COPD: the role of the nurse

Nurses have a key role in the prevention and treatment of chronic obstructive pulmonary disease (COPD) in primary care to enable patients to adjust to their condition and be proactive in their management. This article is aimed at helping nurses to update their knowledge in COPD and the role that they have to play in advising and supporting patients living with this condition.

Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory diseases seen in primary care. Since the publication of the COPD guidelines by NICE (2004) and the implementation of the General Medical Service (GMS) contract in April 2004 within primary care, the profile of care and management for patients with COPD has increased. The implications for those suffering with COPD have an enormous impact, not just with regards to the individuals themselves in terms of affecting their quality of life and life style, but also places an immense burden on the health service within secondary and primary care. Within the United Kingdom there are 900,000 diagnosed cases of COPD (Soriano et al., 2000), with half as many again estimated that have not been diagnosed, living with COPD (NCCCC, 2004). By 2020, COPD is projected to increase and become the third leading cause of death and the fifth leading cause of morbidity, whereas other chronic disease are likely to decrease over this period (Bellamy & Booker, 2004). Although COPD is not curable, there is much that nurse's can implement within their daily clinical practice to influence patient care and to prevent the progression of this disease.

What is COPD?
COPD is a disease that is characterised by airflow obstruction, which is usually progressive, not fully reversible and does not change markedly over several months (NCCCC, 2004). The term COPD encompasses a number of different disease processes, which result in airflow obstruction due to a combination of damage to the airways and lung tissue. These include chronic bronchitis, emphysema and chronic asthma (Figure 1). The composition and overlap of these disease processes will vary between individuals.

Clinical symptoms
COPD is predominantly caused by smoking and may present in patients after the age of 35 years (NCCCC, 2004). The symptoms include:

- Breathlessness on exertion.

- Chronic cough.

- Regular production sputum.

- Wheeze.

- Frequent winter 'chest infections' or 'bronchitis'.

COPD is a slow progressive disease usually following many years of smoking, although other risk factors may also be responsible (Table 1). COPD is rare in someone who has never smoked or has been a light smoker. However, there are some smokers that are not at risk, for reasons that are not fully understood, but may relate to an individuals genetic

Figure 1: Diagrammatic representation of the three conditions that comprise COPD.

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make-up (Chen, 1999). Due to the slow insidious nature of the disease many patients with COPD are not diagnosed until their disease is fairly advanced with a loss of at least 50 per cent of their predicted lung function (Fletcher & Peto, 1977). The symptoms of breathlessness on exertion in the early stages slowly increase over time and as a result the patient adapts unconsciously to their symptoms and relates their slowing down to their age or being unfit. Most smokers accept the symptoms of a chronic cough, sputum production and breathlessness as the normal consequence of smoking and may not appreciate that they are developing COPD. As the disease and the severity of airflow obstruction progresses the symptoms of the disease increase, which eventually prompts patients to visit their General Practitioner (GP).

To make an accurate diagnosis of COPD spirometry is performed (Figure 2) to identify airflow obstruction and differentiate obstructive and restrictive problems. The disease is categorised as mild, moderate or severe, depending on the forced expiratory volume in one second (FEV1) (Table 2). Peak flow measurements, although very useful in asthma, do not measure airflow through small airways and cannot distinguish between different patterns of airflow (McAllister, 2002a). Other differentiating diagnosis should always be born in mind as smokers are also at risk of developing other causes of breathlessness such as lung cancer and cardiovascular disease.

Treatment
Unfortunately, there are no miracle cures for COPD. The damage caused by smoking to the lungs can not be repaired. However, along with smoking cessation and appropriate drug therapy the progression of the disease and further complications can be prevented. Detailed, evidence-based recommendations are provided in the NICE guideline on the treatment and management of COPD (NCCCC, 2004). The aims of treatment available are to:

- Ensure patients are on appropriate therapy.
- Provide relief of symptoms.
- Reduce frequency of exacerbations.
- Improve quality of life and daily activities of living.
- Prevent further disease progression.

Bronchodilators: Pharmacological treatments include bronchodilators, which are the cornerstone of management, and help relieve breathlessness and increase exercise tolerance by reducing air-trapping and improving the efficiency of respiratory muscles to help improve overall symptom control.

There are three classes of bronchodilator used in COPD:

- Beta2-agonists – short and long acting.
- Anticholinergic – short and long acting.
- Theophyllines.

