Chronic Obstructive Pulmonary Disease - Research Paper Example

A Critical Evaluation of the Professional, Practical and Ethical Issues Related To and Raised by Park, et al. The focus of this essay isto discuss and critically analyse the research conducted by Park et al. (2010) which explored the use of xenon ventilation computed tomography (CT) to diagnose Chronic Obstructive Pulmonary Disease (COPD). There are questions that are needed to be answered such as the efficiency and the need for the tests undertaken in the study. Another question is the usefulness or the significance of the outcome of the method, as it can contribute to revolutionising and updating the mainstream applications used in the medical and biological field. The professional, the practical and the ethical aspects are issues which need to be considered and discussed. In terms of the professional aspect, the methods undertaken during the study are needed to be analysed in terms of the presence of licenses and the governing laws and rules to ensure the safety of patients. The practical aspect of the study is related to the application of the process for future diagnosis of patients. The third aspect is of utmost importance specifically for the application of the process in the medical field. The ethical facet of any research process is often related to the safety of the people to which the techniques are applied. Based on the research conducted by Park et al., the xenon ventilation CT had numerous advantages compared to other methods, on the basis of the use of xenon instead of other hyperpolarized gases, and the use of CT as opposed to Magnetic Resonance (MR). The combination of these two methods in the specific condition of the patients with COPD can then be considered hopeful. The general view of the process undertaken and applied by Park et al., can be deemed advantageous based on the assumption that a combination of the xenon ventilation and CT can result in a more efficient method that can change medicine. To be able to discuss and explore the objectives of the research paper, it is important to discuss different topics to be able to have a background and basis for the study such as the definition of COPDand the technique used; specifically Dual-Energy CT (DECT). The main topics that needed to be discussed are the radiation protection issues, safety issues and most importantly the ethical issues. COPD is a progressive type of ailment considered irreversible due to the continuous damage to the lung parenchyma that can result in ultimate airway obstruction. There is also inflammation in the airways that changes the large and the small airways most common in adults. In fact, it is the fourth most common cause of mortality and morbidity in adult people (Park et al., 2010). There are different causes of COPD but the most common cause is emphysema. This is due to the main definition of COPD which is an ailment that can cause chronic inflammation, fibrosis and loss of elastic recoil. It is generally caused by restrictive lung diseases characterised by the “progressive airflow limitation, air trapping, and progressive shortness of breath on exertion” (Barnes, 2007, p0779). COPD patients are classified to have less than 0.7 or 70% ratio of forced expired volume in 1 second (FEV1) over forced vital capacity (FVC). For patients whose FEV1 range from 80% and above, symptoms such as breathlessness or a cough are considered as indications (NICE, 2010, NICE, 2011). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) identifies four stages of classification that had been identified for COPD. This is important in the determination of the treatment that can be used. The incidence of COPD is increasing based on the majority of the references reviewed. Its prevalence is affecting the international community in a passive manner since the manner by which it can cause mortality and morbidity is less evident than other diseases considered of immediate concern in the global scale. The level of awareness and ignorance is contributing to the rise of COPD cases. In the 1990’s COPD had been designated as the sixth most common cause of death in the world by the Global Burden of Science. The latest World Health Organization study revealed that by 2030 COPD would be the fourth most common health issue in the world that can cause death next to ischemic heart disease, cerebrovascular disease, and HIV/AIDS. Compared to other diseases on the list, COPD can be related to the rate of chronic disability with significantly increasing numbers through the decades. One of the most common reasons for the increase in COPD cases is the number of undiagnosed cases, even when the patients already reach the disability stage (Barnes, 2007). In Korea, there is an increasing prevalence of COPD thus the topic had received attention. The behaviour of the COPD patients was studied such as awareness and impact of the disease, doctor visits, treatment pattern and preference (Hwang et al., 2011). The results revealed thatthere is a lack of