PICOT Question and Literature Search

The first step of the evidence-based practice process is to evaluate a nursing practice environment to identify a nursing problem in the clinical area. When a nursing problem is discovered, the nurse researcher develops a clinical guiding question to address that nursing practice problem.

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For this assignment, you will create a clinical guiding question know as a PICOT question. The PICOT question must be relevant to a nursing practice problem. To support your PICOT question, identify six supporting peer-reviewed research articles, as indicated below. The PICOT question and six peer-reviewed research articles you choose will be utilized for subsequent assignments.

Use the “Literature Evaluation Table” to complete this assignment.

Select a nursing practice problem of interest to use as the focus of your research. Start with the patient population and identify a clinical problem or issue that arises from the patient population. In 200–250 words, provide a summary of the clinical issue.
Following the PICOT format, write a PICOT question in your selected nursing practice problem area of interest. The PICOT question should be applicable to your proposed capstone project (the project students must complete during their final course in the RN-BSN program of study).
The PICOT question will provide a framework for your capstone project.
Conduct a literature search to locate six research articles focused on your selected nursing practice problem of interest. This literature search should include three quantitative and three qualitative peer-reviewed research articles to support your nursing practice problem.

Note: To assist in your search, remove the words qualitative and quantitative and include words that narrow or broaden your main topic. For example: Search for diabetes and pediatric and dialysis. To determine what research design was used in the articles the search produced, review the abstract and the methods section of the article. The author will provide a description of data collection using qualitative or quantitative methods. Systematic Reviews, Literature Reviews, and Metanalysis articles are good resources and provide a strong level of evidence but are not considered primary research articles. Therefore, they should not be included in this assignment.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to LopesWrite.

Rubic_Print_
Format

and Literature Search

PICOT Question

5.0%

10.0%

5.0%

10.0%

Format 10.0%

10.0%

Course Code

Class Code

Assignment Title

Total Points

PICOT Question

120.0

Criteria

Percentage

1: Unsatisfactory (0.00%)

2: Less Than Satisfactory (75.00%)

3: Satisfactory (83.00%)

4: Good (94.00%)

5: Excellent (100.00%)

Comments

Points Earned

Content

80.0%

Summary of Clinical Issue

5.0%

A clinical issue is omitted or is not relevant to nursing practice.

A clinical issue is partially presented. It is unclear how the clinical issue relates to nursing practice. Significant aspects are missing, or there are inaccuracies.

A clinical issue is summarized. The issue generally relates to nursing practice.

A clinical issue is presented. The issue relates to nursing practice. Minor detail is needed for clarity.

A clinical issue is thoroughly described. The issue relates to nursing practice.

10.0%

A PICOT question is not included.

A PICOT question is provided but is incomplete. The PICOT question format is used incorrectly.

A PICOT question is provided. The PICOT question format is generally applied. Some information or revision is needed.

A PICOT question is provided. The PICOT question format is applied accurately. Some detail is need for support or clarity.

A PICOT question is clearly presented. The PICOT question format is applied accurately and presents an answerable and researchable question.

APA-Formatted Article Citations With Permalinks

Article citations and permalinks are omitted.

Article citations and permalinks are presented. There are significant errors in the APA format. One or more links do not lead to the intended article.

Article citations and permalinks are presented. Article citations are presented in APA format, but there are errors.

Article citations and permalinks are presented. Article citations are presented in APA format. There are minor errors.

Article citations and permalinks are presented. Article citations are accurately presented in APA format.

Relationship of Articles to the PICOT Question

Three or more articles do not relate to the PICOT question.

At least two articles do not relate to the PICOT question. The remaining articles provide a small degree of support for the PICOT question. Different articles are needed to provide better support for the PICOT question.

At least one articles does not relate to the PICOT question. The remaining articles provide general support for the PICOT question. One or two different articles are needed to provide better support for the PICOT question.

Each article relates to the PICOT question. The articles provide support for the PICOT question.

Each article clearly relates to the PICOT question. The articles provide strong support for the PICOT question.

Quantitative and Qualitative Articles

Fewer than six research articles are presented. Four or more articles do not meet the assignment criteria for a quantitative, qualitative,

Six research articles are presented. Three articles do not meet the assignment criteria for a quantitative, qualitative

Six research articles are presented. Two articles do not meet the assignment criteria for a quantitative, qualitative, or mixed study. Some ability to identify the type of research design used in a study is demonstrated.

Six research articles are presented. One article does not meet the assignment criteria for a quantitative, qualitative, or mixed study. A general ability to identify the type of research design used in a study is demonstrated.

Six research articles are presented. Each article meets the assignment criteria for a quantitative, qualitative, or mixed study. An ability to identify the different types of research design used in a study is consistently demonstrated.

Purpose Statements

Purpose statements are omitted or are incomplete overall.

Purpose statements are referenced but are incomplete in some areas.

Purpose statements are presented. There are minor omissions in some areas, or major inaccuracies.

Purpose statements summarized. There are some minor inaccuracies in some.

Purpose statements are accurate and clearly summarized.

Research Questions

Research questions are omitted or are incomplete overall.

Research question is presented for each article. The research question has been misidentified or misinterpreted for at least two of the articles. Additional information is needed to fully illustrate the research question for several of the articles.

Research questions are presented. The research question has been misidentified or misinterpreted for one of the articles. Some detail is needed to fully illustrate the research question for one or two articles.

Research questions are presented. Minor detail is needed for clarity in some areas.

Research questions are accurate and capture the fundamental question posed by the researchers in each study.

Outcome

Research outcomes are omitted or are incomplete overall.

Research outcome is presented for each article. The research outcome has been misidentified or misinterpreted for at least two of the articles. Additional information is needed to fully illustrate the research outcomes for several of the articles.

Research outcomes are presented. The research outcome has been misidentified or misinterpreted for one of the articles. Some detail is needed to fully illustrate the research outcomes for one or two articles.

Research outcomes are presented. Minor detail is needed for clarity in some areas.

Research outcomes are accurate and described in detail for each article.

Setting

The setting is omitted for one or more of the articles. The setting described for three or more articles is inaccurate or incomplete.

The setting is indicated for each article. The setting described for two of the articles is inaccurate or incomplete.

The setting is indicated for each article. The setting described for one article is inaccurate or incomplete.

The setting is indicated for each article. Some detail is needed to fully illustrate the physical, social, or cultural site in which the researcher conducted the study.

The setting in which the researcher conducted the study is detailed and accurate for each article.

Sample

The sample is omitted for one or more of the articles. The sample described for three or more articles is inaccurate or incomplete.

The sample is indicated for each article. The sample described for at least two of the articles is inaccurate or incomplete.

The sample is indicated for each article. The sample described for one article is inaccurate or incomplete.

The sample is indicated for each article. Minor detail is needed for accuracy.

The sample is indicated and accurate for each article.

Method

Method of study for one or more articles is omitted. Overall, the methods of study are incomplete.

The method of study is partially presented for each article. Key information is consistently omitted. Overall, the methods reported contain inaccuracies.

The method of study for each article is presented. Some key aspects are missing for one or two articles, or there are some inaccuracies for the methods reported.

A discussion on the method of study for each article is presented.

A thorough discussion on the method of study for each article is presented.

Key Findings of the Study

Discussion of study results, including findings and implications for nursing practice, is incomplete.

A summary of the study results includes findings and implications for nursing practice but lacks relevant details and explanation. There are some omissions or inaccuracies.

Discussion of study results, including findings and implications for nursing practice, is generally presented for each article. Overall, the discussion includes some relevant details and explanation.

Discussion of study results, including findings and implications for nursing practice, is complete and includes relevant details and explanation.

Discussion of study results, including findings and implications for nursing practice, is thorough with relevant details and extensive explanation.

Recommendations of the Researcher

Researcher recommendations are omitted for one or more of the articles. The recommendations described for three or more articles are inaccurate or incomplete.

Researcher recommendations are indicated for each article. The researcher recommendations described for two of the articles are inaccurate or incomplete.

Researcher recommendations for each article are presented. Researcher recommendations described for one article are inaccurate or incomplete.

Researcher recommendations for each article are accurately presented. Minor detail is needed for accuracy.

Researcher recommendations accurate are thoroughly described for each article.

Organization and Effectiveness

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present.

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.

Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.

Writer is clearly in command of standard, written, academic English.

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

Sources are not documented.

Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.

Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

Total Weightage

100%

LiteratureEvaluation Table

Student Name:

Summary of Clinical Issue (

00-250 words):

PICOT Question:

Criteria	Article 1	Article 2	Article 3
APA-Formatted Article Citation with Permalink	Moore, D. (2020). Management of COPD exacerbations: pharmacotherapeutics of medications. British Journal of Nursing, 29(13), 738–743. https://doi-org.lopes.idm.oclc.org/10.12968/bjon.2020.29.13.738	Moore, D. (2019). Home oxygen therapy in patients with COPD: safety issues for nurse prescribers. British Journal of Nursing, 28(14), 912–917. https://doi-org.lopes.idm.oclc.org/10.12968/bjon.2019.28.14.912	Alton, S., & Farndon, L. (2018). The impact of community pharmacy-led medicines management support for people with COPD. British Journal of Community Nursing, 23(6), 214–219. https://doi-org.lopes.idm.oclc.org/10.12968/bjcn.2018.23.6.214
How Does the Article Relate to the PICOT Question?
Quantitative, Qualitative (How do you know?)
Purpose Statement
Research Question
Outcome
Setting (Where did the study take place?)
Sample
Method
Key Findings of the Study
Recommendations of the Researcher

Criteria

APA-Formatted Article Citation with Permalink

How Does the Article Relate to the PICOT Question?

Quantitative, Qualitative (How do you know?)

Purpose Statement

Research Question

Outcome

Setting

(Where did the study take place?)

Sample

Method

Key Findings of the Study

Recommendations of the Researcher

Article 4	Article 5	Article 6
Hodson, M. (2016). Integrating nutrition into pathways for patients with COPD. British Journal of Community Nursing, 21(11), 548–552. https://doi-org.lopes.idm.oclc.org/10.12968/bjcn.2016.21.11.548	McGinley, E. (2014). The role of nutrition in the management of COPD patients. Journal of Community Nursing, 28(4), 50–58.	Bades, A. (2014). Community management of chronic obstructive pulmonary disease (COPD). Journal of Community Nursing, 28(3), 51–56.

O
wing to its major burden on secondary health care,
chronic obstructive pulmonary disease (COPD)
is widely established as a health challenge, with
predictions that it will be the third leading cause
of global mortality and reduced health status

within the next 10 years (World Health Organization (WHO),
2020). Fluctuations in stable states of COPD is the second largest
cause of emergency hospitalisation (National Institute for Health
and Care Excellence (NICE), 2011) and, given the expanding
COPD population in Northern Ireland (Department of Health,
Social Services and Public Safety, 2015) where the author is based,
the assessment and management of such individuals is common
within the practice of respiratory nurse specialists (RNSs). The
RNS can have a direct role in advising and prescribing treatment for
this patient population, and it is therefore necessary that the RNS
makes prescribing decisions based on the best available evidence.

Pathophysiology of COPD
COPD is described as a preventable and treatable group of
lung conditions characterised by airflow obstruction that is not
fully reversible (Global Initiative for Chronic Obstructive Lung

Management of COPD exacerbations:
pharmacotherapeutics of medications
David Moore

ABSTRACT
Chronic obstructive pulmonary disease (COPD) is widely established as
a health challenge, with predictions that it will be the third leading cause
of global mortality and reduced health status within the next 10 years.
Exacerbations of COPD are now the second largest cause of emergency
hospitalisation in the UK. The respiratory clinical nurse specialist has
an active role in the acute management of COPD exacerbations in the
hospital setting, and it is essential that prescribing decisions are made
based on the best available evidence. This article critically evaluates the
pharmacotherapeutics and evidence base for the use of two medications,
salbutamol and amoxicillin, in treating unstable COPD, and discusses
implications for clinical practice.

Key words: Chronic obstructive pulmonary disease ■ COPD exacerbations
■ Breathlessness ■ Dyspnoea ■ Respiratory system pathophysiology
■ Amoxicillin ■ Salbutamol ■ Pharmacokinetics ■ Pharmacotherapeutics

David Moore, Respiratory Nurse Specialist and Independent
Nurse Prescriber, Mater Hospital, Belfast, dmoore20@qub.ac.uk

Accepted for publication: June 2020

Disease (GOLD), 2019). It is represented by two pathologies
associated with an abnormal inflammatory response of the
respiratory airways (Barnes et al, 2009), with chronic bronchitis
and emphysema both responsible for developing airflow resistance
within the large and small air passages of the lung (Porth, 2015).
Such heightened inflammatory responses occur mostly as a result
of exposure to inhaled noxious particles (MacNee, 2011), with
tobacco smoking the leading aetiology of COPD development
(GOLD, 2019, NICE, 2019).

The respiratory system is divided into the upper and lower
respiratory tracts, with structures including the nose, pharynx,
larynx and trachea within the upper tract, and the bronchial
tree and lungs within the lower (McLafferty et al, 2013). Its
primary function is concerned with gaseous exchange of oxygen
and carbon dioxide between the blood and the atmosphere
(Hinkle and Cheever, 2014), achieved through the process of
ventilation (Bearsley et al, 2012), whereby the movement of gas
through the conducting and respiratory airways is dependent
on pressure changes from respiratory muscle innervation (West,
2012). Gaseous exchange occurs on an alveolar level (Porth,
2015), with normal regulation of diffusion gradients between
the alveoli and blood in the capillaries essential for stable internal
homeostasis (McLafferty et al, 2013).

The effectiveness of this mechanism is inhibited in the
pathological development of COPD, with resistance to airflow
in narrowed airways due to recurrent inflammatory processes
representative of chronic bronchitis (Lynes, 2007). Porth (2015)
identified increased airflow limitation in chronic bronchitis as
a result of smooth muscle hypertrophy, hyperplasia of mucous-
secreting glands with associated hypersecretion, reduced
ciliary function and fibrosis of bronchiolar walls (Tam, 2012).
Emphysema destroys the walls of gas exchange airways, resulting
in loss of elasticity and over-distention of alveoli (Hinkle and
Cheever, 2014), leading to eventual lack of ventilation, altered
diffusion gradients and impairment of gas transfer (Porth,
2015). Such pathophysiological remodelling of the large and
small airways will therefore manifest in persistent respiratory
symptoms such as cough, sputum production and breathlessness
(Shapiro et al, 2010), the latter of which have minimal variability
and are progressive by nature (GOLD, 2019).

Exacerbations of COPD
COPD is associated with periods of instability, referred to as
exacerbations (Decramer et al, 2012). Wedzicha and Seemungal
(2007) defined an exacerbation as an acute deterioration of usual

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respiratory symptoms requiring additional therapy, with severe
classifications usually resulting in hospitalisation (GOLD, 2019).
The causative factors for exacerbations have been thoroughly
explored, with studies identifying viral and bacterial infections
as the most common trigger in hospitalised unstable COPD
(Wilkinson et al, 2006).

Increased airway and systemic inflammation is the main sign
of COPD exacerbation (Hurst et al, 2006), with bronchitic
abnormalities of oedema, increased mucous production and
bronchoconstriction manifesting symptoms of cough, dyspnoea
and wheeze (Wedzicha and Seemungal, 2007). The combination
of these factors elicit an abrupt increase in airflow resistance, with
the consequence of dynamic hyperinflation through worsening
expiratory flow limitation and compromised time available for
lung emptying (O’Donnell and Parker, 2006). The physiological
response is a rapid and shallow breathing pattern, recognised
as the main cause of acute dyspnoea and the most common
symptom of the COPD exacerbation (Wedzicha and Seemungal,
2007). MacNee (2006) highlighted how respiratory muscle
fatigue is an eventuality in this process, with the consequence
of insufficient ventilation and life-threatening respiratory failure
if poorly treated.

Pharmacotherapeutics of salbutamol
Bronchodilators in COPD
Bronchodilator agents are core pharmacological treatments in
COPD (Wedzicha et al, 2012), with short-acting preparations
arguably most effective in reducing airflow obstruction
and relieving respiratory symptoms in acute exacerbations
(Rodriguez-Roisin, 2006). Recent guidelines provide support,
recommending short-acting bronchodilator agents such as
salbutamol as best practice in the initial treatment of unstable
COPD (GOLD, 2019).

Bazargani et al (2014) described salbutamol as a short-acting
selective beta-2 adrenergic receptor agonist, classified in the
family of bronchodilators in the British National Formulary, (Joint
Formulary Committee, 2020). Its primary function is relaxation
of inflamed and contracted airway smooth muscle (McFadden,
2014) commonly triggered by bacterial illness (Burt and
Corbridge, 2013), with symptoms of severe bronchoconstriction
causing acute respiratory distress in unstable COPD (Jones et
al, 2011).

