Effectiveness of a nurse led-breathing intervention to patients with COPD

Abstract 

Title:

A study of effectiveness of a nurse led-breathing intervention to patients with COPD and the correlation of decreasing anxiety 

Purpose: 

To determine if a nurse-led relaxation breathing intervention will reduce anxiety in COPD patients with exacerbation 

Literature Summary: 

Chronic obstructive pulmonary disease (COPD) as a progressive inflammatory pulmonary disease has been reported by WHO as the 4th leading cause of death globally and has continued to spread in most of the developing countries than in developing countries. Approximately 14.8 million adults have been diagnosed with COPD, and 74% of people with COPD have been associated with increased anxiety levels. Patients diagnosed with COPD experiences shortness of breath or even dyspnea. There is a close correlation between anxiety and COPD. Anxiety treatment falls into two distinct groups including the non-pharmacology and pharmacology. Non-pharmacology particularly the CBT methods are highly effective in treating anxiety disorder. Relaxation approach has been adopted as the primary technique in anxiety disorders. CBD has however been criticized because it is time-consuming and very expensive to undertake. Pharmacology, on the other hand, entails multiple medications such as antidepressants. The contemporary pharmacological methods of treatment for anxiety disorders have been established to be much safer and are highly tolerable. However, pharmacology have been ineffective due to its massive side effects and being non-compliant 

Method: 

The quantitative randomized controlled trial will be the most suitable type of impact evaluation strategy. Randomized access to the social program will be critical to limit potential bias. Randomised access further will help to generate an internally valid effect estimate. The sample population was comprised of hospitalised with acute COPD exacerbation, and the sample size will be comprised of 60 female subjects of ages between 40 years and above in one of the private hospital in New York City hospitals. The sample size will be obtained through stratified sample sampling and this sample will be suitable for the study since it will save on time and financial constrained. Inclusion criteria entailed, smoking related COPD patients with anxiety hospitalised patient and medically stable. Data collection was achieved through the use of observation form and Hamilton Anxiety Rating Scale (HAM-A). 

Introduction 

The research problem in this study is that there is an increased risk of COPD in patients with exacerbation who are suffering from anxiety. It leads to prolong patient’s hospital stay and may cause death. Research has established that COPD has become one of the primary cause of human disability and a leading cause of death throughout the world (Efraimsson, Hillervik & Ehrenberg, 2008). Based on research, COPD has been associated with an intermittent hospitalisation as a result of exacerbation that is often characterised by a severe worsening of main symptoms of sputum production, dyspnea and even cough (Efraimsson, Hillervik & Ehrenberg, 2008). One of the primary complaints of individuals diagnosed with COPD in most instances is dyspnea and even shortness of breath. Further, it has been shown that even in a situation of adequate levels of saturation, dyspnea will bring these patients back to their physician with a disturbing regularity which will result in a highly frequent hospital admission or even longer stay in hospitals (Goldberg, Hillberg & Reinecker, 2002). 

According to Goldberg, Hillberg & Reinecker, (2002), hospitalisation as a result of COPD exacerbation has been established to be very common, and this has formed one of the most important parts of the COPD patient’s care. Evidently, depression and anxiety have been shown to be among the most widespread psychological comorbidities in COPD patients, and this tends to lower the patient’s quality of life. In addition to this, they have further been strongly related to the higher rates of disabilities and other forms of impaired functional position particularly in an individual’s overall health, vitality, social functioning or even mental health functioning. Despite statistically controlling for most of the main impacts of the general health condition such as dyspnea, and the severity of COPD, anxiety has remained one of the major factors affecting the patient’s functional wellbeing (Goldberg, Hillberg & Reinecker, 2002). The frequency of the patient’s breathing tend to increase rapidly as a result of the physiological arousals, and in those individuals diagnosed with COPD, the hyperventilation which often emerges due to anxiety strikingly makes worse the patient’s breathing shortness that results through causing bronchoconstriction in addition to lung hyperinflation. The hyperinflation further tends to increase the works of the patient’s breathing and at the same time reduce inspiratory reserve capacity (Hui & Hewitt, 2003). 

