Helping Patients with COPD Manage Episodes of Acute Shortness of Breath.
Although difficult, helping patients to use breathing techniques during dyspneic episodes may be one of the most effective nursing interventions available to reduce shortness of breath. The purpose of this article is to present an effective method for teaching pursed-lip breathing to patients during acute episodes of dyspnea.
Factors Contributing to Dyspnea
Chronic obstructive pulmonary disease occurs when chronic bronchitis or emphysema causes airflow obstruction (American Thoracic Society, 1995). The obstruction is generally progressive. It can be accompanied by airway hyperreactivity, and may be partially reversible. Patients with chronic bronchitis experience a chronic, productive cough. Emphysema includes abnormal enlargement of the airspaces distal to the terminal bronchioles with destruction of their walls but without obvious fibrosis (American Thoracic Society, 1995). Hyperinflation often accompanies emphysema. Inflammation of the terminal bronchioles may occur prior to the development of other changes in emphysema (Corbridge & Irvin, 1993).
Patients with COPD demonstrate significant airflow obstruction on expiration which can be demonstrated by pulmonary function testing. To overcome chronic airway obstruction, patients with COPD must increase their work of breathing. Additional work is created when hyperinflation is present because with a greater amount of air remaining in the lungs after exhalation, the diaphragm is pushed downward and is unable to move the chest cage effectively on inspiration (Manning & Schwartzstein, 1995). Because the diaphragm cannot work effectively, patients begin to use accessory muscles of breathing including sternocleidomastoid, pectoralis, and external intercostal muscles (Breslin, 1996). An increase in respiratory rate and the use of accessory muscles by patients with COPD has been associated with perceptions of increased dyspnea (Breslin, 1992).
Model of Dyspnea
In planning care for the COPD patient, the nurse must consider not only these likely physiologic factors involved in the sensation of dyspnea, but recognize that dyspnea is a multidimensional symptom (Carrieri & Janson Bjerklie, 1984; Gift, 1990; Steele & Shaver, 1992). A recent statement of the American Thoracic Society (1999, p. 332) defined dyspnea "as a term used to characterize a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavior responses."
Gift (1990) described a comprehensive model of dyspnea which includes five components: sensation, perception, distress, response, and reporting of dyspnea. Sensation includes the stimuli, receptors (mechanical and chemical), and nerve pathways involved in the transmission of impulses to and from the lungs, respiratory muscles, chest wall, respiratory circulation, and brain. Dyspnea may involve an imbalance in all of these sources of sensation. The perception of dyspnea involves the patient's interpretation of the sensation. Perception may be influenced by how long the patient has experienced dyspnea; his expectations of the situation, age, gender; and the presence of other diseases.
Psychological aspects of dyspnea are reflected in the patient's descriptions of distress. High levels of anxiety have been associated with high levels of dyspnea (Gift, 1990). The response that patients have to dyspnea reflects their coping style. Responses can be immediate or long-term as well as problem focused or emotion focused (Carrieri & Janson-Bjerklie, 1986). Immediate responses that COPD patients frequently demonstrate when they are short of breath include sitting quietly and isolating themselves from others. To cope with dyspnea over time, patients may respond by changing their patterns of performing activities of daily living, such as bathing only when others are home to help them, and avoiding social activities with family and friends. These responses affect not only the patient but their families and other caregivers.
How patients report the dyspnea they are experiencing is influenced by a variety of factors (Janson-Bjerklie et al., 1986). The disease process associated with dyspnea such as asthma, COPD, pulmonary fibrosis, and other diseases influences how patients describe shortness of breath. For example, patients with COPD often describe dyspnea as "hard to breathe" while patients with asthma describe it as "chest tightness" (Simon et al., 1990). Reports of dyspnea may be associated with other symptoms such as poor appetite, fatigue, and other somatic complaints. Societal norms may influence how patients report dyspnea (Gift, 1990). Because dyspnea is a multidimensional symptom, nurses must consider all components involved in the Gift (1990) model of dyspnea to develop effective strategies to help patients relieve their shortness of breath.
