Dyspnea, also described as “shortness of breath”, is a common health complication in patients with chronic obstructive pulmonary disease (COPD). Statistically, between 90 and 95 percent of patients with COPD experience dyspnea (Donesky-Cuenco, Nguyen, Paul & Carrieri-Kohlman, 2009). Many patients are admitted to Intensive Care Units when the symptoms of COPD and dyspnea become severe. Consequently, nurses face a complex task to detect the problem and provide complex therapeutic and non-medical solutions to alleviate the symptoms of dyspnea in COPD patients. The current state of literature provides vast empirical evidence supporting the relevance of various dyspnea management models and interventions. Nurses should rely on evidence-based research, while developing the most effective approach to dyspnea in COPD patients admitted to ICU.
Patient Situation
A 62-year-old man is admitted to the Intensive Care Unit with the symptoms of breathlessness. A week ago, the patient was presented to the hospital emergency unit with the following complaints: shortness of breath, difficulty speaking, difficulty laughing. However, after a quick medical investigation, he was released from the hospital with the recommendation to use his metered dose inhaler at home. The patient has a very long history of smoking (more than 40 years). His medical history also shows he has COPD. From his history, it is evident that the patient quit smoking 2 years ago.
Symptoms
The patient looks very pale. Upon being admitted to the intensive care unit, the blood pressure is 130/90, pulse 133, respirations 26. The chest x-ray exam reveals hyperexpanded lung fields. The expiratory phase is prolonged, and wheezes are present in all lung fields. Breath sounds are decreased on both sides. The patient exhibits the decreased level of consciousness bordering on confusion. Poor air excursion, crackles, and chest pain are present. Cough is unproductive. Fever is present. Accessory muscle use suggests of COPD exacerbation.
A Review of Literature
Drugs in dyspnea management
Certainly, pharmacology is one of the fundamental elements of dyspnea management. The use of opioids is, probably, the most debated element of dyspnea management, especially in elderly patients. However, the results of certain randomized trials confirm their efficacy. Mahler et al. (2009) suggest that “endogenous opioids modify dyspnea during treadmill exercise in patients with chronic obstructive pulmonary disease by apparent alteration of central perception” (p.771). Patients and family caregivers also report positive impressions from using opioids for refractory dyspnea, especially in patients with the history of COPD (Rocker, Young, Donahue, Farquhar & Simpson, 2012). Unfortunately, not all nurses are willing to use opioids for dyspnea in COPD patients, mainly because they feel uncomfortable about the risks of addiction and the overall use of opioids in community and home settings (Rocker et al., 2012). However, in ICU, opioids can often become the most relevant means to alleviate the symptoms and address the causes of dyspnea. At the same time, nurses should consider other approaches to dyspnea management in patients admitted to ICU.
Nebulized bronchodilators represent a common approach to dyspnea management in patients with COPD (Albert & Calverley, 2008). Based on what Leyshon (2012) writes, nurses need to ensure that such patients are on maximal bronchodilator therapy. Such patients should be administered formoterol or salmeterol (long-lasting beta agonists), further combined with inhaled steroids (Leyshon, 2012). Tiotropium bronchodilators can improve lung function in patients with COPD (Johansson et al., 2008). Keating (2012) claims that tiotropium bromide leads to considerable improvements in patients with dyspnea, although, in a long-term perspective, no significant differences in the effects of tiotropium and formeterol have found. The effects of antibiotics on dyspnea in COPD patients have been poorly explored, but it possible to assume that ofloxacin does have the potential to reduce the risks of infectious complications in such patients (Albert & Calverley, 2008).
Special attention needs to be paid to the use of corticosteroids in dyspnea management. Albert and Calverley (2008) recommend administering oral steroids for 7-10 days to hospitalized patients, since they reduce the risks of treatment failure and relapses and, at the same time, reduce the length of hospital stay. By contrast, Leyshon (2012) does not approve the use of oral corticosteroids in routine treatment for dyspnea in COPD patients. Thus, the dose of corticosteroids administered to COPD patients should be kept as low as possible. In patients admitted to ICU, the recommended dose is 0.6mg/kg (Albert & Carvelrey, 2008).
