copd patient case study

COPD Case Study: Patient Diagnosis and Treatment (2024)

by John Landry, BS, RRT | Updated: Apr 4, 2024

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that affects millions of people around the world. It is primarily caused by smoking and is characterized by a persistent obstruction of airflow that worsens over time.

COPD can lead to a range of symptoms, including coughing, wheezing, shortness of breath, and chest tightness, which can significantly impact a person’s quality of life.

This case study will review the diagnosis and treatment of an adult patient who presented with signs and symptoms of this condition.

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COPD Clinical Scenario

A 56-year-old male patient is in the ER with increased work of breathing. He felt mildly short of breath after waking this morning but became extremely dyspneic after climbing a few flights of stairs. He is even too short of breath to finish full sentences. His wife is present in the room and revealed that the patient has a history of liver failure, is allergic to penicillin, and has a 15-pack-year smoking history. She also stated that he builds cabinets for a living and is constantly required to work around a lot of fine dust and debris.

Physical Findings

On physical examination, the patient showed the following signs and symptoms:

• His pupils are equal and reactive to light.
• He is alert and oriented.
• He is breathing through pursed lips.
• His trachea is positioned in the midline, and no jugular venous distention is present.

Vital Signs

• Heart rate: 92 beats/min
• Respiratory rate: 22 breaths/min

Chest Assessment

• He has a larger-than-normal anterior-posterior chest diameter.
• He demonstrates bilateral chest expansion.
• He demonstrates a prolonged expiratory phase and diminished breath sounds during auscultation.
• He is showing signs of subcostal retractions.
• Chest palpation reveals no tactile fremitus.
• Chest percussion reveals increased resonance.
• His abdomen is soft and tender.
• No distention is present.

Extremities

• His capillary refill time is two seconds.
• Digital clubbing is present in his fingertips.
• There are no signs of pedal edema.
• His skin appears to have a yellow tint.

Lab and Radiology Results

• ABG results: pH 7.35 mmHg, PaCO2 59 mmHg, HCO3 30 mEq/L, and PaO2 64 mmHg.
• Chest x-ray: Flat diaphragm, increased retrosternal space, dark lung fields, slight hypertrophy of the right ventricle, and a narrow heart.
• Blood work: RBC 6.5 mill/m3, Hb 19 g/100 mL, and Hct 57%.

Based on the information given, the patient likely has chronic obstructive pulmonary disease (COPD) .

The key findings that point to this diagnosis include:

• Barrel chest
• A long expiratory time
• Diminished breath sounds
• Use of accessory muscles while breathing
• Digital clubbing
• Pursed lip breathing
• History of smoking
• Exposure to dust from work

What Findings are Relevant to the Patient’s COPD Diagnosis?

The patient’s chest x-ray showed classic signs of chronic COPD, which include hyperexpansion, dark lung fields, and a narrow heart.

This patient does not have a history of cor pulmonale ; however, the findings revealed hypertrophy of the right ventricle. This is something that should be further investigated as right-sided heart failure is common in patients with COPD.

The lab values that suggest the patient has COPD include increased RBC, Hct, and Hb levels, which are signs of chronic hypoxemia.

Furthermore, the patient’s ABG results indicate COPD is present because the interpretation reveals compensated respiratory acidosis with mild hypoxemia. Compensated blood gases indicate an issue that has been present for an extended period of time.

What Tests Could Further Support This Diagnosis?

A series of pulmonary function tests (PFT) would be useful for assessing the patient’s lung volumes and capacities. This would help confirm the diagnosis of COPD and inform you of the severity.

Note: COPD patients typically have an FEV1/FVC ratio of < 70%, with an FEV1 that is < 80%.

The initial treatment for this patient should involve the administration of low-flow oxygen to treat or prevent hypoxemia .

It’s acceptable to start with a nasal cannula at 1-2 L/min. However, it’s often recommended to use an air-entrainment mask on COPD patients in order to provide an exact FiO2.

Either way, you should start with the lowest possible FiO2 that can maintain adequate oxygenation and titrate based on the patient’s response.

Example: Let’s say you start the patient with an FiO2 of 28% via air-entrainment mask but increase it to 32% due to no improvement. The SpO2 originally was 84% but now has decreased to 80%, and his retractions are worsening. This patient is sitting in the tripod position and continues to demonstrate pursed-lip breathing. Another blood gas was collected, and the results show a PaCO2 of 65 mmHg and a PaO2 of 59 mmHg.

What Do You Recommend?

The patient has an increased work of breathing, and their condition is clearly getting worse. The latest ABG results confirmed this with an increased PaCO2 and a PaO2 that is decreasing.

This indicates that the patient needs further assistance with both ventilation and oxygenation .

Note: In general, mechanical ventilation should be avoided in patients with COPD (if possible) because they are often difficult to wean from the machine.

Therefore, at this time, the most appropriate treatment method is noninvasive ventilation (e.g., BiPAP).

Initial BiPAP Settings

In general, the most commonly recommended initial BiPAP settings for an adult patient include this following:

• IPAP: 8–12 cmH2O
• EPAP: 5–8 cmH2O
• Rate: 10–12 breaths/min
• FiO2: Whatever they were previously on

For example, let’s say you initiate BiPAP with an IPAP of 10 cmH20, an EPAP of 5 cmH2O, a rate of 12, and an FiO2 of 32% (since that is what he was previously getting).

After 30 minutes on the machine, the physician requested another ABG to be drawn, which revealed acute respiratory acidosis with mild hypoxemia.

What Adjustments to BiPAP Settings Would You Recommend?

The latest ABG results indicate that two parameters must be corrected:

• Increased PaCO2
• Decreased PaO2

You can address the PaO2 by increasing either the FiO2 or EPAP setting. EPAP functions as PEEP, which is effective in increasing oxygenation.

The PaCO2 can be lowered by increasing the IPAP setting. By doing so, it helps to increase the patient’s tidal volume, which increased their expired CO2.

Note: In general, when making adjustments to a patient’s BiPAP settings, it’s acceptable to increase the pressure in increments of 2 cmH2O and the FiO2 setting in 5% increments.

Oxygenation

To improve the patient’s oxygenation , you can increase the EPAP setting to 7 cmH2O. This would decrease the pressure support by 2 cmH2O because it’s essentially the difference between the IPAP and EPAP.

Therefore, if you increase the EPAP, you must also increase the IPAP by the same amount to maintain the same pressure support level.

Ventilation

However, this patient also has an increased PaCO2 , which means that you must increase the IPAP setting to blow off more CO2. Therefore, you can adjust the pressure settings on the machine as follows:

• IPAP: 14 cmH2O
• EPAP: 7 cmH2O

After making these changes and performing an assessment , you can see that the patient’s condition is improving.

Two days later, the patient has been successfully weaned off the BiPAP machine and no longer needs oxygen support. He is now ready to be discharged.

The doctor wants you to recommend home therapy and treatment modalities that could benefit this patient.

What Home Therapy Would You Recommend?

You can recommend home oxygen therapy if the patient’s PaO2 drops below 55 mmHg or their SpO2 drops below 88% more than twice in a three-week period.

Remember: You must use a conservative approach when administering oxygen to a patient with COPD.

Pharmacology

You may also consider the following pharmacological agents:

• Short-acting bronchodilators (e.g., Albuterol)
• Long-acting bronchodilators (e.g., Formoterol)
• Anticholinergic agents (e.g., Ipratropium bromide)
• Inhaled corticosteroids (e.g., Budesonide)
• Methylxanthine agents (e.g., Theophylline)

In addition, education on smoking cessation is also important for patients who smoke. Nicotine replacement therapy may also be indicated.

In some cases, bronchial hygiene therapy should be recommended to help with secretion clearance (e.g., positive expiratory pressure (PEP) therapy).

It’s also important to instruct the patient to stay active, maintain a healthy diet, avoid infections, and get an annual flu vaccine. Lastly, some COPD patients may benefit from cardiopulmonary rehabilitation .

By taking all of these factors into consideration, you can better manage this patient’s COPD and improve their quality of life.

Final Thoughts

There are two key points to remember when treating a patient with COPD. First, you must always be mindful of the amount of oxygen being delivered to keep the FiO2 as low as possible.

Second, you should use noninvasive ventilation, if possible, before performing intubation and conventional mechanical ventilation . Too much oxygen can knock out the patient’s drive to breathe, and once intubated, these patients can be difficult to wean from the ventilator .

Furthermore, once the patient is ready to be discharged, you must ensure that you are sending them home with the proper medications and home treatments to avoid readmission.

Written by:

John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.

• Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
• Chang, David. Clinical Application of Mechanical Ventilation . 4th ed., Cengage Learning, 2013.
• Rrt, Cairo J. PhD. Pilbeam’s Mechanical Ventilation: Physiological and Clinical Applications. 7th ed., Mosby, 2019.
• Faarc, Gardenhire Douglas EdD Rrt-Nps. Rau’s Respiratory Care Pharmacology. 10th ed., Mosby, 2019.
• Faarc, Heuer Al PhD Mba Rrt Rpft. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017.
• Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.

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‘This month’s issue highlights innovations in continence care’

STEVE FORD, EDITOR

• You are here: COPD

Diagnosis and management of COPD: a case study

04 May, 2020

This case study explains the symptoms, causes, pathophysiology, diagnosis and management of chronic obstructive pulmonary disease

This article uses a case study to discuss the symptoms, causes and management of chronic obstructive pulmonary disease, describing the patient’s associated pathophysiology. Diagnosis involves spirometry testing to measure the volume of air that can be exhaled; it is often performed after administering a short-acting beta-agonist. Management of chronic obstructive pulmonary disease involves lifestyle interventions – vaccinations, smoking cessation and pulmonary rehabilitation – pharmacological interventions and self-management.

Citation: Price D, Williams N (2020) Diagnosis and management of COPD: a case study. Nursing Times [online]; 116: 6, 36-38.

Authors: Debbie Price is lead practice nurse, Llandrindod Wells Medical Practice; Nikki Williams is associate professor of respiratory and sleep physiology, Swansea University.

• This article has been double-blind peer reviewed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)

Introduction

The term chronic obstructive pulmonary disease (COPD) is used to describe a number of conditions, including chronic bronchitis and emphysema. Although common, preventable and treatable, COPD was projected to become the third leading cause of death globally by 2020 (Lozano et al, 2012). In the UK in 2012, approximately 30,000 people died of COPD – 5.3% of the total number of deaths. By 2016, information published by the World Health Organization indicated that Lozano et al (2012)’s projection had already come true.

People with COPD experience persistent respiratory symptoms and airflow limitation that can be due to airway or alveolar abnormalities, caused by significant exposure to noxious particles or gases, commonly from tobacco smoking. The projected level of disease burden poses a major public-health challenge and primary care nurses can be pivotal in the early identification, assessment and management of COPD (Hooper et al, 2012).

