Journal of the Association of Chartered Physiotherapists in Respiratory Care - Volume 44 | 2012 - ACPRC
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Journal of the
Association of Chartered
Physiotherapists in
Respiratory Care
Volume 44 | 2012
Contents
Introduction
Original Articles
A study to investigate the clinical use and outcomes of EZPAP 4
positive pressure device to determine its effectiveness as an
adjunct to respiratory physiotherapy.
Elliott S
Validity and reliability validation of a questionnaire to explore 12
physiotherapy practice into the use and delivery of nebulised
isotonic saline in the UK.
Hobbs J, Conway J, Craddock D
A qualitative study into the experiences of living with long- 22
term oxygen therapy: the perspective of patients with chronic
obstructive pulmonary disease.
Pugh S, Enright S
Effects of high frequency chest wall oscillation on ventilation in 28
children with cystic fibrosis : A pilot study
Rand S, Hill L, Shannon H, Main E
An Evidence and Consensus Opinion Based Approach to support 35
the selective use of incentive spirometry following elective
cardiac surgery; considerations for practice.
Wright S, Dowsland A, Anderson J
Early rehabilitation of critical care patients: A review of the 42
literature since 2009.
Keen C
Book Review 52
Journal of ACPRC, Volume 44, 2012 12 Journal of ACPRC, Volume 44, 2012
Introduction
Welcome to the 2012 journal of the Association of Chartered
Physiotherapists in Respiratory Care (ACPRC). The aim of the ACPRC is
to promote best practice in respiratory physiotherapy for the benefit
of patients and the journal achieves this by providing a medium for the
dissemination of findings of research which can be discussed within your
workplace.
Editors
The articles in this year’s journal cover the four champion areas:
UNA JONES chronic disease, paediatrics, surgery and critical care and also a range of
jonesuf@cardiff.ac.uk research methodologies from both qualitative and quantitative domains.
These studies highlight the diversity of work within respiratory care and
LEIGH MANSFIELD
also the dedication of physiotherapists to provide the best possible care
leigh_mansfield@btopenworld.com
for their patients.
Design and layout
Drayton Press, West Drayton Looking forward to next year, the ACPRC conference will be held in
Tel: 01895 858000 Leicester 19th-20th April 2013. This is a great opportunity for us to meet,
print@drayton.co.uk discuss hot topics and develop the ACPRC as a professional network of
the Chartered Society of Physiotherapy.
Printing
Drayton Press We hope you enjoy this issue of the ACPRC journal and remind you that
author guidelines with detailed instructions are available on the ACPRC
© Copyright 2012
website www.acprc.org.uk. The deadline for submission to the next
Association of Chartered
Physiotherapists in
journal is 31st January 2013. The editorial team are more than happy to
Respiratory Care discuss any potential article – so get writing!
With best wishes
Una Jones MSc MCSP
Leigh Mansfield MSc MCSP
Journal of ACPRC, Volume 44, 2012 3A study to investigate the clinical use and
outcomes of EZPAP positive pressure device
to determine its effectiveness as an adjunct to
respiratory physiotherapy.
Sarah Elliott MA, PGCert,
BSc(Hons) Correspondence Details
Physiotherapy Practitioner Sarah Elliott
Medway Maritime Hospital, Windmill Road, Tel: 01634 830 000 Bleep 537
Gillingham, Kent, ME7 5NY Email: sarah.elliott@medway.nhs.uk
Summary Keywords:
Few clinical studies relate to the EZPAP
EZPAP positive pressure device Positive Pressure Device
leading to a small investigation to Clinical Effectiveness
analyse physiological outcomes, Respiratory Physiotherapy
allowing for an informed
evidence based decision prior the positive pressure during the respiratory
to purchasing the units. Results cycle prove it is consistent on both the
demonstrated improvements inspiratory and expiratory phase of respiration
in all physiological parameters if flow is set at >5 litres, (CITECH, 1999) and
Ogrinc et al (2002) advocates that the pressure
and the study concluded that achieved is within a clinically useful range for
EZPAP has the potential to be an lung expansion. Black et al, (2006) clarify that
additional and viable adjunct positive pressure is maintained throughout the
to respiratory physiotherapy. patients breathing cycle at predictable airways
pressures at delivered flows.
Introduction
However, there are few clinical trials and a
The EZPAP was first introduced to the UK in 2003 literature search only yielded seven results
after its launch in the USA in 1999. It is marketed which are summarised in table 1.
as an adjunct to respiratory physiotherapy as a
technique to increase lung volume and reduce
atelectasis by amplifying an input flow of
either air or oxygen approximately four times
using the coanda effect. This augmentation
provides a larger flow and volume with less
effort than an unsupported inspiration and
positive expiratory pressure (PEP) is provided
on expiration. Studies regarding reliability of
4 Journal of ACPRC, Volume 44, 2012Paper Study Design Method Main Findings Limitations Conclusions Recommendations
Tarnow & Daniel Observational Study EZPAP used as SaO2 - mean increase Not randomised EZPAP may offer safe Further randomised
(2002) alternative to IPPB and of 2%. alternative treatment studies required.
prescribed 2-4 hourly No comparison to IPPB of atelectasis.
for patients ordered 4 patients did not
for lung expansion require intubation and Limited quantifiable
therapy. ventilation results/physiological
observations measured
Small scale study (5
patients) Doesn't state time
frame/number of
interventions
Daniel & Tarnow Observational Study EZPAP used as Statistically significant Not randomised Preliminary findings Further study required
(2001) alternative to IPPB increase in SaO2 only. to truly establish role
to treat patients (p6
Paper Study Design Method Main Findings Limitations Conclusions Recommendations
Synder et al (2001) Experimental Purpose of study: to Small test group Pressures achieved May cause fatigue at
examine inspiratory are within a clinically higher pressures and
/ expiratory pressure Only tested on healthy useful range and patients may need to
during normal lungs constant throughout rest between cycles.
breathing at different breathing cycle.
flow settings.
Addition of nebuliser
Tested on 3 volunteers doesn't affect
with normal lungs, operation of device.
flow adjusted from
Journal of ACPRC, Volume 44, 2012
1-15 litres.
