High numbers of patient with an exacerbation of chronic obstructive pulmonary disease (COPD) present to emergency assessment units, especially in the winter months (Donaldson and Wedzicha, 2014). Management of these patients will depend on the severity of presentation and is often compromised by the relentless pace and workload of these clinical areas. Such patients may be treated by nurses who do not have a sound knowledge of some of the key aspects of treatment and pathophysiology.
This article explores the care of one such patient, who presented with an exacerbation of COPD, noting his functional status, medical history and symptoms, his respiratory biochemistry and concurrent pathophysiology. It will follow one COPD patient's journey through the acute setting and focuses on decisions made that aimed to improve his condition, and the variables encountered that impacted negatively. The study identifies published best practice, and reveals typical actual practice in order to demonstrate how to improve patient outcomes and safety.
Chronic obstructive pulmonary disease
COPD is a term given to a collection of lung diseases including chronic bronchitis and emphysema (Plant et al, 2000). The World Health Organization (WHO) (2017) estimated that there was a prevalence of 250 million cases of COPD worldwide, in 2016. The British Lung Foundation (2019) estimated that 1.2 million people are living with diagnosed COPD in the UK. Exacerbations of the disease often present with the same symptoms: tachypnoea with high volumes of sputum that can arise spontaneously or can have an infective trigger (Bourke and Burns 2015:150).
Stan James (not his real name), aged 76, presented to an emergency assessment unit during a night shift, wheezing, with tachypnoea (a respiratory rate of over 20 breaths per minute) (Nolan, 2016), hypoxia (oxygen saturations below 94%) (Nolan, 2016) and visibly flushed. He explained that he felt like he was ‘constantly running a marathon’ and his other symptoms were excessive coughing, expectoration of green mucous, feeling tired and intermittently feeling confused. Mr James said the problem had developed some 6 hours previously, which coincided with particularly frosty and cold weather. His symptoms had worsened over the next few hours to the point where he felt he had to telephone for an ambulance. Mr James explained that the symptoms worsened on exertion, and he had achieved temporary relief from his pre-prescribed salbutamol bronchodilator inhaler but had been relying on this more frequently and was scared that it would be depleted with excessive use.
Mr James lived alone with family nearby. He had smoked cigarettes since his mid-twenties, around 10 a day, drank approximately 10 units of alcohol weekly and ate a balanced, nutritious diet. He was usually able to walk to his local shop at the top of his street (around 800 metres), but became breathless on return; his family would take him out in a wheelchair for longer distances. His medical history included a diagnosis of COPD, glaucoma and two admissions in the previous year for exacerbation of his airway disease.
Pathophysiology of the patient's condition
It was suspected that the cold temperatures during the night had triggered a bronchospasm, a constriction in the airway that makes it difficult for air to enter and leave the lungs. In Mr James's airway disease, gas exchange between capillaries and alveoli is impaired due to the alveoli being thickened and functionally damaged by fibrosis. Unlike healthy lungs, which would be able to cope with cold conditions, Mr James struggled to breathe on two levels—by already being impaired by alveolar dysfunction, plus constriction of the bronchioles.
Mr James's tachypnoea and intermittent confusion meant that staff suspected that he had an element of type 2 respiratory failure, which should be diagnosed by arterial blood gas analysis. This analysis shows the adequacy of the respiratory system to maintain a healthy gas exchange by giving a value on arterial oxygen (PaO₂) and carbon dioxide levels (PaCO₂). The type of respiratory failure manifested can be ruled in or out by the lack or presence of hypercapnia, according to the British Thoracic Society (BTS) (Davidson et al, 2015). The respiratory centre, located in the brain, is stimulated by a build-up of carbon dioxide, which stimulates a breath (Hall, 2015). Due to the bronchospasms, Mr James was not able to achieve efficient gas exchange within his lungs, resulting in hypercapnia and hypoxaemia. Thus his respirations increased in an attempt to excrete the build-up of toxic carbon dioxide provoking an attempt to draw in more air (Marhong and Fan, 2014; Gibson and Waters, 2016). This is a response to carbonic acid, produced when water within red blood cells combines with carbon dioxide, causing the pH level to drop. The body attempts to compensate for this by triggering chemoreceptors in the brain to increase respiration rates to excrete more carbon dioxide (Costanzo, 2010: figure 5.32). Mr James's tachypnoea indicated he was doing just that.