Airway smooth muscle tone is controlled by the autonomic
nervous system (McFadden, 2014) whereby parasympathetic
nerve stimulation initiates constriction and sympathetic nerves
dilate. Porth (2015) described how sympathetic innervation
releases adrenaline, a circulatory hormone that binds to beta-2
adrenergic receptors of airway smooth muscle cells (Lilley et
al, 2017). Binding to such receptors initiates bronchial smooth
muscle relaxation throughout the respiratory airways (Porth,
2015). Salbutamol is therefore classified as a sympathomimetic
agent, whereby it binds to beta-2 adrenergic receptors due to its
similar structure to adrenaline (Boarder et al, 2010).

Binding of salbutamol to beta-2 adrenergic receptors in the
airways stimulates the enzyme adenylate cyclase (Lilley et al,
2017), of which is responsible for converting energy-carrying
molecules of adenosine triphosphate into cyclic adenosine

monophosphate (Woo, 2016). Elevated intracellular levels of
this cyclic compound increases protein kinase A activation,
modifying regulatory proteins involved in smooth muscle tone
control and inhibiting release of ionic calcium concentrations
from intracellular stores (Malhatra and Shafique, 2011). This
signalling cascade causes rapid relaxation of airway smooth muscle
(Billington and Hall, 2011), with the effects of bronchodilation
being therapeutic in alleviating acute symptoms of wheeze and
dyspnoea in COPD exacerbations (Rodriquez-Roisin, 2006).

Waller et al (2014) highlighted how salbutamol can
also promote bronchodilation by inhibiting release of
bronchoconstricting agents associated with airway inflammation
in the COPD exacerbation. This supported Malhatra and
Shafique (2011), who argued that beta-2 adrenoceptor activation
supresses inflammatory mediator release from mast cells in the
airways, subsequently reducing airflow limitation and enhancing
mucociliary clearance (Gladson, 2011).

Inhaled administration of salbutamol has been long recognised
as a core standard treatment in obstructive lung disease (GOLD,
2019). Delivery via a pressurised metered-dose inhaler (pMDI)
is the most widely used method due to its low cost, effectiveness
and simplicity of use (Lavorini and Fontana, 2009). Despite this,
it is important to recognise that the pMDI is frequently used
incorrectly (Crompton, 1982; Vincken et al, 2018). Sanchis
et al (2016) argued that more than two-thirds of people take
their inhaled therapy erroneously, and that even with optimal
technique pMDIs can deliver at best only 20% of the inhaled
drug. This was supported by Newman et al (1982) and Vincken
et al (2018). The addition of a spacer device or valved holding
chamber (VHC) to a pMDI device has been found to improve
medication delivery to the airways (McIvor et al, 2018), and it
is now recommended in national and international guidelines
that a VHC device is used with pMDIs for both regular and
emergency use of medications (NICE, 2019; GOLD, 2019).

Various studies have shown that emergency use of salbutamol
in the context of an exacerbation of airways disease via the
use of a pMDi with VHC is at least as effective as nebulised
therapy (Cates et al, 2013; Van Geffen et al, 2016). National
guidelines support the use of either pMDi or nebulised methods
of salbutamol in acute exacerbations of COPD; however, the
choice of delivery system should reflect the dose of drug
required and the ability of the individual to use the device
effectively (NICE, 2019). GOLD (2019) therefore recommends
that the nebulised route may be the easier delivery method
for more acutely unwell patients in the COPD exacerbation.

Aerosolised formulations of salbutamol are considered
effective in acute COPD exacerbations. Nakpheng et al (2017)
identified that therapeutic efficiency of salbutamol was optimised
through delivery directly into the airways. Several authors have
argued this is best achieved through nebulisation (Turner et al,
1997; Boe et al, 2001), whereby rapid conversion of salbutamol
solution into small droplets for inhalation radically improves
acute bronchoconstriction (Laube et al, 2011).

Following deposition onto airway epithelial cells, salbutamol
is rapidly absorbed from the bronchi (Kee et al, 2015). The
Electronic Medicines Compendium (EMC) (2020) states that
less than 20% of inhaled salbutamol reaches the lungs, with the

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remainder staying in the oral cavity or ingested into the stomach.
De Alwis and Weiner (2012) also suggested that only a fifth of
the drug reaches the airways due to smaller tidal volumes as a
consequence of acute bronchoconstriction.

Upon bronchial absorption, salbutamol experiences
transcellular transport due to the compact interconnection
of bronchial epithelial cells (Schneeberger and Lynch, 2004),
reaching airway smooth muscle cells through glycoprotein and
organic cation conveyance (Ehrhardt et al, 2005). Salbutamol
molecules bind to protein-based beta-adrenergic receptors on
airway smooth muscle membranes (McFadden, 2014), which
are ideal targets due to their predominant lung distribution and
high bronchial smooth muscle density in comparison to other
cell types (Waller et al, 2014).

Salbutamol has a rapid onset of action, exerting its
pharmacotherapeutic properties within 5 minutes with
symptomatic bronchodilation in less than 15 minutes (Kee
et al, 2015). Peak plasma levels occur within 90 minutes, with
overall duration of action lasting up to 6 hours (Vallerand et
al, 2015). Hodgson and Kizior (2014) identifed the terminal
half-life of salbutamol as 3.8 hours.

The distribution of inhaled preparations is not fully
understood (Skidmore-Roth, 2015), with variable protein
binding capacity estimated as 10% (Kee et al, 2015). Waller et
al (2014) stated that salbutamol has low systemic levels, affecting
mainly the cardiovascular and skeletal muscle organ systems on
distribution. Salbutamol does not cross the blood-brain barrier
to any significant extent (Ebadi, 2008); however, it does cross the
placenta and is present in breast milk (Skidmore-Roth, 2015).

Metabolism of salbutamol occurs extensively and almost
exclusively in the liver (Vallerand et al, 2015). Gardenhire (2016)
argued that, because both bronchial and gastrointestinal absorption
occurs following aerosolised administration, there is considerable
first-pass metabolism in the liver and also the gastrointestinal wall.
Malhatra and Shafique (2011) stated that metabolism of salbutamol
does not occur in the lung and it has no active metabolites.

Salbutamol excretion occurs primarily in the kidneys
(Hodgson and Kizior, 2014), with up to two-thirds remaining
unchanged (Ashley and Dunleavy, 2014) and over 80% eliminated
in the urine within 24 hours of administration (Kee et al, 2015).
Malhatra and Shafique (2011) suggested that excretion occurs
rapidly given salbutamol’s short plasma half-life. Woo (2016)
added to this by identifying that less than 10% of salbutamol
is excreted in the faeces.

Woo (2016) argued that ideal bronchodilator agents would
only target beta-2 receptors in airway smooth muscle and have
no other systemic effects. Waller et al (2014) acknowledged this
ideal; however; they stressed that all preparations of salbutamol
have unintended interactions with other adrenergic receptors
in skeletal muscle and the cardiovascular system. It is possible
to minimise side effects by gaining selectivity of action through
selective beta-adrenoceptor agonist preparations, with beta-1
selective agonists more active on the heart and beta-2 more
active in the airways (McFadden, 2014). Salbutamol demonstrates
the greatest selectivity between beta-1 and beta-2 receptors
than any other formulation available, and is therefore the most
commonly used (Sears and Lötvall, 2005).

Using inhaled preparations is beneficial because the required
smaller doses directly target the respiratory tract and are
therefore less likely to cause adverse effects in comparison to
oral and parental administration (Boushey, 2012). Symptoms
of tachycardia and palpitation through stimulation of beta-1
receptors in the heart are common (McFadden, 2014), with
associated tremor due to beta-2 receptor activation in skeletal
muscle (Skidmore-Roth, 2015). Malhatra and Shafique (2011)
stated that tremor is the most common side effect, observed
in up to a fifth of individuals receiving inhaled salbutamol in
unstable COPD. Waller et al (2014) cautioned that, in rare
cases, salbutamol can inadvertently cause life-threatening
bronchospasm.

Skidmore-Roth (2015) argued that while pharmacokinetic
interactions of salbutamol are not unusual, pharmacodynamic
relationships are of concern whereby accessory use with other
beta-2 agonists increases hypokalaemia risk and associated
arrhythmia. Vallerand et al (2015) added to this, highlighting
increased adrenergic side effects of tachycardia and tremor when
used with other sympathomimetic agents. Caution in use with
beta-blocking agents is advised (Malhatra and Shafique, 2011),
whereby non-selective preparations block beta-2 receptors and
inadvertently precipitate bronchospasm in COPD (Kee et al, 2015).

GOLD (2019) has recommended the use of long-acting
bronchodilators in the long-term management of COPD. Dong
et al (2015) argued that inhaled long-acting bronchodilators
are more convenient and more effective than short-acting
bronchodilators. While short-acting preparations such as
salbutamol are recognised as important rescue remedies for
acute respiratory symptoms, regular or over use can result in
undesired side effects. Therefore, maintenance use of long-acting
agents can provide a lesser side-effect profile while providing
significant therapeutic benefit, with evidence showing reduced
symptoms of dyspnoea, improved health status and reduced risk
of COPD exacerbations with daily use of inhaled long-acting
beta-2 agonists (Cazzola et al, 2013; Koch et al, 2014), or inhaled
long-acting antimuscarinic antagonists (Karner et al, 2014;
Melani, 2015). Further to this, combinations of both forms of
long-acting bronchodilators can provide additional benefit to
the COPD population, with evidence showing greater efficacy
in combined therapy opposed to monotherapy in preventing
exacerbations (Wedzicha et al, 2013) and improving health
status in COPD patients (Mahler et al, 2015; GOLD, 2019).

Pharmacotherapeutics of amoxicillin
Antibiotics in COPD
Antibiotic therapy use in COPD exacerbations has been debated
(Vollenweider et al, 2012) It has been argued that not only are
bacterial triggers for airway inflammation difficult to accurately
assess (Wedzicha and Seemungal, 2007), but are also difficult
to differentiate from viral precipitants (Woodhead et al, 2005).
Wilkinson et al (2006) suggested that bacterial infection is
common in this disease group, with evidence identifying its
presence in sputum cultures in more than two-thirds of COPD
exacerbations. De Alwis and Weiner (2012) supported this view,
with evidence identifying bacterial triggers in over 50% of
hospitalised unstable COPD individuals.

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Antibiotic treatment in COPD exacerbations is therefore
indicated only when there are clinical signs of bacterial
infection, with increases in dyspnoea and sputum volume
and purulence recognised as cardinal symptoms (Miravittles
et al, 2012). Quon et al (2008) have supported this, with
evidence identifying reductions in mortality, treatment failure
and respiratory symptoms with antibiotic therapy in infective
COPD exacerbations. GOLD (2019) therefore recommends
that antibiotics are used in COPD exacerbations when such
surrogate markers are present, with aminopenicillins such as
amoxicillin identified as suitable agents (Llor et al, 2012), for use
for up to 5 to 7 days (Masterton and Burley, 2001; GOLD, 2019).

Amoxicillin belongs to a family of medications called beta-
lactams, recognised as such due to a functional group known
as a beta-lactam ring within its simple molecular structure
(McFadden, 2014). Its function is bactericidal, whereby it
employs its pharmacological activity by inhibiting bacterial
cell wall synthesis (Gardenhire, 2016).

Bacteria cell walls contain peptidoglycan, a structural molecule
synthesised by the bacterial enzyme transpeptidase (McFadden
2014). Amoxicillin binds to these penicillin-binding proteins
in bacteria (Waller et al, 2014), preventing their coupling to
the structural molecules, which is crucial in bacterial cell wall
development (Gardenhire, 2016). Drawz and Bonomo (2010)
stated that inactivation of transpeptidase enzymes occurs by
opening of the beta-lactam internal lactam ring, preventing the
final stage of bacterial cell wall completion. Inhibition of this
process activates an internal mechanism of self-digestion known
as autolysis (Kaur et al, 2011), resulting in unstable bacterial cell
walls and eventual cell death (McFadden, 2014). Drawz and
Bonomo (2010) added to this, highlighting how transpeptidase
is unique to bacterial cells and is therefore an ideal target for
amoxicillin as normal human cells will not be affected.

Absorption of amoxicillin occurs readily and almost
completely from the gastrointestinal tract with up to 90% oral
bioavailability (Waller et al, 2014), and is not influenced by
food (Lilley et al, 2017). Amoxicillin has a quick onset of action
(Skidmore-Roth, 2015), with peak plasma levels within 2 hours,
lasting up to 8 hours (Vallerand et al, 2015), and terminal half-life
approximated as 60 to 90 minutes (Kee et al, 2015). With oral
absorption of amoxicillin producing high peak concentration
levels, less frequent dosing intervals are required (Bush, 2010).

Amoxicillin binds to plasma proteins (Kaur et al, 2011),
primarily albumin (Amin et al, 1994), with a protein-binding
capacity of 20% (Hodgson and Kizior, 2014). The distribution
of oral preparations is relatively extensive (Waller et al, 2014),
with an apparent volume of distribution estimated as 0.3 litres
per kilogram (Ashley and Dunleavy, 2014), diffusing into most
organ systems and tissues including the liver, lungs, muscle, and
ascitic, pleural and synovial fluid (Kaur et al, 2011), including
exchange across the placenta (Vallerand et al, 2015). Jeske (2014)
argued that amoxicillin has poor infiltration of the blood-brain
barrier except when significant inflammation of the meninges
is present, with associated pathologies including meningitis
commonly described (Nau et al, 2010).

Metabolism of amoxicillin is relatively limited (Yagiela et al,
2011), with 30% metabolised by the liver (Vallerand et al, 2015)

and up to a quarter metabolised into penicillotic acid following
hydrolytic opening of the lactam ring (Bush, 2010). Excretion
occurs predominately through the renal system, eliminated by
both glomerular and tubular secretion (Geddes and Gould,
2010), with 80% of the drug recoverable in the urine (Bush,
2010). Vallerand et al (2015) identified that 70% of excreted
amoxicillin remains unchanged, predisposing to high urinary
concentrations. Furthermore, low concentrations of amoxicillin
are present in breast milk (Hodgson and Kizior, 2014).

Amoxicillin is generally well tolerated, with minor side-
effects common to most penicillins (Bush, 2010). Waller et al
(2014) highlighted its suitability given its high therapeutic index
and low toxic threshold. Symptoms of nausea, vomiting and
diarrhoea are the most commonly reported side effects (Jeske,
2014). However, as absorption occurs readily, gastrointestinal
disturbances are infrequent (Bush, 2010). Adverse reactions
of severe allergy, hypersensitivity and anaphylaxis have been
reported, but are relatively rare (Lilley et al, 2017), with urticaria
the most common allergic reaction (Skidmore-Roth, 2015).

Many medications interact with amoxicillin, with positive
relationships observed with clavulanic acid enhancing bactericidal
effect (Lilley et al, 2017), and negative interactions of decreased
renal elimination of methotrexate and enhanced anticoagulation
effect of warfarin (Ashley and Dunleavy, 2014). Non-steroidal
anti-inflammatory agents compete for protein binding,
inadvertently resulting in more free circulating amoxicillin,
which may be of therapeutic benefit (Lilley et al, 2017).

Comparison of salbutamol and amoxicillin
Although salbutamol and amoxicillin are not known to interact
pharmacokinetically, their pharmacodynamic properties
clearly complement each other. It is important to recognise
that acute bronchoconstriction is a symptom manifested from
the COPD exacerbation, and while salbutamol is essential for
rapid bronchodilation to alleviate acute respiratory symptoms,
amoxicillin is required to treat the bacterial infection that
precipitated the event. They therefore work collaboratively,
targeting different receptors with their specific modes of
action to achieve the same therapeutic outcome in treating
COPD exacerbations.

Implications for practice
Although high-quality evidence is lacking for the efficacy of
short-acting bronchodilators in COPD exacerbations, their
mechanism in relieving acute symptoms of dyspnoea and
wheeze is considered clinically worthwhile. There may be ethical
limitations for further evaluation because this is already accepted
standard treatment, and large-scale research would be required
to determine their short- and long-term outcomes in unstable
COPD. In the absence of this best practice guidance, GOLD
continues to recommend short-acting beta-2 agonists such
as salbutamol as the initial bronchodilator of choice for acute
treatment of COPD exacerbations (GOLD, 2019).

The risk of inappropriate and excessive antibiotic therapy in
unstable COPD has been debated (Rodriquez-Roisin, 2006).
This supports early evidence identifying growing antibiotic
resistance among common respiratory pathogens (Wilson, 2001),

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likely related to unnecessary antibiotic prescriptions in non-
infective COPD exacerbations (Goossens et al, 2005). Further
research could help to accurately determine the presence of
bacterial infection, providing advancements in antibiotic
management for COPD (Wilson, 2008). Antibiotics should be
considered when there are clinical signs of bacterial infection, with
oral aminopenicillins recognised as usual empirical treatment to
achieve clinical improvements in dyspnoea and sputum purulence
in the acute infective exacerbation of COPD (GOLD, 2019).

