and can become a life-changing over time. The occurrence of COPD is a life-threatening disease process that, over time, worsens from symptoms of breathlessness to shortness of breath, predisposes patients to chronic exacerbations and serious illnesses. The most common cause of COPD is related to long-term exposure to tobacco smoke. However, exposure to hazardous air pollutants at the workplace and at home can also increase COPD incidence (Centers for Disease Control and Prevention, 2017).

     Significance of Topic

     COPD is typical from the age of 40 and increases with age. There are roughly fifteen million people across the United States living with a COPD diagnosis, and more than 140,000 people die of the disease every year. Worldwide, one in every ten people have been diagnosed with COPD (Shah et al., 2016). The chronic obstructive pulmonary disease has now been deemed the third leading cause of death in the United States (Pruitt, 2018). Annual costs associated with the diagnosis and treatment of COPD is roughly thirty billion dollars. Over thirteen billion dollars is spent annually due to hospitalization costs related to COPD exacerbation (Pruitt, 2018). COPD accounts for over seven hundred hospitalizations in the United States, one and a half million emergency room visits, and over ten million physician office visits (Lau, Siracuse & Chamberlain, 2017). Twenty percent of patients hospitalized with a COPD diagnosis will experience readmission within thirty days of discharge.

     The main predisposing factor for COPD is long-term cigarette smoking. Family history of chronic asthma, childhood bronchiolitis, premature birth, and mostly where ventilator support was required during birth and low birth weight resulting from restricted growth in the womb (Yang et al., 2018). Exposure to fumes, dust, and chemicals, especially for people who work in manufacturing industries also exposes them to COPD.

     COPD presents one of the issues that increase hospital readmission. The Hospital Readmissions Reduction Program (HRRP) initially focused on decreasing hospital readmissions related to only congestive heart failure (CHF), acute myocardial infarction (MI), and pneumonia (Lau et al., 2017). In 2015, The Centers for Medicare and Medicaid Services (CMS) added COPD diagnosis to the list of conditions that risk being penalized for excessive readmissions (Goldberg, 2015). Initially, the penalty for excessive hospital readmissions was at 1%. However, by 2015 the CMS raised the penalty to 3% (Lau et al., 2017). In 2015, 2,217 hospitals received penalties for reimbursement of Medicare funds of $280 million.

     Acute exacerbations of COPD represent a significant burden for patients and hospitals worldwide (Pedersen et al., 2017). One in five COPD patients are likely to experience preventable readmission within thirty days of discharge; therefore, it has become imperative for facilities to devise plans to change these statistics. Patients are often found to lack proper follow up as well as non-compliance with medications after hospital discharge. Other factors thought to contribute to the incidence of thirty-day readmission include premature discharge, lack of proper medication reconciliation before discharge, lack of appropriate patient and family teaching, and lack of communication with the patient’s primary care physician who will be providing follow up care (Shah et al., 2016).

     Literature Review

     Chronic Obstructive Pulmonary Disease is a progressive and incurable disease, which results in an increased decline in physical activity and difficulty breathing. Various drugs can reduce symptoms of COPD, but no treatment can restore pulmonary function to a patient. Evidence-based approaches for managing COPD include pulmonary rehabilitation and self-management programs. The latter includes computer technology for educating patients about the disease and how to manage it. This section reviews previous studies on how various interventions delay progression and improve COPD patients' quality of life.

     Technology

     Difficulty breathing, also referred to as dyspnea, is a critical factor that limits patients with COPD. Patients experiencing acute COPD exacerbation usually visit the emergency room or be admitted to the hospital. An effective program to assist patients in managing symptoms after discharge is critical in reducing readmission in thirty days, delaying COPD progression, and improving quality of life. Patients who are given discharge instructions on managing COPD usually lose motivation to follow instructions due to lack of support at home. Liu et al. (2013) examined the effects of an animated diagram and video-based online breathing program for patients with COPD. The program allowed patients to contact a nurse and family members who were always available online so patients could communicate and exchange information. Patients who receive conventional education before discharge from the hospital are usually not motivated to follow through with physical exercises and other interventions due to lack of motivation and supervision. This online program allowed patients to interact with healthcare professionals who could also access and review patient information, and accordingly offer feedback. The online training program significantly increased pulmonary function, exercise tolerance, and quality of life for COPD patients.

     Home-based educational programs that utilize technology can also enhance learning for patients in the home and support monitoring symptoms and taking medications. According to Mathar, Fastholm, and Sandholm (2015), easy access to healthcare professionals can help create a sense of control in managing COPD. Televideo consultation used in this study comprised of eight 30 minute televideo consultations over two weeks and was conducted by a trained community nurse and physiotherapist. Mathar et al. (2015) indicated that patients were satisfied with the immediate access to professional help and knowledge and increased their sense of security to manage COPD.

