Pulmonary rehabilitation for COPD: A narrative review and call for further implementation in Saudi Arabia

Prevalence and Management of Chronic Obstructive Pulmonary Disease in the Gulf Countries with a Focus on Inhaled Pharmacotherapy

Background: Chronic obstructive pulmonary disease (COPD) is a preventable, progressive disease and the third leading cause of death worldwide. The epidemiological data of COPD from Gulf countries are very limited, as it remains underdiagnosed and underestimated. Risk factors for COPD include tobacco cigarette smoking, water pipe smoking (Shisha), exposure to air pollutants, occupational dusts, fumes, and chemicals. Inadequate treatment of COPD leads to worsening of disease. The 2024 GOLD guidelines recommend use of inhaled bronchodilators, corticosteroids, and adjunct therapies for treatment and management of COPD patients based on an individual assessment of the severity of symptoms and risk of exacerbations. This article reviews COPD pharmacotherapy in the Gulf countries and explores the role of nebulization in the management of COPD in this region. Methods: To review the COPD pharmacotherapy in the Gulf Countries, literature search was conducted using PubMed, Medline, Cochrane Systematic Reviews, and Google Scholar databases (before December 2022), using search terms such as COPD, nebulization, inhalers/inhalation, aerosols, and Gulf countries. Relevant articles from the reference list of identified studies were reviewed. Consensus statements, expert opinion, and other published review articles were included. Results: In the Gulf countries, pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs), soft mist inhalers, and nebulizers are used for drug delivery to COPD patients. pMDIs and DPIs are most prone to errors in technique and other common device handling errors. Nebulization is another mode of inhalation drug delivery, which is beneficial in certain patient populations such as the elderly and patients with cognitive impairment, motor or neuromuscular disorders, and other comorbidities. Conclusion: There is no major difference between Gulf countries and rest of the world in the approach to management of COPD. Nebulizers should be considered for patients who have difficulties in accessing or using MDIs and DPIs, irrespective of geographical location.

Perception and clinical practice regarding mucus clearance devices with chronic obstructive pulmonary disease: a cross-sectional study of healthcare providers in Saudi Arabia

OBJECTIVES

Clearing secretions from the airway can be difficult for people with chronic obstructive pulmonary disease (COPD). Mucus clearance devices (MCDs) are an option in disease management to help with this, but healthcare provider awareness and knowledge about them as well as current clinical practice in Saudi Arabia are not known.

DESIGN

A cross-sectional online survey consisting of four themes; demographics, awareness, recommendations and clinical practice, for MCDs with COPD patients.

SETTING

Saudi Arabia.

PARTICIPANTS

1188 healthcare providers including general practitioners, family physicians, pulmonologists, nursing staff, respiratory therapists and physiotherapists.

PRIMARY OUTCOME MEASURES

Healthcare providers' level of awareness about MCDs, and the identification of current clinical practices of COPD care in Saudi Arabia.

RESULTS

1188 healthcare providers (44.4% female) completed the survey. Regarding devices, 54.2% were aware of the Flutter, 23.8% the Acapella and 5.4% the positive expiratory pressure mask. 40.7% of the respondents identified the Acapella, and 22.3% the Flutter as first choice for COPD management. 75% would usually or always consider their use in COPD patients reporting daily difficulty clearing mucus, whereas 55.9% would sometimes or usually consider the use of MCDs with COPD patients who produced and were able to clear mucus with cough. In clinical practice, 380 (32%) of the respondents would prescribe MCDs, 378 (31.8%) would give MCDs without prescriptions, 314 (26.4%) would not provide them at all and 116 (9.8%) would only advise patients about them.

CONCLUSION

Healthcare providers are aware of the existence of MCDs and their benefits for sputum clearance and believe that MCDs are beneficial for sputum clearance in some COPD patients.

TRIAL REGISTRATION NUMBER

ISRCTN44651852.

A nationwide survey of public COPD knowledge and awareness in Saudi Arabia: A population-based survey of 15,000 adults

BACKGROUND

There is a concerning lack of representative data on chronic obstructive pulmonary disease (COPD) awareness in Saudi Arabia, and a significant proportion of the population is vulnerable to developing a smoking habit, which is a major risk factor for the disease.