Corticosteroids are more effective in patients, who no longer smoke than in current smokers (Soriano et al., 2007). It is always better to have steroids combined with other bronchodilators, including tiotropium, because tiotropium alone fails to eliminate COPD exacerbations and dyspnea risks in a long-term period (Hodder, Kesten, Menjoge & Viel, 2007). Nurses working in ICU should consider numerous factors, while administering medication to patients. According to Restrepo et al. (2008), pharmoeconomic factors greatly impact patients’ selection of treatment regimens. Consequently, when prescribing medications to treat dyspnea in COPD patients, nurses should always consider the ease of use, patient preferences and beliefs, medication costs, and device-related costs (Restrepo et al., 2008).
Oxygen
Many researchers also speak about the utility of oxygen in nursing interventions for dyspnea in COPD patients. However, their opinions about the efficacy of oxygen in dyspnea vary considerably. Moore and Berlowitz (2011) suggest that oxygen therapy can reduce acute dyspnea in COPD patients with and without hypoxia. By contrast, Leyshon (2012) does not approve the use of oxygen in patients without hypoxia. Uronis and Abernethy (2008) and Abernethy et al. (2010) go further to say that oxygen is of limited value for patients, especially in palliative situations. Also unclear is the efficacy of ambulatory oxygen in treating COPD (Bradley, Lasserson, Elborn, MacMahon & O’Neill, 2007). If oxygen is used, nurses should be able to choose between nasal prongs and masked delivery: the former are less likely to dislodge from the patient’s face but are less precise in administering the required amount of O2 (Albert & Calverley, 2008).
Ventilation
Non-invasive ventilation provides relevant support to patients with COPD and dyspnea (Leyshon, 2012). Non-invasive ventilation offers greater opportunities to reverse the damage caused by ventilatory failure, including respiratory muscle fatigue (Leyshon, 2012). Most researchers and nursing practitioners recognize the validity of non-invasive ventilation for dyspnea. Borghi-Silva (2010) finds that non-invasive ventilation (NIV) alone is much more effective than the use of supplemental oxygen in patients with severe COPD and dyspnea. According to Curtis et al. (2007), NIV can be used as life support coupled with life-sustaining treatments, as life support in situations when patients decide to forego endotracheal intubation, and as a comfort measure when patients and their family members decide to forego all forms of life support available to the patient. At the same time, the success of NIV greatly depends on the skillfulness and experience of the practicing nurse (Ambrosino & Vagheggini, 2007). Also, in patients with “severe acidosis or with altered levels of consciousness due to hypercapnic acute respiratory failure” the risks of NIV failure are very high (Ambrosino & Vagheggini, 2007, p.471).
Clearing secretions
Clearing secretions should become one of the most important elements in all nursing interventions for dyspnea. Leyshon (2012) recommends using mucolytics in patients, who experience chronic cough and cannot expectorate thick viscous sputum. Actually, cough is one of the central mechanisms of mucus clearance, especially in patients with COPD (Homnick, 2007). However, patients in ICU, particularly facing the decreased level of consciousness, can experience difficulties coughing and, therefore, may need assistance to enhance clearance and avoid retained secretions that lead to inflammations, infections, and respiratory failures (Homnick, 2007). Homnick (2007) describes insufflation-exsufflation approaches, which involve the use of a cough assisting device to inflate the lungs and stimulate cough. Unlike Homnick (2007), Kodric et al. (2009) recommend more traditional dyspnea interventions and evaluate bronchial drainage techniques to avoid COPD exacerbations. The effectiveness of these approaches depends on many factors, and nurses should consider the individual and treatment characteristics of each patient to avoid adverse effects of the therapy on their health.
Education
Nurses should educate patients with dyspnea and COPD to manage their health condition and avoid further crises. In ICU, nurses should provide education to patients, who have already passed the most serious crisis. This education should be ongoing (while admitted to the ICU) and rehabilitative (after the patient is transferred from the ICU and discharged from the hospital). Leupoldt et al. (2008) organized a 3-week outpatient rehabilitation exercise course for individuals with dyspnea in COPD and found that the most significant effect of the program was reduced dyspnea during the learning activities. Patients can be offered participation in these courses after they are released from the hospital. All patients with the history of COPD and dyspnea need education to understand the nature of their disease and develop appropriate self-management skills (Foster et al., 2007). Here, face-to-face and internet-based programs are equally effective (Nguyen et al., 2008). Such programs can facilitate symptom management in patients with COPD and dyspnea and increase the program outreach to those, who are physically unable to attend face-to-face training sessions (Nguyen et al., 2008).