awareness in the disease, specifically 40% of the COPD patients are unaware of the implications of the disease. Therefore, patients need more information regarding COPD and its associated risks, the process of determining and knowing the attitude of the patients can also give the health professionals the knowledge needed to improve the treatment process (Hwang et al., 2011).Another similar study to understand COPD patients was undertakenwith the cohort study in the 4th Korea National Health and Nutritional Examination Survey (KHANES) and the Korean National Health Insurance (NHI) claims. The resultsof which determinedthat patients only consult doctors in severe cases. There is an increasing probability of seeking treatment as the disease progresses (Chung et al., 2014). Thus, there is lower probability of giving medical attention during the earlier stages.COPD is becoming a burden and further research is necessary to determine diagnostically related issues such as risk factors to improve potential patients and improve management methods and protocols. To sum up, COPD prevalence is high in Korea but they are not recorded and they are under-treated (Yoo et al., 2011). In 2005, 17% of the adults in Korea aged 45 years and above were diagnosed to have mild stage COPD (Kim et al., 2005). In the United Kingdom, the cases of COPD are also becoming a concern to the nation. In 2000, there was a more serious view on the cases of COPD since it was known to greatly affect the older part of the population. Since the UK has an aging population, there is greater concern related to the disease. In addition, based on UK research COPD is more common in men than in women although the percentages for both are continuously increasing (Soriano et al., 2000).A 2003 international study highlighted concerns such as; the under diagnosis and under treatment COPD, which need to be tackled in order to prevent the continuous increase of future COPD cases (Britton, 2003). Based on the UK and Korea studies mentioned, it can be considered that the issue regarding under diagnosis and under treatment of patients is an international concern. In the United Kingdom, the main observation is that no significant difference in the number and rate of diagnosis can be correlated to the type of healthcare of the nation. Both Korea and UK had issues related to the fact that the people are only commonly diagnosed in later or severe stages of COPD. This situation may be related to the lack of information of the medical personnel regarding the symptoms and risk factors of the disease, a common issue in developed nations. In developing countries, the threat of the disease can be considered non-emergency, thus, people commonly refuse treatment.Another point that is significantly related to the objective of the paper is the determination of a process that can improve the diagnosis process of COPD. In the study by Park et al. (2010), a xenon ventilation DECT is applied. The aim of the application of the said method is to be able to specifically point out the condition of the lungs or technically referred to as the, ‘regional ventilator status.’ Prior to the study, other methods are used which can be considered an estimate of the total capacity of the lungs, but Park and colleagues’ aim is to point out the estimate of activity in the specific parts of the lungs. There are two important factors in the application of xenon ventilation DECT which are the xenon ventilation and the DECT. The xenon ventilation CT is done in two steps. Xenon ventilation is used as a contrast media in DECT as it is a good attenuator. In MRI hyperpolarized gases are used.It is administered to the patient through xenon ventilation in face masks set on positive pressure composed on 30% non-radioactive xenon and 70% xenon and oxygen mixture; specifically composed of 30% xenon and 70% oxygen. Parameters related to the patient such as respiratory rate, oxygen saturation and blood pressure were monitored. Tidal carbon dioxide was also monitored as well as the feeling of comfort of the patients (Park et al., 2010).After the primary step of the procedure which is the inhalation of the radio dense xenon, the dual-energy computed tomography(DECT) is undertaken with more image efficiency.Dual-energy is specifically applied because ordinary CT failed to clearly show the lung attenuations for patients with restrictive lung pathology. It had been effective for healthy baseline population. This led the researchers to look into the DECT. Although this is a promising procedure, no record of clinical application had been done in relation to the issues of safety of the patients. The study of Park et al., still used the CT and the study quoted in the paper by Chae et al., (2008) did not use lungs of actual patients. This process then is still being studied before the actual clinical trial (Park et al., 2010). The DECT has both positive and negative implications in clinical application and research. The positive implications include efficiency in the diagnostic process