It has been established that anxiety is one of the primary predictors, of the regularity of admission of the patient diagnosed with COPD exacerbation, relapse risk, hospital readmission and even mortality risks (Hui & Hewitt, 2003). Currently, few studies have been conducted to explore that possible effect of breathing programs on anxiety. Most of the previous studies conducted established that controlled breathing is an effective treatment for various pulmonary symptoms (Goldberg, Hillberg & Reinecker, 2002). Therefore, the research paper hypothesizes that a controlled deep breathing might help to lower the overall adverse effect. In this case, control breathing will comprise of exercises including pursed lips breathing, active expiration, diaphragmatic breathing and even slow ad deep breathing. For the patient diagnosed with COPD, a controlled breathing might significantly relieve dyspnea through reducing dynamic hyperinflation increase strength, optimizing the pattern of thoracoabdominal motion and even improving gas exchange (Hui & Hewitt, 2003). 

Anxiety treatment falls into two categories non-pharmacology and pharmacology. Non-pharmacology is a therapeutic treatment therapy which includes Cognitive Behavior Therapy (CBT) methods that are said to be effective in treating anxiety disorder. However, CBT has been criticized because it is time-consuming and very expensive to undertake (Hui & Hewitt, 2003). According to Hui & Hewitt, (2003), the therapy is not covered by medical insurance, on the other hand, pharmacology, which consists of medications such as anti-anxiety and anti-depressant are commonly used to treat anxiety disorder. However, medication has been ineffective due to its multiple medication side effects, causing patients to refrain from this form of treatment out of fear, thus leading to non-compliant in most cases (Goldberg, Hillberg & Reinecker, 2002). The respiratory therapists will help the COPD patients using breathing intervention by training them to breathe through the use of straw to stimulate them. Nurse-led intervention including, post extubation and lip breathing exercises are important when addressing patient’s anxiety. A continuous breath through the straw will be comfortable when patients feel relaxed and then breathe slowly and easily (Goldberg, Hillberg & Reinecker, 2002). Anxious patients often experience short breathes hence the need to help them breathe. The patients subjected in lip breathing and diaphragmatic breathing which will be able to control their anxiety. 

Therefore, I am conducting a study of the effectiveness of a nurse led-breathing intervention to patients with COPD exacerbation and the correlation of reducing anxiety. The quantitative randomized controlled trial was the most suitable type of impact evaluation strategy in this study because it will help arrive at factual and objective information that would help to determine the effectiveness of the intervention method proposed (Mikkelsen et al., 2014). In addition to this, it is clear that the use of a randomized access to the social program will help to limit potential bias and generate an internally valid impact estimate. The study will evaluate the effectiveness of a nurse led-breathing intervention to patients with COPD and the correlation of lowering anxiety. 

Research question: 

The research question for the study is as follows: Does a nurse-led relaxation breathe intervention decrease anxiety in COPD patients with the exacerbation? 

Hypotheses: 

A nurse-led relaxation breathing intervention will decrease anxiety in COPD patients with exacerbation 

Theoretical framework 

In order to determine the effectiveness of a nurse led-breathing intervention to patients with COPD and the correlation of lowering anxiety, it is important to understand major components of the intervention in addition to its interrelationship. Social learning theory will help link the anxiety management components with various underlying mechanisms to influence the outcome to patients with COPD. According to Bailey (2004), the theoretical approaches on both the behavioural and organisational change are tightly integrated which supports the premise that bringing together of pharmacological and non- pharmacological intervention to stress treatment and management will strengthen the effects of the COPD management. In testing the effectiveness of the proposed model which is nurse-led breathing, the study will examine the actual COPD management program in a private hospital in New York through a process evaluation. Changes in both the intermediate and the outcome of care are expected to occur from the implementation of the program (Goldberg, Hillberg & Reinecker, 2002). Since professionally directed intervention and patient-related intervention all are aimed at changing behaviour through the mechanism like self-efficacy and gain knowledge, the study will have to evaluate the extend at which the evidence-based care will be offered. 

Literature review: 

Chronic obstructive Pulmonary Disease (COPD)- 

COPD is simply a progressive inflammatory pulmonary illness that is often characterised by the peripheral bronchus’s and pulmonary emphysema’s chronic obstruction. Based on the The World Health Organization (WHO) COPD is the 4th principal cause of death globally and has continued to spread in most of the developing countries (Valenza et al., 2014). Currently, approximately 50 percent of the total population across the world of ages between 75 and above is affected by COPD. WHO through its survey foresaw that COPD would gradually become the third most common cause of death throughout the globe by 2020. However, the mortality rates caused by COPD tend to vary significantly from one country to another, and it has been linked to smoking pervasiveness among individuals, for instance, there is a higher mortality rate in the following states, Australia, China, UK, Mongolia, Ireland, Europe and even Ireland. In Sweden, research has shown that 8 percent of the entire population over a period of the last 50 years greatly suffers from COPD. On the other hand, 30 percent of the residents who are smokers develop the illness, with a very higher risk levels among the aged (Goldberg, Hillberg & Reinecker, 2002). In Swedish, the disease has been argued to cost the country approximately 1.1 billion dollars per year. Research has shown that smoking is one of the greatest risk factors for COPD; therefore, cessation of tobacco use is one of the most prioritized interventions today. 