     Self-Management

     Self-Management programs, whether with or without technology, focuses primarily on action plans to reduce exacerbation and readmissions. Self-management programs are supported by the Chronic Care Model of disease management to minimize the impact of chronic disease (Nici, L., Bontly, T., ZuWallack, R., and Gross, N., 2014). Johnson-Warrington, Rees, Gelder, Morgan, and Singh (2016) investigated a Self-Management Program of Activity, Coping, and Education (SPACE) on patients recently discharged from the hospital. The SPACE program includes practical advice, a home-based exercise program, and an exacerbation action plan to support day to day activities and promote positive behavior changes. Patients were given a survey that revealed that patients receiving the intervention reported feeling better at coping with COPD (Nici et al., 2014). The study proved that the SPACE program improved clinical and health care utilization outcomes for COPD patients. Self-Management programs such as SPACE require behavioral changes to address physical exercise, a healthy diet, and smoking cessation. Cigarette smoking is the leading cause of COPD, and is considered an effective intervention to improve quality of life and prevent COPD progression.

     Thabene and COPD Working Group (2012) conducted an evidence-based analysis to determine the effectiveness and cost-effectiveness of smoking cessation interventions in COPD management. In this study, interventions were grouped as usual care, minimal counseling <90 minutes, intensive counseling >90 minutes without pharmacotherapy, and intensive counseling with pharmacotherapy (Thabene and COPD working Group, 2012). Study results indicated that abstinence rates are significantly higher in COPD patients receiving intensive counseling or a combination of intensive counseling and nicotine replacement therapy, and abstinence rates are significantly higher in COPD patients receiving NRT than the placebo.

     Self-management of COPD is a day-to-day performance necessary to control or minimize the disease's impact. Social Cognitive Theory is used in the study by Brandt (2013) to address patient recognition and response to COPD exacerbation. The social cognitive theory constructs self-regulation in this qualitative study in which patients were interviewed on COPD management of exacerbations. The questions were based on self-observation, self-judgment, and self-reaction. The result of this study indicated that self-regulation was necessary to develop teaching plans for patients, which reflect the self-regulation process and self-management strategies (Brandt, 2013). Teaching patients to recognize symptoms will increase self-observation and self-judgment when managing COPD. The teaching plan should address dyspnea triggers, avoid them, breathing techniques, and correct inhaler use. Brandt (2013) study addresses patient experience for the management of exacerbation and self-reaction.

     Pulmonary Rehabilitation

     Another way patients can manage exacerbations is through pulmonary rehabilitation. Pulmonary rehabilitation effectively reduces breathlessness, improves exercise capacity, and reduces healthcare utilization (Corhay, Dang, van Cauwenberge, & Louis, 2014). Jacome and Marques (2016) investigated PR's short and long-term effects in patients with mild COPD and compared it with patients receiving PR with moderate to severe COPD. The results showed improvements in physical activity, chest press, and knee extension, which resulted in a decrease in exacerbations for both groups (Jacome and Marques, 2016). There was no difference in outcome for both groups at three, six, and nine months. This study suggests PR could manage mild COPD as benefits were maintained at the nine-month follow-up. PR is one of the components in the management of mild, moderate, and severe COPD

     Problem Solution and Management

     Management of stable COPD must be defined by step by step increment in treatment. Health education is vital in enhancing skills and capability to cope with this condition. It helps in achieving particular goals, for example, smoking cessation (Yang et al., 2020). Since none of the medications fully cure this disease, they only function to stop its progression and minimize symptoms and complications. Bronchodilator drugs are essential in COPD’s symptomatic management, and are prescribed regularly to minimize symptoms.

     Foremost, smoking cessation is among the effectual ways of slowing the decline in lung functioning in patients cumbered with COPD (Bourbeau et al., 2018). This involves eliminating risk factors, which is considered the highest priority within the management of this disease, particularly in various severities. In particular, in the view of a multidisciplinary COPD clinic located at ST. Paul’s hospital, smoking cessation, is confirmed to have addressed 76.2 percent of issues compared with 57.5 percent within the general respiratory clinic settings. This is a successful way of helping patients, while addressing the addiction, accompanied by drug therapy.

     Secondly, pulmonary rehabilitation is also considered a structured and multidisciplinary intervention where patients with chronic pulmonary diseases are shown how to improve their body fitness, improve the health-linked livelihood’s quality, and reduce dyspnoea (Maddocks et al., 2016). Indeed, pulmonary rehabilitation in connection to self-management and education has been confirmed to emanate from a substantial hospital admissions reduction. The current randomized and controlled attempt by COPD personal management program has included exercise and clinical means of reducing this malady's impacts.