METHODS

Population-Based Survey of 15,000 people was conducted to assess the public knowledge and awareness of COPD across Saudi Arabia from October 2022 to March 2023.

RESULTS

A total of 15002 responders completed the survey, with a completion rate of 82%. The majority 10314 (69%) were 18-30 year and 6112 (41%) had high school education. The most common comorbidities among the responders were depression (7.67%); hypertension (6%); diabetes (5.77%) and Chronic Lung Disease (4.12%). The most common symptoms were dyspnea (17.80%); chest tightness (14.09%) and sputum (11.19%). Among those who complains of any symptoms, only 16.44% had consulted their doctor. Around 14.16% were diagnosed with a respiratory disease and only 15.56% had performed pulmonary function test (PFT). The prevalence of smoking history was 15.16%, in which current smokers were 9.09%. About 48% of smokers used cigarette, 25% used waterpipe and around 27% were E-cigarette users. About 77% of the total sample have never heard about COPD. Majority of current smokers (73.5%; 1002), ex-smokers (68%; 619), and non-smokers (77.9%; 9911) are unaware of COPD, p value <0.001. Seventy five percent (1028) of the current smokers and 70% (633) of the ex-smokers have never performed PFT, p value <0.001. Male, younger age (18-30 years), higher education, family history of respiratory diseases, previous diagnosis of respiratory disease, previous PFT, and being an ex-smokers increases the odds of COPD awareness, p-value <0.05.

CONCLUSION

There is a significantly low awareness about COPD in Saudi Arabia, especially among smokers. A nationwide approach must include targeted public awareness campaigns, continued healthcare professional education, community-based activities encouraging diagnosis and early detection, advice on smoking cessation and lifestyle changes, as well as coordinated national COPD screening programs.

The Intersection of Health Rehabilitation Services with Quality of Life in Saudi Arabia: Current Status and Future Needs

Quality of life (QoL) is essential for maintaining a healthy, balanced lifestyle, especially among individuals with chronic diseases. Saudi Arabia (SA) launched a health sector transformation program as part of the nationwide Vision 2030 initiative to ensure the sustainable development of efficient healthcare services, aiming to improve health by increasing well-being and QoL. More investigation into the current status of health rehabilitation services provided to individuals with chronic diseases and future needs to optimize services and improve QoL is needed. This was narratively discussed by experts from different health rehabilitation services in SA. Comprehensive health rehabilitation services including orthopedic, occupational, cardiac, pulmonary, critical care, perioperative, hearing and speech, substance use disorders, and vocational rehabilitation services were addressed. Health rehabilitation services in SA, as in other countries, are suboptimal for individuals in health rehabilitation programs. To optimize the QoL of individuals with chronic diseases, health rehabilitation services should be tailored based on the unique requirements of each service and its serving patients. The shared need to improve health rehabilitation services includes the adoption of home-based and telehealth services, the integration of multi-governmental sectors, the empowerment and allocation of health rehabilitation specialists, public awareness campaigns, policy legislation and guideline development, and the implementation of a long-term follow-up system. This review is one of the first to address the intersection of health rehabilitation services and QoL in SA; urgent and holistic actions are paramount to address the pressing need to optimize SA's health rehabilitation services. The experts' recommendations in this study may be applicable to other countries' health systems, as health rehabilitation services are not well optimized globally.

Physicians' Perceptions of and Barriers to Cardiopulmonary Rehabilitation for Heart Failure Patients in Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Cardiopulmonary rehabilitation (CR) serves as a core component of the management strategy for patients with heart failure (HF). CR is administered by multidisciplinary healthcare providers, but their perceptions toward delivering CR to HF patients, and the factors and barriers that might influence referral, have not been studied. This study aims to assess physicians' perceptions toward delivering CR programs to HF patients and identify factors and barriers that might influence their referral decisions.

METHODS

Between 15 February and 5 June 2022, a cross-sectional online survey with ten multiple-choice items was distributed to all general and cardiac physicians in Saudi Arabia. The characteristics of the respondents were described using descriptive statistics. Percentages and frequencies were used to report categorical variables. The statistical significance of the difference between categorical variables was determined using the chi-square (2) test. Logistic regression was used to identify referral factors.

