• Registered Nurses Association of Ontario (RNAO). Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 136 p. [227 references]

This is the current release of the guideline.

• Dyspnea associated with chronic obstructive pulmonary disease (COPD)
• COPD

Evaluation
Management
Screening
Treatment

Family Practice
Internal Medicine
Nursing
Pulmonary Medicine

Advanced Practice Nurses
Nurses

To address the nursing assessment and management of stable, unstable and acute dyspnea associated with chronic obstructive pulmonary disease (COPD)

• Patients with dyspnea associated with chronic obstructive pulmonary disease (COPD)
• Adults with dyspnea who have a history of smoking and who are over the age of 40

Evaluation/Screening

1. Respiratory assessment, including vital signs, pulse oximetry, and chest auscultation
2. Identification of stable and unstable dyspnea, and acute respiratory failure
3. Screening for chronic obstructive pulmonary disease (COPD) in adults over 40 who have a history of smoking
4. Advocating for spirometry testing in at-risk individuals

Management/Treatment

1. Implementation of appropriate nursing interventions, including medications, controlled oxygen therapy, ventilation modalities, and strategies for secretion clearance, energy conserving, relaxation, nutrition, and breathing retraining
2. Remaining with patient during episodes of acute respiratory distress
3. Implementation of smoking cessation strategies
4. Administration of the following pharmacological agents as prescribed: bronchodilators, oxygen, corticosteroids, antibiotics, psychotropics, opioids
5. Assessment of inhaler technique and coaching, if required
6. Discussion of medications with patients
7. Recommendation of annual influenza vaccination and pneumococcal vaccine (chronic obstructive pulmonary disease patients) as appropriate
8. Administration of oxygen therapy as prescribed
9. Support of disease self-management strategies including action plan development and end-of-life decision making directives
10. Promotion of exercise training and pulmonary rehabilitation as appropriate
11. Patient education and referrals, if necessary

• Validity and reliability of dyspnea assessment tools
• Effectiveness of intervention strategies at optimizing self-management of chronic obstructive pulmonary disease (COPD), reducing signs and symptoms of dyspnea, improving dyspnea scores, promoting comfort, improving quality of life and functional health status

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Searches of Unpublished Data

A database search for existing chronic obstructive pulmonary disease guidelines was conducted by a university health sciences library. An initial search of the Medline, Embase, and CINAHL databases for guidelines and articles published from January 1, 1995 to December 2003 was conducted using the following search terms: "chronic obstructive pulmonary disease," "COPD," "chronic obstructive lung disease," "COLD," "chronic bronchitis," "emphysema," "family caregivers," "coping with chronic illness," "oxygen devices," "rehabilitation," "assessing control," "medications," "randomized controlled trials," "systematic reviews," "practice guideline(s)," "clinical practice guideline(s)," "standards," "consensus statement(s)," "consensus," "evidence based guidelines," and "best practice guidelines."

One individual searched an established list of Web sites for content related to the topic area. This list of sites, reviewed and updated in October 2002, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house a guideline but directed to another website or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/e-mail.

A Web site search for existing chronic obstructive pulmonary disease guidelines was conducted via the search engine "Google," using the search terms identified above. One individual conducted this search, noting the results of the search term results, the Web sites reviewed, date, and a summary of the findings. The search results were further critiqued by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were already in possession of a few of the identified guidelines. In some instances, a guideline was identified by panel members and not found through the previous search strategies. These were guidelines that were developed by local groups or specific professional associations and had not been published to date.

This above search method revealed 13 guidelines, several systematic reviews, and numerous articles related to chronic obstructive pulmonary disease.

The final step in determining whether the clinical practice guideline would be critically appraised was to have two individuals screen the guidelines based on the following criteria. These criteria were determined by panel consensus:

• Guideline was in English, international in scope
• Guideline dated no earlier than 1997
• Guideline was strictly about the topic area.
• Guideline was evidence-based (e.g., contained references, description of evidence, sources of evidence).
• Guideline was available and accessible for retrieval.

Nine guidelines met the screening criteria and were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE Collaboration, 2001) instrument.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

In January of 2004, a panel of nurses with expertise in practice, education, and research related to chronic obstructive pulmonary disease was established by the Registered Nurses Association of Ontario (RNAO). At the onset, the panel discussed and came to consensus on the scope of the best practice guideline.

The panel members divided into subgroups to undergo specific activities using the short-listed guidelines, other literature, and additional resources for the purpose of drafting recommendations for nursing interventions. This process yielded a draft set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps, available evidence, and came to a consensus on a draft guideline.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

The draft guideline was submitted to a set of external stakeholders for review and feedback of the content. It was also critiqued using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE) instrument. An acknowledgement of these reviewers is provided at the front of the original guideline document. Stakeholders represented health care consumers, various health care disciplines, as well as a professional association. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel. Discussion and consensus resulted in revision to the draft document prior to publication.

A clinical algorithm is provided in the original guideline document for a chronic obstructive pulmonary disease (COPD) decision tree.

The type of evidence is identified and graded for each recommendation (see "Major Recommendations").

• Appropriate assessment and management of patients with dyspnea associated with chronic obstructive pulmonary disease
• Symptom relief
• Optimization of patient self-management of chronic obstructive pulmonary disease (COPD)
• Improved patient comfort, quality of life, and functional health status
• Nurses, other health care professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessments, and documentation tools.

