Title: Discuss the nurse led intervention in relation to secondary prevention for COPD
Chronic Obstructive Pulmonary disease (COPD) is a growing health concern today all over the world. The World health Organization predicts that by 2020 COPD will rise from it’s current ranking of 12th most prevalent disease worldwide to 5th and from 6th most common cause of death to 3rd.(Murry 1997) Another study by WHO(2002) states that COPD is the third largest cause of respiratory death and account for 20% of respiratory mortality. According to research conducted in UK, around 900000 patients are suffering from COPD in England and Wales currently (NICE 2004). Numbers of patients affected by COPD are increasing in UK and it has taken over the place of heart diseases as one of the major killer diseases leading to 30000 deaths per year. (Gibson 2003). Reason for dramatic increase in COPD includes reduced mortality from other diseases like heart diseases in industrialization countries and infectious diseases in developing countries with marked increase in cigarettes smoking and environmental pollution all over world.
COPD is a chronic progressive disorder characterized airway obstruction with little or no reversibility. COPD affects bronchi, bronchioles and lung parenchyma with predominance on distal airways. It involves two clinical condition- chronic bronchitis and emphysema. Most patients with COPD have both pathological condition but relative extent of emphysema and chronic bronchitis is variable in individual patient.
Chronic Bronchitis and Emphysema
Chronic bronchitis is defined as a cough productive of sputum on most days for 3 months for successive 2 years. Cough is due to hyper secretion of mucus not necessarily accompanied by air flow obstruction.
Chronic bronchitis is characterized by enlargement and multiplication of mucus glands, resulting increased airway mucus production. Evidence suggests that apart from quantity, quality in the form of composition of mucus is also altered becoming more viscous.
Mucus is one of the important component in pathophysiology of COPD. Increased secretion of mucus is the result of goblet cell hypertrophy on exposure to various noxious stimuli. This mucus affects pulmonary function in various ways. Increased secretion for prolong period leads to decrease in FEV1 which is promotional to degree of hyper secretion .Excess mucus causes airway obstruction by accumulation in peripheral airways and increased airway resistance.
Additionally, there is thickening of airway wall and infiltration with lymphocytes, neutrophils and macrophages leading to fibrosis. In contract to asthma, infiltration of lymphocytes and neutrophils are found in greater number in airway lumen. In the event of exaggeration of COPD, Eosiniphils are also observed in airway lumen. Inflammatory process in COPD is powered by interaction of proteolytic enzymes and several chemokines, as sputum of patients with COPD shows increased amount of Leucotriene B4, interleukin- 8 and tumor necrosis factor.
Emphysema is defined as enlargement of airspaces distal to terminal bronchioles with destruction of alveolar wall resulting loss of elasticity of lung and closure of small airways. Elastic recoil of alveolar attachment helps to maintain the patency of airway lumen especially during expiration. With destruction of connective tissue matrix of alveolar walls by proteolytic enzymes called proteases, released by inflammatory cells in the alveolar wall causing destruction of elastin, affects structural integrity of alveolar wall. Pathological changes in emphysema are related to proteolytic activity of these enzymes.
In peripheral airways of patients with COPD, there is airflow limitation due to loss of alveolar attachments, inflammatory obstruction of airways and luminal obstruction with mucus. The airway narrowing in COPD is the end result of combination of structured inflammatory narrowing, loss of elastic recoil and loss of alveolar attachments.
One of the important effects of risk factors of COPD is abnormality in ciliary function. Airway wall is lined by cilia which act as a force to propel mucus or foreign body towards trachea for coughing it out. Mucociliary function is affected by thick and tenacious mucus. It also increases the risk of infection due to accumulation in airway causing recurrent infection in lungs and further lung damage. Mucus plugging and pulmonary infection contributes to V/Q mismatch and hypoxia eventually. Acute hypoxia caused dyspnoea affecting other systems of the body. Chronic hypoxia leads to pulmonary hypertension and right sided failure. Other pathophysiological consequences of COPD include abnormalities in pulmonary function, the mechanism of gas exchange.
Risk factors for COPD
There are several factors responsible for development of COPD called risk factors.
Smoking cigarettes, both active and passive, is considered the major causative factor in development of COPD. More than 80% of COPD patients are or were smokers (Gibson 2003).
