Causes, Diagnosis, Symptoms, and Treatment of Chronic Obstructive Pulmonary Disease - Essay Example

? TECHNIQUES IN THE MANAGEMENT OF DYSPNOEA Techniques in the Management of Dyspnoea Introduction Dyspnoea is one of the most common symptoms seen among chronic obstructive pulmonary disease patients. It is also a term which generally refers to the condition wherein a person has an unpleasant experience while breathing. Braunwald and Goldman (2003, p. 104) describe it as “difficult, laboured, uncomfortable breathing”. This definition can however be different for various individuals depending on the actual symptoms and feelings of the patient. In some cases, dyspnoea is a personal and sometimes subjective experience. It is a generally stressful experience and can cause limitations in one’s functions and activities. When patients’ conditions deteriorate then the dyspnoea can also get worse. In effect, the more that they would be exposed to the risk factors associated with the condition, the more that they are likely to experience dyspnoea. This paper shall seek to establish the different techniques by which dyspnoea can be managed or treated. This paper is being carried out in order to arrive at a comprehensive and scholarly discussion on the subject matter. Physiology of dyspnoea In considering the physiology of dyspnoea, this is a condition which can arise from respiratory diseases which present in various abnormalities inside the afferent pathways, the efferent pathways, or the central control centres of the respiratory system (Irwin, et.al., 1997, p. 5). Dyspnoea is said to be caused by the interruption of the relationship between the force produced by the respiratory muscles and the consequence change in the muscle length (Weisman, et.al., 2002, p. 92). Based on the Thoracic society, the respiratory output is caused by the respiratory neurons during automatic reflex breathing. Corollary discharges play a role in respiratory effort and can sometimes cause dyspnoea. The mechanical receptors in the joints and muscles of the chest are also programmed to send signals to the brain. According to Altose, et.al., (1989, p. 145) vibrations during inspiration activates these receptors which can change dyspnoea scores among COPD patients. From the above possible physiological pathways, feelings of dyspnoea may manifest. Now, different techniques on the management and treatment of dyspnoea shall be discussed. Techniques in the management of dyspnoea Symptomatic management The first step in the management of dyspnoea is its symptomatic management. Dyspnoea is one of those symptoms which need fast and efficient management. Failing to immediately manage it can lead to stress, anxiety, loss of consciousness, angina, and other serious conditions. The symptomatic management can either be through the implementation of pharmacologic and non-pharmacologic interventions. Treatment of dyspnoea The treatment of dyspnoea was considered in a study by Sassi-Dambron, et.al. (1995). The authors carried out a randomized clinical trial in order to establish a pulmonary program focusing on coping strategies for dyspnoea without exercise training. About 89 patients with COPD were enrolled in the study. These respondents were assigned to either a pulmonary rehabilitation treatment or general health education groups. The pulmonary training involved progressive muscle relaxation, breathing retraining, pacing, self-talk, and panic control (Sassi-Dambron, et.al., 1995). The study involved tests of 6-minutes walking distance, quality of well-being, psychological function, and dyspnoea measures at baseline, after treatment, and 6 months after treatment. After the 6-week treatment, the study was able to establish that there was no difference seen in the control and in the test group in the different variables used to measure dyspnoea (Sassi-Dambron, et.al., 1995). This study implied that even with the application of dyspnoea management strategies, the lack of exercise training would still produce a negative outcome for the patient in terms of dyspnoea release. It is therefore important to consider a combination of various interventions in the management of dyspnoea among COPD patients. Dyspnoea at rest Dyspnoea may also be seen at rest and on exertion may also be apparent in patients with COPD. Dyspnoea on exertion is generally a normal condition; it may not indicate the presence of disease. In patients with COPD, exercise and normal exertions may also cause dyspnoea. Normally, people have difficulty of breathing on strenuous exercise (Mukerji, 1990). It would be abnormal however if the patient would feel it while carrying out his normal activities – those which he can normally tolerate well. It is important therefore to verify with the patient, the activities he normally conducts and if he usually