Grace Parker (the patient’s name has been changed) attends a nurse-led COPD clinic for routine reviews. A widowed, 60-year-old, retired post office clerk, her main complaint is breathlessness after moderate exertion. She scored 3 on the modified Medical Research Council (mMRC) scale (Fletcher et al, 1959), indicating she is unable to walk more than 100 yards without stopping due to breathlessness. Ms Parker also has a cough that produces yellow sputum (particularly in the mornings) and an intermittent wheeze. Her symptoms have worsened over the last six months. She feels anxious leaving the house alone because of her breathlessness and reduced exercise tolerance, and scored 26 on the COPD Assessment Test (CAT, catestonline.org), indicating a high level of impact.

Ms Parker smokes 10 cigarettes a day and has a pack-year score of 29. She has not experienced any haemoptysis (coughing up blood) or chest pain, and her weight is stable; a body mass index of 40kg/m 2 means she is classified as obese. She has had three exacerbations of COPD in the previous 12 months, each managed in the community with antibiotics, steroids and salbutamol.

Ms Parker was diagnosed with COPD five years ago. Using Epstein et al’s (2008) guidelines, a nurse took a history from her, which provided 80% of the information needed for a COPD diagnosis; it was then confirmed following spirometry testing as per National Institute for Health and Care Excellence (2018) guidance.

The nurse used the Calgary-Cambridge consultation model, as it combines the pathological description of COPD with the patient’s subjective experience of the illness (Silverman et al, 2013). Effective communication skills are essential in building a trusting therapeutic relationship, as the quality of the relationship between Ms Parker and the nurse will have a direct impact on the effectiveness of clinical outcomes (Fawcett and Rhynas, 2012).

In a national clinical audit report, Baxter et al (2016) identified inaccurate history taking and inadequately performed spirometry as important factors in the inaccurate diagnosis of COPD on general practice COPD registers; only 52.1% of patients included in the report had received quality-assured spirometry.

Pathophysiology of COPD

Knowing the pathophysiology of COPD allowed the nurse to recognise and understand the physical symptoms and provide effective care (Mitchell, 2015). Continued exposure to tobacco smoke is the likely cause of the damage to Ms Parker’s small airways, causing her cough and increased sputum production. She could also have chronic inflammation, resulting in airway smooth-muscle contraction, sluggish ciliary movement, hypertrophy and hyperplasia of mucus-secreting goblet cells, as well as release of inflammatory mediators (Mitchell, 2015).

Ms Parker may also have emphysema, which leads to damaged parenchyma (alveoli and structures involved in gas exchange) and loss of alveolar attachments (elastic connective fibres). This causes gas trapping, dynamic hyperinflation, decreased expiratory flow rates and airway collapse, particularly during expiration (Kaufman, 2013). Ms Parker also displayed pursed-lip breathing; this is a technique used to lengthen the expiratory time and improve gaseous exchange, and is a sign of dynamic hyperinflation (Douglas et al, 2013).

In a healthy lung, the destruction and repair of alveolar tissue depends on proteases and antiproteases, mainly released by neutrophils and macrophages. Inhaling cigarette smoke disrupts the usually delicately balanced activity of these enzymes, resulting in the parenchymal damage and small airways (with a lumen of <2mm in diameter) airways disease that is characteristic of emphysema. The severity of parenchymal damage or small airways disease varies, with no pattern related to disease progression (Global Initiative for Chronic Obstructive Lung Disease, 2018).

Ms Parker also had a wheeze, heard through a stethoscope as a continuous whistling sound, which arises from turbulent airflow through constricted airway smooth muscle, a process noted by Mitchell (2015). The wheeze, her 29 pack-year score, exertional breathlessness, cough, sputum production and tiredness, and the findings from her physical examination, were consistent with a diagnosis of COPD (GOLD, 2018; NICE, 2018).

Spirometry is a tool used to identify airflow obstruction but does not identify the cause. Commonly measured parameters are:

• Forced expiratory volume – the volume of air that can be exhaled – in one second (FEV1), starting from a maximal inspiration (in litres);
• Forced vital capacity (FVC) – the total volume of air that can be forcibly exhaled – at timed intervals, starting from a maximal inspiration (in litres).

Calculating the FEV1 as a percentage of the FVC gives the forced expiratory ratio (FEV1/FVC). This provides an index of airflow obstruction; the lower the ratio, the greater the degree of obstruction. In the absence of respiratory disease, FEV1 should be ≥70% of FVC. An FEV1/FVC of <70% is commonly used to denote airflow obstruction (Moore, 2012).

As they are time dependent, FEV1 and FEV1/FVC are reduced in diseases that cause airways to narrow and expiration to slow. FVC, however, is not time dependent: with enough expiratory time, a person can usually exhale to their full FVC. Lung function parameters vary depending on age, height, gender and ethnicity, so the degree of FEV1 and FVC impairment is calculated by comparing a person’s recorded values with predicted values. A recorded value of >80% of the predicted value has been considered ‘normal’ for spirometry parameters but the lower limit of normal – equal to the fifth percentile of a healthy, non-smoking population – based on more robust statistical models is increasingly being used (Cooper et al, 2017).

A reversibility test involves performing spirometry before and after administering a short-acting beta-agonist (SABA) such as salbutamol; the test is used to distinguish between reversible and fixed airflow obstruction. For symptomatic asthma, airflow obstruction due to airway smooth-muscle contraction is reversible: administering a SABA results in smooth-muscle relaxation and improved airflow (Lumb, 2016). However, COPD is associated with fixed airflow obstruction, resulting from neutrophil-driven inflammatory changes, excess mucus secretion and disrupted alveolar attachments, as opposed to airway smooth-muscle contraction.

Administering a SABA for COPD does not usually produce bronchodilation to the extent seen in someone with asthma: a person with asthma may demonstrate significant improvement in FEV1 (of >400ml) after having a SABA, but this may not change in someone with COPD (NICE, 2018). However, a negative response does not rule out therapeutic benefit from long-term SABA use (Marín et al, 2014).

NICE (2018) and GOLD (2018) guidelines advocate performing spirometry after administering a bronchodilator to diagnose COPD. Both suggest a FEV1/FVC of <70% in a person with respiratory symptoms supports a diagnosis of COPD, and both grade the severity of the condition using the predicted FEV1. Ms Parker’s spirometry results showed an FEV1/FVC of 56% and a predicted FEV1 of 57%, with no significant improvement in these values with a reversibility test.

GOLD (2018) guidance is widely accepted and used internationally. However, it was developed by medical practitioners with a medicalised approach, so there is potential for a bias towards pharmacological management of COPD. NICE (2018) guidance may be more useful for practice nurses, as it was developed by a multidisciplinary team using evidence from systematic reviews or meta-analyses of randomised controlled trials, providing a holistic approach. NICE guidance may be outdated on publication, but regular reviews are performed and published online.

NHS England (2016) holds a national register of all health professionals certified in spirometry. It was set up to raise spirometry standards across the country.

Assessment and management

The goals of assessing and managing Ms Parker’s COPD are to:

• Review and determine the level of airflow obstruction;
• Assess the disease’s impact on her life;
• Risk assess future disease progression and exacerbations;
• Recommend pharmacological and therapeutic management.

GOLD’s (2018) ABCD assessment tool (Fig 1) grades COPD severity using spirometry results, number of exacerbations, CAT score and mMRC score, and can be used to support evidence-based pharmacological management of COPD.

When Ms Parker was diagnosed, her predicted FEV1 of 57% categorised her as GOLD grade 2, and her mMRC score, CAT score and exacerbation history placed her in group D. The mMRC scale only measures breathlessness, but the CAT also assesses the impact COPD has on her life, meaning consecutive CAT scores can be compared, providing valuable information for follow-up and management (Zhao, et al, 2014).

After assessing the level of disease burden,  Ms Parker was then provided with education for self-management and lifestyle interventions.

Lifestyle interventions

Smoking cessation.

Cessation of smoking alongside support and pharmacotherapy is the second-most cost-effective intervention for COPD, when compared with most other pharmacological interventions (BTS and PCRS UK, 2012). Smoking cessation:

• Slows the progression of COPD;
• Improves lung function;
• Improves survival rates;
• Reduces the risk of lung cancer;
• Reduces the risk of coronary heart disease risk (Qureshi et al, 2014).

Ms Parker accepted a referral to an All Wales Smoking Cessation Service adviser based at her GP surgery. The adviser used the internationally accepted ‘five As’ approach:

• Ask – record the number of cigarettes the individual smokes per day or week, and the year they started smoking;
• Advise – urge them to quit. Advice should be clear and personalised;
• Assess – determine their willingness and confidence to attempt to quit. Note the state of change;
• Assist – help them to quit. Provide behavioural support and recommend or prescribe pharmacological aids. If they are not ready to quit, promote motivation for a future attempt;
• Arrange – book a follow-up appointment within one week or, if appropriate, refer them to a specialist cessation service for intensive support. Document the intervention.

NICE (2013) guidance recommends that this be used at every opportunity. Stead et al (2016) suggested that a combination of counselling and pharmacotherapy have proven to be the most effective strategy.

Pulmonary rehabilitation

Ms Parker’s positive response to smoking cessation provided an ideal opportunity to offer her pulmonary rehabilitation (PR)  – as indicated by Johnson et al (2014), changing one behaviour significantly increases a person’s chance of changing another.

PR – a supervised programme including exercise training, health education and breathing techniques – is an evidence-based, comprehensive, multidisciplinary intervention that:

• Improves exercise tolerance;
• Reduces dyspnoea;
• Promotes weight loss (Bolton et al, 2013).

These improvements often lead to an improved quality of life (Sciriha et al, 2015).

Most relevant for Ms Parker, PR has been shown to reduce anxiety and depression, which are linked to an increased risk of exacerbations and poorer health status (Miller and Davenport, 2015). People most at risk of future exacerbations are those who already experience them (Agusti et al, 2010), as in Ms Parker’s case. Patients who have frequent exacerbations have a lower quality of life, quicker progression of disease, reduced mobility and more-rapid decline in lung function than those who do not (Donaldson et al, 2002).

“COPD is a major public-health challenge; nurses can be pivotal in early identification, assessment and management”

Pharmacological interventions

Ms Parker has been prescribed inhaled salbutamol as required; this is a SABA that mediates the increase of cyclic adenosine monophosphate in airway smooth-muscle cells, leading to muscle relaxation and bronchodilation. SABAs facilitate lung emptying by dilatating the small airways, reversing dynamic hyperinflation of the lungs (Thomas et al, 2013). Ms Parker also uses a long-acting muscarinic antagonist (LAMA) inhaler, which works by blocking the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors in airway smooth muscle; release of acetylcholine by the parasympathetic nerves in the airways results in increased airway tone with reduced diameter.

At a routine review, Ms Parker admitted to only using the SABA and LAMA inhalers, despite also being prescribed a combined inhaled corticosteroid and long-acting beta 2 -agonist (ICS/LABA) inhaler. She was unaware that ICS/LABA inhalers are preferred over SABA inhalers, as they:

• Last for 12 hours;
• Improve the symptoms of breathlessness;
• Increase exercise tolerance;
• Can reduce the frequency of exacerbations (Agusti et al, 2010).

However, moderate-quality evidence shows that ICS/LABA combinations, particularly fluticasone, cause an increased risk of pneumonia (Suissa et al, 2013; Nannini et al, 2007). Inhaler choice should, therefore, be individualised, based on symptoms, delivery technique, patient education and compliance.

