COPD Research and Management Studies

This assignment requires a thorough analysis of various research studies related to Chronic Obstructive Pulmonary Disease (COPD). The studies cover topics such as COPD management, self-management, and the impact of stigma and gender on patients with COPD. The articles provided include studies on physical activity and health status in COPD patients, mechanisms of dyspnea during exercise, amygdala hyperactivation in depressed individuals, and the effects of long-term air pollution exposure on COPD in women. The assignment also includes a list of textbooks and research papers related to COPD.

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Chronic Obstructive Pulmonary Disease (COPD)
Essay
[Writer]
[Institute]
[Date]

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Introduction
This essay aims to explore the impact of a long- term condition (LTC) Chronic Obstructive
Pulmonary Disease (COPD) on a patient and his carers.
According to the World Health Organisation (WHO 2013), a long-term condition cannot at
present be cured; but can be controlled by medication and other therapies.
In the UK, there are around 1.2 million people living with diagnosed COPD, making this disease
the second most common lung disease in the country. COPD is also one of the leading
contributors to respiratory mortality in the UK as reported by the British Thoracic Society (BTS).
It is estimated that around 30,000 deaths occur in the UK from this disease each year, 25,000 of
which is from England alone.
In 2016 it was estimated that there were 251 million cases of COPD globally, and in 2015 it was
also estimated that there were 3.17 million deaths globally from this disease within in that year
which was reported by WHO.
The British Lung Foundation reports the cost to the NHS for respiratory diseases, direct and
indirect exceed £11.1 billion per year in England. Furthermore, research indicates that
respiratory illness continues to represent a substantial hardship to individuals, the healthcare
system and the wider society. The research funding allocation for respiratory illness does not
currently reflect this.
In agreement with the Nursing and Midwifery Council 2015 (NMC) no actual name, age or
location will be used in this essay with regards to safe guarding patients.
Case Study
Jack Branning is a 59-year-old man who came into hospital being diagnosed with Pneumonia.
Jack was unwell with a cold and flu for several weeks. He had a continuous cough, which was
making him cough up phlegm from his lungs. The phlegm was green in colour and had hints of
blood in it. He was feeling short of breath and tachycardic. Jack has previously been diagnosed
with COPD; this meant he was at an increased risk of respiratory failure according to the British
Lung Foundation (BLF 2017).

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Jack has multiple long-term conditions which include type 2 diabetes, hypertension,
hypercholesterolaemia. Jack was also a heavy smoker in the past but has stopped since the
increase in illness 10 years ago.
Jack is 5ft 7in height and he weighs at 90kg. According to the Body Mass Index (BMI) Jack
appears to be in the obese category. BMI is a tool which uses height and weight to work out what
a person’s healthy weight range.
Jack has his wife and daughters look after him at home. Jack’s daughter mentioned that due to
shortness of breath, he has not been very active and refused to seek help when symptoms were
increasing. He has also been experiencing tightness in his chest. Jack finds it hard to accept that
he has multiple long-term conditions hence it was difficult for him to get the help he needed.
Jack has had to stop work due to his illness and that too has had an effect on him, physically and
emotionally as he was the family breadwinner.
Pathophysiology
COPD is a life threatening condition; it is not curable but can be managed and controlled with
right medication and therapies. This condition affects the lungs and the ability to breathe due to
the narrowing of the airways. (Gennimata et al., 2010) Two of these lung conditions are
persistent bronchitis and emphysema (BLF 2017). A person can have one of these conditions or
they may have both.
Bronchitis (acute bronchitis) is a temporary inflammation of the airway which causes a person to
cough and produce phlegm when the airway is inflamed it makes it narrow, which then causes
breathing difficulties (Bourdin et al., 2009). People with this produce a lot of phlegm and
sputum. This condition would normally last up to 3 weeks. Acute bronchitis most commonly
affects children under the age 5, although it can affect people of all ages.
Emphysema (chronic bronchitis) is a condition where the air sacs of the lungs are damaged and
enlarged causing breathlessness. This develops over time rather than a sudden offset. Chronic
bronchitis produces large amounts of sticky mucus in the airways (Wells and Dransfield, 2013).
The build-up of mucus around the airway gets worse over time and causes respiratory
difficulties. Both of these processes narrow the airways making it much more difficult to breathe

