COPD



Chronic Obstructive Pulmonary Disease (COPD), is a common chronic condition managed through home health and hospice. Symptoms are chronic and progressive dyspnea, cough and sputum production. A primary goal of COPD care is symptom management. COPD is associated with mental and physical comorbidities such as depression, muscle wasting and heart failure. 
 

Drug therapy for COPD is used to reduce symptoms, frequency and severity of exacerbations and improve health status and exercise tolerance. However, none have been shown to modify the long-term decline in lung function. 24 hr (long-acting) medication products are often preferable but are cost prohibitive for some patients. Smoking cessation is the intervention with the greatest ability to influence the natural history of COPD (GOLD, 2014)  For a comprehensive approach to help patients quit smoking see the 2008 U.S. Department of Health and Human Services guidelines, Treating Tobacco Use and Dependence.

 ElevatingHome Best Practice:

  1. All patients with COPD should be assessed for risk of hospitalization.
  2. Both non-pharmacological and pharmacological interventions for COPD should be addressed in a systematic program that is also formally taught to clinical staff.
  3. Utilize evidence-based disease management program including teaching tools to assure consistent care and patient teaching.
  4. Focus should be on helping patients develop self-care competencies for those that are able to do so.
Critical Interventions

Goal: Ensure comprehensive admission and assessment emphasizing respiratory status.
Best Practice Interventions: 
Table 1: Comprehensive Home Care Approach to COPD
Intake
Obtain the following information as part of the intake process:
  • H&P and/or hospital discharge summary
  • Stage of COPD – Mild, Moderate, Severe, Very Severe
  • Conduct full risk assessment (See Blueprint for Excellence Care Initiation) to identify concerns regarding discharge and safety
  • Discharge/current medication list
  • Ordered treatments and lab tests to be done
  • Assess teach-back readiness and any teaching tools used by referral source
  • Extent of family involvement; identified caregiver; patient representative.
Call/speak to patient on day of dc from a facility to ask about:
  • Who is helping you at home?
  • Has your breathing changed since you got home?
  • Were all of your prescribed medications obtained?  Any questions about them? Was cost an issue if didn’t obtain all of them?
  • Do you have a working thermometer in the house?
  • Have you used your inhaler/nebulizer since coming home?  Any problems?  Do you have/use a spacer for your inhaler?
  • Do you feel safe &/or do you need a visit today/this evening?
  • Provide agency name and contact information and assure 24 hour response to calls.
Recommended Frontloading Schedule
  • SN – Recommend 2- 3 visits in a row - assess, intervene and refocus. Utilize the same RN for visits when possible to assure consistency of care.
  • REHAB  - 1-3 visits a week starting 1-3 days after initial RN visit
  • HHA  -  to assist with personal care when needed
  • MSW -  especially if pt unable to afford medications
  • 5-7 visits/week 1
  • Implement telehealth/telephonic communications 2nd visit if appropriate