Conclusion
The author recognises that, although there is a requirement
for further developments in the treatment of unstable COPD,
reduction of the negative impact of acute exacerbations and
associated mortality remains central to the role of the RNS.
RNS practice is therefore informed by the current evidence
base, with the use of salbutamol in relieving acute symptoms
of dyspnoea and wheeze, and the addition of amoxicillin
where appropriate to treat bacterial infective exacerbations
of COPD. BJN

Declaration of interest: none

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KEY POINTS
■ Chronic obstructive pulmonary disease (COPD) is a growing health concern,

with acute exacerbations now recognised as a leading cause for emergency
hospitalisation in the UK

■ Best practice evidence recommends that short-acting bronchodilator agents
should be used as the initial treatment in acute exacerbations of COPD

■ Antibiotics in unstable COPD should only be considered where there are
clinical signs of bacterial infection. Nurse prescribers can have an active
role in helping to reduce antibiotic resistance through the avoidance of
unnecessary antibiotic prescriptions

■ Independent nurse prescribers are accountable and responsible for their
prescribing decisions in clinical practice. Prescription should therefore
only occur with adequate awareness of a medication’s actions, indications,
dose, contraindications, and unwanted effects

CPD reflective questions

■ What issues have you encountered that have posed a challenge to your
prescribing practice?

■ What can you do to help reduce the frequency and severity of chronic
obstructive pulmonary disease (COPD) exacerbations in your patients?

■ What can you do to reduce the risk of unnecessary antibiotic
prescriptions for COPD patients in your clinical setting?

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Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

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T
he author is a respiratory nurse specialist (RNS)
practising as part of a community nurse-led
respiratory assessment service. The RNS is
responsible for ensuring that individuals with
respiratory disease receive holistic care and is are

empowered to develop expertise and advanced professional
practice. The Department of Health (DH) (2008) advocated that
such proficiency should be achieved through the appropriation
of non-medical prescribing, which is now recognised as one of
the most important developments in nursing since it became a
profession in the early 20th century (Dowden, 2016).

The benefits of nurse prescribing are well documented,
with qualitative evidence demonstrating positive outcomes
in efficiency of care (Courtenay et al, 2011), increased nurse
autonomy (Watterson et al, 2009) and greater patient satisfaction
(Carey and Stenner, 2011). Therefore, with current governmental
demands to ensure high-quality care provision regionally

Home oxygen therapy in patients
with COPD: safety issues for
nurse prescribers
David Moore

ABSTRACT
Two landmark studies demonstrated survival benefit in chronic obstructive
pulmonary disease (COPD) complicated by chronic hypoxaemia with the
prescription of long-term oxygen therapy (LTOT). Best practice evidence
therefore recommends that individuals with stable COPD and resting
hypoxaemia (PaO2≤7.3 kPa) should be assessed for long-term oxygen therapy.
However, it is estimated that up to one-quarter of COPD patients prescribed
LTOT continue to smoke. Oxygen therapy consequently presents an obvious fire
hazard in the case of such patients, who are therefore at greater risk of death
or sustaining devastating head and neck burns. This article critically analyses,
through the context of a care study, the professional, ethical and legal issues
involved in making a safe prescribing decision for LTOT in an individual with
COPD who is a current smoker. Home oxygen prescription is a growing trend in
the COPD population, and it is important for nurse prescribers to be aware of
the issues highlighted in the article to ensure safe prescribing practices.

Key words: Non-medical prescribing ■ Long-term oxygen therapy
■ Chronic obstructive pulmonary disease ■ Smoking ■ Patient safety

David Moore, Respiratory Nurse Specialist and Independent
Nurse Prescriber, Mater Hospital Belfast, dmoore20@qub.ac.uk

Accepted for publication: July 2019

(Department of Health, Social Services and Public Safety
(DHSSPS), 2012) and nationally (DH, 2009), independent and
supplementary non-medical prescribing has been recognised
as a valuable asset for advanced nursing practice.

Nuttall (2016) has argued that it is important to differentiate
between the two forms of non-medical prescribing:

■ Supplementary prescribing refers to prescription from a
specified clinical management plan implemented by an
independent prescriber (DH, 2005)

■ Independent prescribing allows for prescribing decisions to
be made within individual scope of competency (Lovatt,
2010), with its current definition applicable to the RNS
role. Nurses, pharmacists, optometrists, physiotherapists and
podiatrists can be independent prescribers and they are:

‘… responsible and accountable for the
assessment of patients with undiagnosed and
diagnosed conditions and for decisions about
the clinical management required, including
prescribing.’

Department of Health (Northern Ireland), 2019

The Nursing and Midwifery Council (NMC) demands
that nurses prescribe only if they possess sufficient knowledge
of the patient’s health and that the treatment prescribed will
serve the person’s health needs (NMC, 2018a). To ensure safe
and effective prescribing it is therefore the nurse’s responsibility
to complete a holistic assessment (Silverston, 2014), including
history taking and a clinical examination (Rutt-Howard, 2016).
It is of significance, however, that, if during this process an issue
regarding patient safety is identified, this should be addressed
appropriately, because it can affect both the prescribing process
and the eventual prescribing decision.

The aim of this article is therefore to critically evaluate an issue
that poses a challenge to the RNS as an independent prescriber.
The context of a care study is used for analysis: the author used
the context of the Prescribing Competency Framework (Royal
Pharmaceutical Society (RPS), 2016) (Figure 1) to explore the
professional, legal and ethical issues involved in ensuring safe
and appropriate prescribing are explored, along with rigorous
appraisal of the evidence base.

Sue White (not her real name) is a 75-year-old patient who
was referred by her GP to the home oxygen service assessment
and review clinic, which is led by the RNS, for assessment of

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suitability for long-term oxygen therapy (LTOT). Assessment
for LTOT is a core component of the respiratory service, with
the RNS ideally placed to assess, examine and treat patients
autonomously, while applying expert knowledge and clinical
judgement to manage and complete episodes of respiratory care,
an approach recommended for advanced nursing independent
prescribing practice (DH, 2006; RPS, 2016).

Preparation for consultation through review of medical
records and a referral letter provided valuable information
about Mrs White’s current diagnoses and treatments, assisting
in planning areas for exploration (Bickley, 2014). She met the
requirements for referral to the home oxygen service assessment
and review clinic, in that she had a definite diagnosis of chronic
obstructive pulmonary disease (COPD,) and was undergoing
optimised medical treatment as recommended by the Global
Initiative for Chronic Obstructive Lung Disease (GOLD)
(2017). She also had a resting stable oxygen saturation of less than
92%, fulfilling the core recommendation for LTOT eligibility
referral (Hardinge et al, 2015).

The RNS acknowledged the progressive nature of COPD
whereby destruction of the respiratory airways predisposes to
eventual lack of ventilation and impairment of normal gas
transfer (Hinkle and Cheever, 2014), leading to persistent blood
oxygenation reduction (Kent et al, 2011). This is known as
chronic hypoxaemia (Porth, 2015), a common complication
in advanced COPD that usually requires consideration for
LTOT (GOLD, 2017; National Institute for Health and Care
Excellence (NICE), 2018).

The competency framework (Figure 1) promotes safe
prescribing practice through the assessment of the risk and
benefits of taking or not taking a medicine or treatment while
critically analysing a reliable and validated evidence base (RPS,
2016). The NMC (2018a) advises that prescribing practice must
be evidence based and in accordance with relevant guidance.
This builds on legislation that non-medical prescribers have
a professional expectation to ensure adherence to the best
evidence and guidance available for safe and effective prescribing
(DH, 2009).

A review of the evidence showed best practice guidance
on the survival benefit in COPD that is complicated by
severe chronic hypoxaemia continues to be informed by two
landmark randomised controlled trials (Nocturnal Oxygen
Therapy Trial Group (NOTT), 1980; Medical Research
Council, 1981). These are used alongside recommendations
by Hardinge et al (2015) that provide algorithms for referral,
consideration and assessment for LTOT in COPD. Assessment
and examination of Mrs White was therefore required to
ascertain whether LTOT was indicated, with evaluation of
arterial blood gases central to the decision (Suntharalingam et
al, 2016). The patient’s result confirmed low blood oxygen levels,
and she was therefore to be considered for LTOT (DHSSPS,
2015; Hardinge et al, 2015). However, the RNS acknowledged
that the referral letter specified that Mrs White was a current
smoker, raising safety concerns in relation to the potential
prescribing decision.

Although it is therapeutic, oxygen therapy is also a potential
fire hazard. Cooper (2015) highlighted how oxygen, when
exposed to a naked flame can become a serious hazard, with the
potential for injury and death. A retrospective review of 1199
adult burn patients identified that the risk of fire and burn injury
related to cigarette smoking and LTOT is of growing concern
(Murabit and Tredget, 2012), with quantitative retrospective
reviews demonstrating fatality or devastating head and neck
burns due to ignition close to the patient’s face (Chang et al,
2001; Robb et al, 2003; Amani et al, 2012). Hassan et al (2010)
highlighted that such subsequent inhalation injuries usually
require advanced airway management.

Arguably, home oxygen-related burns are prevalent among
the COPD population. In the context of a case study, Lindford
et al (2006) conducted a literature review on reported cases
of burns in home oxygen users in the UK and identified
COPD as the most common diagnosis; about two-thirds of
patients were current smokers and the mortality rate was 10%.
In another study (Murabit and Tredget 2012), retrospective
epidemiological data on COPD patients treated between 1999
and 2008 found similar evidence, with an 11.8% mortality rate

Figure 1. The Prescribing Competency Framework (Royal Pharmaceutical Society, 2016)

PR
ES

CR
IBING

GOVERNANCE

Competencies 7
–1

Competencies

–6

TH
E

CO
NSULTATION

Competencies

1. Assess the patient
2. Consider the options
3. Reach a shared decision
4. Prescribe
5. Provide information
6. Monitor and review

Competencies

7. Prescribe safely
8. Prescribe professionally
9. Improve prescribing practice
10. Prescribe as part of a team

PATIENT

914 British Journal of Nursing, 2019, Vol 28, No 14

during hospitalisation as a result of smoking-related burn injury
in patients on home oxygen therapy.

A previous survey of domiciliary oxygen users selected from
lists of healthcare providers and visited in their own homes
demonstrated a prevalence of smoking of between 14% and
51% (Shiner et al, 1997). Participation data from a randomised
controlled trial by Lacasse et al (2005) analysing oxygen therapy
in COPD found that up to one-fifth of individuals continued
to smoke. The risk of fire hazard can therefore be considered
a significant safety consideration, with more research required
to adequately quantify the assumed growing prevalence within
this specific patient population.

It is therefore essential for the RNS, as an independent
prescriber, to recognise potential hazards of LTOT and assess
all relative risks with current smokers (Suntharalingam et al,
2016). Minimising harm through risk assessment is fundamental
for safe prescribing practice (Broadhead, 2016). The author
determined that Mrs White was at high risk of unsafe LTOT by
completing a recognised structured oxygen risk assessment tool
(Hardinge et al, 2015) (Figure 2), leaving the author with the
dilemma of whether to prescribe LTOT to improve the patient’s
quantity of life, or not to prescribe it due to the significant risk
of personal injury.

Cooper (2010) argued that dilemmas are frequent in
prescribing practice, and a combined application of personal,
group and philosophical ethics are needed for successful
decision-making. The author therefore adopted virtue ethics,
whereby embracing the virtues of honesty, care, benevolence and
courage can help enable safe and effective prescribing decisions
(Edwards 2009). Influenced by the approach of principalism
(Beauchamp and Childress, 2013), the author worked to reach a
shared decision with Mrs White regarding LTOT prescription.

For successful shared decision-making the nurse prescriber
must respect and protect the patient’s autonomy (Adams, 2010).
Griffith and Tengnah (2014) and Lovatt (2010), however, argued
that, although patient choice must be considered a fundamental
right, it cannot be honoured if the autonomous decision is
unacceptable). Broadhead (2016) suggested that in prescribing
practice it can be difficult to achieve this balance. In such
instances, prescribers tend to adopt a protective approach
through a desire to act in the patient’s best interests and, although
it could be argued that this is paternalistic (Edwards and Elwyn,
2009), it can be overcome by developing a therapeutic and
trusting patient-prescriber partnership.

The Standards of Proficiency for Registered Nurses (NMC, 2018b)
state that nurses must ‘support and enable people at all stages
of life and in all care settings to make informed choices about
how to manage health challenges’, a principle the RNS adopted
in building foundations of partnership with Mrs White. This
was facilitated through disclosure of appropriate information
relating to LTOT risk and benefit, including potential for non-
prescription. Mrs White clearly recognised the benefits of the
therapy, but expressed her own dilemma: although she was
happy to be prescribed LTOT, she was also apprehensive, due
to the risks involved and her uncertainty about being able to
stop smoking. The RNS therefore sought to further develop
the patient–prescriber relationship, whereby Mrs White could

relinquish some autonomy in favour of the RNS’s clinical
judgement, a strategy commonly favoured to resolve difficult
prescribing consultations (Broadhead, 2016).

To further develop the patient–prescriber partnership,
Mrs White required reassurance that the RNS was applying
principles of justice, ensuring that she would receive equal and
fair treatment (Adams, 2010). The RNS provided clarity that
Mrs White was being treated fairly and that the prescribing
decision would not be underpinned by discrimination due to
her smoking status. Cooper (2015) acknowledged the ethical
argument of discrimination through withholding treatment,
recognising however that health professionals have a duty of
care to protect patients from harm. Edwards (2009) therefore
argued that this sensitive issue must be discussed thoroughly
in order to demonstrate consideration for patient autonomy
and respect for the patient as a person.

Griffith and Tengnah (2014) argued that patients’ wellbeing
should be promoted and exercised through acting in a beneficent
and non-maleficent manner. The RNS considered application
of this concept in two ways, whereby the author could optimise
good through prescribing LTOT, but also maintain the patient’s
wellbeing by preventing harm through non-prescription. The
RNS therefore acknowledged that to achieve beneficence
required acting with compassion that is not only within the
law, but also in the patient’s best interests (Broadhead, 2016).

Writing about the complexity of advanced clinical
decision-making in prescribing,Young (2010) suggested that
accountability can motivate and influence decision-making for
the nurse prescriber, giving responsibility for prescribing error
and mistake. The NMC (2018b) states:

‘Registered nurses play a vital role in
providing, leading and coordinating care that
is compassionate, evidence-based, and person-
centred. They are accountable for their own
actions and must be able to work autonomously,
or as an equal partner with a range of other
professionals, and in interdisciplinary teams.’

The legal considerations regarding this are within tort law,
which centres on liability due to acts or breaches in the duty
of care leading to harm or injury of another person: there is
therefore direct accountability for causing harm as a result
of prescribing (Broadhead, 2016). It is therefore essential to
recognise the duty of care that nurses have to patients, and
the RNS considered whether it was possible to foresee the
likelihood of injury to Mrs White as a result of a prescribing
decision (Herring, 2008). Furthermore, in the context of
professional indemnity and vicarious liability, the RNS had to
consider the potential consequences of inadvertently incurring
harm to the patient (Dimond, 2011), which could have resulted
in Mrs White claiming that a mistake in clinical judgement had
led to the unsafe prescription of therapy.

With harm considered from the perspectives of both the
patient and the RNS, the author suggested strategies to overcome
and minimise risk, a method frequently used to promote non-
maleficent prescribing practice (Broadhead, 2016). This involved
referring Mrs White to a smoking cessation service, an action

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Home oxygen risk assessment

1. Please use the box below to identify and document all risks associated with the patient named above, and allocate scores using
the risk matrix below

Patients name: Mrs Sue White

H&C No.:

Date of birth:

■ Sue is a current smoker. Risk score 15 (possibility to occur with catastrophic consequence)
■ Sue walks with a rolator frame. She is not known to be unsteady on her feet. Risk score 6 (unlikely to occur however moderate consequence)
■ Sue’s daughter smokes in Sue’s home. She has stated that she would not smoke if LTOT present. Risk score 10 (unlikely to occur however
catastrophic consequence)

Risk Yes/No? Score Risk Yes/No? Score

Mental health issues No Memory loss No

Smoker Yes 15 Family smoker Yes 10

Alcohol misuse/dependency No Illegal drug misuse/dependency No

Risk of falls/trips Yes 6 Open fires/gas fires No

E-cigarette use No Hearing/vision impairment No

Other (please specify): Total risk score 31

3. Please use the box below to documen t all actions taken to manage the risks as identified in Section 1.

IMMEDIATE MANAGEMENT PLAN OF IDENTIFIED RISK

Action/responsibility Signed/Date

1. Educate Sue on smoking and the risks involved

RNS
11/2017

■ Sue prefers to smoke in her home. She smokes mainly in the kitchen, living room and sometimes bedroom. Her daughter
smokes in the kitchen mostly.

