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Original article
Controlling dyspnea in chronic obstructive pulmonary disease patients Salwa R. El-Gendya,b a Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdul-Aziz University, Jeddah, KSA and bDepartment of Physical Therapy, Kasr Al-Aini Teaching Hospitals, Cairo University, Cairo, Egypt
Correspondence to Salwa R. El-Gendy, PhD, Physical Therapy Department, Faculty of Applied Medical Sciences, King Abdul-Aziz University, 21589 Jeddah, KSA Tel: + 966 501 540146; fax: + 966 501 524497; e-mail: [email protected]
Received 11 January 2015 Accepted 11 May 2015 Journal of the Egyptian Public Health Association 2015, 90:58–63
Background Dyspnea and fatigue are the most mutual symptoms known to be present in chronic obstructive pulmonary disease (COPD) patients. COPD patients have extra trouble breathing out fully. They can apply relaxed breathing techniques any time taking a breath such as following coughing or physical activity. By training to preserve energy with daily chores, patients can perform many physical actions with less dyspnea. Aim The aim of the current study was to assess the effect of an educational intervention on knowledge, practices, and disease severity in patients with COPD. Participants and methods A purposive sample of 100 adult male patients was selected randomly from the Respiratory Clinic at King Abdul-Aziz University Hospital, Jeddah. Patients were assessed using a clinical sheet, patients’ dyspnea knowledge questionnaire, patients’ practices observational checklists, the Modified Borg Scale, and the Hospital Anxiety and Depression Scale. Results More than 50% of patients had insufficient knowledge and 100% of them reported that they did not practice respiratory muscles exercises before the educational intervention. These improved after the intervention, showing a highly statistically significant difference. In addition, dyspnea and anxiety improved in COPD patients who had received supervised guidelines. Conclusion and recommendations Application of dyspnea-management guidelines has enhanced patients’ knowledge of their disease, practice, as well as dyspnea and anxiety levels. Health instruction materials for COPD patients can be useful by means of providing simplified guidelines, explanatory videos, leaflets, and/or brochures to clarify, avoid, and manage dyspnea. An additional estimate of the outcome of instructions to avoid and improve dyspnea and distress reactions in a larger sample size is proposed. Keywords: chronic obstructive pulmonary disease, dyspnea, supervised guidelines J Egypt Public Health Assoc 90:58–63 & 2015 Egyptian Public Health Association 0013-2446
Introduction Chronic obstructive pulmonary disease (COPD) is considered one of the main long-lasting illnesses and it is well known to be ‘a disease state characterized by airflow limitation that is not fully reversible’. Airflow restraint is typically progressing and commonly related to inflammatory lung reactions to several harmful particles and gases. Airway constriction and loss of elastic recoil accompany this pathology [1,2]. Airflow obstruction usually occurs with prolonged cough, expectoration, exertion dyspnea, fatigue, as well as wheezes. Patients are affected physically, emotionally, and socially, leading to a burden in the social care of patients [3]. Tobacco smoke is the primary cause of COPD, but other factors include indoor air pollution (e.g. rock-solid fuel used in food cooking and heating system); outdoor air pollution; occupational dusts and some chemicals (e.g. gases, irritants, and smokes); and repeated childhood lower 0013-2446 & 2015 Egyptian Public Health Association
respiratory tract infections. The WHO reported that the total deaths from COPD are suspected to increase by more than 30% in the next 10 years. Urgent actions must be undertaken to reduce risk factors, especially tobacco habit. In fact, COPD is commonly found in men, but as tobacco usage has increased among women in highincome countries and because of the greater hazard of indoor air pollution in low-income countries, it currently affects both sexes almost to a similar extent [4,5]. Undiagnosed COPD incidence in Egyptians is 4 197 651 and the rate of diagnosis is 3 777 886. It is likely that nearly 80 million individuals globally suffer from moderate to severe COPD [4]. Indicator symptoms and exacerbations are accountable for extensive health care costs, with high levels of consultation and hospital admissions [6,7]. The diagnosis and definition of the degree of severity of COPD was established in agreement with the Global DOI: 10.1097/01.EPX.0000466428.62006.8c
Copyright r 2015 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Controlling dyspnea in COPD El-Gendy 59
Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines [1,2]. Stage 0 (at risk) is diagnosed when patients report long-lasting coughing with expectoration, whereas their lung function is quite average. In stage I, mild COPD, there may be mild airflow drawback, but the patient may not recognize that his/her lung function is starting to deteriorate. By the time COPD patients progress to stage IV, very severe COPD, quality of life is seriously compromised and exacerbations become life threatening. By this stage, chronic respiratory failure exists frequently, and may lead to cardiac medical problems, such as corpulmonale and/or finally death [8]. Patients with COPD experience fatigue and it is identified as one of the primary symptoms. Patients describe it as the second most prevalent symptom after dyspnea. Fatigue is ‘almost always’ described by 43–58% of patients [9,10]. Patient education is basic to self-manage the disease – That is, to enhance patient’s ability to cope with the disease. Only informative interventions that raise awareness are inadequate; patients should also be able to integrate the knowledge and tools into their daily lives, producing behavioral change. Provision of simple instructions help improving their fulfillment levels [11,12]. COPD patients should be involved in management planning, including quitting smoking and avoiding relapse, identifying the drugs that should be taken, using inhalers, avoiding and managing outbreaks, indulging in workouts and physical activity, dyspnea and breath control, besides energy-conserving techniques, and airway cleaning: clearing lungs, home oxygen treatment, and management of worry, anxiety, and depression [13–15]. The aim of this study was to assess the effect of an educational intervention on knowledge, practices, and disease severity in patients with COPD.
