Chronic life long conditions are disabling, reducing quality of life. Physiotherapists play a key role managing patients with chronic respiratory disease (Garrod and Lasserson, 2007) such as Chronic Obstructive Pulmonary Disease (COPD), aiming to reduce the severity of symptoms and the impact on a person’s life (HealthInsite, 2009). COPD affects a range of clients; from stable COPD to those suffering exacerbations, as well as those with different histories and exposures (British Medical Journal [BMJ], 2009). The management of COPD is discussed and depends on the severity of the disease and the setting of the patient, be it community, ward or within critical care.
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With the Department of Healths in the process of producing a National Service Framework for COPD (Department of Health, 2010a), healthcare professionals must work along side current guidelines to ensure high quality, evidence based treatment for patients (Department of Health [DoH], 2010b). These documents provide guidance and support for heath professionals ensuring treatment of all patients to the same national standards (DoH, 2010b). Clinical experience revealed that treatment occasionally deviates slightly from the literature. Ensuring professional practice is in-line with these guidelines is essential to ensure patient-centred practice (Department of Health [DoH], 2008b) inline with the multi-disciplinary team (MDT) (Department of Health [DoH], 2008a).
Continuing professional development ensures knowledge of policies and guidelines for competent and confident treatment (Gunn and Goding, 2009). A problem solving approach is needed to identify the validity of current evidence (Rosenberg and Donald, 1995) guaranteeing treatment is evidence-based and within the scope of practice (Chartered Society of Physiotherapy, 2008).
Problem solving is the basis to effective clinical reasoning and patient treatment (Taylor, 1998). Steiner et al (2002) produced a model, using problem solving to identify the patient’s main impairments, causes and how it affects function and participation (World Health Organisation [WHO], 2002). COPD presents differently in each patient (Steiner et al, 2002) depending on the cause of the symptoms (BMJ, 2009), and the patient’s co-morbidities (Global Initiative For Chronic Obstructive Lung Disease (GOLD), 2009a). The problem solving process involves the initial understanding, gathering of thoughts, interpretation of data (McGuire, 1985) and the use of clinical reasoning to develop an effective treatment plan (Mikelsons, 2008). This problem solving theory relies on the therapist obtaining sufficient information. Clinical practice revealed that this differs with experience (McGuire, 1985) with students obtaining less relevant information than more experienced problem solvers (therapists), thus leading to different treatments depending on the information gained.
Physiotherapy management of COPD requires problem solving to identify the main issues (Steiner et al, 2002) involving airway clearance, reducing the work of breathing and improving physical function (Garrod and Lasserson, 2007). This overview of systematic reviews provides essential information into the management of such patients. A problem solving approach is needed during the management of patients in community pulmonary rehabilitation classes (The National Institute for Clinical Excellence (NICE), 2004) to recognize the patients main problems, and to identify the areas of the programme they should to focus on. Clinical demonstration of adaptability used outcome measures, continuously assessing the effectiveness of treatment, using problem solving to make appropriate changes as necessary (Steiner et al, 2002). The effectiveness of this resulted in discharge of patients. Education in areas such as mood, muscle wasting and exercise de-conditioning is encouraged (GOLD, 2009b) to increase the quality of life of a COPD patient (Matharu et al, 2009). Appendix 1 demonstrates personal experience of a pulmonary rehabilitation class. Although a multi-disciplinary approach is encouraged in managing these patients (NICE, 2004), only the physiotherapist was involved in the delivery of this session. It can be assumed that dieticians would be involved in the nutrition sessions, and nurses in other sessions, providing more specialised information targeted to each patient to fulfil the guidelines for chronic conditions (Steiner et al, 2002).