Smiths Medical (nd) Clinical Testimonials Subjective reviews by Varying comments Subjective Respiratory therapists Personal testimonials
respiratory therapists including: who use EZPAP in
across USA who had • Easy to use Single patient case clinical practice report
used EZPAP in practice. • Imprved atelectasis studies positive outcomes
• Effectively clears following interventions
secretions. Lack of quantitive data
Kopp (2009) Observational study in Review of EZPAP in Easy to use Perceptions of staff EZPAP has high level of No sufficient clinical
own workplace authors workplace in and patients patient compliance studies to prove
post operative patients Good patient positive clinical
compliance Lack of quantifiable experiences
data, no objective
Improvement of gas measures
exchange
Harland (2003) Testimonial Review of products Identified EZPAP as Proposed Identifies that EZPAP Not tested
available possible adjunct to hyperinflation protocol could be more
respiratory therapy - not yet tested effective than incentive
Development of spirometer if patient
hyperinflation protocol unable to inhale
10ml/kg
Table 1 – Summary of StudiesReferring to table 1, it can be seen that most respect to effectiveness and ease / difficulty
of the evidence in respect EZPAP is mainly of use. A pragmatic approach of using several
observational or personal testimonials, outcome measures was utilised within this
with only the result of a single clinical trial study because it has to be acknowledged that
published. However, this limited research there may be subjective bias in completion of
does suggest that in clinical practise EZPAP is physiological observations, therefore multiple
effective in treating atelectasis, sputum load outcome measures may improve validity and
and decreased gas exchange. Other benefits also aid in drawing conclusions in relation to
identified by these studies included the risks and benefits.
simplicity of the set up, for both the patient and
those administering (Daniel & Tarnow 2002). Physiotherapists involved in data collection all
Additionally, patients have also perceived the received theoretical and practical workshops
system more comfortable and demonstrate a on EZPAP, as well as being up to date with
high level of compliance with the treatment their on call competency programme. Other
(Kopp 2009 & Harland 2003). respiratory physiotherapy adjuncts remained
available throughout the duration of the study.
Due to a lack of clinical studies it was necessary The physiotherapist chose the treatment
to investigate the outcomes of EZPAP prior to adjunct based on clinical reasoning.
purchasing this device, ensuring it was effective
an adjunct to respiratory physiotherapy. Results
The aim, through a small scale, department In respect to data analysis, the free text
based clinical study was to measure clinical questions, patient and physiotherapists
outcomes of the EZPAP in relation to increasing perceptions were analysed by content analysis,
lung volume, sputum clearance and gaseous and quantitative data was analysed by simple
exchange. The results would then determine if percentages with percentage differences
the EZPAP device was purchased. documented where applicable for changes in
physiological measurements so comparisons
Methods could be made pre and post treatment.
Physiotherapists carried out comprehensive Eighteen sets of data were returned giving a
respiratory assessments on all patients referred return rate of 90%. There was a wide variety of
to the physiotherapy service during the study patients with differing medical diagnosis across
which lasted six months, and on analysis of the the whole spectrum of clinical specialities
patient’s problems the physiotherapist had the where EZPAP had been utilised and this is
professional autonomy to select the treatment shown in figure 1.
technique. If EZPAP was selected, the patient
then entered the study and data collection
was completed on the specifically designed
measurement tool. Twenty EZPAP units were
provided for the study by Henley’s Medical
Ltd. Physiotherapists were asked to document
all physiological parameters, completed as
part of a normal respiratory assessment
before and after treatment, and their analysis
of the intervention and the reason for their
treatment choice. Additionally, as part of the
subjective assessment patients were asked to
comment about the treatment technique in
Journal of ACPRC, Volume 44, 2012 7Figure 1 - Pie Charts to demonstrate the clinical When selecting EZPAP as the treatment
speciality and admitting diagnosis of patients technique, physiotherapists chose to use it
who were selected for EZPAP instead of other modalities in 42% of the
cases to increase lung volume, 36% to clear
secretions, 14% to increase gas exchange
and 8% to prevent atelectasis. Comments to
justify treatment choice included; required
positive pressure intervention, ease of use for
both patient and practitioner and neurological
deterioration. In 24% of occasions it was
used as an additional adjunct to respiratory
physiotherapy. On average patients required
2.8 treatment sessions over a mean of 1.2 days,
when in 72% of cases alternative treatment
modalities, namely mobilisation were then
practised, only a small minority ceased due to
complications; too drowsy (11%), pain (5.5%)
and non compliance (5.5%).
Table 2 summarises the outcomes of EZPAP
in relation to physiological observations,
physiotherapist’s analysis of treatment and
patient perceptions. For ease of comparison,
the results have been grouped into outcomes
for increasing lung volume, sputum clearance,
gas exchange, decreasing work of breathing
and any other comments. Included in this
table is the physiotherapist’s analysis of
their treatment intervention, plus subjective
comments from the patient. Dawes et al
(2005) advocates that those delivering and
receiving the treatment should be involved in
the process.
8 Journal of ACPRC, Volume 44, 2012Clinical Outcome Physiological Observation Phsiotherapist Analysis Patient Perception
Lung Volume 72% patients who demonstrated decreased Improved lung volume (40%) Feels like I've done exercise to open my lungs
breath sounds bi basally pre treatment had an
improvement post treatment Chest feels more mobile
100% increase in patients who initially Increased air going into my lungs
demonstrated decreased unilateral expansion to
achieve noraml expansion Feels like I am taking deep breaths
Sputum Retention 45% reduction of crepitations on auscultation Cleared secretions (16%) Feels something has moved
83% reduction of tactile fremitus Stimulated cough (12%) Feels something has shifted
Feels less sputum after treatment
Gas Exchange 33% of patients of demonstrated an improvement Increased SaO2 (33%) of patients
in SaO2
Decreased oxygen demand (12%)
2 patients weaned off oxygen
Prevent Atelectasis Physiological observations maintained Maintained respiratory status in neurological
patients (4%)
Work of Breathing Mean decrease of 3.5 breaths per minute Reduced work of breathing (4%) Improved breathing pattern
Greatest reduction of 10 breaths per minute Easier to breath (2)
Decreased my breathing rate
Other Comments No changes in heart rate post EZPAP intervention Non complian Tiring (5)
Unable to achieve seal Discomfort on inspiration due to surgical wound
Drosy patient Feels much better after treatment (4)
Ease of Use Ease of use (12) Comfortable (2)
Quick to set up Easy to use (6)
Can teach Nursing Staff and patient to use Visual Aid with manometer
between physiotherapy sessions
Table 2 – Table to show outcomes of EZPAP intervention
Journal of ACPRC, Volume 44, 2012
9Discussion et al (2005).