RESULTS

Overall, 513 physicians (general physicians (78%) and cardiac doctors (22%)) completed the online survey, of which 65.0% (n = 332) were male. Of the general physicians, 236 (59%) had referred patients with HF to CR. Sixty-six (58%) of the cardiac doctors had referred patients with HF to CR. A hospital-supervised program was the preferred mode of delivering CR programs among 315 (79%) general physicians, while 84 (74%) cardiac doctors preferred to deliver CR programs at home. Apart from the exercise component, information about HF disease was perceived by 321 (80%) general physicians as the essential component of a CR program, while symptom management was perceived by 108 (95%) cardiac doctors as the essential component of a CR program. The most common patient-related factor that strongly influenced referral decisions was "fatigue related to disease" (63.40%). The availability of CR centers (48%) was the most common barrier preventing the referral of patients to CR.

CONCLUSIONS

CR is an effective management strategy for HF patients, but the lack of CR centers is a major barrier to the referral of patients. A hospital-supervised program is the preferred method of delivering CR from the general physicians' perspective, while cardiac doctors prefer home-based CR programs. Apart from the exercise component, information about HF disease and symptom management is essential components of CR programs from general physicians' and cardiac doctors' perspectives, respectively.

Nurses’ Beliefs and Barriers of Delivering Cardiopulmonary Rehabilitation for Heart Failure Patients in Saudi Arabia: A Cross-Sectional Study

Background: Patients with heart failure (HF) may benefit greatly from cardiopulmonary rehabilitation (CR), which is provided by a team of healthcare professionals that often includes nurses. There has been no research on how nurses perceive providing CR or the hurdles that may affect referrals. Methods: All registered nurses in Saudi Arabia’s Eastern Province were given access to a cross-sectional online survey consisting of nine multiple-choice questions that address attitudes, beliefs, and barriers to CR for HF patients in Saudi Arabia. Descriptive statistics were used to characterize the respondents. Results: Altogether, 439 registered nurses participated in the online survey, with men making up 194 (44%) and women 245 (56%). The mean and SD of years of clinical experience in caring for patients with HF were 6 ± 5 years. Out of 439 nurses, 107 (24%) strongly agree, and 255 (58%) agree that CR will enhance the physical fitness of patients. However, 94 (21.1%) strongly agree, and 248 (56.4%) agree that CR might alleviate dyspnea in HF patients. The vast majority of the nurses either strongly agree (90 (20.5%)) or agree (240 (55%)), that CR would help reduce palpitations and fatigue in HF patients. Indeed, 87 (19.81%) strongly agree, and 262 (59.68%) agree that CR would help improve HF patients’ ability to perform daily activities, while 51 (11.6%) strongly agree and 223 (51%) agree that CR would help in reducing hospital readmission. It was shown that 360 (82%) of the 439 nurses favored the delivery of CR programs in hospital-supervised programs, while 368 (83.8%) ranked information on HF disease as the most important aspect of the CR program, followed by information about medications at 305 (69.4%). The availability of CR facilities (36%), the cost of therapy (35%), and the absence of an established standardized referring strategy (34%) were identified as the most significant barriers affecting the referral of patients with HF for CR by nurses. Conclusion: Generally, nurses believed CR helped improve desired clinical outcomes in HF patients. Although a hospital-based program with close supervision is optimal for administering CR, few such options exist. Referrals of patients with HF were hampered by the lack of CR facilities, the cost of intervention, and the lack of a systematic approach to referrals.

Healthcare providers' attitudes, beliefs and barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease in Saudi Arabia: a cross-sectional study

OBJECTIVES

To assess the attitude of healthcare providers (HCPs) towards the delivering of pulmonary rehabilitation (PR) to patients with chronic obstructive pulmonary disease (COPD) and identify factors and barriers that might influence referral.

DESIGN

A cross-sectional online survey consisting of nine multiple-choice questions.

SETTINGS

Saudi Arabia.

