Perspectives that influence action plans for chronic obstructive pulmonary disease

Amygdalar involvement in respiratory dysfunction

The brainstem has long been recognized as the major respiratory control center, but it has become increasingly appreciated that areas upstream of the brainstem modulate respiration and airway defensive behaviors. This review aims to define the role of the amygdala, a key temporal brain region essential for limbic function, in respiration and airway defenses. We summarize literature describing roles for the amygdala in control of respiration, swallow, cough, airway smooth muscle contraction, and mucus secretion. We emphasize the need to understand how the amygdala regulates these functions both at a local scale and network scale and identify knowledge gaps for current and future investigations. Lastly, we highlight literature suggesting that amygdala dysfunction may contribute to respiratory dysfunction.

Self-treatment of acute exacerbations of chronic obstructive pulmonary disease requires more than symptom recognition - a qualitative study of COPD patients' perspectives on self-treatment

BACKGROUND

Self-treatment of acute exacerbations of COPD with antibiotics and/or oral corticosteroids has emerged as a promising strategy to reduce hospitalization rates, mortality and health costs. However, for reasons little understood, the effect of self-treatment, particularly when not part of comprehensive self-management programs, remains unclear. Therefore, this study aims to get insight into the patients' perspective on self-treatment of acute exacerbations of COPD, focusing specifically on how patients decide for the right moment to start treatment with antibiotics and/or oral corticosteroids, what they consider important when making this decision and aspects which might interfere with successful implementation.

METHODS

We interviewed 19 patients with chronic obstructive pulmonary disease using qualitative semi-structured interviews, and applied thematic analysis for data analysis.

RESULTS

Patients were well equipped with experiential knowledge to recognize and promptly respond to worsening COPD symptoms. Worries regarding potential adverse effects of antibiotics and oral corticosteroids played an important role in the decision to start treatment and could result in hesitation to start treatment. Although self-treatment represented a practical and appreciated option for some patients with predictable symptom patterns and treatment effect, all patients favoured assistance from a medical professional when their perceived competence reached its limits. However, a feeling of obligation to succeed with self-treatment or distrust in their doctors or the health care system could keep patients from timely help seeking.

CONCLUSION

COPD patients regard self-treatment of exacerbations with antibiotics and/or oral corticosteroids as a valuable alternative. How they engage in self-treatment depends on their concerns regarding the medications' adverse effects as well as on their understanding of and preferences for self-treatment as a means of health care. Caregivers should address these perspectives in a collaborative approach when offering COPD patients the opportunity for self-treatment of exacerbations.

Physiotherapy management of acute exacerbations of chronic obstructive pulmonary disease

[Holland AE (2014) Physiotherapy management of acute exacerbations of chronic obstructive pulmonary disease.Journal of Physiotherapy60: 181-188].

Primary and secondary care clinicians' views on self-treatment of COPD exacerbations: a multinational qualitative study

OBJECTIVE

To explore clinicians' views on antibiotic and/or steroid 'rescue packs' used as self-treatment for patients with exacerbations of COPD.

METHODS

21 focus groups conducted in 7 countries--Netherlands, Russia, Norway, China (Hong Kong), Wales, Germany and Poland involving 142 primary care clinicians and pulmonologists.

RESULTS

We found wide variation in reported use of and attitudes to self-treatment among GPs and pulmonologists in the participating countries. Clinicians highlighted the importance of identifying patients who were most likely to benefit (those with more severe disease) and most likely to use the treatment appropriately (demonstrated by previous behaviour), and the importance of adequate patient education and ongoing communication in regard to use of self-treatment packs. Clinicians recognised patient empowerment and facilitating prompt treatment as potential benefits of self-treatment. However, many felt they did not have the time or resources for appropriate patient selection and education.

CONCLUSION

Clinicians do not feel it is appropriate to offer self-treatment rescue packs to all patients routinely without careful consideration of patient understanding of their illness and their capacity for self-management.

PRACTICE IMPLICATIONS

Adequate resources and continuity of patient care are required for clinicians to feel confident in the safe and effective implementation of this strategy.

Pulmonary rehabilitation at the time of the COPD exacerbation

Pulmonary rehabilitation (PR) is associated with improvements in exercise capacity, health related quality of life, psychological symptoms and response to utilization. Acute exacerbations threaten these improvements. An awareness of the clinical sequelae of acute exacerbation of chronic obstructive pulmonary disease enables approaches, such as early post exacerbation rehabilitation to mitigate its negative effects.

'Consumed by breathing' - a critical interpretive meta-synthesis of the qualitative literature

OBJECTIVE

To derive an improved understanding of how patients respond to, appraise, and understand the experience of an acute exacerbation of chronic obstructive pulmonary disease via a critical interpretive meta-synthesis.

METHODS

Search terms - Exacerbate* OR hospital* AND 'Chronic obstructive' OR emphysema OR bronchitis AND interview* OR qualitative. Inclusion criteria - Primary research published in English of patients' experiences of an acute exacerbation of chronic obstructive pulmonary disease. Data extraction and synthesis - eight papers were identified. Data were extracted by three researchers and constructs elicited via reciprocal translational analysis.

FINDINGS

Themes reflected two domains of understanding an acute exacerbation: (1) Acute effect - encompassing intense emotions, somatic awareness and patients need for rescue. (2) Sustained regulation - reflecting life as interrupted, ongoing beliefs and behaviour and help-seeking.