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air in and out of the lungs, which also causes the lungs to take in less oxygen and get rid of
carbon dioxide (Wells and Dransfield, 2013).
The most common causes of COPD are cigarette smoking, breathing in air pollution, fumes or
dust over a long period of time (Agusti, 2007). Symptoms of COPD are build-up of mucus,
coughing, wheezing when a person breathes, chest tightness and shortness of breath (Siafakas,
Anthonisen and Georgopoulos, 2004). Although there are many more symptoms these are some
of the most common ones.
In Jack case he has been experiencing shortness of breath and chest tightness. Shortness of breath
(which doctors call dyspnoea) is the painful sensation of having trouble breathing. People
experience and describe their breathlessness differently depending on the cause (Gennimata et
al., 2010). Typically, the frequency and intensity of breathing increases during physical activity
and at high altitudes, but this increase does not cause discomfort (Bourdin et al., 2009). The
respiratory rate can also increase at rest in Jack with different diseases, whether they are lung or
affect other parts of the body. For example, fever increases the respiratory rate (Wells and
Dransfield, 2013).
In case of Jack’ dyspnea, the acceleration of breathing is associated with a sensation of lack of
air. The person has the feeling of not being able to breathe sufficiently, quickly or deeply
(O'Donnell and Laveneziana, 2007). He may notice the need for greater effort to inflate the chest
when inhaling or to blow out air during exhalation. It may also have the uncomfortable feeling
that it is urgently necessary to get air into the lungs (inspiration) before even having finished
exhaling the air (exhaling); finally, other sensations are often described, such as chest tightness
(O'Donnell and Laveneziana, 2007).
Other symptoms, such as coughing or chest pain, may occur depending on the cause of dyspnea
(O'Donnell and Laveneziana, 2007).
People with lung disease, like Jack in this case, often have dyspnea during physical exertion.
During physical exercise, the body produces more carbon dioxide and consumes more oxygen
(Ofir et al., 2008). The cerebral respiratory centre activates breathing when the blood oxygen
level is low, or when the blood level of carbon dioxide is high. In case of abnormal heart or lung
function, even a small effort can lead to a significant increase in respiratory rate and dyspnoea

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(Ofir et al., 2008). Dyspnea is so uncomfortable that people avoid stress. When worsening
pulmonary disease, dyspnea can also occur at rest (O'Donnell and Laveneziana, 2007).
The dyspnea can come from the following (Asker and Asker, 2015):
 Restrictive lung disorders
 Obstructive lung disorders
In the case of restrictive lung disorders (such as idiopathic pulmonary fibrosis), the lungs become
rigid and require a greater effort to inflate during inspiration. An abnormal curvature of the spine
(scoliosis), when severe, may also restrict breathing by decreasing the range of motion of the
chest (Asker and Asker, 2015).
In obstructive disorders (such as COPD or asthma) and it is the case of Jack, resistance to airflow
is increased by narrowing of the airways. The airways widening in inspiration, air can enter the
lungs. However, it cannot come out as easily because the airways shrink in expiration, resulting
in hissing and making breathing more difficult. Dyspnea occurs when too much air remains in
the lungs after expiration. (Asker and Asker, 2015)
People with asthma experience dyspnea when they have an attack. Doctors usually advise these
people to keep an inhaler handy to use in case of an attack. The medicine in the inhaler helps to
open the airways.
Psychological, Social and Physical Challenges
Psychological Impact
Cognitive and psychological impairment in COPD is believed to be partially caused
by insufficient amount of oxygen delivery to the brain damaging neurons and neurotransmitter
synthesis (the production of brain chemical messengers) (Coventry et al., 2014). It has been
reported by neuroimaging studies (Cook et al., 2007; Peluso et al., 2009) that there are lesions of
the cerebral white matter which lead to a reduction of the transmission of information in the
brain.
In patients suffering from a major depressive disorder or anxiety (usually external to COPD),
anxiety and depressive symptoms are indicative of a lack of understanding of the disease,