PARTICIPANTS

980 HCPs including nurses, respiratory therapists (RT) and physiotherapists.

PRIMARY OUTCOME MEASURES

HCPs attitudes towards and expectations of the delivery of PR to COPD patients and the identification of factors and barriers that might influence referral in Saudi Arabia.

RESULTS

Overall, 980 HCPs, 53.1% of whom were men, completed the survey. Nurses accounted for 40.1% of the total sample size, and RTs and physiotherapists accounted for 32.1% and 16.5%, respectively. The majority of HCPs strongly agreed that PR would improve exercise capacity 589 (60.1%), health-related quality of life 571 (58.3%), and disease self-management in patients with COPD 589 (60.1%). Moreover, the in-hospital supervised PR programme was the preferred method of delivering PR, according to 374 (38.16%) HCPs. Around 85% of HCPs perceived information about COPD, followed by smoking cessation 787 (80.3%) as essential components of PR besides the exercise component. The most common patient-related factor that strongly influenced referral decisions was 'mobility affected by breathlessness' (64%), while the 'availability of PR centres' (61%), the 'lack of trained HCPs' (52%) and the 'lack of authority to refer patients' (44%) were the most common barriers to referral.

CONCLUSION

PR is perceived as an effective management strategy for patients with COPD. A supervised hospital-based programme is the preferred method of delivering PR, with information about COPD and smoking cessation considered essential components of PR besides the exercise component. A lack of PR centres, well-trained staff and the authority to refer patients were major barriers to referring patients with COPD. Further research is needed to confirm HCP perceptions of patient-related barriers.

Physiotherapists' Attitudes, and Barriers of Delivering Cardiopulmonary Rehabilitation for Patients with Heart Failure in Saudi Arabia: A Cross-Sectional Study

Background

Cardiopulmonary rehabilitation (CR) is an effective management approach for heart failure (HF) patients and is delivered by multidisciplinary teams including physiotherapists (PTs). PT attitudes about delivering CR and barriers that might affect referral have not been explored. Thus, this study is aimed to explore PT attitudes about delivering CR programs to patients with HF and identify factors and barriers that might affect referral decisions.

Methods

A cross-sectional online survey was disseminated to all PTs in Saudi Arabia between 19 February and 27 June, 2022. The characteristics of the respondents were described using descriptive statistics. Percentages and frequencies were used to report categorical variables.

Results

Overall, 553 PTs, 289 (52.30%) male and 264 (47.70%) females, completed the online survey. Of these, 360 (65.1%) strongly agreed that CR would improve patients’ physical fitness and 334 (60.4%) strongly agreed that CR would reduce breathlessness in patients with HF. The majority of PTs (321, 58%) strongly agreed that CR would improve HF patients’ palpitation and fatigue. Out of 553 PTs, 349 (63.1%) strongly agreed that CR would improve patients’ ability to perform daily activities. A hospital-supervised program was the preferred mode of delivering CR programs by 499 (90.20%) of the respondents. Apart from the exercise component, stress management was perceived by 455 (82.30%) as an essential component of CR programs. The most common patient-related factor that strongly influenced referral decisions was “fatigue related to disease” (42%). A lack of CR centers was reported by 59.90% as the most common referring barrier.

Conclusion

PTs perceived CR as a successful strategy for patients with HF. Although a supervised hospital-based program with stress management as an essential component aside from the exercise component was perceived as the preferred mode of delivery, CR was lacking, which caused a significant barrier to CR referral from the PTs’ perspective.

Nurses' Perception of, and Barriers to, Delivering Cardiopulmonary Rehabilitation for Heart Failure Patients: A National Survey in Saudi Arabia

BACKGROUND

Heart failure (HF) patients require a holistic management approach to improve their clinical outcomes. Cardiopulmonary rehabilitation (CR) is a core component of HF patients' management and is supervised by a multidisciplinary team including nurses. Nursing attitudes regarding CR delivery for patients with HF and the possible barriers and factors that potentially affect referral have not been explored. Therefore, this study seeks to evaluate nurses' attitudes towards the delivery of CR programs and the possible barriers and factors that potentially influence the decision for a referral.

METHODS

An online survey with eight multiple-choice items was disseminated to all nurses between February and July 2022 in Saudi Arabia. The characteristics of the respondents were described using descriptive statistics. Percentages and frequencies were used to report categorical variables.