Patients and methods An experimental pretest–post-test study design was used. A random sample of 100 adult COPD male patients diagnosed and identified as stage II and III and who were clinically stable were recruited from the outpatient clinic of King Abdul-Aziz University Hospital. Identification of COPD was performed according to GOLD standards [1]. Exclusion criteria were as follows: patients with airflow limitation because of tuberculosis, asthma, bronchiectasis, or heart failure, extremely ill patients, and individuals with impaired cognition. The study was carried out from November 2013 to July 2014. An official approval was obtained from the directors of King Abdul-Aziz University Hospital and the head of the Respiratory Disease Clinic. A written informed consent form, approved by the Research Ethical Board of the Faculty of Applied Medical Sciences at King AbdulAziz University, was signed by all the patients enrolled. All formats were distributed to the participants to obtain their baseline health information and to attain starting point with a response rate of 80%.
Data collection tools Patients’ assessment and clinical data sheet
The sheet was prepared by the researcher to collect demographic data such as age, sex, education, present and previous smoking history, and work. The sheet also included duration of disease, disease severity, frequent hospital admissions, and concomitant signs and symptoms. Dyspnea knowledge questionnaire
Fifty close-ended MCQs were prepared by the researcher in the Arabic language. It included knowledge of monitoring dyspnea, use of energy-saving relaxation techniques, and deep breathing exercises. The overall scoring was 50. One point was assigned for each correct response, whereas zero was assigned for a wrong response. For every area of knowledge, points were summed and the total was divided by the number of items, yielding a mean score for the area that was transformed into a percentage score. Overall participants’ knowledge scoring was considered acceptable if it was 70% or more and unacceptable if it was lower than 70%. Patients’ practices observational checklists
Similar to Cleary and Serisier [16] pre and post assessment of deep breathing exercises, inhaler use, and energy conservation for dyspnea control. One score was assigned for the done item and zero for the item not done, and the total was calculated and transformed into a percent. For each practice, the scores were measured as adequate if the percent score was 70% or above and inadequate if it was less than 70%. Assessment of patients’ condition
To assess the level of dyspnea and anxiety, the following scales were used: (1) Modified Borg Scale [17]: It is a fairly subjective tool for detection of the severity of dyspnea in several actions using a straight up 0– 10-point scale with words labeling grades of supposed exertion linked to numbers. The scores assumed for each patient were summed and divided by the total number of items, to yield a mean score. (2) Hospital Anxiety and Depression Scale: It is a valid and reliable tool to measure depression state as well as nervousness related to dyspnea in COPD patients. It was developed by Zigmond and Snaith [18]. It includes 14 items to measure anxiety and depression in dual distinct subscales, of which seven items quantify symptoms of depression during the last week, whereas the rest quantify them during the previous week. Every component is valued on a four-point scale (0 = no, not at all; 1 = no, not much; 2 = yes, sometimes; and 3 = yes, certainly). The item scores are then summed to provide subscoring for anxiety and depression. Scores range from 0 to 21 for each subscale.
Data collection
Before starting the study, an approved agreement was obtained from the executives of King Abdul-Aziz
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Journal of the Egyptian Public Health Association
University Hospital as well as from the head of the respiratory disease clinic to start the study. (1) Pre-test: The pretest was administered. It included questions on knowledge of coping with dyspnea. (2) The intervention: (a) An educational program, using videos and brochures adapted from Saudi guidelines for the diagnosis and management of COPD, was implemented. The guidelines were focused toward each patient individually and were clarified over lectures, discussions, and demonstrations tailored to his needs and understanding Table 1. General and clinical characteristics of the studied sample, chronic obstructive pulmonary disease patients, King Abdul-Aziz University Hospital, Saudi Arabia, 2013 Personal characteristics Age 40 to < 50 50 to < 60 60–69 Range Mean ± SD Sex Male Education Illiterate Basic Middle Higher Occupation White-collar worker Blue-collar worker laborer in factories emitting irritants Retired Smoking Yes No Clinical characteristics Disease duration o1 year Z1 year Disease severity Stage II (moderate) Stage III (severe) Frequent hospital admission No Once Two times Three times and more
% (N = 100) 10.0 58.0 32.0 42–69 53 ± 6.3 100.0 14.0 23.0 27.0 36.0 25.0 31.0 38.0 6.0 76.0 24.0 43.0 57.0 70.0 30.0 59.0 32.0 5.0 4.0
over two to three consecutive sittings. Instructional media were used. Every sitting lasted around 30–45 min, three times weekly in the daytime, for 4 weeks. (b) All of the participants agreed to participate. The researcher’s phone number was given to the participants and their phone numbers were saved to facilitate interaction and consultation through follow-up appointments in outpatients’ clinics for completion of data collection throughout followup. (3) Post-test: (a) Immediately after the guidelines were presented, a reassessment was carried out using identical pretest tools, except patients’ assessment and clinical sheet. (b) Comparison of the collected preintervention and postintervention data was carried out to determine the effectiveness of the guidelines in the control of dyspnea. Statistical analysis
Data analysis was carried out using the statistical package for the social sciences (SPSS, version 16; SPSS Inc., Chicago, Illinois, USA). Participants’ data were presented by descriptive statistics as means, SD, and percentages. A paired T-test was used at a 0.05 significance level.