The aim of this study was to measure changes in Daniel & Tarnow (2002) and Kopp (2009) revealed
physiological observations pre and post EZPAP that the simplicity and ease of use of the EZPAP,
intervention so to establish clinical outcomes comfort for the patient and compliance were
for EZPAP in relation to lung volume, sputum additional benefits to this treatment modality
clearance and gaseous exchange which in turn when considering effectiveness and efficiency.
would lead to an informed decision whether This study confirms that both physiotherapists
to purchase EZPAP as an adjunct to respiratory and patients highlighted these factors. Further
physiotherapy care. This decision was also research needs to be undertaken in relation to
supported by the comments and opinions financial costs. As highlighted in this study and
gained from the practising physiotherapists and supported by Kopp (2009), EZPAP can be used
patients. It is acknowledged that the reliability by the nursing staff or independently by the
and validity of this research would have been patient, thus reducing physiotherapy contact
improved by using radiological studies and time and possible on call visits.
arterial blood gas analysis; however, this wasn’t
feasible at this time. The small scale of this study
Conclusion
utilised the outcome measures of physiological It can be seen from this study that there
observation which are normally conducted as was a wide variety of clinical conditions and
part of a respiratory physiotherapy assessment, specialities that the physiotherapists identified
thus not creating extra pressure on staff to suitable for the use of EZPAP. Effectiveness
complete data collection. The physiological of the device has been proved on a small
observations of auscultation, lung expansion, scale by the improvements of physiological
respiratory rate and SpO₂ all showed an observations for increasing lung volume,
improvement after EZPAP and this is recorded preventing atelectasis, clearing secretions
in table two. The results therefore support and improving gas exchange as identified in
existing research. Daniel & Tarnow (2002) existing research. However, where much of this
identified EZPAP as a technique to increased literature was circumstantial this study used
lung volume, as did Wiersgalla (2002). Whereas objective markers to clarify the successful
Harland (2003) suggested EZPAP as an effective outcome of EZPAP interventions, however it is
method to clear secretions and Kopp (2009) acknowledged additional outcome measures
to improve gas exchange. Regarding work of such as arterial blood gas analysis and chest
breathing, there is little evidence available; x rays would have improved the validity and
Daniel & Tarnow (2001) found it decreased reliability of this study. This study also identified
respiratory rate in a small number of patients that EZPAP may also be used as a physiotherapy
with atelectasis. The results of this study technique to reduce the work of breathing and
demonstrated improvements in respiratory this requires further investigation.
rate, physiotherapist analysis identifying the
work of breathing to be reduced and patient Alongside clinical improvements, both patients
perception of improved respiratory status. and clinicians found the device easy and
Except for the identified study, the literature comfortable to use, quick to set up with rapid
search only yielded circumstantial case studies, results, utilising only one clinician therefore
DHD Healthcare, (n.d) to support EZPAP as a is a cost effective adjunct, and it was the
treatment modality, so it could be concluded physiotherapist’s perceptions that EZPAP is
that this study enhances the evidence base potentially an alternative adjunct to respiratory
by utilising physiological outcome measures, physiotherapy and EZPAP has subsequently
even at this small scale and also involves those been purchased for use at our hospital.
receiving the treatment as advocated by Dawes
10 Journal of ACPRC, Volume 44, 2012Recommendations Daniel, B. M. , Tarnow, J. L. 2002. EZPAP: an
effective treatment in segmental and lobar
This study was small scale at a local level and atelectasis, Chest 122 (4 supplement) 208S
further randomised trials utilising ABG’s, -209S
radiological evidence and amount of sputum
cleared should be carried out. EZPAP should Dawes, M. 2005. Sicily statement on evidence
also be compared to devices such as the cough based practice BMC Medical Education, 5:1
assist mechanical insufflators – exsufflator,
DHD Healthcare, EZPAP peer reviews, DHD
flutter, acepella and PEP masks.
Healthcare, USA
Key Points
Ferreira, G.M. , Haeffner, M.P. , Barreto, S.S.
• EZPAP is a versatile tool for physiotherapists & Dall’Ago, P. 2010. Incentive Spirometry with
in respiratory care expiratory positive airway pressure brings
benefit after myocardial revascularisation, Arq
• EZPAP is easy to use with a high level of Bras Cardiol, 94 (2) 230-5
patient compliance
Harland, R. 2003. Hyperinflation Protocol, St
Acknowledgments Josephs Hospital
The author wishes to thank Henly’s Medical Kopp, R. 2009. EZPAP in postoperative
Supplies Ltd for providing the EZPAP units respiratory therapy, MTD, 10, 68-69
and for providing theoretical and practical
workshops enabling all physiotherapists at Ogrinc, S.R. , Martin, J.E. , 2002. Minimum
Medway Maritime Hospital to be competent in inspiratory pressure levels during simulated
the use of the equipment. spontaneous breathing using an EZPAP system.
A bench study. The Science Journal of the
References American Association for Respiratory Care, www.
rcjournal.com/abstracts/2002/?id=OF-02-085
ACPRC (2011) ACPRC Conference
– Latest News, online http://www. Snyder, R.J. , Slaughter, S.L. & Chatburn, R. 2001.
a c p rc . o rg . u k / i n d ex . p h p ? o p t i o n = c o m _ Pressure / Flow characteristics of the EZPAP
content&task=view&id=148&Item positive airway pressure therapy system, The
Science Journal of the American Association
Black, P.J. , Gnahn, E.R. , Loechler, R.M. , for Respiratory Care, www.rcjournal.com/
Peterson, W. V. , Sampson, K.D. Witzke, S.M. abstracts/2001/?id=A00000140
Findlay, J.Y. & Stroetz, R.W. 2006. Does EZPAP
deliver predictable airway pressures, The Wiersgalla, S. 2002. Effects of EZPAP post
Science Journal of the American Association for operatively in coronary artery bypass graft
Respiratory Care, online http://www.rcjournal. patients, The Science Journal of the American
com/abstracts/2006/?id=OF-06-106 Association for Respiratory Care, www.
rcjournal.com/abstracts/2002/?id=OF-02-084
CITECH 1999 Test Report EZPAP Positive Airway
Pressure Device #490-370, DHD Healthcare,
Wampsville New York
Daniel, B. M. , Tarnow, J. L. 2001. EZPAP?
An alternative in lung expansion therapy,
Science Journal of the American Association
for Respiratory Care, www.rcjournal.com/
abstracts/2001/?id=A00000193
Journal of ACPRC, Volume 44, 2012 11Validity and reliability validation of a
questionnaire to explore physiotherapy
practice into the use and delivery of nebulised
isotonic saline in the UK
Joanna Hobbs MRes, PG Cert,
MCSP.