RESULTS

Overall, 1056 nurses completed the online survey, of which 395 (37.40%) were male. Out of 1056 nurses, 414 (39.20%) strongly agreed that CR would improve patients' physical fitness, and 392 (37.10%) strongly agreed that CR would reduce breathlessness in patients with HF. In total, 381 nurses strongly agreed (36.10%) that CR would improve HF patients' palpitation and fatigue. Out of 1056 nurses, 396 (37.50%) strongly agreed that CR would improve HF patients' ability to perform daily activities, and 326 (30.90%) strongly agreed that CPR would reduce the rate of hospital readmission. The at-home program was the preferred mode of delivering CR programs among 607 (57.50%) nurses. Apart from the exercise component, symptom management was perceived by 704 (66.70%) nurses as the fundamental component of CR programs. The most common patient-related factor that strongly affected the decisions regarding referral was "mobility affected by breathlessness" (57%). A lack of CR centers (46%) was the most common barrier.

CONCLUSION

Nurses perceived CR as an effective management strategy for HF patients. Although a home-based program, with symptom management being an essential component, in addition to the exercise component, was perceived as the preferred mode of delivery, CR centers are lacking, which represented a significant barrier to CR referral from the nurses' perspective.

Needs Assessment for the Establishment of Master's Degree Programs in Respiratory Care in the Kingdom of Saudi Arabia

BACKGROUND

Despite recent advancements in the respiratory care (RC) profession, no single institution in the Kingdom of Saudi Arabia (KSA) offers a master's degree program in RC.

METHODS

A nationwide and validated survey was used to explore the current needs and interests in establishing RC master's degree programs in the KSA. The process included representatives from the healthcare industry, universities, and professional societies.

RESULTS

A total of 1250 stakeholders across the KSA completed the survey. The sample includes 722 (58%) males, 504 (40%) respiratory therapists, 547 (44%) students, 138 (11%) leaders, and 61 (5%) were academic respondents. Most respondents were from Central 491 (39%) and Eastern 307 (25%) regions, with 1003 (80%) of the total sample worked or studied in governmental sectors. A total of 574 (82%) of the leaders and RTs had Bachelor degree and 430 (61%) of them had 1-5 years working experience. According to 80% of the employers and employees, only 0-5% of the RTs in their organization had a master's degree. The calculated mean % of the agreement (agree/strongly agree) on the needs was 83% in all needs' assessment items, which shows a great support for establishing a master's in RC to meet the personal, professional and society needs. The mean % of the agreement for the level of interests among all participants was 86%, indicating a great level of interests in establishing a master degree in RC. The agreement % on the needs assessment and level of interests in establishing a master degree in RC in KSA were ≥80% in each stakeholder group.

CONCLUSION

There are obvious needs and interests in establishing master's degree programs in RC in the KSA. A master's degree in RC should be established to address the growing needs for advanced RC services throughout the nation and enhance RC research.

A quasi-experimental study of the effect of a comprehensive blended health educational program on self-management practices among patients with chronic obstructive pulmonary disease

BACKGROUND

The prevalence and illness burden of chronic obstructive pulmonary disease (COPD) are both high. Currently, limited guidance is available to support the establishment of effective health programs to increase self-management practices in patients with COPD.

OBJECTIVES

To explore the effect of a comprehensive blended health education program on self-management practices in patients with mild-to-moderate COPD in Jeddah City, Saudi Arabia.

METHODS

A quasi-experimental research study was carried out with a convenience sample of 60 discharged or stable patients with COPD following treatment. Participants were divided into an intervention group (n = 30) that received usual hospital care and blended health education program, and a control group (n = 30) that obtained the usual hospital care without involvement in the health education program from May 2021- to August 2021. Data were collected before and three months after the intervention using the COPD Self-Management Scale and patient socio-demographic and clinical information surveys.

RESULTS

Statistically significant differences were found between the control and intervention groups after three months of the intervention based on total COPD Self-Management Scale scores. There were no statistically significant relationships between the participants' mean COPD Self-Management Scale scores in both groups with their socio-demographic and clinical characteristics before and after the intervention.