It is essential to teach and assess inhaler technique at every review (NICE, 2011). Ms Parker uses both a metered-dose inhaler and a dry-powder inhaler; an in-check device is used to assess her inspiratory effort, as different inhaler types require different inhalation speeds. Braido et al (2016) estimated that 50% of patients have poor inhaler technique, which may be due to health professionals lacking the confidence and capability to teach and assess their use.

Patients may also not have the dexterity, capacity to learn or vision required to use the inhaler. Online resources are available from, for example, RightBreathe (rightbreathe.com), British Lung Foundation (blf.org.uk). Ms Parker’s adherence could be improved through once-daily inhalers, as indicated by results from a study by Lipson et al (2017). Any change in her inhaler would be monitored as per local policy.

Vaccinations

Ms Parker keeps up to date with her seasonal influenza and pneumococcus vaccinations. This is in line with the low-cost, highest-benefit strategy identified by the British Thoracic Society and Primary Care Respiratory Society UK’s (2012) study, which was conducted to inform interventions for patients with COPD and their relative quality-adjusted life years. Influenza vaccinations have been shown to decrease the risk of lower respiratory tract infections and concurrent COPD exacerbations (Walters et al, 2017; Department of Health, 2011; Poole et al, 2006).

Self-management

Ms Parker was given a self-management plan that included:

• Information on how to monitor her symptoms;
• A rescue pack of antibiotics, steroids and salbutamol;
• A traffic-light system demonstrating when, and how, to commence treatment or seek medical help.

Self-management plans and rescue packs have been shown to reduce symptoms of an exacerbation (Baxter et al, 2016), allowing patients to be cared for in the community rather than in a hospital setting and increasing patient satisfaction (Fletcher and Dahl, 2013).

Improving Ms Parker’s adherence to once-daily inhalers and supporting her to self-manage and make the necessary lifestyle changes, should improve her symptoms and result in fewer exacerbations.

The earlier a diagnosis of COPD is made, the greater the chances of reducing lung damage through interventions such as smoking cessation, lifestyle modifications and treatment, if required (Price et al, 2011).

• Chronic obstructive pulmonary disease is a progressive respiratory condition, projected to become the third leading cause of death globally
• Diagnosis involves taking a patient history and performing spirometry testing
• Spirometry identifies airflow obstruction by measuring the volume of air that can be exhaled
• Chronic obstructive pulmonary disease is managed with lifestyle and pharmacological interventions, as well as self-management

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200506 diagnosis and management of copd – a case study.

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A COPD Case Study: Jim B.

This post was written by Jane Martin, BA, LRT, CRT, Assistant Director of Education at the COPD Foundation .

We're interested in your thoughts on our latest COPD case study: Jim B., a 68-year-old man here for his Phase II Pulmonary Rehabilitation intake interview.

A bit more about Jim:

Medical history: COPD, FEV1 six weeks ago was 38% of normal predicted, recent CXR shows flattened diaphragm with increased AP diameter, appendectomy age 34, broken nose and broken right arm as a child.

Labs: Lytes plus and CBC all within normal limits.

Physical exam: Breath sounds markedly diminished bilaterally with crackles right lower lobe and wheeze left upper lobe. Visible use of accessory muscles. O2 Saturation 93% room air, 95% O2 on 2lpm. Respiratory rate 24 and shallow, HR 94, BP 150/88, 1+ pitting pedal edema.

Current Medications: Prednisone 10mg q day / DuoNeb q 4 hrs. / Ibuprofen 400mg BID / Tums prn (estimates he takes two per day).

Respiratory history: 80-pack-year cigarette history, quit last year. He has developed a dry, hacking, non-productive cough over the last six months. Had asthma as a child and was exposed to second-hand smoke and cooking fumes while working at family-owned restaurant as a child. Lately, he has noticed slight chest tightness and increased cough when visiting his wife’s art studio.

Family history: Father had emphysema, died at age 69, mother died of breast cancer at 62. Grandfather died at age 57, grandmother died in her 40s of suicide. Six adult children, alive and well.

Previous respiratory admissions: Inpatient admission for six days last winter for acute exacerbation of COPD with bacterial pneumonia requiring 24-hour intubation and mechanical ventilation.

Psych: Jim presents to his Phase II Pulmonary Rehab intake interview appearing disheveled, wearing a sweatshirt, pajama pants and bedroom slippers. He is accompanied by his wife and adult daughter who appear neat, clean and well dressed. Patient states, “I don’t think you people can do anything to help me. I’m only here because they (referring to wife and daughter) made me go.” Jim states that he has been doing less and less at home since discharged from the hospital last winter. Wife states, “He walked outside a little with our grandchildren last Sunday and got so short of breath, he almost collapsed.” Became emotional when saying, “It scared the kids. It tore me up for them to see me that way. Besides that, with this darn shoulder I can’t even pick up the little ones anymore.”

Social: Lives at home with his wife of 43 years who works as an artist. Two out of his six children live within 30 miles of Jim’s home.

Occupation: Building contractor, retired three years ago. Jim states, “I made a good living. All the kids were able to go to college. I was strong. I could work circles around anybody in my crew. And now look at me. I’m tied to that darn breathing machine (referring to nebulizer) and I might as well hang it up.” Wife states, “He used to have all kinds of energy. Now all he does is sit in his chair watching TV, eating potato chips and peanuts.”

Tell us your impressions!

• What co-morbidities should be explored?
• How would you change Jim’s medication regime?
• What psych/social recommendations would you make?
• What other medical disciplines should do a consult on this patient?
• This is a real case. What are your thoughts on what took place following Jim’s pulmonary rehab intake interview?

This page was reviewed on March 3, 2020 by the COPD Foundation Content Review and Evaluation Committee

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• Open access
• Published: 21 July 2021

Evaluating the implementation of a chronic obstructive pulmonary disease management program using the Consolidated Framework for Implementation Research: a case study

• Stefan Paciocco 1 ,
• Anita Kothari 2 ,
• Christopher J. Licskai 3 ,
• Madonna Ferrone 4 &
• Shannon L. Sibbald 5  

BMC Health Services Research volume  21 , Article number:  717 ( 2021 ) Cite this article

2634 Accesses

2 Citations

Metrics details

Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease that requires comprehensive approaches to manage; it accounts for a significant portion of Canada’s annual healthcare spending. Interprofessional teams are effective at providing chronic disease management that meets the needs of patients. As part of an ongoing initiative, a COPD management program, the Best Care COPD program was implemented in a primary care setting. The objectives of this research were to determine site-specific factors facilitating or impeding the implementation of a COPD program in a new setting, while evaluating the implementation strategy used.

A qualitative case study was conducted using interviews, focus groups, document analysis, and site visits. Data were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) to assess the impact of each of its constructs on Best Care COPD program implementation at this site.

Eleven CFIR constructs were determined to meaningfully affect implementation. Five were identified as the most influential in the implementation process. Cosmopolitanism (partnerships with other organizations), networks and communication (amongst program providers), engaging (key individuals to participate in program implementation), design quality and packaging (of the program), and reflecting and evaluating (throughout the implementation process). A peer-to-peer implementation strategy included training of registered respiratory therapists (RRT) as certified respiratory educators and the establishment of a communication network among RRTs to discuss experiences, collectively solve problems, and connect with the program lead.

Conclusions

This study provides a practical example of the various factors that facilitated the implementation of the Best Care COPD program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the Best Care COPD program and future implementation of other chronic care programs.

Peer Review reports

The prevalence of chronic diseases in Canada has increased dramatically within the last few decades [ 1 , 2 ]. The number of individuals with chronic obstructive pulmonary disease (COPD) has almost doubled since 2000–2001 [ 3 ]. COPD is a debilitating chronic respiratory disease that accounts for the greatest number of chronic illness-related hospital admissions in Canada [ 4 ].

The use of team-based primary care has been explored to manage and combat the rise of chronic illnesses [ 5 ]. Chronic disease management programs using team-based primary care have been successful at mitigating the negative impacts of chronic diseases such as diabetes [ 6 ], chronic kidney disease [ 7 ], and congestive heart failure [ 8 ]. Using primary care to manage chronic diseases has become a successful part of comprehensive care, resulting in these models becoming a standard for chronic disease management and care around the world [ 9 ]. Unfortunately, there is limited literature describing how best to engage primary care in the management of COPD utilizing an integrated disease management approach. Indeed, in Canada and other jurisdictions the management of COPD falls below guideline standards, is reactive, not proactive, and in this way distinct from other conditions such as diabetes, where the obverse is true [ 10 – 14 ].

Canada has a universal health care system delivered under provincial jurisdiction. Ontario, Canada’s most populous province (14.7 million), implemented family health teams (FHTs) as a collaborative primary care model consisting of providers from multiple disciplines including primary care clinicians and allied health professionals [ 15 ]. Since their implementation in 2005, FHTs have resulted in improved health outcomes and increased access to interprofessional care for patients in Ontario [ 16 ]. For patients with COPD who may struggle to navigate the health system, interprofessional team-based primary care is often a better alternative to emergency department or solo practitioner care [ 17 ].

Accessibility limits the impact of FHTs in general, and on patients with COPD specifically, as only approximately 20% of the population in Ontario has access to team care within an FHT [ 15 , 18 ]. The Best Care COPD program (BCC), the subject of this case study, is an efficacious interprofessional team care program that was developed within the FHT context [ 10 ]. The impact of BCC and other chronic disease management programs in primary care is dependent on effective implementation.

In order to effectively implement chronic disease management programs context-specific guidance is needed [ 19 ]. The implementation of any program into a new setting requires a rich understanding of local context, analysis of stakeholders, and evaluation of provider, organization, and system factors [ 1 ].

Using an evidence-based implementation framework for evaluation ensures research is theoretically grounded [ 20 ]. There are a number of available frameworks such as promoting action on research implementation in health services [ 21 ], the theoretical domains framework [ 22 ], and the consolidated framework for implementation research (CFIR) [ 23 ]. CFIR, an amalgamation of 19 different theories [ 23 ] considers constructs known to affect implementation (see Table  1 and Additional file  1 ) [ 24 ]. Information from CFIR can be used both prescriptively to facilitate the implementation of a program into specific local contexts or retroactively to evaluate implementation efforts [ 25 ]. We chose CFIR to evaluate the implementation of the BCC program.

In Ontario, a team-based COPD management program (BCC) based in primary care focusing on patient self-management through education, skills training and case management, was spread from the region where it was originally developed and implemented, to a neighbouring region using a peer-to-peer implementation approach. While current literature lacks a clear definition, or common name for peer-to-peer approaches in implementation, in general terms, peer-to-peer approaches involve using peer-led education and peer assessment as a method to support learning about the intervention [ 26 – 28 ]. Using a peer-to-peer approach implementation processes can facilitate buy-in and successful uptake/program implementation [ 27 ]. Although more research is needed, preliminary evidence shows peer-to-peer learning as facilitating improved clinical education [ 29 , 30 ]. The purpose of this research was to explore the implementation of the BCC management program at a new clinical site in a different region, using the CFIR framework. Two research objectives guided this study.

Determine the enabling and impeding factors to implementation and spread of an interprofessional team-based primary care model, and

Explore the peer-to-peer approach to implementing a team-based primary care model.

