RESPIRATORY CARE
Community pulmonary rehabilitation: a multidisciplinary approach Lindsay Welch
KEYWORDS:
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One of the main causes of COPD is smoking, although other genetic, environmental and occupational factors can be involved (Decramer et al, 2012). COPD symptoms can vary between individuals, due to factors such as: The stage of disease progression according to the GOLD (2016) staging categories (Table 1) Coexisting comorbidities Coexisting psychological disorders Frequent or colonised bacterial or viral infections (Wedzicha and Donaldson, 2003).
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hronic obstructive pulmonary disease (COPD) is a progressive, life-limiting respiratory condition that primarily features symptoms of breathlessness, chronic cough, fatigue and reduced mobility (Collins et al, 2012). Currently, the prevalence of COPD in the UK is over one million people (Health and Safety Executive [HSE], 2012), and it is the fourth leading cause of death worldwide (Halbert et al, 2003).
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COPD Pulmonary rehabilitation Multidisciplinary team
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COPD is diagnosed by using lung function tests (i.e. spirometry) to identify airflow obstruction and computer tomography (CT) scans to highlight emphysema, as well as the clinical symptoms at presentation, such as breathlessness, cough and chronic sputum production (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2016).
Lindsay Welch, ICOPD team lead, Solent NHS Trust and UHS Foundation Trust
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Pulmonary rehabilitation is a well-evidenced programme of therapy for patients with chronic obstructive pulmonary disease (COPD) and includes the provision of breathlessness interventions, nutritional support and exercise therapy, all of which can be delivered by community nurses. Pulmonary rehabilitation is also considered a low cost intervention and can be delivered by healthcare professionals of varying disciplines. This article explores the clinical elements of pulmonary rehabilitation, as well as investigating the 'added value’ provided by multidisciplinary teams in the community.
Current strategies for the management of COPD include a combination of: Self-management education Exacerbation action planning Pharmacological management Smoking cessation and healthy living advice.
The average age of the UK population has been rising recently (The Office for National Statistics, 2014), which has resulted in more people living in the community with a long-term condition (NHS England, 2014a). COPD makes up a large proportion of these long-term conditions and is one of the most common reasons for emergency admission to hospital (National Institute for Health and Care Excellence [NICE], 2011), with 115,000 admissions per year (NHS England, 2014b). Mortality rates are high, with one in 12 patients dying during their hospital stay and one in six dying within 90 days (NHS England, 2014b).
These vary in delivery and effectiveness and many have been rigorously tested in the form of randomised controlled trials (RCTs) (Lacasse et al, 2006). One COPD management strategy that has considerable clinical evidence is pulmonary rehabilitation. For example, a Cochrane systematic review found that pulmonary rehabilitation reduces mortality and readmission rates when delivered after admission for acute exacerbation of COPD (McCarthy et al, 2015). This is reflected in the NICE quality standard (NICE, 2011; Bolton et al, 2013), and the COPD and asthma outcomes strategy recommendations (Department of Health [DH], 2012). There is also emerging evidence that pulmonary rehabilitation in stable COPD improves survival (Puhan, 2011; NHS England 2014b). Pulmonary rehabilitation is considered a ‘complex intervention’ (Bolton et al, 2013), as many of its individual components — group therapy, socialisation, exercising with peers, group education — work together to form an effective COPD management tool. The exercise component of pulmonary rehabilitation can include walking and incremental strength training. The 2012 IMPRESS guidelines (IMPRESS is a joint initiative set up in 2007 between the British Thoracic Society and the Primary Care Respiratory Society-UK [PCRSUK] to promote improvement and
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RIGHT PATIENT, RIGHT PRODUCT, RIGHT OUTCOMES
RESPIRATORY CARE
Mild limitation of airflow. Patients may not be aware that their lung function is abnormal
Stage II: moderately severe COPD
Limitation of airflow causes symptoms such as coughing, coughing up phlegm and shortness of breath on exertion. Patients usually seek medical treatment
Stage III: severe COPD
Limitation of airflow is greater. Patients complain of worsening shortness of breath, tiredness, limitations to activities of daily living and repeated exacerbations — all of which affect quality of life
Stage IV: very severe COPD
Very severe reduction of airflow to the extent that it also affects heart and blood vessels. Daily administration of extra oxygen may be needed. Complaints are so severe that temporary worsening can be life-threatening
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Stage I: mild COPD
(Spruit et al, 2013): ... a comprehensive intervention based on a thorough patient assessment followed by patienttailored therapies that include, but are not limited to, exercise training, education, and behaviour change designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to healthenhancing behaviours.