Physiotherapy Team Lead - Home Oxygen Correspondence Details
Service, Physiotherapy Department, Solent Joanna Hobbs
N.H.S. Trust, St James Hospital, Locksway
Road, Portsmouth, PO4 8LD Tel: 02392 685098
Email: joannahobbs1@nhs.net
Joy Conway PhD, MSc, MCSP.
Professor of Inhalation Sciences, Faculty of Keywords:
Health Sciences, University of Southampton Nebulised Isotonic Saline
Deborah Craddock PhD Respiratory
Director of Programmes for Researcher Physiotherapy
Development, Faculty of Health Services,
University of Southampton
Summary
but there is little scientific evidence on which
Nebulised isotonic saline (0.9%) to base its use (Kellet et al., 2005). In current
as a method of enhancing airway clinical practice, the use of nebulised isotonic
saline to aid the clearance of sputum appears
clearance has become a clinically
to be based mainly on anecdotal evidence. No
accepted adjunct to physiotherapy studies were found that investigated the use of
in the treatment of many chronic nebulised isotonic saline within physiotherapy
lung conditions despite little clinical practice, although there have been
scientific evidence for its use. The those exploring humidification (Conway et al,
1992).
aim of this research study was
to develop and validate a data The value of a questionnaire depends on the
collection tool to explore current validity and reliability of the information it
physiotherapy practice in the gathers. Validity is how well the questionnaire
measures what it is intended to measure
United Kingdom on the use of (Meadows, 2003). The validity of the
nebulised isotonic saline. questionnaire was measured by face and
content validity. Face validity is based on
whether the items look appropriate and
Introduction
content validity is assessed on the extent to
Nebulised isotonic saline (0.9%), as a method which the questionnaire’s content includes
of enhancing airway clearance, has become a everything it should and does not include
clinically accepted adjunct to physiotherapy in anything it should not (Meadows, 2003).
the treatment of many chronic lung conditions,
12 Journal of ACPRC, Volume 44, 2012Reliability refers to how well the data collected of the nebuliser, participants’ clinical views
by using the questionnaire can be reproduced. and in the closing part of the questionnaire
an opportunity for the participant to add
This is part of a larger study, which used the qualitative comments (see, Appendix 1). This
questionnaire to gather data from respiratory design approach ensured that specific questions
physiotherapists in the UK. followed on from general questions (Meadows,
2003) and that there was a consistency to the
Aim presentation of visual information (McColl et
The aim of this study was to develop and assess al., 2001).
the reliability and validity of a questionnaire
Face and content validity were assessed on two
exploring physiotherapy practice on the use of
occasions; firstly by using an expert panel and
nebulised isotonic saline.
secondly by carrying out directive interviews
Method (Oppenheim, 1992). The expert panel was
comprised of a clinical respiratory specialist
This methodological study assessed the physiotherapist, a professor in aerosol medicine
face and content validity and reliability of a and a consultant respiratory physiotherapist.
questionnaire, designed in order to collect The questionnaire was considered by the panel
data from a large geographical area, containing in terms of content, flow and terminology
mainly closed questions. This method of data used. The changes made from this stage
collection minimises the risk of interviewer were fed forward to the second stage of face
bias. As there were no funds available for and content validity, directive interviews
printing and posting, the aim was to distribute with two respiratory physiotherapists, from
the questionnaire electronically. a local clinical interest group, who were also
members of the Association of Chartered
To promote the response rate in this study, Physiotherapists in Respiratory Care (A.C.P.R.C).
the questionnaire was developed to be The purpose of these two stages was to ensure
short and simple with minimal jargon and the questionnaire did not contain inappropriate
acronyms (Houser and Bokovoy, 2006). Careful material and that the contents were suitable to
attention was paid to design and layout of fulfil the larger study research objectives. Again
the questionnaire, reducing the risk of errors the changes made in the second stage were
in posing and interpreting questions and in carried forward to stage three, which assessed
recording and coding of responses (McColl et reliability.
al., 2001). This also helped to minimise the
potential for inter-rater variability. The content Stage Three involved the questionnaire being
of the questions were informed by current pre-piloted on five different volunteers,
literature and the lead author’s experiences from the local clinical interest group, on
of working in the respiratory physiotherapy two occasions, one week apart, to ensure
field. The studies found concerning nebulised reliability of the data collecting tool, with a
isotonic saline revealed numerous models of test-retest reliability method (Knapp, 1998).
nebuliser and many different protocols used. The five volunteers completed the electronic
For example, the protocols varied in the gas questionnaire and followed the protocol for
choice and gas flow rate to drive the nebuliser the main study to return the questionnaire to
and some papers did not state these at all. the lead author.
The questions were grouped together in six The expert panel and directive interviews
sections, including demographic background were recorded, with consent, to assist the
of participants, prescription of nebulised lead author in engaging with the panel and
isotonic saline, clinical indications, the setup volunteers. The lead author kept a research
Journal of ACPRC, Volume 44, 2012 13diary in order to reflect upon the process and be completed in approximately 10 minutes.
to ensure that all comments were included.
Ethical approval was granted from the Faculty The usability of the questionnaire was assessed
of Health Sciences Ethics Committee at The in both Stage One and Two, when further
University of Southampton and permission was alterations were made to the questionnaire,
granted for product photography inclusion in including the addition of coherent instructions
this research study from the various nebuliser for more complex questions in bold type to
equipment manufacturers. ensure clarity for participants; an increase in
the size of the text boxes to enable a longer
Results answer to be typed; and the addition of
question options were changed to text boxes
Face and content validity were judged by the to allow specific answers rather than a range
expert panel and directive interviewees, on being chosen.
the relevance of the questions and the themed
sections. Recommendations were made for Reliability was via test-retest analysis at Stage
amendments to the questionnaire. It was Three. The five participants had the same
decided after discussion that Question 11 demographic data answers when completing
regarding the clinical indications and diagnoses the questionnaires on the two different
should include surgical and paediatric options. occasions. One of the five participants gave
Suggestions were also put forward regarding the the same answer for the closed questions on
terminology used in the questionnaire and the each occasion and recorded similar answers
consistency of the terminology throughout the to the open questions. For Question 12,
questionnaire. For example, advice was given on the reasons for using nebulised isotonic
to change isotonic saline nebuliser to nebulised saline, three participants answered one part
isotonic saline. The expert panel were also able differently and one participant made an error
to highlight to the lead author that permissions by checking two boxes in one part of the
needed to be sought regarding the inclusion of question. This equated to 84% of the questions
pictures of the nebulisers in the questionnaire. being answered consistently on the two
Some ideas that arose during the two stages occasions. The three differing answers differed
were deemed too far removed from the topic by one point, one moving from disagree to
of nebulised isotonic saline. An example of this uncertain; one changing from Strongly Agree
was a question about using saline in Intermittent to Agree and the final one from Agree to
Positive Pressure Breathing equipment, to Strongly Agree.
