Research Question

A phenomenology qualitative research study to investigate the experience of a patient with chronic obstructive pulmonary disease (COPD). Investigate how pulmonary rehabilitation helps in the improving the overall quality of life of the patients with COPD?

According to Ministry of Health New Zealand (2018), Chronic Obstructive Pulmonary Disease (COPD) is a lung disease which mainly common among the population who have a past history of smoking. Both chronic emphysema and chronic bronchitis are classified under COPD. Milne and Beasley (2015) highlighted hat COPD is an important non-communicable disease which has high level of prevalence, mortality and morbidity in New Zealand. It is the fourth leading cause of death in New Zealand which amounts to 6% of deaths, as reported in 2009. COPD is also the underlying reason of common comorbidity of hospitalization for the people who are admitted to hospitals for other reasons and this increases the overall tenure of hospitalization. The rate of hospitalization is twice among the Maori in comparison to non-Maori. It is still not known to what extent this represents a higher rate of incidence of COPD among the Maori population or a higher severity of disease or a diverse threshold for hospital admission. However, due to its high morbidity and mortality, COPD cause a huge healthcare burden. The main cost of care is directly associated with increased level of hospitalization (Milne & Beasley, 2015).

According to Ministry of New Zealand (2018), the best way to treat COPD is to quit smoking and to take proper medication on time in order to relive the symptoms. One of the important pharmacologic interventions used for treating COPD is inhalation of iloprost. Inhaled iloprost is stated to improve gas exchange and hemodynamics in patients with COPD and secondary pulmonary hypertension (PH) (Dernaika, Beavin & Kinasewitz, 2010). However, the double bling randomised control trial conducted by Boeck et al. (2016) highlighted that use of iloprost failed to improve the stamina and energy of 6-minute walking distance along with significant impairment of oxygenation while at rest. Khdour et al. (2012) majority of the population suffering from COPD fail to abide by medication adherence which increases the potential complication of the disease. Milne and Beasley (2015) highlighted the importance of evidence-based interventions in order to improve the health-related quality of life of the patient suffering from COPD in order to improve the mortality and morbidity rate.  Thus keeping into consideration of the importance of the evidence-based interventions in COPD treatment and side-effects of pharmacologic interventions, I am fascinated and intrigued to conduct research over the non-pharmacologic interventions in treating COPD. There are numerous quantitative research published on the importance of pulmonary rehabilitation as non-pharmacologic intervention in treating COPD. Many have highlighted the requirement of further research on a larger scale but to my surprise, there is very little qualitative research on this domain. So I am planning to conduct a qualitative research in order to study the importance of pulmonary rehabilitation as a non-pharmacologic intervention for the treatment of COPD and subsequent experience of the individual.

Background

My interviewee was had past history of smoking and is suffering from COPD and at present is on medication and had been treated with pulmonary rehabilitation during his stay in hospital. The patient and his family member were contacted privately through mail. The detailed explanation about the background and the scope of the research along with my assignment and university communication were communicated through the same mail chain. When the patient agreed to participate in the study, a telephonic conversation was held with the patient and his family members in order to answer to all their queries. Upon their approval, they received a information sheet and a consent form to review via email. When the interviewee confirmed about his participation, the consent letter was signed dully by the patient and then the interview was commended. The consent form stated that the interviewee is participation in the interview with full knowledge about the reason of the interview and that his name will be kept confidential and his personal data will not be used against his consent. The scheduling of the interview was done as per the convenience of the patient. The interview was 30 minutes long and was held at patient’s own home. The interview was recorded through a recording app on interviewer’s private mobile for transcript analysis. “Interview-guided approach” was employed during the interview under which selected themed questions were covered during the interview process. This helped the to develop question which complements the topic and helped the conversation to continue with the flow. This approach helped the interviewee to express their thoughts and feelings openly with more emotional bonding.

The themes covered in this interview:

• Theme 1: Treatment of COPD and side-effects of pharmacologic interventions
• Theme 2: The benefits of pulmonary rehabilitation as non-pharmacologic intervention n COPD treatment
• Theme 3: Impact of non-pharmacologic interventions on daily life
• Theme 4: Support of nurses in medication adherence and improvement in daily life

The recording of the interview was transcribed and then analysed qualitatively and the main themes were highlighted manually in order to identify the potential and pattern of conversation and to explore the unexpected results.  (Interview transcript is given in the appendix.