Approximately 14.8 million adults have been diagnosed with COPD. 74% of COPD patients might develop a clinically relevant anxiety levels (O'Donnell et al., 2007). COPD is believed to be a disabling disease with different symptoms including shortness of breath, chronic cough, wheezing, even dyspnea and even phlegm. For the severely ill COPD patients, there are other symptoms including malnutrition, congestive heart failure, cognitive dysfunction, muscular weakness and even fatigue and depression. Research has shown that there is a close correlation between anxiety and COPD. 

Controlled breathing program on anxiety and depression 

Studies have shown that there is a psychological and physical effect of hospitalisation, however; there are not current studies that have focused on the effects in an acute COPD. The majority of the previous studies established a poor physiological status, higher anxiety levels and depression and even impaired life’s quality. Patients with COPD often report episodes of both intractable and even heightened dyspnea which is inextricably associated with anxiety (Goldberg, Hillberg & Reinecker, 2002). It is clear that both depression and anxiety are the primary risk factors for re-hospitalization in COPD patients and who have been determined to be associated with poor life qualities. Most studies have attempted to assess the effectiveness of anxiety’s therapy; life’s quality in addition to the function in patients who are hospitalised with COPD exacerbation and such outcome tend to be highly contradictory. In one of the studies, incentive spirometry was shown to have significantly enhanced St George’s Respiratory Questionnaire score than with the standard care. There was no significant improvement established in the day-to-day sleeping, eating, exercise and even weight scores in the situation where incentive spirometry groups were contrasted to the standard care groups (Hui & Hewitt, 2003). 

COPD exacerbation substantially impacts health-related life quality, pulmonary function and even COPD patient’s survival. Most studies established that there is a significant enhancement in the psychological and functional variables in the interventions within the intervention group and worsening in the controlled group as result of the effects of hospitalisation. Based on this, it can be argued that a higher level of inactivity among patients particularly throughout the hospitalisation period is a primary component within the functional and psychological impairment during COPD exacerbation. According to Hui & Hewitt, (2003), a pulmonary rehabilitation program has proven highly effective and can significantly reduce anxiety levels among COPD patients. Exercises training programs together with adequate education such as stress management technique have further been argued to be very influential in reducing the patient’s anxiety level. Evidently, stress management session without introducing aspects of exercise training might not be effective in improving anxiety. In addition to this, an added exercise’s value, particularly in its modality such as global and breathing training, has the potential to improve the psychological status in COPD patients (O'Donnell et al., 2007). 

Anxiety treatment: 

Non-pharmacology 

Non-pharmacologic treatments have been used for a long time for the social anxiety disorders such as cognitive behaviour therapy (CBT). It has gained an extensive empirical support for the last two decades. Despite its effectiveness, the major question has remained related to ways to maximize the overall benefits of the currently available methods of treatment (Cottraux, 2002). CBT has been shown to be the most efficient approach compared to the psychoanalytic therapy as far as the Generalised Anxiety Disorder (GAD) and performance anxiety Psychological debriefing for PTSD are concerned. Nonpharmacological treatments have been used extensively for anxiety disorders particularly behaviour therapy (BT). Relaxation methods are currently the primary technique in the treatment and management of anxiety disorders. An example of most employed relaxation strategy like Ost’s applied relaxation has been recently adopted and is made of numerous behavioural and cognitive techniques. The combination of both the antidepressant and CBT has been established to be highly effectively in managing panic and anxiety among patients with COPD (Goldberg, Hillberg & Reinecker, 2002). However, CBD might not be accessed much easily as a result of the limited number of the practitioners, particularly in the developing countries. The limited accessibility primarily rests on the limited CBT training opportunity within a nation’s medicine and psychology facilities. In addition to this, despite the fact that CBD is the highly effective method with long-term benefits in treating anxiety, a majority of the patients have argued that it is highly expensive and time-consuming. However, in the long-term, CBT tend to cost much less compared to medication because it prevents relapse form occurring. 