In time, as with most muscles, Mr James's respiratory muscles would tire with acute overuse and would ultimately have to rest, reducing his rate of respiration, known as decompensation. Due to this ‘rest’, carbon dioxide levels will rise, this is known as decompensated respiratory failure. The effects of decompensation result in little or no air entering the alveoli due to ventilation being reduced, bringing about an additional elevation in carbon dioxide, which then further drops pH and oxygen levels. If left untreated, this will be life threatening. Major deviations in Mr James's pH would result in cells becoming poisoned by their own toxic waste and dying. Woodrow (2011) identified normal cellular metabolism as the requirement for pH in the blood to be 7.35–7.45 and, if the arterial pH falls below 7.35, characterises this as life threatening,
Owing to the long-term effects of Mr James's cigarette smoking, his mucociliary apparatus had become severely impaired. Smoke inhalation may have led to the destruction and deformation of the cilia in the respiratory tract, which are integral to removing unwanted material out of the respiratory system (Bustamante-Marin and Ostrowski, 2016). This prolonged smoke damage had also led to parenchymal destruction and fibrosis of the respiratory tract (Vestbo et al, 2013). In cold temperatures, the cilia that are still functioning will cease to work fully because the optimum temperature for function is 37°C and the bronchi and bronchioles of the lungs will constrict further.
Mr James also had a low-grade pyrexia of 37.7°C, which may have been in response to the cilia in his respiratory tract not providing moisture or allowing the removal of bacteria. Bacteria will colonise if function is not resumed at an optimum level, leading to a respiratory infection.
Nursing assessment
While being triaged, Mr James's vital signs were recorded. His oxygen saturation level was 85% on room air. The triage nurse decided to initiate oxygen therapy to try to get his saturations above 88% using a 24% venturi mask. This was done in accordance with the hospital trust's sepsis policy (Newcastle upon Tyne Hospitals NHS Foundation Trust, 2017) because Mr James's condition had triggered multiple ‘red flags’ indicative of sepsis. The trust's sepsis pathway directs staff to initiate oxygen to maintain saturations within 88-92% for patients at risk of hypercapnic respiratory failure; the BTS (2017) guidance on oxygen therapy underpins this. However, the BTS (2017) advises clinicians to attain saturations of more than 94% until blood gas analysis results improve, but each trust will have different sepsis pathways. The effectiveness and timeliness of providing oxygen therapy would, in part, be affected by the knowledge and expertise of the triage nurse.
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2017) undertook a study to look at patients receiving non-invasive ventilation and aspects of care that could be improved. The study reported that just under a third of patients (32%) had been administered oxygen inappropriately, and only 17% had been administered oxygen via a venturi (controlled oxygen) mask or similar device. After starting correct oxygen therapy, urgent blood tests should be undertaken including full blood count, urea and electrolytes, liver function tests, C-reactive protein and lactate to aid management, as well as an urgent chest X-ray and electrocardiogram according to National Institute for Health and Care Excellence (NICE) (2019) guidelines.
On physical examination, Mr James appeared visibly flushed and said he had been feeling feverish intermittently for the past day. The triage nurse took his temperature with an ear probe thermometer, and he was found to be pyrexial with a temperature of 38.6°C. A study by Rohde et al (2003) found that patients who exhibit signs of viral respiratory illness such as pyrexia have higher inflammatory markers systemically, and overall display more severe symptoms of exacerbation. Mr James and his relatives' anxiety levels were high on arrival, because it had taken him a long time to recover from a previous exacerbation of his condition. It was important for nurses to allay fears and provide comfort, but also to explain that, if he continued to smoke, his airway disease would likely worsen and he should expect longer recovery times after each bout. This is particularly highlighted in a longitudinal study by Donaldson et al (2003), which found that, over time, COPD exacerbation recovery time took longer and sputum purulence became more frequent. A factor that negatively affected this was Mr James continuing to smoke cigarettes.