A combination of these drugs can be effective in controlling individual patient's symptoms. It is important to assess the effectiveness of the medication from both an objective perspective (lung function) and in terms of symptomatic improvement by asking the following questions (Jones, 2001):

- Is your breathing easier in any way?
- Has the treatment made any difference to your symptoms?
- Are you able to do some activities now that you could not do before, or do the same things without having to stop?
- Are you less breathless doing some things or notice that you recover a little quicker than before?
- Has your sleep improved (if experiencing problems previously)?

Individual patients respond differently and therefore should be determined by giving a trial of the drug for at least a month and the effects evaluated. Any improvement noticed symptomatically indicates the drug should be continued.

Corticosteroids: Although inflammation is present in the airways of patients with COPD, it differs from asthmatic inflammation and the response to corticosteroids are different (Barnes, 2000). There is little evidence to suggest that corticosteroids have any place in mild COPD. However, there is evidence to suggest that patients with moderate to severe COPD – defined as FEV1 less than 50 per cent predicted – that corticosteroids may provide benefits in terms of reducing frequency of exacerbations and reduce the rate of decline of health-related quality of life (Burge et al., 2000). NICE (2004) recommend those patients with a FEV1 less than 50 per cent
predicted and experience two or more exacerbations, requiring treatment with oral steroids or antibiotics over a 12-month period should be prescribed a

Figure 2: Nurse performing spirometery.

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steroid inhaler, generally combined with a long-acting bronchodilator.

Oral corticosteroids are not recommended for long-term use as the risk of side effects outweighs the benefits. However, some patients with severe COPD needing frequent short courses may relapse as soon as the corticosteroids are withdrawn and may therefore benefit from a maintenance dose of oral corticosteroids. The dose should be kept as low as possible and patients monitored for osteoporosis (NCCCC, 2004).

Mucolytics: Many patients with COPD experience a chronic cough and produce sputum. Mucolytics such as carbocisteine and mecysteine, are drugs that thin secretions making it easier to expectorate.

Inhaler devices: Hand-held inhaler devices if used correctly are very effective and convenient method of treatment. It is vital that patients are taught correctly how to use their inhalers by a competent health professional and that the patient's inhaler technique as well as drug compliance is checked regularly (Figure 3). This simple check, which is so important, is often overlooked. Some patients may have difficulty with manual dexterity or cognitive impairment, which may need to be considered when selecting inhaler devices (Booker, 2005). In most cases multi-dose inhalers (MDI) are the most effective using a spacer device (NCCCC, 2004).

Nebuliser therapy: Nebulised therapy may be required by some patients with distressing or disabling breathlessness, despite maximal therapy using inhalers. Patients should be assessed by a specialist following a trial to establish one or more of the following (NCCCC, 2004):

Figure 3: Checking patients inhaler technique.

- A reduction in symptoms.
- An increase in the ability to undertake activities of daily living.
- An increase in exercise tolerance.
- An improvement in lung function.

If nebuliser therapy is prescribed, the patient should be provided with equipment (tubing, nebuliser chambers, masks or mouthpieces), support and advice as well as regular servicing and electrical safety checks (NCCCC, 2004).

Preventive measures and patient education
Although there is no cure for COPD and many of the medical interventions available are limited in helping relieve symptoms, there is much that nurses can do to help educate patients to enable them to cope with their condition and to reduce the progression of the disease. This requires a multi-disciplinary approach to be successful.

Smoking cessation: The main intervention that significantly alters the disease progression of COPD and has any influence on lung function is smoking cessation. Nurses can play a vital part in either helping patient's to stop smoking or referring them to a smoking cessation advice service. It can not be over emphasised to patients that this is the one intervention that they can do to help themselves. Smokers susceptible to COPD lose up to 60ml of lung function per year, over the age 25, which in comparison to that of a non-smoker, who loses 30ml of lung function per year. Once smoking has stopped, the loss of lung function reverts to 30ml per year, but the existing lung tissue damage cannot be repaired (Marley, 2000).

Smoking cessation is difficult, and most smokers may try several times before succeeding (McAllister, 2002b). The use of nicotine replacement therapy and bupropion are likely to help increase the patient's success rate.