     Third, the inhaled bronchodilators are also used as an alternative for symptomatic management within stable COPD, both through the use of an as-needed course or regular treatment (Horita et al., 2017). There is recently confirmatory information indicating that bronchodilators anticholinergic and agonists have improved compliance, and are more efficacious compared to their shorter-acting equivalents. Apart from the inhaled corticosteroids having no impact in declining FEV1, they have been witnessed to minimize the exacerbation rate in patients who are moderate to severe COPD, and there is some authentication for their function in reducing total mortality. The enduring cumbered with challenges while mastering the inhaler method through metered-dose inhaler is advised to use a spacer contained with a device. Otherwise, diverse forms of inhalers and spacer devices must be experimented with during an attempt to determine whether the patient can efficiently and effectively use it. 

     Moreover, rescue medications are also applied during COPD exacerbation, and it is viewed as the most feasible discussion for overuse. At the time of exacerbation, an average of a single additional puff during daytime, and half during the night is experienced two weeks before and after an exacerbation, not considering the COPD stage. Otherwise, changes in rescue medication intake are considered to correlate with exacerbations poorly. At this juncture, during application of plus long‐acting beta‐agonist (LABA), ICS has been linked with significant minimization on average puffs per day during short long‐acting beta‐agonist (SABA), which significantly heightens the percentage of nights without the need of awakening SABA as well as placebo, and an essential distinction in the median portion of days without application of relief treatment (Horita et al., 2017).

     Pulmonary rehabilitation has emerged as an evidence-based medication for patients with severe pulmonary disease (COPD). Otherwise, vast numbers of patients suffering from mild to moderate COPD obtain medication from general practitioners (GPs) (Maddocks et al., 2016). To motivate compliance, patients' suggestion in general practice needs to be clear, acceptable, and practical. Indeed, this is particularly factual of the advice that is provided by GPs to heighten their patient’s physical conditions through cycling, walking, or swimming. This starts by conducting a literature search on the implications of physical activity for the patients cumbered with mild to sensible COPD on tolerating exercising, quality of life (QOL), and dyspnea.

     Furthermore, de-conditioned patients require taking extra breaths while carrying out simple activities, and this is a specific problematic for patients with minimized lung functionality. As a result, inactive patients shall encounter more symptoms while occasionally engaging in exercise. As a result of this unpleasant nature of the dyspnea and fatigue, enduring shall attempt, thus avoiding them to become even less active. Generally, this vicious circle seems devastating to patients and leads to a relentless reduction in health-linked quality of life.

     Recommendation

     Various recommendations can be made from this study. To begin with, individuals should be supplied with relevant information regularly. This is because the findings indicate that persons who had been educated on the COPD topic were more aware of the disease and can, therefore, develop the necessary remedial actions. Through the availability of information, individuals can also identify the ailments at an early stage and, therefore, seek medical attention before they reach severe levels.

     More effort should also be placed on encouraging individuals with smoking habits to cease before their health undergoes massive deterioration. Research indicated that the number of smokers suffering from chronic respiratory ailments is significantly higher than that of individuals who do not smoke. An increase in centers providing rehabilitation facilitation would also improve the management of such illnesses. Therefore, it increases the quality of health among individuals. The attainment of results will also require the right process in selecting patients to be interviewed to ensure reliability of the information obtained.

     Implementation Report

     The implementation plan will focus on educating patients and respiratory care teams on self-management programs. There will be ongoing routine educational meetings, assessment, and competency sections. Moreover, there will be a complete revision and modification of the current policy and procedure guidelines and establishing new protocols if necessary. The implementation plan will include:

     • Identifying patients at risk of developing COPD.
     • Preventing COPD before it is thoroughly established.
     • Protecting the affected lung using lung protection means.
     • Educating patients on appropriate behavior changes for managing COPD

     It is important that all members of the respiratory care team understand the new policies and protocols. Moreover, to avoid and reduce possible resistance to changes, it is essential that those members fully understand the reason for the change and have a complete understanding of the improved outcomes associated with these changes.

     All newly admitted patients should be screened for COPD risk factors. Patients with COPD predisposing factors should be treated according to the disease’s prevention guidelines. This plan should be initiated once policies, procedures, and protocols are reviewed, modified, and approved by the medical director. Program outcomes should be closely monitored by the head of the respiratory care department.

     To determine the practicality of the implemented plan, and to optimize the health care quality, the head of the respiratory care department should be aware of the following:

     • The number of patients screened for COPD risk factors.
     • The number of patients with COPD risk factors.
     • The number of patients treated with COPD preventive means.
     • The number of patients diagnosed with COPD.