Effect of Pulmonary Rehabilitation on Pulmonary Function Measures among COPD patients at Jubilee Mission Medical College and Research Institute, Thrissur, Kerala
Bini. M. D1*, Angela Gnanadurai2, Sr. Philo Reshmi3
1MSc Nursing, Dept. of Medical Surgical Nursing, Jubilee Mission College of Nursing, Thrissur, Kerala, India.
2Principal, Jubilee Mission College of Nursing, Thrissur, Kerala, India.
3Professor and HOD, Dept of Medical Surgical Nursing,
Jubilee Mission College of Nursing, Thrissur, Kerala, India.
*Corresponding Author E-mail: bini.md91@gmail.com
ABSTRACT:
The study sought to ascertain if and how lung function assessments were enhanced in individuals with chronic obstructive pulmonary disease (COPD). Objectives: Measure pulmonary function in COPD patients after the intervention, compare pre- and post-rehabilitation levels of knowledge and practice, and correlate pretest scores on measures of knowledge and practice with certain socio-demographic and clinical data variables. Methodology: The study indicates that the Betty Neuman system model was used. With a single group, the study used a pretest-posttest pretest procedure using a quasi-experimental methodology. Thirty chronic obstructive pulmonary disease patients were selected at random from the pulmonology outpatient department. Using the Borge dyspnoea scale (degree of breathlessness), heart rate, and oxygen saturation, pulmonary function measurements were evaluated before and after the intervention using a standardised 6-minute walk test. Before learning about pulmonary rehabilitation and breathing exercises, participants were given a structured knowledge questionnaire and a practice checklist as a pretest. When the four weeks were over, the same practice checklist and structured knowledge questions were used to give the posttest. Results: The study's results showed that 46.7% of the participants were male, 86.7% were in the age bracket of 61–70, 43.3% had only completed elementary school, and 0% had completed high school.100% of subjects were married, 66.7% of subjects resides at rural area and 33.3% at urban area. 26.7% were industrial workers, 30% of COPD patients had the monthly income below Rs 5000, 33.3% had above 6 years of duration of illness.76.7% of COPD patient had history of smoking. None of them had no previous exposure to pulmonary rehabilitation. The overall mean posttest knowledge score (18.306.78, t29=3.038, p0.000) and practice score (15.935.40, t29=1.67, p0.000) showed a substantial increase compared to the pretest knowledge score of 6.175.40 and the practice score of 8.278.12. The 6-minute walk test, which gauges how pulmonary rehabilitation affects pulmonary function measures in individuals with chronic obstructive pulmonary disease (COPD), was shown to have a statistically significant correlation (p=0.001) with pulmonary function measurements. Association of pretest level of knowledge score with educational status is highly significant (p=0.001) and practice score was moderately significant (p=0.002) with measures to relive breathing difficulty. Conclusion: There is a great need to educate the COPD patients about pulmonary rehabilitation to improve the pulmonary function measures.
KEYWORDS: Effect, Pulmonary rehabilitation, 6 Minute walk test, Borg dyspnea scale, heart rate, oxygen saturation, COPD patients.
INTRODUCTION:
''Lungs for life''
When a child is born it cries to take its first breath, which continues till death. The respiratory process is thus vital for human survival. Sherill nuns, Kim miracle (1996)1
To stay alive, all creatures must have access to air. One of the most fundamental physiological requirements for human beings. The respiratory system provides for all of the body's physiological requirements. In order to maintain metabolic processes, our bodies need an oxygen supply that is always available.
Millions of individuals suffer from chronic obstructive pulmonary disease (COPD), the fourth biggest killer globally. In India, it is frequent among adults over the age of 30, with a prevalence rate of around 5% in men and 2.7% in females. There was a total of 12.36 million cases of illness. World Health Organisation estimates put the number of people living with chronic obstructive pulmonary disease (COPD) at 210 million. India is thought to bear 89% of the global burden of chronic obstructive pulmonary disease (COPD).5
Chronic obstructive pulmonary disease (COPD) is one of the world's major causes of death and is predicted to be in third place in the global burden of disease by 2020. By 2030, chronic obstructive pulmonary disease (COPD) will surpass all other causes of death, predicts the World Health Organisation. The World Health Organisation (2008) lists COPD as the ninth most common cause of DALYs (disability-adjusted life years) worldwide. It is estimated that in the next ten years, the number of deaths from chronic obstructive pulmonary disease would increase by more than thirty percent if early preventive measures are not taken (COPD 2007).6
Providing patients, the knowledge and abilities to handle the restrictions placed on them by their sickness is the aim of educational therapy for chronic illnesses. lung rehabilitation for chronic obstructive lung disease may enhance health outcomes and quality of life (COPD). The latest COPD treatment recommendations include education as a critical requirement.11
NEED FOR THE STUDY:
A chronic disease puts a person's goals, ambitions, and sense of purpose in life in jeopardy. A third of people on the planet suffer from a chronic illness, and in most countries, this percentage is gradually increasing.
