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The Effectiveness of Nurse-Led, Home-Based Pulmonary Rehabilitation in Patients with COPD in Turkey
The goal of this study was to determine the effectiveness of nurse-led, home-based pulmonary rehabilitation in patients with stage 3 or 4 chronic obstructive pulmonary disease (COPD), according to the Global Initiative for COPD (GOLD) staging system. The study consisted of 32 patients—a nurse-led, home-based pulmonary rehabilitation group (16) and a control group (16). In the rehabilitation program, patients received education about their diseases and performed breathing exercises and lower- and upper-extremity aerobic exercises at their homes during the 3-month period of the study. There was meaningful improvement in the rehabilitation group in terms of pulmonary function tests (FEV1 % predicted value), artery blood gases (PaCO2), quality of life, dyspnea, and functional capacity. On the other hand, no meaningful change was observed in the control group. The study showed that the nurse-led, home-based pulmonary rehabilitation program had positive effects on the patients with COPD.
Chronic obstructive pulmonary disease (COPD) is a chronic, progressive, and irreversible disease of the lungs that reduces airflow over time. As the disease progresses, COPD patients gradually become less physically active and their quality of life is severely worsened because of limited airflow (Farquhar & Fantasia, 2005; Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2009). Pulmonary rehabilitation is an integral part of the clinical management and health maintenance of those patients with COPD who remain symptomatic or continue to suffer from the decrease in functions despite the implementation of standard medical treatment (American Thoracic Society [ATS], 1999; Barnett, 2006; Troosters, Casaburi, Gosselink, & Decramer, 2005). Pulmonary rehabilitation is “a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise physical and social performance and autonomy” (ATS, p. 1666). These programs primarily include patient education and exercise training (British Thoracic Society Standards of Care Subcommittee on Pulmonary Rehabilitation, 2001). Related guidelines from the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommend the pulmonary rehabilitation program for the patients with COPD, citing that pulmonary rehabilitation can help improve a patient’s exercise tolerance, dyspnea, and health-related quality of life (Ries et al., 2007). Nursing management of patients suffering from COPD is aimed at helping to control an individual patient’s symptoms and improve their exercise tolerance and quality of life (Barnett, 2008). For this reason nurses use the pulmonary rehabilitation program to manage COPD. Nurse-led, home-based rehabilitation programs eliminate the difficulty a patient may have in getting to a hospital for treatment and improve access to and participation in the rehabilitation program. Other than a few specific centers, there are no routine pulmonary rehabilitation programs directed at patients with COPD in Turkey. This study will contribute to the nursing literature on organizing home-based pulmonary rehabilitation for patients with stage 3 or 4 COPD (according to GOLD staging system).
This study was conducted to determine the effectiveness of nurse-led, home-based pulmonary rehabilitation on pulmonary function tests, artery blood gases, quality of life, dyspnea, and functional capacity in patients with stage 3 or 4 COPD (according to GOLD staging system).
This controlled experimental study was designed to assess the effect of nurse-led, home-based pulmonary rehabilitation.
One hundred ninety-eight COPD patients were in an outpatient clinic of the department of chest diseases at a university hospital; 107 of these patients had stage 3 or 4 COPD. Sixty-eight subjects met the inclusion criteria and agreed to participate in the study, although only 52 of these patients ended up participating. These patients were divided into a rehabilitation group (n = 27) and a control group (n = 25). In the pulmonary rehabilitation group, five patients did not perform the assigned exercise, five patients had acute exacerbation of COPD, and one patient died. In the control group, five patients did not attend the second evaluation and four patients had exacerbation. Thus, the study was conducted with 16 rehabilitation patients and 16 control patients. Data were collected from September 1, 2005, to June 30, 2007.
Inclusion criteria for the study included having stage 3 or 4 COPD (according to the GOLD system), being in a clinically stable condition with no history of infections or exacerbation of respiratory symptoms, and having no observable change in medication during the 2 months preceding the study. Patients were aksed whether they were willing to participate in the study and those who said yes were included in the study.
Exclusion criteria for the study included myocardial infarctions within the preceding 4 months, unstable anginas, severe congestive heart diseases, severe hypertension problems, diabetes mellitus with complications, and muscle and joint problems. Patients with these conditions were disqualified from the study because they would not be able to participate in the exercise program. Patients with cancer and asthma, on the other hand, were excluded because they were at risk for exacerbation.
The study was conducted in the outpatient clinic of the department of chest diseases at a university hospital in Istanbul, Turkey.