Results The general characteristics of the study sample are described in Table 1. Over half of the participants (58%) were from 50 to less than 60 years old. All the study participants (100%) were men; 37% were illiterate or had received basic education, 25% were white-collar workers, and 76% were current smokers. With respect to the patients’ clinical characteristics, over half of the participants (57%) were identified to have COPD for 1 year or more. In addition, 70% had COPD stage II, 59% had not been formerly admitted to hospital, and only 4% had been admitted three times or more.
Table 2. Signs and symptoms associated with dyspnea before and after study (N = 100) N (%) Dyspnea associated signs and symptoms Breathing difficulty Yes No Sense of suffocation or choking Yes No Chest tightness Yes No Difficulty getting enough air Yes No
Paired T-test
Before
After
Test
P
Significance
83 (83.0) 17 (17.0)
14 (14.0) 86 (86.0)
57.853
o0.000
HS
95 (95.0) 5 (5.0)
28 (28.0) 72 (72.0)
49.066
o0.000
HS
54 (54.0) 46 (46.0)
20 (20.0) 80 (80.0)
2.398
o0.000
HS
64 (64.0) 36 (36.0)
4 (4.0) 96 (96.0)
o0.000
HS
36.0
HS, highly significant.
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Controlling dyspnea in COPD El-Gendy 61
Table 3. Severity of dyspnea and anxiety among participants before and after the intervention (%) (N = 100) Before
After
Borg scale for dyspnea (max = 10) No 0.0 6.0 Mild (1–3) 18.0 42.0 Moderate (4–7) 68.0 48.0 Severe (8–10) 14.0 4.0 Mean (0–10) 6 ± 1.1 3.2 ± 3.1 Anxiety level No anxiety Mild Moderate Severe
0 13 25 62
Table 4. Percent of patients with acceptable knowledge level before and after the study
Test
% (N = 100)
Paired T-test
P
12.3
o0.01**
Kruskal–Wallis test 4.99
0.08
23 52 12 13
13.3
o0.001**
**Highly statistically significant at Po0.01.
Table 2 shows the preintervention and postintervention signs and symptoms of dyspnea. A highly statistically significant difference was found (Po0.000). According to the Modified Borg Scale, over two-thirds (68.0%) of the participants had moderate dyspnea compared with 48.0% after the intervention, with a high statistically significant difference. In addition, the total number of patients with severe dyspnea decreased after the intervention (4.0%) compared with 14.0% before the intervention, with a highly statistically significant difference (Po0.01). There was a highly statistically significant difference between pre and post mean scores. In terms of anxiety levels, 62% of patients had severe anxiety, followed by 25% with moderate anxiety and 13% with mild anxiety before the intervention, which decreased to 13, 12, and 52%, respectively, after the intervention, with a highly statistically significant difference (Po0.001) (Table 3). Table 4 shows he knowledge levels before and after the intervention. None of the participants had an acceptable level of knowledge of COPD and respiratory muscle exercises before the intervention. After the intervention, the majority of them (83.7%) had acceptable knowledge (Po0.001). With respect to patients’ practice level, Table 5 shows that small number of them had adequate effect of breathing exercises, and inhaler use preintervention, with high significant progress postintervention. Furthermore, none of them reported adequate practice of respiratory muscle exercises before the intervention, which improved to 81% after the intervention. Similarly, there was a statistically significant increase in the use of relaxation exercises after the intervention (Po0.001). Evaluating dyspnea ratings before and after the intervention using the Medical Research Council (MRC) Breathlessness Scale (Table 6) shows that there was a high statistically significant difference between the numbers of patients with different grades before and after the intervention. Whereas 47.0% of patients had grade 3 dyspnea before the study, only 26.0% had grade 3 dyspnea after the study. Similarly, 36.0% of patients had grade 4 dyspnea before the intervention compared with 12.0%
Items
Before After Paired T-test
COPD Controlling dyspnea Energy conserving Breathing exercises Relaxation techniques Respiratory muscles exercises Total knowledge
0 24 52 10 12 0 16.3
84 76 86 98 78 80 83.7
81.8 13.15 11.97 77.94 44.0 89.8 78.6
P 0.000** 0.001** 0.001** 0.000** 0.000** 0.000** 0.000**
COPD, chronic obstructive pulmonary disease. **Highly significant at Po0.001.
Table 5. Percent of patients with adequate level of self-care for both dyspnea and fatigue before and after the intervention Self-care practice Breathing exercises Relaxation techniques Respiratory muscles exercises Inhaler use
Before (%)
After (%)
Paired T-test
10 12 0
96 20 81
77.94 o0.001** 4.5 o0.05* 81.8 o0.001**
11
98
77.94 o0.001**
P
*Statistically significant at Po0.05. **Highly statistically significant at Po0.001.
Table 6. Dyspnea grades before and after the intervention Dyspnea grades Grade Grade Grade Grade Grade
1 2 3 4 5
Before (%)
After (%)
Paired T-test
P value
3.0 8.0 47.0 36.0 6.0
18.0 39.0 26.0 12.0 5.0
23.1
o0.01**
**Highly statistically significant at Po0.001.
after the intervention. The least change in grade was observed among patients with grade 5 dyspnea.