The interview highlighted that in order to manage his complications due to COPD he was administered with inhaled corticosteroid. However, such treatments forced him to suffer from numerous complications like horse ness in voice or dysphonia. Interviewee reported that: “Though the severity of the disease improved the administrated of the inhaled corticosteroid but my quality of life decreased [line: 3]. My voice became hoarse, the smell of my moth became pungent” [line:4] The interviewee also reported that, “I used to become conscious when I was asked to communicate with others due to bad breath [line: 5]” and “I was asked to do gargle but that to impose an additional work apart from taking tons of medication”. According to Gillissen et al. (2016), inhaled corticosteroids are markedly less effective against COPD in comparison to asthma. ICS though lowers the frequency and severity of COPD exacerbations in comparison to the monotherapy but have no direct effect on mortality. It also fails to improve the health related quality of life. Saag, Furst and Barnes (2014) highlighted that inhaled corticosteroid is only effective for the treatment of grade III and grade IC COPD but long term use can bring in complications.

Patient Interview and Methods

In response to the pulmonary rehabilitation, interview stated that, “Pulmonary rehabilitation helped me to improve my overall health-related quality of life” [line: 7]. The respondent stated that “I used to stay physically active but COPD was creating a barrier against this but practising pulmonary rehabilitation helped me to indulge in mild to moderate physical activity” [line: 10]. Thus from the theme it can be stated that use of non-pharmacologic interviews like the use of pulmonary rehabilitation helped to improve the overall quality of life of the patient with COPD. His faith and confidence upon himself increase as he was now able to perform his daily living activities and tasks of his liking like physical exercise. According to McCarthy et al. (2015), pulmonary rehabilitation helps to recover from dyspnoea which is the main side-effects of inhaled corticosteroids. It also help in the recovery of fatigue and emotional function. This help to improve the overall health-related quality of life of the patients. McCarthy et al. (2015) also reported that pulmonary rehabilitation enhances the sense of control that a person have over their condition and this serves as an important component for managing COPD.

The respondent highlighted that, “pulmonary rehabilitation helped me a lot in order to join in the main course of life” [line: 11]. Respondent of the interview is of the opinion that, “this procedure helped me to overcome my intoxication towards smoking and this further helped to fight against the complication of COPD” [line: 13]. He also said that, “doctors told me to quit smoking in order to survive but none of the medicines prescribed by the doctors helped me to quit smoking but while practising pulmonary rehabilitation, I got significant results [line: 14]. It helped me to quit smoking” [line: 15]. According to Postolache et al. (2015) pulmonary rehabilitation helps in improving the quality of life the patients. This improvement in the quality of life is achieved through decrease in the tendency of smoking and increase in the adherence in medication.

According to Khdour et al. (2012), proper medication awareness and improvement in the overall lifestyle are two determining factor behind the effective treatment of COPD. The study conducted by Khdour et al. (2012) highlighted that lack of medication adherence among the population of COPD is mainly due to psychological consequences rather than demographic factor. Elevation of mood and decrease in the co-morbid illness helps in improving the medication awareness. The respondent of the interview highlighted, “after the diagnosis of COPD and fighting it for a prolong period of time I was depressed and lost all hope because my condition was not improving” [line: 16]. However, my nursing professionals who use to take care of me at home and helped me with pulmonary rehabilitation, increased by medication awareness”. The respondent informed that the nurse helped him with mood elevation. “Regular counselling from nurse helped me overcome my depressed state of mind” [line 17]. The respondent highlighted that recovery from depression and hopelessness helped him to properly manage his medication.

Analysis and Results

Conclusion

Thus from the above discussion, it can be clearly stated that non-pharmacologic interventions holds potential significance in the treatment of COPD. In this study, pulmonary rehabilitation was selected as the main non-pharmacologic interventions for the treatment of COPD. The thematic analysis of the interview and linking the same with the literature highlighted that COPD hampers the health-related quality of life of the patients. Long-term treatment of COPD through the use of inhaled corticosteroid (pharmacologic medication) brings in several complications which hamper the quality of life and these complications included dyspnoea and bad breath of the mouth. In order to overcome these complications and to improve medication adherence, application pulmonary rehabilitation (non-pharmacologic intervention) is important.  Pulmonary rehabilitation helps to improve the dyspnoea and at the same time helps to improve breathless which helps the individuals with COPD to perform their daily living activity along with indulging into mild to moderate physical exercise. This helps to improve the quality of life further. Pulmonary rehabilitation also helps to quit smoking. However, it is the duty of the nursing professional to improve the mental state of mind in order increase the mediation adherence and thereby promoting fast improvement in the diseased condition.  More research are required to be undertaken in this domain in order to improve the importance of non-pharmacologic interventions towards treating COPD.