which it was decided against including, as the
lead author and her supervisors felt that is was The four participants that put a different
outside of the scope of this study. answer on the first semantic differential scale,
in Question 17a, all moved their answer to a
Directive interviews were completed, more extreme point on the scale, agreeing
individually, with two volunteers during that nebulised isotonic saline is effective as
completion of the questionnaire, with short-term humidification. One participant
verbalisation of their thoughts and subsequent answered Question 17f responded at opposite
questions. This was to ensure the practicalities ends of the scale on each occasion. Three
of completing the questionnaire were not parts of Question 17 had an error in one of the
overlooked. Examples of this were to ensure answers, when the participant had given two
the question was understood as intended by the
lead author and that the questionnaire could
14 Journal of ACPRC, Volume 44, 2012answers to one question. These answers were ensure it was not too long. This in turn would
excluded from the analysis, as it could not be help to encourage participants to take part in
determined which answer was chosen. the main study, enhancing the response rate
(Oppenheim, 1992).
Overall, there was 81.1% agreement on answers
over the two tests, and the questionnaire By involving the expert panel and the clinicians
was considered reliable. Due to low numbers the questionnaire was examined and face
of volunteers, statistical analysis of internal and content validity of the questionnaire was
consistency, for example Cronbach’s coefficient supported.
alpha, was not carried out.
To ensure the reliability of the questionnaire
The final version of the questionnaire is a test-retest method (Knapp, 1998), in
presented in Appendix 1. Stage Three, allowed data to be produced.
Unfortunately, due to the small sample
Discussion number, the data were not suitable for
inferential analysis. A comparison of data from
The aim of this study was to test the reliability
Stage Three evidenced good agreement for
and validity of the designed questionnaire,
the majority of the questionnaire. The main
prior to the main study. After each stage of
questions for inconsistency were Question
the testing changes were made to develop and
12 and Question 17. Both were scale answers
improve the questionnaire, before the next
with a greater chance of different answers
stage was started, ensuring rigour. Meadows
being documented on the two occasions, than
(2003) described this process in order to focus
the other questions. Question 12 had 84%
on testing the whole administrative procedure
agreement of the answers. This may be due to
of using the questionnaire in a smaller sample
the fact that there were only 5 points on the
of participants before the main study.
Likert scale to choose from. Question 17 used
Stage One, the expert panel of three key experts a seven point semantic differential scale and
in respiratory care gave their consent to take this was reflected in the increase in number of
part in the study and assisted by critiquing the different answers. The one participant in Stage
questionnaire and ensured that the questions Three that answered Question 17f with a five
were not biased towards the lead author’s area point different answer on the two occasions,
of respiratory care, considering all aspects. may have misread the question on one or both
The experts also were able to suggest ideas occasions or may have changed their mind in
to develop the questionnaire further. Some between time one and time two. This may
of these were carried forward, for example, have been due to enquiring or discussing with
to change the terminology used for nebulised colleagues during the week in between the
saline. As experts in the field of respiratory two occasions. Overall, the level of agreement
care, these professionals ensured that the between time one and time two questionnaire
content of the questionnaire was appropriate answers was 81.1%. These results showed that
to the research question. the questionnaire was a reliable tool to collect
data.
The directive interviews in stage Two ensured
the practicalities of completing the Conclusions
questionnaire were not overlooked. This
Research to date does not provide a conclusive
was to ensure the question was understood
rationale, protocol or prevalence data
as intended by the lead author and thus
regarding the use of nebulised isotonic saline.
limiting error-variance in the final result. It
This emphasised the need to develop and
also enabled the length of time needed to
validate a questionnaire to explore current
complete the questionnaire to be reviewed to
Journal of ACPRC, Volume 44, 2012 15physiotherapy practice regarding the use of Key Points
nebulised isotonic saline in the United Kingdom
from the respiratory physiotherapy population. A valid and reliable data collection tool is now
The value of a questionnaire depends on the available to explore the current physiotherapy
validity and reliability of the information it practice regarding the use of nebulised isotonic
gathers; the face and content validity regarding saline.
how well the questionnaire measures what it
is intended to measure and the reliability to More research is needed into the use and
collect reproducible data. delivery of nebulised isotonic saline.
Impact on Clinical Practice References
This questionnaire has now been validated and Conway, J. H. 1992 The effects of humidification
can be used to collect important information for patients with chronic airways disease,
on the use and delivery of nebulised isotonic Physiotherapy, 78 (2), 97-101.
saline in physiotherapy practice in the UK.
Houser, J. and Bokovoy, J. 2006 Clinical
This questionnaire has subsequently been sent Research in Practice: A Guide for the Bedside
out to members of the Association of Chartered Scientist. London: Jones and Bartlett Publishers
Physiotherapists in Respiratory Care and the International
findings will be presented in a separate paper.
Kellett, F, Redfern, J. and McL Niven, R. 2005
Recommendations for Future Evaluation of nebulised hypertonic saline (7%)
Research as an adjunct to physiotherapy in patients with
stable bronchiectasis Respiratory Medicine,
Further research needs to be carried out, to 99, 27 - 31.
investigate nebulised isotonic saline, in a range
of different ways: Knapp, T. R. 1998 Quantitative Nursing
Research. Thousand Oaks: Sage.
• Exploration of the patient perspective
regarding the use of nebulised isotonic McColl, E., Jacoby, A., Thomas, L., Soutter, J.,
saline. Bamford, C., Steen, N., Thomas, R., Harvey, E.,
Garratt, A. and Bond, J. 2001 'Design and use
• Interviews or focus groups would provide of questionniares: a review of best practice
a more in-depth exploration into the use applicable to surveys of health service staff
and prescription of nebulised isotonic and patients', Health Technology Assessment
saline by physiotherapists. [Online], 5. Available: http://www.hta.ac.uk/
pdfexecs/summ531.pdf [Accessed 28/02/10].
