Multidisciplinary Case Management in a Patient with COPD - Essay Example

?Multidisciplinary Case Management in a Patient with COPD Case 60 year old John, a known heavy smoker for more than 20 years presented with frequent bouts of cough for 2-4 months each year for the past 3-4 years. the cough was productive in nature. On further inquiry, the patient reported frequent breathlessness, easy fatiguibility and intolerance to exercise. The patient complained that during walking with his friends her had to stop frequently even on level ground. In many situations, cough was triggered by common cold and though the cold subsided in few days time, the cough continued for several weeks despite antibiotics, mucolytics and bronchodilators. He was advised to quit smoking by the general practitioner, but the patient was unable to do so. In view of persistent cough and worsening health condition, the patient was referred to our center for further management and counseling. Other health problems in John include hypertension and hemorrhoids. He has been taking amlodipine 5 mg for hypertension. Overview of the disease Chronic obstructive pulmonary disease (COPD) is one of the devastating medical conditions that causes a great degree of suffering to humans (Mosenifar, 2011). It is a source of both economic and social burden (Sullivan et al, 2000 and Fromer and Cooper, 2008). It is defined as "a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema" (Mosenifar, 2011). There are 2 sides of coin to the disease and they are emphysema and chronic bronchitis. Chronic bronchitis refers to presence of chronic cough with no other etiology and which is productive for at least 3 months during each of the two consecutive years. Emphysema is a condition in which damage of the air spaces that are present distal to the terminal bronchioles occurs. The damage is irreversible, abnormal and associated with destruction of the air space walls with no obvious fibrosis (Fromer and Cooper, 2008). COPD is frequently under-diagnosed and contributes to mortality and morbidity. It is not possible to cure the disease. However, timely interventions and certain preventive strategies can reduce the burden of symptoms, increase the quality of life of the patient and decrease mortality and morbidity (GOLD, 2008). The most distressing symptom of COPD is breathlessness which is a progressive problem and the crux of treatment of COPD is management of breathlessness. Pathophysiology Understanding of the pathophysiology of the disease helps elaborate a good management plan. The most common cause of COPD is cigarette smoking. It develops in about 15 percent of chronic smokers (NICE, 2004). Thus, John developed COPD because of chronic smoking. Other risk factors for the development of COPD are air pollution especially due to solid cooking fuels, presence of airway hyperresponsiveness (Mosenifar, 2011). The characteristic pathophysiological changes in COPD are seen in the central airways, the peripheral airways and also the lung parenchyma. Diverse mechanisms are implicated in the pathophysiology of COPD (Thurlbeck, 1990). Primary offenders like oxidative stress due to free radicals from cigarette smoke and oxidants from phagocytes and polymorphonuclear leukocytes trigger the release of certain enzymes like leukocyte elastase in such proportions that they cannot be counteracted effectively by anti-proteases, resulting in destruction of the lung tissues (Thurlbeck, 1990) leading to necrosis or apoptosis of the lung tissue. Due to these mechanisms, certain pathological changes occur in the airways and the lung tissue like inflammation and globlet cell hyperplasia in chronic bronchitis and loss of elastic recoil in emphysema. Other changes include ciliary abnormalities, airway smooth muscle hyperplasia, bronchial wall thickening and sometimes atrophy (Mosenifar, 2011). These pathophysiological changes contribute to airway flow obstruction, airway hyperresponsiveness and mucus accumulation leading to poor ventilation and oxygenation, breathlessness, cough and infection. A patient may have either emphysema or chronic bronchitis or both. The clinical presentation depends on which pathology is more dominant. When emphysema dominates, features due to loss of elastic recoil is more obvious than bronchiolar disease and when chronic bronchitis dominates, bronchiolar abnormalities contribute to the lung function deficits. Airflow obstruction in emphysema is not reversible at all. However, in chronic bronchitis, the obstruction is due to inflammation and hence is partially reversible (Mosenifar, 2011). Clinical presentation The most common clinical presentation of COPD is productive cough or acute chest infection. In John, productive cough is the main clinical presentation. However, as the disease progresses, breathlessness ensues and it becomes the most predominant symptom. Along with breathlessness easy fatiguibility and exercise intolerance also develop making the life of the patient miserable. Breathlessness