PRINCIPLES OF PULMONARY REHABILITATION
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The Association of Respiratory Nurse Specialists (ARNS)/European Respiratory Society (ERS) have defined pulmonary rehabilitation as
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Other cost-effective therapies for COPD include smoking cessation and having a winter flu vaccination. Inhaled therapies are costly and may result in issues such as poor patient uptake and adherence to treatment. The cost values of interventions for COPD per quality adjusted life year (QALY), a way of demonstrating disease burden, including the quality and quantity of life lived, are demonstrated in Figure 1 (London Respiratory Team, 2013).
Table 1: Four stages of COPD according to GOLD categorisation (GOLD, 2016)
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integration in respiratory services), and the recent national audit (Bolton et al, 2013), currently call for all patients with COPD to have access to pulmonary rehabilitation, due to its noted health improvement benefits and its relative low cost. Pulmonary rehabilitation thus serves as an important component in the management of COPD and is beneficial in improving health-related quality of life and exercise capacity (McCarthy et al, 2015).
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The key element of pulmonary rehabilitation is effective exercise
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Triple therapy £35,000–187,000 QALY
Tiotropium or LABA* £5–8,000/QALY
Pulmonary rehabilitation £2,000–8,000/QALY
Stop smoking support with pharmacotherapy £2,000/QALY
Flu vaccination £1,000/QALY in 'at risk' population Figure 1. London cost value pyramid developed by the London Respiratory Team (2013). * Long-acting beta agonist 58
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training, although education, nutritional intervention and psychological support also play important roles. Pulmonary rehabilitation is designed to reduce the patient's symptom burden and optimise their functional status, thus reducing healthcare costs through stabilising or reversing systematic manifestations of the disease (Lacasse et al, 2006).
COPD clinical benefits and breathlessness monitoring Pulmonary rehabilitation relieves dyspnoea (subjective awareness of being short of breath, which can vary in intensity) and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition. These improvements are clinically significant (McCarthy et al, 2015). Patients participating in pulmonary rehabilitation are monitored throughout using the BORG breathlessness scale (Borg, 1962), a validated tool that assesses patient perception of shortness of breath (dyspnoea) during exercise. Exercise itself as well as the amount of time that a patient can continue exercising is individually tailored using the Borg breathlessness scale. Current guidelines (BTS, 2016) suggest that patients should exercise to their maximal tolerable capacity, to receive the physiological benefits of exercise. Due to the exercise and mobility components, pulmonary rehabilitation has been traditionally led and delivered by physiotherapists
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The role of the multidisciplinary team in developing a comprehensive, evidence-based programme of education and patient support in pulmonary rehabilitation should not be overlooked. Components such as nutrition, psychological wellbeing and preventing social isolation are essential to building patient’s confidence and ability to self-care.
Although pulmonary rehabilitation is delivered differently across the country (Bolton et al, 2013), there are clear guidelines on outcome measures, and the muscle groups that require exercise. Walking and incremental strength training have a good clinical evidence base in the treatment of COPD (Bolton et al, 2013). However the delivery method and exact content of the educational sessions are open to interpretation.
condition; and where clinicians can empathise with the fear and anxiety it causes while actively teaching breathing control and active recovery.
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In the author's clinical experience, improving self-efficacy in patients with COPD or respiratory disorders helps them re-engage with society and daily activity by developing coping skills for breathlessness and ‘managing’ the condition. Key components of pulmonary rehabilitation that are aimed at managing breathlessness and improving self-efficacy include: Patients understanding their own 'normal' function Using positioned/pursed lip breathing techniques Energy conservation Relaxation — fear and anxiety reduction Increasing fitness and overall functional capacity.
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Self-efficacy Self-efficacy involves an individual's conviction that actions will bring about change. People with low selfefficacy have little faith that their actions or behaviours will have any effect on future outcomes. In the case of COPD, previous episodes of breathlessness can lead to patients developing a fear that nothing they can do will impact on future episodes (Wigal, 1991). This can lead to them actively avoiding activity due to a fear of breathlessness and a feeling that they are powerless to control it.
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Currently, pulmonary rehabilitation is being increasingly delivered by other healthcare professionals, such as nurses and occupational therapists (Vincent and Sewell, 2014). However, in the author's clinical experience nurses are often asked to deliver pulmonary rehabilitation despite little previous exposure to exercise therapies as part of their training (although traditional nursing care does offer a patient-centred approach focusing on the ability to perform activities of daily living). Furthermore, the ability to ensure that patients with respiratory conditions remain socially, psychologically and physically healthy is something nurses can deliver and, therefore, with supplementary exercise and pulmonary rehabilitation training, they can have a significant input to pulmonary rehabilitation programmes.