CONCLUSIONS

A nurse-led, comprehensive blended health education program was found to be an effective method for improving COPD patients' self-management practices. COPD nurses and nurse researchers must collaborate to identify the most common interventions with the best cost/benefit ratios and greater positive effects on early COPD patients' self-management practices and general well-being.

Prevalence, incidence, morbidity and mortality rates of COPD in Saudi Arabia: Trends in burden of COPD from 1990 to 2019

Background

The available data to determine the chronic obstructive pulmonary disease (COPD) burden in Saudi Arabia are scarce. Therefore, this study closely examines and tracks the trends of the COPD burden in Saudi Arabia from 1990 to 2019 using the dataset of the Global Burden of Disease (GBD) 2019.

Methods

This study used the GBD 2019 dataset to analyse the COPD prevalence, incidence, morbidity and mortality rates in the Saudi Arabian population from 1990 to 2019, stratified by sex and age. The age-standardised rate was used to determine the prevalence, incidence, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs) and deaths.

Results

In 2019, an estimated 434,560.64 people (95% Uncertainty Interval (UI) 396,011.72–473,596.71) had COPD in Saudi Arabia, corresponding to an increase of 329.82% compared with the number of diagnosed people in 1990 [101,104.05 (95% UI 91,334.4–111,223.91)]. The prevalence rate of COPD increased by 49%, from 1,381.26 (1,285.35–1,484.96) cases per 100,000 in 1990 to 2,053.04 (1918.06–2194.29) cases per 100,000 in 2019, and this trend was higher in males than females. The incidence rate of COPD in 2019 was 145.06 (136.62–154.76) new cases per 100,000, representing an increase of 43.4% from the 1990 incidence rate [101.18 (95.27–107.86)]. In 2019, the DALYs rate was 508.15 (95% UI 434.85–581.58) per 100,000 population. This was higher in males than females, with a 14.12% increase among males. In 2019, YLLs contributed to 63.6% of DALYs due to COPD. The death rate due to COPD was 19.6 (95% UI 15.94–23.39) deaths per 100 000 in 2019, indicating a decrease of 41.44% compared with the death rate in 1990 [33.55 deaths per 100 000 (95% UI 25.13–47.69)]. In 2019, COPD deaths accounted for 1.65% (1.39–1.88) of the total of deaths in Saudi Arabia and 57% of all deaths caused by chronic respiratory diseases.

Conclusion

Over the period 1990–2019, the prevalence and incidence of COPD in Saudi Arabia have been steadily rising. Even though COPD morbidity and death rates have been decreasing, they remain higher in men and older age. The holistic assessment and interventions with careful attention to optimising the community-based primary care management, such as screening for early diagnosis, smoking cessation programs and pulmonary rehabilitation, are likely to be the most successful strategies to reduce the burden of COPD in Saudi Arabia.

Physicians' Attitudes, Beliefs and Barriers to a Pulmonary Rehabilitation for COPD Patients in Saudi Arabia: A Cross-Sectional Study

This study aimed to assess physicians’ attitudes toward delivering pulmonary rehabilitation (PR) to chronic obstructive pulmonary disease (COPD) patients and identify factors and barriers that might influence referral decisions. Between September 2021 and January 2022, a cross-sectional online survey was distributed to all physicians in Saudi Arabia. A total of 502 physicians completed the online survey, of which 62.0% (n = 312) were male. General physicians accounted for 51.2%, while internal-medicine specialists and pulmonologists accounted for 26.9% and 6.6%, respectively. Only 146 (29%) physicians had referred COPD patients to a PR program. The difference in referral rates between all specialties (p = 0.011) was statistically significant. Physicians with more years of experience were more likely to refer COPD patients to PR (p < 0.001). Moreover, a home-based PR program was preferred by 379 physicians (75.5%), and 448 (89.2%) perceived smoking cessation as an essential component of PR. Availability of PR centers (69%) was the most common barrier for not referring patients to PR. The overall referral rate was low among all physicians, owing to a lack of PR centers and trained staff. Home-based delivery was the preferred method of delivering PR, with smoking cessation as an essential component.