Gaps in clinical practice have been identified based on guidelines and improvements should involve actively encouraging smoking cessation (NICE 2004), by recommending nicotine replacement therapy (American Thoracic Society and European Respiratory Society [ATS and ERS], 2004). The use of clinical reasoning and problem solving involves adapting treatment techniques to suit individuals so that relevant advice can be incorporated into the pulmonary rehabilitation programme for those who need it. Clinically, this was not achieved, as any advice given was provided to the whole group, indicating a lack of problem solving and individual treatment. Although preventative strategies are encouraged (DoH, 2010b), they will only be successful if patients comply. While research supports the use of airway clearance techniques such as Active Cycle of Breathing (ACBT) (Pryor and Prasad, 2008), particularly, forced expiration (Holland and Button, 2006), identification of the underlying pathology (Holland and Button, 2006) is needed, to ensure adverse affects do not occur (Taube et al, 2000). The importance of conveying any adverse effects to patients is paramount and this was not evident clinically. The social aspect of pulmonary rehabilitation is encouraged (DoH, 2010b) with patients reporting its usefulness in increasing motivation by providing support and information.
Savci et al, (2000) supports autogenic drainage over ACBT, finding it to be more effective in improving peak expiratory flow rate and oxygen saturation. This study did not investigate the ease of the technique, and functional improvements are only found if the correct technique is used. Problem solving is needed to identify which technique the patient prefers, and which is clinically more effective. Adaptability ensures the physiotherapist is able to teach and adapt both techniques to suit the patient. Clinically (appendix 1), ACBT was favoured, as patients found it easier and could implement a better technique. This study, however, used only a small number of male participants with stable COPD, and a short follow up period, questioning the validity of the study and whether the results can be applied to both genders.
Limited evidence supports the use of long-term oxygen therapy in increasing survival in COPD patients (Górecka et al, 1997). This study is dated and assessed participants with moderate COPD, thus it may have a different effect on those with mild COPD. A lack of research in this area prevented the use of more recent studies. On the contrary, a small amount of evidence supports improvements in quality of life and frequency of hospital admissions following the use of long-term oxygen therapy (Croxton and Bailey, 2006). Although there is a lack of evidence in its favour, clinically, it appears that the use of long-term oxygen helps. Perhaps psychologically it calms the patient, making breathing deeper and slower, thus blowing off more carbon dioxide.
Ward management is similar to that at home, with closer monitoring by nurses and doctors. Clinical reasoning and problem solving are needed on the ward to correctly prioritise patients. COPD patients on the ward are encouraged to use their inhalers to relieve initial breathlessness (NICE, 2004). Although literature suggests they should be used in conjunction with mucus clearance devices such as flutters (Wolkove et al, 2002), clinical practice revealed, the use of flutters (Konstan et al., 1994) is not always possible due to funding from the National Health Service, and for this reason adaptability and problem solving was needed to identify another approach to use (appendix 2).
Techniques taught in the community, such as airway clearance, (NICE, 2004) can be adapted to ward patients. Problem solving identifies any further disabilities these patients may have (WHO, 2002) and whether they can effectively carry out such techniques. Clinical practice revealed the use of intermittent positive pressure breathing (e.g. BIRD), supported by literature to give extra support in increasing lung volume and aiding airway clearance when other methods have failed (Pryor and Prasad, 2008).
Formulation of hospital guidelines on oxygen administration (Sandwell and West Birmingham Hospitals National Health Service Trust, 2009) to keep oxygen saturation (SaO2) above 90% (ATS and ERS, 2004) should act as a guide. However this does not always work realistically as many COPD patients survive on saturation levels lower than this. Clinical judgement and problem solving successfully identify whether patients are symptomatic of low oxygen levels, warranting an increase in oxygen. The guidelines should be used for guidance, without rigidly basing decisions on them.
Another range of COPD clients, requiring management and treatment in a different setting are those with COPD exacerbations. Strategies outlined by the Department of Health (2010b) are met clinically, by initially assessing patients on the Emergency Admissions Unit, following an exacerbation at home with the aims of returning them home, minimising hospital admissions. Clinical reasoning is then used to allocate remaining patients to a ward depending on the severity of the disease.
Problem solving along with knowledge of guidelines are used clinically to identify if a patient is slipping into respiratory failure (ATS and ERS, 2008) and if noninvasive intermittent ventilation (NIV) or intubation (GOLD, 2009b) are required.
Effective clinical problem solving is imperative for prioritisation of patients (Myllykangas et al, 2003), with patients in critical care prioritised highly. An MDT approach improves survival rates of those with chronic conditions (Steiner et al, 2002) within critical care (Jham, 2009).