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difficulties of psychological adjustment to illness, bad communication and loneliness (Coventry
et al., 2014). Except for serious cases where the use of drugs is necessary, there are
accompanying solutions, therapeutic education, appropriation and behavioural regulation through
rehabilitation, training in the patient-caregiver relationship and health networks.
Anxiety and depressive symptoms are present in many patients with COPD. These symptoms are
common, as mentioned earlier. However, they are poorly evaluated, under-diagnosed and under-
treated despite known risk factors and deleterious consequences at various levels. This low
consideration suggests that it is normal to present these disorders in a systemic disease whose
major symptom is dyspnea, and the patient is old having depressive personality and / or guilt by
his smoking (Coventry et al., 2014). The relationship between anode-depressive disorder and
COPD is not self-evident. During the natural history of COPD, anxiety and depression will be a
risk factor (inherent in the individual or from the environment that may cause illness), prodrome
(warning sign, pre-illness symptom), aggravating accelerating the damage caused by the disease)
and comorbidity (COPD-related health problems) (Bourdin et al., 2009).
Anxiety and depressive symptoms in COPD patients impair the quality of life. More specifically,
in Jack’ case, these disorders may increase his frequency of exacerbations and hospitalisations
and prolong the duration of hospitalisation. For example, a comparative study shows that
compared to a group of COPD patients not reporting depression-wide hospitalisation depression
([HAD] depression score≤7), the group with depressive symptoms (score≥8) twice as many
exacerbations and stay in hospital for one third of additional time in the year of follow-up
(Almagro et al., 2006). Now, evidence is sufficient to make clinicians attentive that the presence
of symptoms associated with anxiety or depressive will be a meaningful risk factor for
readmission within a year of being detected once again.
Moreover, anxiety and depressive disorders may impair compliance of Jack, while impairing his
exercise tolerance, promote risky behaviour towards health, aggravate feelings of fatigue, and
degrade communication with caregivers (Peluso et al., 2009).
Psychologically, the relationship of depression with the quality of life is very strong. COPD
patients experience a feeling of fatalism caused by the low reversibility of their disease. This
great pessimism leads them to be passive in the face of the disease and its consequences. They go

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through the psychological stages of the illness, between appropriation and resignation. Mostly,
they depreciate and consider themselves unfit for sustained and / or long-term effort. The
depressive symptoms explain 18% of the variance of the limitations of the physical functioning.
Depression is much related to fatigue, especially to mental origin. Finally, they take little
pleasure during social activities. The more depression develops, the more they are sensitive to
negative events and lower the positives.
Carers of COPD patients may also go through major psychological issues similar to those
recognised for the COPD patient. They portray stress in relation to feeling restricted, restless and
intensely helpless due to difficult respiration, accompanied by a sense of engrossment with their
relative and an enfeebling hypervigilance (Gea, Agustí and Roca, 2013).
Socioeconomic Impact
Jack’s impaired physical and social dimensions associated with his routine life frequently led to a
sedentary lifestyle with ultimate dyspnoea and exhaustion. Thus, this health condition usually
results in social isolation and an incapability of participating in many social activities of routine
life.
As a social construction, stigma defines human beings as a distinguishing characteristic or mark,
while devaluing them consequently (Johnson et al., 2007). The cause behind occurrence of
stigma is labelling someone by the society as tainted or disabled. Research studies show rich
evidence in which COPD has been established as a physical condition with some major social
and economic consequences (Johnson et al., 2007). The individual’s valuing and devaluing
within society or community are called the social judgments that have deep roots in sociocultural
norms and values, dictating the distinctive roles and behaviours that are anticipated of both
genders in a given cultural pattern (Johnson et al., 2007). Social responses to patients with COPD
can have a major impact on their poor health experience, and thus the patient with COPD
ultimately feels scared to go out due to his or her breathlessness, continuous cough and phlegm,
which make individuals embarrassed.
Studies established association between COPD and lower socioeconomic status of people. It has
been found that Forced Expiratory Volume (FEV) and Forced Vital Capacity (FVC) enhanced
with high education and household income level in both genders (Schikowski et al., 2005).

