Caring for patients with chronic obstructive pulmonary disease: part 2
Author
Donna Jones, District nurse sister, Shropshire Community Health NHS Trust, Shrewsbury, England.
Donna Jones, District nurse sister, Shropshire Community Health NHS Trust, Shrewsbury, England.
Short description
Update your knowledge and skills in caring for people with chronic obstructive pulmonary disease. This module focuses on non-pharmacological therapies such as mindfulness in the management of breathlessness.
Update your knowledge and skills in caring for people with chronic obstructive pulmonary disease. This module focuses on non-pharmacological therapies such as mindfulness in the management of breathlessness.
Detailed description
Chronic obstructive pulmonary disease (COPD) is a common, progressive and disabling disease that causes significant burden to patients, their families, and the NHS. Research suggests that the complexity of factors contributing to the disease requires a deeper understanding of the patient experience and a more holistic approach to care provision. This learning module discusses the non-pharmacological therapies for managing patients with COPD and explores the concept of mindfulness as a therapy in the management of breathlessness.
Chronic obstructive pulmonary disease (COPD) is a common, progressive and disabling disease that causes significant burden to patients, their families, and the NHS. Research suggests that the complexity of factors contributing to the disease requires a deeper understanding of the patient experience and a more holistic approach to care provision. This learning module discusses the non-pharmacological therapies for managing patients with COPD and explores the concept of mindfulness as a therapy in the management of breathlessness.
Aims
The aim of this module is to increase readers’ knowledge of chronic obstructive pulmonary disease (COPD), while also encouraging critical thinking and a reflective approach to non-pharmacological management options for patients. It explores mindfulness as a new concept in the treatment of COPD.
The aim of this module is to increase readers’ knowledge of chronic obstructive pulmonary disease (COPD), while also encouraging critical thinking and a reflective approach to non-pharmacological management options for patients. It explores mindfulness as a new concept in the treatment of COPD.
Intended learning outcomes
After reading this module and undertaking the time out activities, you should be able to:
- Explain the importance of effective health promotion and symptom management in relation to the provision of high quality care and efficient use of resources.
- Develop a holistic approach to address the biological, social and psychological care needs of patients with COPD who have extensive and complex health problems.
- Discuss non-pharmacological interventions for the management of COPD.
- Analyse and present the evidence for mindfulness as a therapy for breathless patients.
After reading this module and undertaking the time out activities, you should be able to:
- Explain the importance of effective health promotion and symptom management in relation to the provision of high quality care and efficient use of resources.
- Develop a holistic approach to address the biological, social and psychological care needs of patients with COPD who have extensive and complex health problems.
- Discuss non-pharmacological interventions for the management of COPD.
- Analyse and present the evidence for mindfulness as a therapy for breathless patients.
Psychological distress
Although pulmonary dysfunction is the underlying cause of COPD-related distress, breathlessness, fatigue and their psychological consequences dominate patients’ perceptions of quality of life (Barnett 2005, Seamark et al 2007). Patients with advanced COPD experience distress, encompassing complex and interwoven physical, emotional and spiritual aspects (Taylor 2007). Fear, anxiety, panic disorder and depression are major problems in COPD, yet they tend to be under-diagnosed and under-treated, especially in the context of concurrent physical illness (Wagena et al 2005, Adams et al 2007, Seamark et al 2007). Anxiety was found to be the leading cause of hospital admission, in one study of patients with COPD (Burgess 2005). Patients vividly describe feelings of uncertainty, profound anxiety and fear of death at times of markedly worsening breathlessness (Kunik et al 2005). Rates of anxiety disorders are higher among patients with COPD than among the general population (Gudmundsson et al 2005, Cully et al 2006), which suggests a need for effective models of care to assess and address breathlessness-related anxiety disorders in these patients (Kunik et al 2005).
Forms of psychological distress related to breathlessness:
- Anxiety.
- Panic disorder.
- Depression.
- Feelings of uncertainty.
- Fear of death.
