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Originally posted February 2001
NAOMI A. DUNN, RN, CEN
NAOMI DUNN is a staff nurse at the Department of Veterans Affairs Medical Center, Huntington, W.V. Ms. Dunn would like to acknowledge the support of the Department of Veterans Affairs Medical Center in producing this article.
KEY WORDS: chronic obstructive pulmonary disease (COPD), patient education, pulmonary rehabilitation, respiratory assessment Too often, acute attacks mean repeat ED visits for patients with chronic obstructive pulmonary disease. Making time to teach them these behavioral techniques and encouraging rehab can help patients better manage the next episode and cut down on the emergencies that prompt a rush to the hospital. Nearly 16 million people have chronic obstructive pulmonary disease (COPD), a term that includes chronic bronchitis and emphysema.1 Yet, in all my years in nursing, I had never found any effective techniques to help COPD patients reduce acute attacks and stop the "revolving door" effect so many patients experience. Take Mr. Manuel. When I first met him, he was too short of breath to speak, but his panic-stricken eyes said it all: "Can you help me?" Although he had just received treatment in the ED, it clearly had not relieved his anxiety. What's more, just a few weeks earlier he had rushed to the ED because of a similar acute attack resulting from his COPD. He had received a quick fix of a bronchodilator, antibiotics, and steroids. Now he was back through the door, frightened and short of breath. To develop a more effective approach to patients like Mr. Manuel, I spoke with a local pulmonary rehabilitation program director, ordered patient education videos on breathing techniques, and contacted an affiliated VA Medical Center that ran a pulmonary patient education program. In this article you will find a summary of what I learned— techniques and tips that not only help COPD patients feel more in control, but also prevent the crises that often bring them back to the ED.2
Proper breathing can relieve attacks
During exertion, COPD patients may develop pressure or tightening in the chest and feel short of breath. Two controlled-breathing techniques—pursed-lip breathing and diaphragmatic, or abdominal, breathing—can greatly improve patients' ability to get control over these acute attacks.3 Pursing the lips as breath is exhaled creates resistance that keeps the small airways in the lungs open, thus relieving the pressure in the chest. To teach the technique, tell your patient to inhale slowly through the nose or the mouth, purse his lips as if he's going to whistle, and then breathe out gently as if to make the flame of a candle flicker, but without extinguishing it. Practicing this method could enable a patient to proceed up a staircase or walk farther without having to stop and rest. Breathing with their abdominal muscles may feel odd to patients at first, especially if they are accustomed to using only neck and shoulder muscles to breathe. Teach them that their body's real breathing muscle is the diaphragm, the large muscle between the chest and the belly. Moving the diaphragm downward draws air into the lungs. Moving it up during exhalation pushes on the bottom of the lungs, forcing trapped, old air out and making room for fresh air to enter. The technique will feel more natural with practice. To teach a patient abdominal breathing, tell him to picture his stomach as a balloon. When inhaling, he should allow it to expand as if it's a balloon he is filling with air. Another suggestion: Tell him to lie flat on the floor with his hand or a book resting on his abdomen; the mild resistance helps enhance the sensation of expansion. As he exhales, he should pull those abdominal muscles in and the book (or his hand) will sink. Remind your patients that daily practice will improve their exchange of air. Pursed-lip breathing can be used in combination with the "tripod position," which helps maximize chest expansion while reducing the work of breathing.4 The patient should be sitting, feet firmly planted on the floor, with a waist-high table or stand in front of him. He should place his forearms on the table, with his hands together and the arms forming the sides of a triangle, and then lean forward, letting his weight rest on his arms. This takes stress off the patient's chest muscles during respiratory distress.
Techniques to prevent and control panic
There are times when breathing techniques alone will not be sufficient to relieve shortness of breath, especially if the patient's anxiety progresses to panic. Simply telling patients to calm down during an acute attack will not help them gain control of their breath. However, teaching them to practice panic control and relaxation techniques can. One method to avert panic is to place a cloth band or the belt from a bathrobe above the waist, just below the ribs, and cross—but do not tie—it once in the front, letting the tails of both ends hang loose. The patient should hold the band loosely while breathing in, being careful not to restrict lung expansion during inhalation. During exhalation, he should gently tighten the band. Doing so will help push the diaphragm up and force out trapped air, which was causing the feeling of pressure. The process should be repeated until breathing becomes more controlled. Again, daily practice will help the patient learn how to push out trapped air before it becomes a problem. The patient can get the same effect by folding his arms just below the rib cage. When breathing out, he should push into his belly with both arms, then release during inhalation. This technique can be used anywhere. After I'd taught it to one of my patients, Mr. Allen, he told me that when he became short of breath at church, he moved to the back pew and used the folded-arms method to support abdominal breathing and also used pursed-lip breathing. The combination relieved his shortness of breath, and he was able to remain for the rest of the service. Another useful practice for patients who have COPD is progressive muscle relaxation, with or without guided imagery. The basic technique involves tensing and then releasing individual muscle groups, usually starting from the feet and moving up. This lets patients recognize when they have unconsciously become very tense, and they can then proceed to relax their body. During an attack of shortness of breath, progressive relaxation eases the workload on muscles that are not helping the breathing process. This helps to reduce the body's oxygen requirement. As they practice the technique, your patients can add a tape or video recording of soft-spoken dialogue to help them picture relaxing images.