Pharmacology 

Research has established that most of the modern day pharmacological methods for the treatment of anxiety disorders are highly safe and tolerable compared to what they used to be some 30 years ago. Currently, anxiety patients tend to benefit greatly from the massive psychopharmacological explorations which have shown to be efficient in yielding a highly endurable and safer side effect profiles with little or no enhanced efficacies. Despite their widespread application, the efficacies of the treatment in addition to duration have not yet been improved even with the massive understanding of the pathophysiology. About one-third of the patients on current antidepressant have been reported not to have attained a sustained remission from anxiety (Farach et al., 2012). Patients have been using antidepressants medication for a very long time, but there is still limited reliable information on the long-term efficacy of these drugs. The same problem has further been made worse by numerous emerging drug classes which are believed to have prompted clinicians to recommend these drugs in combination and alter the dose with poor information on the combination of optimal treatment. Currently, the common types of antidepressants used are SNRIs and SSRIs which have helped reduced the level of patient’s anxiety; however, they tend to react slowly and fail to result in what can be considered as sustained remission (Kayahan et al., 2006). In the contemporary world, various pharmacological treatments have been designed to management and treat anxiety that are being produced which focuses on drugs meant for particular neuroreceptor target and the pharmacological memory’s manipulation with the aim of enhancing the adaptive progression and at the same time block maladaptive processes. 

Methodology: 

Method: 

In completing the study, I will use quantitative randomized controlled trials as my main research design. The randomized controlled trial (RCT) is a research methodological approach where population under study will be randomly allocated for the researcher to evaluate a given intervention (Mikkelsen et al., 2014). Randomized controlled trial (RCT) is suitable for this study because it allows the participants to be randomly assigned to control group and experimental group. It is considered to be the gold standard for yielding reliable evidence about the cause and effect of the study. In the case, I will be assigning the participants numbers from 1- 60. The control group will have even numbers 1-60, and experimental group will have an odd number between 1-60. Both groups will get standard treatment as ordered by their medical provider but only the experimental group will be getting 10 minutes nurse-led breathing intervention session once a day for three days. The intervention will be identical because I plan to use only trained registered nurses to administer the breathing intervention. Although, we do not know if the nurse-led this intervention will reduce anxiety. We do know that in similar research conducted found that nurse-led intervention is associated with lower rate of doctor visit and decrease hospital readmission. 

Setting 

The study will take place in the New York City hospitals area between the January 2018 and April 2020. 

Sample: 

The Sample population will comprise of hospitalized patients with COPD, ages 40 years and above. The study will include both men and women; the participant must be medical stable which means that they will not on a ventilator, not terminal ill, able to give consent. The exclusive criteria will be a participant with lung cancer, unconscious and unable to understand simple English. I plan to email the New York City hospital administrators after I received the Institutional Review Board (IRB) approval. The email will include a copy of the approved proposal from the IRB. The will request a meeting with the nursing chief of staff, managers and charge nurses. We granted a meet. I will present my proposal to them and seek their assistance to help identify patients that meet the criteria. Also, I plan to obtain approval from the NYC hospital ethical committee since will be using their hospital. The numbers will be assigned as the hospital flagged the patients that may be candidates for the study. According to the power analysis conducted, I will be using a total number of 60 participants. Control group and experimental group with have 40 participants respectively. 

Intervention: 

The participants within the intervention groups will receive the education which will lay much emphasis on the self-care capability in addition to ways to help the persons according to their exclusive necessities in addition to skills to effectively deal with the condition and treatments. All the educational visits will have to be founded on the motivation dialogues, and further must be tailored individually to each participant based on their age, lifestyle and illness. The major component that will be taken into consideration is the description of physiology and the anatomy of airways and COPD impacts, spirometry measurement and clarification of the results to the patients in addition to the optimization of the optimization of pharmacological treatments (Guell et al., 2006). The other intervention that will be taken into consideration in the study is by giving the participants a 10 minutes relaxation breathing intervention after every 8 hours in the patient’s room. The response was imperative in the study to allow the members enough time to cool down and relax after a strenuous exercise. 

Data collection: 

I will be using Hamilton Anxiety Rating Scale (HAM-A). It suitable data collection tool for anxiety. According to Goldberg, Hillberg & Reinecker, (2002 ), HAM- A is one of the first anxiety rating scales developed to measure the severity of anxiety symptoms and is currently in use today. Goldberg, Hillberg & Reinecker, (2002) , concluded in their study that HAM-A scale can be used with confidence and has increased consistency across the outcome rating. HAM-A has 14 items scale. A participant can score between 0-56. Control group will get the HAM-A assessment once a day whereas; the experimental group will be getting the HAM-A assessment as soon as they finish the breathing intervention. I will be ensuring validity and reliability through the use of simple randomization. The use of randomization will be used to limit any form of bias when assigning groups. The patient will be assigned to a control group and experimental group. Using even and odd number 1-60. I also, plan on training registered nurse prior to the start of the research. This will ensure that the entire experimental group will get identical interventions. 

