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FOCUS ON COPD
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RESPIRATORY CARE TODAY
2015,Vol 1, No 1
23
Patient training is important
(NICE, 2010) and primary care
nurses are in a key position to
check if inhalers are being used
correctly — this should be checked
at every contact and at least yearly.
Improved adherence can be fostered
by ensuring that each patient
understands not only the importance
of treatment, but also how to use and
maintain their prescribed device, and
that they should tell the prescribing
healthcare professional when
experiencing difficulties with, or
dislike of, a particular inhaler.
Other supportive interventions
Patients’ body mass index (BMI)
should also be calculated and if
found to be abnormal (high or low),
or changing over time, referral to a
dietitian is appropriate. If patients
have excessive sputum, consider
referring to the local physiotherapist;
most patients can be taught to use
positive expiratory pressure (PEP)
masks and breathing techniques for
sputum clearance.
Anxiety and depression are
common in patients with COPD, and
this is an important component of
care because depression adversely
affects outcomes through reduction
in activity and exercise capacity, and
is associated with hospital admissions
and reduced quality of life (Baraniak
and Sheffield, 2011). It has been
demonstrated that psychological
and/or lifestyle interventions that
include exercise significantly improve
symptoms of depression and anxiety
by around 25% in COPD patients
(Coventry et al, 2013).
To ensure that patients who
require oxygen therapy are identified,
pulse oximetry should be available in
all healthcare settings (NICE, 2010),
with primary care nurses having their
own one to use in clinical practice.
Nurses should closely monitor
patients’ oxygen saturations at every
contact and refer to the local home
oxygen and assessment centre for an
oxygen assessment if saturations are
equal to, or below 92% on room air.
Preventing deterioration and
managing COPD exacerbations
Exacerbations (‘sustained worsening
of the patient’s symptoms’, Burge
and Wedzicha, 2003) are associated
with higher mortality, reduction
in lung function, and worsening
HRQoL (Almagro and Castro,
2013). Exacerbations are described
as ‘distressing and disruptive, and
account for a significant proportion
of the total costs of caring for patients
with COPD’ (NICE, 2010).
NICE (2010) recommends
hospital-at-home and assisted-
discharge schemes as an alternative
way of caring for patients with
exacerbations, who would otherwise
need to be admitted or stay
in hospital.
The primary care nurse’s role
is to identify patients at risk of
exacerbation and to give self-
management advice that encourages
them to respond promptly to
symptoms, e.g. when to start oral
corticosteroid and/or antibiotic
therapy and when to adjust their
bronchodilator therapy. Primary
care nurses are also in a position to
provide self-management education
through the annual COPD review.
Patients and carers should also
have access to COPD self-
management plans.
Planning for the future and
end-of-life care
Working alongside colleagues in the
community (e.g. dieticians, specialist
nurses, physiotherapists), primary care
nurses have a role to play in ensuring
that advance care is part of every
suitable patient’s care plan. The need
for possible supportive and palliative
care should be assessed regularly for
all patients with COPD, particularly
after hospital admissions due to
exacerbations (Pinnock et al, 2011).
The process of advance care
planning allows patients to have a say
in their current and future treatment
(Detering et al, 2010). It is supported
by the Department of Health’s
End of
Life Care Strategy
(DH, 2008) and the
NICE quality standard (QS) for end
of life care for adults (NICE, 2011c).
Advance care planning improves end
of life care and patient and family
satisfaction, and reduces the anxiety,
depression and stress of relatives/
carers (Detering et al, 2010; Janssen
et al 2012).
CONCLUSION
COPD is one of the most prevalent
and debilitating diseases (Almagro
and Castro, 2013). There are no
treatments that can repair the lung
and airway damage that causes the
disease, but addressing the symptoms
of COPD improves quality of life.
A thorough clinical history and
objective assessment of lung function
are vital components in diagnosing
COPD, and distinguishing it from
other conditions such as asthma.
Symptom control and minimising
hospital admissions are the primary
goals of patient care. For those
patients who continue to smoke,
intensive smoking cessation
programmes with pharmacotherapy
are warranted. The ‘value pyramid’
(
Figure 3
) shows that even with the
costs of pharmacotherapy, intense
efforts to persuade cessation are cost-
effective and offer value to the
health economy.
Bronchodilation is the basis of
pharmacological treatment of COPD,
helping to relieve lung hyperinflation
with associated improvements
in dyspnoea.
For those with continuing
symptoms, pulmonary rehabilitation
should be strongly considered, as
it is a valuable and cost-effective
intervention beyond bronchodilation
alone. Through the COPD annual
review, primary care nurses have the
opportunity to see many patients
with COPD who specialist teams do
not. Therefore, the recommendations
in this paper are critical to ensuring
that every person living with COPD
is offered the correct treatments
and support.
RCT
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Practice point
Primary care nurses have the
opportunity during routine reviews
to make lifelong improvements for
patients living with COPD, helping
to maximise their quality of life.