Discussion COPD patients most commonly experience dyspnea and fatigue; both these symptoms lead to decreased activity levels and reduced quality of life [11]. This study assessed the effect of an educational intervention on knowledge, practices, and disease severity in patients with COPD. With respect to the clinical characteristics of the patients, it was clear that 57% had COPD for 1 year or more and 70% had COPD stage II, with a considerable proportion (41%) admitted formerly. This finding was comparable with Baghai-Ravary et al. [19], who found high admission rates among COPD patients, which increases with age. Similarly, Tel et al. [13] proved that scores of activities of daily living were decreased for 12 years or more. The aim of health education is to change clinical state by providing instructions on suitable self-controlling skills. In terms of the level of knowledge, the study showed the
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62 Journal of the Egyptian Public Health Association
presence of highly statistically significant differences in all knowledge items. In terms of overall patients’ knowledge, a highly statistically significant increase was observed after the intervention, showing the impact of the guidelines. This may have been because of the importance of knowledge for the patient. Many patients first diagnosed with COPD reported feelings of confusion and worry; these are calmed after clarifications regarding dyspnea and other symptoms is still needed. Also, these reduced with patients’ active involvement in decision making and development of a management plan. All these could improve the subject’s medical state [19]. The present study found a highly statistically significant improvement in almost all aspects. Surviving with a chronic condition needs skills, learning to manage symptoms, and intentionally considering and making routine lifestyle changes. It was found that patients who were assisted with health care personnel had a managing strategy & follow up to stay in a better way with COPD [5,20]. The primary symptom that commonly affects COPD patients is dyspnea. The MRC Dyspnea Scale represents an easy and valid means of classifying COPD patients on the basis of their disability. The data was obtained by assessing breathlessness using the Modified Borg Scale and MRC Breathlessness Scale. It indicated a highly statistically significant progress after the intervention. This may be attributed to the patients’ desire to learn and use methods to control this debilitating symptom as also noted by other studies [17,21,22]. It is worth mentioning that nearly half of the study patients had grade 3 dyspnea, which decreased significantly after the educational intervention. This result was better than that of Wong et al. [20], who reported that 53.3% of their study participants expressed no improvement. In the present study, most of the participants showed moderate to severe anxiety before the intervention, whereas after the intervention, significant improvement was found. This outcome was similar to that of Maurer et al. [23], who reported that anxiety is a very common morbid factor in COPD and has a clear statistically significant impact on patients, relatives, the public, and disease progression. Neglected and unobserved anxiety can lead to an increase in physical disability and illness, besides being a healthcare burden.
The following suggestions are recommended:
(1) Further study including female patients should be carried out for comparison with the results obtained from male patients. (2) Complete health education should be provided for COPD patients in chest outpatient clinics as well as physiotherapy clinics with videos, guidelines, leaflets, or pamphlets clarifying how to avoid and manage dyspnea and fatigue. (3) Estimation of the impact of strategies for controlling dyspnea should be advanced in a larger sample in order to generalize results. (4) Establish and implement a home program to efficiently relieve dyspnea and fatigue in these patients.
Acknowledgements Conflicts of interest There are no conflicts of interset.
References 1 Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2005. Available at: http://goldcopd.com/ Guidelineitem.asp?l1 = 2&12 = 1&intld = 989. [Accessed January 2015]. 2 Khan JH, Lababidi HM, Al-Moamary MS, Zeitouni MO, Al-Jahdali HH, AlAmoudi OS, et al. The Saudi Guidelines for the Diagnosis and Management of COPD. Ann Thorac Med 2014; 9:55–76. 3 Aras A, Tel H. Determination of perceived social support for patients with COPD and related factors. Turk Thorax J 2009; 10:63–68. 4 World Health Organization (WHO). Chronic obstructive pulmonary disease (COPD), fact sheet no. 315. Available at: http://www.who.int/mediacentre/ factsheets/fs315/en/. [Accessed 23 January 2015]. 5 National Heart, Lung, and Blood Institute. How Does COPD Affect breathing. Available at: https://www.nhlbi.nih.gov/health/educational/copd/what-iscopd/how-does-copd-affect-breathing.htm. [Accessed 11 Febraury 2013]. 6 Khattab A, Javaid A, Iraqi G, Alzaabi A, Kheder A, Koniski M, et al. Smoking habits in the Middle East and North Africa. Respir Med 2012; 106: 16–24. 7 Idrees M, Koniski ML, Taright S, Shahrour N, Polatli M, Ben Kheder A, et al. BREATHE Study Group. Management of chronic obstructive pulmonary disease in the Middle East and North Africa: results of the BREATHE study. Respir Med 2012; 106 Suppl 2 (Suppl 2):S33–S44. 8 Raouf HAE, Sebaee HAA. Impact of obesity on selected parameters among patients with chronic obstructive pulmonary disease. J Am Sci 2011; 7:714–725. 9 Leader D. The stages of COPD define the disease according to severity, 2013. Available at: http://copd.about.com/od/copdbasics/a/stagesofcopd. [Accessed October 2014]. 10 Blinderman CD, Homel P, Billings JA, Tennstedt S, Portenoy RK. Symptom distress and quality of life in patients with advanced chronic obstructive pulmonary disease. J Pain Symptom Manage 2009; 38:115–123. 11 Peters JB, Heijdra YF, Daudey L, Boer LM, Molema J, Dekhuijzen PN, et al. Course of normal and abnormal fatigue in patients with chronic obstructive pulmonary disease, and its relationship with domains of health status. Patient Educ Couns 2011; 85:281–285. 12 Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, et al. Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007; 131 (Suppl):4S–42S.