Data Collection Process
Data from both study groups were collected in the COPD policlinic when the study was initiated and at the end of the 3-month study period. Pulmonary function tests, artery blood gases, quality of life, dyspnea level, and functional capacity were evaluated in the study. Data collecting process for each patient took 30–40 minutes.
Pulmonary function tests were performed with a spirometer (ZAN 100 handy) using the American Thoracic Society’s criteria. The forced expiratory volume in first second (FEV1% predicted value) and FEV1/FVC ratio were measured during these tests. Artery blood gases were analyzed on a blood analyzer (ABL 700 series, Radiometer, Copenhagen). Blood was drawn from the radial artery when the patient was at rest and breathing room air. The values for arterial oxygen saturation in artery (SaO2), partial pressure of arterial oxygen (PaO2), and partial pressure of arterial carbon dioxide (PaCO2) were measured for as evaluation criteria.
Quality of life was evaluated using St. George’s Respiratory Disease Questionnaire (SGRQ), which was developed by Jones, Quirk, Baveystock, and Littlejohns (1992). Durna and Ozcan (1999) made adaptations to the survey to make it suitable for Turkish society. SGRQ is a disease-specific quality-of-life questionnaire that contains 76 items. SGRQ measures three domains: symptoms, activity, and impacts. SGRQ scores range from 0 (perfect health) to 100 (worst possible state; Durna & Ozcan; Jones et al.). In the reliability and validity study of the Turkish version of the SGRQ conducted by Durna and Ozcan, the Cronbach alpha values of the subgroups were found to be high, with symptoms subgroup at 0.86, the activity subgroup at 0.88, and the impacts subgroup at 0.86.
Dyspnea level was evaluated with the Baseline Dyspnea Index (BDI), which was developed by Mahler, Weinberg, Wells, and Feinstein (1984). The adaptation of the index for Turkish society was performed by several different researchers (Demir, Akkoca, Dogan, Saryal & Karabiyikoglu, 2003; Ozalevli & Ucan, 2004). The BDI score depends on ratings for three categories: functional impairment, magnitude of task, and magnitude of effort. Dyspnea in each category is rated on a 5-point scale from 0 (severe) to 4 (unimpaired). Ratings for each category are added to form a total dyspnea score (ranging from 0 to 12). Higher scores indicate worse dyspnea (Mahler et al., 1984). The Cronbach’s alpha value of BDI was 0.87 in our study.
Functional capacity was evaluated with a 6-minute walking test (6MWT). The 6MWT, developed by McGavin, Artvinli, Naoe, and McHardy (1978), is commonly used in scientific researches. The test is performed on a 30-meter corridor. The corridor is marked at every 3 meters and cones are placed at turning points. Before the test begins, the patient is informed about the goal of the test and is instructed to sit and rest for at least 10 minutes. During this test, the patient is asked to walk by himself or herself at the maximum speed possible (as determined by the patient). The patient is allowed to stop and rest whenever he or she feels the need. Although values for heart rate and oxygen saturation and dyspnea and fatigue levels are noted before and after the test, walking distance is recorded as the result of this test (ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories, 2002; Enright, 2003).
Pulmonary Rehabilitation Program
In this study the rehabilitation program, which was based on patient education and exercise, was conducted by medical professionals. Medical professionals contributed to rehabilitation by arranging patients’ treatment and determining the suitability of exercises for patients. A nurse who was specialized in pulmonary rehabilitation conducted a patient education and exercise program.
Patient education was conducted 2–3 times in patients’ homes during the course of pulmonary rehabilitation; each session lasted 2–3 hours. The information presented during patient education sessions was also collected in a booklet provided to patients. The educational booklet included the anatomy and physiology of the lungs, changes in airways due to COPD, causes of the disease, symptoms, medications, instructions for using inhaler medication, breathing exercises, breathing control, relaxation techniques, airway clearance techniques, modifications on daily living activities, energy conservation techniques, exercises, and methods for smoking cessation. The educational content was tailored to the requirements of each patient based on their particular symptoms, and the researcher explained the information and handed out supporting material during each visit. The exercise program consisted of a lower-extremity aerobic exercise (walking), an upper-extremity aerobic exercise (arm exercises), and breathing exercises (pursed lips and diaphragmatic breathing). The methods for walking, arm exercises, and breathing exercises were taught to patients during the first days of their education sessions. Patients were then asked to perform these exercises by themselves at home and record any problems they encountered; these problems would be reported during the second visit. During the second visit, patients were evaluated regarding whether they had performed their exercises. Any problems they encountered while performing their exercises were also handled during this visit. During the third visit, however, any problems that had occurred after the second visit were discussed. Nurses also observed whether patients performed their exercises correctly during the third visit. Patients were instructed to walk for 30 minutes, perform the pursed lips and diaphragmatic breathing exercises for 30 minutes each, and perform each of the arm exercises 15 times during a minimum period of 1 minute. Arm exercises included stirring the soup in the cauldron, pulling up the anchor, hitting the punching bag, rowing the boat, marching soldier arm movements, punching, waxing on the car, waxing off the car, performing the crawl stroke and breast stroke, playing the drums, playing the accordion, chopping wood, picking cherries, pulling up weeds, wiping a windshield, stretching the springs, and scissoring the arms. Patients were allowed to perform the exercises in intervals and did not have to do them all at once. Patients were given a chart to record their daily exercises; nurses checked whether exercises had been completed—every 15 days during the first month and once a month during the second and third months via phone conversations. Patients in the control group continued their standard treatment; no procedure related to the rehabilitation program was performed with these patients. Doctors or nurses weren’t provided with any training regarding the clinical routine of the patients in the control group.