■ Sue is unsure if she can stop smoking currently, and would prefer to smoke in her home. Her willingness to significantly reduce
risk unsatisfactory for safe LTOT prescription

■ Smoking cessation advice given. Consenting to referral to smoking cessation specialist

2. Mobility ■ Using delta rolator aid

3. Reinforce education with family regarding smoking

4. Arrange review and repeat assessment (including risk assessment) in Home Oxyge n Service Assessment and Review
within 3 weeks’ time

Impact (consequence) levels

Likelihood scoring descriptors Insignificant
(1)

Minor
(2)

Moderate
(3)

Major
(4)

Catastrophic
(5)

Almost certain (5) Medium 5 Medium 10 High 15 Extreme 20 Extreme 25

Likely (4) Low 4 Medium 8 Medium 12 High 16 Extreme 20

Possible (3) Low 3 Low 6 Medium 9 High 12 Extreme 15

Unlikely (2) Low 2 Low 4 Medium 6 High 8 High 10

Rare (1) Low 1 Low 2 Moderate 3 High 4 High 5

Risk = likelihood of risk happening x consequence

2. Please use the box below to provide a summary of all the risks identified and reasons for the overall risk score

Figure 2. Assessment of Sue White for long-term oxygen therapy

916 British Journal of Nursing, 2019, Vol 28, No 14

advised for all smokers regardless of a need for LTOT; this
alone can improve survival outcome for patients with COPD
(Suntharalingam et al, 2016). It is also in line with regional
and national guidance that recommends offering smoking
cessation counselling by trained advisors to all LTOT candidates
(DHSSPS, 2015; Hardinge et al, 2015).

The RNS also considered strategies to reduce the risks with
Mrs White should LTOT be prescribed while she continued
to smoke. Smoking cessation is clearly recognised as an
effective action to reducing the risk of fire with home oxygen
therapy, but there are other possible approaches to explore. For
example, national guidelines produced for the British Thoracic
Society (BTS) (Hardinge et al, 2015) highlight the contractual
responsibilities of home oxygen providers to conduct a home
risk assessment prior to LTOT installation, which should include
notifying the prescriber if any fire-related risks are identified.
In addition, the use of safety devices such as fire breaks and
flow-stop devices on all LTOT equipment is currently a legal
requirement under European Union regulations for companies
manufacturing home oxygen equipment, in order to reduce
the acceleration of oxygen-related fires, prevent death and
reduce the severity of any subsequent injury (Cooper, 2015).
The author recognised that, although such strategies are useful
in the context of the prescribing decision and can help reduce
risk for Mrs White, they most certainly do not remove the risk
completely.

The competency framework recommends that relevant
prescribing frameworks, policies and guidelines be used for
prescribing decisions (RPS, 2016). With previous national
guidance from the BTS (2006) being described as vague in its
LTOT prescription recommendations for smokers (Lacasse et
al, 2006), its update (Hardinge et al, 2015) has been welcomed:
it recommends assessment and consideration on a case-by-case
basis focusing on patient attitude towards risk and smoking
behaviour. This updated guidance (Hardinge et al, 2015) implies
that, where there is reasonable doubt and if, in the prescriber’s
judgement, the risk is too high, LTOT should not prescribed.

Considering the outcomes from Mrs White’s risk assessment,
the author had cause for reasonable doubt about the safety
of home oxygen therapy. The NMC (2018a) recommends
that nurses make timely and appropriate referrals to other
practitioners, when this is in the best interests of the patient.
With this in mind, the RNS discussed Mrs White’s risk
assessment with the respiratory nurse consultant, who agreed
that it would be unsafe to prescribe LTOT at this time.

Although the benefits of LTOT in COPD are clear, it is the
responsibility of the RNS to attempt to eliminate or reduce
the risk of burn injury before prescription. By making an
individualised and careful risk assessment the author was able
to foresee the professional, legal and ethical dilemmas posed;
there were grounds to consider the possibility of inadvertent
harm to Mrs White despite beneficent intentions. Therefore,
in disclosing the rationale for not prescribing LTOT, the RNS
was able to maintain honesty and integrity with Mrs White,
enabling informed shared decision-making, whereby the patient
recognised not only the benefits of LTOT but also the realisation
of its potential unsafe use. Development of this trusting and

therapeutic relationship placed Mrs White at the centre of her
care, resulting in a shared autonomous decision for referral to
smoking cessation. The Prescribing Competency Framework
(RPS, 2016) (Figure 1) advocates that a satisfactory outcome
be achieved for both the patient and the prescriber, and this
was facilitated through the joint decision by the RNS and
Mrs White to review her again at the home oxygen service
assessment and review clinic at a later date to repeat her oxygen
assessment and reconsider safe LTOT prescription.

Home oxygen therapy is a potential serious fire hazard
for patients, with unsafe use potentially leading to personal
injury or even death. It is the responsibility of the RNS as an
independent nurse prescriber to educate patients about the risks
of smoking and home oxygen therapy, including completion of
an individualised patient-centred risk assessment before making
a prescribing decision. There is clear evidence that smoking
cessation not only reduces the risk of unsafe LTOT use, but that
as an approach on its own it can improve survival outcome in
the COPD population (Suntharalingam et al, 2016). It should
therefore be a priority for all health professionals.

Independent nurse prescribers who encounter similar
dilemmas regarding the safe prescription of home oxygen
therapy should consider the approaches described in this article
to help them appraise the professional, legal and ethical issues
involved the decision whether or not to prescribe LTOT for
a particular patient. BJN

Declaration of interest: none

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KEY POINTS
■ Best practice evidence recommends that individuals with stable

chronic obstructive pulmonary disease (COPD) and resting hypoxaemia
(PaO2≤7.3kPa) should be assessed for long-term oxygen therapy (LTOT)

■ Oxygen therapy is an obvious fire hazard, with several studies demonstrating
that cigarette smoking and LTOT use can lead to fatality and personal injury

■ Smoking cessation alone can improve survival outcome in COPD

■ Implementation of the Prescribing Competency Framework can help
Independent nurse prescribers, who are accountable and responsible for
their prescribing decision, to consider the professional, ethical and legal
issues to make safe prescribing decisions for LTOT in patients with COPD
who are current smokers

CPD reflective questions

■ Consider prescribing in your clinical setting. What can you do to enhance the safety of prescribing LTOT?

■ What issues have you encountered that have posed a challenge to your prescribing practice?

■ Reflect on those challenges. What measures did you take to manage such situations from professional, ethical and
legal points of view?

( 020 7738 5454 8 bjn@markallengroup.com @BJNursing

Have an idea for BJN?

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LONG-TERM CONDITIONS

214 British Journal of Community Nursing June 2018 Vol 23, No 6

The impact of community
pharmacy-led medicines management
support for people with COPD

Sarah Alton, Lisa Farndon
Sarah Alton is Head of Community Pharmacy, Combined Community and Acute Care Group; Lisa Farndon is Clinical
Research Podiatrist/Research Lead, Integrated Community Care Directorate; both at Sheffield Teaching Hospitals NHS
Foundation Trust, Sheffield

lisa.farndon@nhs.net

It is estimated that three million people have chronic obstructive pulmonary disease (COPD) in the UK (Healthcare Commission, 2006), and it is the fourth lead-
ing cause of death worldwide (Global Initiative for Chronic
Obstructive Lung Disease (GICOLD), 2018). It has been
defined as a non-fully reversible airflow obstruction, charac-
terised by breathlessness; it is mainly caused by smoking or

exposure to air pollutants (National Institute for Health and
Care Excellence (NICE), 2010). The condition can affect daily
activities and reduce quality of life (Weldam et al, 2013).

Clinical diagnosis is based on shortness of breath, a chronic
cough or sputum production and a history of exposure to a
risk factor, which is followed by spirometry to confirm
(GICOLD, 2018).

Treatment
The goals of COPD treatment are to slow down disease
progression, limit symptoms, increase overall health and
prevent and treat flare-ups.

National guidelines set out best clinical practice for the
assessment, diagnosis and management of patients with
COPD (NICE, 2010). Treatment consists of non-pharma-
cological and pharmacological interventions. Non-drug
interventions and lifestyle advice, such as smoking cessa-
tion, flu vaccination and pulmonary rehabilitation, should
be offered to all patients with COPD. Rehabilitation pro-
grammes can reduce the risk of hospital readmission and
improve the quality of life and the short-term exercise
capacity of people with COPD.

Inhaled therapies are the mainstay of treatment.
Bronchodilators (short and long acting) have an important and
established role in the management of COPD and have been
shown to significantly reduce the risk of adverse outcomes
such as COPD exacerbations (Department of Health (DH),
2012). The addition of inhaled corticosteroids may benefit
patients who remain symptomatic despite regular treatment
with a long-acting bronchodilator.

In most cases, bronchodilator therapy is best administered
using a handheld inhaler device (including a spacer device if
appropriate). If a patient is unable to use a particular device
satisfactorily, it is not suitable, and an alternative should be found.

Inhalers should be prescribed only after patients have been
trained in how to use them and have demonstrated satisfactory
technique. Patients should have their ability to use an inhaler

ABSTRACT
Chronic obstructive pulmonary disease (COPD) is a common long-term
condition involving restricted airflow, which reduces quality of life.
Treatments include lifestyle changes (smoking cessation), pulmonary
rehabilitation and medication with inhaled therapies. However, medication
adherence is often suboptimal, resulting in poor health outcomes. A pilot
project assessed the impact of medicines management support from a
community pharmacy team for people with COPD, delivered in their own
homes. Individuals were given a medication review and an assessment of
their inhaler technique and were followed up at 3 and 6 months. The COPD
Assessment Test (CAT) score was administered before and after the
intervention. A change in score of 2 or more suggests a significant
difference; the average score was 19.2 at the first assessment and 16.7 at
the six month follow-up. Seventeen patients had improved CAT scores, 10
patients had a reduced score and three remained unchanged. Most
patients evaluated the project positively as it helped them to improve their
inhaler technique. Medicines optimisation was also achieved as a person-
centred approach was taken; suboptimal practice had not been picked up
by health professionals previously. Community pharmacists working in
integrated care teams provide invaluable support to patients with COPD.
This project will be rolled out across the community team, and training on
medicines management and inhaler technique provided to other health
professionals involved in the care of these patients.

KEY WORDS
w COPD w Pharmacist w Integrated community care w Integrated disease
management

216 British Journal of Community Nursing June 2018 Vol 23, No 6

device regularly assessed by a healthcare professional and, if
necessary, should be retaught the correct technique.

Oral therapies such as theophylline can be used if symptoms
persist or if the patient is unable to use an inhaler. Oral steroids
and antibiotics (if there is sign of infection) can be used to
manage exacerbations.

Nonadherence to COPD medication is estimated to be
30–70%; as much as 50% of this may be deliberate and 30%
or more of these patients may be on suboptimal therapy for
the severity of their disease (DH, 2012). Inhaler technique
should therefore be assessed regularly to ensure patients get
the best from their medication. There should be an emphasis
on ensuring medicines are clinically appropriate, cost effective
and acceptable by carrying out regular medication reviews to
reduce waste, save money and improve outcomes for patients.

Aim
The integrated care pharmacy team works with community
nursing and therapy staff to provide medicines management
support to housebound patients with long-term conditions.

There is increasing evidence to demonstrate that pharmacy-
led care for people with long-term conditions can improve
outcomes and reduce hospital admissions.

Between October 2015 and May 2016, the community
pharmacy and nursing teams undertook a pilot project; the
aim was to assess the impact of pharmacy-led medicines man-
agement support (in addition to the routine annual nurse-led
reviews for long-term conditions) in patients with COPD in
one community nursing team in Sheffield.

Outcome measure
The outcome measure was the COPD assessment test score
before and after intervention as a measure of symptom
assessment.

Patient selection
This was a service improvement project so ethical approval was
not required. An ‘intention to treat approach’ was adopted and
all patients with a diagnosis of COPD on the GP register and
the community nursing caseload were selected for inclusion.

The patients were referred to pharmacy by the community
nursing team, and the pharmacy team contacted them to ask
for their consent to visit to review their medication and to
participate in the project; verbal consent was obtained for
each patient.

Patients were excluded from follow-up if they declined to
take part, if they could not be contacted or if they had been
taken off the community nursing caseload.

Method
All GP practices were contacted by letter to inform them
about this initiative.

A member of the pharmacy team carried out an initial visit
to assess each patient’s inhaler technique, then undertook a
clinical medication review in line with local and national
evidence-based guidelines.

At this visit, patients were asked to complete the COPD
assessment test (CAT) (GlaxoSmithKline, 2012). This is a vali-
dated questionnaire designed to measure the impact of COPD
on a person’s life, and how this changes over time. It consists
of eight simple questions that most patients should be able to
understand and answer easily. CAT scores are in the 0–40
range, with 0 being very low impact/symptom severity and
40 indicating a very high impact/symptom severity. A change
in score by 2 points or more suggests a significant alternation
in health status. The CAT test was used to measure the impact
of COPD on patients in the project group and to help inform
discussions and decisions with regard to medicines manage-
ment options.

CAT scores were recorded on each patient’s electronic
record and in the pharmacy’s secure database for the project.

A follow-up visit was carried out after 3 months to reassess
inhaler technique and provide further advice and support as
appropriate. A third visit or phone call was made at 6 months
to provide further support, reassess inhaler technique if need-
ed, repeat the CAT questionnaire and follow up on any rec-
ommendations from previous visits (Table 1).

Results
Fifty-four patients were initially identified for inclusion. From
this sample, nine were excluded for a number of reasons
including: moving to a different care home out of the area;
discharge from community nursing care; not using inhalers;
declined visits; or being in hospital. Forty-five patients were
therefore included in the project and were visited by a mem-
ber of the pharmacy team.

The average number of visits received per patient was 2.9
within a range of 1–9. Six patients received fewer than two
visits for the following reasons: declined follow-up; moved out
of the area; or were awaiting hospital treatment; and one
patient passed away during the study period. Some patients
had more visits if they required additional input from the
pharmacy team, for instance if any issues were identified at
their medication review that needed follow-up, such as a
change in formulation or inhaler that required counselling.

The average length of time spent visiting overall was 89
minutes per patient. More time was spent with each patient

Table 1. Visit schedule
Initial visit 3 month follow-up 6 month review

ww Demonstrate and observe
ww Initial holistic patient review
ww Patient information leaflets provided
ww COPD assessment test (CAT) questionnaire undertaken
ww Liaise with GP to consider change of inhaler device
ww Medication review and follow up as appropriate

ww Reassess inhaler technique
ww Further advice and support
ww Option for telephone call if needed

ww Repeat CAT questionnaire
ww Final inhaler check
ww Follow up any outstanding COPD
changes/recommendations

British Journal of Community Nursing June 2018 Vol 23, No 6 217

at the initial visit, with subsequent visits taking up less time.
Most patients did not know how to use their inhalers cor-

rectly, so visits led to observed improvements in inhaler tech-
nique. A number of significant interventions were made dur-
ing the course of the project for individual patients:
ww Smoking cessation advice was offered and accepted, result-
ing in a reduction of 50% in the number of cigarettes
smoked per day
ww An Oxis Turbohaler replaced a Seretide inhaler as it was
causing muscle cramps, which resulted in the patient report-
ing that their chest felt much clearer and better
ww A patient with a past history of stroke was referred to an
occupational therapist/physiotherapist, as their medication
was not suitable. They were swapped to a Fostair MDI with
spacer and tidal breathing. Carers reported an improvement
in symptoms
ww A patient with dementia was using an inappropriate device

with a spacer. This was changed to one that was appropriate
to use (also with a spacer), which improved symptoms and
COPD control
ww Medication was changed because a patient’s comoborbid
condition had altered but they did not require hospital
admission
ww A patient was taking a tiotropium inhaler capsule orally, rather
than via inhalation, as it had been prescribed in error without
the inhaler device into which the capsule is placed; an inhaler
was dispensed so the medication could be taken correctly
ww Some patients were not able to use their inhaler device
properly as they did not have sufficient lung capacity to
activate it. These patients were switched to a more appropri-
ate device that they were able to use
ww Recommendations were made to prescribe spacer devices
where these were indicated but had been omitted from the
original prescription

Table 2. Change in CAT scores at baseline and 6 months follow up
CAT score at baseline CAT score at 6 months Result Differential

19 12 Improved 7 points

18 17 Improved 1 point

4 4 Static n/a

24 24 Static n/a

28 15 Improved 13 points

5 21 Declined 16 points

15 5 Improved 10 points

26 31 Declined 5 points

18 14 Improved 4 points

11 10 Improved 1 point

19 20 Declined 1 point

19 16 Improved 3 points

23 10 Improved 13 points

14 19 Declined 5 points

24 20 Improved 4 points

27 24 Improved 3 points

32 29 Improved 3 points

9 11 Declined 2 points

4 11 Declined 7 points

6 3 Improved 3 points

18 16 Improved 2 points

17 17 Static n/a

33 12 Improved 21 points

23 26 Declined 3 points

20 29 Declined 9 points

12 9 Improved 3 points

33 14 Improved 19 points

27 28 Declined 1 point

24 16 Improved 8 points

19 20 Declined 1 point

218 British Journal of Community Nursing June 2018 Vol 23, No 6

ww Recommendations were made to prescribe alternative
therapies for patients with dementia as they were unable to
use their inhalers appropriately.
CAT scores were recorded in 30 patients. A number of

patients were unable to complete this questionnaire because
of a cognitive impairment or because the questions were not
relevant to their situation. The average score was 19.2 at the
first assessment, and 16.7 at the six month follow-up. A
change in score of 2 or more suggests a significant difference
or change in health status. Seventeen patients reported an
improved CAT score, 10 patients had a reduced score and
three patients’ scores remained static (Table 2).