occurs because of the poor oxygenation and ventilation occurring mainly due to airflow obstruction and partly due to impaired mucus clearance. The degree of breathlessness can vary and it can be measured using The Medical Research Council (MRC) Dyspnea Scale (NICE, 2004) (Table-1). Some patients may present with wheezing, especially during exacerbations and exertion. As the disease progresses, the frequency of exacerbations increases, cyanosis develops and right heart failure may ensue which further worsens breathlessness (Mosenifar, 2011). Diagnosis The diagnosis of COPD is mainly on the basis of clinical presentation and exclusion of other causes of cough and breathlessness. According to NICE (2004), "diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze." John presented with recurrent bouts of cough for 3-4 years, suggestive of chronic bronchitis. He was evaluated in detail to rule out other causes of cough. Complete blood picture, chest X-ray and body-mass index were done, which were within normal limits. Pulmonary functions tests also were done to help in the assessment of the severity of lung pathology and also in monitoring response to treatment. FEV1 was decreased in John. The most common index of obstruction of air flow is FEV1 (Fromer and Cooper, 2008). NICE (2004) recommends confirmation of airflow obstruction by spirometry in all patients with COPD. Serial domiciliary peak flow measurements are useful to rule out asthma (Fromer and Cooper, 2008). ECG and ECHO are useful in advanced stages to assess the cardiac status (NICE, 2004) and even these tests were done. While ECG was normal, ECHO was suggestive of mild hypertrophy of both the ventricles. Assessment of cardiac status is essential not only to institute proper treatment but also to set limits for exercise training and other physical therapies (NICE, 2004). Table.1: The Medical Research Council (MRC) Dyspnea Scale (NICE, 2004). Multidisciplinary management The main goals of treatment in John are symptom relief, amelioration of disease progression, increase in exercise tolerance, improvements in health status, prevention of exacerbations and decrease in the risk of death due to COPD (Fromer and Cooper, 2008). Before starting treatment in COPD, the severity of the disease must be estimated. Since COPD is heterogeneous, there is no single measure which can ascertain the severity of the condition in any patient. However, assessment of severity is important for deciding treatment. The assessment can be made using 3 important aspects which include degree of airflow obstruction, frequency of exacerbations and also certain prognostic factors. The severity of airflow obstruction can be assessed based on the reduction in FEV1. The main prognostic factors are FEV1, MRC scale of breathlessness, exercise capacity, BMI, etc (NICE, 2004). 1. Anti-smoking counseling with counselors and psychotherapists There is no cure for COPD. However, the symptoms can be controlled effectively by prompt treatment and diligent follow-up. The first and foremost step in the management of COPD is smoking cessation. Smoking history along with pack years smoked should be elicited and documented in the records of every COPD patient. John was encouraged to give up smoking. Appropriate support programs and if necessary nicotine replacement therapy should be instituted to bring about cessation of smoking (NICE, 2004). Cessation of smoking prevents further progression of the disease, decreases exacerbations and thus decreases symptoms including breathlessness. 2. Medical management by general practitioners and pulmonologists The next step in treatment is aimed at reducing the severity of breathlessness and also in decreasing cough. Medical therapy involves usage of drugs like bronchodilators, steroids and other drugs. The bronchodilators which are useful in COPD are anticholinergics, methylxanthines and beta-2 adrenergic receptors (Fromer and Cooper, 2008). The initial empirical treatment for relief of breathlessness and limitation of exercise should be short-acting bronchodilators. When the patient starts, the effectiveness of the medications should be evaluated based on improvement in exercise capacity, day-to-day activities and the rapidity of symptom relief. In case there is no proper response to these medicines, then either long-acting bronchodilators or a combination of short-acting anticholinergic should be switched over to. In patients who have 2 or more exacerbations in one year, long-acting bronchodilators must be the first line of treatment for breathlessness (NICE, 2004). Oral Corticosteroids have a role during exacerbations. Inhaled corticosteroids are prescribed in those with an FEV1 of 50% or less than 50% of predicted and also in those who are suffering from more than 1 exacerbation in a year which requires oral corticosteroids or antibiotics (NICE, 2004). Combination therapies should be started if patients continue to be breathless when on monotherapy. Some of the effective combinations are beta2-agonist and anticholinergic, beta2 agonist and theophylline, (NICE, 2004). Mucolytics like N-acetyl cysteine can decrease the number of exacerbations (Poole and Black, 2001) and thus decrease breathlessness. Cough syrups have no role in the management of breathlessness in COPD (ATS, 2005). 