Current literature lacks context empirical examples of the implementation of team-based primary chronic care models specifically for patients with COPD [ 31 ] as well as examples of using a peer-to-peer approach for implementation. Our research set out to fill this gap.

Case description

The BCC management program is a model of care consisting of primary care practitioners (physicians and nurse practitioners), nurses, a respirologist, RRT’s with certified respiratory educator training, and health administrators all working together to provide COPD-specific care to patients. This model was created for the purposes of “delivering standardized, high-impact best-practices, within an interdisciplinary care model” ([ 32 ] p.6). BCC has demonstrated improved patient outcomes (such as reduced severe exacerbations) and reduced urgent health services use (including emergency department visits) [ 10 ]. Best practices in the program include creating action plans, skills training (including inhaler and breathing techniques), how to handle exacerbations, spirometry pre- and post-intervention to measure progress, and medication and exercise prescriptions [ 33 ] . Program standardization and evaluation was supported by a program specific technology solution that guided every encounter and captured performance and outcome metrics [ 32 ]. In Canada, health care providers can obtain a certification as certified respiratory educator (a CRE program recognized by the Canadian Network of Respiratory Care)[ 34 ]; in this case, all RRTs providing care within BCC had (or obtained) a certified respiratory educator designation.

An important component of the BCC program is an advisory committee, called the Primacy Care Innovation Collaborative (PCIC). The PCIC focuses on healthcare system innovation within primary care including participating in the development of provincial standards [ 35 ], and work to better integrate services within primary care through a ‘medical home’ approach [ 36 ]. Specific to BCC, PCIC supported and facilitated the robust evaluation and spread of the program outside the original region [ 32 ]. As a proof of concept project to demonstrate the programs ability to spread as well as to support the feasibility of the peer-led implementation approach, BCC was spread into a five-site FHT within Ontario (B-FHT). The unit of analysis in this case was considered the FHT. All individuals and organizations external to this were considered the outer setting.

Peer-to-peer implementation of this program was multi-pronged and began with BCC program leads presenting to healthcare teams and practitioners promoting the program. In this case, after the presentation to B-FHT, the BCC RRT program lead worked directly with the RRT at B-FHT to commence program implementation. This began with training providers (RRTs) through both an internal three-day intensive didactic training BCC training process along with the external CRE training requirement. Peer-training continues as patients are recruited and enrolled into the BCC program and new RRTs shadow existing RRTs (and vice versa as new RRTs take on new patients). Peer implementation is also happening concurrently for executive directors – who can reach out to current executive directors already running the BCC program as well as for physicians, who can call on BCC physicians and/or the specialist physician (respirologist) for support. Research is currently on-going exploring the peer-to-peer implementation process in greater detail.

Qualitative case study methodology was selected because it allows an in-depth exploration of a single selected entity or case [ 37 ]. Stake’s constructivist case study was chosen specifically because he advocates for the researcher’s active involvement in the case [ 38 ]. CFIR was used as a theoretical background to collect and analyze the data. CFIR has been used extensively in implementation and evaluation to become aware of influential factors, facilitate analysis, and organize the findings of an implementation [ 39 ].

Setting and participants

The BCC management program evaluated in this study was implemented within one FHT with five clinical sites in Southwestern Ontario. The FHT included different types of providers (physician, nurses, RRTs) and FHT staff working collaboratively to deliver healthcare and management education to patients. Implementation was evaluated at all sites as a single case, since providers interviewed worked across all five sites.

A convenience sample was used for recruitment with all having specific roles on the FHT. Participants included providers implementing BCC within the FHT (i.e., RRTs), providers referring patients to the BCC management program (primary care providers), and patients enrolled in the program (Table  2 ). Access to participants was granted through the FHT’s executive director. We relied on providers to assist in patient recruitment; recruitment remained ongoing throughout the course of data collection and analysis.

Data collection

Data were collected from a variety of qualitative sources which collectively contributed to the analysis to ensure that the individual, collective, and documented experiences of participants were obtained. Focus groups were conducted to gather the collective experience of the participants [ 40 ]. Provider and patient focus groups were conducted independently during sites visits. Observational field notes were taken during the site visits. The purpose of the site visits and field notes were to allow for substantiation of the data through triangulation, as well as to provide an element of reflexivity [ 38 ]. Data collection tools were guided by CFIR [ 24 ]; interview and focus group questions were built from CFIR as well as from expert opinion (i.e., those involved in the program delivery and implementation). Questions were considered and subsequently selected by the research team with the main goal of eliciting important information about implementation. All questions were piloted and used in previous research [ 41 ]. Final focus group and interview guides are available upon request.

One-on-one phone interviews with additional primary care providers who referred patients to the BCC program were conducted. The goal was to gather additional views about the implementation of the program from individuals working indirectly with the program.

Review of FHT documents such as memorandums of understanding, reports, and data sharing agreements produced contextual data that was primarily used to support analysis. Documents were accessed through the executive director of the site and the PCIC.

Throughout the entire research process, written reflexive notes were created by the researchers to ensure that the interviewer’s thoughts and assumptions could be incorporated during data analysis and interpretation [ 38 ].

Data analysis

To ensure a thorough understanding of the context of the site and data collected, an ongoing deductive coding strategy based on CFIR was used, supported by NVivo. Data were coded by 3 researchers (SP, SLS, SM) into related CFIR constructs and sub-constructs. To acknowledge and account for data that did not directly fit into CFIR more effectively (such as patient experience), inductive coding was also performed. Discrepancies were discussed and if there were multiple agreeable codes, segments of data were double-coded. Data categorization methods were performed as per Stake [ 38 ]‘s recommendations: direct interpretation and categorical aggregation. All analysis was discussed by the entire research team including a primary care physician. The key enabling constructs were identified as most important during the data analysis process due to being discussed most frequently by the participants and were determined to have a greater impact on implementation through member checking and research team discussion.

While implementation at the FHT took place over 5 sites, the implementation was viewed and evaluated as a single case. Implementation success was qualitatively assessed, using data collected from the provider and patient participants. Throughout data collection, participants reported a high level of satisfaction with the program implementation and delivery.

Field notes and collected documents were integrated into our analysis iteratively. This was done by deductively coding information related to implementation in a similar manner as described above. This additional data was then used in conjunction with focus group and interview data to identify facilitators and barriers to implementation. Participants received an interim report which was discussed during a focus group. Feedback was incorporated into our results. A member check (method of qualitative data triangulation) was conducted to explore the validity of our findings. Member checking involved returning to the implementation site after initial data collection and analysis for a follow-up visit. This allowed the researchers to confirm their interpretation of the data with the participants as well as ask additional questions.

In total, three focus groups (2 provider, 1 patient), n  = 1 phone interview, and n  = 1 key informant interview were conducted involving a total of 28 participants. n  = 24 providers and n  = 4 patients (Table  3 ). All FHT providers invited to participate took part in the study. Informed consent was obtained from all participants prior to any data collection. Response rate for the patients was unknown due to the recruitment of patients being performed by RRTs.

Factors affecting Implementation

Our results are presented according to the 5 main categories of CFIR, while incorporating results from the patient perspective and peer-to-peer implementation. Quotes are provided to illustrate our findings.

Intervention characteristics

Design quality and packaging.

The design quality and packaging of the program was discussed as a critical factor in the decision to adapt the model and its successful implementation. This included the presence of highly trained team members with experience implementing and delivering the BCC program as part of the peer-to-peer approach. They acted in a hands-on and advisory capacity during and following implementation. They trained individuals on how to execute the program as well as offered continued advice post-implementation.

When [the BCC Program Leads] came in, they knew what the expectations were, they knew what the outcomes would look like. They had that experience, where we were just fishing and hoping we would get the outcomes we were hoping for, but we didn’t really have the experience with that to confidently approach all those physician groups (Provider #3, Provider Focus Group #1) .

Participants believed previous program success translated to a smooth process for B-FHT staff in terms of program implementation. “Right away we were sold … it’s an easy sell because they… drop a program and a person attached to it in your lap. It is zero work” (Provider #2, Key Informant Interview #1). The participants further discussed the low complexity of the implementation. “Once… the patients were being seen, there’s not a lot of other admin, oversight really required. It’s the simplest honestly. So simple… everything just fell into place.” (Provider #2, Provider Focus Group #1). Providers elaborated on how they felt the implementation was done effectively and efficiently. “It seems really simple … it didn’t really disrupt … your everyday (Provider #1). If we could roll out every single program that way, it’d be great” (Provider #2, Provider Focus Group #1).

Providers felt the recruiting of patients into the program was smooth and effective. Patients concurred with this statement, saying: “[I] flowed right through [into the new program]” (Patient Focus Group #1). Even though patient awareness of the transition into the program was low; providers believed this facilitated implementation because it did not disrupt usual patient appointments. Providers appreciated being able to spend more time focusing on patient transition and less on other aspects of implementation.

Relative advantage

Providers discussed that prior to implementation of the BCC program, B-FHT had been unsuccessful in their attempts to create their own COPD management program. The relative advantage of the BCC program offered a successful and adaptable solution for their patients.

There [were] challenges. One, that there wasn’t an established program, for [the RRT] to mimic. And two … we are a multi-site organization, and with a 0.5 [full-time equivalent RRT] position it is really hard to establish any programming without a consistence presence. Which … just wasn’t possible (Provider #2, Key Informant Interview #1) .

Physician #1 echoed this explaining the advantage of having a comprehensive COPD specific care program in “free (ing) me up to focus on other things during appointments” (Phone Interview #1). Providers agreed this was a clear benefit of the program. The physician was confident in the abilities of the newly educated RRTs to provide COPD-specific care to the patients. As a result, they were able to focus their time on a patient’s other concerns and needs, allowing for more efficient use of time during appointments.

Patients also appreciated the coordinate afforded by the BCC program explaining how they prefer this program to alternatives they have previously experienced. “I’ve got a specialist that I’m not agreeing with and that’s not helping me, I might as well not even go to him. [The RRT in this program] is doing [more for me] than he is” (Patient #4, Patient Focus Group #1). From the patient’s view, the RRT was delivering better care for their COPD than was the specialist working external to the program.

Providers discussed the challenges of adding the program’s new reporting technology on top of existing technology. “They have their own system … I hate adding systems. That was the one thing probably that I really was not happy about … we have an [electronic medical record] (EMR). We’re seeing our patients but will be documenting in [the BCC’s system]” (Provider #2, Key Informant Interview #1).

Outer setting

Patient needs and resources.

Providers discussed the patient needs in the community as one of the reasons B-FHT proceeded with program implementation. “COPD was a problem. And COPD patients are complex, time-consuming, and costly. There’s plenty of patients and ongoing work to keep you busy full-time” (Provider #3, Provider Focus Group #1).

Cosmopolitanism

Participants described B-FHT’s cosmopolitanism efforts (i.e., efforts to collaboration with external organizations) to be instrumental in implementing the program. There was a shared agreement amongst providers about how “[the BCC’s] guidance was key for us being successful so quickly” (Provider #3, Provider Focus Group #1). In addition to working with the BCC program team, the B-FHT had the chance to learn from the PCIC and strengthen their coordinated efforts with the local hospital.

