Pulmonary Rehabilitation in COPD Patients - Essay Example

? Compare and contrast the outcome differences between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD NAME CLASS Chronic Obstructive Pulmonary Disease (COPD) is a term used to describe chronic bronchitis or emphysema (commonly both) and the resultant narrowing of the airways (Lundback et al, 2003). COPD is characterized by limited air flow into (and out of) the lungs, which can lead to shortness of breath and rhonchi. COPD is commonly caused by noxious air particles from smoking, and is a destructive disease for the sufferers, particularly when it limits physical activity (Fabbri & Herd, 2003). There are a number of ways of treating COPD (although it cannot be cured) commonly involving pulmonary rehabilitation, a term used to describe various therapeutic approaches with a holistic approach. Pulmonary rehabilitation can occur in a number of settings and involve a wide variety of approaches depending on the patient and the treating physician. The purpose of this paper is to compare and contrast the outcomes of an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. By exploring the nature of COPD and the available programs it will become obvious that each has strengths and weaknesses, many of which depend on the prognosis of the patient. There is wide variety within these programs, often producing different health outcomes for the patient, and these are important in tackling such a common and debilitating disease. Chronic Obstructive Pulmonary Disease (COPD) The importance of COPD can be partially highlighted by how common it is. In the United States, it is estimated that one in 20 people suffer from COPD, which totals about 5% (Fabbri & Herd, 2003). COPD is more common in areas which are deprived than those which are considered affluent. It is really important that COPD is diagnosed early because it gradually worsens with time, leading to death; early diagnosis and immediate treatment can slow this course (Celli et al, 2004). COPD is worse in those with extremely severe airflow obstruction and extreme shortness of breath, and patients exhibiting these symptoms may have a poorer prognosis and need a more rigorous scheme of treatment (Lacasse et al, 1996). Diagnosis of COPD is fairly simple. Firstly, the patient should be asked whether they have a history of smoking as this is the most important risk-factor and COPD is unlikely to be found in a non-smoker unless they have a particularly dangerous environment (Lacasse et al, 1996). A spirometer measuring the forced expiratory volume from the lungs is then used to ascertain whether the lung volume is normal. It should be noted that values for forced expiratory volume vary greatly depending on the sex and size of the individual. Chest x-rays can also be used in cases where diagnosis is not clear, as COPD patients can show signs of hyperinflation, a flattened diaphragm and bullae (Fabbri & Herd, 2003). Other lung diseases which show the same symptoms of COPD, such as pneumonia, often have very visible symptoms on x-ray (Fabbri & Herd, 2003) and therefore this technique is important for ruling out differential diagnoses. The treatments for COPD vary. The most important thing for those diagnosed is to quit smoking, as smoking is the most common cause and most dangerous environmental exacerbation (Celli et al, 2004). Patients may receive help with this from the medical authority as part of a wider treatment program. There are also pharmaceuticals that help with the symptoms of COPD. These commonly include bronchodilators which relax the smooth muscle around the airways, improving the airflow and relieving shortness o breath (Lacasse et al, 1996). Corticosteroids are also often used, although there is some debate about how useful these actually are in the treatment of COPD (Fabbri & Herd, 2003). It is also important for the patient to have adequate nutrition, as being severely underweight or overweight makes the symptoms and prognosis of COPD much worse (Lacasse et al, 1996). Exercise can also help with the symptoms of COPD, and is often used as part of the pulmonary rehabilitation programs discussed below because of the therapeutic benefits for the patient (Lacasse et al, 1996). Outpatient Hospital-Based Pulmonary Rehabilitation Program It is very common for a patient with COPD to visit a hospital with their concerns, and they may be placed on an outpatient hospital-based pulmonary rehabilitation. This involves, as the name suggests, the patient receiving several sessions in a hospital outpatient ward with the aim of improving the airflow and the symptoms of COPD. Perhaps the main benefit of outpatient programs is that the clinicians can control the treatment that the patient is receiving much more than in a similar home-care situation. Another