The statistical analysis was performed by using the Statistical Package for the Social Sciences (SPSS) for Windows version 15.0. During data analysis, descriptive statistics were computed according to patients’ characteristics. Mann-Whitney U test was used to determine similarities of variables between the control group and the pulmonary rehabilitation group. As the final step, Wilcoxon signed-rank test was conducted to determine whether there was a significant difference among the variables at pre-¨rehabilitation and postrehabilitation. The significance level (p < .05) was established prior to data collection.
All of the procedures performed in the study were approved by the research ethics committee of the university hospital in Istanbul, Turkey. Patients were made aware of the proposed study procedures and freely presented written informed consent.
Baseline demographic and clinical characteristics of the subjects are shown in Table 1.
Changes in the Pulmonary Function Tests
FEV1% predicted value in the rehabilitation patients was significantly improved (p = .003; Table 2); in the control patients, however, no significant difference from the baseline was observed (Table 3). FEV1/FVC was increased in both groups but it was not statistically meaningful (Tables 2 and 3).
Changes in the Artery Blood Gases
The amount of SaO2 and PaO2 did not change at a statistically significant level in either of the groups (Table 2 and 3). Although the PaCO2 values dropped in both groups, it was only statistically significant in the rehabilitation group (p = .049; Tables 2 and 3).
Changes in the Quality of Life
The quality-of-life score and its subscale scores were decreased significantly in the rehabilitation group. The symptoms score was decreased from 56 to 44 (p = .004); impacts score was decreased from 43 to 26 (p = .001); the activity score was decreased from 66 to 42 (p = .001); and the total quality-of-life score was decreased from 55 to 37 (p = .001; Table 2). On the other hand, no significant difference was observed in the control group when compared with the baseline (Table 3).
Changes in the Dyspnea Level
The dyspnea score of the rehabilitation group was higher after 3 months compared with the baseline score (p = .001; Table 2); there was no significant difference in the dyspnea score in the control group compared with the baseline score (Table 3).
Changes in the Functional Capacity
The 6MWD values increased significantly in the rehabilitation group from 157 meters to 190 meters (p = .001; Table 2); however, there was no significant difference observed in the control group compared with the baseline (Table 3).
This study demonstrates the effectiveness of the nurse-led, home-based pulmonary rehabilitation in patients with stage 3 or 4 COPD (according to GOLD staging system). When compared with the control patients, the values related to the pulmonary function test (FEV1% predicted), quality of life, and functional capacity were significantly increased while the values of artery blood gases (PaCO2) and dyspnea were significantly decreased in the pulmonary rehabilitation group.
Pulmonary rehabilitation should be considered for patients with COPD who have symptoms such as dyspnea or other respiratory symptoms, reduced exercise capacity, restriction in activities, or impaired health status. Because symptoms and functional limitations inform the need for pulmonary rehabilitation (Celli et al., 2004), there are no specific pulmonary function inclusion criteria that indicate the need for pulmonary rehabilitation. However, patients with stage 3 or 4 COPD were included in the pulmonary rehabilitation program because the symptoms and functional limitations mentioned earlier emerge in stage 3 or 4 COPD. AACVPR and ACCP recommended including lower-extremity exercise training and endurance training of the upper extremities in pulmonary rehabilitation programs for patients with COPD (Ries et al., 2007). Pulmonary rehabilitation can be organized in outpatient, inpatient, and home settings. Choosing the setting for pulmonary rehabilitation depends on the prerehabilitation physical, functional, and psychosocial status of the patient; the availability of and distance to the program; reimbursement; and patient preference (Celli et al., 2004). Home-based rehabilitation programs are cheaper, and patient participation is higher because exercises are performed at home. For these reasons, home-based pulmonary rehabilitation program was used in this study.
