Self-management programmes for adult patients with bronchiectasis: a systematic review and realist synthesis

PURPOSE

Self-management for patients with bronchiectasis has been identified as an important component that could potentially empower patients to manage their condition and improve their quality of life. Evidence was reviewed to investigate what self-management programmes work, why and in what circumstances.

METHODS

A systematic review and realist synthesis were conducted. A comprehensive database search was performed on seven databases for evidence published up to July 2021. Leading candidate self-management programmes identified from the systematic review became the focus of the realist synthesis. A realist logic of analysis was applied to produce explanatory context-mechanism-outcome configurations. These explanations were consolidated into programme theories drawing on health behaviour change theory.

RESULTS

By synthesising the data from eight eligible articles, programme theories articulated how three different self-management programmes work that included: (i) education and action planning, (ii) education and airway clearance techniques (ACT) and, (iii) education, exercise and ACT. Patient characteristics and collaborative partnership between healthcare professionals and patients were identified as important contexts that influenced the improvement in self-efficacy, health-related quality of life, and exercise capacity.

CONCLUSIONS

This review contributes to a better understanding of how the complex interaction between contexts and mechanisms can improve outcomes of clinical interest.IMPLICATIONS FOR REHABILITATIONThis evidence synthesis has identified potentially important combinations of interventions to be considered in self-management programmes for adults with bronchiectasis.Collaborative partnership between patient and healthcare professionals should be considered to improve short-term self-efficacy.Targeting self-management programmes to increase short-term health-related quality of life and exercise capacity should consider the context of patient characteristics.

'It's not one size fits all': a qualitative study of patients' and healthcare professionals' views of self-management for bronchiectasis

Background

Bronchiectasis is a chronic respiratory condition that impacts significantly on individuals and healthcare services. Self-management is recommended in clinical guidelines for bronchiectasis as an intervention to enable patients to manage their condition, yet there is little evidence to support it.

Methods

Three face to face focus groups (17 adults with bronchiectasis) were conducted at three National Health Service (NHS) sites in North West England. Additionally, semi-structured telephone interviews were undertaken with 11 healthcare professionals (HCPs), including doctors, nurses and physiotherapists. Thematic analysis identified common themes and occurrences verified by independent audit.

Findings

Four common overarching themes were identified: the meaning of self-management; benefits; barriers and influencers to self-management; subthemes varied. Both groups recognised component interventions. Patients highlighted that self-management enabled them to learn what works and moderate behaviour. Aspects of delivery and structure were important to HCPs but a ‘make do’ culture was evident. Benefits for both groups included empowering patients. Common barriers for patients were time, mood and lack of access to support which could mitigate engagement with self-management. HCPs identified barriers including patient characteristics and lack of resources. Influencers for patients were peer, carer and psychosocial support, for HCPs influencers were individual patient attributes, including ability and motivation, and HCP characteristics such as knowledge and understanding about bronchiectasis.

Summary

This is the first study to explore patients’ and HCPs’ views of self-management for bronchiectasis. The need for an individual, flexible and responsive self-management programme specific to bronchiectasis was evident. Personal characteristics of patients and HCPs could affect the uptake and engagement with self-management and HCPs knowledge of the disease is a recognised precursor to effective self-management. The study identified key aspects for consideration during development, delivery and sustainability of self-management programmes and findings suggest that patients’ psychosocial and socioeconomic circumstances may affect adoption and activation of self-management behaviours.

Dual antibiotics for bronchiectasis

BACKGROUND

Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation of the smaller airways and associated with a mortality rate greater than twice that of the general population. Antibiotics serve as front-line therapy for managing bacterial load, but their use is weighed against the development of antibiotic resistance. Dual antibiotic therapy has the potential to suppress infection from multiple strains of bacteria, leading to more successful treatment of exacerbations, reduced symptoms, and improved quality of life. Further evidence is required on the efficacy of dual antibiotics in terms of management of exacerbations and extent of antibiotic resistance.

OBJECTIVES

To evaluate the effects of dual antibiotics in the treatment of adults and children with bronchiectasis.

SEARCH METHODS

We identified studies from the Cochrane Airways Group Specialised Register (CAGR), which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), and PsycINFO, as well as studies obtained by handsearching of journals/abstracts. We also searched the following trial registries: US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We imposed no restriction on language of publication. We conducted our search in October 2017.