due to the fact that it can separate the attenuations coefficients, thus enabling the different components in the target area to be perceived. It had been initially studied by Alvarez and Macovski in 1976 focusing on organs such as lung, liver, and soft tissue. Due to the capability of the system to differentiate different organ and body structures, it has many clinical applications. It is also used in combination with other contrasts such as Iodine imaging in CT angiography (Bruesewitz et al., 2007). Another perceived advantage is related to cost. DECT had been considered less expensive than MRI with noble gas, thus, it is used (Park et al., 2010). Another application of dual energy CT is the kidney stone differentiation to be able to diagnostically determine the properties of the stone to determine the course of treatment. Also, due to the capability of the dual energy CT to differentiate structures within the body, it can explore and characterise different abnormalities such as malignant or benign lesions so as the need to operate on a person can be lessened (Riedel, n.d.). In the latest research undertaken by Ibrahim and Bowman (2014), the use of dual energy CT had been recommended as compared to MRI, specifically since new models of scanners had been developed to have low radiation-exposure and shorter scan-time, thus reducing the exposure of the patient to any form of radiation. Another significant advantage xenon ventilation CT which include coverage of the whole thorax in wash-in and wash-out periods allowing both qualitative and quantitative data analysis on the ventilation of the entire lung, or referred to as the static quantification of data from two periods of xenon ventilation (Park et al., 2010). There are also disadvantages in the use of DECT. One is the limitation in the process due to the need for two different scan acquisitions to acquire the final assessment (Bruesewitz et al., 2007). Another limitation is the applicability of the system in processes that use large atomic numbers such as iodine and xenon to be able to achieve the differentiation needed in the processes wherein it is applied (Kang et al., 2010). Based on the research understudy by Park et al other limitations of the DECT include limited field of view and degradation of image due to different factors in near the lungs. The most significant limitation which can affect patients with COPD is related to the observation that the scatter radiation occurs in the most susceptible area which is the lung apex where emphysema is commonly located (Park et al., 2010). COPD patients have less than 0.7 or 70% FEV1 /FVC, thus, they are more susceptible to side effects brought about by the procedure (NICE, 2010, NICE, 2011). The main concern of the study though is related to the diagnostic examination of the patients with COPD. Xenon as a noble gas can be considered as one of the basic reasons for its application in the said scientific process. It is a radiopaque gas that functions as contrast for CT. In terms of photoelectric absorption it has similar behaviour as iodine. In the process of xenon ventilation CT, xenon is known to distribute evenly in the lungs (Kang et al., 2010). There is an issue with regards to the safety of the patients in relation to the inhalation of xenon. In 1986 study, there were concerns in the retention of xenon specifically since the diagnostic examination would target the patients with COPD (Wahl, 1986). Upon determination of the different characteristics, advantages, disadvantages and even the possible dangers of the method of xenon-DECT, there are concerns related to the ethical acceptability of using a combination of these two components specifically in patients with COPD, a disease that is related to restrictive breathing. The practical answer to the question related to the application and use of the method, is that the clinical and the medical field of science are always trying to revolutionise the manner by which patients are diagnosed and treated. Xenon ventilation is more practical and feasible than other contracts for this particular application since it is already being used in the diagnosis of lungs and other adjacent organs. In the case of the DECT, the advantages can be deemed more important as compared to the limitations.There are other contrast mediasuch as Krypton that are used in ventilation CT examinations. In the study by Hachulla et al. (2012) which involved the Krypton attenuation, the excellent clinical tolerance became the basis for use with CT.The patients in a clinical research trial had successfully experienced krypton ventilation CT without side effects. The said study had received ethical and institutional approval(Hachulla et al., 2012). Based on the study related to Krypton, it can be considered as an alternative to xenon but the conditions within which the study was undertaken can be considered still doubtful. The manner by which the researchers described the application of krypton is that there is an expectation of it being