Conclusion and recommendations In the present study, application of controlling guidelines led to beneficial effects on patients’ knowledge and practice levels in the management of dyspnea. Dyspnea and anxiety were relieved to a huge extent in COPD participants who developed dyspnea and fatigue-control strategies.
13 Tel H, Bilgic¸ Z, Zorlu Z. Evaluation of dyspnea and fatigue among the COPD patients, chronic obstructive pulmonary disease – current concepts and practice; 2012. Available at: http://www.intechopen.com/books/chronicobstructive-pulmonary-disease-current-concepts-and-practice/evaluation-ofdyspnea-and-fatigue-among-the-copd-patients. [Accessed January 2015]. 14 Velloso M, Jardim JR. Functionality of patients with chronic obstructive pulmonary disease: energy conservation techniques. J Bras Pneumol 2006; 32:580–586. 15 Knowles M, Holton E, Swanson R. The adult learner: the definitive classic in adult education and human resource development, 6th ed. San Diego: Elsevier Inc.; 2005.
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Controlling dyspnea in COPD El-Gendy 63
16 Cleary M, Serisier D. Better living with chronic obstructive pulmonary disease: a patient guide, 2nd ed.. Queensland: The Australian Lung Foundation, Queensland Government; 2005. pp. 11–12. 17 Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982; 14:377–381. 18 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67:361–370. 19 Baghai-Ravary R, Quint JK, Goldring JJ, Hurst JR, Donaldson GC, Wedzicha JA. Determinants and impact of fatigue in patients with chronic obstructive pulmonary disease. Respir Med 2009; 103:216–223. 20 Wong CJ, Goodridge D, Marciniuk DD, Rennie D. Fatigue in patients with COPD participating in a pulmonary rehabilitation program. Int J Chron Obstruct Pulmon Dis 2010; 5:319–326.
21 Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Anto´ JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 2006; 61: 772–778. 22 Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999; 54:581–586. Available at: http://thorax.bmj.com/content/54/ 7/581.full.html#reflist1. 23 Maurer J, Rebbapragada V, Borson S, Goldstein R, Kunik ME, Yohannes AM, Hanania NA. ACCP Workshop Panel on Anxiety and Depression in COPD. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest 2008; 134 (Suppl):43S–56S.
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Original article
Controlling dyspnea in chronic obstructive pulmonary disease patients Salwa R. El-Gendya,b a Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdul-Aziz University, Jeddah, KSA and bDepartment of Physical Therapy, Kasr Al-Aini Teaching Hospitals, Cairo University, Cairo, Egypt
Correspondence to Salwa R. El-Gendy, PhD, Physical Therapy Department, Faculty of Applied Medical Sciences, King Abdul-Aziz University, 21589 Jeddah, KSA Tel: + 966 501 540146; fax: + 966 501 524497; e-mail: [email protected]
Received 11 January 2015 Accepted 11 May 2015 Journal of the Egyptian Public Health Association 2015, 90:58–63
Background Dyspnea and fatigue are the most mutual symptoms known to be present in chronic obstructive pulmonary disease (COPD) patients. COPD patients have extra trouble breathing out fully. They can apply relaxed breathing techniques any time taking a breath such as following coughing or physical activity. By training to preserve energy with daily chores, patients can perform many physical actions with less dyspnea. Aim The aim of the current study was to assess the effect of an educational intervention on knowledge, practices, and disease severity in patients with COPD. Participants and methods A purposive sample of 100 adult male patients was selected randomly from the Respiratory Clinic at King Abdul-Aziz University Hospital, Jeddah. Patients were assessed using a clinical sheet, patients’ dyspnea knowledge questionnaire, patients’ practices observational checklists, the Modified Borg Scale, and the Hospital Anxiety and Depression Scale. Results More than 50% of patients had insufficient knowledge and 100% of them reported that they did not practice respiratory muscles exercises before the educational intervention. These improved after the intervention, showing a highly statistically significant difference. In addition, dyspnea and anxiety improved in COPD patients who had received supervised guidelines. Conclusion and recommendations Application of dyspnea-management guidelines has enhanced patients’ knowledge of their disease, practice, as well as dyspnea and anxiety levels. Health instruction materials for COPD patients can be useful by means of providing simplified guidelines, explanatory videos, leaflets, and/or brochures to clarify, avoid, and manage dyspnea. An additional estimate of the outcome of instructions to avoid and improve dyspnea and distress reactions in a larger sample size is proposed. Keywords: chronic obstructive pulmonary disease, dyspnea, supervised guidelines J Egypt Public Health Assoc 90:58–63 & 2015 Egyptian Public Health Association 0013-2446
Introduction Chronic obstructive pulmonary disease (COPD) is considered one of the main long-lasting illnesses and it is well known to be ‘a disease state characterized by airflow limitation that is not fully reversible’. Airflow restraint is typically progressing and commonly related to inflammatory lung reactions to several harmful particles and gases. Airway constriction and loss of elastic recoil accompany this pathology [1,2]. Airflow obstruction usually occurs with prolonged cough, expectoration, exertion dyspnea, fatigue, as well as wheezes. Patients are affected physically, emotionally, and socially, leading to a burden in the social care of patients [3]. Tobacco smoke is the primary cause of COPD, but other factors include indoor air pollution (e.g. rock-solid fuel used in food cooking and heating system); outdoor air pollution; occupational dusts and some chemicals (e.g. gases, irritants, and smokes); and repeated childhood lower 0013-2446 & 2015 Egyptian Public Health Association