feels dyspnoea while or after carrying out these activities (Mukerji, 1990). In order to manage this condition, it is important to first monitor the patient’s respiratory condition, this includes his colour, respiratory rate, respiratory effort, oxygen saturation, breathe sounds, as well as cough and sputum (White and Duncan, 2002, p. 399). Assisting the patient to a position which helps ease his breathing may also be implemented. The patient may also be advised to have alternate rest periods with his care activities (White and Duncan, 2002, p. 399). The patient may also be advised to carry out activities based on his tolerance and based on the doctor’s recommendations. Oxygen therapy may also be applied on the patient in order to ease his breathing and to prevent hypoxia (White and Duncan, 2002, p. 399). Non-pharmacologic interventions: oxygen therapy Oxygen therapy can also be used to relieve dyspnoea. In instances when the dyspnoea is caused by a lack of oxygen, oxygen therapy can be used in order to address the cause of the dyspnoea. Oxygen therapy can also provide some form of psychological relief to the patient. When the patient feels like he cannot seem to get enough air, oxygen therapy can easily remedy such “air” deficiency (Thompson and von Gunten, 2003, p. 28). This therapy is also symbolic in the sense that it would make the patient feel like the medical staff is doing something to help him. In the end, it can bring him some form of psychological relief. Moreover, on the part of the medical staff, oxygen therapy is also something they feel like they can easily do for the dyspnoeic patient (Thompson and von Gunten, 2003, p. 28). Cognitive and behavioural management Dyspnoea is a condition with a psychological as well as physiological basis. Its management therefore must also include cognitive and behavioural interventions. In a paper by Bredin, et.al., 1999, p. 901), the authors set out to evaluate the efficacy of nursing interventions for lung cancer patients suffering from breathlessness and dyspnoea. The authors were able to establish that patients who completed the study registered with a poor prognosis in their cancers and difficulty in their breathing was a major manifestation of their worsening condition. Patients who were able to undergo cognitive and behavioural interventions were able to experience improved breathing, as well as improvements in their physical and emotional states (Bredin, et.al., 1999, p. 901). Cognitive and behavioural therapy is similar to the therapy taught in pulmonary rehabilitation clinics taught in rehabilitation clinics for COPD patients. This therapy is about teaching the patient breathing control, pacing activities, and relaxation (Thomas and von Gunten, 2003, p. 27). For clinicians applying this therapy for their patients, displaying a calm and confident manner is important in managing the patient. It helps reassure and calm the patient down. It is easy enough to deduce that responding to an anxious and dyspnoeic patient in a frightened and panicked manner would exacerbate the patient’s dyspnoea (Thomas and von Gunten, 2003, p. 30). A paper by Gift, et.al., (1992) evaluated the efficacy of a taped relaxation message in decreasing dyspnoea and anxiety among chronic obstructive pulmonary disease patients. In their study, they covered about 26 adult COPD patients experiencing dyspnoea who were randomly assigned to two groups. One group was taught relaxation through a prerecorded tape and the other group was taught to sit quietly. The outcome measures of the authors considered skin temperature, heart rate, respiratory rate over a total of 2 weekly sessions were set forth. The respondents’ anxiety, dyspnoea, and airway constriction were all measured before and after the start of the study (Gift, et.al., 1992). The relaxation group was able to gain preset relaxation criteria. Moreover, the dyspnoea, anxiety, and airway constriction was decreased in the relaxation group. The control group did not experience any change in their dyspnoea; for some, their dyspnoea got worse (Gift, et.al., 1992). This study indicates important considerations in the non-pharmacological management of dyspnoea. Treatment of underlying cause: COPD It is also important to consider the fact that dyspnoea is a symptom – a symptom of another disease or condition. Therefore, it is important for the health professionals to manage first the underlying cause in the hope of eliminating or reducing patient’s dyspnoea. Among COPD patients, they may be treated with the application of different interventions including antimicrobials like tetracyclines, ampicillin, amoxicillin, and bactrim (Leader, 2011). Bronchodilators can help relax the airways and corticosteroids improve lung function. Aerosol therapy can also ease the breathing and decrease