Self-management is defined as taking responsibility for one's own actions and behaviour. In COPD, this can mean self-medicating when experiencing increasing COPD symptoms, which might suggest an acute or infective exacerbation. In pulmonary rehabilitation, selfmanagement is delivered in a broader context to try and empower and build patients' skills in making longterm lifestyle changes. However, teaching self-management alone is not enough to bring about behaviour changes such as taking more exercise and smoking cessation (Bourbeau, 2003). Patients also need to 'believe' that they have the skills and capability to change situations and behaviours (Wigal et al, 1999).
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Shared skill-sets/ interchangeable roles
Health promotion and knowledge of disease are required parts of the educational programme, which also includes principles of selfmanagement, and key features to ensure patient wellbeing is fully addressed (Table 2).
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— physiotherapy being a professional discipline in which detailed anatomy and physiology of muscles and kinetics are fundamental elements. Therefore, physiotherapists have historically provided the exercise programmes, as they have the skills and knowledge to prescribe exercise, monitor and assess functional capacity, and modify exercise due to patients' potential musculoskeletal comorbidities.
Pulmonary rehabilitation is designed to provide a ‘safe’ environment where patients can learn that breathlessness is part of the
The COPD self-efficacy scale can be used as an outcomes measure (Wigal, 1991), however, many other tools are now available to measure patients' success, improvement in wellbeing, and functional capacity during and after pulmonary rehabilitation (Table 3). These tools can be implemented by any member of the multidisciplinary team and can be performed by community nurses without a physiotherapy background. However, specialist outcome measures may require specialist physiotherapy skills, i.e. muscle strength testing. In the author's clinical experience, involving the multidisciplinary team in patient care will enable other treatment avenues to be explored, which will benefit the patient and improve outcomes. This could include
Table 2: Pulmonary rehabilitation components for wellbeing and ability to self-manage Relaxation: anxiety management — psychological Nutrition: maintaining a healthy body mass index [BMI], fighting infection — physical wellbeing Benefits and claiming: social care, access to housing and social support Managing breathlessness: physical and psychological techniques Energy conservation: managing your day; tips to ensure management of activities of daily living — social/physical
Disease-specific interventions/teaching, including teaching about medication
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Having read this article, UHÁHFWRQ
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How you identify patients with COPD How patient education can help people with COPD Your knowledge of pulmonary rehabilitation and why it is vital to COPD management.
D Then, upload the article to the new, free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation 60
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REFERENCES
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Table 3: Possible pulmonary rehabilitation outcome measures `COPD assessment tool (CAT) — measures burden of disease (Jones et al, 2009)
`St George's respiratory questionnaire — measures quality of life
`Six-minute walk test — measures functional capacity
`Sit-to-stand — measures functional capacity `PHQ-9 — psychological wellbeing score
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(focuses on mood)
`GAD-7 — psychological wellbeing score
(focuses on generalised anxiety disorder) (Spitzer et al, 2006)
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Importantly, increasing the confidence and skills of more healthcare professionals across the UK so that they can deliver pulmonary rehabilitation will enable more patients to gain from this cost-effective and highly beneficial treatment option (Hodson and Sherrington, 2015).
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The literacy levels of the patients in the group need to be considered and obtaining good evidence-based patient-facing literature is important, including inhaler regimens, medicines management prompts, and clear pictorial action plans for exacerbations ('flare-ups'). The British Lung Foundation (BLF) website provides examples of this type of literature (http://shop.blf.org.uk/ collections/copd)
The ‘added’ value of involving the multidisciplinary team means that patient-focussed sessions can include medicines management and activities of daily living guidance, for example. However, nurses require training and supervision if they are to provide exercise as a therapy.
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Southampton integrated COPD team have a mixed-model approach to pulmonary rehabilitation, employing a physiotherapist as the pulmonary rehabilitation lead, with nurses, exercise therapists and healthcare assistants working together to provide complimentary skills in pulmonary rehabilitation. The format varies and there is a rolling session schedule, including 12 different sessions with visiting speakers from psychological services.
The fundamentals of pulmonary rehabilitation can be delivered successfully in the community by any member of the multidisciplinary team. However, exercise training and specialist physiotherapy interventions may be necessary in some patients (for example where they are unable to complete a six-minute walk test), and in those with complex comorbidities who require exercise modification, e.g. osteoarthritis.
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PULMONARY REHABILITATION IN PRACTICE
FUTURE COMMUNITY-BASED RESPIRATORY CARE
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physiotherapists, specialist nurses and occupational therapists, specialist support staff, exercise trainers, and healthcare assistants. Ensuring a good skill-mix in each session means that any exercise and health issues can be quickly and accurately addressed.