Start of Care Interventions/Actions

  • Admit with 24 hours
  • OASIS, total clinical assessment AND complete respiratory assessment including VS, pain status, SP02, dyspnea assessment using rating scale, standardized tests (BORG,CCQ, CAT), breath sounds, use of accessory muscles, nasal flaring, weight, cough, presence of sputum with change in consistency, color, activity tolerance, mental status, smoking history, oxygen use, ability to use inhaler, nebulizer, manage 02 therapy.  Complete respiratory assessment at each visit.
  • Assess patient/family concerns and refer to MSW for community resources/psych RN for anxiety and depression.
  • Complete medication reconciliation using VERIFY CLARIFY RECONCILE.
  • Assess educational needs regarding medications and use of inhalers, nebulizers, 02 equipment.
  • Assess immunization status and record in clinical record.
  • Check that medications ordered are in home and process exists for obtaining medications as needed including ability to pay for them.
  • Introduce Stoplight Method for symptom awareness and self-management
  • Provide on-call number, MD contact number and use of 911.
  • Assess for tele-health appropriateness
  • Refer to PT for exercise, activity tolerance; Refer to OT for energy conservation
  • Schedule PCP follow-up appointment within 7 days
Self-Management Education
Smoking Cessation
  • Ask patients at each visit about tobacco use to ascertain readiness/willingness to make a “quit attempt” to stop smoking.
  • Using empathetic communication skills, strongly urge patients to quit.
  • If/when patient willing, make referral to local smoking cessation program that includes tobacco dependence counseling and social support.
  • Notify PCP of readiness and obtain orders for nicotine replacement products and/or medications such as varenicline, or bupropion SR (sustained release) that help with the physiological addition to tobacco.
  • Consider recommending antidepressant to help treat psychological aspect of addiction.
  • Counsel patient that because tobacco dependence is a chronic disease, relapse is common, and he/she should not be discouraged
Reducing symptoms - Coping strategies for self-management of Shortness of Breath, cough, sputum production
  • Teach patient to use a dyspnea rating scale and encourage to log-in levels daily.
  • Teach techniques such as pursed lip and diaphragmatic breathing and have patient demonstrate ability to use them to help reduce dyspnea and the anxiety associated with it.
  • Proper positioning, in which the patient sits or stands leaning forward with arms supported should be encouraged to help reduce the work of breathing.
  • Teach controlled coughing to help clear airways.
  • Teach energy conservation techniques and assure patients understanding and ability to use them.
  • Work with patient to identify environmental triggers of dyspnea including temperature extremes and exposure to air pollution, chemical fragrances and dust and develop a plan to avoid these triggers.
  • Teach clinical signs of a bacterial infection such as increased sputum purulence. and volume and/or dyspnea requiring need for antibiotic treatment.
  • Teach secretion clearing strategies such as controlled coughing.
  • Some patients may benefit from a trial with an incentive spirometer to help clear airways.
  • Explore methods to help improve sleep quality. These may include: (1) go to bed sleepy; (2) adhere to a consistent sleep schedule; (3) adjust timing of medications; (4) avoid sleeping pills; (5) add nighttime oxygen and (6)use of CPAP if sleep apnea is a coexisting factor.
Nutritional Needs
  • Ask patient to keep a log of food and fluid intake and review on each visit.
  • Discuss ways to improve intake of protein and calories.
  • Help patient plan for small, frequent meals high in protein.
  • Avoid gas-forming foods such as beans, and foods in the cabbage family
  • High-caloric nutritional supplements may be indicated
  • If possible, refer to dietician for help with understanding dietary requirements including fluid requirements/restrictions
  • Suggest use of breathing medication one hour before meals.
Emotional Health/relaxation techniques: Help patients/caregivers verbalize feelings using empathetic listening skills. (See Blueprint for Excellence Hospice module - Treatment Preferences and Beliefs - for a a discussion of 'artful conversations.'
  • Identify healthy coping behaviors such as meditation, listening to music, guided imagery and visualization exercises, breathing and relaxation techniques, to help reduce anxiety.
  • Encourage patients to share feelings with family members, friends or health care personnel.
  • If patient is positive for depression utilizing the PHQ2 and PHQ 9 or GDS, notify primary care physician (PCP) and make appropriate referrals.
Exercise: Some form of daily exercise is beneficial for patients with COPD to improve exercise tolerance and reduce dyspnea and fatigue.  Work with patients to set exercise goals and overcome barriers. Many patients need to start off very slowly with postural training, simple flexibility and chair exercises.
  • Refer to PT and/or OT so an individualized routine can be developed based on the patient’s level of disease and functional capacity.
  • Encourage patient to keep an exercise log and review at each visit.
  • Suggest new technology such as FITBIT that tracks steps taken and can provide positive reinforcement. (See VNAA Heart Failure Blueprint for details)
  • Use the 3 minute walk if 6 minute walk is overwhelming.
Oxygen therapy and equipment: Long term oxygen therapy (O2) (>15 hrs/day) has been shown to increase survival in patients with severe resting hypoxemia (SPO2 at or below 88%). Medicare coverage guidelines require a SPO2 at or below 88%. Although used to treat exacerbations, CPAP isn’t indicated in the routine, long-term management of COPD.
  • O2 safety should be discussed especially if patient or caregiver smokes.
  • Discuss patient O2 requirements with DME company and assure patient/caregiver know how to contact the company when problems with equipment arise.
  • Assess need for humidification and request PCP order if needed.
  • Teach patient how to clean and maintain O2 equipment.
Breathing aides – inhalers and nebulizers: Assess proper use of inhalers. Recommend a SPACER prescription from the PCP to assure delivery of full dose of inhaled medications.
  • Assess proper inhaler technique using teach back method.
  • Review proper storage as many inhalers become compromised if exposed to moisture or light.
  • Consider need for nebulizer. Nebulizers are recommended if the patient is unable to understand or physically use an inhaler so are often more beneficial for patients who are older or have end-stage disease. Nebulizers may be easier to use for some patients but are more expensive and less portable.
  • Teach patient to clean nebulizer after every use and allow to air dry to avoid contamination.
  • Teach when to use rescue/controller inhaler and assess understanding using teach-back.
Self-Monitoring of comorbidities that are common, complicate treatment and impact prognosis.: For Heart Failure management, see the Blueprint for Excellence Module
  • Hypertension – teach importance of monitoring and maintaining BP goal.
  • Osteoporosis – as it is associated with poor health status and prognosis.  Discuss avoidance of recurring courses of systemic corticosteroids for COPD exacerbations.
  • Anxiety and Depression – screen for and encourage patient to seek treatment if present.
  • Infections – patients should monitor for signs and symptoms of infection including increased cough, sputum production, change in color of sputum, and temperature.
  • Diabetes – teach importance of keeping Hemoglobin A1c at goal
Teaching on preventing and managing exacerbations
  • Monitor frequency, severity and likely causes of any exacerbations.
  • Mark on calendar each time a PRN inhaler is used. Increased use may be first sign of increase in SOB.
  • Recognize other signs of exacerbations including worsening dyspnea, chest congestion or discomfort, sleep disturbance and feelings of weakness, fatigue, fear or anxiety.
  • Importance of early recognition to initiate prompt treatment and reduce risk of hospitalization, future exacerbations and impaired quality of life.
  • Teach staff to be able to identify severity or exacerbations and when a patient can safely be treated at home or should be transferred to the hospital. (See Table below).
  • Promote oral hygiene and periodontal health to avoid bacterial infections.
  • Increase exercise to help prevent complications of immobility.
  • Address nutritional needs for increased protein to decrease risk of infection and monitor weight weekly.
  • Assure adequate oxygenation and secretion clearance. Avoid cough suppressants.
  • Teach patient to focus on reducing exposure to risk factors
  • Avoid persons with respiratory infections.
    • Wash hands often to help prevent respiratory infections.
    • Avoid gastroesophageal reflux disease.
    • Avoid second hand smoke and other environmental pollutants
    • Yearly flu vaccination, ideally by October, and pneumonia vaccine