Pulmonary Function Tests
There was a meaningful improvement in FEV1% predicted value in our study. According to their study, Takigawa and colleagues (2007) also reported a significantly improved FEV1% predicted value of patients after a rehabilitation program. However, studies conducted by Barakat, Michele, George, Nicole, and Guy (2008) and Na and colleagues (2005) found that pulmonary rehabilitation programs were not effective in improving pulmonary function test results in patients with COPD. The additional upper-extremity aerobic exercises and breathing exercises performed by the patients in our study may explain the increased FEV1 in our patients.
Artery Blood Gases
There was a meaningful decline in the PaCO2 value in this study. A study conducted by Takigawa and colleagues (2007) showed that pulmonary rehabilitation was effective for decreasing the PaCO2 value. Breathing exercises, especially the pursed lips breathing used in our study, may explain this decrease in PaCO2. Pursed lips breathing prolongs exhaling and prevents the air from being trapped in alveoli, thereby promoting carbon dioxide elimination. Pursed lips breathing also decreases the respiratory rate and decreases the amount of PaCO2. Upper-extremity aerobic exercises may have also contributed to the decrease in PaCO2. This study demonstrated that pulmonary rehabilitation is effective in decreasing the amount of PaCO2.
Quality of Life
Patients’ quality of life meaningfully improved during this study. Almost all studies assessing pulmonary rehabilitation (Barakat et al., 2008; Ghanem, Elaal, Mehany & Tolba, 2010; Na et al., 2005; Paz-Diaz, Montes de Oca, Lopez, & Celli, 2007) affirm that quality of life in patients with COPD is improved after pulmonary rehabilitation. A better quality of life could be the result of improved pulmonary functions and dyspnea level. This study shows that the pulmonary rehabilitation programs improve quality of life.
In this study, the dyspnea level was a meaningfully decrease. Other similar studies (Kyung & Chin, 2007; Paz-Diaz et al., 2007; Takigawa et al., 2007) also confirm that after pulmonary rehabilitation has been implemented, the dyspnea level has decreased. This reduction in the dyspnea level could be the result of the desensitization of dyspnea, the increase in FEV1, and the decrease in PaCO2. According to our study’s results, pulmonary rehabilitation can have a positive effect on the dyspnea level.
During this study, patients experience a meaningful increase in the increment of walking distance. Similar studies (Alkan et al., 2006; Barakat et al., 2008; Ghanem et al., 2010; Kyung & Chin, 2007; Na et al., 2005; Takigawa et al., 2007) also showed that functional capacity increased after a pulmonary rehabilitation program had been implemented. Pulmonary rehabilitation programs that include a walking exercise can increases functional capacity.
This study showed that nurse-led, home-based pulmonary rehabilitation can have positive effects for pulmonary function tests, artery blood gases, quality of life, dyspnea, and functional capacity in patients with stage 3 or 4 COPD. Although these effects were weaker for pulmonary function and artery blood gases, it was considerably strong for improving quality of life, dyspnea, and functional capacity.
Application to the Practice
When a rehabilitation program does not exist in the hospital setting, the physical conditions of patients with stage 3 or 4 COPD could be improved with nurse-led, home-based pulmonary rehabilitation. During pulmonary rehabilitation programs, nurses can educate patients about their diseases and teach them exercises. Nurses can play an active role in sustaining the physical well-being of COPD patients.
Deficiencies of the Study
One deficiency of this study was the small sample size. For this reason, these results cannot be generalized to all patients with stage 3 or 4 COPD. Another deficiency involved the patient education sessions, which were presented in patients’ homes because the physical environment of the hospital was not suitable for education purposes. The patient education and exercises could have been taught to patients at the hospital and then the exercises could have been performed at their homes, saving health professionals from the hassle and time commitment of commuting back and forth from the hospital to patients’ homes.
The efficiencies of nurse-led rehabilitation programs in which education and instruction regarding daily exercises are provided at the hospital and the exercises are implemented at home should be evaluated.
About the Authors
Ayse Cil Akinci, PhD, is an assistant professor at Kirklareli University, Health College in Kirklareli, Turkey. Address correspondence to firstname.lastname@example.org
Nermin Olgun, PhD, is a professor at Acibadem University, Health Sciences Faculty in Istanbul, Turkey.
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