respiratory tract infections. The WHO reported that the total deaths from COPD are suspected to increase by more than 30% in the next 10 years. Urgent actions must be undertaken to reduce risk factors, especially tobacco habit. In fact, COPD is commonly found in men, but as tobacco usage has increased among women in highincome countries and because of the greater hazard of indoor air pollution in low-income countries, it currently affects both sexes almost to a similar extent [4,5]. Undiagnosed COPD incidence in Egyptians is 4 197 651 and the rate of diagnosis is 3 777 886. It is likely that nearly 80 million individuals globally suffer from moderate to severe COPD [4]. Indicator symptoms and exacerbations are accountable for extensive health care costs, with high levels of consultation and hospital admissions [6,7]. The diagnosis and definition of the degree of severity of COPD was established in agreement with the Global DOI: 10.1097/01.EPX.0000466428.62006.8c
Copyright r 2015 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Controlling dyspnea in COPD El-Gendy 59
Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines [1,2]. Stage 0 (at risk) is diagnosed when patients report long-lasting coughing with expectoration, whereas their lung function is quite average. In stage I, mild COPD, there may be mild airflow drawback, but the patient may not recognize that his/her lung function is starting to deteriorate. By the time COPD patients progress to stage IV, very severe COPD, quality of life is seriously compromised and exacerbations become life threatening. By this stage, chronic respiratory failure exists frequently, and may lead to cardiac medical problems, such as corpulmonale and/or finally death [8]. Patients with COPD experience fatigue and it is identified as one of the primary symptoms. Patients describe it as the second most prevalent symptom after dyspnea. Fatigue is ‘almost always’ described by 43–58% of patients [9,10]. Patient education is basic to self-manage the disease – That is, to enhance patient’s ability to cope with the disease. Only informative interventions that raise awareness are inadequate; patients should also be able to integrate the knowledge and tools into their daily lives, producing behavioral change. Provision of simple instructions help improving their fulfillment levels [11,12]. COPD patients should be involved in management planning, including quitting smoking and avoiding relapse, identifying the drugs that should be taken, using inhalers, avoiding and managing outbreaks, indulging in workouts and physical activity, dyspnea and breath control, besides energy-conserving techniques, and airway cleaning: clearing lungs, home oxygen treatment, and management of worry, anxiety, and depression [13–15]. The aim of this study was to assess the effect of an educational intervention on knowledge, practices, and disease severity in patients with COPD.
Patients and methods An experimental pretest–post-test study design was used. A random sample of 100 adult COPD male patients diagnosed and identified as stage II and III and who were clinically stable were recruited from the outpatient clinic of King Abdul-Aziz University Hospital. Identification of COPD was performed according to GOLD standards [1]. Exclusion criteria were as follows: patients with airflow limitation because of tuberculosis, asthma, bronchiectasis, or heart failure, extremely ill patients, and individuals with impaired cognition. The study was carried out from November 2013 to July 2014. An official approval was obtained from the directors of King Abdul-Aziz University Hospital and the head of the Respiratory Disease Clinic. A written informed consent form, approved by the Research Ethical Board of the Faculty of Applied Medical Sciences at King AbdulAziz University, was signed by all the patients enrolled. All formats were distributed to the participants to obtain their baseline health information and to attain starting point with a response rate of 80%.
Data collection tools Patients’ assessment and clinical data sheet
The sheet was prepared by the researcher to collect demographic data such as age, sex, education, present and previous smoking history, and work. The sheet also included duration of disease, disease severity, frequent hospital admissions, and concomitant signs and symptoms. Dyspnea knowledge questionnaire
Fifty close-ended MCQs were prepared by the researcher in the Arabic language. It included knowledge of monitoring dyspnea, use of energy-saving relaxation techniques, and deep breathing exercises. The overall scoring was 50. One point was assigned for each correct response, whereas zero was assigned for a wrong response. For every area of knowledge, points were summed and the total was divided by the number of items, yielding a mean score for the area that was transformed into a percentage score. Overall participants’ knowledge scoring was considered acceptable if it was 70% or more and unacceptable if it was lower than 70%. Patients’ practices observational checklists
Similar to Cleary and Serisier [16] pre and post assessment of deep breathing exercises, inhaler use, and energy conservation for dyspnea control. One score was assigned for the done item and zero for the item not done, and the total was calculated and transformed into a percent. For each practice, the scores were measured as adequate if the percent score was 70% or above and inadequate if it was less than 70%. Assessment of patients’ condition
To assess the level of dyspnea and anxiety, the following scales were used: (1) Modified Borg Scale [17]: It is a fairly subjective tool for detection of the severity of dyspnea in several actions using a straight up 0– 10-point scale with words labeling grades of supposed exertion linked to numbers. The scores assumed for each patient were summed and divided by the total number of items, to yield a mean score. (2) Hospital Anxiety and Depression Scale: It is a valid and reliable tool to measure depression state as well as nervousness related to dyspnea in COPD patients. It was developed by Zigmond and Snaith [18]. It includes 14 items to measure anxiety and depression in dual distinct subscales, of which seven items quantify symptoms of depression during the last week, whereas the rest quantify them during the previous week. Every component is valued on a four-point scale (0 = no, not at all; 1 = no, not much; 2 = yes, sometimes; and 3 = yes, certainly). The item scores are then summed to provide subscoring for anxiety and depression. Scores range from 0 to 21 for each subscale.