A variety of illnesses that affect the lungs' ability to breathe in and out are included in COPD. Rural residents and clients with less financial resources are more likely to be affected by this. The lethal and morbid effects of chronic obstructive pulmonary disease (COPD) are increasing due to pollution and ongoing irritation.14
For patients with severe chronic obstructive pulmonary disease (COPD), pharmacology is not a panacea for dyspnoea or enhancing quality of life. Patients suffering from dyspnoea will need to depend on self-care measures to alleviate their symptoms. The nurse's involvement in informing patients about the efficacy of pulmonary rehabilitation is crucial.16
The greatest phrase in health promotion is "People's health in people's hands.'' The findings of this study could motivate COPD patients to practice breathing techniques, which should result in improved reactions and the adoption of better lifestyle choices.17
The number of COPD patients admitted to Jubilee Mission Hospital in 2013 and 2014 was 424. The investigator noted that many COPD patients hospitalised belonged to poor socioeconomic group throughout the clinical experience. The study's investigators also discovered that breathing exercises are not routinely given to patients receiving medical care, and that when they are, it is usually only administered after issues have already developed. Thus, the investigator was extremely motivated to examine the impact of pulmonary rehabilitation on pulmonary function measurements among COPD patients after discovering, via conversation with COPD patients, that they were highly motivated to engage in the program.
PROBLEM STATEMENT:
An inquiry has focused on pulmonary function measurements in patients with chronic obstructive pulmonary disease (COPD) receiving treatment at Jubilee Mission Medical College and Research Institute in Thrissur.
OBJECTIVES OF THE STUDY:
1. Find out how well people understood and used pulmonary rehabilitation both before and after the intervention.
2. Before and after the intervention, compare the pulmonary function measurements of COPD patients.
3. Evaluate the pre- and post-intervention levels of pulmonary rehabilitation knowledge and practice.
4. There is still uncertainty about the association between certain sociodemographic and clinical data components and the pretest knowledge and practice scores on pulmonary rehabilitation among COPD patients.
OPERATIONAL DEFINITIONS:
Effect: Change in the level of knowledge and practice on pulmonary rehabilitation that result on improvement in pulmonary function measure.
Pulmonary rehabilitation:
Teaching given by the investigator on pulmonary rehabilitation includes general awareness on COPD, dietary modification, behavioural intervention, emotional support and development of coping skill, after that demonstration on breathing exercise was performed, which will be assessed by self-developed structured knowledge questionnaire and practice check list.
Pulmonary function measures: The standardised 6-minute walk test (6MWT) is used to assess the patient's oxygen saturation (Spo2%), heart rate (beats/minutes), and degree of dyspnoea (Modified Borg dyspnoea scale). The total distance walked (meter) was recorded.
Chronic Obstructive Pulmonary Disease (COPD) patients: Patients who diagnosed as COPD by the physician.
Hypothesis:
H1: Following the intervention, COPD patients' comprehension of pulmonary rehabilitation significantly varies.
H2: Pulmonary rehabilitation practice levels among chronic obstructive pulmonary disease (COPD) patients change significantly after the intervention.
H3: As a result of the operation, COPD patients show a considerable improvement in pulmonary function tests.
METHODOLOGY:
Research approach: Quantitative research approach was adopted in this study.
Research design: One group pretest-posttest design with quasi-experimental parameters.
Research Variable:
● Independent variable: Pulmonary rehabilitation
● Dependent variable: The COPD patients in pulmonology outpatient department. Setting of the study.
Population: The target population was all COPD patients in selected hospital.