Within ITU, prioritisation is given to those who are ventilated. Appendix 3 shows how the changing conditions of these patients involve adaptability and problem solving to resolve patient associated problems (Taylor, 1998) for effective, patient-centred (DoH, 2008a) treatment. Although the problem solving theory of creating an effective treatment plan during the first visit works theoretically, realistically, the patient’s condition can change from the initial assessment. Flexibility (DoH, 2008a), adaptability and effective problem solving skills are demonstrated clinically by physiotherapists to correctly identify current problems and provide patient-centred care (DoH, 2008a) for the ever-changing management of such pathologies (Steiner et al, 2002).
Awareness of guidelines and adequate clinical reasoning ensure appropriate invasive mechanical ventilation for patients not tolerating NIV, in severe acidosis or when respiratory rate increases to more than 35 breaths per minute (GOLD, 2009).
Clinical experience suggests that the majority of treatment techniques used in ITU patients are aimed at sputum clearance, as supported by Mikelsons (2008). Literature recommends the use of limb exercises, positioning, and chest physiotherapy (Clini and Ambrosino, 2005). From clinical experience, positioning was the most commonly used treatment in all patients, with side lying used for ventilated patients, but high sitting encouraged for those that were alert and self ventilating. Adaptability and quick thinking are needed if positions are not tolerated by some ventilated patients. Problem solving is used clinically to find an alternative treatment if positioning causes a rise in blood pressure. Other techniques used in ventilated ITU patients to aid secretion clearance were percussion, expiratory vibrations and expiratory overpressures (Clini and Ambrosino, 2005), and problem solving was used to decide the appropriate treatment based on the patient’s main impairments. Adaptability to think of alternatives are needed if treatment is not tolerated.
Closed-suctioning in ventilated patients is clinically reasoned to clear sputum due to its reduced risk of de-saturation and decreasing lung volume compared to open-suctioning (Cereda et al, 2001). There is a lack of evidence and guidance in favour of using saline during suctioning (Blackwood, 1999), but clinically, it appears to have a positive effect, thus there is slight deviation from the literature. It is important to monitor oxygen levels, however, to ensure no de-saturation occurs.
Clinically, standing and mobilising were encouraged with patients on NIV; however, for those invasively ventilated, emphasis was on the use of manual hyperinflation (MHI) (Clini and Ambrosino, 2005) and suctioning as reduced lung volume (Jones et al, 2008), is seen to be the main problem. MHI in ventilated patients has been advocated in some research (Hodgson et al, 2000); however, the side effects and complications with the use of manual hyperinflation are highlighted (Denehy, 1999) resulting in mixed evidence regarding its safety and use (Singer et al, 1994). Evidence is limited on MHI, as small sample sizes and different techniques of MHI were used (Denehy, 1999). Further research is therefore needed to fully evaluate the effectiveness of this technique. Clinical practice advocated the use of MHI through a problem solving approach identifying the advantages and disadvantages and then making a clinically reasoned decision based upon that. Often MHI was used clinically due to the experience of the physiotherapists involved.
While on placement, patients in ITU on CPAP hoods (Jones et al, 2008), still received physiotherapy based on ACBT. The ability to problem solve adapt the ACBT technique to focus on patient breathlessness and relaxed breathing is needed for effective physiotherapy treatment.
Physiotherapy management continuously changes according to the patient’s condition. Management may change from day to day, but, particularly within the critical care setting, it may also change within treatment sessions if patients react adversely (appendix 2). This demonstrates adaptable problem solving to be able to change the treatment technique according to the patient’s changing condition.
Through evaluation of practice and reflection, it appears that physiotherapists work as adaptable problem solvers, basing treatment of COPD on current guidelines. Guidelines provide a basis for treatment, but some deviations from guidelines are found when research does not support a treatment found to be clinically effective. Awareness of these guidelines ensures physiotherapists are aware of the safety and efficacy of high quality treatment needed in the service delivery of complex conditions. Adaptability to change, time management and problem identification are part of the problem solving skills a physiotherapist must have to ensure patients are treated appropriately, and none are left untreated.
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