benefit concerns patient compliance, which may become an issue if the patient is not supervised during treatment (Celli et al, 2004). Pulmonary rehabilitation programs are very multidisciplinary in their approach and often involve a number of professionals and therefore offering this service in an outpatient facility can mean that the patient gets constant advice and treatment from these individuals. Outpatient programs also often offer better equipment to the patient, as they can be shared amongst those with COPD rather than needing to be installed in a home environment (Fabbri & Herd, 2003). These benefits are huge, but they can be costly which is important to note especially as COPD is often more common in deprived areas where these facilities may not be available or within the economic reach of the patient. Home-Care Pulmonary Rehabilitation Program The home-care approach is very similar to the outpatient approach when considering the types of treatment that are available to the COPD patient. The home-care rehabilitation programs often include a visit to the hospital to get advice from various health professionals but then taking the information home and following it. The main problem with this is evidently patient compliance which cannot be monitored as completely in a home environment. Patients may continue to smoke, not follow the nutrition plan and ignore medications when in a home-environment, particularly without regular check-ups (Celli et al, 2004). Home-care programs have the benefit of being much cheaper for the patient and the healthcare provider because they involve less interaction with clinical staff (Fabbri & Herd, 2003). Home-care programs are also often much more convenient for patients, particularly if they have full-time jobs which prevent them from making appointments at a hospital. Home-care programs are also useful if the patient has family members who are willing and able to assist with the use of rehabilitation programs or with motivation for smoking cessation and exercise programs (Lacasse et al, 1996). There are a number of technologies which have allowed home-care pulmonary rehabilitation programs to become more useful and appropriate for the COPD patient, including spirometers and portable supplementary oxygen. Outcome Differences in Rehabilitation Programs in COPD Patients Although both home-care and hospital outpatient pulmonary rehabilitation programs have been shown to be effective in COPD patients (Celli et al, 2004), there are some differences in the outcomes. In a study of 65 patients with COPD all receiving 2 hours of outpatient education and one hour of outpatient exercise, there was a 10.4% increase in forced expiratory volume (Finnerty, Keeping, Bullough & Jones, 2001). A similar study examines the results of 43 patients and finds only a 7.3% increase in forced expiratory volume (Wijkstra et al, 1994), which suggests that the outpatient procedure may be more effective. It should be noted that there are a number of studies showing similar results to those outlined above, but the best way of examining the outcome differences is by looking at those studies that directly compare home-care and outpatient rehabilitation program results. Strijbos, Postma, van Altena, Gimeno & Koeter (1996) compared the effects of two twelve-week programs; one based at home and one based within the hospital. The study found that both the rehabilitation programs improved the exercise capacity of the patients in equal measure, suggesting that both have a huge amount of impact on the lives of the individual. The study found, however, that exercise capacity of those on the outpatient program had a consistent improvement over the 18 months of the study, whilst those who received their care at home were more likely to return to baseline levels. Outpatient programs are therefore possibly more effective at long-term improvement of the patient. Celli (1995) confirmed this result with a meta-analysis of a number of available pulmonary rehabilitation programs. In all cases, a number of functions were improved equally or more in the outpatients than those receiving their care at home, with the important difference being that the outpatients were consistently improved on a long-term basis. There are a number of reasons for this. Firstly, those receiving outpatient care are more likely to comply with the program, particularly if it involves education about COPD and the risk factors of exacerbation (Lacasse et al, 1996). Patients in the hospital are not likely to forget medication and often have supervised exercise as part of the rehabilitation, meaning that their treatment is often more consistent and holistic than those receiving treatment at home (Lacasse et al, 1996). This explains why the results last longer in these patients, as