We actually built it to [be] part of one [program] to refer hospital discharges... with the COPD diagnosis... to automatically send a message to the RRT saying that, that person was discharged (Provider #5, Provider Focus Group #2) .

B-FHT had a pre-existing relationship with the local hospital, which had been responsible for performing diagnostic lung function testing (spirometry). The collaboration was challenged because the BCC program standard was for the RRT to complete the spirometry in the local B-FHT office. Transferring spirometry from the hospital to the B-FHT office was a concern because it meant shifting care away from the hospital. A compromise was reached allowing B-FHT to maintain the relationship with the hospital and respecting the requisite program fidelity.

Inner setting

Networks and communication.

In implementing BCC, a network of RRTs was created to enhance communication and facilitate a peer-to-peer approach. This was discussed as a key factor for implementation success because it facilitated information sharing across a broad context which informed practice. This peer-to-peer approach facilitated the training of providers within B-FHT and supported implementation of the program. “The RRTs have their own network where they communicate with each other” (Provider #6, Provider Focus Group #2). “It’s an opportunity for them to … say what’s working, what’s not working, what are they finding out there in the field. They [also] have a [messaging] group” (Provider #4, Provider Focus Group #2). The peer-to-peer approach strengthened communication between providers within the program. BCC Program leads were seen as a highly valued resource for providers. “[She is] always available if we run into any problems or have questions … [we] just reach out to her directly” (Provider #4, Provider Focus Group #2).

Occasionally, poor communication amongst leadership and providers acted as a barrier to implementation. One provider noted “if [meetings are announced] last minute or we forget… it’s just not going to be priority to move all our other appointments around … (Provider #7, Provider Focus Group #2). This was especially significant when the meetings included training or were meant to connect new providers.

Readiness for Implementation - available resources

Resource support was also discussed as a factor for successful implementation. Typically, RRTs were newly hired to support program delivery, however “[B-FHT] (used) their existing [RRT] to deliver [the BCC] model” (Provider #4, Provider Focus Group #2). This was both seen as a facilitator (i.e., using available resources) and as a barrier (i.e., requiring unlearning of existing, possibly hindering practices and habits). With the BCC program, the current RRT role was expanded into a full-time position, making it easier to implement the program in B-FHT’s multi-site clinical setting.

Administrative support including affirmation from senior management, secretarial/scheduling support, and chart audit support from the BCC leads was particularly important during the initial stages of implementation. Without this support, RRTs believed they would have had to spend excessive time doing administrative work rather than focusing on patient care. “If you’re rolling a program like this into a [FHT] office without a lot of allied health, those cold calls … for [a patient’s] first visit might be time-consuming if they didn’t have that support” (Provider #3, Provider Focus Group #1).

However, the providers discussed how data in the primary care EMR, distinct from the program electronic health record, was of poor quality. This hampered the ability for the program RRT to identify high risk individuals. Providers felt “better data in [the EMR] would’ve helped. But that’s not… likely or possible” (Provider #2, Provider Focus Group #1).

Characteristics of individuals

Self-efficacy.

Peer-to-peer implementation allowed providers to learn about the program and its intended implementation first-hand from experienced RRTs. Providers felt this increased their confidence in program delivery. “I really appreciate having people who are experts in COPD care that can give me recommendations. The more knowledge I start to feel comfortable with … in COPD in particular is because of [the RRT]” (Provider #3, Provider Focus Group #1).

Throughout focus group discussion, patients remarked how “you follow what [the RRT] says and [what] the doctor says and … my quality of life is better” (Patient #2, Patient Focus Group #1). This trust built between the providers and patients was important for implementation success. Patients reported they felt empowered to manage their care and talked about sharing that with peers and family members.

Knowledge and beliefs about the intervention

Providers and patients valued the program from the start. This buy-in of the program enhanced implementation. Providers and patients highly valued the RRT role and expressed many positive views about the RRTs: “If we could clone [the B-FHT RRT], that’s part of what has … made it so successful for us is that she was able to just come in” (Provider #2, Provider Focus Group #1).

Support from senior leadership was essential during the implementation process. The initial impetus to implement the program stemmed from collaboration between RRTs, however, the executive director of the site fully supported and actively facilitated implementation. Participants reported buy-in from senior leadership as a major facilitator to implementation. In addition, other primary care providers engaged with the program throughout the implementation process by learning about program offerings and supporting patient recruitment into the program.

Initially… we were reminded to refer any of our COPD patients for the [RRTs] to make sure that there was a demand. I would really emphasize the importance of frequent reminders to … everyone who would refer patients to the program, reminding them of what kinds of [patients] they can and should refer (Physician #1, Phone Interview #1) .

Providers praised the BCC’s intensive approach to early implementation. They explained how it resulted in buy-in from the start.

That initial, really strong blitz on talking to, providing the education to the physicians, speaking with the physician groups individually, getting the searches ready to go... It seemed like that period was probably short, but intense, and necessary (Provider #3, Provider Focus Group #1) .

Providers also reported the peer-to-peer approach enabled rapid implementation the program. Peer-to-peer training was conducted by an RRT and supported by a respirologist. Provider #1 said that she “sat with somebody who’d been doing it for twenty, five, and three years” respectively (Provider Focus Group #1). Provider #2 elaborated: “the training piece was also big … that training then does ensure that there’s a consistency in [program delivery]” (Provider Focus Group #1).

Reflecting and evaluating

In an effort to collect data on the implementation and performance of the BCC management program, feedback data was collected by B-FHT and the PCIC. Data was collected using patient satisfaction surveys as well as regular debriefing with stakeholders. This data was then used to facilitate adjustments to the implementation and execution of the program as needed.

When discussing the results of this data during reflection of the implementation process, many participants boasted at its success. “I don’t have a single criticism about the program. I really can’t think of how it could have been done better” (Provider #2, Key Informant Interview #1). “We always look at outcome measures, which are always really positive.” (Provider #3, Provider Focus Group #1). Providers explained that not only is patient satisfaction increasing but “hospital admissions had been decreased” (Provider #1, Provider Focus Group #1). When asked to provide advice to other teams considering implementing the program, a key informant said:

Take advantage of this program it is zero work on your end. They will come in and do everything and they will also return. If you are struggling at any point... having trouble identifying patients or... with physician buy-in, if you’re having process issues, they are happy to return... my only advice actually, is “say yes” (Provider #2, Key Informant Interview #1) .

Patients echoed provider’s positive views of the program and focused their conversation on the care they received from the program. Patients reflected on their own care and found value in their improved overall quality of life: “[The RRT] was very thorough … with their explanations of your puffers [and] your medication … [the RRT] gave you [advice]… I find it very good, helpful (Patient Focus Group #1).

This implementation case study was the pilot site to evaluate the opportunity for program spread to multiple sites across multiple regions. All of the CFIR constructs analyzed affected implementation, however five were determined as key enabling constructs (based on the frequency of their occurrence in participant comments and in documents) to consider when implementing a team-based chronic care program such as the BCC program: cosmopolitanism, networks and communication, engaging, design quality and packaging, and reflecting and evaluating.

CFIR constructs acting as barriers to be managed during implementation were also identified. These were: complexity (of the new patient reporting system); communication (between providers and management as well as between providers and specialists); and lack available resources (in this case, lack of quality data in the clinic-based primary care EMR).

In a systematic review, Kadu and Stolee [ 25 ] evaluated the implementation of chronic care management models in primary care settings. To do this, they used CFIR constructs to determine facilitators and barriers to implementation. Although within each of the 22 studies included there were many combinations of all 39 CFIR constructs affecting implementation, they identified seven constructs which had a meaningful effect on implementation across the studies included in their review. These were: networks and communication, culture, implementation climate, structural characteristics, engaging, executing, readiness for implementation, and knowledge and beliefs about the intervention [ 25 ]. Our analysis approach overlapped the Kadu and Stolee [ 25 ] review in three constructs: networks and communication, engaging, and knowledge and beliefs about the intervention. This is not to say the others were not important during the implementation of the BCC program, they simply did not appear frequently in our analysis. Our study shows, as others do, that it is a combination of multiple CFIR constructs which meaningfully affect successful implementation [ 24 ]. Although Kadu and Stolee [ 25 ] evaluated the implementation of chronic care management models in primary care settings, there were no studies among the 22 included that focused specifically on COPD. This may be one reason why only 3 of Kadu and Stolee [ 25 ]‘s primary constructs aligned with our finding. Our study adds to this work by providing insight into the implementation of a COPD-specific management program.

Key enabling CFIR constructs

The strong cosmopolitan relationship developed between B-FHT and the BCC leadership was supported by the evidence-based characteristic of the program. Participants could easily align cognitively and philosophically on evidence-based treatment standards. It also facilitated networking with external organizations. When implementing a chronic care management program, it is important to first consider collaboration with external organizations [ 1 ]. The established networks present with PCIC and other RRT networks gave B-FHT providers opportunities to collaborate and gain access to knowledge from a broad network of providers.

Literature on the implementation of chronic care models states that when a collaborative effort is made with external organizations, implementation and sustainability efforts are more effective [ 1 ] and factors such as communication, cohesion, and role primacy increase [ 42 ]. This finding is mimicked in recent works by Brown et al. [ 43 ] and Huang et al. [ 44 ]. In our case study, B-FHT’s partnership with the BCC program team acted as a key facilitator to implementation.

Networks and communication or information and communication as termed in Davy et al. [ 1 ] are facilitators within literature that were important in this case study. The BCC program in its initial stages created strong networks and communication which supported program delivery [ 45 ]. Enhancing communication among providers and establishing provider-specific networks are key components to facilitating the peer-to-peer implementation [ 46 ]. Kadu and Stolee [ 25 ] uphold that strong implementation efforts require established internal communication networks. This helps improve long-term sustainability, keep track of patients, and proactively notice gaps in service provision [ 1 ]. When information and communication systems are not in place or are insufficient, they can become a significant barrier to implementation [ 47 ].

Engaging champions in implementation efforts is a key factor to success [ 48 ]. Champions can help increase provider support through enthusiasm and support [ 48 ]. Participants identified champions within the PCIC, B-FHT management, and the RRT as peer leaders during implementation. When leadership is engaged, there is more likely to be support from other providers [ 1 , 25 ]. Alternatively, if leadership is not engaged, stakeholders may begin to lose interest [ 48 ].

The excellent design and packaging of the intervention positively influenced B-FHT’s decision to implement and supported the ease of implementation. The BCC structured program coupled with the support from BCC program team, the PCIC and other RRT networks infused quality within the whole implementation. Literature has shown that poor design quality or lack of attention to packaging can be a barrier to implementation [ 47 – 49 ]. Well-designed educational materials, such as those used by BCC, can also facilitating implementation by fostering engagement and increasing clarity [ 50 ].

In our study, evidence-based data, specifically regular reflecting on performance metrics and peer-to-peer feedback methods were used effectively to support implementation. Integrating regular monitoring and evaluation throughout program delivery can support implementation efforts [ 10 ]. Regular debriefing with stakeholders to allow for critical reflection and evaluation is also important and should be embedded early on in implementation [ 1 , 38 ]. Feedback systems that are used to support implementation can also work to support program sustainability [ 1 , 49 ].