The data obtained from the study will be analyzed using inferential statistics method. It will determine how the control group performed on the anxiety scales without the intervention and how experimental group performed on the HAM-A scale after receiving the nurse-led breathing intervention. Both group with analyzed using SSPS statistical analysis. 

Limitations: 

To complete the study efficiently and get reliable and objective I will take into consideration certain factors including: first, it will be critical to ensure that rigor is achieved in the study through applying an appropriate research tool that will meet the research objective. It would be critical I ensure that the tools will be able to gather information which is suitable for a required precision in the study. The tools that would be employed in data collection should be able to maximize chances of identifying a full range of the phenomenon. Lastly, the tools should be able to maximize the chance of generating data with a discernible pattern. 

Based on the hypothesis that states that a nurse-led relaxation breathing intervention will decrease anxiety in COPD patients with exacerbation, there would be several types of limitation that the study would experience. First, the sample size that will be used was small and will be comprised of males only. The study will only use 30 individuals which is small for the generalization of the outcome to the large population of the patients with COPD. There results that would be obtained might not be a representative of the entire study population. Further, the study only will use men as the study sample population hence the same could not be generalized to women since they will not be included in the research. The study will be conducted on hospitalized patients only and may not be applicable to outpatients. Also, some patients may be discharged or unable to complete the study due to worsening medical condition. In the further, more study may be needed to further evaluate the effectiveness of the nurse-led intervention to reduce anxiety among COPD patients.  

References  

Bailey, P. H. (2004). The dyspnea-anxiety-dyspnea cycle—COPD patients’ stories of breathlessness:“It’s scary/when you can’t breathe”. Qualitative health research , 14 (6), 760-778. 

Cottraux, J. (2002). Nonpharmacological treatments for anxiety disorders. Dialogues in clinical neuroscience , 4 , 305-319. 

Efraimsson, E. Ö., Hillervik, C., & Ehrenberg, A. (2008). Effects of COPD self ‐ care management education at a nurse ‐ led primary health care clinic. Scandinavian journal of caring sciences , 22 (2), 178-185. 

Farach, F. J., Pruitt, L. D., Jun, J. J., Jerud, A. B., Zoellner, L. A., & Roy-Byrne, P. P. (2012). Pharmacological treatment of anxiety disorders: Current treatments and future directions. Journal of anxiety disorders , 26 (8), 833-843. 

Goldberg, R. T., Hillberg, R. E., & Reinecker, L. (2002). Evaluation of patients with severe COPD in pulmonary rehabilitation.(COPD: 12: 00pm-1: 45pm). Chest , 122 (4), 139S- 139S. 

Guell, R., Resqueti, V., Sangenis, M., Morante, F., Martorell, B., Casan, P., & Guyatt, G. H. (2006). Impact of pulmonary rehabilitation on psychosocial morbidity in patients with severe COPD. Chest Journal , 129 (4), 899-904. 

Hui, K. P., & Hewitt, A. B. (2003). A simple pulmonary rehabilitation program improves health outcomes and reduces hospital utilization in patients with COPD. CHEST Journal , 124 (1), 94-97. 

Kayahan, B., Karapolat, H., Atýntoprak, E., Atasever, A., & Öztürk, Ö. (2006). Psychological outcomes of an outpatient pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease. Respiratory medicine , 100 (6), 1050-1057. 

Mikkelsen, R. L., Middelboe, T., Pisinger, C., & Stage, K. B. (2004). Anxiety and depression in patients with chronic obstructive pulmonary disease (COPD). A review. Nordic journal of psychiatry , 58 (1), 65-70. 

O'Donnell, D. E., Banzett, R. B., Carrieri-Kohlman, V., Casaburi, R., Davenport, P. W., Gandevia, S. C., ... & Webb, K. A. (2007). Pathophysiology of dyspnea in chronic obstructive pulmonary disease: a roundtable. Proceedings of the American Thoracic Society , 4 (2), 145-168. 

Valenza, M. C., Valenza-Peña, G., Torres-Sánchez, I., González-Jiménez, E., Conde- Valero, A., & Valenza-Demet, G. (2014). Effectiveness of controlled breathing techniques on anxiety and depression in hospitalized patients with COPD: a randomized clinical trial. Respiratory care , 59 (2), 209-215.