Non-invasive ventilation
The junior doctor responsible for Mr James decided that he would benefit from non-invasive ventilation (NIV). NIV is strongly recommended by the BTS (Davidson et al, 2015), the European Respiratory Society and the American Thoracic Society (Rochwerg, 2017) in the treatment of acute respiratory failure, but relies heavily on appropriate timing, delivery and monitoring. NIV is commonly defined as the use of mechanical ventilation without the need for an artificial airway (endotracheal intubation or tracheostomy) (Mas and Masip, 2014). NIV involves using intermittent positive airway pressure via a nasal or facial mask to correct the abnormalities shown in a patient's arterial blood gas analysis, and return homeostasis relative to the patient's underlying health conditions. During inspiration, a higher level of pressure is delivered, which then assists ventilation and aims to reduce carbon dioxide levels. Alongside this there is a lower level of pressure, which ensures the airway is patent while expiring, which in turn increases the level of oxygen inhaled.
Clinical decisions were made in conjunction with Mr James's wishes—the clinicians discussed his treatment plan and the need for serial blood gas analysis. The junior registrar and medial registrar explained the options available if treatment was unsuccessful. Mr James did not want to discuss resuscitation status because it was something he had not thought about before. It is important to emphasise that the probability of survival without NIV is low in patients with respiratory failure (Piggin, 2011).
NIV for patients who have significant comorbidities can often present as the optimal treatment available for them without significant risk of death from complications arising from anaesthesia and intubation.
In patients who have several exacerbations of COPD, discussions about resuscitation and the ‘ceiling of care’ or ‘ceiling of treatment’ should be undertaken and explanations of palliative treatments available given. This was not undertaken in Mr James's case because he was not yet at that stage of his illness. Confalonieri et al (2005) alluded to the fact that treatment will fail in 20–40% of patients and that a management plan should be put in place in such circumstances. There are measurable predictors of failure in type 2 respiratory failure, which include deteriorating or unaltered pH or respirations, absence of co-operation or understanding, and high acuity of illness, as shown on aggregate scoring systems such as the National Early Warning Score (Carron et al, 2010). These factors will have informed and guided clinicians in the treatment process for Mr James.
Initiation of treatment
NICE guidelines (2019) on COPD state that respiratory failure should be treated pharmacologically no more than 1 hour before commencing ventilation, and that the causative factor is also established. Taking this guidance into consideration, Mr James received nebulised bronchodilators to inhale and high-dose steroids. He also received intravenous antibiotics to treat any potential infection source in accordance with the ‘red flag sepsis’ pathway set by the hospital trust. The on-call chest physiotherapist was asked to initiate the NIV. The on-call physiotherapist arrived 45 minutes later as they had to travel from home. Mr James was therefore experiencing unpleasant symptoms of breathlessness during this time.
There is evidence that patients fear NIV and the technology involved (Slater, 2011; Broström et al, 2013; Hu et al, 2014). In these studies, patient fear was the most common indicator for failure to tolerate treatment and it also has significant effects on the outcome of treatment; this includes the fear of dying, the fear of the mask and of distress. The studies also underlined that patients felt a loss of control and were heavily reliant on technology. While awaiting the arrival of the physiotherapist, Mr James's named nurse explained what the NIV process involved, the mechanics of the equipment and what to expect. It was important to explain what the machine's noises and alarms indicated throughout the treatment process. Patients' common misconceptions are that they will have to use the machine indefinitely, or that they will be unable to eat, drink or communicate while using the mask. If such fears are alleviated early, this increases chances of compliance and prompts patients to voice any fears and questions. Studies show that the ability to adapt to and accept ventilation can be greatly increased by providing specific education on the benefits and adverse effects, and for these to be available and given before initiation of ventilation (Willman et al, 2012; Fung et al, 2015). There is a stark correlation between age and the effectiveness of NIV—older people tend to have more difficulties than young adults (Salepci, 2013). The reason for this disparity remains unclear and more studies are needed to ascertain why (Yang et al, 2013).