• Investigation into the financial cost of
nebulised isotonic saline. Meadows, K. A. 2003 'So you want to do
research? 5: Questionnaire design', Research
• Development of protocols and guidelines Methods, 8 (12), 562 -570.
would provide support for healthcare
professionals providing nebulised isotonic Oppenheim, A N 1992 Questionnaire design,
saline. interviewing and attitude measurement.
London: Continuum
16 Journal of ACPRC, Volume 44, 2012Appendix 1
Jo Hobbs, Final Questionnaire v1.1, 23Jun2010 Ethics No:
Questionnaire
My name is Jo Hobbs and I am a respiratory physiotherapist studying at the University of
Southampton for my master’s degree. The following questionnaire explores the provision and use
of nebulised normal (isotonic/0.9%) saline in clinical practice in spontaneously ventilating patients.
Please read the information email with this questionnaire, complete by either: selecting from the
drop down box, checking the tick box or typing in the free text box. Please then save the
questionnaire as a word document and return by email as an attachment to
____________________by _________________________.
1. Are you male or female? Male/Female
2. What Agenda for Change Physiotherapy Banding are you? 5/6/7/8a/8b/8c/8d/9/Other
If other, (please state in text box): Text Box
3. How many years have you been a qualified Physiotherapist? (please state in text box)
Text Box Years
4. How many years have you specialised in respiratory? (please state in text box)
Text Box Years
5. What department or speciality of practice do you work in? (please state in text box)
(E.g. Medicine, Critical Care, Community etc.) Text Box
6. What type of patients do you work with? Adults/Paediatrics/Both
7. How many respiratory patients have you treated in the last 7 days?
Text Box
8. How many of those respiratory patients, whom you have treated in the last 7 days, were
receiving saline nebulisers?
Text Box
9. Do you personally prescribe normal (isotonic/ 0.9%) saline nebulisers?
No/ Yes, via Patient Group Directive (P.G.D.)/ Yes, as supplementary prescriber/ Yes, as
independent prescriber
If other, (please state in text box): Text Box
10. How often do you think normal (isotonic/ 0.9%) saline nebulisers should be prescribed?
Every hour/ 2/ 3/ 4/ 5/ 6/ 7/ 8/ PRN as needed/ Other
Please explain your answer to this question: (please state in text box)
Text Box
11. In what circumstances do you think normal (isotonic/ 0.9%) saline nebulisers are indicated?
Journal of ACPRC, Volume 44, 2012 17Jo Hobbs, Final Questionnaire v1.1, 23Jun2010 Ethics No:
(Please check all boxes that apply below)
Chronic Obstructive Pulmonary Disease (COPD)
Cystic fibrosis
Asthma
Bronchiectasis
Pneumonia
Sputum retention
Increased work of breathing
Decreased lung volumes
Other (please state in text box): Text Box
12. What do you think of normal (isotonic/ 0.9%) saline nebulisers?
(Please check one box per statement below)
Strongly Agree Uncertain Disagree Strongly
Agree Disagree
5 4 3 2 1
a) I would use nebulised saline to aid
secretion clearance.
b) I believe nebulised saline can cause
bronchoconstriction.
c) I believe nebulised saline can relieve
bronchoconstriction.
d) I would use nebulised saline to reduce
sputum viscosity.
e) I would use nebulised saline to reduce
work of breathing.
13. Do you have a Standard Operating Procedure (SOP) for the use of nebulisers?
Yes/ No/ Unsure
If no or unsure go to Question 15.
If yes go to Question 14.
14. What is the source of the SOP for the use of nebulisers?
Physiotherapy policy/ Hospital policy/ Other If other, (please state in text box): Text Box
18 Journal of ACPRC, Volume 44, 2012Jo Hobbs, Final Questionnaire v1.1, 23Jun2010 Ethics No:
15. What model of nebulisers do you use?
(please check all boxes that apply below)
Sidestream Ventstream Devilbiss Whisper jet Acorn ll
Other (please state in text box): Text Box
16. What is used to drive the nebuliser?
Driver of nebuliser: Flow rate of gas used Reason for use?
litres/min:
(please check all boxes that (please state in text boxes below)
apply below)
(please state in text boxes below)
Air Text Box Text Box
Oxygen Text Box Text Box
Nebuliser Box N/A Text Box
Other Text Box Text Box
Please state: Text Box
17. Please read the statements below regarding nebulised normal (isotonic/ 0.9%) saline:
(Please check one box per statement in the box you feel is most appropriate)
a) As short term humidification nebulised Effective Ineffective
saline is:
b) Nebulised saline is: Safe High risk
c) Nebulised saline has a: Weak evidence Strong evidence
base base
d) Nebulised saline is: Easy to use Complicated to use
e) Nebulised saline is: Misunderstood Well understood
f) Nebulised saline is: Difficult to assemble Easy to assemble
g) Nebulised saline is: Acceptable to Not acceptable to
patients patients
h) Regarding infection control and nebulised High infection risk Low infection risk
saline, there is:
Journal of ACPRC, Volume 44, 2012 19Jo Hobbs, Final Questionnaire v1.1, 23Jun2010 Ethics No:
18. Have you ever encountered an adverse event regarding the use of a normal (isotonic/
0.9%) saline nebuliser? Yes/ No/ Unsure
If no or unsure go to Question 20.
If yes go to Question 19.
19. Please describe the adverse incident(s) involving normal (isotonic/ 0.9%) saline nebulisers.
Text Box
20. From the list below please select which area are you currently working in?
Northern Ireland/ England/ Scotland/ Wales/ Other
If Other please state: Text Box
If you answered England please go to question 21.
If you answered Northern Ireland, Scotland, Wales or Other please go to question 22.
21. Physiotherapists working in England please select which Strategic Health Authority you
currently work in geographically:
North East
North West
Yorkshire and Humber
East Midlands
West Midlands
East of England
South West
South Central
London
South East Coast
For reference only
20 Journal of ACPRC, Volume 44, 2012Jo Hobbs, Final Questionnaire v1.1, 23Jun2010 Ethics No:
22. Please use this section to express any comments or suggestions regarding nebulised
(isotonic/ 0.9%) saline in physiotherapy practice that you feel has not been addressed.
Text Box
Thank you for completing this questionnaire.
Please save this completed questionnaire and send as an attachment to: ___________________
For Office Use Only.