The accessible population for the study was COPD patients in Pulmonology outpatient department (OPD) at Thrissur District.
Sample:
In the present study subjects were 30 COPD patients from the Pulmonology outpatient department at Jubilee Mission Medical College and Research Institute, Thrissur.
Sampling technique:
Simple random sample utilising the lottery method was the sampling strategy used for the investigation.
Tool/ Instrument:
The following tools have been used for the study:
Section A: Clinical and Socio-Demographic Data Variables Questionnaire
Section B: It includes
Part I: Structured Knowledge Questionnaire on pulmonary rehabilitation
Part II: Practice Checklist: To assess the practice on pulmonary rehabilitation
Section C: Pulmonary function measures.
Part I: Six-minute walk test
Part II: Modified Borg Dyspnoea scale: To assess the shortness of breath.
Description of the tool:
Section A: It consists of 15 items of sociodemographic variables and clinical data variables.
Section B: Part I: To assess the patient's familiarity with pulmonary rehabilitation, we devised a 25-question structured knowledge assessment that they could complete on their own. The questions had four possible answers and were of the multiple-choice kind. The questions were organized under 5 domains. They are general awareness on COPD, pulmonary rehabilitation, breathing exercise, dietary modification, behavioural intervention and development of coping skills.
|
Level of Knowledge |
Range of Scoring |
Percentage |
|
Adequate |
19-25 |
76- 100 |
|
Moderately adequate |
13-18 |
51- 75 |
|
Inadequate |
<12 |
< 50 |
Part II: It consists of 20 Yes or No questions to assess the level of practice followed by the COPD patients.
|
Level of practice |
Score |
Percentage |
|
Adequate |
16-20 |
76-100% |
|
Moderately adequate |
11-15 |
51-75% |
|
Inadequate |
<10 |
<50% |
Section C: Part I: 6 Minute walk test (6MWT)
The six-minute walk test is a globally recognised and accepted method for evaluating pulmonary function. In order to accommodate patients who may require a break, testing was carried out along a 50-meter hospital hallway that was furnished with seats. The standardised dyspnoea measurement was used. A portable pulse oximeter was used to record vital signs (heart rate, oxygen saturation, and modified Borg dyspnoea scale) both before and after the test. When the 6-minute walk test was over, the overall distance covered was noted. The parameters were recorded in the 6-minute walk test recording sheet.
Part II: Modified Borg dyspnoea scale (from burden 1982): Degree of shortness of breath assessed by standardized Modified Borg dyspnea scale (from burden 1982). Test was conducted along with before and after 6 minute walk test. You may rate the difficulty of breathing on this scale from 0 to 10. It goes from zero, when breathing is completely easy, to ten, where it becomes quite tough.
Method of data collection:
Data was collected from pulmonology outpatient department in JMMCH & RI, Thrissur. The hospital administration had to provide their agreed-upon approval before any data collection could start. A systematic knowledge questionnaire, a practice checklist, and a pre- and posttest evaluating pulmonary function were given once sample consent was obtained. Four weeks later was the posttest given. The collected data were analysed using both descriptive and inferential statistics.
RESULTS:
1. Distribution of socio-demographic and clinical data variables: In terms of socio-demographic statistics, 46.7% of the participants were male, 86.7% were in the 61-70 age range, 43.3% had only completed elementary school, and 0% had completed high school.100% of subjects were married, 66.7% of subjects resides at rural area and 33.3% at urban area. 26.7% were industrial worker, 16.7% were farmer, 30% of COPD patients had the monthly income below Rs 5000, 33.3% had above 6 years of duration of illness.76.7% of COPD patient had history of smoking. None of them had no previous exposure to pulmonary rehabilitation.
2. Level of knowledge and practice on pulmonary rehabilitation among COPD patients before and after intervention: Nearly all of the COPD patients (24 out of 80) had an insufficient amount of knowledge on the pretest. In the posttest the maximum subjects 16(53.3%) had adequate knowledge. The posttest showed a very substantial improvement (p=0.000). The distribution of the participants as a whole revealed that whereas 19 out of 30 had a sufficient practice score on the posttest, 28 out of 30 got an inadequate score on the pretest. Patients with chronic obstructive pulmonary disease (COPD) who underwent pulmonary rehabilitation showed a considerable improvement in their practice levels after the intervention (p=0.000).
