Non-Pharmacological Management of COPD: A Qualitative Study on the Experience of Patients with Pulmonary Rehabilitation

This qualitative research study investigates the experience of patients with chronic obstructive pulmonary disease (COPD) and how pulmonary rehabilitation helps in improving their overall quality of life. The study highlights the importance of non-pharmacological interventions in treating COPD.

Running head: QUALITATIVE RESEARCH METHODS
Qualitative Research Methods
Name of the Student
Name of University
Author’s note

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Non-Pharmacological Management of COPD
Research Question
A phenomenology qualitative research study to investigate the experience of a patient
with chronic obstructive pulmonary disease (COPD). Investigate how pulmonary rehabilitation
helps in the improving the overall quality of life of the patients with COPD?
Background
According to Ministry of Health New Zealand (2018), Chronic Obstructive Pulmonary
Disease (COPD) is a lung disease which mainly common among the population who have a past
history of smoking. Both chronic emphysema and chronic bronchitis are classified under COPD.
Milne and Beasley (2015) highlighted hat COPD is an important non-communicable disease
which has high level of prevalence, mortality and morbidity in New Zealand. It is the fourth
leading cause of death in New Zealand which amounts to 6% of deaths, as reported in 2009.
COPD is also the underlying reason of common comorbidity of hospitalization for the people
who are admitted to hospitals for other reasons and this increases the overall tenure of
hospitalization. The rate of hospitalization is twice among the Maori in comparison to non-
Maori. It is still not known to what extent this represents a higher rate of incidence of COPD
among the Maori population or a higher severity of disease or a diverse threshold for hospital
admission. However, due to its high morbidity and mortality, COPD cause a huge healthcare
burden. The main cost of care is directly associated with increased level of hospitalization (Milne
& Beasley, 2015).

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According to Ministry of New Zealand (2018), the best way to treat COPD is to quit
smoking and to take proper medication on time in order to relive the symptoms. One of the
important pharmacologic interventions used for treating COPD is inhalation of iloprost. Inhaled
iloprost is stated to improve gas exchange and hemodynamics in patients with COPD and
secondary pulmonary hypertension (PH) (Dernaika, Beavin & Kinasewitz, 2010). However, the
double bling randomised control trial conducted by Boeck et al. (2016) highlighted that use of
iloprost failed to improve the stamina and energy of 6-minute walking distance along with
significant impairment of oxygenation while at rest. Khdour et al. (2012) majority of the
population suffering from COPD fail to abide by medication adherence which increases the
potential complication of the disease. Milne and Beasley (2015) highlighted the importance of
evidence-based interventions in order to improve the health-related quality of life of the patient
suffering from COPD in order to improve the mortality and morbidity rate. Thus keeping into
consideration of the importance of the evidence-based interventions in COPD treatment and side-
effects of pharmacologic interventions, I am fascinated and intrigued to conduct research over
the non-pharmacologic interventions in treating COPD. There are numerous quantitative
research published on the importance of pulmonary rehabilitation as non-pharmacologic
intervention in treating COPD. Many have highlighted the requirement of further research on a
larger scale but to my surprise, there is very little qualitative research on this domain. So I am
planning to conduct a qualitative research in order to study the importance of pulmonary
rehabilitation as a non-pharmacologic intervention for the treatment of COPD and subsequent
experience of the individual.

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Patient Interview and Methods
My interviewee was had past history of smoking and is suffering from COPD and at
present is on medication and had been treated with pulmonary rehabilitation during his stay in
hospital. The patient and his family member were contacted privately through mail. The detailed
explanation about the background and the scope of the research along with my assignment and
university communication were communicated through the same mail chain. When the patient
agreed to participate in the study, a telephonic conversation was held with the patient and his
family members in order to answer to all their queries. Upon their approval, they received a
information sheet and a consent form to review via email. When the interviewee confirmed about
his participation, the consent letter was signed dully by the patient and then the interview was
commended. The consent form stated that the interviewee is participation in the interview with
full knowledge about the reason of the interview and that his name will be kept confidential and
his personal data will not be used against his consent. The scheduling of the interview was done
as per the convenience of the patient. The interview was 30 minutes long and was held at
patient’s own home. The interview was recorded through a recording app on interviewer’s
private mobile for transcript analysis. “Interview-guided approach” was employed during the
interview under which selected themed questions were covered during the interview process.
This helped the to develop question which complements the topic and helped the conversation to
continue with the flow. This approach helped the interviewee to express their thoughts and
feelings openly with more emotional bonding.
The themes covered in this interview:
 Theme 1: Treatment of COPD and side-effects of pharmacologic interventions