The physiotherapist started Mr James on the recommended initial pressures set by the BTS (Davidson et al, 2015). It was important that he was able to tolerate these before titrating pressures in accordance with his arterial blood gases. At this stage, the nurse should be looking for signs of distress such as discomfort, pulling of the mask or synchronicity problems. Longhini et al (2017) suggested that asynchrony could occur due to an undetected inspiratory effort if mask leakage is present. This could happen if the mask is too tight or too slack. The nurse could assist the patient by counting breaths for them to help them find a rhythm, or simply by adjusting the straps on the mask for a better fit. Olivieri et al (2012) stated that most NIV machines account for leakage to a certain degree, and that this is expected and accepted, but not to the detriment or comfort of the patient; the nurse should explain this to the patient in an effort to reduce any fears that they are not receiving sufficient oxygen because of a leak. A good seal is also necessary to prevent oxygen blowing into the patient's eyes (Confalonieri et al, 2005).
The BTS (Davidson et al, 2015) recommends trialling a full face mask, which helps to prevent excessive leakage and is generally tolerated better by confused or agitated patients; it also prevents the complication of nasal bridge ulceration (Ozsancak et al, 2011). A standard oronasal mask is more commonly used and was provided for Mr James by the physiotherapist. In the early use of NIV, Brochard (1995) found that an alarming number of patients—upwards of 20–30%—could not tolerate treatment, the predominant reason being poor mask fit and asynchrony. A more recent study undertaken by Liu et al (2015) reported just 5.2% intolerance in 961 subjects; this could be because of advances in technology or the wider use of NIV and clinician familiarity with equipment. Oronasal masks are effective, but not tolerated by every patient.
The author recommends that wards stock a range of masks, including full-face masks and helmets, which can be trialled initially, and other conventional masks used thereafter if these are not tolerated. Staff should be appropriately trained and experienced in fitting the masks available (Davidson et al, 2015). Having a wider range of masks and nurse training would be costly, but would improve the overall outcome for the patient. In some hospitals ‘mask rotation’ is used—different types of mask are alternated sequentially to relieve areas of high pressure on the bridge of the nose (Navalesi et al, 2000). A skincare checklist is required so that nurses can identify any pressure damage, and can follow recommendations for best practice to treat and alleviate this.
It was important that Mr James felt empowered and confident while using the ventilation machine and this was a key nursing responsibility. Being unable to call for help can be a major if not fatal problem. A patient safety alert by NHS England (2015) in relation to incidents reported to the National Learning and Response System (NLRS) highlighted poor practice and outcomes in patients with limited ability to summon help. Mr James was placed in an observable bed space with a call bell to hand.
Complicating factors
In 2012 the NHS Medical Directorate produced a best practice toolkit to manage exacerbations of COPD, which acts as the framework on which local guidelines can be based. It states that patients who present with hypercapnic respiratory failure should be assessed swiftly to determine that they are suitable and able to receive NIV and that this should be commenced within 1 hour of the decision being made. The rationale for this is largely based on systematic reviews that revealed mortality rates for those commenced on NIV were halved, representing huge technological advances in treatment over the past 20 years (Lightowler, 2003).
