Write a critical appraisal that demonstrates comprehension of two quantitative research studies. Use the "Research Critique Guidelines – Part II" document to organize your essay. Successful completion

Chronic obstructive pulmonary disease (COPD) is a serious, long-term and irreversible disease, which obstructs airflow to the lungs due to inflammation of the air passages and lung tissue damage.

The most debilitating and frightening symptom 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 aims to provide an overview of COPD to facilitate a general understanding of the disease, assist community nurses with early identification for prompt detection and highlight the pathways and management options available.

Due to its complexity, COPD can be challenging for both patients and healthcare professionals, thus the earlier it is diagnosed and management plans started, the sooner its progression can be slowed and any impact reduced.

KEYWORDS:

COPD • Self-management Assessment • Screening C hronic obstructive pulmonary disease (COPD) is the term given 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 52 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 I 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.

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

f I Indoor 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.

54 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.

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