Definition
Breathlessness is a common and distressing symptom in patients with advanced COPD (Bruera et al2000, Nordgren and Sorensen 2003, Solano et al 2006) and is defined as ‘a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity’ (American Thoracic Society 1999).
Breathlessness is known to increase as death approaches (Lynn et al 2000), particularly in the last days of life; this is one of the most difficult symptoms health professionals will manage (Taylor 2007).
Pathophysiology of psychological distress
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Breathlessness often causes people with COPD to abandon activities that require exertion.
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Individuals limit their activity, which decreases their exercise tolerance.
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Further breathlessness on mild exertion and subsequently during activities of daily living.
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Contributes to the physical disability, psychological distress and decrease in the quality of life experienced by people with COPD(Carrieri-Kohlman 1993).
Breathlessness often causes people with COPD to abandon activities requiring exertion. This occurs through a ‘cycle of dyspnoea’ (Figure 1), where breathlessness on moderate exertion causes anxiety. Therefore, the role of the nurse is to provide education, advice and support, and co-ordinate the involvement of professionals from appropriate disciplines to manage anxiety and breathlessness and encourage exercise. This can improve physical ability, psychological status and quality of life for patients with COPD.
Figure 1. The cycle of dyspnoea
Complete time out activity 1
Discuss with a physiotherapist how you could educate and encourage breathless patients to exercise to improve their health, independence and quality of life. Identify the pulmonary rehabilitation, exercise and empowerment services in your area and share this information with your team.
Learning Points
- Fear, anxiety, panic disorder and depression are major problems in COPD, yet they tend to be under-diagnosed and under-treated, especially in the context of concurrent physical illness.
- Breathlessness is a common and distressing symptom in advanced COPD and is defined as ‘a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity’.
- The role of the nurse is to provide education, advice and support and co-ordinate the involvement of professionals from appropriate disciplines to manage anxiety and breathlessness and encourage exercise.
Non-pharmacological treatments for breathlessness
It is recognised that COPD should be treated with a combination of pharmacological and non-pharmacological interventions (Box 1) (Guthrie et al 2001, Bausewein et al 2008).
Box 1. Pharmacological and non-pharmacological treatments for COPD
Pharmacological interventions
- Opioids
- Oxygen
Non-pharmacological interventions
- Increase patients’ self-efficacy
- Patient positioning
- Using fans or open windows
- Breathing strategies
- Relaxation techniques
- Pulmonary rehabilitation services
- Low-intensity psychological therapies
Pharmacological interventions
Pharmacological interventions such as opioids and oxygen rarely help the person to achieve adequate relief from breathlessness (Bausewein et al 2008).
Non-pharmacological treatment
Patients’ self-efficacy is increased through education or a combination of education and exercise programmes aimed at managing dyspnoea (Zimmerman et al 1996, Scherer et al 1998). Beliefs about personal efficacy are known to influence a person’s motivation, course of action, perseverance, thought patterns, emotional response and attribution of accomplishment and failure (Bandura 1997).
The use of patient positioning in the relief of breathlessness is not well supported by evidence (Jantarakupt and Porock 2005). However, anecdotal reports support the benefits of positioning to relieve breathlessness (Davis 2005). Leaning forward, sitting on the edge of a chair or bed with the arms folded on a table, is a comfortable position that reduces trans-diaphragmatic pressure. This position allows the abdominal wall to move outwards more easily, providing greater space for lung expansion and gaseous exchange (Jantarakupt and Porock 2005).
The use of a fan or open window should be offered before oxygen is prescribed (Jantarakupt and Porock 2005). This is because of the risk of adverse effects with oxygen therapy, such as physical limitations, impaired communication, psychological dependence, fire hazard, hypercapnic respiratory failure and the cost of oxygen (Booth et al 2004). The evidence is limited on the use of fans (Bausewein et al 2008). However, Booth (2006) suggests that the relief might come from cooling the face in the region of the trigeminal nerve and that fans offer patients a degree of control over their symptoms.