Patient Strategies for Managing Dyspnea
Patients often discover, through trial and error, effective strategies for managing their acute episodes of dyspnea. Some of these strategies include: reducing their activities; assuming a leaning forward position with upper body and arms supported; using breathing techniques, medications, oxygen, and home remedies; removing themselves from the cause of shortness of breath; seeking exposure to fresh air; seeking to be alone and telling themselves to calm down; requesting social support; and using distraction or diversion (Carrieri & Janson-Bjerklie, 1986). While evaluating patients' perceptions of dyspnea experiences during hospitalization, DeVito (1990) identified nursing behaviors that patients found most helpful in assisting them to manage episodes of dyspnea. These included acknowledging that the patient is experiencing anxiety and fear associated with dyspnea, accepting the patient's perception of dyspnea severity, assisting with self-care activities, demonstrating breathing techniques, and assisting the patient to concentrate on using breathing techniques. It is evident from the findings of these studies that patients perceive the help they receive in using breathing techniques to be an important nursing intervention for dyspnea management.
How Pursed-Lip Breathing Works to Reduce Dyspnea
It is well known that without having previous instruction, patients with COPD often demonstrate the use of pursed-lip breathing when they become short of breath (Thoman, Stoker, & Ross, 1966). Pursed-lip breathing is breathing out through the mouth while the lips, except for a section in the center, are held together. Exhalation should be at least twice as long as inhalation and should be a steady stream of air without blowing too hard. Inhalation should be through the nose and not too deep (Tiep, Burns, Kao, Madison, & Herrera, 1986). Previous studies have demonstrated that pursed-lip breathing decreases respiratory rate, increases tidal volume, decreases arterial [CO.sub.2], increases arterial oxygen, and improves exercise performance (Casciari et al., 1981; Mueller, Petty, & Filley, 1970; Thoman et al., 1966; Tiep et al., 1986). More recently Breslin (1992) evaluated the pattern of respiratory muscle recruitment during pursed-lip breathing. She found that pursed-lip breathing resulted in increased use of muscles of the rib cage and other accessory muscles on both inspiration and expiration, decreased time of inspiration as compared with the total time of the respiratory cycle, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels. She also found that the diaphragm was being spared from fatigue by using this breathing pattern. Diaphragm fatigue is associated with respiratory failure. Despite the fact that dyspnea is associated with increased use of accessory muscles, the use of pursed-lip breathing may improve the breathing pattern by increasing the efficiency of the accessory muscles of inspiration, supporting the movement of the diaphragm, and decreasing the respiratory rate.
In addition to these physiological outcomes of using pursed-lip breathing, there may be several other positive outcomes. If pursed-lip breathing decreases respiratory rate, improves the efficiency of breathing and increases tidal volume, the patient should be better able to administer inhaled bronchodilators. Studies have demonstrated that even when patients are not short of breath, they have difficulty administering inhaled medications correctly (Fink & Hunt, 1998). It is reasonable to assume that if patients can use pursed-lip breathing first to reduce their respiratory rate and allow more time for medication absorption, the inhaled medications they administer will be more effective.
Using pursed-lip breathing has also been associated with increased exercise performance (Casciari et al., 1981). By effectively using pursed-lip breathing, patients can increase their activities and reduce isolation. Using pursed-lip breathing also empowers the patient by providing a self-implemented treatment that is controlled only by the patient. There is no need to rely on others to obtain medication or to provide assistance. Pursed-lip breathing helps the patient to relax and decrease anxiety related to shortness of breath. Although more research is necessary to fully evaluate techniques such as pursed-lip breathing, patients with COPD continue to use these techniques and support their benefit.