Medicines optimisation was achieved with this pilot project,
as a person-centred approach to using medicines in a safe and
effective way to ensure people obtained the best outcomes
was possible with one-to-one input from the community
pharmacy team. Problems may not always have been picked
up previously by other health professionals or carers because
of time constraints or a lack of training.

Feedback
GPs were very positive about the project and acted on the
recommendations of the team. Respiratory and practice nurs-
es found communication with the pharmacy team very useful
to keep them informed about any medication changes. The
project raised the profile of the pharmacy team within the
integrated care service and, as a result, they received more
referrals for inhaler review. Patients valued the input from the
pharmacists as it helped them to improve their inhaler tech-
nique; many reported that they had never been shown how
to use their inhalers correctly.

Discussion
The data suggests that more patients showed an improvement
than a decline in health status during the intervention period
of this project. It is difficult to attribute the improvements
directly to the pharmacy interventions, as patients may have
been receiving care from other practitioners during this time,
but it is likely that the pharmacy project contributed to this.

This study used an integrated disease management approach
(Peytremann-Bridevaux et al, 2008) where different compo-
nents of care are provided by different health professionals and
delivery in a coordinated manner can maximise health out-
comes. A large systematic review found this approach to be
beneficial for patients with COPD, resulting in improved

quality of life and exercise tolerance up to a year after participat-
ing in such a programme; hospital admissions related to exac-
erbations in the disease were reduced (Kruis et al, 2013).
However, these programmes were delivered in hospitals and GP
clinics rather than patients’ own homes as in this current study.

Community pharmacists have been shown to improve
symptoms of asthma that were previously poorly controlled
in adults by demonstrating correct inhalation techniques and
providing education on medicines adherence (Mehuys et al,
2006). They are therefore well placed to provide these types
of interventions and can offer advice and support to other
community practitioners.

Patients with dementia or significant cognitive impairment
were not able to complete the CAT test. They also found it
difficult to demonstrate their inhaler technique or use the
devices, which are factors that have been highlighted as sig-
nificant when investigating adherence with medicines, as part
of the list of multifactorial influences for people with COPD
(Bourbeau and Bartlett, 2008).

Conclusion
This was a short, time-limited project that aimed to assess the
role of the pharmacy team in the management of patients with
moderate COPD, with a focus on inhaler technique, assess-
ment and medication review.

Most patients did not know how to use their inhalers cor-
rectly, so improvements in inhaler technique were shown after
each visit. However, patients with cognitive impairment or
dementia were not able to use their inhalers properly and
treatment options for these patients are limited. Further
research should be directed at improving inhalation tech-
niques and ease of use for this group. Medicines optimisation
is therefore not straightforward, which highlights the need for
specific treatment guidelines to be developed for housebound
patients with comorbidities and cognition problems.

Patients appreciated the time taken by the team and found
the face-to-face contact invaluable, resulting in improvements
in inhaler technique and medicines optimisation that had not
been picked up elsewhere.

Further evaluation is needed to assess the impact of this
intervention on exacerbations and hospital admissions.

It is hoped that inhaler technique training will be intro-
duced for support workers so they can reinforce techniques
at each patient contact. Advice and support for carers on
medicines management and inhaler technique could improve
overall compliance.

Further work will investigate how community pharmacy
and nursing teams can work together on COPD reviews to
ensure different skills can be used for patient benefit to work
towards a true integrated disease management programme.
Highlighting and referring patients to other services that can
help with COPD, including pulmonary rehabilitation,
Breathingspace community respiratory specialist nurses and
community smoking cessation support, will also be incorpo-
rated into future training. BJCN

Accepted for publication: April 2018
Declaration of interest: None

KEY POINTS
ww Chronic obstructive pulmonary disease (COPD) is a common long-term
condition in which airflow is restricted

ww While COPD is often managed using inhaled medication, many patients do
not use inhalers correctly

ww Community pharmacists working in integrated care teams provide
invaluable support to patients with COPD

ww The COPD assessment (CAT) test is a questionnaire that measures the
impact of COPD on a person’s life

British Journal of Community Nursing June 2018 Vol 23, No 6 219

Bourbeau J, Bartlett SJ. Patient adherence in COPD. Thorax. 2008; 63(9):831–838.
https://doi.org/10.1136/thx.2007.086041

GlaxoSmithKline. COPD assessment test. 2012. https://tinyurl.com/y8zpppge
(accessed 1 May 2018)

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the
diagnosis, management, and prevention of COPD. 2018 https://tinyurl.com/
yb2dv6jh (accessed 2 May 2018)

Healthcare Commission. Clearing the air: a national study of chronic obstructive
pulmonary disease. London: Healthcare Commission; 2006

Kruis AL, Smidt N, Assendelft WJ et al. Integrated disease management
interventions for patients with chronic obstructive pulmonary disease.
Cochrane Database Syst Rev. 2013; (10):CD009437. pub2. https://doi.
org/10.1002/14651858.cd009437.pub2

Mehuys E, Van Bortel L, Annemans L et al. Medication use and disease con-
trol of asthmatic patients in Flanders: a cross-sectional community pharmacy

CPD REFLECTIVE QUESTIONS
ww Would reviewing medicines for a group of your patients result in some better outcomes?

ww Could you introduce the COPD Assessment Test for your patients with Chronic Obstructive Lung Disease to assess this disease on their
quality of life and map any changes over time?

ww Are there any examples in your practice where an integrated disease management approach is used?

study. Respir Med. 2006; 100(8):1407–1414. https://doi.org/10.1016/j.
rmed.2005.11.013

Department of Health. An outcomes strategy for COPD and asthma: NHS com-
panion document. 2012

National Institute for Health and Care Excellence. Chronic obstructive pulmonary
disease in over 16s: diagnosis and management. Clinical guideline [CG101].
www.nice.org.uk/cg101 (accessed 2 May 2018)

Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B..
Effectiveness of chronic obstructive pulmonary disease-management pro-
grams: systematic review and meta-analysis. Am J Med. 2008; 121(5):433–443.
e4. https://doi.org/10.1016/j.amjmed.2008.02.009

Weldam SW, Lammers JW, Decates RL, Schuurmans MJ. Daily activities and
health-related quality of life in patients with chronic obstructive pulmonary
disease: psychological determinants: a cross-sectional study. Health Qual Life
Outcomes. 2013;11:190. https://doi.org/10.1186/1477-7525-11-190

Fundamental Aspects of Community Nursing

Edited by John Fow

ler

n What does it feel like to be a student on
your community experience?

n How do the various nurses who work in the
community organise their time and plan
their care?

n What does a practice manager do?

n What does it feel like to be a patient in the
community?

This is a text book written by a variety of
people who are delivering or receiving
community nursing. It captures the lived
experience of community nursing in a way
that seamlessly combines theory and practice
underpinned by a core belief in holistic care.

ISBN-13: 978-1-85642-302-1; 234 x 156 mm; paperback; 136 pages; publication 2006; £19.99

Order your copies by visiting
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Fundamental Aspects of
Community Nursing
Edited by John Fowler

Fundamental Aspects of Nursing series

Fundamental Aspects of Community Nursing
Edited by John Fow

ler

www.quaybooks.co.uk

About the book
What does it feel like to be a student on your community experience? How do the various nurses who work in the community organise their time and plan their care? What does a practice manager do? What does it feel like to be a patient in the community?
This is a text book written by a variety of people who are delivering or receiving community nursing. It captures the lived experience of community nursing in a way that seamlessly combines theory and practice underpinned by a core belief in holistic care.
As you read each chapter you cannot fail to be inspired by the
commitment of the health care professionals and the quality of care that they display to their patients, students and each other.

About the author
Dr John Fowler has a joint appointment as Principal Lecturer in
Nursing at De Montfort University & Nursing Educational Consultant to Leicester City West PCT. Much of his current work focuses on
helping people learn from their clinical experiences either through clinical supervision or independent study.

Other titles in the Fundamental Aspects
of Nursing series include:
Adult Nursing Procedures
Caring for the Acutely Ill Adult
Caring for the Person with Dementia
Complementary Therapies for Health Care Professionals
Gynaecology Nursing
Legal, Ethical and Professional Issues in Nursing by
Men’s Health
Tissue Viability Nursing
Palliative Care Nursing
Women’s Heath

FA CommNurs cover.indd 1

7/8/06 12:04:38

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without the copyright holder’s express written permission. However, users may print,
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LONG-TERM CONDITIONS

548 British Journal of Community Nursing November 2016 Vol 21, No 11

Integrating nutrition into
pathways for patients with COPD
Matthew Hodson
Chair, Association of Respiratory Nurse Specialists; Honorary Respiratory Nurse Consultant, Homerton University Hospital, London

info@arns.co.uk

Malnutrition is an imbalance of energy, protein and other nutrients that cause adverse effects on the body (size, shape and composition), the way
in which it functions and clinical outcomes (Elia, 2000).
The term can refer to under-nutrition (being under-weight
or losing weight) or over-nutrition (being overweight or
obese), for the purposes of this article we are focusing on
the issue of under-nutrition in COPD.

According to the British Lung Foundation (BLF) approxi-
mately 1.2 million people in the UK are diagnosed with
COPD (BLF, 2012), it is estimated however that more
than 3 million people may live with the disease (NHS
Choices, 2014). Around 21% of outpatients with COPD
(up to 630,000 people in the UK) are at risk of malnutri-
tion (Collins et al, 2010). Malnutrition may develop follow-
ing periods of exacerbations or gradually over several years.
Community nurses play a vital role in the ongoing care of
patients living with COPD, and are ideally placed to identify
patients who are at risk of malnutrition and implement an
appropriate nutritional care plan.

Causes of malnutrition
The causes of malnutrition in patients with COPD are var-
ied, some of which are detailed in Table 1.

The consequences of malnutrition
The consequences of malnutrition in COPD patients are
significant and varied and are likely to further affect nutri-
tional intake (Cochrane and Afolabi, 2004). Evidence sug-
gests that patients with COPD at risk of malnutrition have
an increased risk of hospitalisation, longer hospital stays,
more frequent readmissions and increased mortality (Steer

et al, 2010; Weekes et al, 2007). In patients with a low BMI
(<20kg/m2) 1-year mortality is four-fold higher when compared to overweight or obese patients (BMI >25kg/
m2) (Collins et al, 2010).

The cost of malnutrition
As outlined the clinical consequences of malnutrition in
patients with COPD are widespread. These undoubtedly
have financial implications. Current evidence estimates that
the total cost of malnutrition in England alone is £19.6 bil-
lion (Elia, 2015). This research also estimates that the health
and social care costs of patients at risk of malnutrition is over
3 times that of non-malnourished patients (£7408 versus
£2155) (Elia, 2015). Treating the 1 in 5 patients with COPD
who are estimated to be at risk of malnutrition could there-
fore relate to significant cost savings to the health and social
care system. When a budget impact analysis is applied it can
be shown that the investment necessary to implement better
nutritional care is more than counteracted by the result-
ing cost savings, and when the Clinical Guidelines (CG32)/
Quality Standard (QS24) is applied to 85% of patients with
a high risk of malnutrition it has been suggested that there

ABSTRACT
This article looks at the role of the community nurse in assessing the
nutritional status of patients with COPD and in integrating nutrition into the
COPD care pathway.

KEY WORDS
w COPD w malnutrition w low BMI
w nutritional screening w oral nutritional supplements

Table 1. Causes of malnutrition in COPD

Disease effects Patients with COPD have increased
nutritional requirements due to a
high energy expenditure caused by
systematic inflammation and increased
requirements during breathing (Ezzell et
al, 2000)

Medication
effects

The use of oxygen, nebulisers and
inhalers can cause dry mouth making
it difficult for patients to swallow foods
and this can also lead to taste changes
(Manual of Dietetic Practice, 2014)

Psychological
factors

The disease may cause patients to
suffer from lack of motivation, anxiety
and depression

Social factors Patients may suffer from social isolation
(Odencrants, 2005)

Environmental
factors

Patient’s living conditions may not be
ideal to assist with food preparation

550 British Journal of Community Nursing November 2016 Vol 21, No 11

would be an overall cost saving of approximately £120 000
per 100 000 capita (Elia, 2015).

Nutritional screening
NICE recommends that BMI is calculated in all patients
with COPD (NICE, 2010) using a validated screening tool
(e.g.‘MUST’). Screening should take place on first contact
with the patient and/or upon clinical concern (for example
after an exacerbation or a change in social or psychological
status). A review should take place at least annually or more
frequently if risk of malnutrition is identified (NICE, 2006).

‘Managing Malnutrition in COPD’ is a new practical guide
that has been launched to assist health professionals, and
particularly those working in the community, in identify-
ing and managing people with COPD who are at risk of
disease-related malnutrition and includes a pathway for the
appropriate use of oral nutritional supplements. The docu-
ment and supporting patient materials have been endorsed
by 10 key professional and patient associations including
the Association of Respiratory Nurse Specialists (ARNS),
the British Dietetic Association (BDA), the British Lung
Foundation, the Royal College of Nursing (RCN) and
more recently received an endorsement statement from the
National Institute for Health and Care Excellence (NICE)
(see Box 1).

This new guidance, which replaces the ‘Respiratory
Healthcare Professional’s Nutritional Guideline for COPD
Patients’ launched in 2011, provides an up to date consensus
of evidence and expert opinion in identifying and manag-
ing patients with COPD who are at risk of malnutrition.
It includes an easy to follow flowchart that logically guides
the user through the ‘Malnutrition Universal Screening
Tool’ (‘MUST’); a 5-step approach to assessing and manag-
ing those who may be malnourished or at risk of malnutri-
tion. Steps 1–3 calculate BMI, weight loss and acute disease
affecting the patient’s ability to eat for 5 days or more (the
latter being less likely in the community). Step 4 combines
the scores from steps 1 to 3 and formulates an overall score of
between 0–6, which is then utilised in step 5 to identify the
level of malnutrition risk to the patient and the appropriate
intervention required.

Where it is difficult to ascertain the patients weight, alter-
native measures such as a mid-upper arm circumference
(MUAC) measurement and subjective (visual) assessment of
the patient can be used to help formulate a clinical impres-
sion of the patient’s risk category. Further information on
MUAC and alternative measurements can be found via the
‘MUST’ Report – www.bapen.org.uk/pdfs/must/must_explan.
pdf.

The ‘Managing Malnutrition in COPD’ pathway outlines
the nutritional intervention required, advising when to refer
on to a dietitian and also when a prescription of oral nutri-
tional supplements may be required; a pathway for using oral
nutritional supplements is also included, which advises when
and if oral nutritional supplements are appropriate, monitor-
ing of compliance and progress, and advice on when to stop
the prescription of oral nutritional supplements.

Assessing patient needs and goal
setting
As already outlined it is important that we carry out a nutri-
tional assessment of our patients so that we can understand
the physiological, social, psychological and environmental
factors that may affect the patients ability to eat and can help
to restore some pleasure for the patient around food, help-
ing to meet their nutritional needs and own personal goals.
Discussions around diet and lifestyle can assist in producing
a tailored nutritional care plan and in agreeing the most
appropriate goals for the patient.

It is important to set realistic patient goals that are achiev-
able for the individual. The setting of such goals should be
made in partnership between the patient and the health pro-
fessional, ensuring a patient-centered approach to nutritional
care. It should be noted that where patients are malnourished
a 2kg weight increase is a suggested threshold where func-
tional improvements are seen (Collins et al, 2013; Collins et
al, 2012; Stratton and Elia, 2007; Schols et al, 1998), however,
timescales for such a weight increase will depend on the
patients overall condition and simple goals aimed at increas-
ing calorie and protein intake may be the most effective.