Breathing strategies are supported by moderate-strength evidence (Bausewein et al 2008) and are commonly used in pulmonary rehabilitation. A relaxed and controlled breathing pattern minimises the work of respiration and provides more effective ventilation than the shallow, rapid breathing pattern associated with dyspnoea (Twycross et al 2009). Inhaling deeply through the nose followed by pursed-lip exhalation improves lung expansion and gaseous exchange. This also re-establishes a sense of control for the patient, promotes relaxation and breaks the cycle of increasing breathlessness and panic (Jantarakupt and Porock 2005).
Relaxation techniques decreases oxygen consumption and reduces carbon dioxide production through muscular relaxation and lowering the respiratory rate (Jantarakupt and Porock 2005). There are few data on the effectiveness of relaxation techniques (Bausewein et al 2008); however, such therapies are considered useful given the role of anxiety in precipitating and exacerbating breathlessness (Barnes 2010).
Pulmonary rehabilitation services in the UK offer non-pharmacological individualised interventions to improve self-management and enhance self-efficacy (Endicott et al 2003, Booth 2006). However, attendance at a programme may be limited by the disabling nature of COPD, and the effectiveness of these programmes is difficult to research (O’Donnell et al 2004).
Low-intensity psychological therapies such as cognitive behavioural therapy (CBT) centre on challenging thoughts and setting behavioural goals. CBT is used to help change the way an individual thinks and behaves. The process involves making sense of problems by categorising them into thoughts, emotions, physical feelings and actions. In doing so, the individual may understand how these features are connected and awareness may challenge and change their thought processes and have a positive effect on behaviour (Royal College of Psychiatrics 2015).
Coventry et al (2013) found CBT to be ineffective for people with COPD, whose ruminative thinking and avoidance behaviours are associated with real and meaningful symptoms, especially breathlessness. There is growing evidence that CBT can improve generalised anxiety disorder and overall mental health in older adults with medical diagnoses. However, psychological interventions that promote an ‘accepting mode of response’, such as mindfulness, may be more appropriate and effective for managing psychological distress in COPD patients and, in particular, breathing-related anxiety (Coventry et al 2013).
Mindfulness-based interventions
Mindfulness is rooted in Eastern spiritual and, in particular, Buddhist traditions (Bishop et al 2004). It was first used more than 30 years ago to manage patients with chronic pain, and has since become increasingly common in treating a range of medical and psychological conditions. Mindfulness-based interventions have been associated with longer-term benefits for psychological health, compared with stand-alone relaxation interventions (Coventry et al 2013). Research on mindfulness has accompanied this rise in popularity, producing a growing body of evidence supporting dissemination of these interventions (Goldberg et al 2014).
Despite advances in knowledge of the benefits of mindfulness-based interventions, there is still limited understanding of the nature of this phenomenon and its psychological and neuronal causal mechanisms (Holas and Jankowski 2013). At least a dozen different definitions of mindfulness occur in the literature (Holas and Jankowski 2013).
Definition
One module defines mindfulness as “a state of being in which individuals bring their ‘attention to the experiences occurring in the present moment, in a non-judgemental and accepting way’” (Baer et al2006).
Basics of mindfulness
Mindfulness can be incorporated into daily life, does not require much time and can be practised in many different forms. The basics are to:
- Find a comfortable sitting position and sit upright in a relaxed posture.
- Concentrate on your breathing and allow yourself to be aware of the present moment and your body in the present moment.
- Guide your mind back gently to the breathing if it wanders.
- Feel the sense of being present in the moment and take this forward into the rest of your day.
Benefits of mindfulness-based interventions
- Mindfulness is a receptive awareness and registration of inner experiences (emotions, thoughts, behavioural intentions) and external events, where information is processed in preconception – that is, individuals simply notice what is happening without evaluating, analysing or reflecting on it (Bishop et al 2004).
- Mindfulness practice supports the creation of a vibrant and meaningful life because it helps individuals to perceive more clearly what is happening in their mind and to notice when their mood is changing or becoming more negative.