Bourbeau J (2003) Disease-specific selfmanagement programs in patients with advanced chronic obstructive pulmonary disease: a comprehensive and critical evaluation. Dis Manag Health Outcomes 11(5): 311–19 Bolton C, Bevan-Smith E, et al (2013) BTS Guideline on Pulmonary Rehabilitation in Adults. Available online: www.britthoracic.org.uk (accessed 10 May, 2016) Borg G (1962) Physical performance and perceived exertion. Studia Psychologica et Paedagogica (Series altera, Investigationes XI) Lund: Gleerup Bolton. C, Bevan-Smith E, Blakely JD, et al (2013) BTS Guideline on Pulmonary Rehabilitation in Adultss. Available online: www.brit-thoracic.org.uk (accessed 10 May, 2016) Collins PF, Stratton RJ, Elia M (2012) Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J Clin Nutr 95(6): 1385–95
Decramer M, Janssens W, Miravitlles M (2012) Chronic obstructive pulmonary disease. Lancet 379(9823): 1341–51 Department of Health (2012) An Outcomes Strategy for COPD and Asthma: NHS Companion Document. DH, London. Available online: www. gov.uk/government/uploads/system/ uploads/attachment_data/file/216531/ dh_134001.pdf GOLD (2016) Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD). Available online: http://goldcopd.org/ global-strategy-diagnosis-managementprevention-copd-2016 (accessed 10 May, 2016) Halbert RJ, Isonaka S, George D, Iqbal A (2003) Interpreting COPD prevalence estimates: what is the true burden of disease? Chest 123(5): 1684–92 Health and Safety Executive (2012) Chronic obstructive pulmonary disease (COPD). Available online: www.hse.gov. uk/Statistics/causdis/copd/index.htm (accessed May 18, 2016) Hodson M, Sherrington R (2015) Management of chronic obstructive pulmonary disease in primary care. Respiratory Care Today 1(1): 18–23 Jones PW, Harding G, Berry P, Wiklund I, Chen W-H, Kline Leidy N (2009) Development and first validation of the COPD Assessment Test. Eur Respir J 34: 648–54 Lacasse Y, Goldstein R, Lasserson TJ, Martin S (2006) Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 4: CD003793 London Respiratory Team (2013) Annual Report. September 2010–August 2011. Available online: www.networks.nhs.uk (accessed May 18, 2016)
RESPIRATORY CARE
Pulmonary rehabilitation is a well-evidenced programe of therapy for patients with chronic obstructive pulmonary disease (COPD).
It includes the provision of breathlessness interventions, nutritional support, and exercise therapy, all of which can be delivered by community nurses.
Pulmonary rehabilitation is also considered a low cost intervention and can be delivered by healthcare professionals of varying disciplines.
This
article explores the clinical elements that comprise pulmonary rehabilitation as well as investigating the ‘added value’ provided by multidisciplinary teams in the community.
HEALTH PROMOTION
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ACUTE CARE
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PRESCRIBING
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LONG-TERM CONDITIONS
uk (accessed 10 May, 2016) NHS England (2014a) Five Year Forward View. www.england.nhs.uk (accessed 10 May, 2016) NHS England (2014b) Our Ambition to Reduce Premature Mortality. Available online: www.england.nhs.uk (accessed 10 May, 2016) Office for National Statistics (2014) Ageing of the UK population. Available online: http://webarchive.nationalarchives.gov.uk (accessed 10 May, 2016)
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McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y (2015) Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review). Cochrane Database Syst Rev. 2015 Feb 23;2:CD003793 IMPRESS (2012) IMPRESS Guide to the relative value of COPD interventions. Available online: www.impressresp.com NICE (2011) Chronic obstructive pulmonary disease. Quality standard (QS10). NICE, London. Available online: www.nice.org.
Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J (2011) Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2011 Oct 5;(10):CD005305 Spruit MA, Singh SJ, Garvey C, et al (2013) An official American Thoracic Society/ European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 188(8): e13-64 Spitzer RL, Kroenke K, Williams J, Lowe B (2006) A brief measure for assessing generalized anxiety disorder. The GAD-7. Arch Intern Med 166(10): 1092–7 Vincent E, Sewell L (2014) The role of the nurse in pulmonary rehabilitation. Nurs Times 110(50): 16–18 Wigal JK, Creer TL, Kotses H (1991) The COPD Self-Efficacy Scale. Chest 99(5): 1193–96 Wedzicha JA, Donaldson GC (2003) Exacerbations of chronic obstructive pulmonary disease. Respir Care 48(12): 1204–15. Available online: www. airguardmedical.com/html/content/ wedzicha%20j_48_12.pdf
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