Strategies for Teaching Patients Pursed-Lip Breathing
To effectively teach patients to use pursed-lip breathing during episodes of acute shortness of breath, nurses should use several strategies at the same time. These strategies incorporate the use of visual, tactile, and verbal stimuli. The effective use of these stimuli together requires intensive, ongoing assessment of and interaction with the patient without distraction. Because dyspneic patients are already using a significant amount of energy to breathe and are anxious, they have little energy left to invest in learning a new skill. Directions to the patient should be clear, short, and spoken calmly. Nurses should first acknowledge that these patients are in significant distress because of their dyspnea while, at the same time, provide them with reassurance and demonstrate confidence that these techniques will be effective at relieving their distress.
Starting to Use Pursed-Lip Breathing
Once the patient has been reassured that help has arrived, the patient should be positioned to maximize use of the respiratory muscles. Patients should assume an upright position leaning forward with arms supported. An alternative position for the patient who is weak is a side-lying position with the head of the bed elevated. Both of these positions support the movement of the diaphragm and the use of abdominal accessory muscles. They also provide support for the upper chest, facilitating efficient use of the accessory muscles of inspiration.
Once the patient is positioned to facilitate respiratory muscle movement, intensive interventions are implemented. First, pursed-lip breathing should be demonstrated to the patient, not described. The patient should be directed to breathe with the nurse. At this time the nurse demonstrates pursed-lip breathing at the patient's respiratory rate. This communicates to the patient again that the nurse appreciates the degree of distress the patient is experiencing.
Slowing the Patient's Respiratory Rate
Since the outcome is to decrease the respiratory rate, other strategies should be implemented to accompany pursed-lip breathing. As the patient begins to purse-lip breathe with the nurse, tactile stimulus may be used by the nurse to encourage the patient to decrease his or her respiratory rate. This is accomplished by placing the hands lightly on the patient's shoulders, maintaining contact throughout the respiratory cycle. If the patient is in a side-lying position, an alternative hand placement is one hand on the shoulder and the other hand on the patient's opposite lateral lower chest. After a few breaths, the nurse begins to exert slight downward pressure on the shoulders or shoulder and lateral lower chest for a few seconds at the end of expiration. This encourages the patient to breathe out longer.
At the same time, the nurse demonstrates the visual stimulus of breathing out longer with each breath to encourage the patient to slow his or her respiratory rate. While demonstrating breathing out longer using pursed-lips, the nurse also provides the patient with a verbal stimulus by saying "Breathe with me" or "Breathe out a little longer." As the patient begins to breathe out longer, the nurse uses a verbal stimulus again to reinforce the patient's positive behavior. Appropriate statements might be "That was a good breath," "You are breathing out longer," and "Your breathing is slowing down." Positive reinforcement should be based on accurate assessment of the patient's performance to achieve a further decrease in respiratory rate. Inappropriate positive reinforcement will confuse the patient about what is expected of him or her and prolong dyspnea distress. During these activities, the nurse should be positioned at eye level with the patient and maintain frequent eye contact. This demonstrates a commitment to help and a willingness to give the patient full attention. This close attention will help the nurse more carefully evaluate the patient's respiratory rate and pattern as well as anxiety level (Respiratory Nursing Society, 1994). Pulse oximetry, if available, can also be used to provide patients with visual feedback on the effectiveness of using pursed-lip breathing by demonstrating improvement in their oxygen saturation.
These interventions continue until the patient's respiratory rate has decreased and acceptable control of breathing is achieved by the patient. Although initially the interventions may require a significant amount of the nurse's time, as the patient achieves success in managing dyspnea during these episodes, the time required will decrease. The patient will develop increased confidence in the use of pursed-lip breathing and initiate this technique when dyspnea occurs. The next step is to help the patient integrate the use of pursed-lip breathing with activities to prevent or minimize shortness of breath.