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Moreover, the relationship between education and income were very strong with admission to
hospital, and adjustment for smoking did not affect this (Schikowski et al., 2005). In the lowest
socioeconomic group, the risk for hospitalisation was about three times greater than in the
highest group, and was alike in both genders (Johnson et al., 2007).
COPD is a major economic problem faced by people across the world and the growth of its
prevalence is extremely rapid. The belief of WHO is that the reduction of COPD risk factors,
better and timely information, improved diagnosis and treatment are the priority objectives that
we must set ourselves to overcome the economic problem of COPD in the future (cited in Jindal
and Agarwal, 2011).
For COPD, smoking is the most important risk factor, as smoking is responsible for the disease
in 80-90% of cases; the evolution of the disease then relies on the cessation or not of smoking
and the stage at which the diagnosis is made (Getsios et al., 2013). If smoking intoxication is
stopped by Jack while the obstruction of the bronchi is very moderate, he can hope a stabilisation
(at times even a recovery of a nearly normal respiratory state) (Getsios et al., 2013). For this very
reason, the fight against smoking dependence is essential and all the effective means available
must be implemented, whether it is drug treatments or psychological assistance. Other causes are
exposure to high air pollution and exposure to dust. Further, genetic factors may also be involved
in the risk of developing COPD (Jindal and Agarwal, 2011). Although COPD remains more
common among men because their smoking has long been greater than that of women, we now
know that they run the same risk of developing this disease and the number of women who
smoke is increasing.
Because of high prevalence of COPD, compared with other diseases and in particular other lung
diseases, COPD represents a huge socio-economic burden for society. The course of the disease
frequently leads to complications, or more frequent and severe exacerbations.
Patients with such exacerbations, which may comprise more benign symptoms such as
continuous coughing, wheezing, and dyspnea, may require physician consultation, emergency
management, or hospitalisation. All this adds to the cost of managing COPD for society.
Physical Impact

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As COPD typically affects people over the age of 40, its symptoms are frequently attributed by
the patient to the natural process of aging (Miravitlles et al., 2013). This frequently leads the
patient to consult doctors too late when symptoms have become severe and at a more critical
phase of the disease (Miravitlles et al., 2013). Consequently, adequate treatment along with early
management is not received by many COPD patients (Miravitlles et al., 2013). There are many
cases in which the perplexity of diagnosis with asthma also results in improper treatment. The
major impacts of breathlessness, continuous cough and phlegm, and overall COPD disease are
borne mostly by the patients themselves and have substantial impacts on their quality of life in
terms of physical impacts (Di Marco et al., 2013). Fatigue and exhaustion, frequently aggravated
by dyspnea and difficulties in sleeping, considerably limits the patient’s physical activity while
hindering them from social and professional life, as mentioned earlier (Di Marco et al., 2013).
The symptoms most often found are breathlessness and continuous coughing. COPD is an
evolving disease and many people living with COPD experience a decrease in their physical
health and simultaneously are facing more difficulties when they come to perform their routine
life activities (van de Bool et al., 2015).
The breathlessness and continuous coughing characterising COPD leads Jack to do less and less
physical effort, to run away from any sports activity, aggravating the handicap, and then physical
impairment of the patient may lead to the infernal spiral of "deconditioning" marked by a melting
of muscles (van de Bool et al., 2015). The retraining in the exercise of the whole body
musculature, essential complement of the COPD treatment, opposes this deconditioning and
enhances the tolerance to the exercise. In the initial COPD phases, it is important to maintain
physical activity so that the patient can maintain his or her quality of life (van de Bool et al.,
2015).
Having COPD makes it hard for Jack to breathe easily as less air flows in and out of the airways
in his lungs. The reason behind this is as follows (van de Bool et al., 2015):
 Thick and inflamed airways.
 The elastic quality is lost by airways and air sacs.
 Destruction of lung tissue.
 Excessive mucus is made and blocks (obstructs) airways.

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When Jack do not get sufficient amount of air, his body tissues only receive less oxygen and it
gets more difficult for him to dispose of the waste gas carbon dioxide. Ultimately, this leads to
difficulties in breathing in routine life. Jack with COPD can also go through fatigue and
exhaustion, chronic and continuous cough and frequent respiratory infections as well. Patients
with COPD are also vulnerable to other health associated issues, which are cardiac related like
heart attacks, strokes, as well as cancer of lung. As breathing is very difficult, staying physically
active for Jack cannot be very easy, mainly as the disease progresses. Thus, impact of COPD can
be in terms of limiting (Di Marco et al., 2013):
 The work ability
 The normal physical exertion
 The routine or household jobs
 The social activities
 The sleeping patterns
Integrated and Holistic Care Approach
Patients with COPD are frequently out of breath, as we have seen in Jack’s case. Difficulties in
breathing immensely make even simple physical activities complicated. The disease integrates
chronic bronchitis and emphysema and leads to development of mucus, chronic cough and
airway blockage (Sunde et al., 2014). Further, it is also unfortunate that major depression,
anxiety, social isolation and economic burden are frequently part of the game (Coventry et al.,
2014). Thus, a team of medical and nursing professionals is needed to assist patients with COPD
cope with this chronic disease. For such a team, adopting an integrated care approach is essential
which should be based on the patients’ case management and self-management.
An integrated care approach means efforts to provide people with the best healthcare services,
bringing together every single component that make humans healthy (Hernández et al., 2015).
Due to the health promotion involves various factors (social, psychological, biological, and
economic, etc.), integrated approach to medical and nursing care can and should look quite
different o the basis of the healthcare delivery setting and the participants (Hernández et al.,
2015). Moreover, the World Health Organisation defines integrated care as a concept that brings
together efforts, service delivery, service management and organisation associated with