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 Theme 2: The benefits of pulmonary rehabilitation as non-pharmacologic intervention n
COPD treatment
 Theme 3: Impact of non-pharmacologic interventions on daily life
 Theme 4: Support of nurses in medication adherence and improvement in daily life
Analysis and Results
The recording of the interview was transcribed and then analysed qualitatively and the
main themes were highlighted manually in order to identify the potential and pattern of
conversation and to explore the unexpected results. (Interview transcript is given in the
appendix.
Theme 1
The interview highlighted that in order to manage his complications due to COPD he was
administered with inhaled corticosteroid. However, such treatments forced him to suffer from
numerous complications like horse ness in voice or dysphonia. Interviewee reported that:
“Though the severity of the disease improved the administrated of the inhaled corticosteroid but
my quality of life decreased [line: 3]. My voice became hoarse, the smell of my moth became
pungent” [line:4] The interviewee also reported that, “I used to become conscious when I was
asked to communicate with others due to bad breath [line: 5]” and “I was asked to do gargle but
that to impose an additional work apart from taking tons of medication”. According to Gillissen
et al. (2016), inhaled corticosteroids are markedly less effective against COPD in comparison to
asthma. ICS though lowers the frequency and severity of COPD exacerbations in comparison to
the monotherapy but have no direct effect on mortality. It also fails to improve the health related
quality of life. Saag, Furst and Barnes (2014) highlighted that inhaled corticosteroid is only

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effective for the treatment of grade III and grade IC COPD but long term use can bring in
complications.
Theme 2
In response to the pulmonary rehabilitation, interview stated that, “Pulmonary
rehabilitation helped me to improve my overall health-related quality of life” [line: 7]. The
respondent stated that “I used to stay physically active but COPD was creating a barrier against
this but practising pulmonary rehabilitation helped me to indulge in mild to moderate physical
activity” [line: 10]. Thus from the theme it can be stated that use of non-pharmacologic
interviews like the use of pulmonary rehabilitation helped to improve the overall quality of life
of the patient with COPD. His faith and confidence upon himself increase as he was now able to
perform his daily living activities and tasks of his liking like physical exercise. According to
McCarthy et al. (2015), pulmonary rehabilitation helps to recover from dyspnoea which is the
main side-effects of inhaled corticosteroids. It also help in the recovery of fatigue and emotional
function. This help to improve the overall health-related quality of life of the patients. McCarthy
et al. (2015) also reported that pulmonary rehabilitation enhances the sense of control that a
person have over their condition and this serves as an important component for managing COPD.
Theme 3
The respondent highlighted that, “pulmonary rehabilitation helped me a lot in order to
join in the main course of life” [line: 11]. Respondent of the interview is of the opinion that, “this
procedure helped me to overcome my intoxication towards smoking and this further helped to
fight against the complication of COPD” [line: 13]. He also said that, “doctors told me to quit
smoking in order to survive but none of the medicines prescribed by the doctors helped me to
quit smoking but while practising pulmonary rehabilitation, I got significant results [line: 14]. It

