Inspiration!
Nurses promote increased quality of life for patients with COPD

By Linda Childers
February 28, 2005

A 68-year-old woman was having difficulty climbing the stairs to her doctor’s office. She was less than halfway up the stairs when she paused to catch her breath. Without a brief rest she knew from experience that she would soon feel as though she were suffocating.

More than 13 million Americans suffer from chronic obstructive pulmonary disease (COPD), a condition characterized by chronic cough, excess mucus production and shortness of breath. For these people, everyday physical tasks often seem like overwhelming obstacles.

For nurses such as Virginia Carrieri-Kohlman, RN, DNSc, FAAN, of the University of California, San Francisco, School of Nursing, working patients who have COPD presents a constant challenge. While there is no cure for the condition, nurses like Carrieri-Kohlman agree that new medications seem to improve the quality of life for patients with COPD. In addition, a number of clinical studies are currently taking place that promise to yield new insights and treatment options.

Chronic bronchitis and emphysema are among the most common conditions considered part of the COPD family. According to the American Lung Association (ALA), COPD is the fourth leading cause of death in the United States after cardiovascular disease, certain cancers and stroke. The number of deaths due to COPD has nearly doubled in the past two decades, and the most dramatic increase has occurred in women. By the year 2020, the ALA estimates that COPD will be the third leading cause of death worldwide. Many mistakenly believe that COPD is a disease that only affects the elderly, but in reality many patients exhibit symptoms of the disease in their 40s .

Smokers in denial

Although smoking is the leading cause of COPD, many smokers appear to be unconcerned about the long-term effects of smoking, according to a national study by the ALA conducted in 2004.

The study showed that nearly two-thirds (64%) of smokers aren’t concerned about developing COPD, even though more than half of them (55%) experience at least one of the symptoms of COPD on a regular basis. Although factors including genes and pollution can play a part in the disease, about 85% of all cases can be attributed to smoking.

Carrieri-Kohlman has worked with pulmonary patients for the past 35 years, and is currently conducting a study on how yoga can help reduce symptoms for patients with COPD.

“Management of dyspnea (shortness of breath) is a major concern for patients who have COPD,” she says. “Many patients believe exercise will make their condition worse, but we’ve seen that simple exercises help patients improve their endurance and reduce their anxiety levels, which in turn helps them breathe more easily.”

Simple yoga moves can even aid those with advanced COPD.

“We have 70-year-old patients on oxygen who are able to get down on the floor and do some of the simple poses and breathing exercises,” Carrieri-Kohlman says. “Many patient who have COPD think they are incapable of exercise but learn that if they push themselves, their limits increase and their breathing becomes easier.”

Over the years, her work with pulmonary patients has taught her that some of the best strategies in caring for patients with COPD are treatments that allow patients to feel they are more in control of their symptoms.

“When a patient who has COPD is hospitalized, nurses should ask what strategies have been successful in managing dyspnea in the past and capitalize on those strategies,” Carrieri-Kohlman says. “This often means ensuring the patient is in a comfortable position for breathing, having a fan at the bedside to help with shortness of breath, and employing methods of distraction such as music or guided imagery.”

Carrieri-Kohlman notes that in the past 10 years, there have been significant milestones in the field of COPD. Pulmonary rehabilitation programs have been shown to help patients while also teaching them methods of self-care. Inhaled steroids are being used to reduce inflammation in a patient’s lungs.

Chris Garvey, MSN, FNP, MPA, manager of pulmonary and cardiac rehabilitation at Seton Medical Center in Daly City, Calif, and a nurse volunteer with the ALA, attributes the increase in COPD cases to several different factors.

“I think we’re seeing the impact of high cigarette use in the 1950s and 1960s,” Garvey says. “Many of the people who have smoked a pack a day or more for the past 25 years are now suffering from chronic lung problems.”

New medication shows promise

Garvey is encouraged by the new medications available for patients with COPD, and she cites Spiriva, (tiotropium bromide). It’s the first once-daily inhaled bronchodilator and is one of the more exciting recent developments introduced in the COPD field.

“Early evidence of Spiriva usage has been very encouraging,” Garvey says. “Not only does it appear to help patients with shortness of breath, but it also appears to help reduce hospitalization for patients with COPD.”

Lung volume reduction surgery (LVRS), is another treatment that involves removal of parts of the lung badly affected by COPD.

By removing these damaged air sacs or alveoli, air trapping is reduced and the function of the rest of the lung is improved.

A five-year national, randomized trial of LVRS, known as the National Emphysema Treatment Trial or NETT was completed in 2003. The findings showed that breathing significantly improved, but by the two year mark lung function had returned to the pre-surgical condition.