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diagnosis, care, intervention, remedy and rehabilitation and health promotion (Sunde et al.,
2014). The approach of integration to patient care is an approach to enhance the care services in
terms of easy and timely access, best quality, user satisfaction and efficiency.
The important of clinical integration is much more for the health care team treating the COPD
patient. The clinical integration, in this setting, has a very broad scope, which begins with
addressing key symptoms and disablement from the respiratory disease, its universal
manifestations and the frequently-present co-morbid conditions. The best strategies include
interventions to enable the patient to stop smoking and to foster regular physical exercise,
optimisation of pharmacotherapy and collaborative self-management, and palliative and hospital
care.
Focus of holistic care is on moderate to severe COPD patients, their families and carers,
suggesting that this approach to care is person-centred care approach (Sunde et al., 2014). The
professional team continues to implement an outreach programme by connecting and developing
a care model including community care, community social work, and palliative care (Sunde et
al., 2014). Patients and families will be fully capable of improving g their self-management skills
and other tools to enhance their health while reducing pressures on the health system (Sunde et
al., 2014).
Multi-Disciplinary Professionals
Multidisciplinary professionals involved in COPD treatment include general practitioners (GPs),
pulmonologists, radiotherapists, sleep specialists, and critical care nursing staff, with realistic
clinical guidance and insights on COPD and its comorbidities. Besides respirologists and nursing
staff, a large team consisting of health care professionals in physiotherapy, respiratory therapy,
nutrition and social work assist patients in their COPD journey.
Self-Management Plan
Self-management is a major component of pulmonary rehabilitation. Programmes associated
with self-management have been designed with the aim of assisting patients with COPD manage
their lung health by changing their lifestyle and optimally managing their chronic lung disease.
Self-management always integrates a partnership with a health professional (Kaptein, Fischer

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and Scharloo, 2014). For a self-management programme to work well, it must integrate both the
education and behavioural change component along with functional associations with the health
care system.
One of the important components is education component enabling the patient with COPD to
acquire knowledge while developing self - management skills, so as to better manage his poor
health. Nevertheless, education should not be limited to acquiring knowledge. (Simpson and
Jones, 2013)
Education must also (Simpson and Jones, 2013):
 Support in enhancing the self-confidence of patient;
 Enable it to better care for the disease by making sure preventive actions and managing
everyday symptoms and the integration of healthy behaviour;
 Education cannot be done if there is no good educator.
Thus, any pulmonary rehabilitation programme needs to include a comprehensive education
programme and its focus must be on development of patient self-management skills and includes
the following important aspects (Cramm and Nieboer, 2013):
 Recommendations on stopping smoking
 Fundamental information associated with physiopathology
 Information relate to medicines and methods for using inhalers
 Self-management (problem solving, decision-making, action)
 Strategies how to control dyspnea
 Proper action plan for the initial treatment of acute exacerbations
 Decision making at the end of life
 Recognition of the best educational resources
Conclusion
Typically, shortness of breath (dyspnea) or breathlessness is due to lung or heart disease. In
patients with COPD like Jack inn this case, flare-up of chronic disease is the most frequent cause
of dyspnea, but these patients may also experience another problem, heart attack), contributing to
dyspnea. People with restless dyspnea, low consciousness level or confusion, such as Jack, need

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to get hospital treatment immediately for emergency appraisal. To ascertain the problem’s
severity, the oxygen level in the blood is measured by doctors through pulse oximetry process
(by placing a sensor at the end of the finger). Doctors assess the patient for insufficient supply of
blood and oxygen to the heart (myocardial ischemia) and for pulmonary embolism, but at times
there may be vague symptoms of these disorders.
The treatment of COPD and dyspnea is focused on its root cause. Supplemental oxygen is
received by people having low levels of oxygen blood. In more severe situations, mainly if a
patient cannot breathe easily and deeply or quickly enough, mechanical ventilation can assist in
breathing.

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