Other CFIR factors affecting implementation

There were other CFIR constructs found to be supportive of implementation, but not necessarily as impactful as those already discussed. Complexity: When stakeholders believe an implementation is simple, the program is more easily implemented into practice [ 51 ]; overly complex programs or processes can impede the implementation of chronic care models [ 1 ]. In our case, the simplicity of implementation, attributed to the high level of support from the BCC program team, was a facilitator – often supporting other key constructs such as engagement and reflection. Patient Needs and Resources: There is consensus in the literature around the importance of considering context in implementation efforts - this should consider factors at multiple levels including patient, provider, team, organization, and community [ 1 , 24 , 51 – 53 ]. A systematic review by Davy et al. [ 1 ] described how implementation is enabled when providers believe their intervention helps their patients, rather than a change for change’s sake. The BCC program in our study addressed a clear and growing need for COPD-specific care in the B-FHT community. Relative Advantage: Providers believed the program had a relative advantage to what was currently being offered to patients; this, combined with the perceived need within their community, facilitated implementation. Our results echo the findings of Greenhalgh et al. and others [ 47 , 51 ] who have explained the importance of programs having a “clear, unambiguous advantage in either effectiveness or cost-effectiveness [as] more easily adopted and implemented” [ 51 p.594]. Readiness for Implementation – Available Resources: There is consensus in the literature that a lack of resources, or a misuse of available resources (ex. time, funding, and space) can hinder implementation [ 1 , 54 , 55 ]. In our study, the addition of a full-time RRT position made a meaningful difference in the overall provision of services. While the addition of resources can support implementation, it is important to ensure any resource is added or appropriate for the context [ 1 ]. Self-Efficacy/Knowledge and Beliefs about the Intervention: Ensuring providers possess the necessary skills to achieve implementation goals is essential [ 1 ]. BCC’s training helped build confidence and empowerment in providers, and the peer-to-peer approach facilitated buy-in to the possibilities of the program (i.e., positive outcomes for patients and providers) [ 43 ]. Low self-efficacy and high staff turnover can undermine the implementation process [ 56 , 57 ]. When providers feel more confident in their scope of practice, they can build trust and support implementation.

Peer-to-peer implementation

Literature describes peer-led education as a powerful approach to achieving program goals and objectives [ 26 – 28 ]. To our knowledge, using a peer-led approach to implementation has not been directly studied, however our case shows the potential for such an approach. In this case RRTs, as regulated health professionals with specialized COPD training as certified respiratory educators, worked directly with other RRTs in implementation and program delivery. Their professional-efficacy and commitment to program goals was amplified by regular peer-to-peer education and training. The providers mentioned how regular training sessions, along with the program lead’s availability throughout implementation, as essential in the success of program implementation and ultimately the program overall. The creation of the RRT network, which allowed RRTs to share emerging ideas and concerns about the program and their patients throughout and following implementation, was seen as a key component successful implementation. Positive views surrounding the program and the critical role of the RRTs during implementation were shared by all participants echoing the findings of Pfadenhauer et al. [ 58 ] who explained how key individuals who can be champions during an implementation can enhance overall program success.

Limitations

Our small sample size and in depth look at one case meant there was a potential for both social desirability bias and the Dunning-Kreuger effect (the belief that implementation was better than it actually was) [ 59 ]. The latter point is mitigated by positive outcomes reported in the seminal randomized control trial from which the spread initiative was launched [ 10 ]. Participants all worked together which may have affected their willingness to share experiences; however, we ensured there were multiple opportunities for feedback, including our formal member checking. We acknowledge our results are specific to this case study, however our standardized methodology and evaluation framework support our results can being interpreted in other contexts. Triangulation of data and member checking supported the rigor and trustworthiness of our data. Due to the fact this is a single case study, determination of important factors affecting implementation success was based on in-depth discussion with our research team and research participants; we also relied on inference from factors including the frequency with which particular barriers/facilitators were mentioned. Future research is ongoing examining the variability in implementation success across multiple sites and examining differences in facilitators at successful sites versus barrier’s unsuccessful sites. Even though the findings came from a single case study, our results will be useful in planning spread and implementation efforts of the BCC program at other sites and for others wanting to implement a chronic disease management program.

This study was conducted to understand the facilitators and barriers that affect the implementation of a chronic care management program for patients with COPD in a primary care context. Our aim was to determine enabling factors of implementation and spread of an interprofessional team-based primary care model to support future spread efforts. The five most influential constructs to implementation according to CFIR were cosmopolitanism, networks and communication, engaging, design quality and packaging, and reflecting and evaluating. Our results align with those from the literature including Kadu and Stolee [ 25 ]‘s systematic review using CFIR of factors affecting the implementation of chronic disease management programs. The successful implementation of the BCC program within B-FHT can be attributed to multiple factors. The program’s overall success was well regarded by both providers for its positive outcomes and by patients for the improvement in their COPD-specific care. Overall, CFIR was a suitable determinant framework for conducting our study. It provided a broad and useful set of constructs from which was able to determine factors affecting the implementation of the BCC management program. We also aimed to understand the peer-to-peer approach to implementation. This implementation was understood as vital to assist in communication, engagement, and self-efficacy of providers.

This study provides a practical example of the various factors that facilitate the implementation of the BCC management program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the BCC program and future implementation of other chronic care programs.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available in order to maintain the confidentiality of the participants but are available from the corresponding author on reasonable request.

Abbreviations

Chronic Obstructive Pulmonary Disease

Family Health Team

Consolidated Framework for Implementation Research

Electronic Medical Record

Registered Respiratory Therapist

Best Care COPD

Primary Care Innovation Collaborative

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Acknowledgements

We would like to acknowledge the participants in this study. Thank you to Dr. Judy Belle Brown, Dr. Sayra Cristancho and the entire research team for your guidance throughout this process. Thank you especially to Dr. Shiraz Malik for your assistance during the data analysis process. Thank you also to Alvina Asif Jiwani who assisted with referencing for this manuscript.

This study was funded through a 2-year grant from Lawson Research. Lawson Research had no role in the design of the study, data collection, data analysis, or preparation of the manuscript.

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Stefan Paciocco

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Anita Kothari

Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada

Christopher J. Licskai

RRT-CRE, Asthma Research Group Inc., London, Canada

Madonna Ferrone

School of Health Studies, Faculty of Health Sciences, Department of Family Medicine, Schulich School of Medicine and Dentistry, The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Canada

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Contributions

SP was the graduate student during the research process. SP was lead interviewer during focus groups and interviews. SP performed all of the initial deductive and inductive coding and drafted the first version of the manuscript. AK was a member of the advisory committee and provided advice on the scope and direction of the research. AK reviewed the manuscript during writing, provided feedback and made edits throughout the entire process. SLS supported data collection and analysis. SLS created field notes during focus groups. SLS was involved in the deductive and inductive coding of the data. SLS contributed to the writing of the manuscript. CJL an MF made substantial contributions to the development of the BCC program as members of the PCIC, supported data collection at B-FHT sites, and in the interpretation of data for the work. CJL and MF reviewed the manuscript critically for important intellectual content. By design, CJL and MF did not participate in the direct acquisition, coding, or primary interpretation of the data. All authors read and approved the final manuscript.

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Stefan Paciocco 1 , MSc; Anita Kothari 2 , PhD; Christopher J. Licskai, MD 3 ; Madonna Ferrone 4 ; Shannon L. Sibbald 2,3,5 , PhD.

Health and Rehabilitation Sciences -Western University 1 , School of Health Studies, Faculty of Health Sciences - Western University 2 , Department of Family Medicine, Schulich School of Medicine and Dentistry 3 , Asthma Research Group Incorporated 4 , The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry 5 .

When doing constructivist research, we must have an active personal role in data collection and analysis. This will be done by stating preconceived notions and assumptions and discussing how they affected the interpretation of the data. SLS had worked alongside the PCIC in the past and knew their program and implementation strategy well. The initial iteration of the program was evaluated and deemed a notable success. As a result, SP possessed an understanding that the BCC management program was a successful program. Although SP found the majority of results to be positive, on occasion, he may have been more likely to code in a positive manner rather than neutral or negative. Therefore, there may exist other interpretations of which the researchers were not immediately aware of which may have been understood by another researcher unaware of the program’s successful origins.

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Correspondence to Shannon L. Sibbald .

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The Western University Ethics and Review Board granted ethics approval for this study (Project Number: 108415). Additionally, Lawson Research funded this project, and we were required to submit a Research Database Application (ReDA ID: 6416), which was also approved. As this research involved human participants and human data, all research was performed in accordance with the Declaration of Helsinki. Informed consent to participate was obtained from each participant including the executive director through the reading, explanation, and signing of a letter of information and informed consent for participation and publication.

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Additional file 1..

Consolidated Framework for Implementation Research Constructs. This document provides an organized list including the categories and constructs of the consolidated framework for implementation research, as well as a short definition for each construct.

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Paciocco, S., Kothari, A., Licskai, C.J. et al. Evaluating the implementation of a chronic obstructive pulmonary disease management program using the Consolidated Framework for Implementation Research: a case study. BMC Health Serv Res 21 , 717 (2021). https://doi.org/10.1186/s12913-021-06636-5

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Respiratory infections are common causes of acute exacerbation of chronic obstructive lung disease (AECOPD). We explored whether the pathogens causing AECOPD and clinical features changed from before to after the coronavirus disease 2019 (COVID-19) outbreak. We reviewed the medical records of patients hospitalized with AECOPD at four university hospitals between January 2017 and December 2018 and between January 2021 and December. We evaluated 1180 patients with AECOPD for whom medication histories were available. After the outbreak, the number of patients hospitalized with AECOPD was almost 44% lower compared with before the outbreak. Patients hospitalized with AECOPD after the outbreak were younger (75 vs. 77 years, p  = 0.003) and more often stayed at home (96.6% vs. 88.6%, p  < 0.001) than patients of AECOPD before the outbreak. Hospital stay was longer after the outbreak than before the outbreak (10 vs. 8 days. p  < 0.001). After the COVID-19 outbreak, the identification rates of S. pneumoniae (15.3 vs. 6.2%, p  < 0.001) and Hemophilus influenzae (6.4 vs. 2.4%, p  = 0.002) decreased, whereas the identification rates of P. aeruginosa (9.4 vs. 13.7%, p  = 0.023), Klebsiella pneumoniae (5.3 vs. 9.8%, p  = 0.004), and methicillin-resistant Staphylococcus aureus (1.0 vs. 2.8%, p  = 0.023) increased. After the outbreak, the identification rate of influenza A decreased (10.4 vs. 1.0%, p  = 0.023). After the outbreak, the number of patients hospitalized with AECOPD was lower and the identification rates of community-transmitted pathogens tended to decrease, whereas the rates of pathogens capable of chronic colonization tended to increase. During the period of large-scale viral outbreaks that require quarantine, patients with AECOPD might be given more consideration for treatment against strains that can colonize chronic respiratory disease rather than community acquired pathogens.

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Introduction.