An effective way to cough
When mucus in a patient's airways causes him to cough, it is important that he does so effectively. To teach effective coughing, have your patient take a deep breath, hold it for three seconds (which builds pressure in the lungs), and then cough gently to shake mucus loose. He should then inhale gently through the nose, hold the breath for three seconds, and cough again to move the mucus up the sides of the airway. The patient should rest, then repeat the process as necessary. Coughing, however, will not help if the mucus is too thick. Increasing fluid intake will keep secretions thin.5 Eight or more 8-ounce glasses of fluids a day are recommended, unless the patient has been placed on a fluid restriction. Diet, decaffeinated, and low-sodium drinks are acceptable alternatives to water.
Reducing fatigue during exercise, work, and sex
COPD patients will naturally feel frustrated when they can't be as active as they would like. But if they limit their activity, their muscles will weaken. This promotes an unhealthy cycle: The less daily activity they get, the less they feel like doing anything. Weak, unconditioned muscles demand more oxygen. Chest muscles in particular need to be exercised because they help expand the lungs during inhalation. Patients may not realize that they can incorporate exercise into their normal daily activities—while watching the evening news, for instance. That's when one patient of mine likes to perform resistance exercises using a large rubber stretch band; timing it with her other activities helps to make it a daily practice. Many ordinary tasks become difficult for people with breathing problems. If that's the case with your patient, ask how he schedules his days and look for ways to help him conserve physical energy. Some patients try to get everything done at once and then rest for the remainder of the day. But all that effort all at one time can leave them feeling fatigued. Suggest to a patient that falls into that trap that he prioritize his tasks and space them out during the day, with brief rest periods in between. Remind him that thinking smart and planning ahead —even with mundane tasks—will leave him energy for more enjoyable pursuits. Here's one simple adjustment: For patients who find it tiring to carry grocery bags from the car into the house, suggest that they have their perishable groceries packed together so that they can carry them in first, rest a while, and then return to the car for the nonperishable items. One patient of mine, Mrs. Ross, learned another solution to an ordinary activity. Because she was becoming short of breath when she bathed, she bought a shower chair and a handheld showerhead. She rinses herself, shuts the water off so she can handle the soap and shampoo, then rinses again. With these minor adjustments, she says she can shower and still feel energetic afterward. COPD patients may also worry about how their breathing problems affect sexual activity. The National Jewish Medical and Research Center (800-222-LUNG) produces a booklet called "Being Close" that addresses the sexual concerns of patients with respiratory problems. It gives advice on breathing techniques and sexual positions that
require less energy, recommends resting before and after sex, and suggests alternatives for intimacy like hugging and talking quietly.
Handling humidity and allergens
Many patients with respiratory problems don't realize how much humidity affects their ability to breathe comfortably. Room air should be at humidity levels between 40% and 50%.1,3 A simple hygrometer, available at most hardware stores, will let patients monitor humidity levels. They should turn on a humidifier when humidity levels fall below 40% and use a dehumidifier if there is excess water vapor in the air. If high humidity levels during showering cause shortness of breath, tell patients to leave the bathroom door open, turn the exhaust fan on, and use cooler water. Allergens are another environmental factor that affect breathing. You should advise patients to use a respiratory mask while dusting or mowing the lawn and to limit use of aerosol sprays (furniture polish, hair spray, spray deodorants, etc.) to reduce exposure to potential irritants. Also encourage them to change the filters in heating and cooling units frequently. On days when the allergy index is high—most newspapers carry such data—COPD patients should stay indoors as much as possible. In addition, patients may want to speak with their doctor about the appropriateness of allergy shots.
Guarding against colds, giving up smoking
Besides modifying their environment, their activity levels, and their breathing techniques, COPD patients should pay special attention to signs of respiratory infection. Teach them to recognize early signs based on changes in the color, consistency, and amount of their sputum. Letting them know when to call the doctor's office will lead to earlier treatment and reduced costs. If an antibiotic is prescribed, stress how important it is to finish all the medication, even if symptoms have improved. Immunizations will also help keep them out of the ED. Flu shots and immunization against pneumococcal pneumonia are recommended for anyone with chronic respiratory problems.6 Employers often offer free flu shots, as do some community health centers for certain patient populations. COPD patients who smoke may need continual advice about its damaging effects on their condition. If they keep smoking, though, do not write them off. Several attempts are often necessary before a smoker successfully quits. Work with your patient one step at a time.