Nutrition: Patients with COPD tend to use up high energy levels to breathe and therefore need to replace these calories throughout the day by eating little and often, especially if eating increases their sensation of breathlessness. Patients should be advised to eat fresh fruit and vegetables if possible. Evidence suggests that foods with high levels of antioxidants in vitamins C and E have a protective effect on lung tissue and are beneficial in slowing down the progression of COPD (Bellamy & Booker, 2004). Fish high in omega 3 fish oils such as salmon, tuna or mackerel are also thought to protect the lungs due to antioxidants.

It is not unusual for patients with advanced COPD to have a low body mass index (BMI) which suggests a poorer prognosis (Landbo et al., 1999), while an increase in BMI with treatment improves prognosis (Schols et al., 1998). Dietary supplements may help in advanced COPD, but should not replace a normal diet (McAllister, 2002b). Referral to a dietician should be made for advice.

Keeping active: Ensuring patients with COPD maintain an active life style is essential to their overall wellbeing and general fitness. It is important to reassure patients that being breathless is not harmful, although can be distressing to the patient. Patients are likely to avoid activities that make them breathless and over time become increasingly less active and housebound. It is therefore important to encourage patients to keep active and to take some form of exercise every day either in the form of gentle exercises in the home to maintain upper and lower limb strength (Figure 4), daily walks or regular swimming. Patients should be taught energy conservation tactics and encouraged to pace their activities and rest between tasks. Sitting down to perform activities will use up less energy and reduce the degree of breathlessness. Referral to a community occupational therapist for an assessment for aids to

Figure 4: Patient performing gentle exercises.

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make practical daily activities easier should be considered if the patient is finding difficulty in performing various tasks.

Breathing control: To enable patients to keep active and to avoid breathless attacks, patients should be taught to control their breathing using abdominal breathing, which will improve the efficiency of the respiratory muscles and reduce the amount of air trapped in the lungs at the end of expiration. Teaching patients breathing control reduces the work of breathing and improves the patient's confidence and ability to control their breathlessness. Referral to a community physiotherapist should be considered if patients require support in being taught the correct abdominal breathing technique.

Pulmonary rehabilitation: These programmes are extremely effective and can help improve individual patients functional ability and quality of life. Pulmonary rehabilitation is a multi-disciplinary educational programme for patients with chronic respiratory impairment, which provides information on all aspects of their disease and an individually tailored exercise programme to optimise physical activity. Programmes are run over an eight-week period and can be based within secondary care or in some locations, within the community. All patients with moderate to severe COPD should be provided with the opportunity to attend such programmes, which are proved to be highly effective in terms of improving health-related quality of life and reducing use of health service resources (Lacasse et al., 2004).

Vaccination: Patients with COPD should be encouraged to have an annual influenza vaccination. Vaccination of patients with chronic respiratory disease against influenza has shown to reduce hospital attendance and admission rates as well as reducing death rates from influenza (Gorse et al., 1997). It is also common to vaccinate patients against the Pneumococcus, which is usually, life lasting and has reduced the incidence of pneumococcal disease in patients with chronic lung disease (Franzen, 2000).

Weather changes: It has been shown that there is a direct relationship between weather changes and air quality and the effects this has on patients with COPD. Very hot or very cold weather is associated with an increase in hospital admissions (Donaldson et al., 1999). The Meteorological office is working closely with many primary care trusts to help provide forecast information one-week in advance so primary care staff can alert vulnerable patients and enable them to pick up early signs of an exacerbation. Patients are contacted by phone by a nurse to check that the patient is well, their symptoms are controlled and that they are taking their medication, eating and keeping the house at the correct temperature. At the signs of an exacerbation appropriate treatment is implemented and monitored.

Self-management plans: Individual self-management plans are a good way of providing advice and a management plan for patients to follow (Figure 5). Each plan should contain information of the patient's lung function and usual medication for any visiting GP to see, as well as instructions for the patient to follow if their symptoms increase to suggest an exacerbation. Patients should hold a 'stand by' course of antibiotics and corticosteroids, together with clear written instructions about how and when to take them to enable them to start therapy straight away. Patients should be encouraged to inform their respiratory nurse or GP so they can be monitored to ensure a full recovery.

Conclusion
Nurses can have a major impact on the management of patients with COPD and can facilitate significant improvements in their health and general well being. It is essential that individual patient's symptoms are well controlled and patients are taught to take control and mange their chronic illness. Caring for patients with COPD in primary care requires a multi-disciplinary approach to ensure optimal care is delivered.

Figure 5: Nurse providing information and discussing self-management plan.

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