Relaxation
Numerous methods of relaxation and rehabilitation are available to COPD patients with dyspnea. Leyshon (2012) lists breathing techniques, relaxation through positioning, fan therapy, energy conservation, cognitive behavioral therapy and models involving family members can greatly benefit such patients. Elderly patients with COPD and dyspnea can benefit from yoga, which is claimed to improve their functional performance (Donesky-Cuenco et al., 2009). Acupuncture and acupressure are often mentioned in empirical literature on COPD and dyspnea. Suzuki et al. (2008) writes that acupuncture can reduce COPD-related symptoms, whereas Wu, Lin, Wu and Lin (2007) propose an evidence-based tool for managing chronic dyspnea and its psychological consequences, based on acupressure. Both acupuncture and acupressure can be applied in ICU. Yoga can be used as a supplemental approach to rehabilitation of patients with the history of COP and dyspnea. Additionally, Glennon and Seskevitch (2008) assert that nurses working with dyspnea patients must possess relevant stress management skills. Pulmonary rehabilitation programs can be used to support patients with dyspnea after they are discharged from hospitals (Pitta et al., 2008). These rehabilitation programs should necessarily include a physiotherapy element (Garrod & Lasserson, 2007).
Conclusion and Implications
The current state of literature provides abundant recommendations to relieve the symptoms of dyspnea in patients with COPD. Corticosteroids, opioids, oxygen, secretion clearance, as well as education and relaxation should make up the final model of dyspnea management in an elderly patient with COPD. Care should be taken in the choice of the methods most appropriate for use in ICU: the ease of administration and use of drugs should be considered, while relaxation and education should be provided in ways that do not disrupt the basic course of treatment. Upon discharge, the patient should be referred to any existing education program to develop better self-management skills. Participation in rehabilitation programs should be encouraged to sustain the positive effects of traditional therapy in long-term periods.
References
Abernethy, A.P., McDonald, C., Frith, P., Clark, K., Herndon, J.E., Marcello, J. […] Currow, D.C. (2010). Effect of palliative oxygen versus medical (room) air in relieving breathlessness in patients with refractory dyspnea: A double-blind randomized controlled trial. Lancet, 376(9743): 784-793.
Albert, P. & Calverley, P.M. (2008). Drugs (including oxygen) in severe COPD. European Respiratory Journal, 31, 1114-1124.
Ambrosino, N. & Vagheggini, G. (2007). Non-invasive ventilation in exacerbations of COPD. International Journal of COPD, 2(4), 471-476.
Borghi-Silva, A., Mendes, R.G., Toledo, A.C., Sampaio, L.M., Silva, T.P., Kunikushita, L.N. […] Costa, D. (2010). Adjuncts to physical training of patients with severe COPD: Oxygen or noninvasive ventilation? Respiratory Care, 55(7), 885-894.
Bradley, J.M., Lasserson, T., Elborn, S., MacMahon, J. & O’Neill, B. (2007). A systematic review of randomized controlled trials examining the short-term benefit of ambulatory oxygen in COPD. Chest, 131, 278-283.
Curtis, J.R., Cook, D.J., Sinuff, T., White, D.B., Hill, N., Keenan, S.P. […] Levy, M.M. (2007). Noninvasive positive pressure ventilation in critical and palliative care settings: Understanding the goals of therapy. Critical Care Medicine, 35, 932-939.
Donesky-Cuenco, D., Nguyen, H.Q., Paul, S. & Carrieri-Kohlman, V. (2009). Yoga therapy decreases dyspnea-related distress and improves functional performance in people with Chronic Obstructive Pulmonary Disease: A pilot study. The Journal of Alternative and Complementary Medicine, 15(3), 225-234.
Foster, J.A., Yawn, B., Maziar, A., Jenkins, T., Rennard, S.I. & Casebeer, L. (2007). Enhancing COPD management in primary care settings. Medscape General Medicine, 9(3), 24-29.
Garrod, R. & Lasserson, T. (2007). Role of physiotherapy in the management of chronic lung diseases: An overview of systematic reviews. Respiratory Medicine, in press, 1-8.
Glennon, C. & Seskevich, J. (2008). Relaxation technique to ease dyspnea: A tool for oncology nurses. Clinical Journal of Oncology Nursing, 12(2), 369-371.