Air pollution, industrial smoke and chemicals used in industry are responsible for development of COPD. Exposure to industrial dust is a causative factor in diseases like asbestoses, mesothelioma and black lung disease. Infection especially in early childhood and frequent exposure to allergens leading to changes in airway are contributing factors in development of COPD. People with Alfa -1 antitrypsin deficiency are more likely to develop COPD due to genetic defect in production of enzyme alfa-1 antitrypsin. It is believed that patients having periodontal diseases are more likely to develop COPD as the bacteria casing periodontal diseases travel to lung and cause infection and inflammation.
Babies with low birth weigh have shown increase incidence of COPD and poor nutrition during fetal development leading to small dysfunctional lung is considered the responsible factor for development of COPD. COPD in more common in men, over sixty years of age. At this age it is at its highest level of development, which started in young age.
Out of all the risk factors discussed smoking cigarettes is most important factor in causing COPD. Effects of smoking cigarettes on human body are due to nicotine present in a cigarette. Nicotine molecule was produced over 60 million years ago by tobacco plant to overcome insect herbivores. Tobacco introduced in Europe in 1492 when Christopher Columbus sailed to America and its cultivation then spread to many parts of world (Corti 1931). Today tobacco is widely prevalent in society in the form of cigarette smoking. Typical cigarette contain 9 mg of nicotine of which 1 mg is absorbed by smoker.
Burning tobacco produce a complex mixture of compounds divided in gas and particulate phase components. In gas phase component, carbon monoxide (4%) forms the significant amount in concentration in addition to nitrogen, oxygen and carbon dioxide. The particulate phase component is consisting of aerosol of tar. Tar is the sticky, brown, residual substance left after removal of nicotine and moisture. Both gas and particulate phase are responsible for COPD
Delivery of smoke compound is variable according to type of tobacco used in cigarette, addition of filter and the vigor with which an individual smokes cigarette. Smoking affects lung at the level of bronchi, bronchiole and lung parenchyma. Tobacco smoke affects structure and function of bronchial mucous gland. Number and size of mucus secreting glands increase due to smoking leading to more production and deposition of mucus in airway. Tobacco smoke also produces structural changes in airway cilia. These changes are related to dose and duration of smoke exposure. It also affects the function of cilia with abnormal clearance of secretion. Additionally, it also cases narrowing of small airways with inflammation and fibrosis. Apart from this, smoking has some short term effects like increase in carboxyhaemoglobin, decreased appetite and emotional dependence on nicotine.
COPD is treated with elimination of risk factors, bronchodilators such as beta-agonists and anti-cholinergic, corticosteroids, low concentration of oxygen and mucus thinner like guaifenesic. The cost of COPD is enormous as economic burden on health care system, society, patients and their family is significant. An audit of 1400 patients admitted in a hospital revealed that 34% patients readmitted and 14% had died within 3months. (Roberts 2002)
It is imperative to act upon risk factors responsible for COPD. Smoking is major risk factor for development of COPD and it is never too late to stop smoking and benefits starts immediately. (Price 2004).Usually smoking starts in teen age and continues for long time, but those who have never smoked remain non-smoker for many years.
Study indicated decline in number of male smokers in UK from 70% in 1950 to 28% in 1998 (Macfadyen 2001).More positively, men are giving up smoking in increasing number. These changes in behavior of people in society towards smoking are the result of implementation of health promotion strategies in communities. Health promotion is the science and art of helping people changing life style to move towards the state of optimum health. Optimum health is defined as a balance of physical, emotional, social, spiritual and intellectual health (Irwin 2005)
Health promotion is directing the plan to foster communities’ abilities to take effective actions at local level. It covers the methods to map and mobilize local resources, to activate citizens, government for management of positive changes, and transform institutions into health promoting environment. It involves the actions to improve ability of health care system for primary and secondary prevention and assist citizens in taking control and improve their own health by behavior and lifestyle changes. Life style changes can be facilitated with combination of enhanced awareness and creating environment that support good health practice.
Health promotion is that element of public health that focus on social conditions for maintenance and development of better health for productive society. Evaluation of health education programmes reveled that change in knowledge did not result in action and improved health. Knowledge alone is not sufficient but people need the confidence that they can change their lives.
Hubley (2002) explained that health empowerment has two components self efficacy and health literacy. Self efficacy implies feeling of power and control and confidence of taking action. Health literacy is related to ability to communicate health related issues.