SELECTION CRITERIA

We searched for randomised controlled trials comparing dual antibiotics versus a single antibiotic for short-term (< 4 weeks) or long-term management of bronchiectasis diagnosed in adults and/or children by bronchography, plain film chest radiography, or high-resolution computed tomography. Primary outcomes included exacerbations, length of hospitalisation, and serious adverse events. Secondary outcomes were response rates, emergence of resistance to antibiotics, systemic markers of infection, sputum volume and purulence, measures of lung function, adverse events/effects, deaths, exercise capacity, and health-related quality of life. We did not apply outcome measures as selection criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of 287 records, along with the full text of seven reports. Two studies met review inclusion criteria. Two review authors independently extracted outcome data and assessed risk of bias. We extracted data from only one study and conducted GRADE assessments for the following outcomes: successful treatment of exacerbation; response rates; and serious adverse events.

MAIN RESULTS

Two randomised trials assessed the effectiveness of oral plus inhaled dual therapy versus oral monotherapy in a total of 118 adults with a mean age of 62.8 years. One multi-centre trial compared inhaled tobramycin plus oral ciprofloxacin versus ciprofloxacin alone, and one single-centre trial compared nebulised gentamicin plus systemic antibiotics versus a systemic antibiotic alone. Published papers did not report study funding sources.Effect estimates from one small study with 53 adults showed no evidence of treatment benefit with oral plus inhaled dual therapy for the following primary outcomes at the end of the study: successful management of exacerbation - cure at day 42 (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.22 to 2.01; 53 participants; one study; very low-quality evidence); number of participants with Pseudomonas aeruginosa eradication at day 21 (OR 2.33, 95% CI 0.66 to 8.24; 53 participants; one study; very low-quality evidence); and serious adverse events (OR 0.48, 95% CI 0.08 to 2.87; 53 participants; one study; very low-quality evidence). Similarly, researchers provided no evidence of treatment benefit for the following secondary outcomes: clinical response rates - relapse at day 42 (OR 0.57, 95% CI 0.12 to 2.69; 53 participants; one study; very low-quality evidence); microbiological response rate at day 21 - eradicated (OR 2.40, 95% CI 0.67 to 8.65; 53 participants; one study; very low-quality evidence); and adverse events - incidence of wheeze (OR 5.75, 95% CI 1.55 to 21.33). Data show no evidence of benefit in terms of sputum volume, lung function, or antibiotic resistance. Outcomes from a second small study with 65 adults, available only as an abstract, were not included in the quantitative data synthesis. The included studies did not report our other primary outcomes: duration; frequency; and time to next exacerbation; nor our secondary outcomes: systemic markers of infection; exercise capacity; and quality of life. We did not identify any trials that included children.

AUTHORS' CONCLUSIONS

A small number of studies in adults have generated high-quality evidence that is insufficient to inform robust conclusions, and studies in children have provided no evidence. We identified only one dual-therapy combination of oral and inhaled antibiotics. Results from this single trial of 53 adults that we were able to include in the quantitative synthesis showed no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, serious adverse events, sputum volume, lung function, and antibiotic resistance. Further high-quality research is required to determine the efficacy and safety of other combinations of dual antibiotics for both adults and children with bronchiectasis, particularly in terms of antibiotic resistance.

Self-management for bronchiectasis

BACKGROUND

Bronchiectasis is a long term respiratory condition with an increasing rate of diagnosis. It is associated with persistent symptoms, repeated infective exacerbations, and reduced quality of life, imposing a burden on individuals and healthcare systems. The main aims of therapeutic management are to reduce exacerbations and improve quality of life. Self-management interventions are potentially important for empowering people with bronchiectasis to manage their condition more effectively and to seek care in a timely manner. Self-management interventions are beneficial in the management of other airways diseases such as asthma and COPD (chronic obstructive pulmonary disease) and have been identified as a research priority for bronchiectasis.

OBJECTIVES

To assess the efficacy, cost-effectiveness and adverse effects of self-management interventions for adults and children with non-cystic fibrosis bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Specialised Register of trials, clinical trials registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 13 December 2017.