swelling. Pulmonary rehabilitation can also assist in assisting the patient cope with the COPD symptoms – eventually easing the dyspnoea (Leader, 2011). Other techniques in managing dyspnoea on exertion and at rest include the following interventions: pursed lips breathing, paced breathing, position changes, relaxation techniques including panic control measures, distraction, and guided imagery. Other techniques like exercise and activity modification and energy conservation can also ease dyspnoea. These all fall under non-pharmacologic management techniques. Pursed-lip breathing Pursed lips breathing can be carried out by instructing patient to breathe in normally through their nose as they count to two; and then they are instructed to breathe out slowly with their lips pursed while counting to four (Ropka and Williams, 1998, p. 373). Instead of pursing their lips, they may be asked to breathe out with their fingers cupped in front of their mouths. The breathing must not be done too deeply as it can cause dizziness and the exhalation process must not be done too vigorously because it can lead to bronchospasm (Ropka and Williams, 1998, p. 373). The application of pursed-lip breathing in COPD patients was evaluated by Spahija and colleagues (2005) in one of their studies. Their study sought to specifically evaluate the impact of volition pursed-lip breathing on breathing patterns, respiratory mechanics, operational lung volumes, and dyspnoea. After carrying out the research, the authors were able to establish the pursed-lip breathing promoted a much slower and deeper breathing pattern at rest and during exertion (Spahija, et.al., 2005). For patients who had no dyspnoea at rest but had it on exertion, pursed-lip breathing significantly affected them. The impact of pursed-lip breathing on dyspnoea is related to the combined impact which it generated in the tidal volume and its impact on the capacity of the respiratory muscles to meet the demands placed on them in relation to pressure generation (Spahija, et.al., 2005). A study by Breslin (1992) sought to determine the pattern of respiratory muscle recruitment during pursed-lip breathing. This study was able to establish that a change in chest wall recruitment and improved ventilation was apparent with the application of pursed-lip breathing in patients with COPD. The study further indicated that pursed-lip breathing increased rib cage and accessory muscle recruitment during inspiration and expiration. It also increased abdominal recruitment during expiration and it reduced the duty cycle of the inspiratory muscles and respiratory rate; it also improved oxygen saturation (Breslin, 1992). The study also indicated that pursed-lip breathing caused no change in the pressure across the diaphragm, thereby causing less fatigue on the diaphragm. Changes seen in chest wall muscle recruitment along with the increase in oxygen saturation led to improved ventilation while protecting the diaphragm from fatigue caused by COPD (Breslin, 1992). This study manifests the importance and the benefits of using pursed-lip breathing in the management of dyspnoea among COPD patients. The benefits of pursed-lip breathing for COPD patients were also emphasized in the study by Gosselink (2003). The study was able to establish that in patients with COPD, pursed-lip breathing reduced dyspnoea by decreasing the dynamic hyperinflation of the rib cage and by improving gas exchange. Pursed-lip breathing also improved the strength and endurance of the respiratory muscles; it also maximized the pattern of thoracoabdominal motion (Gosselink, 2003). The study also established that the benefits for pursed-lip breathing were also apparent with the use of the forward leaning position during breathing and with inspiratory muscle training (Gosselink, 2003). Paced breathing Paced breathing is another remedy which can be applied to dyspnoeic patients. This type of breathing involves the “coordination of inspiration and PLB during expiration with activities such as walking, stair climbing, and bending” (Ropka and Williams, 1998, p. 373). Specifically, the patient is asked to breathe in while at rest before carrying out a strenuous activity, and then to exhale slowly through pursed lips while carrying out the activity. Changing positions Changing positions can also help relieve dyspnoea (Vancouver Island Health Authority, n.d, p. 1). Dyspnoeic patients must be allowed to choose the position wherein they experience improved breathing. Among COPD patients, this is already an accepted intervention. “Body positions that increase abdominal pressure may improve intrinsic characteristics of the respiratory muscles and their function” (American Thoracic Society, 1999). One such position is that of leaning forward. This can improve muscle strength during inspiration; improve