they are more educated about how to prevent problems with COPD than those who have not had this exposure. Another reason for the difference is that patients receiving outpatient treatment are likely to have check-ups at the same time, or at least on a more frequent basis. This means that they can receive motivation as they see their lung function improve from their exercise, nutrition and medication (Fabbri & Herd, 2003). This is not available at home, particularly if the reason for home-care is that the patient lives far away from a hospital or cannot make time for check-ups due to other commitments. The facilities in hospitals are also often superior to those available within the patient’s home, meaning that the care given could be of a superior standard. Outpatient exercise programs, for example, could include treadmill sessions which wouldn’t necessarily be available to those receiving home-care. Patients at home may also be afraid of the consequences of their new nutrition and exercise because they do not have access to oxygen, which means that they could involve themselves less with the treatment than they need (Lacasse et al, 1996). The difference doesn’t, however, account for the fact that patients at home may receive more support and assistance from family members than outpatients, so it could be that this is not important in compliance with COPD treatment regimes. Conclusions From the evidence above, it is obvious that any type of pulmonary rehabilitation is useful in patients with COPD, particularly in moderate to severe cases. The evidence above shows that forced expiratory volume (and often other lung functions) increased in all patients receiving some form of rehabilitation program, regardless of the location of this. It is, however, interesting to contemplate the differences in outcomes between the two most common forms, the home-care and the outpatient programs. Much of the literature suggests that outpatient programs are more effective in reducing the severity of COPD symptoms and improving a number of important lung capacity and expiration measurements. There are a number of reasons why this should be the case. The first of these is that the outpatient programs encourage compliance from the patient, particularly if treatment is combined with check-ups. This means that the patient is going to receive not only pharmaceutical treatment but exercise and nutrition advice on a regular basis, something which cannot be guaranteed through home-care programs. A second reason for this difference could be due to the facilities available in outpatient units which may be far superior to those available to patients at home, particularly exercise machinery. Patients with outpatient programs may also have more frequent check-ups, allowing them to feel motivated by the effect that their treatment has. These factors are all less in home-care programs and therefore patients will not benefit, although the cost may be significantly lower. Evidently, there is a need to ensure that all patients are receiving the correct treatment preventing exacerbation of COPD which means that the comparative effectiveness of outpatient programs should not be ignored. References Celli, B. R. (1995). Pulmonary rehabilitation in patients with COPD. American journal of respiratory and critical care medicine, 152(3), 861–864. Celli, B. R., MacNee, W., Agusti, A., Anzueto, A., Berg, B., Buist, A. S., Calverley, P. M. A., et al. (2004). Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. European Respiratory Journal, 23(6), 932–946. Fabbri, L. M., Hurd, S. S., & others. (2003). Global strategy for the diagnosis, management and prevention of COPD: 2003 update. European Respiratory Journal, 22(1), 1–1. Finnerty, J. P., Keeping, I., Bullough, I., & Jones, J. (2001). The Effectiveness of Outpatient Pulmonary Rehabilitation in Chronic Lung Disease* A Randomized Controlled Trial. Chest, 119(6), 1705–1710. doi:10.1378/chest.119.6.1705 Lacasse, Y., Wong, E., Guyatt, G. H., King, D., Cook, D. J., & Goldstein, R. S. (1996). Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. The Lancet, 348(9035), 1115–1119. Lundback, B., Lindberg, A., Lindstrom, M., Ronmark, E., Jonsson, A. C., Jonsson, E., Larsson, L. G., et al. (2003). Not 15 but 50% of smokers develop COPD?—report from the Obstructive Lung Disease in Northern Sweden studies. Respiratory medicine, 97(2), 115–122. Strijbos, J. H., Postma, D. S., van Altena, R., Gimeno, F., & Koeter, G. H. (1996). A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. Chest, 109(2), 366–372. Wijkstra, P. J., Van Altena, R., Kraan, J., Otten, V., Postma, D. S., & Koeter, G. H. (1994). Quality of Life in Patients with Chronic Obstructive Pulmonary Disease Improves After Rehabilitation at Home. European Respiratory Journal, 7(2), 269–273. Read More