An acute exacerbation of COPD (AECOPD) is a key event in the natural history of the disease, associated with declining health, worsening lung function, and poor prognosis 1 , 2 .{, #9;(GOLD), 2023 #1} Such exacerbations can be triggered by various factors, among which respiratory infections are most common 3 . Bacteria including Hemophilus influenzae , Moraxella catarrhalis , Streptococcus pneumoniae , and Pseudomonas aeruginosa , as well as various viruses, are strongly associated with exacerbation.

The patterns of infection with respiratory viruses other than severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) changed during and after the global pandemic of coronavirus disease 2019 (COVID-19) 4 . The incidences of common, seasonal respiratory viral infections dramatically decreased. Influenza infections have been at historically low levels since 2020; the rates of infection by human metapneumovirus, enterovirus, adenovirus, respiratory syncytial virus (RSV), and human rhinovirus (HRV) have also substantially decreased 5 . Moreover, the rates of certain bacterial infections have fallen since the outbreak. An earlier prospective analysis of surveillance data showed that the transmission rates of S. pneumoniae , H. influenzae , and Neisseria meningitidis decreased in many countries worldwide; these changes were associated with significant reductions in life-threatening invasive diseases 6 .

Equally impressive decreases in COPD exacerbation rates were reported worldwide during and after the pandemic 7 , the declines ranged from 44 to 73% globally 7 , 8 , 9 , 10 . Such findings may be associated with reduction in transmission of respiratory pathogens causing AECOPD 3 . However, detailed data regarding changes in these pathogens after the COVID-19 outbreak have not been reported. Therefore, this study evaluated whether the pathogens causing AECOPD, and the clinical features of the condition, changed after the COVID-19 outbreak.

Study design and methods

Study design.

This retrospective multicenter cohort study was performed in four hospitals within the Republic of Korea. We collected the medical records of patients with AECOPD admitted between January 2017 and December 2018 (before the outbreak of COVID-19) and between January 2021 and December 2022 (after the outbreak). The inclusion criteria were: a history of COPD diagnosed via post-bronchodilator forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC) < 0.7; admission with AECOPD; age > 40 years; and availability of all conventional test data for pathogens causing AECOPD.

AECOPD was defined by a need for additional medication or hospitalization because of worsening clinical symptoms such as cough, sputum production, and/or dyspnea based on the definition within the Global Initiative for Obstructive Lung Disease (GOLD) guidelines 1 .

We collected demographic and clinicopathological information including age, sex, all comorbidities, lung function test results, smoking history, body mass index, exacerbation history, and medications used before AECOPD development. Clinical courses were evaluated in terms of intensive care unit admission and hospital mortality rates, inability to be discharged to home (i.e., transfer to a nursing hospital), and total hospitalization period.

Oral medications taken before AECOPD included xanthine derivatives, phosphodiesterase-4 inhibitors, and mucolytic agents. Inhaled treatments included long-acting beta 2-agonists (LABAs), long-acting muscarinic antagonists (LAMAs), inhaled corticosteroids, and combinations of these over ≥ 6 months before AECOPD development.

The microbiologic examination to identify the causative pathogen in patients with AECOPD was based on the first test performed upon hospitalization. Microbiological examinations included cultures of sputum or endotracheal aspirates; sputum polymerase chain reaction (PCR) tests for Chlamydophila pneumoniae, H. influenzae, S. pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila , and viruses; serum tests for immunoglobulin M against C. pneumoniae and M. pneumoniae ; urinary antigen tests for L. pneumophila and S. pneumoniae ; and nasal swab tests for influenza A and B virus antigens. C. pneumoniae and M. pneumoniae were detected in respiratory specimens via PCR or (indirectly) in serum through immunoglobulin M measurements. L. pneumophila was detected in respiratory specimens via PCR and in urine using an antigen test. H. influenzae was detected in respiratory specimens by either PCR or culture. S. pneumoniae was detected in respiratory specimens by either PCR or culture, and in urine using an antigen test. All single or multiple pathogens identified were recorded.

Statistical analysis

Absent pathogen test data were treated as missing values. Frequencies were expressed as numbers (%); descriptive data were expressed as medians with interquartile ranges. The chi-squared test or Fisher’s exact test was used to compare categorical variables; continuous variables were compared with the Mann–Whitney U test. Factors significantly associated with survival were subjected to Cox proportional hazards modeling after adjustment for age and tested by the log-rank test. The duration of in-hospital survival was defined as the time between admission and hospital discharge, as noted in medical records. Hazard ratios with 95% confidence intervals were calculated. The threshold for statistical significance was set to p  < 0.05.

Ethical approval

This study protocol was approved by the Institutional Review Board of Hallym University Kangnam (HKS 2023-11-008) Sacred Heart Hospital. All patient information was anonymized before analysis. Our institutional review boards (the Ethics Committee of Hallym University Kangnam Sacred Heart Hospital, Ethics Committee of Hallym University Sacred Heart Hospital, Ethics Committee of Hallym University Chuncheon Sacred Heart Hospital and the Ethics Committee of Ethics Committee of Hallym University Dontan Sacred Heart Hospital) approved this retrospective study and waived the requirement for informed consent from the patients. This study adhered to all relevant tenets of the 2013 revision of the Declaration of Helsinki.

Patient characteristics

During the study period, 1186 patients with AECOPD were admitted to four hospitals. Among them, 418 patients were hospitalized after the outbreak of COVID-19, a decrease of approximately 44% over the same period compared to before the outbreak of COVID-19 (Table 1 ). The median age was 77 years, and 84% were men. After the COVID-19 outbreak, the patients were younger and more often men. In terms of comorbidities, congestive heart failure and liver cirrhosis were more common among patients admitted after the outbreak; the frequencies of other comorbidities did not differ between the two periods. The absolute FVC and FEV 1 values were higher after the outbreak, but the predicted values did not differ, perhaps because the patients were younger compared with before the COVID-19 outbreak. Before COVID, more patients used LABAs or LAMAs alone than after the outbreak; LABA/LAMA combinations were more commonly utilized after the outbreak. Inhaled corticosteroid use did not differ between the two groups.

After COVID-19, the number of patients coming from home has increased, and the number of patients discharged to other hospitals after treatment has also decreased. Although the patient’s hospitalization period became longer after COVID-19 outbreak, there was no difference in the intensive care unit hospitalization rate or mortality rate between the two groups.

Microbiological analysis: changes after the COVID-19 outbreak

Detection rate of bacteria and virus after COVID-19 outbreak were 29.3% and 5.1%, respectively, which has decreased compared over same period before COVID-19 outbreak (Fig.  1 ). Before the outbreak, the most frequently identified bacteria were S. pneumoniae (11.7%) and P. aeruginosa (11.1%). However, after the outbreak, the identification rates of S. pneumoniae (15.3 vs. 6.2%, p  < 0.001) and Hemophilus influenzae (6.4 vs. 2.4%, p  = 0.002) decreased, whereas the identification rates of P. aeruginosa (9.4 vs. 13.7%, p  = 0.023), K.pneumoniae (5.3 vs. 9.8%, p  = 0.004), and methicillin-resistant Staphylococcus aureus (MRSA) (1.0 vs. 2.8%, p  = 0.023) increased. The detection rates of all viruses except COVID-19 considerably decreased after the outbreak. In particular, the influenza A detection rate decreased from 10.4% to 1% (Fig.  2 , Table 2 ). There were 44 cases (5%) in total with mixed bacterial and viral infections, 41 cases (6.6%) before the COVID-19 outbreak and 3 cases (0.6%) after the COVID-19 outbreak (Table 2 ).

Overall bacterial and viral detection rates during AECOPD before and after the COVID-19 outbreak: ( A ) Bacteria. ( B ) Viruses.

Bacterial and viral detection rates during AECOPD before and after the COVID-19 outbreak: ( A ) Detection rates of all bacterial species. ( B ) Detection rates of all viral species. * p  < 0.05. MRSA, methicillin-resistant Staphylococcus aureus. RSV, respiratory syncytial virus. COVID-19, coronavirus disease 2019.

Factors prognostic of mortality

Before the outbreak, histories of admission to another hospital and/or COPD exacerbation, and the presence of K. pneumoniae and/or MRSA, were prognostic of mortality. After the outbreak, only MRSA detection was prognostic of mortality (Table 3 ).

The present study revealed changes in the AECOPD hospitalization rates and isolation rates of corresponding respiratory pathogens after the COVID-19 outbreak. The number of patients hospitalized with AECOPD decreased by approximately 44% compared with the number over the same period before the outbreak. Similar phenomena have been reported globally. In the United States, an analysis of the Veterans Affairs Corporate Data Warehouse, a national repository of electronic health records created during visits to all Veterans Affairs facilities, revealed a 48.4% decline in COPD admissions to Veterans Affairs hospitals after the outbreak 8 . In the United Kingdom, analysis of data from Public Health Scotland and the Secure Anonymized Information Linkage Databank of Wales revealed a 48% pooled reduction in AECOPD requiring hospital admission 9 . In Singapore, the monthly rate of acute COPD admissions decreased by more than 50% in the first 5 months (February–July 2020) after the outbreak 10 .

Decreases in AECOPD may be associated with reduced transmission of respiratory-associated pathogens. Most COPD exacerbations are caused by bacterial or viral infections 3 . Globally, the incidence of AECOPD and transmission levels of respiratory viruses simultaneously decreased 11 . The present study also showed that the overall detection rates of bacteria and viruses decreased after the outbreak, explaining the observed AECOPD reduction.

H. influenzae , M. catarrhalis , S. pneumoniae , and P. aeruginosa were commonly isolated from AECOPD patients in previous studies 12 . The most commonly detected viruses in such patients were rhinovirus, influenza A, and RSV 13 . As in a previous study 12 , 13 , S. pneumonia and P. aeruginosa were the frequently identified bacteria, whereas influenza A and rhinovirus were the most common viruses, in the present study. H. influenzae , M. catarrhalis , and RSV were also detected in the present work.

Notably, we found that pathogen detection rates changed after the COVID-19 outbreak. The incidences of S. pneumoniae , H. influenzae, and all viruses except COVID-19 significantly decreased after the outbreak. Such changes have been reported worldwide. A previous study demonstrated significant and sustained reductions in invasive diseases caused by S. pneumoniae , H. influenzae , and N. meningitidis, beginning in early 2020 6 . All viral detection rates have declined worldwide. The Centers for Disease Control and Prevention reported a 98% decrease in influenza activity, from a median of 19.34% to 0.33%, in the United States 14 . Southern Hemisphere countries (Australia, Chile, and South Africa) have also reported minimal influenza activity. Furthermore, the detection rates of RSV, rhinovirus, metapneumovirus, and parainfluenza virus have decreased 4 . Consistent with previous international reports, we found that the influenza detection rate substantially decreased from 10.4 to 1.0%.

The changes may be partly explained by the widespread introduction of COVID-19 lockdown policies. S. pneumoniae and H. influenzae are typically transmitted person-to-person via the respiratory route 15 . Respiratory viruses are transmitted in respiratory droplets and aerosols 16 . Therefore, widespread adoption of COVID-19 containment policies, such as social distancing and the use of face masks in public spaces, may have reduced the transmission rates of respiratory-related pathogens and COVID-19. The COVID-19 containment policies and relevant public information campaigns slowed the transmission of respiratory-related pathogens, thereby reducing AECOPD rates. Therefore, COVID-19 containment policies are effective in lowering AECOPD levels. Although long-term implementation of strict COVID-19-like containment policies is impossible considering the socioeconomic costs, the COVID-19 experience may aid the establishment of strategies to prevent AECOPD.