diaphragmatic recruitment; reduce pressure on the neck and upper intercostals muscles during respiration; and decrease abdominal paradoxical breathing (American Thoracic Society, 1999). Relaxation methods Various relaxation methods may also be applied with the use of panic control measures. These measures may involve the application of rapid, panting respirations, followed by gradual coaching of the patient to slow respiratory process and increase expiratory time (Ropka and Williams, 1998, p. 373). The application of distraction measures can also help ease the patient’s breathing. The distraction measures can sometimes depend on each patient. Some may like listening to music or watching TV in order to gradually ease their breathing (Buckholz and von Gunten, 2009, p. 98). Finally, guided imagery can also help a person relax and eventually to help him ease his breathing. Exercise Other techniques which can help ease dyspnoea involve exercise. “Exercise helps condition muscles so that oxygen is used efficiently, and exercise has been shown to decrease dyspnoea in chronic lung disease” (Ropka and Williams, 1998, p. 375). This process must however be used with proper guidance from one’s physician and with the company of a friend. In a study Stulbarg, et.al., (2002, p. 109) the authors set out to evaluate whether or not exercise training helps in dyspnoea self-management. The authors measured exercise performance and the degree of improvement in breathing and in the ease of breathing. Based on the results, the authors concluded that exercise was able to significantly improve the patient’s breathing and reduce the dyspnoea experienced by the patient (Stulbarg, et.al., 2002, p. 109). The authors further concluded that the improvement in the patient’s breathing was impacted by the dose or the amount of exercise put in by the patient. Activity modification Activity modification and energy conservation are also two ways by which dyspnoea may be managed. Among patients who suffer from severe dyspnoea, it may be difficult to pace their activities and conserve their energy. In this case, it may be important to implement lifestyle changes in the daily activities of the patient. These lifestyle changes may include a shift in activities from strenuous to moderate; as well as reduction in the duration of these activities (Ropka and Williams, 1998, p. 373). The patients may also be instructed to sit during most activities, to shower rather than to bathe, to integrate activities with plenty of rest periods, to sit on the edge of bed while dressing, to organize tasks into smaller activities, to move slower, to avoid rushing through tasks, and in preparing meals, to gather as many utensils and as many ingredients as possible at one time to the work station (Ropka and Williams, 1998, p. 373). In a paper by Victorson, et.al. (2009, p. 1018), the authors set out to identify the important patient-reported concepts in dyspnoea and related activities. The authors were able to establish that in their dyspnoea experience, they went through fatigue, activity modification, activity limitation, and emotional responses. They expressed that applying behavioural strategies, stopping and scaling back on work and activities, taking more time to carry out activities, as well as applying adaptive measures successfully managed their dyspnoea (Victorson, et.al., 2009, p. 1018). This study measured the coping strategies of the patients, evaluating such patients based on their activities and modifications of said activities in the management of their dyspnoea. This study was able to establish the importance of activity modification in the overall management of dyspnoea. Conclusion Based on the above discussion, the different techniques which can help manage dyspnoea have been enumerated and evaluated. The discussion above exemplifies the importance of applying both pharmacologic and non-pharmacologic interventions in the management of dyspnoea. Opioids and anxiolytics are two of the primary drugs which can be used to ease dyspnoea. Other pharmacologic interventions are now based on the underlying cause of the dyspnoea. The non-pharmacologic interventions for dyspnoea include oxygen therapy and cognitive behavioural therapy. Dyspnoea at rest and on exertion have similar management. These interventions include: pursed lip breathing, paced breathing, position changes, relaxation techniques including panic control measures, distraction, and guided imagery. Activity modification and exercise are also crucial activities which may help ease dyspnoea. These interventions focus on working around the existing condition and gradually easing the process of breathing. Dyspnoea is a subjective experience and may largely depend on what can work for each patient. 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