Data collection
Before starting the study, an approved agreement was obtained from the executives of King Abdul-Aziz
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Journal of the Egyptian Public Health Association
University Hospital as well as from the head of the respiratory disease clinic to start the study. (1) Pre-test: The pretest was administered. It included questions on knowledge of coping with dyspnea. (2) The intervention: (a) An educational program, using videos and brochures adapted from Saudi guidelines for the diagnosis and management of COPD, was implemented. The guidelines were focused toward each patient individually and were clarified over lectures, discussions, and demonstrations tailored to his needs and understanding Table 1. General and clinical characteristics of the studied sample, chronic obstructive pulmonary disease patients, King Abdul-Aziz University Hospital, Saudi Arabia, 2013 Personal characteristics Age 40 to < 50 50 to < 60 60–69 Range Mean ± SD Sex Male Education Illiterate Basic Middle Higher Occupation White-collar worker Blue-collar worker laborer in factories emitting irritants Retired Smoking Yes No Clinical characteristics Disease duration o1 year Z1 year Disease severity Stage II (moderate) Stage III (severe) Frequent hospital admission No Once Two times Three times and more
% (N = 100) 10.0 58.0 32.0 42–69 53 ± 6.3 100.0 14.0 23.0 27.0 36.0 25.0 31.0 38.0 6.0 76.0 24.0 43.0 57.0 70.0 30.0 59.0 32.0 5.0 4.0
over two to three consecutive sittings. Instructional media were used. Every sitting lasted around 30–45 min, three times weekly in the daytime, for 4 weeks. (b) All of the participants agreed to participate. The researcher’s phone number was given to the participants and their phone numbers were saved to facilitate interaction and consultation through follow-up appointments in outpatients’ clinics for completion of data collection throughout followup. (3) Post-test: (a) Immediately after the guidelines were presented, a reassessment was carried out using identical pretest tools, except patients’ assessment and clinical sheet. (b) Comparison of the collected preintervention and postintervention data was carried out to determine the effectiveness of the guidelines in the control of dyspnea. Statistical analysis
Data analysis was carried out using the statistical package for the social sciences (SPSS, version 16; SPSS Inc., Chicago, Illinois, USA). Participants’ data were presented by descriptive statistics as means, SD, and percentages. A paired T-test was used at a 0.05 significance level.
Results The general characteristics of the study sample are described in Table 1. Over half of the participants (58%) were from 50 to less than 60 years old. All the study participants (100%) were men; 37% were illiterate or had received basic education, 25% were white-collar workers, and 76% were current smokers. With respect to the patients’ clinical characteristics, over half of the participants (57%) were identified to have COPD for 1 year or more. In addition, 70% had COPD stage II, 59% had not been formerly admitted to hospital, and only 4% had been admitted three times or more.
Table 2. Signs and symptoms associated with dyspnea before and after study (N = 100) N (%) Dyspnea associated signs and symptoms Breathing difficulty Yes No Sense of suffocation or choking Yes No Chest tightness Yes No Difficulty getting enough air Yes No
Paired T-test
Before
After
Test
P
Significance
83 (83.0) 17 (17.0)
14 (14.0) 86 (86.0)
57.853
o0.000
HS
95 (95.0) 5 (5.0)
28 (28.0) 72 (72.0)
49.066
o0.000
HS
54 (54.0) 46 (46.0)
20 (20.0) 80 (80.0)
2.398
o0.000
HS
64 (64.0) 36 (36.0)
4 (4.0) 96 (96.0)
o0.000
HS
36.0
HS, highly significant.
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Controlling dyspnea in COPD El-Gendy 61
Table 3. Severity of dyspnea and anxiety among participants before and after the intervention (%) (N = 100) Before
After
Borg scale for dyspnea (max = 10) No 0.0 6.0 Mild (1–3) 18.0 42.0 Moderate (4–7) 68.0 48.0 Severe (8–10) 14.0 4.0 Mean (0–10) 6 ± 1.1 3.2 ± 3.1 Anxiety level No anxiety Mild Moderate Severe
0 13 25 62
Table 4. Percent of patients with acceptable knowledge level before and after the study
Test
% (N = 100)