.Health literacy is achieved only by means of health education leading to understanding of health issues and application of it in decision making. Many traditional health education methods rather disempower person by creating more dependency on health professionals. Important element in health promotion is to provide cognitive input through educational process which will not undermine community confidence. Health education using participatory learning methods creates a way forward for heath literacy and self efficacy.
Nurses in health care set up facilitate these components of health promotion by helping smoking cessation in society and directing health care for secondary prevention of COPD. Nurses as health care professionals act by providing information and support to smokers either by telephone contact or nurse led clinic to obtain objective of reducing smoking in communities. There are clear objectives for nurses in smoking cessation programmes of advocating positive social and environment changes for health promotion and organizing supporting activities that leads to secondary prevention of health related morbidity and mortality. It is important for nurses to educate the people to influence the positive behavior changes in health related issues. Apart from providing information, it is important for nurses to use the information to bring change by communicating and convincing smokers and organizing individual action. Government says that smokers are four times more likely to quit smoking using NRT with local NHS stop smoking programme than if they only rely on their will power. (DH 2004)
Smoking is seen in three phases: initiation, maintenance and cessation. Initiation occurs in early teens and begins with experimentation with cigarettes. There is evidence that adolescent of more rebelling or risk taking, out going nature are more likely to take up cigarettes. Individuals of more neurotic personality are also more prone to take up cigarettes. Some degree of genetic predisposing has also been observed, which not particularly specific to nicotine but also for alcohol and caffeine. High status individuals in media also have great influence in initiation of smoking. Maintenance of smoking is promoted by direct and indirect effect of nicotine releasing central dopamine, noradrenalin and opiate peptides. It helps in coping with stress and also improves performance due to its tranquillizing effect, in a variety of tasks but it eventually leads to dependence, addiction and withdrawal symptoms.
On initial contact with patient, nurse establishes that the person is a smoker and obtains informed consent from person. Nurse gives a questionnaire to patient to know smoking history of patient in the form of numbers of cigarettes smoked in a day by a person. It also includes disclosure of information about duration and pattern of smoking.
Nurses then assess the willingness of the person to stop smoking. By asking smoker to rate the importance of quitting on a scale one to ten, with one number having least importance. Smokers are also asked to rate their confidence in their ability to quit. This gives an idea to nurse about the readiness of a smoker for quitting.
Nurse also assess level of breathlessness in patient with COPD, which is graded as follows (Gibson 2003).
- Not troubled by breathlessness on strenuous exercise.
- Breathlessness when walking uphill
- Walks slower than counterpart on the level because of breathlessness
- Stops to take a breath after 100m or a few min on the level
- Too breathless leave the home or breathless on dressing.
After initial assessment, nurse counsel patient to educate and prepare him/ her to take action to quit smoking. Nurse explains the benefits of smoking cessations with emphasis on the explanation that a person starts getting benefits immediately after stopping and set a quit day with explanation of problem they may come across.
In clinic, most patients say they would like to give up and also tried to stay away from cigarette (Percival 2004).A study indicates that long term success of smoking cessation depends on several factors like low daily cigarettes and delayed first cigarette of day; low consumption of alcohol or caffeine, high socioeconomic class; non smoking spouse and less neurotic or depressive personality. Some evidence also suggests that women find it difficult to give up. It is important for the nurses to now the degree of self confidence from the outset that the goal will be achieved and absence of stressful episodes during the therapy as contributing factors for long term abstinence from smoking. Study suggests that, persons usually give up smoking after five to six trial and error sequences. (Gibson 2003)
The duration of therapy is usually six weeks. Nurses lead session either in a group or one to one and manage for regular follow up. After initial contact, nurses remain in contact with person by telephone or in clinic at 2 days, one week, three weeks and three months interval. Patients are given booklet about COPD and disadvantages of smoking. Booklet also contains the benefit s of quitting smoking. It also explains the patient about how to quit smoking, how to cope with withdrawal symptoms like need to smoke, depression, irritability, insomnia, difficulty in concentration, restlessness and increased appetite… Patients with strong withdrawal urge are explained about NRT. At the end of six weeks patients have consultation with nurses. Those who continued smoking or relapsed are offered additional support.