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helped me to quit smoking” [line: 15]. According to Postolache et al. (2015) pulmonary
rehabilitation helps in improving the quality of life the patients. This improvement in the quality
of life is achieved through decrease in the tendency of smoking and increase in the adherence in
medication.
Theme 4
According to Khdour et al. (2012), proper medication awareness and improvement in the
overall lifestyle are two determining factor behind the effective treatment of COPD. The study
conducted by Khdour et al. (2012) highlighted that lack of medication adherence among the
population of COPD is mainly due to psychological consequences rather than demographic
factor. Elevation of mood and decrease in the co-morbid illness helps in improving the
medication awareness. The respondent of the interview highlighted, “after the diagnosis of
COPD and fighting it for a prolong period of time I was depressed and lost all hope because my
condition was not improving” [line: 16]. However, my nursing professionals who use to take
care of me at home and helped me with pulmonary rehabilitation, increased by medication
awareness”. The respondent informed that the nurse helped him with mood elevation. “Regular
counselling from nurse helped me overcome my depressed state of mind” [line 17]. The
respondent highlighted that recovery from depression and hopelessness helped him to properly
manage his medication.
Summary and Conclusion
Thus from the above discussion, it can be clearly stated that non-pharmacologic
interventions holds potential significance in the treatment of COPD. In this study, pulmonary
rehabilitation was selected as the main non-pharmacologic interventions for the treatment of

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COPD. The thematic analysis of the interview and linking the same with the literature
highlighted that COPD hampers the health-related quality of life of the patients. Long-term
treatment of COPD through the use of inhaled corticosteroid (pharmacologic medication) brings
in several complications which hamper the quality of life and these complications included
dyspnoea and bad breath of the mouth. In order to overcome these complications and to improve
medication adherence, application pulmonary rehabilitation (non-pharmacologic intervention) is
important. Pulmonary rehabilitation helps to improve the dyspnoea and at the same time helps to
improve breathless which helps the individuals with COPD to perform their daily living activity
along with indulging into mild to moderate physical exercise. This helps to improve the quality
of life further. Pulmonary rehabilitation also helps to quit smoking. However, it is the duty of the
nursing professional to improve the mental state of mind in order increase the mediation
adherence and thereby promoting fast improvement in the diseased condition. More research are
required to be undertaken in this domain in order to improve the importance of non-
pharmacologic interventions towards treating COPD.
Reflection
While working as a community health nurse, I was made of understand that both
pharmacologic and non-pharmacologic intervention holds equal significance in the management
of disease. While taking care for the patients with COPD, I have noticed that disease COPD is
debilitating and it shatters a person both mental and physically and which hampers the overall
health-related quality of life. However, I think there is a gap in understanding the importance of
non-pharmacologic interventions against managing COPD. Hence I took initiative in order to
conduct a study over COPD and non-pharmacologic interventions. I mainly selected pulmonary

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rehabilitation as non-pharmacologic intervention and also planned to study how it influence the
health related quality of life of the patients.
Since my research approach was phenomenology analysis, I first selected by my
respondents and he was a patient of COPD. My selection criteria were older adults with COPD
history for more than 5 years. My selected interviewee was a man (Mr X) who was 65 years old
and was suffering from COPD for the past 7 years. He was also a chain smoker and had high
blood pressure. Initial contact was made and the subsequent discussion was done in order to
provide an understanding of the scope of the research and research questions. The list of
questions was communicated to the participant one week before the interview through mail and
he was given full liberty of leave the interview at any point of time and freedom to not-to answer
any question. Sending questions before hand helped him get prepared with his answers. I was
previously aware that my interviewee might become emotional or reluctant in responding to all
my questions in detail. Hence I made as strategy to develop a friendly relationship with him
before the onset of the interview which helped him to discuss all his matter clearly with trust.
The interview was conducted in presence of his family member (his wife) and this further helped
him to open up about his complications in COPD and his overall experience of treatment..
My personal experience while conducting this research was very compelling. It helped to
increase my personal understanding in how to conduct a proper interview while managing the
emotions of an interview. It also helped me to improve my understanding my knowledge about
COP and its comprehensive management.