Stopping smoking may also help with improving the senses
of taste and smell making food more pleasurable, so smoking
cessation is also a key thread throughout consultations with

Box 1. NICE Endorsement Statement – Managing
Malnutrition in COPD

National Institute for Health and Care Excellence August 2016

This guide supports some of the recommendations on identification and
management of malnutrition in the NICE guideline on nutrition support
in adults and chronic obstructive pulmonary disease in over 16s. It also
supports the statements about identifying and managing malnutrition in the
NICE quality standard for nutrition support in adults.

This resource is intended for use with adults and not children.

British Journal of Community Nursing November 2016 Vol 21, No 11 551

Box 2. Tips for high risk patients
(The following information is available in a patient leaflet – ‘Nutrition Support in COPD’ (red leaflet) which is available free to download from
www.malnutritionpathway.co.uk/copd)

Making the most of food and drink
The following advice aims to help patients with COPD make the most of their food and drink; it should be noted that some of this advice is
contrary to the healthy eating advice that patients may have previously followed and they may be concerned about weight gain. It is important
that the goals of these nutritional interventions (e.g. to improve or preserve lean body mass, overcome infection, improve ability to perform
daily activities etc.) are discussed with the patient. Not all advice may be acceptable to all patients so talking through the possibilities and
picking out those which they feel are achievable goals can be helpful:
ww Choose full fat or high energy options e.g. whole milk, and avoid low fat or ‘diet’ varieties. Include them in your diet as often as possible as
part of meals or snacks:
ww High energy foods are those that are high in fat (e.g. chips, fried foods, meat pies), high in sugar (e.g. fizzy drinks, sweets), or high in both
sugar and fat (e.g. chocolate, cream cakes)
ww Add grated or cream cheese to mashed potato, soups, sauces, scrambled eggs, baked beans
ww Add cream to sauces, scrambled eggs, soups, curries, mashed potatoes, desserts and porridge
ww Use mayonnaise, salad cream or dressing in sandwiches and on salads
ww Add extra butter, margarine or ghee to vegetables, potatoes, scrambled eggs and bread
ww Fortify your usual milk: whisk 2–4 tablespoons of milk powder into one pint of milk, use for drinks, on cereals etc.
ww Add honey, syrup and jams to porridge, milky puddings, on bread, toast or tea cakes
ww Take nourishing drinks e.g. smoothies, soups, fruit juice, milkshakes or hot chocolate
ww Use convenience foods from the cupboard or freezer, e.g. long life milk, savoury snacks, biscuits, rice puddings, corned beef, baked beans,
soups, tinned puddings and custard
ww Don’t fill up on drinks before or during meals
ww Eat more of the foods that you enjoy at the times of day when you feel more like eating

If patients who are living independently feel too tired to shop for, prepare or cook meals the following could be considered:
ww Asking a family member, friend or their carer to help with cooking, shopping or ordering food for home delivery
ww Do they need to be assessed for a package of care (via social services)?
ww Could you recommend a local ‘meals on wheels’ service or home delivery services offering pre-prepared meals?
ww Could they arrange to eat regularly with a friend or family member or attend a local lunch club?

Oral nutritional supplements (ONS)
If patients are struggling to eat enough to meet their nutritional needs they may be prescribed oral nutritional supplements (ONS) – it is
recommended that patients with COPD and a low body mass index (BMI <20kg/m2) are prescribed ONS (NICE CG101, 2010). ONS provide extra energy, protein, vitamins and minerals and are usually taken in addition to the normal diet, and unless advised they should not replace food, drinks or meals. There are a range of styles, types, formats and flavours available (e.g. ready-made drinks, powders to be made up with fresh milk, savoury, dessert, milk, juice or yogurt styles). Some ONS contain more of certain nutrients (e.g. extra protein and/or energy), which may be helpful for some people with COPD, some are also available in a smaller volume, which may be easier to manage if a patient is breathless or struggles to eat or drink large amounts. If patients are prescribed ONS they should be monitored by a health professional to ensure compliance – this should initially take place after 6 weeks, then after 12 weeks and then every 3 months, or sooner if there is clinical concern. Once nutritional goals have been met the ONS prescription can be stopped (Managing Malnutrition in COPD, 2016). The ‘Managing Malnutrition in COPD’ pathway for using ONS gives further details of this intervention. A leaflet for health professionals containing more information on ONS along with an up to date list of available products is available from: www.malnutritionpathway.co.uk/files/uploads/Managing_Malnutrition_with_ONS_final_2016

Pratical dietary advice/tips for common symptoms
COPD patients may have a number of issues when eating and drinking and there are several practical tips that nurses can give to patients:
Patients who are short of breath may struggle to eat large amounts, tips to assist them include:
ww Choose softer, moist foods at these times, e.g. casseroles, curries, adding sauces, gravy, milky puddings, fruit smoothies, ice creams
ww Aim to eat something 6 times per day, even if it is smaller meals and nutritious drinks or snacks between

Dry mouth can be caused by using oxygen, nebulisers or inhalers and can make it difficult to chew and/or swallow foods. Tips to help include:
ww Choosing softer or moist foods, e.g. minced beef in shepherd’s pie rather than pieces of dry meat
ww Sucking fruit sweets, ice cubes made with fruit juice or squash, or chewing sugar-free gum
ww Pastilles or saliva sprays can be prescribed if the problem continues

Changes in taste (another consequence of dry mouth) which may cause loss of appetite and put the patient off their usual foods.
Helpful hints include:
ww After using a steroid inhaler rinse your mouth and gargle with water to prevent oral thrush
ww Look after your mouth: regularly clean teeth/dentures, use mouthwash and floss
ww Focus on the foods you enjoy but don’t be afraid to try new foods
ww Try sharp or spicy or sugary foods, as they have a stronger taste
ww Experiment with different seasonings and sauces
ww If you go off a particular food try it again regularly as your tastes may continue to change

552 British Journal of Community Nursing November 2016 Vol 21, No 11

patients. Pulmonary rehabilitation is a recommended part
of the management of patients with COPD. Malnourished
patients undertaking such exercise programmes will have
increased energy requirements and nutrition interven-
tion is likely to support the effectiveness of such exercise
programmes in malnourished patients (Schols et al, 2014;
Collins et al, 2013; NICE, 2010; Sugawara et al, 2010; Van
Wetering et al, 2010). Additional assistance and advice may
be needed during periods of exacerbation when nutritional
requirements are likely to increase and nutritional intake
may decrease.

Community nurses are ideally placed to discuss and assess
the many issues outlined that may affect a patient’s ability to
eat and drink, and to refer patients to relevant professionals,
such as a dietitian, specialist respiratory nurse/physiotherapist
or social care professional, who can assist them further with
other concerns if required.

As part of the newly launched ‘Managing Malnutrition in
COPD’ guidelines three colour coded patient leaflets have
been developed to complement the pathway – the red leaflet
is for those patients who have been identified at high risk of
malnutrition, yellow for those at medium risk and green for
those at low risk. The leaflets include simple tips for making
the most of food and drink in order to improve nutritional
intake as well as advice on the use of oral nutritional supple-
ments when required. They also provide advice for coping
with common symptoms such as shortness of breath, dry
mouth and taste changes. All can be downloaded for free via
the website – www.malnutritionpathway.co.uk/copd.

The information in Box 2, taken from the ‘Managing
Malnutrition in COPD’ materials, aims to assist community
nurses in their discussions with patients about their diet and
issues with eating.

Conclusions
Malnutrition is common among COPD patients and com-
munity nurses play an important role in the nutritional
assessment of these patients. The ‘Managing Malnutrition in
COPD’ guideline has been developed to assist community
health professionals in identifying and managing malnutri-
tion appropriately and the pathway is supported by patient
materials aimed to advise patients on their nutritional intake.

It is hoped that these materials will be integrated into
existing COPD care pathways to ensure that patients are
screened for malnutrition and receive appropriate nutritional
care. Copies of the ‘Managing Malnutrition in COPD’ docu-
ment and supporting patient materials are available free to
download via www.malnutritionpathway.co.uk/copd. BJCN

Accepted for publication: October 2016
Declaration of interest: None

British Lung Foundation (2012) Chronic obstructive pulmonary disease (COPD)
statistics. www.statistics.blf.org.uk/copd (accessed 7 September 2016)

Brotherton et al (2010) Malnutrition Matters Meeting Quality Standards in
Nutritional Care. A Toolkit for Commissioners and Providers in England. www.
bapen.org.uk/pdfs/bapen_pubs/mm-toolkit-exec-summary (accessed 12 October
2016)

Cochrane WJ, Afolabi OA (2004) Investigation into the nutritional status, dietary
intake and smoking habits of patients with chronic obstructive pulmonary disease.
J Human Nutr Dietetics 17: 3–11

Collins PF et al (2013) Nutritional support and functional capacity in chronic
obstructive pulmonary disease: a systematic review and meta-analysis. Respirology
18: 616–29

Collins PF et al (2012) Nutritional support in chronic obstructive pulmonary disease:
a systematic review and meta- analysis. Am J Clin Nutr 95(6): 1385–95

Collins PF et al (2010) Prevalence of malnutrition in outpatients with chronic
obstructive pulmonary disease. Proc Nut Soc 69(OCE2): E148

Collins PF et al (2010) ‘MUST’ predicts 1-year survival in outpatients with chronic
obstructive pulmonary disease. Clin Nutrition 5(Suppl 2): 17

Elia M (2015) The cost of malnutrition in England and the potential cost sav-
ings from nutritional interventions. www.bapen.org.uk/pdfs/economic-report-full
(accessed 20 October)

Elia M (2000) Detection and management of malnutrition. BAPEN: Maidenhead
Ezzell L, Jensen GL (2000) Malnutrition in chronic obstructive pulmonary disease.

Am J Clin Nutr 72(6): 1415–16
Commission for Healthcare Audit and Inspection (2006) Clearing the air: A national

study of chronic obstructive pulmonary disease. Commission for Healthcare Audit and
Inspection: London

Managing Malnutrition in COPD: Including a pathway for the appropriate use of
ONS to support community healthcare professionals. 2016. www.malnutritionpath-
way.co.uk/copd (accessed 12 October 2016)

Gandy J (2014) Manual of Dietetic Practice. Blackwell Publishing: London
National Institute for Health and Clinical Excellence (2010). NICE clinical guide-

line CG101. Chronic obstructive pulmonary disease in over 16s: diagnosis and
management.

National Institute of Health and Clinical Excellence (2006). NICE clinical guideline
32. Nutrition support in adults: oral nutrition support, enteral tube feeding and
parenteral nutrition. www.nice.org.uk/guidance/CG32 (accessed 20 October 2016)

NHS Choices (2014) Chronic obstructive pulmonary disease. www.nhs.uk/
Conditions/chronic- obstructive-pulmonary-disease/Pages/Introduction.aspx (accessed
12 October 2016)

Odencrants S et al (2005) Living with chronic obstructive pulmonary disease: Part I.
Struggling with meal-related situations: experiences among persons with COPD.
Scan J Caring Sci 19: 230–9

Schols AM et al (2014) Nutritional assessment and therapy in COPD: a European
Respiratory Society statement. Eur Respir J 44: 1504–20

Schols AM et al (1998) Weight loss is a reversible factor in the prognosis of chronic
obstructive pulmonary disease. Am J Respir Crit Care Med 157: 1791–7

Steer et al (2010) Comparison of indices of nutritional status in prediction of in-
hospital mortality and early readmission of patients with acute exacerbations of
COPD. Thorax 65: A127

Stratton RJ, Elia M (2007) A review of reviews: A new look at the evidence for oral
nutritional supplements in clinical practice. Clin Nutr 2(1): 5–23

Sugawara K et al (2010) Effects of nutritional supplementation combined with
low-intensity exercise in malnourished patients with COPD. Resp Med 104(12):
1883–9

Van Wetering CR et al (2010) Efficacy and costs of nutritional rehabilitation in
muscle-wasted patients with chronic obstructive pulmonary disease in a com-
munity-based setting: a prespecified subgroup analysis of the INTERCOM trial.
J Am Med Dir Assoc 11(3):179–87

Weekes et al (2007) A nutrition screening tool based on the BAPEN four ques-
tions reliably predicts hospitalisation and mortality in respiratory outpatients.
Proceedings of the Nutrition Society 66: 9A

KEY POINTS
ww Malnutrition is prevalent among patients with COPD and has serious
consequences for both the patient and local health care economy

ww Malnutrition in COPD is often due to the effects of the disease but
environmental, social and psychological factors also play a role

ww Patients with COPD have a wide range of nutritional problems and should
receive nutritional assessment, appropriate early nutritional intervention
and monitoring to improve patient experience and quality of life

ww Community nurses are ideally placed to identify and manage patients
living with COPD who are at risk of malnutrition, including referral to a
dietitian for patients with complex nutritional needs

NUTRITION

The role of nutrition in the
management of COPD patients

Edel McGinley

This article examines the role of m alnutrition in chronic
obstructive pulmonary disease (COPD). Until recently, weight
loss was considered an inevitable consequence of COPD,
however, modern research has dem onstrated that weight gain is
in fact achievable and can result in functional improvements. It
is im portant that community nurses are aware of the importance
of nutrition in COPD, both in screening for m alnutrition and
developing appropriate treatm ent plans, including the use of oral
nutritional supplem ents alongside dietary advice and counselling.
The current NHS policy of moving care ‘closer to home’ is
resulting in more complex COPD patients being managed in
the community and with this comes the challenge of managing
reduced weight and low oral intake. It is, therefore, essential that
community nurses develop the necessary skills and resources to
deal with this growing group of patients.

KEYWORDS:
Malnutrition ■ COPD ■ Nutritional supplements ■ Diet

An estimated 835,000 people are affected by chronic obstructive pulmonary
disease (COPD) in the UK, with
a further two million remaining
undiagnosed (Shahab et al, 2006).
COPD is a chronic progressive lung
disease, which makes breathing
difficult due to partially obstructed
airflow into and out of the lungs.
It results from inflammation
stimulated by exposure to toxins,
primarily due to a history of
smoking. It is the fifth largest cause
of respiratory deaths in the UK
(British Thoracic Society, 2006).

Edel McGinley, lead specialist community
nutrition support dietitian, Ealing Hospital
NHS Trust, London

‘In pa tien ts w ith COPD,
lo w bo dy w e ig h t a n d
s ig n ifican t w e ig h t loss
a re assoc ia ted w ith a
redu ced overa ll prognosis
a n d increased m orta lity ,
in d e p e n d e n t o f th e severity
o f th e d isea se 1

COPD is an umbrella term that
includes both emphysema and
chronic bronchitis. Patients with
emphysema experience shortness
of breath due to a reduction in the
elasticity and eventual damage to
the air sac walls in the lungs. This
leads to impaired exhalation and a
resultant build-up of carbon dioxide
in the lungs. These patients typically
present as underweight, often
exhibiting significant weight loss
due to the increased energy output
associated with laboured breathing
(Wouters, 2000).

In contrast, in the author’s
experience, patients with chronic

bronchitis typically present as normal
weight or overweight, but have a
persistent cough, increased mucous
production and shortness of breath
due to inflammation, scarring, and
eventual narrowing of the airways.

Compared to those who are
undernourished, obese and overweight
COPD patients can experience:
► Improved survival (Landbo

et al, 1999)
► Fewer early readmissions (Steer

et al, 2010)
► Fewer emergency hospital

admissions and shorter lengths
of stay (Collins et al, 2011).

ROLE OF NUTRITION IN COPD

In patients with COPD, low body
weight and significant weight
loss are associated with a reduced
overall prognosis and increased
mortality, independent of the
severity of the disease (Landbo
et al, 1999). Therefore, dietary

Table 1: Reasons for poor nutritional intake

Difficulty swallowing or chewing due to dyspnoea
(shortness of breath)

Chronic ‘mouth breathing’, which can alter the
taste of food

Chronic mucous production

Coughing

Fatigue

Morning headache or confusion due to
hypercapnia (increased carbon dioxide in
the blood)

Anorexia

Depression

Side-effects of medications

50 JCN 2014, Vol 28, No 4

NUTRITION

education and intervention
play important roles in the
management of patients
with COPD.

Malnutrition is a significant
problem in patients with COPD,
with several factors contributing to

a lowered body weight and weight
loss, including (Congleton, 1999;
Slinde et al, 2002):
► Increased resting

energy expenditure
► Increased energy expenditure

during activity
► Reduced dietary intake.

‘M U ST’ Tool

a
Add scores together to calculate overall risk of malnutrition.

Score 0:
Low risk

Score 1:
Medium risk

Score 2 or more:
High risk

*
——————————1

0
Low risk

i 1
M edium risk

r—————————- 1
2 or m ore
H igh risk

R o u t in e c l in ic a l O b s e r v e T re a t*

c a r e
• Follow’MUSTT care • Follow action plan for

• Ensure appropriate food pathway on page 10 medium risk

and drink choices of guidelines booklet • Refer to dietitian*
• Repeat screening every (available at: www. • Re-weigh weekly

3-6 months, unless there bapen.org.uk/screening- • Document action taken

are clinical concerns for-malnutrition/must/

• Document action taken must-toolkit/the-must- *unless ‘detrimental1 or ‘no’
explanatory-booklet) benefit is expected from

nutritional support, i.e. end
o f life care pathway

———– ■ ■ J S 1 ^ J
This tool is to assist your assessment.