- Through practising mindfulness, individuals can mitigate negative emotions by entering into present-moment living (Johnstone 2013).
Box 2 outlines a helpful guide for practice.
Box 2. The RAIN acronym for mindfulness
R – Recognise what is happening in the present moment.
A – Allow your inner life to unfold just as it is.
I – Investigate your experience (sensations, emotions and thoughts).
N – Non-identification with whatever is there.
(Johnstone 2013)
Complete time out activity 3
Set aside some quiet time to practise mindfulness. You may find the ten-minute podcast on the following website useful: tinyurl.com/pvf4ulo. Reflect on the experience and note how you felt afterwards. Find out if mindfulness is used in your local services.
Different studies on mindfulness
Researchers have argued that mindfulness is a natural human capacity that can be undertaken by the untrained person (Brown, Ryan et al 2011, Dane 2011). Research on mindfulness in the general population with participants without any formal meditation experience has shown that mindfulness varies between individuals (Brown, West et al 2011, Goldberg et al 2014).
Mindfulness strategies may help to reduce breathlessness by (Mularski et al 2009):
- Decreasing the stress response.
- Inducing relaxation.
- Enabling a less distressing interpretation of physical disorders.
However, research on applying mindfulness to breathlessness in patients with COPD is limited and contradictory. It has been shown that eight-week periods of mindfulness instruction produce measurable biological effects such as alterations in brain structure and function (Hölzel et al 2011). Holas and Jankowski (2013) suggest that, over time, there is an increasing ability to remain in this state during everyday activities. A randomised controlled study investigating the physiological effects of applying guided imagery found a significant increase in oxygen saturation in the treatment group (Louie 2004).
Benzo’s (2013) study of patients with COPD who practised mindfulness during an initial eight-week course, with monthly face-to-face visits for a year afterwards, found that participants had an improved appreciation of life. This was achieved by viewing hardships as opportunities, valuing the self through compassion and awareness, cultivating connectedness with others, acquiring joy and adopting healthy behaviours. Although this study did not focus on breathlessness, the results showed a positive effect on participants in areas that would subsequently affect the experience of breathlessness. This includes reducing the negative emotions associated with feelings of self-consciousness, accepting one’s feelings in a non-judgemental way through disengaging from distressing thoughts, and focusing on goal-based actions and the potential for smoking cessation, if the individual smokes.
Studies by Greenfield (2010) and Mularski et al (2009) reported no benefit of mindfulness-based therapy in reducing breathlessness. Greenfield (2010) remarked that the findings of his study are puzzling, since previous studies have shown benefits for relaxation therapies in asthma. Although COPD is a result of irreversible lung damage, it might be assumed that mindfulness could be a beneficial method to reduce stress, anxiety and panic (Greenfield 2010). The conflicting results of research on mindfulness in patients with COPD may reflect variation in mindfulness between individuals (Brown, West et al 2011, Goldberg et al 2014).
A minority (5%) of participants in Greenfield’s (2010) study remarked that mindfulness was ‘weird’ or ‘silly’. This may reflect a misunderstanding of the purpose of mindfulness and highlight a need for further education before commencing any intervention. Participants in the Greenfield (2010) and Mularski et al (2009) studies were older and predominantly male. These characteristics may reflect barriers to mindfulness-based interventions that are rooted in the tendency for older people to have a more external locus of control (a belief that life events are influenced by external factors outside of their control), which Sarafino (2002) considers a product of the more paternalistic attitudes of the older generation. An external locus of control is also found in lower socioeconomic groups where a higher proportion of the public smoke and have COPD (Acheson 1998).
Ogden (2000) suggested that health behaviour correlates with health beliefs, and several approaches have been developed as a result. One approach, the transtheoretical model of behaviour change (Lundh et al 2012), suggests that the individual’s readiness to undertake a mind-body therapy should be assessed and strengthened to increase the efficacy of treatment.