Hodder, R., Kesten, S., Menjoge, S. & Viel, K. (2007). Outcomes in COPD patients receiving tiotropium or salmeterol plus treatment with inhaled corticosteroids. International Journal of COPD, 2(2), 157-167.
Homnick, D.N. (2007). Mechanical insufflation-exsufflation for airway mucus clearance. Respiratory Care, 52(10), 1296-1307.
Johansson, G., Lindberg, A., Romberg, K., Nordstrom, L., Gerken, F. & Roquet, A. (2008). Bronchodilator efficacy of tiotropium in patients with mild to moderate COPD. Primary Care Respiratory Journal, 17(3), 169-175.
Keating, G.M. (2012). Tiotropium bromide inhalation powder: A review of its use in the management of Chronic Obstructive Pulmonary Disease. Drugs, 72(2), 273-300.
Kodric, M., Garuti, G., Colombian, M., Russi, B., Porta, R.D., Lusuardi, M. & Confalonieri, M. (2009). The effectiveness of a bronchial drainage technique (ELTGOL) in COPD exacerbations. Respirology, 14, 424-428.
Leupoldt, A., Balewski, S., Petersen, S., Taube, K., Schubert-Heukeshoven, S., Magnussen, H. & Dahme, B. (2007). Verbal descriptors of dyspnea in patients with COPD at different intensity levels of dyspnea. Chest, 132, 141-147.
Leupoldt, A., Hahn, E., Taube, K., Schubert-Heukeshoven, S., Magnussen, H. & Dahme, B. (2008). Effects of 3-week outpatient pulmonary rehabilitation on exercise capacity, dyspnea, and quality of life in COPD. Lung, 186, 387-391.
Leyshon, J. (2012). Managing severe breathlessness in patients with end-stage COPD. Nursing Standard, 27(6), 48-56.
Mahler, D.A., Murray, J.A., Waterman, L.A., Ward, J., Kraemer, W.J., Zhang, X. & Baird, J.C. (2009). Endogenous opioids modify dyspnoea during treadmill exercise with COPD. European Respiratory Journal, 33, 771-777.
Moore, R.P. Berlowitz, D.J. (2011). Dyspnoea and oxygen therapy in chronic obstructive pulmonary disease. Physical Therapy Reviews, 16(1), 10-18.
Nguyen, H.Q., Donesky-Cuenco, D., Wolpin, S., Reinke, L.F., Benditt, J.O., Paul, S.M. & Carrieri-Kohlman, V. (2008). Randomized controlled trial of an internet-based versus face-to-face dyspnea self-management program for patients with chronic obstructive pulmonary disease: Pilot study. Journal of Medical Internet Research, 10(2): e9-e19.
Pitta, F., Troosters, T., Probst, V.S., Langer, D., Decramer, M. & Gosselink, R. (2008). Are patients with COPD more active after pulmonary rehabilitation? Chest, 134(2), 273-280.
Restrepo, R.D., Alvarez, M.T., Wittnebel, L.D., Sorenson, H., Wettstein, R., Vines, D.L. […] Wilkins, R.L. (2008). Medication adherence issues in patients treated for COPD. International Journal of COPD, 3(3), 371-384.
Rocker, G., Young, J., Donahue, Farquhar, M. & Simpson, C. (2012). Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced Chronic Obstructive Pulmonary Disease. Canadian Medical Association Journal, 184(9), E497-E504.
Soriano, J.B., Sin, D.D., Zhang, X., Camp, P.G., Anderson, J.A., Anthonisen, N.R. (2007). A pooled analysis of FEV1 decline in COPD patients randomized to inhaled corticosteroids or placebo. 131, 682-689.
Suzuki, M., Namura, K., Ohno, Y., Tanaka, H., Egawa, M., Yokoyama, Y. […] Yano, T. (2008). The effect of acupuncture in the treatment of chronic obstructive pulmonary disease. The Journal of Alternative and Complementary Medicine, 14(9), 1097-1105.
Uronis, H.E. & Abernethy, A. (2008). Oxygen for relief of dyspnea: What is the evidence? Current Opinion in Supportive & Palliative Care, 2(2), 89-94.
Wu, H.S., Lin, L.C., Wu, S.C. & Lin, J.C. (2007). The psychologic consequences of chronic dyspnea in chronic pulmonary obstruction disease: The effects of acupressure on depression. The Journal of Alternative and Complementary Medicine, 13(2), 253-261.