Journal of ACPRC, Volume 44, 2012 21A qualitative study into the experiences of
living with long-term oxygen therapy:
the perspective of patients with chronic
obstructive pulmonary disease
Correspondence Details
Sheila Pugh, MSc, MCSP Sheila Pugh
Principle Respiratory Physiotherapist
Ceredigion Division, Hywel Dda Health Board Tel: 01970 635539
Email: shelia.pugh@wales.nhs.uk
Dr Stephanie Enright PhD, MCSP Keywords:
Senior Lecturer, Cardiff School of Healthcare
Studies, Cardiff University Long-term oxygen therapy
Self Management
Quality of Life
Summary
characterised by chronic systemic inflammation
Long-term oxygen therapy (LTOT) (Gea et al. 2009). Pulmonary manifestations
is proven to improve mortality include breathlessness, cough and sputum
(NICE 2010). Patients with severe COPD have
and reduce the risk of serious
daily challenges in terms of their physical, social
complications in patients with and psychological well-being due to effects
hypoxic chronic obstructive of the disease. This often involves complex,
pulmonary disease (COPD). This multidimensional adaptations by patients in
order to manage their condition (McMahon
small-scale qualitative study 2002).
aimed to gain insight into the
experiences of COPD patients Some patients with severe COPD develop
chronic hypoxaemia, which if left untreated
living with LTOT in order to increases patients’ risk of serious compensatory
develop services to support their complications such as polycythaemia,
self-management and improve pulmonary hypertension, cor pulmonale and
increases mortality (Lynes and Kelly 2009).
their quality of life.
Long-term oxygen therapy (LTOT) is a proven
treatment to improve mortality and reduce risk
Introduction of complications in COPD patients with chronic
hypoxaemia (Nocturnal Oxygen Therapy Trial
Chronic obstructive pulmonary disease 1980 and Medical Research Council 1981)
(COPD) is an incurable long-term condition which is still valid today (Royal College of
22 Journal of ACPRC, Volume 44, 2012Physicians 1999 and NICE 2010). This life-long sadly passed away, therefore their data was
treatment involves using supplemental oxygen removed from analysis. The sixth interview
therapy for a minimum of fifteen hour daily was the point of ‘theoretical saturation’, since
and for mobile patients the use of ambulatory no new data was being generated, although
oxygen therapy using portable cylinders for importantly, previous findings were being
activities outside the home. confirmed (Holloway 2005). Each transcribed
interview was forwarded to the participants
Previously scant attention has been paid to the to validate the data. The researcher utilised
effect that LTOT has on British individuals from a phenomenological attitude to analyse the
a qualitative perspective. Robinson (2005) data following Giorgi’s five manageable steps
addressed a qualitative aspect of living with (Giorgi 2008).
COPD in hypoxic patients requiring LTOT, but
with emphasis on COPD rather than LTOT. Results
This study aimed to identify, explore and gain The participants described breathlessness as
understanding of the multifactoral experiences the main symptom which was an unpleasant
of COPD patients using LTOT, in order to develop sensation and affected their every move.
services to support their self management and This resulted in reduced activity, increased
improve their quality of life. dependence on others and avoidance
strategies.
Methods
Two groups of patients emerged; non-oxygen
This descriptive phenomenological study dependant (NOD) i.e. those using oxygen
sought to gain an understanding of the fifteen hours daily, and those who were oxygen
personal experiences of COPD patients living dependant (OD) i.e. constant oxygen therapy.
with LTOT. Taylor (2005) advocates that tape-
recorded interviews, which accurately record Analysis of the six interviews identified four
the participant’s words directly, are the most main categories which most affect these COPD
appropriate method of data collection, which patients living with LTOT:
was therefore adopted.
• increased work to live;
The study commenced after ethical approval
was granted which included methods to ensure • loss of spontaneity;
confidentiality and anonymity. ‘Purposeful
• significant others;
sampling’ was used to select that specific group
of patients via the respiratory department’s • struggle to live with it/can’t live without it.
LTOT database (Carter and Henderson 2005).
Eleven patients were forwarded Welsh and The participants describe how living with COPD
English invitation letters, information sheets required increased effort, but also how the
and consent forms in accordance with the extra burden of the oxygen therapy required
Department of Health’s Research Governance constant planning, and organisation in order
Framework for Health and Social Care (DOH to avoid running out of oxygen, which limited
2005). Nine consent forms were returned. activities outside the home:
Two participants were selected for piloting,
to assess and refine the novice researcher’s “I have to plan to make sure I have enough to
interviewing skills but were not included in the get home, and then have to order some for
analysis. Seven participants were interviewed in when I’m back in two days and it gets very
their home, the interviews tape-recorded and
transcribed by the researcher. One participant
Journal of ACPRC, Volume 44, 2012 23complicated …” routine, everyday activities, which translates
into increased work (McMahon 2002). Analysis
Two patients in the NOD group described of this study’s interviews reinforces this issue
difficulties achieving the minimum daily hours: and revealed two groups of oxygen use; i.e.
NOD and OD groups. The NOD group avoided
“My biggest difficulty I suppose is trying to
using their prescribed ambulatory supply. This
maintain fifteen hours a day.”
reluctance was due to; being embarrassed by
Due to the extra effort, some participants it; wanting some ‘normality’ in their life or; the
developed strategies to avoid its use in effort of using it was deemed too great. This
situations which it would be beneficial: trend was seen by Lacasse et al. (2005) in their
randomised trial of ambulatory oxygen and
“Oh I can walk further with it … but it’s a fine compressed air usage in LTOT patients. Despite
line between helping me and being a blinking a carefully chosen group where a benefit was
nuisance …” anticipated, early analysis revealed minimum
use of ambulatory equipment, (either oxygen
or air), therefore the study was stopped.