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References
Boeck, L., Tamm, M., Grendelmeier, P., & Stolz, D. (2012). Acute effects of aerosolized iloprost
in COPD related pulmonary hypertension-a randomized controlled crossover trial. PloS
one, 7(12), e52248. https://doi.org/10.1371/journal.pone.0052248
Dernaika, T. A., Beavin, M., & Kinasewitz, G. T. (2010). Iloprost improves gas exchange and
exercise tolerance in patients with pulmonary hypertension and chronic obstructive
pulmonary disease. Respiration, 79(5), 377-382. https://doi.org/10.1159/000242498
Gillissen, A., Haidl, P., Kohlhäufl, M., Kroegel, K., Voshaar, T., & Gessner, C. (2016). The
pharmacological treatment of chronic obstructive pulmonary disease. Deutsches
Ärzteblatt International, 113(18), 311. doi: [10.3238/arztebl.2016.0311]
Khdour, M. R., Hawwa, A. F., Kidney, J. C., Smyth, B. M., & McElnay, J. C. (2012). Potential
risk factors for medication non-adherence in patients with chronic obstructive pulmonary
disease (COPD). European journal of clinical pharmacology, 68(10), 1365-1373.
https://doi.org/10.1007/s00228-012-1279-5
Khdour, M. R., Hawwa, A. F., Kidney, J. C., Smyth, B. M., & McElnay, J. C. (2012). Potential
risk factors for medication non-adherence in patients with chronic obstructive pulmonary
disease (COPD). European journal of clinical pharmacology, 68(10), 1365-1373.
https://doi.org/10.1007/s00228-012-1279-5
McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015).
Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database

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of Systematic Reviews, (2). Retrieved from:
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003793.pub3/abstract
Milne, R., & Beasley, R. (2015). Hospital admissions for chronic obstructive pulmonary disease
in New Zealand. Retrieved from: https://www.nzma.org.nz/journal/read-the-journal/all-
issues/2010-2019/2015/vol-128-no-1408/6412
Ministry of Health New Zealand. (2018). Chronic obstructive pulmonary disease. Access date:
24th October 2018. Retrieved from: https://www.health.govt.nz/your-health/conditions-
and-treatments/diseases-and-illnesses/chronic-obstructive-pulmonary-disease
Postolache, P., Nemes, R. M., Petrescu, O., & Merisanu, I. O. (2015). Smoking cessation,
pulmonary rehabilitation and quality of life at smokers with COPD. The Medical-
Surgical Journal, 119(1), 77-80. Retrieved from:
https://www.ncbi.nlm.nih.gov/pubmed/25970946
Saag, K. G., Furst, D. E., & Barnes, P. J. (2014). Major side effects of inhaled
glucocorticoids. UpToDate, 19. Retrieved from:
https://www.uptodate.com/contents/major-side-effects-of-inhaled-glucocorticoids

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Appendix
Question: 1 How was the treatment of COPD, do you encountered any side effects
1 The treatment of COPD was a long tiring experience
2 There were tons of medicines and I was tired and the common was inhaler
3 Though the severity of the disease improved the administrated of the inhaled corticosteroid
but my quality of life decreased
4 My voice became hoarse, the smell of my moth became pungent
5 I used to become conscious when I was asked to communicate with others due to bad
breath
6 I was asked to do gargle but that to impose an additional work apart from taking tons of
medication
Question 2: What benefits do you enjoyed from pulmonary rehabilitation as non-
pharmacologic intervention in COPD treatment
7 Pulmonary rehabilitation helped me to improve my overall health-related quality of life
8 It was very helpful, it had no side-effect as per my knowledge
9 It helped to resume my normal life
10 I used to stay physically active but COPD was creating a barrier against this but practising
pulmonary rehabilitation helped me to indulge in mild to moderate physical activity
Question: 3 How Pulmonary rehabilitation improved your daily life?
11 Pulmonary rehabilitation helped me a lot in order to join in the main course of life
12 As you know, I was a chain smoker and was unable to quit smoking

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13 this procedure helped me to overcome my intoxication towards smoking and this further
helped to fight against the complication of COPD
14 Doctors told me to quit smoking in order to survive but none of the medicines prescribed
by the doctors helped me to quit smoking but while practising pulmonary rehabilitation, I
got significant results
15 It helped me to quit smoking
Question: 4. What kind of support you got from nurses?
16 After the diagnosis of COPD and fighting it for a prolong period of time I was depressed
and lost all hope because my condition was not improving
17 However, my nursing professionals who use to take care of me at home and helped me
with pulmonary rehabilitation, increased by medication awareness
18 She helped me to overcome my depression and hopeless and gradually helped to join the
normal flow of life with healthy life style