Adverse effects of pharmacological agents. Common side effects are listed in Appendix L in the original guideline document.

• Currently available evidence does not support the clinical use of nebulized opioids; however, some clinicians utilize opioids to treat the symptom of dyspnea in end-stage chronic obstructive pulmonary disease (COPD). Opioid use is contraindicated in COPD management due to the potential respiratory depression and worsening hypercapnia.
• Tiotropium bromide is contraindicated in patients with hypersensitivity to atropine or its derivatives or lactose monohydrate.

• This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence-based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them, nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• It is acknowledged that individual competencies of nurses vary between nurses and across categories of nursing professionals (registered nurses [RNs] and registered practical nurses [RPNs]) and are based on knowledge, skills, attitudes and judgement enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of care for which they have received appropriate education and experience. Both registered nurses and registered practical nurses should seek consultation in instances where the patient's care needs surpass the individual nurse's ability to act independently.
• Although this guideline contains recommendations for RNs and RPNs, caring for individuals with chronic obstructive pulmonary disease is an interdisciplinary endeavour. It is acknowledged that effective care depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and patients. Personal preferences and unique needs as well as the personal and environmental resources of each individual patient must always be kept in mind.

Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support as well as appropriate facilitation. Registered Nurses Association of Ontario (RNAO), through a panel of nurses, researchers and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Evaluation and Monitoring

Organizations implementing the recommendations in this nursing best practice guideline are encouraged to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on a framework outlined in the Registered Nurses Association of Ontario Toolkit: Implementation of Clinical Practice Guidelines (2002) illustrates some indicators for monitoring and evaluation.

Implementation Strategies

The Registered Nurses Association of Ontario and the guideline development panel have compiled a list of implementation strategies to assist health care organizations or health care disciplines who are interested in implementing this guideline. See the original guideline document for a summary of strategies.

Getting Better
Living with Illness

Effectiveness

• Registered Nurses Association of Ontario (RNAO). Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 136 p. [227 references]

The Registered Nurses Association of Ontario (RNAO) panel selected the following guidelines to adapt and modify for the current guideline:

• Clinical Epidemiology and Health Service Evaluation Unit (1999). Evidence based guidelines Royal Melbourne Hospital -- Hospital management of an acute exacerbation of chronic obstructive pulmonary disease. Melbourne: National Health and Medical Research Council.
• Institute for Clinical Systems Improvement (2003). Health care guideline: Chronic obstructive pulmonary disease. Institute for Clinical Systems Improvement [Electronic version].
• McKenzie, D. K., Frith, P. A., Burdon, J. G. W., & Town, I. (2003). The COPDX Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2003. Medical Journal of Australia, 178(6 Suppl), S1-S40.
• O'Donnell, D. E., Aaron, S., Bourbeau, J., Hernandez, P., Marciniuk, D., Balter, M. et al. (2003). Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2003. Canadian Respiratory Journal, 10(Suppl. A), 11A-65A.
• Pauwels, R. A., Buist, A. S., Jenkins, C. R., Hurd, S. S., & the GOLD Scientific Committee (2001). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute and World Health Organization Global Initiative for Chronic Obstructive Lung Disease (GOLD): Executive summary. Respiratory Care, 46(8), 798-825.
• Veterans Health Administration (2000). VHA/DOD clinical practice guideline for the management of chronic obstructive pulmonary disease. Clinical Practice Guidelines Office of Quality and Performance [Electronic version].

2005 Mar

Registered Nurses Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Development Panel Members

Pat Hill Bailey, RN, PhD
Team Leader
Professor
Laurentian University
School of Nursing
Sudbury, Ontario

Ann Bartlett, RN, BScN, CAE
NARTC/Diploma in COPD
COPD Educator
Nurse Clinician
Firestone Institute for Respiratory Health
St. Joseph's Healthcare
Hamilton, Ontario

Gail Beatty, RN, BNSc, MN, ACNP
Clinical Nurse Specialist/Nurse Practitioner
COPD Ambulatory Program
Kingston General Hospital
Kingston, Ontario

Janice Bissonnette, RN, MScN, ACNP, CAE, CNCC(C)
Clinical Nurse Specialist/Acute Care
Nurse Practitioner -- ICU/Medicine
Queensway-Carleton Hospital
Ottawa, Ontario

Bozena Dabrowski, RN
Staff Nurse
Day Hospital -- Respiratory Rehabilitation
West Park Healthcare Centre
Toronto, Ontario

Meeran Manji, RN
COPD Educator
Pulmonary Rehabilitation Program
University Health Network
Toronto Western Hospital
Toronto, Ontario

Christina McMillan, RN, BScN, MScN(c)
Graduate Teaching Assistant
Laurentian University
School of Nursing
Sudbury, Ontario

Ruth Pollock, RN, MScN
Professional Practice Leader -- Nursing
Cornwall Community Hospital
Cornwall, Ontario

Josephine Santos, RN, MN
Facilitator, Program Coordinator
Nursing Best Practice Guidelines Program
Registered Nurses Association of Ontario
Toronto, Ontario

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses Association of Ontario.

This is the current release of the guideline.

None available

This summary was completed by ECRI on June 3, 2005. The updated information was verified by the guideline developer on June 21, 2005.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses Association of Ontario (2005). Nursing care of dyspnea: the 6^th vital sign in individuals with chronic obstructive pulmonary disease (COPD). Toronto, Canada: Registered Nurses Association of Ontario.