However, researchers found that lung function in patients who were assigned to the control group, ( receiving medical treatment only and no surgery), were much worse than at the start of the study. Therefore LVRS does buy some time for those with COPD. Garvey notes that this surgery is only targeted for patients with severe COPD with emphysema located primarily in the upper lobes of the lungs.

“The majority of patients with COPD are going to benefit from medications and beginning an exercise regimen that helps to improve their shortness of breath,” Garvey says.

Pulmonary rehabilitation programs provide exercise and education, and have been shown to help people coping with COPD lead fuller lives as well as reduce their number of hospital stays.

“Patients with COPD should always begin an exercise program under the supervision of a pulmonary rehab program,” Garvey says. “After being involved in a six-week program, patients will feel more confident performing the exercises on their own.”

Promoting awareness and self-care strategies

Although 13 million Americans suffer from COPD, nurses believe there are many more cases that haven’t been diagnosed because it’s common for patients to ignore their symptoms until their breathing capacity has become severely diminished.

COPD is typically diagnosed as part of pulmonary function testing. Another diagnostic tool which has been underutilized, according to nurses such as Garvey, is a device known as a spirometer, which allows doctors to assess lung function. It has proven helpful in diagnosing COPD, especially in the early stages of the disease before the symptoms are debilitating or even before they are recognized and acknowledged by the patient.

“There has been more of a move toward using the spirometer on patients with a long history of smoking,” Garvey says.

There are also steps that patients can take to prevent COPD.

“If people quit smoking, they can actually improve their lung function,” says Diane Harris, RN, BSN, a nurse at Boswell Memorial in Sun City, Ariz. “Many people don’t realize that COPD is largely preventable.”

Harris also helps her patients with COPD learn coping and relaxation skills to reduce the anxiety and fear that accompanies a patient’s shortness of breath.

“The fear makes their breathing worse, so it’s important for patients to learn how to relax,” she says. “We also help patients learn how to conserve their energy by doing things like eating six small meals a day, so that they can conserve energy while still maintaining good nutrition.”

Heather Maxey, RN, of First Choice Home Healthcare in Denver, Colo., empathizes with her patients who have COPD. Maxey has asthma and knows firsthand how scary it is to have breathing difficulties. Approximately 50% of the patients that Maxey cares for have COPD.

Memory Loss

A study being conducted by Paula Meek, RN, PhD, FAAN, a nursing professor at the University of New Mexico and Kathie Insel, RN, Ph.D., an assistant nursing professor at the University of Arizona, is examining whether build-up of carbon dioxide in the bloodstream can cause memory loss in those with COPD. Early indications show that some patients with COPD may have difficulties processing information.

Nurses know that lung and respiratory diseases hurt the body’s ability to bring oxygen to the brain, but Meek and Insel’s study is the first to examine carbon dioxide build-up in the blood. The results of their study could eventually lead to more effective drug treatments for people with COPD as well as a better understanding of how to care for patients whose memory loss stems from COPD.

The memory problems in patients with COPD are not like Alzheimer’s disease, but are related to processing information in a patient’s short-term memory. For example, remembering a seven-digit phone number wouldn’t be a severe problem, but processing that number-putting the digits in order from smallest to largest-might be increasingly difficult for people with COPD.

Maxey has witnessed confusion among many of her patients who have COPD. She often leaves them written reminders to take their medications or to wear oxygen. She also works with patients and their families to practice pulmonary breathing exercises and reviews each patient’s dietary and
sleeping habits.

“Care plans for patients with COPD are as unique as each individual,” Maxey says. “I check to see if patients are taking pain medications that can depress respiration, and I work with them to decrease their naps and increase their activity level.”

Despite having run a successful smoking cessation program, Maxey says helping patients dealing with COPD kick the tobacco habit is a formidable challenge.

Unfortunately, many patients who have COPD are diehard smokers.” she says. “If people stop smoking their lung function can increase. The number-one way to slow progression of the disease is to stop smoking, but for many patients quitting isn’t a possibility.”

Spread the word

For their second annual educational partnership, The American Lung Association and ALTANA Pharma US have developed a free care package to help nurses and others spread the message of COPD. To symbolize their campaign slogan of "Hungry for Air; Care, Share, Commit," the package includes a 10-minute calling card, a Hungry for Air: Sharing the Facts About COPD information card with key facts about COPD; and a plastic drinking straw to illustrate how difficult it is to breathe with COPD.

The care packages are designed to encourage smokers and friends and family members of smokers to become more knowledgeable about COPD and to seek diagnosis and treatment options that may help lead to longer, more active lives. Many local ALA chapters also offer support groups such as their "Better Breathers" group that can help patients with COPD.

For more information, or to obtain a care package call (877) COPD-INFO or visit their website at www.lungusa.org.

Linda Childers is a freelance writer for NurseWeek.