The mask fitted on Mr James was a reasonably snug fit and had been checked for leakages by the nursing team. However, the use of masks means there is a risk of pressure damage, particularly on the bridge of the nose (Rathore et al 2016; Stygall, 2016). There is a higher incidence of pressure damage in correlation with an increase in age, and now that NIV is being used widely on severely ill patients the incidence of tissue damage will be proportionate. Apold and Rydrych (2012) suggested that nurses are not proficient in the fitting and removal of masks. If Mr James had complained of nasal bridge tenderness, the application of adhesive foam dressings cut to size and applied directly to the skin may have relieved this. In a study on reducing ventilation-acquired tissue damage Weng (2008) found fewer incidences of pressure damage in the group who had dressings applied, than in the control group who did not. Mr James did not experience any pressure damage from his mask.
While receiving NIV, Mr James was prescribed regular salbutamol, a bronchodilator, to ease his breathing, nebulised through the ventilator. The doctor wanted Mr James to remain on his ventilator, but evidence suggests that administering a bronchodilator while allowing the patient to breathe spontaneously is more beneficial (Kaul, 2006). The effectiveness of this method of delivery was tested by Chatmongkolchart et al (2002) who concluded that results were determined by rate of breathing and optimal positioning of the adjunct. Applying the results of this study would have meant that Mr James would have had to have been breathing at a rate of 20 breaths per minute with the nebuliser adjunct at the optimum position—distally, between the leak port and the patient connection, allowing optimum intake of the medication. In theory, as the NICE (2019) guidelines determine breathlessness as respiration rates above 20, the bronchodilator would have been suboptimal in terms of treating Mr James's tachypnoea. NICE (2019) guidelines state that patients who are hypercapnic or acidotic should be administered nebulisers via compressed air and not oxygen. The reason for this is to avoid further hypercapnia; this is a practice that is not always adopted on wards, because of patient incidents where the wrong gas has been administered because it has not been swapped back to oxygen following medical air nebulisation. The way in which this could be rectified is standalone medical air in a cylinder for specific nebulisation purposes, but this is resource managed at cost to the trust, and cannot be rectified at staff nurse level.
Continuing treatment and monitoring of the patient is a highlighted failing identified in the NCEPOD report (2017). There needs to be adequate staffing available. The BTS guidelines (Davidson et al, 2015) gave a recommended ratio of one nurse to every two patients on NIV. This is due to the perilous nature of an exacerbation and the variables involved such as weaning of oxygen and pressures needed, adjustment of masks, alleviating fears and discomfort. Such staffing levels are currently not available in many hospitals. Mr James was sent to a monitored bay where two nurses looked after nine patients. Technically, the nurses could be looking after nine patients on ventilation machines, a ratio of one nurse to 4.5 patients. Hourly observations are recommended by NCEPOD (2017) until respiratory acidosis has improved. In Mr James's case, the two nurses were under pressure to care for several patients on NIV.
Further monitoring
Following the first few hours of intense input, the nurses and doctors monitored Mr James, continued his arterial blood gas analysis to plot the course of his exacerbation and hoped to see some improvement within the next 12 to 24 hours, which are crucial in exacerbation management.
NICE guidelines recommend that all hospitals admitting patients with COPD have provision to commence NIV treatment (NICE, 2019). The hospital in this case study does have this provision; however, on a night shift the respiratory physiotherapists are on call and have to be contacted at home. This delays the time at which the patient will begin their treatment. There are clear recommenced oxygen pressures set by the BTS (Davidson et al, 2015) to guide practice; however, at a local level it is the responsibility of the trust to appoint staff who are able to set up NIV. At present, staff nurses in this trust are not trained to perform this task. While waiting for the chest physiotherapist to attend patients may display signs of distress. Training in the use of NIV equipment for nurses and annual updates, or ‘refreshers’, would embed knowledge and skills and would allow any new advances or equipment to be introduced and any questions or concerns answered. A study by Bülow et al (2007) found more patients are started on NIV and treatment time is decreased significantly due to nurses having the skills both to introduce and to wean patients off the ventilators.
Mortality rates in COPD patients have risen in recent years, as reflected in audits carried out by the BTS (BTS, 2010; 2011; 2012; 2013). This has prompted NCEPOD to carry out reviews.