If in doubt, use your professional judgement

British Assodation for Parenteral and Enteral Nutrition (BAPEN)
Malnutrition Universal Screening Tool BAPEN (2004)

Available from: www.bapen.org.uk/pdfs/must/must_full

Figure 1.
The MUST malnutrition assessment tool.

R e d F la g
S u d d e n s h o rtn e s s

o f b r e a th

S u d d e n u n e x p e c t e d
b r e a t h l e s s n e s s c a n b e a c lu e
t o a n u m b e r o f p o t e n t i a l l y
d a n g e r o u s h e a l t h p r o b l e m s ,
i n c l u d i n g :

► C O P D : i f a p a t i e n t
h a s C O P D , s u d d e n
b r e a t h l e s s n e s s i s a s i g n t h a t
t h e i r c o n d i t i o n h a s s u d d e n l y
w o r s e n e d a n d m e d i c a l
h e l p s h o u l d b e s o u g h t
i m m e d i a t e l y

► A s t h m a a t t a c k : t h i s w i l l
c a u s e t h e a i r w a y s t o n a r r o w
a n d p r o d u c e i n c r e a s e d
p h l e g m r e s u l t i n g in
w h e e z i n g a n d c o u g h i n g
— a g a i n m e d i c a l a t t e n t i o n

s h o u l d b e s o u g h t

► P n e u m o n i a ( l u n g
i n f l a m m a t i o n ) c a n a l s o c a u s e
s h o r t n e s s o f b r e a t h , u s u a l l y
a s a r e s u l t o f a n i n f e c t i o n .
T h e p a t i e n t m a y n e e d a
c o u r s e o f a n t i b i o t i c s .

Other factors that contribute to a
reduced nutritional intake include:
► Increased shortness of breath
► Chronic ‘mouth breathing’
► Coughing
► Loss of appetite
► Difficulty swallowing or chewing

due to dyspnoea (shortness of
breath) (Table T).

Other factors that can affect
nutritional intake in COPD include
anorexia and early satiety (where a
person feels full after eating a small
amount of food) (Cochrane and
Afolabi, 2004).

Those patients identified
as malnourished or at risk of
malnutrition are more likely to be
admitted to hospital, experience
increased length of hospital stay,
have earlier readmission rates
and have a poorer prognosis. In
particular to COPD, malnutrition
can impair pulmonary function,
increase susceptibility to infection,
lower exercise capacity, and increase
the risk for mortality and morbidity
(Ferreira et al, 2000).

5 2 J C N 2014, Vol 28, N o 4

NUTRITION

Five-minute test

Answer the following questions
about this article, either to test the

new knowledge you have gained or
to form part of your ongoing practice

development portfolio.

1 – What is a common definition
of malnutrition?

2 – Name some of the causes
of malnutrition.

3 – How does malnutrition affect the
patient with COPD?

4 – How can community nurses
best assess people’s risk of
malnutrition?

5 – List five practical ways in which
community nurses can help to
treat malnutrition in patients
with COPD.v__ ;____

When addressing the nutritional
status of COPD patients who present
as underweight (body mass index
[BMI] of less than 18.5kg/m2), and/or
with significant weight loss (greater
than 10% in six months), the main
focus is to increase total calorie intake
thus maintaining a stable weight, or
to promote weight gain to improve
clinical and functional outcomes
(Ferreira et al, 2012).

IDENTIFYING MALNUTRITION

It is essential that community
nurses understand how to
undertake regular nutritional
screening to identify and develop
appropriate care plans in all
patients, but specifically in those
with COPD. To do this they should
know how to use a validated
nutritional screening tool.

The tool most commonly used
in the UK is MUST (malnutrition
universal screening tool) developed
by BAPEN (British Association of
Parenteral and Enteral Nutrition,
2004) — this is recommended in
the National Institute for Health
and Care Excellence (NICE) (2006)
guidelines for nutritional support.

MUST is a validated tool for use
within the primary care setting and
involves three steps:
► BMI score
► Percentage weight loss score
► Disease effect score (likely

decrease in oral intake for more
than five days) (Figure 1).

It is vital that community
nurses screen all new patients and
continue to regularly screen current
patients as per local guidelines —
only in this way will they be able
to spot any deterioration in the
patient’s nutritional status.

Patients with a MUST score of ‘2’
or more should be referred directly

to a dietitian for further assessment
and support. Those patients who
score ‘1’, have a medium risk of
malnutrition and, in the case of
COPD, it is essential that dietary
advice is provided to prevent further
weight loss.

DIETETIC INTERVENTION

In the management of malnutrition,
the dietitian may use one or a
combination of the following
approaches in a patient with COPD:
► Dietary advice and support to

increase dietary intake, focusing
on the frequency of meals and
the types of food/fluid consumed

► Food fortification — aimed at
improving the energy ‘density’
of meals and snacks

► Prescription of oral nutrition
support supplements.

Dietary advice should include
the following:
► Eat meals when energy levels

are at their highest, which is
usually in the morning

► Eat several small energy dense
meals to avoid becoming
breathless while eating

► Eat slowly and chew foods
thoroughly to avoid ‘swallowing
air’ while eating

► Choose foods that are easy
to chew or change the food
consistency if the patient reports
fatigue on eating. This can be
done by using energy dense
liquids to create a softer texture,
e.g. adding full-fat milk and
butter to mashed potato or meat-
based gravy to cottage pie. Avoid
the use of water or clear fluids
such as stock and broth as these
will increase the volume of food
but decrease the energy content
further, thereby increasing the
risk of decreased calorie intake

► Choose foods that are easy to
prepare — this conserves energy
for eating

► Eat while sitting up to ease
pressure on the lungs

► Drink fluids at the end of the
meal rather than during — this
will lessen the likelihood of the
patient ‘feeling full’ while eating.

Stratton et al (2003) have
demonstrated the benefit of

nJ THE SCIENCE — UNDERSTANDING MALNUTRITION
^ Malnutrition develops when an individual’s diet does not contain

the right amount of nutrients. It is commonly used to mean
‘undernutrition’ — where people do not take in enough nutrients —
however, it can also mean ‘overnutrition’, where the individual takes
in more nutrients than required. It is estimated there are about three
million malnourished people in the UK at any one time and up to
one-in-three people admitted to hospital are malnourished or at risk
of malnourishment. Malnutrition results from either an inadequate diet
or a problem that prevents a person from absorbing enough nutrients
from food, including reduced mobility, long-term health conditions or
low income. By far the most obvious sign of undernutrition is unplanned
weight loss, however, other signs include weakened muscles, persistent
tiredness, low mood, and a rise in illnesses or infections.

Source: NHS Choices: www.nhs.uk/conditions/malnutrition

JCN 2014, Vo\ 28, No 4 53

NUTRITION

oral nutrition supplements in
malnourished patients with stable
COPD, including:
► Improved energy and

protein intake
► Improved body weight
► Improved functional

outcomes (such as peripheral
muscle strength, and
maximum inspiratory and
expiratory pressure).

However, oral nutrition
supplements are not effective as a
sole treatment option in all patients
and reported compliance rates
can be as low as 50%, especially
in the elderly (Payette et al,
2002; Bonnefoy et al, 2003). Poor
compliance can be influenced by:
► Taste fatigue (where patients

who have been taking oral
nutrition supplements for a long
time become bored with the lack
of flavour or similar flavours)

► Gastrointestinal symptoms
► Individual preference.

As discussed above, other factors
that can affect patients’ tolerance of
oral nutrition supplements include
early satiety and anorexia. Anker
et al (2006) recommended energy
dense (high in calorie and protein)
and small volume oral nutrition
supplements, and/or small energy
dense and frequent meals to help
alleviate these problems. The
author’s recent practice also shows
that poor compliance can
be improved with the use of
energy dense oral nutrition
supplements, which are now
readily available on prescription
for disease-related malnutrition,
including in COPD patients.

Weight gain
Stratton et al (2003) reported
that a weight gain of at least 2kg
is required in COPD patients in
order to achieve any benefit from
nutritional intervention.

This was similarly reported in
a study by Weekes et al (2008),
which demonstrated that dietary
counselling resulted in significant
benefits for dietary intake, body
composition and quality of life
in a COPD patient group who
achieved weight gain of at least

2kg. The researchers focused on
dietary education and counselling
for a period of at least six months
and advice was tailored and
individualised for each patient
(Weekes et al, 2008). It was also
noted that some beneficial effects
persisted for at least six months
after the intervention period,
in contrast to the use of oral
nutrition supplements as a sole
treatment option.

These results were backed up in
research by Efthimiou et al (1988),
which demonstrated decreased
oral intake and further weight
loss when nutrition supplements
were discontinued, particularly in
patients with COPD.

‘W hen addressing nutritional
intake and status with COPD
patients, it is im portant
for community nurses to
rem em ber that not all
symptoms can be tackled by
nutritional intervention alone
— often a multidisciplinary
approach needs to be
considered1

Counselling
The kind of dietary counselling
mentioned in the above studies can
consist of:
► Taking a detailed dietary history,

which gathers information on
frequency of meals, snacks and
drinks, portion sizes, cooking
methods, and the patient’s
support network

► The drawing up of personalised
dietary goals to increase calorie
and protein intake based on
the dietary history. These goals
can include food fortification
(adding extra calories to meals
or snacks using high-calorie,
high-protein foods, e.g.
butter, cream, yogurt, milk);
manipulating meal patterns
(increasing frequency of energy
dense snacks between meals);
and/or recommending energy
dense drinks (e.g. full-fat milk;
making coffee/tea with half
milk/half water; and malt or hot
chocolate drinks).

KEY POINTS

ntil recently, weight loss
was considered an inevitable
consequence of COPD,
however, modern research has
demonstrated that weight gain
is in fact achievable.

It is important that community
nurses are aware of the
importance of nutrition in
COPD, both in screening for
malnutrition and developing
appropriate treatment plans.

The current NHS policy of
moving care ‘closer to home’
is resulting in more complex
COPD patients being managed
in the community, and with
this comes the challenge of
managing reduced weight and
low oral intake.

It is essential that community
nurses develop the necessary
skills to deal with this growing
group of patients, including
knowledge of therapies such
as oral nutritional supplements
and dietary advice.

The above studies suggest that
with the use of tailored advice
based on a patient’s dietary
preferences, symptoms, support
network and lifestyle, it may be
possible to achieve compliance
for longer periods, even in the
absence of long-term direct dietetic
intervention and monitoring.
For example, Weekes et al (2008)
demonstrated that in stable COPD
outpatients, dietary advice plus a
six-month supply of whole milk
powder had beneficial effects,
including:
► Significant improvements in

nutritional intake, body weight,
functional status and quality
of life

► Effects lasting for six months
beyond the intervention period.

Leaflets
Weekes et al (2008) also examined
the use of dietary advice leaflets
versus nutritional counselling
(with or without oral nutrition

56 JCN 20U,Vol 28, No 4

NUTRITION

supplements) and found that
providing literature is ineffective
in achieving weight gain and
functional benefits in COPD
patients.

It is important to stress the
importance of education and
counselling alongside oral nutrition
supplements as, in the author’s
experience, it is common in primary
and secondary care for patients
to be prescribed oral nutrition
supplements as a sole treatment
for weight loss without referral to
a dietitian for specialist input or
dietary advice.

The combination of education
and counselling alongside oral
nutrition supplements provides
the patient with greater choice
and results in long-term
changes, ultimately supporting
improvements in nutritional status
and weight gain beyond the initial
intervention period.

MULTIDISCIPLINARY
APPROACH

When addressing nutritional intake
and status with COPD patients,
it is important for community
nurses to remember that not
all symptoms can be tackled by
nutritional intervention alone —
often a multidisciplinary approach
needs to be considered. An example
would be a patient whose dyspnoea
(shortness of breath) causes
problems when eating — this
could be discussed with a
respiratory nurse specialist, who
might suggest the use of oxygen
therapy alongside small easy-
to-prepare energy dense meals,
thereby minimising the burden of
eating on the patient’s breathing.

CONCLUSION

In the author’s opinion, the way
that nutrition in COPD patients is
managed within the community
needs more thought, particularly
as nutritional interventions often
extend no further than the provision
of dietary leaflets.

Although many community
nurses already educate and

support patients, initiating changes
where possible, it is vital that all
community staff are aware of the
range of interventions available.

This article highlights the need
for a multidisciplinary approach
to pulmonary rehabilitation and
management of COPD patients,
including timely referral to the
dietitian for specialist input.

It is also crucial that community
nurses do not simply provide oral
nutrition support to patients with
COPD, but also consider the use
of dietary counselling in order to
maintain any improvements over a
longer period of time. jcn

REFERENCES

Anker SD, John M, Pederson PU, et al
(2006) ESPEN Guidelines on enteral
nutrition; cardiology and pulmonology.
Clin Nutr 25: 311-18

BAPEN (2004) Malnutrition Universal
Screening Tool. Available at: www.
bapen.org.uk/must_tool.html (accessed
4 July, 2014)

Bonnefoy M, Cornu C, Normand S, et
al (2003) The effects of exercise and
protein-energy supplements on body
composition and muscle function in
frail elderly individuals: a long term
controlled randomised study. Br J Nutr
89: 731-38

British Thoracic Society (2006) The
Burden of Lung Disease. 2nd edn. British
Thoracic Society, London

Cochrane WJ, Afolabi OA (2004)
Investigations into the nutritional
status, dietary intake and smoking
habits of patients with chronic
obstructive pulmonary disease./
Human Nutr Diet 17: 3-11

Collins PF, Stratton RJ, Elia M (2011)
An economic analysis of the costs
associated with weight status in
chronic obstructive pulmonary disease
(COPD). Proc Nutr Soc 70: E324

Congleton J (1999) The pulmonary
cachexia syndrome: aspects of energy
balance. Proc Nutr Soc 58: 321-28

Efthimiou J, Feming J, Gomes C, et al
(1988) The effect of supplementary oral
nutrition in poorly nourished patients

with chronic obstructive pulmonary
disease. Am J Resp Dis 137: 1075-82

Ferreira IM, Brooks D, Lacasse T,
Goldstein RS (2000) Nutritional
support for individuals with COPD: A
meta-analysis. Chest 117(3): 672-78

Ferreira IM, Brooks D, White J, Goldstein
R (2012) Nutritional supplementation
for stable chronic obstructive
pulmonary disease. Cochrane Database
Syst Rev 12: CD000998

Landbo C, Prescott E, Lange P, Vestbo J,
AlmdalTP (1999) Prognostic value of
nutritional status in chronic obstructive
pulmonary disease. Am ] Resp Crit Care
Med 160: 1856-61

NICE (2006) Nutrition Support in Adults:
oral nutrition support, enteral tube
feeding and parenteral nutrition. Clinical
Guideline 32. NICE, London

Payette H, BoutierV, Coulombe C,
et al (2002) Benefits of nutritional
supplementation on free living, frail,
undernourished elderly people: a
prospective randomised community
trial. J Am Diet Assoc 102: 1088-95

Shahab L, Jarvis M J, Britton J, West
R (2006) Prevalence, diagnosis and
relation to tobacco dependence
of chronic obstructive pulmonary
disease in a nationally representative
population sample. Thorax 61(12):
1043-47

Slinde F, Gronberg AM, Engstrom CP,
Rossander-Hulthen L, Larrson S
(2002) Individual dietary intervention
in patients with COPD during MDT
rehabilitation. Resp Med 96: 330-36

Steer J, Gibson GJ, Bourke SC. Stratton
RF (2010) Predicting outcomes
following hospitalization for acute
exacerbations of COPD. QJM 103(11):
817-29

Green CJ, Elia M (2003) Disease-related
Malnutrition: an evidence-based approach
to treatment. CAB International
Wallingford, Oxon

Weekes CE, Emery PW, Elia M (2008)
Dietary counselling and food
fortification in stable COPD: a
randomised trial. Thorax 64: 326-31

Wouters EFM (2000) Nutrition
and metabolism in COPD
Chest 117(5 Suppl): 274-80

58 JCN 2014, Vol 28, No 4

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RESPIRATORY

Community management of chronic
obstructive pulmonary disease (COPD)

Annette Bade:

Chronic obstructive pu lmonary disease (COPD) is a serious,
long-term and irreversible disease, which obstructs airflow to the
lungs d u e to inflammation of the air passages and lung tissue
damage . The most debilitating and frightening s y m p t o m is
breathlessness, which can affect an individual ‘s ability to walk,
exercise, work, socialise, sleep and eat, thus having a major impact
on all activities of daily living. This article a ims to provide an
overview of COPD to facilitate a general unders tand ing of the
disease, assist communi ty nurses wi th early identification for p rompt
detection and highlight the pa thways and managemen t opt ions
available. Due to its complexity, COPD can be challenging for both
patients and healthcare professionals, thus the earlier it is d iagnosed
and m a n a g e m e n t p lans started, the sooner its progression can be
slowed and any impact reduced.