Figure 1: Bar diagram showing percentage distribution of COPD patients based on duration of illness (n = 30)
Table 1: Distribution of subjects based on level of knowledge on pulmonary rehabilitation (n = 30)
|
SI. No. |
Domains of Knowledge |
|
Level of knowledge |
||||||
|
Adequate |
Moderately adequate |
Inadequate |
|||||||
|
F |
(%) |
F |
(%) |
F |
(%) |
||||
|
I |
General awareness of COPD |
Pretest |
1 |
3.3 |
4 |
13.3 |
25 |
83.3 |
|
|
Posttest |
16 |
53.3 |
11 |
36.7 |
3 |
10.0 |
|||
|
II |
Pulmonary rehabilitation |
Pretest |
1 |
3.3 |
5 |
16.7 |
24 |
80 |
|
|
Posttest |
17 |
56.7 |
10 |
33.3 |
3 |
10.0 |
|||
|
III |
Breathing exercise |
Pretest |
1 |
3.3 |
5 |
16.7 |
24 |
80 |
|
|
Posttest |
17 |
56.7 |
10 |
33.3 |
3 |
10.0 |
|||
|
IV |
Dietary modification |
Pretest |
2 |
6.7 |
3 |
10 |
25 |
83.3 |
|
|
Posttest |
19 |
63.3 |
8 |
26.7 |
3 |
10.0 |
|||
|
V |
Behavioural intervention and development of coping skills |
Pretest |
1 |
3.3 |
5 |
16.7 |
24 |
80.0 |
|
|
Posttest |
15 |
50 |
10 |
33.3 |
5 |
16.7 |
|||
|
VI |
Overall |
Pretest |
1 |
3.3 |
5 |
16.7 |
24 |
80 |
|
|
Posttest |
16 |
53.3 |
11 |
36.7 |
3 |
10.0 |
|||
Table 2: Distribution of subjects based on level of practice on pulmonary rehabilitation (n = 30)
|
SI. No. |
Domains of Practice |
|
Level of practice |
|||||
|
Adequate |
Moderately adequate |
Inadequate |
||||||
|
F |
(%) |
F |
(%) |
F |
(%) |
|||
|
I |
Breathing exercise |
Pretest |
1 |
3.3 |
5 |
16.7 |
24 |
80 |
|
Posttest |
19 |
63.3 |
8 |
26.7 |
3 |
10.0 |
||
|
II |
Dietary modification |
Pretest |
1 |
3.3 |
- |
- |
29 |
96.7 |
|
Posttest |
19 |
63.3 |
11 |
36.7 |
- |
- |
||
|
III |
Behavioural intervention |
Pretest |
1 |
3.3 |
- |
- |
29 |
96.7 |
|
Posttest |
18 |
60 |
9 |
30 |
3 |
10 |
||
|
IV |
Emotional support and development of coping skill |
Pretest |
1 |
3.3 |
3 |
10 |
26 |
86.7 |
|
Posttest |
27 |
90 |
2 |
6.7 |
1 |
3.3 |
||
|
V |
Overall |
Pretest |
2 |
6.7 |
- |
- |
28 |
93.3 |
3. Compare the pulmonary function measures among COPD patients before and after intervention.
Table 3: Mean, standard deviation, t value and p value on 6MWT (6 Minute Walk Test) before and after intervention. (n = 30)
|
Variable |
Before Pulmonary rehabilitation |
After Pulmonary rehabilitation |
t value |
p value |
||
|
Mean |
SD |
Mean |
SD |
|
|
|
|
6MWT, distance m |
459.2 |
19.4 |
511.2 |
19.3 |
8.94 |
0.001* |
|
6MWT, % predicted |
65.8 |
4 |
72.6 |
3 |
|
|
|
SpO2, % |
|
|
|
|
|
|
|
Pretest |
96.1 |
2.1 |
96.8 |
1.9 |
0.395 |
0.533 |
|
Posttest |
91.5 |
1.8 |
91.7 |
2.2 |
|
|
|
Dyspnea, Borg scale |
|
|
|
|
|
|
|
Pretest |
2.3 |
0.4 |
1.5 |
0.6 |
33.6 |
0.874 |
|
Posttest |
4.2 |
0.9 |
2.7 |
1.6 |
|
|
|
Heart rate, (beats/ minutes) |
|
|
|
|
|
|
|
Pretest |
81 |
5 |
79 |
5 |
11.45 |
0.182 |
|
Posttest |
128 |
10 |
117 |
12 |
|
|
(t29=3.038 p<0.05) *Moderate significant p<0.05
Abbreviations: 6MWT- 6 minute walk test, SpO2-peripheral oxygen saturation.