3. Pulmonary rehabilitation program Most experts use a combination of medicines and physical therapy to decrease breathlessness (Mosenifar, 2011). Research has shown that combination therapy is more effective than only drug-therapy in the management of breathlessness in COPD. This is evident from the study by Cambach et al (1997). In most COPD patients with breathlessness, pulmonary rehabilitation programme is advocated. Pulmonary rehabilitation is defined as “a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy” (ATS, 1999). This program should be offered to all patients with breathlessness of grade 3 or above but are not suffering from unstable angina, recent attack of myocardial infarction or inability to walk (NICE, 2004). The program must incorporate disease education, physical training, nutritional intervention, psychological support and behavioural therapy. Pulmonary rehabilitation program improves the quality of life of the patient, increases exertional and exercise tolerance, decreases breathlessness, increases autonomy and coping skills, decreases exacerbations and prevents complications (Brooks et al, 2002). Pulmonary rehabilitation plays an important role in the management of COPD. Research has shown that comprehensive pulmonary management significantly improves exercise performance and decreases the amount of breathlessness. Ries et al (1995) evaluated the effects of comprehensive pulmonary rehabilitation programmes in COPD patients and opined that these interventions significantly decrease the symptoms and the benefits can be partially maintained for atleast a period of one year. The benefits of rehabilitation programme are further emphasized by a randomized case-control study by Toshima et al (1990). Education is important in the program because it enhances active participation in health care, increases coping skills, enhances the understanding of the disease, assists in self-management and increases adherence to treatment plan (Neish and Hopp, 1988). The type of exercises to be included is aerobic and resistance exercises (Bendsrup et al, 1997). Aerobic or endurance exercise training should be performed atleast 3-4 times a week for about 20-30 min per session. The intensity of exercise must be at least 50% of maximal oxygen consumption. The mainstay of endurance training is lower extremity training. Strength training or resistance exercises improve respiratory muscle strength (ATS, 2004). Many COPD patients suffer from anxiety and depression which decrease the coping ability of the patient. Psychological and behavioural interventions which include stress management, progressive muscle relaxation and panic control increase the coping skills of the patient (Renfroe, 1988). Nutritional advice is essential because both underweight and obesity can contribute to increased morbidity and mortality in COPD (Chailleux et al, 2005). Nutritional advice is based on the BMI. Nutritional intervention should be considered in all patients with BMI less than 21 kg-m2, involuntary weight loss of >10% in the previous 6 months or >5% in the past one month, and also in cases where there is depletion in FFM (ATS, 2004). Nutrition advice consists of adaptation of patient's dietary habits supplemented by energy-dense supplements. The nutrition advised should avoid loss of appetite and at the same time prevent adverse metabolic and ventilatory efforts. Some research has questioned the benefits of nutritional supplements in COPD (Ferreira et al, 2000). According to Casaburi et al (2005), introduction of a bronchodilator like tiotropium can add to the benefits of the program 4. Physiotherapy through self-management and assistance from physiotherapists and chest physiotherapists Physiotherapy helps control of breathlessness by means of certain breathing techniques, relaxation and airway clearance. According to the NICE guidelines (2004), physiotherapy must be instituted to reduce work of breathing associated with COPD, to restore the maximum function of the patient and to improve respiratory and peripheral muscle weakness. John was advised physiotherapy in home. Whether to administer physiotherapy at home or in the hospital/clinic is based on the severity of the disease and the ability to perform alone at home. Clinic-based physiotherapy is costly and often non-compliant. Hence many experts advise home-based exercise protocol for physical rehabilitation. Moore et al (2009) compared the benefits of home-based physiotherapy over clinic-based physiotherapy and reported that the benefits were similar in both when the proper protocol was followed. There are many techniques in physiotherapy which help to manage breathlessness. Positioning of body, control of breathing, chest