KEYWORDS:
COPD • Self-management Assessment • Screening

Chronic obstructive pulmonarydisease (COPD) is the termgiven to progressive airflow
obstrucfive conditions, namely
chronic bronchitis and emphysema
(Nafional Insfitute for Health and
Care Excellence [NICE], 2010). It
is a serious, long-term, irreversible
disease which obstructs airflow to
the lungs due to inflammafion of the
air passages and lung tissue damage
(British Lung Foundafion [BLF], 2014).

It is estimated that three million
people in the UK are affected by
COPD — 900,000 having been
diagnosed, with around two million
being undiagnosed due to initial

symptoms being ignored (Healthcare
Commission, 2006). COPD has
been the cause of between 25,000
and 30,000 deaths each year for the
last 25 years (Health and Safety
Executive, 2013).

‘Community nurses have an
important role to play in the
early identification of COPD’

COPD costs the NHS more than
£800 million each year and results
in an estimated £2.7 billion of costs
in lost working days (Department of
Health [DH], 2010). However, there
is no real price that can be attached
to the changes people have to make
to their lifestyles, due primarily
to the restrictions enforced by
ongoing disease progression and the
potenfially disabling effects COPD
can have.

SYMPTOMS

is breathlessness (BLF, 2014). This can
affect an individual’s ability to walk,
exercise, work, socialise, sleep and
eat, thus having a major impact on all
their activifies of daily living.

NICE (2010) suggests that due
to the lifestyle changes required,
the development of anxiety and
depression is also common. The
physical, psychological and social
impact to each individual affected can
be huge. Although COPD cannot be
cured, the earlier it is diagnosed and a
management plan implemented, the
sooner symptoms can be improved
and progression slowed, and thus
fewer lifestyle restrictions will be
necessary (BLF, 2014).

Early identification
Community nurses have an
important role to play in the early
identification of COPD and Jones
et al’s (2014) study highlights
the ‘opportunities lost’ for early
diagnosis, both in primary and
secondary care.

The study reveals that of
the participafing 38,859 people
diagnosed with COPD, opportunities
to diagnose 85% of these in the
five years preceding their diagnosis
had been missed. There were many
reasons for this, including education.

However, there are now clinical
guidelines and pathways in place
to support practitioners, as well as
enhanced knowledge surrounding
COPD and many opportunities to

Table 1: Risk factors for COPD (World Healfh
Organization, 2014)

Annette Bades, district nursing specialist
practitioner and clinical lead cardio-respiratory,
Lancashire Care NHS Foundation Trust

As COPD progresses the most
debilitating and frightening symptom

Smoking

Occupational-related exposure

Air pollution, indoor and outdoor

Genetic factors

RESPIRATORY CARE

educate patients. Community nurses
have a definitive role in assisting with
the early identification of COPD and
Csikesz and Gartman (2014) suggest
primary care staff have the potential
to make a real difference to the high
number of hospital admissions and
deaths caused by the disease.

However, management of
COPD, including the essential
techniques of self-management
and positive behavioural change, is
complex and difficult, therefore, a
good understanding of this chronic
disease is vital for community nurses
(Rennard et al, 2013).

COPD RISK FACTORS

COPD is, in the main, a preventable
disease. The predominant cause of
COPD is smoking, including passive
smoking (Table I; World Health
Organization, 2014). Smoking causes
inflammation of the lining of the
airways, resulting in permanent,
irreversible damage.

Over the past 10 years there have
been dramatic public health measures
taken to promote health and to
reduce deaths by assisting people to
stop smoking, including:
• Increased spending on stop

smoking campaigns
• More smoking cessation services
• Banning smoking in public places
• Enhanced education in relation to

smoking (DH, 2004)

All community nurses have a
role in the area of health promotion
and a responsibility to recommend
services within their area to support
their patients.

Occupational-related exposure to
fumes, dust and chemicals can also
be a contributory factor to COPD.
Workplaces are now educated and
more aware of these dangers than
they were in the past, so it is vital
that protective clothing is worn and
exposure regulations are in place
and followed (Health and Safety
Executive, 2013).

Indoor air pollution from biomass
fuels, used for heating and in cooking,
is a risk factor, although these mainly
affect women in developing countries

Table 2: Key indicators of COPD

Indicator

Chronic cough

Chronic sputum production

Dyspnoea (shortness of breath)

Risk Factors

Characteristics

May be intermittent
May be productive or unproductive
May be worse in the morning
Often categorised as a ‘smoker’s cough’

Regular sputum production — any pattern

Progressive
Worsens on exertion
Persistent
Becomes a cause of anxiety

Smoker — how many packs/years
ftssive smoker
Occupational exposure
Family history of COPD

(World Health Organization, 2014).
General outdoor air pollution has
been shown to be a minimal risk,
however, studies aimed at clarifying
any links continue (Global Initiative
for Chronic Obstructive Lung Disease
[GOLD], 2014).

‘The difficulty is that in its
early stages COPD may show
no, or minimal symptoms
making it difficult to detect
and diagnose’

There are also genetic risk factors
for COPD — alphal antitrypsin
deficiency being the most commonly
known. Lung infections in childhood,
low birth weight and general bacterial
and viral infections can all increase
an individual’s risk of developing the
disease (GOLD, 2014).

Early diagnosis of COPD is vital
to slow disease progression, facilitate
positive behavioural change and
develop individual management
plans — these aim to improve
symptoms and facilitate an active
lifestyle (Lyngso et al, 2013).

Community nurses are ideally
placed to recognise symptoms and
act upon them accordingly. However,
the difficulty is that in its early stages
COPD may show no — or minimal
— symptoms (NICE, 2010) making it
difficult to detect and diagnose.

Table 2 lists the key indictors of
COPD as determined by GOLD
(2014) and NICE (2010). NICE (2010)

recommends that a diagnosis of
COPD is considered for all adults,
aged over 35, that present with one or
more of the key indicators (Table 2),
alongside a risk factor (for example,
being a smoker or passive smoker;
having occupational exposure; or
family history of COPD).

In addition to the key indicators,
COPD has other symptoms that may
help with identification:
• Wheezing
• Weight loss
• Effort intolerance
• Waking at night
• Reduced exercise tolerance.

However, many symptoms are not
exclusive to COPD and are common
in other conditions. Spirometry is the
only accurate method of measuring
airflow obsfruction in COPD,
therefore, its use is fundamental
in arriving at a COPD diagnosis
(GOLD, 2014; NICE, 2010).

Spirometry
This is a non-invasive procedure
that involves the patient breathing
into a spirometer. This measures the
volume of air exhaled in one second,
known as ‘forced expiratory volume’
(FEVl), and the total amount of
air exhaled, known as ‘forced vital
capacity’ (EVC).

In the author’s experience,
spirometry is widely performed
in the community and provides
instant information on the patient’s
breathing status. However, due
to the number of conditions that
can present in similar ways to

5 2 JCN 2014, Vol

RESPIRATORY CARE

COPD, such as asthma, congestive
heart failure and carcinoma of the
bronchus, further investigations
should be undertaken to ensure
differential diagnoses have been
considered before a final diagnosis of
COPD is made (NICE, 2010).

In addition — as with all
conditions — it is essential that a
patient’s full history is taken and
considered, as this might reveal vital
information that could assist the
commurüty nurse in arriving at an
accurate diagnosis.

The effects of COPD can
vary greatly and impact people
differently. Also, its symptoms are
easily attributed to other diseases
or conditions, which can make
COPD difficult to identify at first.
Community nurses are ideally placed
— partly due to the sheer numbers of
people they come into contact with
and the range of experience they
accrue — to be alert for the possibility
that a pafient has COPD symptoms
and, with the patient’s consent, seek
further invesfigations.

TREATMENT

COPD affects individuals in different
ways, therefore, its management
should be guided by the symptoms
experienced. However, management
plans for people with COPD should
include the following components:
• Assessment and monitoring
• Reduction of risk factors
• Management of stable COPD
• Management of exacerbations.

The aim is to (NICE, 2010; GOLD,
2014):
• Prevent disease progression
• Relieve symptoms
• Improve exercise tolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality.

An essential element of fhe
management plan is to reduce any
known risk factors, which have the
potential to cause an exacerbation.
As discussed above, smoking is
the primary cause of COPD, thus
the most significant intervention
is to encourage smoking cessation

therapy. Both Van der Meer et al
(2003) and Kanner et al’s (1999)
studies demonstrate that — if
identified and acted upon early —
eliminating smoking will reduce the
symptoms of COPD.

Inhaled drug therapy
(corficosteroids) is also central to
the management of COPD and
is used to prevent and/or reduce
symptoms (GOLD, 2014). Inhaled
bronchodilator medication relaxes
the bronchial muscles, increasing the
size of the airways and improving
breathing — there are short and
long-acfing variations (British Medical
Association/Royal Pharmaceufical
Society [BMA/RPS], 2013).

‘Smoking is Ihe primary cause of
COPD, thus the most significant
intervention is to encourage
smoking cessation ttierapy’

Inhaled corticosteroids can
also be used in combination with
bronchodilators (NICE, 2010). Due
to the importance of inhaled therapy
in the management of COPD, an
effective inhalation technique is vital
and patients must be supported and
their techniques regularly reviewed
(Bades, 2012). Nebulisers and
oral medication are also available
and normally used for patients
undergoing a severe exacerbation.

In addition, the use of oxygen
therapy can be considered. However,
as some patient’s respiratory drive
(respiration is primarily controlled, or
‘driven’, by the level of carbon dioxide
dissolved in the blood) is dependent
upon their degree of hypoxia, a
specialised assessment must be
undertaken to avoid respiratory
depression (NICE, 2010).

Educafion is vital if people are
to take responsibility for their own
health and wellbeing (DH, 2013).
Pulmonary rehabilitafion requires a
mulfidiscipHnary approach, involving
numerous health professionals
including nurses, physiotherapists and
occupafional therapists to facilitate
educafion and an individualised
exercise programme (BLF, 2014).
This aims to increase patients’

KEY POINTS

a progressive,

debilitating disease that cannot
be cured, but can be managed

j.with early diagnosis.

T Individuals living with COPD
¡may suffer from depression due
I to the impact upon their quality
I of Ufe.

Management of COPD,
including self-management and

^ positive behavioural change, is
HIcomplex and difficult.

Education is vital to facilitate
[ individuals in taking
I responsibility for their own
[ health and wellbeing.

COPD affects individuals in
different ways, therefore, its

1 management should always
[be guided by the symptoms
[experienced by the patient.

Pulmonary rehabilitation is a
vital stage in the management
of COPD, as are the specialist
respiratory nurses who are
available to offer advice, support fl
and management plans.

The predominant cause of COPD
is smoking, including passive

Ismoking.

Occupational-related exposure
[ to fumes, dust and chemicals can
also be a contributory factor

ho COPD.

f
IIndoor air pollution from

biomass fuels, used for heating
and in cooking, is a risk factor,
but niainly affects women in
developing countries.

General outdoor air pollution
I has been shown to be a minimal
t risk, however, studies aimed at
[ clarifying any links continue.

Inhaled drug therapy is central to
I the management of COPD and
Fis used to prevent and/or reduce
symptoms.

Community nurses are ideally
placed to be alert to the possible
symptoms and, with their

‘ patient’s consent, seek further
investigations.

5 4 JCN 2014, Vol 28, No 3

RESPIRATORY CARE

Five-minute test

Answer the following questions
about this article, either to test the

new knowledge you have gained or
to form part of your ongoing practice

development portfolio.

1 – What are the causes of COPD?

2 – What are the key indicators
of COPD?

3 – Can asthma be mistaken for COPD
and, if so, what steps can be taken
to ensure an accurate diagnosis?

4 – How can community nurses make
a difference to the management
of COPD?

5 – List the essential elements of
pulmonary rehabilitation.

understanding, teach self-
management techniques and coping
strategies, and thereby enhance
their quality of life. Pulmonary
rehabilitation is a vital stage in the
management of COPD, as are the
specialist respiratory nurses who are
available to offer advice, support and
management plans.

Individuals living with the
physical limitations caused by
COPD can experience depression
due to the impact on their quality
of life (BLF, 2014). Pooler and
Beech’s (2014) study indicates
that individuals with depression
and anxiety have a significantly
increased risk of being hospitalised
due to COPD exacerbations.
It is, therefore, important that
psychological aspects, such as
anxiety, depression and feelings
of wellbeing are considered and
incorporated into any management/
self-management strategies.

CONCLUSION

COPD is a progressive, debilitating
disease that cannot be cured, but can
be effecfively managed with early
diagnosis, the removal of risk factors,
educafion and regularly reviewed
management/self-management plans.

COPD is complex, but if all
community nurses have at least a
basic understanding of the disease, are
able to act upon an assessment of the
symptoms, promote health and provide
informafion about local services, many
people with COPD will benefit from
an enhanced quality of Hfe. In addifion,
hospital admissions and deaths from
COPD will be reduced. JCN

REFERENCES

Bades A (2012) Effective management of
COPD./ Co/)/)iJW)7/fi/ Ntíí-s 26(6): 4-8

BLF (2014) COPD. BLF, London. Available
at: http://www.blf.org.uk/F^ge/chronic-
obstructive-pulmonary-ciisease-COPD
(accessed 10 March, 2014)

BLF (2014) What is Pulmonary Rehabilitation’?
BLF, London. Available at: http://www.blf.
org.uk/Pbge/Pulmonary-rehab (accessed
02 April, 2014)

BMA/RPS (2013) British National Formulanj.
BMA/RPS, London

COPD Foundation (2014) Wliat is COPD?
Available at: http://www.copdfoundation.
org/What-is-COPD/Understanding-
COPD/What-is-COPD.aspx (accessed 20
March, 2014)

Csikesz G, Gartman N (2014), New
developments in the assessment of
COPD: early diagnosis is key. ¡nt j COPD
9: 277-86

DH (2004) Choosing Health: Making Healthy
Choices Easier, DH, London

DH (2010) Health Facts about COPD 20Í0,
DH, London. Available online at: http://
webarchive.nationalarchives.gov.
uk/+/www.dh.gov.uk/en/Healthcare/
Longtem-iconditions/COPD/DH_113006
(accessed 15 March, 2014)

DH (2013) Long-tenn Conditions Compendium
of Information. DH, London. Available at:
https://w%vw. gov.uk/government/uploads/
system/uploads/attachment_data/
aie/216528/dh_134486 (accessed 20
April, 2014)

GOLD (2014) Global Strategy for the
Diagi7osis, Management and Prevention
of COPD. GOLD. Available at: http://
www.goldcopd.org/uploads/users/files/
GOLD_Pocket2014Jan30 (accessed 1
March, 2014)

Health and Safety Executive (2013) Chronic
Obstructive Pulmonary Disease (COPD)
in Great Britain 2013, Health and Safety

Executive, London. Available at: http://
www.hse.gov.uk/STATISTICS/causdis/
copd/copd (accessed 10 March, 2014)

Healthcare Commission (2006) Cleaning
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Obstructive Pulmonary Disease. Healthcare
Commission, London

Iones R, Price D, Ryan D, Sims E, et al (2014)
Opportunities to diagnose COPD in
routine care in the UK. Lancet 2(4): 267-
76. Available at: http://www.thelancet.
com/journals/lanres/article/PIIS2213-
2600(14)70008-6/fuUtext (accessed 16
April, 2014)

Kanner R, Connett ], Williams D, et
al (1999) Effects of randomized
assignment to a smoking cessation
intervention and changes in smoking
habits on respiratory symptoms in
smokers with early chronic obstructive
pulmonary disease: the Lung Health
Study, Am]Med 106: 410-16

L)aigso A, Gottleib V, BakerV, Nybo B,
Frolick A (2013) Early detection of COPD
in primary’ care.J COPD 10(13): 208-15

National Institute for Health and Care
Excellence (2010) Chronic Obstructive
Pulmonary Disease: management of chronic
obstructive pulmmmry disease in adults in
primary and secondary care, NICE, London

Pooler A, Beech R (2014) Examining
the relationship between anxiety and
depression and exacerbations of COPD
which result in hospital admission: a
systematic review, hit] COPD 9: 315-30.
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gov/pmc/articles/PMC3974694/ (accessed
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Rennard S, B)Tom T, Crapo J, et al (2013)
Introducing the COPD guide for
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Van der Meer R, Wagena E, Ostelo R (2003)
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5 6 JCN 2074, Vo/28, No 3

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