Interestingly, participants in this study left
There is a sense of loss about not being able to
their home three times more often without
just ‘get-up-and-go’, especially when it comes
cylinders than with cylinders.
to travel and all reflected on how they rely on
‘significant others’: The lack of spontaneity described by the
participants in this study can be seen in the
“Because of the oxygen you have to stay in
literature, together with the constant planning
this country, and then you can’t just go for a
required to assess oxygen requirements
weekend”
outside the home. Ring and Danielson (1997)
“I have to admit it, I couldn’t manage without identified the restrictions of COPD and LTOT
XX. Either washing or doing most of the things in their Swedish interviews, together with
I do” the constant planning, and the restriction
of outings despite the availability of oxygen
However, despite the frustrations of living with supply. Robinson (2005) had a more positive
home oxygen: view from her interviewees regarding LTOT,
but the sense of freedom described by one of
“I feel like yanking this off and throwing it her participants was due to the their ability to
through the window, you know it can be a fund a more portable system. Robinson’s study
nuisance and I get all worked up and everything (2005) emphasised the effects of living with
as I can’t do what I want to do”; COPD as opposed to LTOT, whereas this study
focuses primarily on experiences relating to
All the participants said they couldn’t, and
oxygen therapy as opposed to COPD. However
wouldn’t, want to envisage life without it:
the two elements are difficult to separate, as
“ … I don’t know what it would be like without endorsed by a number of the participants of
oxygen now. I just wouldn’t do anything. I this study.
suppose I’d probably die in my sleep …”
The majority of participants described
“Well without it I wouldn’t be here would I?” restriction of domestic travel, and the loss
of travel abroad. Despite the availability
Discussion of domestic holiday oxygen supply, some
participants had not tried it. For those that
The literature recognises that patients with had, it had generally been a very positive
COPD have to expend more energy undertaking experience, but again an element of restriction
24 Journal of ACPRC, Volume 44, 2012due to the need for frequent portable cylinder for the relief of breathlessness, is supported by
deliveries. There does not appear to be any Ring and Danielson’s study (1997).
literature to either support or refute this
finding. The purpose of this study was to gain insight
into the experiences of COPD patients living
Living with COPD and LTOT requires the with LTOT in order to improve services. Wilcock
support of family and friends for a reasonable et al. (2003) advises that first you have to
quality of life to be attained (McMahon identify the individuals’ needs and concerns.
1992). This was evident from the experiences Whilst they recognised that interviews are
of the participants of this study, and all bar time-consuming and costly, they deem them
one volunteered this information, without an extremely effective method of exploring
prompting. Kanervisto and colleagues (2007) and discovering an individual’s experiences,
studied thirty-five Finnish patients with severe leading to improved health care services. This
COPD with and without LTOT. Their quantitative proved to be the case for this study as well.
study identified dimensions of family dynamics.
They concluded that families living with COPD Wilcock et al. (2003) continue by postulating
patients with LTOT were significantly better that an improvement in service quality is
in the dimensions of individuation, mutuality, achieved when the service matches the needs
flexibility, and stability compared to families of those who utilise the service. This study
living with COPD patients without LTOT. identified minor immediate changes to improve
Whilst this may be a surprising finding, these spontaneity for two patients with the provision
families and patients may have had longer of liquid oxygen to facilitate more freedom.
to adapt to the effects of COPD. According However further assessment of the present
to the experiences of the participants of this service, support and oxygen equipment is
study, other than helping them use the oxygen required to match the service to the patient’s
therapy, friends and family did not seem to be needs i.e. more freedom.
affected by it, once they were familiar with its
use. They described how they were dependant
Conclusion
on their partners for varying degrees of Long-term oxygen therapy (LTOT) is proven to
personal care, mobility and household chores, improve mortality and reduce the risk of serious
but perhaps were either not aware of the complications in patients with hypoxic chronic
impact of their illness and oxygen therapy obstructive pulmonary disease (COPD).This
had on others, or preferred not to discuss it, small-scale phenomenological study into the
possibly not wanting to tell the researcher, experiences of a group of COPD patients who
as their clinician. Cornwell (1984) suggests live with LTOT has highlighted areas that affect
that patient narratives facilitate the ‘private’ their daily lives. This includes: increased work
account of their experiences, as opposed to the required to live, loss of spontaneity, reliance
‘public’ account which is conveyed at a clinical on significant others and a struggle to live with
level which may be the case in this study. it yet can’t live without it. They describe life
overshadowed by the constant need to plan
Whilst all the participants described varying
their every move due to their dependence on
degrees of burden of living with LTOT, none
oxygen. Being a novice, the researcher had
could envisage living without it. For both oxygen
not envisaged the depth and richness of data
usage groups there was an understanding
that would be gained from the interviews, and
of the body’s need for oxygen therapy, and a
the impact this experience would have on her
sense of relief in the knowledge that the body
personally.
would be getting some oxygen when the nasal
cannulae were in situ. Knowledge that the A system of assessing patient’s satisfaction with
body needs oxygen, rather than just a modality
Journal of ACPRC, Volume 44, 2012 25home oxygen services should be developed to S. 2003. Using patient stories to inspire quality
facilitate feedback in a more structured way, improvement within the NHS Modernization
with the inclusion of interviews as part of Agency collaborative programmes. Journal of
that system, so that the true experiences of Clinical Nursing. 12, 422-430
the individuals may be captured. This should
be augmented by the increased availability of Department of Health. 2005. Research
devices and equipment provided by the home Framework for health and social care.
oxygen service suppliers, allowing patients 2nd edition. http://www.dh.gov.uk/en/
greater freedom to leave their homes and Publicationsandstatistics/Publications/
enjoy travel. PublicationsPolicyAndGuidance/DH_4108962.
Accessed 6th September 2010
The researcher believes that these findings
should be disseminated and further research Gea, J., Barreiro, E., and Orozoco-Levi, M.
into the effects of living with LTOT should be 2009 Systemic inflammation in COPD. Clinical
undertaken to identify the needs of COPD Pulmonary Medicine, 16 (5), 233-242.
patients in larger numbers and in different
Giorgi, A. and Giorgi, B. 2008 Phenomenology.
locations. In addition qualitative research
In Smith, J. A. ed. Qualitative Psychology.
should be undertaken with patients with other
London: Sage 112-113
pathologies causing chronic hypoxaemia, such
as pulmonary fibrosis, to identify their specific Holloway, I. 2005. Qualitative writing. In:
experiences and needs. Holloway, I. ed. Qualitative Research in Health
Care. 1st ed. Maidenhead: Open University
Press. 270-286.
Key Points Kanervisto, M., Paavilainen, E., and Heikkila,
LTOT improves mortality in hypoxic COPD J. 2007 Family dynamics in families of severe
patients. COPD patients. Journal of Clinical Nursing,
16(8), 1498-1505.
COPD patients struggle to live with LTOT, lack
spontaneity and are dependant on others. Lacasse, Y., Lecours, R., Pelletier, C., Begin, R.,
and Maltais, F. 2005 Randomised control trial
Further assessment of equipment and support of ambulatory oxygen in oxygen-dependant
services are required to improve patient’s COPD. European Respiratory Journal, 24, 1032-
quality of life. 1038.
Lynes, D. and Kelly, C. 2009 Domiciliary oxygen
therapy: assessment and management.
References Nursing Standard, 23 (20), 50-56.
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