clearance, exercise training and chest physiotherapy were advised to John. Within few weeks of initiation of physiotherapy, John reported improvement in symptoms. Adaptation of certain positions decreases oxygen consumption of the body and also increases ventilation-perfusion of the lungs, thus decreasing breathlessness. John was advised to choose a position that makes them feel comfortable. While adopting such a position, the arms must be relaxed and supported. Breathing control techniques also helped John cope with breathlessness. John was advised to first listen to the noise of breathing as he breathes out. He was then advised to try to lessen the noise of breathing out with as little effort as possible. He advised not to take deep breaths in, even if he gets tempted. John was advised to rest in the comfortable position and do this exercise. Over sometime, as the patient begins to learn the proper technique of breathing in and out, the work of breathing and also the rate of breathing slow down. Clearance of sputum is essential to decrease the risk of recurrent infections of the chest, to allow easy breathing during exertion and to reduce cough. Chest clearance is done using active cycles of breathing and must be preferably done after inhaler therapy (ATS, 2004). The 'active cycle of breathing’ exercises begins with rest phase. John was advised to rest until the breathing is quiet and there is no wheezing. Then, he was advised to take 2-3 deep breaths with a quiet breathe out. He was then advised to take 1-2 huffs with open mouth with the noise of the sputum as guide, followed by rest. John was advised to continue the cycle for as much clearance as possible. After the rest cycle, relaxation of the body was advised. Relaxation is important because it reduces tension, decreases the consumption of oxygen and provides a sense of control over symptoms (Mosenifar, 2011). Relaxation can be done in any comfortable position. The patient can lie on his back with a pillow under the knees and the head or he can sit in chair with back and knees supported or he can sit on a table with arms and head supported on pillows. First, each part of the body must be moved into the direction which is opposite to the position of tension. Then the movement must be stopped and an attempt must be made to register the new position of comfort Exercise trains the body to deliver more oxygen to the muscles so that day-to-day activities can be carried out without causing breathlessness and fatigue. Exercise must be started with small amounts and then gradually increased. Other benefits of exercise are relaxation, weight control and increased efficiency of heart. Exercise not only improves the stamina of respiratory muscles in COPD patients, but also improves the autonomic nervous control, thus decreasing heart rate variability during stress. Aerobic exercises also increase oxygen consumption and cause improvements in blood lactate, dyspnea at peak exercise, parasympathetic and sympathetic activities, and minute ventilation. This is evident from the study by Borghi-Silva et al (2009) in which a 6-week aerobic exercise training in moderate-severe COPD patients showed improvements in suboptimal performances. While imparting physical training, both upper extremity and lower extremity exercises must be included. Upper extremity training is important to help improvement of breathlessness and fatigue when activities which involve the accessory muscles of ventilation are involved. Some researchers do not see any added benefits with upper extremity exercises. Costi et al (2009) conducted a systematic review on the benefits of upper-extremity exercise in COPD patients and reported that there is not much evidence to support the definite need to include upper extremity exercise training in the rehabilitation regimen of COPD patients with breathlessness. Inspiratory muscle training which involves breathing at graded increase in resistance improves the strength of the inspiratory muscles, thus improving exercise performance and dysnea in day-to-day activities. This form of training is essential because in COPD, respiratory muscles need to work more and are actually compromised due to airway collapse and low elastic recoil. An improvement in the respiratory muscle performance is associated with decreased perception of breathlessness (Patessio et al, 1989). Whether interval physical training or continuous physical training is effective in COPD is often a brooded topic. Mador et al (2009) compared the two types of training and revealed that both had similar effects on quality of life and exercise performance and hence interval training is more preferred because it is easier to follow. Yoga is another intervention that improves gas exchange in moderate to severe COPD patients. This aspect has been studied by Pomidori et al (2009) who reported improvement in breathlessness in patients with COPD after short term yoga training. Physical training in the form of exercise within the context of pulmonary