Paired T-test
P
12.3
o0.01**
Kruskal–Wallis test 4.99
0.08
23 52 12 13
13.3
o0.001**
**Highly statistically significant at Po0.01.
Table 2 shows the preintervention and postintervention signs and symptoms of dyspnea. A highly statistically significant difference was found (Po0.000). According to the Modified Borg Scale, over two-thirds (68.0%) of the participants had moderate dyspnea compared with 48.0% after the intervention, with a high statistically significant difference. In addition, the total number of patients with severe dyspnea decreased after the intervention (4.0%) compared with 14.0% before the intervention, with a highly statistically significant difference (Po0.01). There was a highly statistically significant difference between pre and post mean scores. In terms of anxiety levels, 62% of patients had severe anxiety, followed by 25% with moderate anxiety and 13% with mild anxiety before the intervention, which decreased to 13, 12, and 52%, respectively, after the intervention, with a highly statistically significant difference (Po0.001) (Table 3). Table 4 shows he knowledge levels before and after the intervention. None of the participants had an acceptable level of knowledge of COPD and respiratory muscle exercises before the intervention. After the intervention, the majority of them (83.7%) had acceptable knowledge (Po0.001). With respect to patients’ practice level, Table 5 shows that small number of them had adequate effect of breathing exercises, and inhaler use preintervention, with high significant progress postintervention. Furthermore, none of them reported adequate practice of respiratory muscle exercises before the intervention, which improved to 81% after the intervention. Similarly, there was a statistically significant increase in the use of relaxation exercises after the intervention (Po0.001). Evaluating dyspnea ratings before and after the intervention using the Medical Research Council (MRC) Breathlessness Scale (Table 6) shows that there was a high statistically significant difference between the numbers of patients with different grades before and after the intervention. Whereas 47.0% of patients had grade 3 dyspnea before the study, only 26.0% had grade 3 dyspnea after the study. Similarly, 36.0% of patients had grade 4 dyspnea before the intervention compared with 12.0%
Items
Before After Paired T-test
COPD Controlling dyspnea Energy conserving Breathing exercises Relaxation techniques Respiratory muscles exercises Total knowledge
0 24 52 10 12 0 16.3
84 76 86 98 78 80 83.7
81.8 13.15 11.97 77.94 44.0 89.8 78.6
P 0.000** 0.001** 0.001** 0.000** 0.000** 0.000** 0.000**
COPD, chronic obstructive pulmonary disease. **Highly significant at Po0.001.
Table 5. Percent of patients with adequate level of self-care for both dyspnea and fatigue before and after the intervention Self-care practice Breathing exercises Relaxation techniques Respiratory muscles exercises Inhaler use
Before (%)
After (%)
Paired T-test
10 12 0
96 20 81
77.94 o0.001** 4.5 o0.05* 81.8 o0.001**
11
98
77.94 o0.001**
P
*Statistically significant at Po0.05. **Highly statistically significant at Po0.001.
Table 6. Dyspnea grades before and after the intervention Dyspnea grades Grade Grade Grade Grade Grade
1 2 3 4 5
Before (%)
After (%)
Paired T-test
P value
3.0 8.0 47.0 36.0 6.0
18.0 39.0 26.0 12.0 5.0
23.1
o0.01**
**Highly statistically significant at Po0.001.
after the intervention. The least change in grade was observed among patients with grade 5 dyspnea.
Discussion COPD patients most commonly experience dyspnea and fatigue; both these symptoms lead to decreased activity levels and reduced quality of life [11]. This study assessed the effect of an educational intervention on knowledge, practices, and disease severity in patients with COPD. With respect to the clinical characteristics of the patients, it was clear that 57% had COPD for 1 year or more and 70% had COPD stage II, with a considerable proportion (41%) admitted formerly. This finding was comparable with Baghai-Ravary et al. [19], who found high admission rates among COPD patients, which increases with age. Similarly, Tel et al. [13] proved that scores of activities of daily living were decreased for 12 years or more. The aim of health education is to change clinical state by providing instructions on suitable self-controlling skills. In terms of the level of knowledge, the study showed the
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presence of highly statistically significant differences in all knowledge items. In terms of overall patients’ knowledge, a highly statistically significant increase was observed after the intervention, showing the impact of the guidelines. This may have been because of the importance of knowledge for the patient. Many patients first diagnosed with COPD reported feelings of confusion and worry; these are calmed after clarifications regarding dyspnea and other symptoms is still needed. Also, these reduced with patients’ active involvement in decision making and development of a management plan. All these could improve the subject’s medical state [19]. The present study found a highly statistically significant improvement in almost all aspects. Surviving with a chronic condition needs skills, learning to manage symptoms, and intentionally considering and making routine lifestyle changes. It was found that patients who were assisted with health care personnel had a managing strategy & follow up to stay in a better way with COPD [5,20]. The primary symptom that commonly affects COPD patients is dyspnea. The MRC Dyspnea Scale represents an easy and valid means of classifying COPD patients on the basis of their disability. The data was obtained by assessing breathlessness using the Modified Borg Scale and MRC Breathlessness Scale. It indicated a highly statistically significant progress after the intervention. This may be attributed to the patients’ desire to learn and use methods to control this debilitating symptom as also noted by other studies [17,21,22]. It is worth mentioning that nearly half of the study patients had grade 3 dyspnea, which decreased significantly after the educational intervention. This result was better than that of Wong et al. [20], who reported that 53.3% of their study participants expressed no improvement. In the present study, most of the participants showed moderate to severe anxiety before the intervention, whereas after the intervention, significant improvement was found. This outcome was similar to that of Maurer et al. [23], who reported that anxiety is a very common morbid factor in COPD and has a clear statistically significant impact on patients, relatives, the public, and disease progression. Neglected and unobserved anxiety can lead to an increase in physical disability and illness, besides being a healthcare burden.
The following suggestions are recommended:
(1) Further study including female patients should be carried out for comparison with the results obtained from male patients. (2) Complete health education should be provided for COPD patients in chest outpatient clinics as well as physiotherapy clinics with videos, guidelines, leaflets, or pamphlets clarifying how to avoid and manage dyspnea and fatigue. (3) Estimation of the impact of strategies for controlling dyspnea should be advanced in a larger sample in order to generalize results. (4) Establish and implement a home program to efficiently relieve dyspnea and fatigue in these patients.
Acknowledgements Conflicts of interest There are no conflicts of interset.
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