While working as a community health nurse, I was made of understand that both pharmacologic and non-pharmacologic intervention holds equal significance in the management of disease. While taking care for the patients with COPD, I have noticed that disease COPD is debilitating and it shatters a person both mental and physically and which hampers the overall health-related quality of life. However, I think there is a gap in understanding the importance of non-pharmacologic interventions against managing COPD. Hence I took initiative in order to conduct a study over COPD and non-pharmacologic interventions. I mainly selected pulmonary rehabilitation as non-pharmacologic intervention and also planned to study how it influence the health related quality of life of the patients.

Since my research approach was phenomenology analysis, I first selected by my respondents and he was a patient of COPD. My selection criteria were older adults with COPD history for more than 5 years. My selected interviewee was a man (Mr X) who was 65 years old and was suffering from COPD for the past 7 years. He was also a chain smoker and had high blood pressure. Initial contact was made and the subsequent discussion was done in order to provide an understanding of the scope of the research and research questions. The list of questions was communicated to the participant one week before the interview through mail and he was given full liberty of leave the interview at any point of time and freedom to not-to answer any question. Sending questions before hand helped him get prepared with his answers. I was previously aware that my interviewee might become emotional or reluctant in responding to all my questions in detail. Hence I made as strategy to develop a friendly relationship with him before the onset of the interview which helped him to discuss all his matter clearly with trust. The interview was conducted in presence of his family member (his wife) and this further helped him to open up about his complications in COPD and his overall experience of treatment..

My personal experience while conducting this research was very compelling. It helped to increase my personal understanding in how to conduct a proper interview while managing the emotions of an interview. It also helped me to improve my understanding my knowledge about COP and its comprehensive management.

References

Boeck, L., Tamm, M., Grendelmeier, P., & Stolz, D. (2012). Acute effects of aerosolized iloprost in COPD related pulmonary hypertension-a randomized controlled crossover trial. PloS one, 7(12), e52248. https://doi.org/10.1371/journal.pone.0052248

Dernaika, T. A., Beavin, M., & Kinasewitz, G. T. (2010). Iloprost improves gas exchange and exercise tolerance in patients with pulmonary hypertension and chronic obstructive pulmonary disease. Respiration, 79(5), 377-382. https://doi.org/10.1159/000242498 

Gillissen, A., Haidl, P., Kohlhäufl, M., Kroegel, K., Voshaar, T., & Gessner, C. (2016). The pharmacological treatment of chronic obstructive pulmonary disease. Deutsches Ärzteblatt International, 113(18), 311. doi:  [10.3238/arztebl.2016.0311]

Khdour, M. R., Hawwa, A. F., Kidney, J. C., Smyth, B. M., & McElnay, J. C. (2012). Potential risk factors for medication non-adherence in patients with chronic obstructive pulmonary disease (COPD). European journal of clinical pharmacology, 68(10), 1365-1373. https://doi.org/10.1007/s00228-012-1279-5

Khdour, M. R., Hawwa, A. F., Kidney, J. C., Smyth, B. M., & McElnay, J. C. (2012). Potential risk factors for medication non-adherence in patients with chronic obstructive pulmonary disease (COPD). European journal of clinical pharmacology, 68(10), 1365-1373. https://doi.org/10.1007/s00228-012-1279-5

McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, (2). Retrieved from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003793.pub3/abstract

Milne, R., & Beasley, R. (2015). Hospital admissions for chronic obstructive pulmonary disease in New Zealand. Retrieved from: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1408/6412

Ministry of Health New Zealand. (2018). Chronic obstructive pulmonary disease. Access date: 24^th October 2018. Retrieved from: https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/chronic-obstructive-pulmonary-disease

Postolache, P., Nemes, R. M., Petrescu, O., & Merisanu, I. O. (2015). Smoking cessation, pulmonary rehabilitation and quality of life at smokers with COPD. The Medical-Surgical Journal, 119(1), 77-80. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/25970946

Saag, K. G., Furst, D. E., & Barnes, P. J. (2014). Major side effects of inhaled glucocorticoids. UpToDate, 19. Retrieved from: https://www.uptodate.com/contents/major-side-effects-of-inhaled-glucocorticoids