The table (3) displays the results of the 6-minute walk test taken both before and after pulmonary rehabilitation. Heart rate, oxygen saturation, and dyspnoea scale did not show any statistically significant changes. Both the total distance walked and the percentage of the expected walk distance showed a statistically significant improvement (p=0.001). The average distance walked increased by 50 meters during pulmonary rehabilitation.
4. Compare the level of knowledge and practice on pulmonary rehabilitation before and after intervention.
The total mean knowledge score after the exam (18.30±6.78) was much more than the score before the test (6.17 ± 5.40). Compared to the pretest overall mean practice score of 8.278.12, the posttest overall mean practice score of 15.935.40 was much greater.
Figure 2: Distribution of mean pre-test and post-test of pulmonary function measures among COPD patients before and after pulmonary rehabilitation. 6MWT (6 minute walk test), SpO2 (peripheral oxygen saturation) (n = 30)
Table 4: Mean standard deviation, standard error and t value of pre and posttest knowledge and practice score on pulmonary rehabilitation among COPD patients (n = 30)
|
Variable |
|
Mean |
SD |
SE |
Df |
t value |
P value |
|
Level of knowledge |
Pretest |
6.17 |
5.40 |
0.987 |
29 |
9.628 |
0.000*** |
|
Posttest |
18.30 |
6.78 |
1.23 |
|
|
|
|
|
Level of practice |
Pretest |
8.27 |
8.12 |
1.48 |
29 |
5.414 |
0.000*** |
|
Posttest |
15.93 |
5.40 |
0.986 |
|
|
|
*** Highly significant p < 0.05
Figure 3: Distribution of mean pre-test and post-test knowledge scores of COPD patients with different coponents of knowledge on pulmonary rehabilitation (n = 30)
Figure 4: Distribution of mean pre-test and post-test practice scores of COPD patients with different components of practice on pulmonary rehabilitation
5. Association of pretest level of knowledge and practice with selected socio-demographic and clinical data variable among COPD patients.
Table 5: Chi square (x2), degree of freedom (df) and p value of association of pretest level of knowledge on pulmonary rehabilitation with selected socio-demographic and clinical data variables among COPD patients (n=30)
|
Selected socio-demographic and clinical data variables |
Chi square |
Df |
P value |
|
Age |
6.60 |
6 |
0.35 |
|
Gender |
0.36 |
2 |
0.8 |
|
Educational status |
24.911 |
6 |
0.000*** |
|
Marital status |
- |
- |
- |
|
Pattern of job |
4.825 |
6 |
0.566 |
|
Religion |
4.364 |
4 |
0.359 |
|
Place of residence |
2.856 |
4 |
0.582 |
|
Monthly income |
14.743 |
6 |
0.725 |
|
Duration of COPD |
8.006 |
6 |
0.238 |
|
Previous history of hospitalization |
2.016 |
4 |
0.733 |
|
History of smoking |
8.618 |
2 |
0.582 |
|
Family history of smoking |
0.361 |
2 |
0.835 |
|
Previous information about pulmonary rehabilitation |
5.366 |
4 |
0.252 |
|
Co-morbid condition |
1.895 |
6 |
0.929 |
|
Measures to relive breathing difficulty |
6.275 |
6 |
0.393 |
*** Highly significant p < 0.05
The pretest revealed a statistically significant relationship between knowledge level and educational achievement. The amount of knowledge may be significantly impacted by the educational position of COPD patients (χ2= 24.91, p = 0.000).100% of COPD patient did not have prior knowledge about pulmonary rehabilitation was found to be increased.