Anti smoking public health campaign helps smokers by drawing attention more frequently and pushing them to take action. It also helps nurse in facilitating their advice. Self reported motivation of smokers, wish to avoid further health problem and in some cases actual ill health are important factors in giving up smoking. For example, a pregnant lady is inclined to give up smoking to avoid harm to her baby. Smokers receiving advice from hospital physician specially after admission for myocardial infarction had quit rate of 50%, compared to success rate for advice by physician in general practice of around 5% in unselected patients.(Pety 2000 ) Concern of passive smoking and many times social pressure by family and friends also contributes in moving forward for help in smoking cessation clinic. Rising price of cigarettes and ban or restriction of smoking in public places also tend to discourage smokers. Socioeconomic model suggest that for every one percentage rise in cigarette price leads to 0.5 % drop in consumption (NICE 2004).Smoking advertisements and perceived status of smoking from them are significant factors in encouraging people to become smoker.
Nurse encourages person in finding alternate source of enjoyment and different coping strategies in the event of stress leads to successful outcome on long term. Nurse also takes help of specialist in search for other ways of mastering concentration during sustained task. Nurse also asks spouse to quit smoking to create the environment for behavior change. Many smokers have poor central control system for arousal reward and punishment, and then alternative strategies may involve physical sports, mental relaxation, assertiveness techniques and different scheduling for work activities. Nurses help smokers understanding and reducing the image smoking as’ something exciting and sophisticated’.
Most smokers give up with the help of their own efforts but those who cannot manage themselves nurses propose specific methods with the social support. For those , who will not give up in immediate future some damage limitation can be achieved by production of safe cigarettes; transfer to pipe or cigar or chewing tobacco; other formulation of tobacco like nicotine gum, nasal spray, transdermal patch inhalable aerosol- called nicotine replacement therapy (NRT). Before starting medication nurse rules out contraindication for medication like severe cardiovascular diseases, recent MI, severe cardiac arrhythmia, recent CVA, transient ischemic attack, pregnancy and breast feeding. Variety of other drugs apart from medications used for NRT are also used in practice which counteract unpleasant aspects of nicotine withdrawal, includes amphetamine, benzodiazepines, ACTH, vasopressin, clonidine, fluoxetine, bupropion and naloxone. Mecamylamine (nicotinic antagonist) is another important medication used in smoking cessation.
Nicotine replacement therapy in the form of nicotine gum or patch is better than smoking and decrease health risk. NRT and bupropion are prescribed to those who have set a date as a target to stop smoking. Transfer to pipe decrease the risk of lung damage, but can not protect upper oesophageal tract. With nicotine nasal spray, absorption from mucosa is much faster than gum and the blood level achieved are comparable with cigarette smoking. Nicotine aerosol has irritant sensation in nose but it is still the attractive option in switching from cigarettes. Nicotine patches application on skin promotes slow absorption of nicotine from the skin .It is devoid of sufficient sensory stimulation involved in smoking. It has limitation in alleviating withdrawal symptoms during smoking cessation therapy.
Practically more useful are nicotine gum, transdermal nicotine patch, nasal spray and antidepressant bupropion. They are equally effective and safe, doubling quitting rate. Study indicates less than 5% drop out rate due to adverse effects if these drugs, but combination is superior in effects compared to single drug (Gibson 2003).Combining medication with counseling by nurse boost the quit rate. Nurse explains side effects of NRT like headache, nausea, dizziness, palpitation, dyspepsia, hiccups, insomnia, myalgia, anxiety, and irritability to patients before starting it.
For many novice ex-smokers major difficulties emerge after initial euphoria of successfully having overcome the first week of withdrawal symptoms. The more complex task then begins to manage and overcome withdrawal symptoms for longer term for successful outcome. NRT forms the mainstay of management of withdrawal symptoms. There are differences in response from various types of NRT .In case of heavy smokers( more than 20 cigarettes a day) 4mg nicotine gum is more effective than 2mg. In medium to heavy smokers standard patch of 21 mg is more effective than lower dose patch. Treatment with NRT is continued for 10 to12 weeks with gradual withdrawal. If person is unsuccessful in quitting after 3 months, the treatment is again reviewed. (West 2000)
Addition to anti-smoking measures, nurse should check effectiveness of inhaled drug, it’s technique and if they are symptomatic despite short acting bronchodilators.
Nurse also takes care of nutrition and vaccination in COPD case.
Nurse led clinic for smoking cessation is a part of pulmonary rehabilitation program which involves exercise and education over 6to 8 weeks to anyone who feels that COPD is affecting quality of his or her life. It is closely related to health promotion by creating an environment and providing education for improving personal and community health.
Educating people to change behavior and empowering them to take actions leading to smoking cessation are essential elements of smoking cessation clinics.
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