harmful. According to research undertaken, there are DECT scanners that have low radiation-exposure and shorter scan-time. This can be considered as the answer to the main concern regarding radiation effects on patients with COPD. The DECTbased on the result of the 2014 study can be considered more advantageous and efficient as compared to MRI (Ibrahim and Bowman, 2014). There are Ionising Radiations Regulations in 1999 and 2000 that include people with medical exposures. Patients with COPD include cases of exposure as part of medical diagnosis or treatment as well as the cases of exposure as part of health screening programs. In addition, the examples of cases covered in qualitative and quantitative research studies for COPD patients are included in the classification of medical exposures of patients or other persons,voluntarily participating in medical or biomedical, diagnostic or therapeutic, research programmes. IRR 1999 and 2000 also discusses the radiation protection of patients and people specifically for procedues related to overexposure to ionising radiation (IR (MR) R, 2000; IRR, 1999). Different countries have different legislations related to radiation protection. Legislations in Korea and United Kingdominclude institutions and organisations that are responsible for the safeguarding of the patients and the medical practitioners. The protection provided by the government can be related to the ethical conditions. The ethical points commonly serve as the bases for the rules that are implemented regarding the safety of the patients. In Korea, the Korean Association of Institutional Review Boards is responsible for the implementation of the operation of institutional review boards (IRBs). One of the main rules being implemented by the IRB is the Korean Good Clinical Practice (KGCP) established in 1995 (Kim et al., 2002) The concern regarding radiation can be related to the fact that the human body has a limitation in the amount of radiation that it can be exposed too. According to the International Commission on Radiological Protection, there is a tolerance dose which is the acceptable level of exposure to radiation. The limit of exposure for the safety of workers for example medical practitioners is 20mSv/year set in 1991 and 2007. Also, it should strictly not exceed 50 mSv in a year, a value which should be the strictly implemented. If this is the limit for workers, it can be surmised that the limit for patients should be lower compared to the given value. The said risk factor of 20 mSv effective whole body dose can have fatal cancer risk in 1 out of 1000. For COPD patients, the concern can be recognised since they are already suffering from the said disease and can increase the stress to their body (ICRP, 2012b). There are side effects in the xenon ventilation observed in the patients in Park and colleague’s study. Of the 32 patients, 31% experienced side effects namely dizziness, heavy feeling, tingling extremities, and a combination of tingling extremities and headache. According to the accounts of the study, these side effects were gone after 30 minutes (2010) According to the National Institute for Clinical Excellence Guidelines there is no single diagnostic test required or designated for COPD. In 2010 when the document was published, spirometry was given as the main example. In this case, xenon ventilated CT can be compared to spirometry (NICE, 2010;Henzler, et al., 2012). There are important advantages in the use of spirometry such as the capability to record both FEV1 and FVC and the fact that it can be used for any level of severity of airway obstruction with similar reproducibility (Pearson & Wedzicha, 2008). Aside from spirometry and imaging procedures, there are also other parameters and methods used to access the condition of COPD patients that can affect the necessity for a risky procedure. The BODE index is an example of a parameter that can increase the consciousness of the medical professionals regarding the condition of the patient. It is used to determine the risk of death of a patient through its components namely body mass index (BMI), airway obstruction (FEV1), dyspnea (Medical Research Council dyspnea score) and exercise capacity (6-minute-walk distance). BODE score is between 0 to 10, with 7-10 meaning 80% at and 0-2 means 20% 52 months (Cislo, De Fer & Hendersor, 2008). Looking back to the study undertaken by Park et al., it can be considered that the methods that had been applied on a personal note can be deemed acceptable based on the evidence gathered. Such evidence includes the weighing of the advantages and dangers of the procedure specifically the xenon ventilation and the DECT (2010). Additional evidence that can be presented is the successful case of a 19 year old patient with pulmonary embolism. The patient was diagnosed using the xenon ventilation DECT even in the case of lung ventilation/perfusion mismatch. The patient had been cured successfully without any bad effects (Zhang et al., 2012). Ethical aspect of any activity can be