Another explanation might be that men are reluctant to embrace mindfulness as a result of male socialisation, where the male stereotype is one of masculinity and dominance (Crespi 2004). Men may be discouraged from participating in a therapy that requires openness and acceptance in a public class-based delivery setting, which might explain why participants in Greenfield’s (2010) study considered mindfulness weird or silly.
A statement from the American Thoracic Society in 2012 concluded that there is insufficient evidence to recommend mindfulness for the relief of breathlessness (Parshall et al 2012). However, the author suggests that mindfulness has the potential to help reduce the anxiety and stress associated with breathlessness, increasing oxygen saturation levels, promoting relaxation, disengaging with distressing thought process, and improving and increasing goal planning and behaviour change. It is, however, important that any barriers such as low patient self-efficacy are identified, explored and improved before mindfulness therapy begins.
Complete time out activity 4
Reflect on this module and devise an action plan on how you can improve your care and support for patients with COPD.
Learning Points
- Mindfulness-based interventions have been associated with longer-term benefits for psychological health, compared with stand-alone relaxation interventions.
- Mindfulness is receptive awareness and registration of inner experiences. Through practising mindfulness individuals can mitigate negative emotions by entering into present-moment living, supporting a vibrant and meaningful life.
- Mindfulness can be incorporated into daily life, does not require a lot of time and can be practised in many different forms. The basics are: a) sit upright in a relaxed posture; b) concentrate on your breathing and be aware of the present moment; c) guide your mind back gently to the breathing if it wanders d) feel the sense of being present in the moment.
- Although COPD is a result of irreversible lung damage, it might be assumed that mindfulness could be a beneficial method to reduce stress, anxiety and panic.
- Mindfulness has the potential to help reduce the anxiety and stress associated with breathlessness, increasing oxygen saturation levels, promoting relaxation, disengaging with distressing thought process and improving and increasing goal planning and behaviour change.
Conclusions
- Breathlessness associated with COPD causes significant anxiety. It dominates daily activities and is a major cause of avoidable hospital admission, resulting in extensive costs to the NHS.
- Non-pharmacological interventions such as education, exercise, patient positioning, use of a fan, breathing strategies and relaxation are recognised as being important interventions alongside pharmacological treatment. However, evidence for psychological therapies is limited.
- There is insufficient evidence to support CBT, because the ruminative thinking and avoidance behaviours observed in patients with COPD are often based on real symptoms.
- Mindfulness is a new concept in managing breathlessness in COPD patients, with observed benefits in terms of stress reduction, relaxation, enabling a less distressing interpretation of physical symptoms (Mularski et al 2009) and psychological health promotion (Grossman et al 2004, Chiesa and Serretti 2009).
- At present, the literature on mindfulness in patients with COPD is sparse, contradictory and insufficient to support its use in practice, although benefits have been observed in other chronic respiratory conditions.
- COPD is complex and there are many underlying factors in patients’ experiences. Further investigation is required to determine fully the worth of this therapy in such patients.
Acronyms
CBT: cognitive behavioural therapy
COPD: chronic obstructive pulmonary disease
NHS: National Health Service
RAIN: R – Recognise what is happening in the present moment.
A – Allow your inner life to unfold just as it is.
I – Investigate your experience (sensations, emotions and thoughts).
N – Non-identification with whatever is there.
A – Allow your inner life to unfold just as it is.
I – Investigate your experience (sensations, emotions and thoughts).
N – Non-identification with whatever is there.
Glossary
Breathlessness: a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. It is a common and distressing symptom in patients with advanced COPD.
Chronic obstructive pulmonary disease (COPD): a progressive lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.
Cognitive behavioural therapy: a talking therapy that focuses on how thoughts, beliefs and attitudes affect feelings and behaviour, and teaches coping skills for dealing with different problems. It uses techniques from both the cognitive and behavioural therapies.
Cycle of dyspnoea: where breathlessness on moderate exertion causes anxiety. Individuals limit their activity, which decreases exercise tolerance. This, in turn, results in further breathlessness on mild exertion and during daily activities.
Mindfulness: a state in which attention focuses on experiences in the present moment, in a non-judgemental and accepting way.
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