Problems with Pursed-Lip Breathing
Although many patients are able to learn pursed-lip breathing with coaching, others find this technique difficult to use. The problems patients experience using pursed-lip breathing include: breathing out through lips that are too tight which increases the use of accessory muscles of expiration; inhaling too deeply which may further increase hyperinflation; pursing the lips only partially through expiration which may result in increased use of accessory muscles; exhaling too long causing patients to inhale the next breath too deeply; and giving up using pursed-lip breathing all together after only a few breaths. Although most of these problems can be remedied, the patient usually requires intensive coaching to be successful. Further research is necessary to determine the characteristics which differentiate patients who use pursed-lip breathing effectively to manage shortness of breath from those who find that it is not a helpful tool. Table 1 describes patient behaviors indicating effective use of pursed-lip breathing.
Table 1. Patient Behaviors Indicating Effective Pursed-Lip Breathing
1. Respiratory rate within 8 to 16 breaths per minute. 2. Decreased use of accessory muscles as indicated by no lifting of clavicle during inhalation. 3. Relaxed, prolonged expiration through pursed lips as indicated by: * Expiration twice as long as inspiration. * Expiration not strained. * Constant airflow is maintained during expiration. 4. Verbalizes that shortness of breath has decreased.
Although pursed-lip breathing can be effective in helping patients manage their dyspnea, it does not always replace appropriate use of bronchodilator therapy. While one nurse is assisting the patient to use pursed-lip breathing, another may need to obtain and administer an inhaled bronchodilator. Hopefully, by the time the medication is ready for administration, the patient's respiratory rate is decreased by using pursed-lip breathing so that the medication is effective.
Preparing Nurses to Teach Pursed-Lip Breathing
Although most patients report that pursed-lip breathing is an effective technique for managing dyspnea, experience at our institution indicates that many nurses did not feel confident teaching patients to use pursed-lip breathing particularly during dyspneic episodes. The nurses also expressed concerns about the time they needed to spend with COPD patients because the patients were so anxious. To alleviate these problems, several teaching strategies were developed to prepare nurses to teach patients to use pursed-lip breathing during episodes of dyspnea. A competency program was developed and implemented by a clinical nurse specialist who was an expert in managing dyspneic patients. The program provided nurses with the rationale for using pursed-lip breathing with COPD patients and gave them the opportunity to practice teaching pursed-lip breathing to a patient actor. By the end of the program, nurses were required to successfully teach the patient actor pursed-lip breathing without assistance of the instructor. The clinical nurse specialist used additional teaching strategies to support the competency program. These included role modeling of teaching pursed-lip breathing to dyspneic patients on the unit and providing assistance to nurses in managing difficult patients. As the nurses became skilled in teaching patients pursed-lip breathing, the clinical nurse specialist celebrated with the nurses each success they experienced in teaching patients this technique which positively reinforced their learning.
Although no formal process was used to evaluate these training strategies, several positive outcomes were achieved. Nurses reported an increase in their confidence in managing COPD patients during dyspneic episodes. Requests for assistance in managing patients were made to the clinical nurse specialist only for the most difficult patients and after the nurse had attempted to assist the patient. Based on reports from nurses and the clinical nurse specialist's own experience, at least three intubations were avoided by effectively coaching patients to perform pursed-lip breathing.
Pursed-lip breathing is one of the critical survival skills that COPD patients need to maintain function and avoid hospitalization. It does not require any equipment or expense. It has no side effects, and patients can implement it when needed. Teaching pursed-lip breathing to patients should be a priority nursing intervention when caring for these patients in any setting.
Acknowledgment: The assistance of Marilyn Oermann, PhD, RN, FAAN, Audrey Gift, PhD, RN, and Michele Geiger-Bronsky, MSN, RN, CS, FAACVPR, NP, in the review and preparation of this article is gratefully appreciated.
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Sandra Truesdell, MSN, RN, CS, is a Clinical Nurse Specialist, Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI.
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|Title Annotation:||chronic obstructive pulmonary disease|
|Date:||Aug 1, 2000|
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