Discharge/Transition Planning

Consider:
  • Pulmonary rehab; Elder services; Private pay services; Continuance of telehealth; Exacerbation prevention; Ongoing determination of tobacco use; Referral to hospice and palliative care when appropriate; Hand off of up-to-date medication list and discharge summary
  • Review Blueprint for Excellence modules on Preventing Readmissions / Discharge to Community for recommendations on community stay
 
Goal: Ensure appropriate pharmacologic interventions and medication management 
Best Practice Interventions
  • Conduct a thorough medication reconciliation during the SOC and ROC visit.
  • Referral to Medical Social Worker (SW) if cost or ability to obtain medications is a problem. Identify distant family members who may be involved &/or willing to cover costs.
  • Teach nursing staff need to be extremely cautious of prescribed anticholinergics such as Spiriva if patient has significant asthma component to disease.
  • Teach proper use of long acting (LABA’s)verses short acting beta-2 agonists (SABA’s).
  • Opioids can be recommended for patients who are poorly controlled.
  • Assess understanding of all medication actions and side effects, and on subsequent visits adherence to medication schedule.
  • Work with patient to develop self-care behaviors (using teach-back techniques etc) including decisions and plans to incorporate medication taking into daily activities, obtaining initial and refill prescriptions, and managing a change of routine brought about by appointments, travel and other illnesses. Assess for need to obtain devices such as pill boxes to help with medication adherence.
  • Assure patient understands which medications should be taken regularly and which are used only as needed to control symptoms Refer to occupational therapy(OT) or speech therapy(ST) for cognitive skills if necessary to help with medication adherence.
  • If on multiple inhalers instruct use of inhaler that opens the airways such as short-acting beta-2 agonist (SABA’s) first before an inhaled corticosteroid (ICS), to receive full benefit of both medications.

Goal: Address advance care planning and palliative/hospice options proactively

Patients with severe and very severe COPD should be offered a formal Palliative Care consult if available in the community. Revisit advanced care planning discussions periodically as preferences change particularly as the patient’s health declines. Use a simple, structured approach to facilitate these conversations (See Blueprint for Excellence Modules on Hospice and Palliative Care)
Best Practice Interventions:
  • Refer to Palliative Care, or hospice for patients with severe or very severe COPD
  • Discuss advanced care planning, palliative care and end-of-life-care options with patients who have severe and very severe COPD including Advanced Directives and POLST.
  • Recommend and refer to Hospice care if patient meets Medicare eligibility guidelines. Guidelines include:  disabling dyspnea at rest and poorly or unresponsive to bronchodilators, increasing visits to ER or hospitalization for pulmonary disease, hypoxemia at rest on room air, heart failure secondary to COPD, unintentional progressive weight loss and resting tachycardia.
Goal: Ensure appropriate discharge plan
Best Practice Interventions:
  • Consider pulmonary rehabilitation post discharge.
  • Discuss advantages (especially for younger patients) of pulmonary rehabilitation programs post discharge. Make pulmonary rehab referrals/recommendations as needed.
  • Review Blueprint for Excellence modules on Preventing Readmissions / Discharge to Community for recommendations on helping patients stay at home safely
Tools
Page reviewed August 2019