considered as an important issue to give attention to. In the research undertaken wherein the health and safety of people are at risk, the ethical considerations are included in the main priority. There are different approaches in the implementation of ethics and ethical aspect in a biomedical research. One theory that can be applied is the moral theory which is composed of the different layers such as core rationale, deontological layer, consequential layer and external considerations. The outermost layer is the external consideration composed of the codes of practice, the risks, the law, the use of resources, the effectiveness and efficiency of action and the degree of certainty of the evidence on which action is taken (Stutchbury and Fox, 2009). The biomedical research and the case of patients for procedures such as the xenon ventilation CT, is covered and related to the codes of practice, the efficiency of action and the degree of certainty of the method. In terms of the consequences of the research, it can be considered that the success of a diagnostic procedure can affect the different levels including oneself, the individual, and a particular group of individuals (e.g. COPD patients) and the society. The ethical duties and motives are also included in the focus of studies such as Parks et al.’s research which include telling the truth, minimising harm, keeping promises between involved parties, and doing goodness or positivity. In general, the ethical concerns are mostly related to the individuals, which in this case the COPD patients. Included in the actions towards the person revolve around respect of the need of the individual, of the autonomy, of equality and of trust(ibid). The medical field involves the trust and respect between the patients and the medical professionals. Adhering to these points can be considered ethical.The safety of the human participants in a biomedical research is included in the ethical aspect. The Declaration of Helsinki is one of the guidelines in terms of maintaining the ethical aspect of scientific research (Kim et al., 2002). Based on the data gathered in connection to the researchof Park et al., it can be considered that xenon ventilation is the most practical and efficient element to use and DECT can give the most accurate result in terms of imaging.There are other elements such as krypton being compared to xenon to determine which is safer to use, but more evidences and studies are needed to give a concrete evaluation on the safety of use. In terms of the CT and DECT, although other methods were known that can be applied in cases which involve the lungs and heart, specifically COPD cases, the efficiency of the system helped numerous cases not only in the diagnostic stage but also in the management, treatment and prognosis of different ailments. Other imaging processes and techniques have limitations but CT had been able to improve imaging through DECT. In relation to ethical concerns of the procedure, the treatment of the patient outweighs the possible risks in radiation. This can be attributed to the fact that most diagnostic modalities use ionizing radiation except MRI. DECT with xenon ventilation compared to simpler, less complicated and less risky methods of diagnosis can be considered most accurate but in terms of ethical standards, it is necessary when there is a doubt regarding the safety of the patient. The ethical question then is if the patient would lean towards a questionable and less specific method of diagnosis with the risk of being repeated due to error or would he or she lean towards a more advanced and efficient method of diagnosis.Upon the analysis of the methods applied by Park et al., it can be concluded the study is highly experimental in the sense that they are trying to break new ground by introducing a procedure that is still ethically questionable in nature. Although there are advantages in using the dual energy CT, there are also restrictions and limitations such as limited field of view and degradation of image due to different factors in near the lungs. The most significant limitation related to the observation that the scatter radiation occurs in the most susceptible area which is the lung apex where emphysema is commonly located (Park et al., 2010). Based on the result of this study, there is a question regarding the necessity of using dual-energy CT. Future application of xenon ventilation DECT needs in depth study ad research to be able to clear doubts and questions. The analysis of the study conducted by Park and colleagues revealed ethical issues in relation to the safety of the patients. This presents the obvious importance of putting the patients’ health before other reasons, even if it is regarding the advancement of medical science. References Cislo, G.S., De Fer, T.M. and Hendersor, K.E. (2008). General Internal Medicine Consult. Lippincott Williams & Wilkins. Pearson, M. And Wedzicha, J. (2008). Chronic Obstructive Pulmonary Disease: Critical Debates. John Wiley & Sons. Read More