The S. pneumoniae and respiratory virus detection rates significantly declined, but the detection rates of P. aeruginosa and MRSA significantly increased, after the COVID-19 outbreak. Both P. aeruginosa and MRSA are associated with poor AECOPD outcomes 17 , 18 . In other studies, K.pneumoniae, P.aerusinosa , and MRSA were reported as strains causing colonization in COPD patients 19 , 20 , 21 , 22 . Additionally, approximately 20% of hospitalized COPD patients is colonized with MRSA 18 . These pathogens have the capacity to engage in chronic colonization; the corresponding numbers may be less affected by COVID-19 quarantine policies, compared with the numbers of other pathogens. Colonization precedes obvious clinical infection. Murphy et al. 23 reported that exacerbations caused by P. aeruginosa were more common in patients with advanced COPD compared with early COPD. The median predicted FEV 1 of patients in the present study was 45% and almost half of the patients had a history of AECOPD, reflecting the severity of COPD. These results may explain the increased detection rate of P. aeruginosa after the COVID-19 outbreak.

MRSA is associated with adverse outcomes among patients with AECOPD. Narewski et al. 18 reported that COPD patients colonized with MRSA had longer hospitalizations, required longer courses of antibiotics, and was more likely to require intensive care. Additionally, persistent infection with MRSA in patients with cystic fibrosis was associated with a more rapid rate of decline in lung function 24 . Similarly, we found that MRSA infection was prognostic of mortality before and after the COVID-19 outbreak. COPD patients colonized with MRSA may require close attention.

The present work was a multicenter study including a large number of patients and we comprehensively evaluated the changes in pathogens infecting AECOPD patients before and after the COVID-19 outbreak. However, our study had some limitations. First, this was a retrospective work. Second, we could not evaluate the pathogen status of AECOPD patients after COVID-19 containment policies were completely lifted. It remains unclear whether the observed changes have persisted since easing began. In May 2023, the World Health Organization declared that the COVID-19 public health emergency was over. Thus, an additional study is needed. Third, changes in healthcare utilization by patients with non-COVID-19 conditions during and after the outbreak may have affected pathogen detection rates 25 , 26 , 27 . Forth, this study was conducted on patients hospitalized for acute exacerbations of COPD, patients with severe bronchiectasis were not included, but there may have been patients with focal bronchiectasis, and there is a lack of distinction between respiratory structural abnormalities and their impact on microbial colonization. In the present study, the numbers of patients transferred from other hospitals and discharged to other hospitals after treatment both decreased during and after the outbreak. These findings may be related to difficult transfer between hospitals during lockdown, which could have impacted the pathogen detection rates.

After the COVID-19 outbreak, the number of hospitalized AECOPD patients decreased by almost 44% compared with the number during the same period before the pandemic. After the outbreak, the incidences of community-transmitted AECOPD pathogens tended to decrease, whereas the incidences of pathogens capable of chronic colonization tended to increase. The widespread introduction of COVID-19 containment policies, such as social distancing, may have lowered the transmission of respiratory-associated pathogens, thereby lowering the incidence of AECOPD. When MRSA was identified in AECOPD, patients had a high mortality rate both before and after the COVID-19 outbreak. Regardless of the viral outbreak situation, it is very important to consider treatment for strains associated with chronic colonization or drug resistance in AECOPD patients. However, since strains related to chronic colonization are detected at a higher frequency in AECOPD patients in large-scale viral outbreak situation, chronic colonization strains might need to be given more consideration in the treatment of AECOPD patients in outbreak.

Data availability

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

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Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea

Soo Jung Kim, Taehee Kim, Hayoung Choi, Tae Rim Shin & Yun Su Sim

Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang-si, Korea

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Soo Jung Kim, Taehee Kim, Hayoung Choi, Tae Rim Shin, Hwan Il Kim, Seung Hun Jang, Ji Young Hong, Chang Youl Lee, Soojie Chung, Jeong-Hee Choi & Yun Su Sim

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Y.S.S., S.J.K., T.K., and H.C.: Conceptualization and Methodology, writing original draft. T.R.S., H.I.K., S.H.J., and J.I.H.: data curation and validation. C.Y.L., S.C., and J.C.: formal analysis. All authors have read and approved the final manuscript.

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Kim, S.J., Kim, T., Choi, H. et al. Respiratory pathogen and clinical features of hospitalized patients in acute exacerbation of chronic obstructive pulmonary disease after COVID 19 pandemic. Sci Rep 14 , 10462 (2024). https://doi.org/10.1038/s41598-024-61360-4

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Clinical Simulation Exam Scenario: COPD Patient Case Study

Here is a case study for students and medical practitioners aimed at providing a clinical simulation exam scenario in patients with COPD.

A COPD case study

The 56-year-old patient presents with a difficulty in breathing. The patient complained of feeling short of breath in the morning upon waking up. The breathlessness became worse after climbing just a few steps. He is too short of breath even while talking and has difficulty in finishing sentences.

His wife has revealed that the patient has a history of hepatic failure and allergy to penicillin. He also has a smoking history of 15 pack-year. His occupation involves building cabinets for which he is constantly required to work around fine dust and debris.

Physical examination

The patient's pupils are equal and reactive and he appears alert and oriented. He also has a pursed-lip pattern of breathing. His trachea is in the midline and there is no jugular venous distension.

The vital parameters of the patient are as follows:

• Heart rate: 92 beats per min
• Respiratory rate: 22 breaths per min

Chest assessment:

• The patient presents with a larger than the normal anterior-posterior (AP) diameter of the chest.
• An equal and bilateral chest expansion is noted.
• The chest auscultation reveals diminished breath sounds and a prolonged expiratory phase
• Palpation does not reveal any tactile fremitus
• Percussion of the chest reveals increased resonance
• Subcostal retractions are need

Per abdomen examination

• The abdomen is soft and tender
• Distension: Not present

Extremities:

• The skin appears to be slightly yellowish
• There is no pitting edema in the legs
• Digital clubbing is noted in the fingertips

Laboratory and radiology findings

• ABG Results: PaCO2 59 mm of Hg, pH 7.35 mm of Hg, PaO2 64 mm of Hg, and HCO3 30 mEq/L
• Chest X-ray: Revealed a flat diaphragm, dark lung fields, increase in the retrosternal space, a narrow heart, and mild hypertrophy of the right ventricle
• Blood tests: Hemoglobin 19 gm per 100 mL, RBC 6.5 mill per m3, and hematocrit value 57%

Based on the medical history of the patient, his symptoms, and physical examination, he is suspected to have Chronic Obstructive Pulmonary Disease (COPD).

What are the key findings from the patient’s medical history and assessment in view of the diagnosis?

Here are some important signs and symptoms the patient has complained of that are common in those suffering from COPD:

• A prolonged expiratory time
• Barrel-shaped chest
• Use of accessory muscles of breathing
• Diminished breath sounds
• Pursed lip breathing
• Digital clubbing
• Exposure to dust at the workplace
• History of smoking

How do the abnormal laboratory findings and radiology results justify the diagnosis of COPD in this patient?

The chest x-ray of the patient has revealed the classic signs of COPD such as hyperextension, a narrow heart, and dark lung fields.

It is important to note that though the patient does not have a history of cor pulmonale, congestive heart failure is very common in patients with COPD. Also, the right ventricle of the patient is hypertrophied. It needs to be brought to the attention of the cardiologist for further investigation and assessment of the heart functions.

The laboratory values such as the increased RBC, hematocrit, and hemoglobin levels also point to the diagnosis of COPD. These levels often increase in response to chronic hypoxemia experienced commonly by COPD patients.

The ABG results of the patient also indicate the possibility of COPD as the interpretation suggests compensated respiratory acidosis with hypoxemia. Compensated blood gas levels indicate an issue that could have existed for an extended duration of time.

Which other tests could be helpful in confirming the diagnosis of COPD?

A series of PFT (pulmonary function tests) can be recommended to assess the lung volumes, functions, and capacities of the patient. This would help to confirm or rule out the diagnosis of COPD and provide insights into the severity of the condition.

Generally, the PFT of COPD patients shows the FEV1:FVC ratio to be lower than 70% and an FEV1 value to be less than 80%.

Treatment of COPD

What is the initial treatment for the patient.

As this patient has COPD, the initial line of treatment could be low-flow oxygen to manage hypoxemia. A nasal cannula at 1 to 2 L/min is often recommended along with the air-entrainment mask to ensure the exact FiO2 supply to the lungs.

The patient may be treated with the lowest possible FiO2. The FiO2 can be titrated later based on how he responds to the oxygen being delivered.

What is the next treatment recommendation?

The recent ABG results have revealed a rise in the PaCO2 levels and a decline in the PaO2 levels. This suggests that the patient needs further treatment with ventilation and oxygenation.

Mechanical ventilation needs to be avoided in COPD patients as much as possible as they often have a difficulty in weaning from the device. So, the most appropriate treatment for this patient could be BiPAP (Bilevel Positive Airway Pressure).

Which drug therapies are recommended?

Home oxygen therapy can be recommended if the PaO2 reduces below 55 mm of Hg or the SpO2 reduces below 88% more than twice in a 3-week period.

Other than these, the patient may be prescribed a short-acting or long-acting bronchodilator, an anticholinergic agent, inhaled corticosteroids, and methylxanthines.

Smoking cessation is critical for all patients who smoke. Nicotine replacement therapy could also be indicated in this case.

During the treatment of a patient with COLD, the amount of oxygen being delivered needs to be kept at the lowest possible for maintaining the correct levels of FiO2. Non-invasive ventilation before conventional mechanical ventilation or intubation may also be helpful in emergency situations.

Medical students and doctors can attend our AARC Approved Live Respiratory CEUs to learn more about similar cases. Our Respiratory Therapy Continuing Education CEUs are aimed at providing a clinical simulation of a range of pulmonary conditions to help you improve your knowledge and skills needed for the management of acute and chronic lung diseases.

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Managing a patient with COPD and comorbidities: a case study

Affiliation.

• 1 Peninsula community health community matron service, Newquay hospital, Newquay, Cornwall, England.
• PMID: 26602679
• DOI: 10.7748/ns.30.13.46.s46

This case study provides a critical analysis of the management of a patient with long-term conditions in a community matron service. Particular attention is given to the effect of chronic obstructive pulmonary disease (COPD). The effect of COPD on health and wellbeing, quality of life and hospital admissions is examined, and outcomes are detailed that resulted from the implementation of evidence-based interventions and a case management approach.

Keywords: COPD; case study; chronic obstructive pulmonary disease; community matron service; comorbidities; complex care; long-term conditions.

Publication types

• Case Reports
• Comorbidity*
• Disease Management*
• Middle Aged
• Pulmonary Disease, Chronic Obstructive / complications
• Pulmonary Disease, Chronic Obstructive / therapy*
• Self Efficacy
• United Kingdom