rehabilitation can improve exercise capacity, health-related quality of life and breathlessness in COPD patients. However, the intensity and duration of exercise that can be performed is limited by breathlessness and easy fatigability. The exercising capacity can be increased by several interventions like oxygen therapy and addition of titropium. Some experts recommend helium-hyperoxia during pulmonary rehabilitation to increase the intensity and duration of exercise training, thus improving the constant-load exercise time. (EVES et al, 2009). However, many researchers add little value to the benefits of these interventions. According to cochrane review (Nonoyama et al, 2007), there is not much evidence about the usefulness of oxygen therapy during exercise sessions of COPD to strongly recommend it in practice. COPD exacerbations are characterized by increased mucus production and hence difficult to treat, thus increasing breathlessness and also worsening the outcomes of the patient. Hence aggressive management of exacerbations is essential. Chest physiotherapy is an useful intervention to clear the airways of secretions and mucus. One of the widely recommended non-invasive airway clearance technique is expiration with the glottis open in the lateral posture, also known as ELTGOL. Though this test has been considered to be useful in draining and clearing mucus in COPD patients, especially during exacerbations, this intervention has not been completely declared useful and many experts like Kodric et al (2009) who do not find much use in this intervention. Other chest physical therapy interventions for airway clearance are postural drainage using manual percussion with hands alone or a flexible mask or cup followed by postural drainage, mechanical vibrators or percussors using ultrasonic devices and oscillating positive expiratory pressure using FLUTTER device. Research has shown that all the 3 interventions are safe to use and do not cause desaturations during therapy (Bellone et al, 2000). However, percussion and postural drainage is associated with many hazards and complications and also poor patient compliance and hence not useful in many patients. Other techniques like intrapulmonary percussive ventilation and high frequency chest compression with Thairapy vest are very expensive and elaborate procedures. Their use is limited to those patients with lack the ability to perform the simpler techniques (Langenderfer, 1998). An useful adjunct to physiotherapy is inhaled hypertonic and normotonic salines. Increased secretion of mucus due to inflammation and goblet cell hypertrophy results in obstruction of the airways, increased airway resistance, gas trapping, flow limitation and increased residual volume. The increased mucus needs to be cleared promptly to prevent bacterial colonisation and recurrent chest infections and also deterioration in lung function. Though there are many drugs available to control and expectorate mucus, research has shown that these medicine have limited value in preventing exacerbations and improving quality of life (Poole and Black, 2009). Inhaled hypertonic saline and normal saline have a place in the management of breathlessness in COPD patients when given in conjunction with physical therapy. The drugs hydrate airway mucus and increase the mucociliary clearance and also clearance by cough. Hypertonic and normal salinesthus increase the efficacy of chest physiotherapy. Which of the two are more efficacious was studied by Valderramas and Atallah (2009). The study compared the benefits of both the drugs and found that normal saline was equally as efficacious as hypertonic saline and that the latter drug was associated with certain side effects like bronchospasm and cough, limiting its use when compared to nomal saline. Exertional dysnea limits the usefulness of physiotherapy. Hence currently, researchers are looking into other modalities of managing breathlessness like transcutaneous neuromuscular electrical stimulation or NMES. Sillen et al (2007) conducted an extensive literature review pertaining to the usefulness of NMES in managing breathlessness in COPD. According to the literature review, NMES improves muscle strength, health status and exercise capacity significantly enough to be considered as a good means of rehabilitation in COPD patients. Conclusion COPD is a chronic incurable illness that causes intense suffering and affects quality of life. However, appropriate treatment and interventions can decrease the amount of suffering and help the patient lead a good health-related quality of life. The most progressive and frightening symptom of COPD is breathlessness which poses a challenge to the health professionals as far as management is concerned. The main forms of treatment for breathlessness are medical therapy and physical therapy. While medical therapy alone is useful in initial stages, introduction of physical therapy becomes essential as the disease progresses. 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