Andersson et al (2002) estimated the cost of an exacerbation of COPD to be 35% to 40% of the full cost of the management of the disease as a whole. Prevention of exacerbations of COPD should therefore be a priority. In a study focusing on the cost of exacerbations, conducted by Oostenbrink and Rutten-van Molken (2004), 90% of the cost of managing exacerbations was attributed to being admitted to hospital. The same study identified that a lower body mass index and increased dyspnoea are likely indictors of those patients who will generate high costs as a result of hospitalisation. Thus it would be prudent to recommend that community support such as dietetic and pulmonary rehabilitation be available to reduce the likelihood of these costly admissions, ideally at best offered at diagnosis of airway disease or after the patient's first hospitalised exacerbation.
Mr James stayed on the unit for a further 18 hours. With continued use of NIV, regular nebulisers and steroids, his condition improved to the point where he was cycling between 2 hours of ventilation and 2 hours of no ventilation and his blood gas analysis results had improved. Mr James then was transferred to a respiratory ward to continue his recovery and was discharged home 3 days later with respiratory nurse follow-up in the community.
Discussion
There is still progress to be made in relation to improving the outcomes of COPD exacerbation management with the use of NIV in the UK. This was plainly shown in three alarming consecutive audits by the BTS (2011; 2012; 2013), which prompted the NCEPOD (2017) involvement due to increased mortality and substandard care when compared internationally. These reports focus on issues raised by this case study. Effective management and treatment will always be affected by appropriate timing and delivery of treatment and monitoring of the patient which, if carried out correctly with the recommended resources, will achieve the optimal outcome for the patient. A failure of any one of these steps reduces the efficacy of NIV treatment.
When initially administering oxygen, there needs to be an increased emphasis on controlled delivery and achieving appropriate target saturations. If this were improved then this would have the potential of reducing the need for NIV and invasive ventilation. This could be achieved by further education of nurses at the point of triage and creation of a flowchart to aid with delivery tools. The safe conclusion and key message for effective management is to start the patient on oxygen and obtain an arterial blood gas result promptly for analysis to steer further therapy because any apparent hypoxia should be treated with oxygen as a life-saving treatment (O'Driscoll et al, 2008).
Nurses need to be armed with the correct tools to address patient concerns and allay misconceptions surrounding NIV. There is no formal nurse training within this hospital trust on this topic, yet nurses are expected to take a major role in the delivery of safe and effective care. If mandatory training were to take place this would only benefit the patient experience and increase the nurses' familiarity with the equipment.
The provision of cascade training from physiotherapists to aid acute ward nurses so that the nurses could start NIV treatment would be an advantage for patients. This could be competency-based training which, when completed, would allow the nurse to set up the patient on ‘basic’ pressures as set by national guidelines. This would aid symptom relief, have a positive effect on the patient immediately, and save time for the chest physiotherapist so that, on arrival, the physiotherapist could fine tune the settings with assistance from serial arterial blood gas analysis results.
In relation to the mask interface, a number of studies, such as that of Fodil et al (2011) draw attention to the interface actually having little to no effect on the outcome, but these studies are small; more detailed studies are needed to detect differences between interfaces. The risk of pressure damage from prolonged mask wear remains, but with a formal checklist the risk can be reduced and/or avoided. It may be considered that the respiratory support given via the NIV equipment is more important than skin care; this may be true, but attention to the skin and avoidance of pressure damage should not be overlooked as part of overall care.
Greater emphasis needs to be placed on community services and empowering patients to reduce exacerbations of COPD, particularly smoking-cessation services, dietetic services and pulmonary rehabilitation. There should be a symbiotic relationship between community and frontline services. The delivery of patient-centred community care has the potential to make an impact on the number of presenting cases seen, if care is accessed early and regularly.
A literature search on NIV revealed much qualitative work. However, there are few studies on the patient experience, especially of the older generation (Smith et al, 2015). Further research exploring the patient experience would inform future guidelines and practice and ultimately improve patient experience and outcomes.