Table 6: Chi square (x2), degree of freedom (df) and p value of association of pretest level of practice on pulmonary rehabilitation with selected socio-demographic and clinical data variables among COPD patient (n=30)
|
Selected socio-demographic and clinical data variables |
Chi square |
Df |
P value |
|
Age |
2.662 |
3 |
0.447 |
|
Gender |
0.283 |
1 |
0.595 |
|
Educational status |
2.167 |
1 |
0.141 |
|
Marital status |
- |
- |
- |
|
Pattern of job |
1.857 |
3 |
0.603 |
|
Religion |
0.963 |
2 |
0.618 |
|
Place of residence |
0.963 |
2 |
0.618 |
|
Monthly income |
6.440 |
3 |
0.092 |
|
Duration of COPD |
4.540 |
3 |
0.209 |
|
Previous history of hospitalization |
0.248 |
2 |
0.884 |
|
History of smoking |
1.994 |
1 |
1.58 |
|
Family history of smoking |
0.283 |
1 |
0.595 |
|
Previous information about pulmonary rehabilitation |
0.216 |
2 |
0.898 |
|
Co-morbid condition |
3.534 |
3 |
0.316 |
|
Measures to relive breathing difficulty |
14.733 |
3 |
0.002* |
*Moderately significant p < 0.05
The level of practice on pulmonary rehabilitation has statistically association with measures to relive breathing difficulty. The measures to relive breathing difficulty evinces that moderately significant (χ2 = 14.73, p = 0 .002) influence to improve the level of practice among COPD patients those who follow proper medication and relive breathing difficulty they have a better outcome of practice.
· The computed t-value (t = 9.62) was significantly higher than the table value (t = 3.03 at p<0.05), with a p-value of 0.000. Pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) improves lung function measurements as well as patients' knowledge and practice levels.
INTERPRETTION AND CONCLUSION:
The study's results indicate that COPD patients' knowledge and practice levels significantly differed following pulmonary rehabilitation at a p0.05 level. Pulmonary function assessments, knowledge, and practice are all greatly improved by pulmonary rehabilitation". The results showed a substantial correlation (p0.05) between educational status and pretest level of knowledge, and a moderately significant correlation (p = 0.002) between pretest level of practice score and methods to alleviate breathing difficulties.
IMPLICATION OF THE STUDY AND RECOMMENDATION:
The present study has included these results, which have significant implications for nursing administration, nursing practice, nursing education, and research.
Nursing education:
Nursing education is very vital in modelling the future nurses who play a major role in promoting the health of COPD patients. Nurse educator has to emphasise on the prevention of COPD complications by early diagnosis and treatment. Nursing students can utilize the study findings while taking care of COPD patients.
Importance of pulmonary rehabilitation should be included in the curriculum. Pulmonary rehabilitation should be an integral part of the health education curriculum, including topics such as introduction, definition, indication, objective, areas of benefits, and nursing responsibilities. In this way, pulmonary rehabilitation may be taught by student nurses while they are stationed in hospitals and community settings. Whether in a clinical setting or out in the community, student nurses may learn patient-specific activities to do at home.
Nursing practice:
Nurse can use this evidence-based knowledge in their practice. They may inform COPD patients of the value of pulmonary rehabilitation and motivate them to participate in the program.
Community and hospital-based nurses should be well-versed in caring for patients with chronic obstructive pulmonary disease (COPD), and patients and their families should have access to sufficient information on the disease and the advantages of pulmonary rehabilitation.
Nursing administration:
Nursing administration can plan for continuing nursing education programme, workshops to discuss importance of pulmonary rehabilitation. They can ensure that health education imparted to COPD patients which can help in prevention of complication, reduce morbidity and mortality rates. Hospital management have to notify the education department about the health concerns and designate staff members to oversee health education initiatives. Administrators of community health must set up rehabilitation clinics inside the community.
Nursing research:
There has to be more study to determine what COPD patients need to learn so that we can add to what is already known. Improving nursing care requires a focus on research and clinical investigations. The effects of education and demonstration on pulmonary function metrics in patients with COPD are a topic that may need further investigation, of which the present study is merely the beginning. More thorough research is needed in the following areas to ensure that patients with chronic obstructive pulmonary disease (COPD) fully recover: quitting smoking, treating allergies, exercising, and taking spiritual and financial factors into account.
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Received on 06.09.2024 Revised on 14.10.2024 Accepted on 08.11.2024 Published on 16.12.2024 Available online on December 31, 2024 Int. J. Nursing Education and Research. 2024;12(4):241-248. DOI: 10.52711/2454-2660.2024.00051 ©A and V Publications All right reserved
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