DISCUSSION

Acute exacerbations of chronic obstructive pulmonary disease result in heightened patient arousal, vigilance and powerlessness in response to symptoms. Ongoing, psychological interventions which promote partnership working by both acknowledging patients fear and shaping their appraisals may mitigate distress, enhancing the impact of health messages and engagement in pulmonary rehabilitation.

COPD self-management supportive care: chaos and complexity theory

This paper uses the emergent theories of chaos and complexity to explore the self-management supportive care of chronic obstructive pulmonary disease (COPD) patients within the evolving primary care setting. It discusses the concept of self-management support, the complexity of the primary care context and consultations, smoking cessation, and the impact of acute exacerbations and action planning. The author hopes that this paper will enable the acquisition of new insight and better understanding in this clinical area, as well as support meaningful learning and facilitate more thoughtful, effective and high quality patient-centred care within the context of primary care.

Psychological distress in women with chronic bronchitis in a fishing community in the niger delta region of Nigeria

Background. Biomass smoke exposure is a known risk factor for chronic bronchitis. Psychiatric comorbidities may have significant impact on the quality of life of patients with chronic bronchitis. Methods. Women who engage in fish preservation by drying over burning firewood in a fishing community were recruited for this survey. The British medical research questionnaire was used to determine chronic bronchitis, and psychological distress was determined using the hospital anxiety and depression scale. Results. A total of 342 women were recruited for this study and 63 of them had chronic bronchitis. 96 women had features suggestive of psychological distress: 57 (16.6%) women with anxiety, 51 (14.9%) women with depression and 12 women (3.5%) had combined features. Psychological distress was more common among women with chronic bronchitis. Anxiety was significantly associated with chronic bronchitis and the level of biomass exposure while depression was significantly associated with chronic bronchitis, level of exposure, and a history of sleeping in the fish smoking room. Conclusion. Anxiety and depression show significant association with chronic bronchitis among women with biomass smoke exposure with the level of exposure having an aggravating effect on the relationship.

Patient outcomes according to COPD action plan adherence

AIMS AND OBJECTIVES

To identify the level of pulmonary function, number of unplanned hospital visits, knowledge level of chronic obstructive pulmonary disease (COPD), level of anxiety and depression, and level of health-related quality of life (HRQoL) according to COPD action plan (AP) adherence in Korean patients with COPD.

BACKGROUND

Previous studies reported conflicting results about the effect of COPD AP on patient outcomes, with little descriptive information.

DESIGN

A cross-sectional descriptive study design was used.

METHODS

A total of 126 patients with COPD were recruited from Chonnam National University Hospital in Gwangju city from September 2009 to March 2010. COPD action plan adherence and the levels of knowledge of COPD, anxiety and depression, and HRQoL were measured using a short COPD AP developed by the Family Physician Airway Group of Canada executive members, Bristol COPD Knowledge Questionnaire (BCKQ), the hospital anxiety and depression scale (HADS) and the St George's Respiratory Questionnaire (SGRQ), respectively.

RESULTS

The score of COPD AP adherence was positively associated with the level of knowledge of COPD and negatively associated with the number of unplanned hospital visits and the level of anxiety and depression.

CONCLUSION

Good adherence to COPD AP is likely related to better health outcomes in COPD. Healthcare providers may need to enhance COPD AP aspect in various COPD self-management programmes to improve the health status of patients with COPD.

RELEVANCE TO CLINICAL PRACTICE

Chronic obstructive pulmonary disease AP aspect targeting frequent individual education with a written guideline would be helpful to enhance self-management in patients with COPD.

Effect of airway clearance techniques in patients experiencing an acute exacerbation of chronic obstructive pulmonary disease: A systematic review

Answers were sought to the following question: Are techniques, applied predominantly with the aim of clearing secretions from the airways, to patients during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), safe and effective? A systematic review was undertaken of studies that (i) were either randomized controlled or randomized cross-over trials, (ii) recruited patients during an AECOPD, (iii) reported the results of between-group analyses and (iv) investigated the effect of techniques applied primarily with the aim of clearing secretions from the airways. Studies that examined non-invasive positive pressure ventilation (NIPPV) and early rehabilitation were excluded. Data were extracted pertaining to resting lung function, gas exchange, sputum expectoration, symptoms, NIPPV use and hospital stay. Five studies were included with a mean Physiotherapy Evidence Database (PEDro) score of 4.4 ± 1.1 (range: 3—6). The main findings were that (i) airway clearance techniques did not improve measures of resting lung function or produce any consistent change in measures of gas exchange, (ii) the application of 5 min of continuous chest wall percussion reduced forced expiratory volume in 1 second (FEV 1), (iii) in people with copious secretions, mechanical vibration, and non-oscillating positive expiratory pressure (PEP) mask therapy increased sputum expectoration and (iv) in patients with hypercapnic respiratory failure, intrapulmonary percussive ventilation (IPV) and PEP mask therapy reduced the need for, and duration of, NIPPV, respectively. With the exception of continuous chest wall percussion, airway clearance techniques were safe in patients during an AECOPD. Vibration and non-oscillating PEP facilitated sputum expectoration in patients characterized by copious airway secretions. In patients with respiratory failure, techniques that apply a positive pressure to the airways may reduce either the need for, or duration of, NIPPV and hospital length of stay.