Teach proper use of medication
COPD patients need to understand the appropriate use of medication, side effects, contraindications, and the potential for toxicity. To reinforce what you and their doctors tell them, encourage patients to take responsibility for educating themselves, starting at their local pharmacy, which should provide written information on each medication. Education about the use of inhalers is especially important. To increase the effectiveness of inhaled medication, teach your patients how to use the spacers or holding chambers the inhalers come with (see the "Tips for using inhalers" figure). The patients should pause between inhaled puffs to allow time for the upper airways to open. This way, the next inhalation will draw medication deeper into the lungs. You should have them demonstrate the technique. For patients who are prescribed an inhaled bronchodilator and an inhaled steroid, proper sequencing is important. Remind them to use the bronchodilator first (it opens the airways), and then the steroid, which reduces inflammation. Because steroid inhalers may cause sores or candida in the mouth, tell patients to rinse the mouth with water and gargle after each use.
Psychosocial support and rehab programs
A wide range of emotions—denial, anger, depression—are common before the COPD patient gets to some level of acceptance of life with a respiratory disorder. How can you assist? Be sure your patient knows you're listening, and either provide or point the way to resources that specifically address the welfare of COPD patients. Social support, including that of family members, should not be overlooked. As a nurse, you are a means of support for both the patient and his family. But the daily assistance of a spouse or other significant relation is invaluable. Pulmonary rehabilitation programs are another essential means of support and improving physical stamina.7 If needed, the patients receive oxygen as they start on an exercise program and are monitored by professionals. This helps them feel it's safe to test their physical limits.
COPD patients can also benefit from support groups. One advantage is learning that they are not alone with the difficult feelings and concerns that arise from having a chronic condition. Patients also learn coping skills from one another. Your ability to understand and share this knowledge with COPD patients does make a difference in their outcome. Preventing the "revolving door" effect means that the frightening episodes that bring them back to the ED over and over have been reduced. Mr. Manuel eventually entered a breathing education program at our hospital. When I recently asked him how he was doing, he said, "I haven't been back in the hospital for two years, and at times I even feel like golfing." Instead of the panic I first saw in his eyes, I recognized a look of appreciation from a patient who now had the knowledge to take control of his breathing problem.
1. National Heart, Lung, and Blood Institute. "1999 Fact Book." 1999. http://rover2.nhlbi.nih.gov/resources/index.htm (August 2000). 2. Meighan-Davies, J., & Parnell, H. (1999). Empower patients to take control of COPD. Practice Nurse, 17(9), 622. 3. Barrow Madline, H., & Hull, N. R. (1995). To air is human (pp. 1 80). Atlanta: Pritchett & Hull Associates. 4. Humphrey, C. J. (1998). Home care nursing handbook (pp. 202 204). Gaithersburg, MD: Aspen Publishers. 5. Mayo Clinic Health Oasis. "Chronic obstructive pulmonary disease." 2000. www.mayoclinic.com/home?id=HQ00430 (2 Jan. 2001). 6. Lewis, L. (2000). Optimal treatment for COPD. Patient Care, 35(10), 60. 7. Harrison, G. (1999). Respiratory care: Out of breath, into rehab. Nursing Times, 95(17), 58.
Checklist for teaching COPD patients
• Steps to prevent and control acute attacks Proper use of inhaler Pursed-lip exhalation Diaphragmatic (abdominal) breathing Tripod position Folded-arms or loose-band exercise to control panic Progressive muscle relaxation • Effective coughing to expel sputum Cough technique Adequate fluid intake to thin mucus • Conserving/maximizing energy for activities Exercise Pace daily activity Simplify tasks Explore less strenuous sexual positions • Minimizing exposure to allergens/irritants; humidity control Identify and avoid triggers Humidifier/dehumidifier use • Preventive interventions Recognize early signs of infection Annual flu shots Pneumococcal pneumonia vaccine Quit smoking • Participation in rehab programs and support groups
Tips for using inhalers
• Get ready. Remove cap and shake inhaler. Breathe out all the way before pressing inhaler. Position inhaler as instructed by doctor. • Breathe in slowly through mouth. As you start breathing in, press down on inhaler one time. (If using a holding chamber, first press down on inhaler and then begin to breathe slowly within five seconds.) Keep breathing slowly and as deeply as possible. • Hold your breath. Hold breath to a count of 10, if possible. When using quick-relief medications (beta2agonists), wait about one minute between puffs. • Clean inhaler as needed. Clean inhaler if powder is present in or around hole where spray is emitted. Remove canister from plastic mouthpiece and rinse mouthpiece and cap in warm water. Let them dry overnight. Reassemble in the morning. • Keep track of how many puffs are available per canister and/or expiration date of medication. • Know positions for commonly used inhalers. Patients should hold the inhaler as recommended by their physicians. In general, positions A and B are recommended. Position C is an alternative for patients who have trouble with the first two.
Source: National Heart, Lung and Blood Institute. "Controlling Your Asthma." NIH Publication No. 97-2339. 1997. www.nhlbi.nih.gov/health/public/lung/asthma/ (28 Aug. 2000).
Diane Boccadoro, ed. Naomi Dunn. Keeping COPD patients out of the ED. RN 2001;2:33. Published in RN Magazine.
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