SELECTION CRITERIA

We included all randomised controlled trials of any duration that included adults or children with a diagnosis of non-cystic fibrosis bronchiectasis assessing self-management interventions delivered in any form. Self-management interventions included at least two of the following elements: patient education, airway clearance techniques, adherence to medication, exercise (including pulmonary rehabilitation) and action plans.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened searches, extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were, health-related quality of life, exacerbation frequency and serious adverse events. Secondary outcomes were the number of participants admitted to hospital on at least one occasion, lung function, symptoms, self-efficacy and economic costs. We used a random effects model for analyses and standard Cochrane methods throughout.

MAIN RESULTS

Two studies with a total of 84 participants were included: a 12-month RCT of early rehabilitation in adults of mean age 72 years conducted in two centres in England (UK) and a six-month proof-of-concept RCT of an expert patient programme (EPP) in adults of mean age 60 years in a single regional respiratory centre in Northern Ireland (UK). The EPP was delivered in group format once a week for eight weeks using standardised EPP materials plus disease-specific education including airway clearance techniques, dealing with symptoms, exacerbations, health promotion and available support. We did not find any studies that included children. Data aggregation was not possible and findings are reported narratively in the review.For the primary outcomes, both studies reported health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), but there was no clear evidence of benefit. In one study, the mean SGRQ total scores were not significantly different at 6 weeks', 3 months' and 12 months' follow-up (12 months mean difference (MD) -10.27, 95% confidence interval (CI) -45.15 to 24.61). In the second study there were no significant differences in SGRQ. Total scores were not significantly different between groups (six months, MD 3.20, 95% CI -6.64 to 13.04). We judged the evidence for this outcome as low or very low. Neither of the included studies reported data on exacerbations requiring antibiotics. For serious adverse events, one study reported more deaths in the intervention group compared to the control group, (intervention: 4 of 8, control: 2 of 12), though interpretation is limited by the low event rate and the small number of participants in each group.For our secondary outcomes, there was no evidence of benefit in terms of frequency of hospital admissions or FEV1 L, based on very low-quality evidence. One study reported self-efficacy using the Chronic Disease Self-Efficacy scale, which comprises 10 components. All scales showed significant benefit from the intervention but effects were only sustained to study endpoint on the Managing Depression scale. Further details are reported in the main review. Based on overall study quality, we judged this evidence as low quality. Neither study reported data on respiratory symptoms, economic costs or adverse events.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether self-management interventions benefit people with bronchiectasis. In the absence of high-quality evidence it is advisable that practitioners adhere to current international guidelines that advocate self-management for people with bronchiectasis.Future studies should aim to clearly define and justify the specific nature of self-management, measure clinically important outcomes and include children as well as adults.

An evaluation of the Open and Honest Care Programme in acute NHS trusts in Northern England

AIM

To explore the impact of the National Health Service England's Open and Honest Care Programme on patient safety, patient and staff experience and improvement practices within acute National Health Service settings.

BACKGROUND

The Open and Honest Care Programme forms a key tenet of the Nursing Midwifery and Care Staff Strategy launched by the Department of Health in England and Wales in 2012.

METHODS

An electronic survey (n = 387) was administered to National Health Service staff. Semi-structured telephone interviews (n = 13) were conducted with senior nurses and ward managers.

RESULTS

Over 70% of the survey respondents agreed that the programme increased transparency with the public about the quality of care, helped the working experience of National Health Service staff and improved patient safety respectively. Interviews revealed the Open and Honest Care Programme had enabled National Health Service staff to appraise the effectiveness of their improvement efforts.

CONCLUSION

The Open and Honest Care Programme could be an important part of the National Health Service Improvement Strategy. The collection of metric and narrative information highlighted where patient-centred improvements were required, facilitating the targeting and development of specific interventions or resources.

IMPLICATIONS FOR NURSING MANAGEMENT

The results indicate that the programme may assist managers to identify areas for improvement and that programmes such as this deserve consideration by health-care management globally.

Acute oxygen therapy for patients in the community

This article discusses the administration of acute oxygen therapy in the community setting, and emphasises the importance of achieving target blood oxygen saturation ranges for each patient. Respiratory assessment and monitoring, including blood gas analysis, and the role of pulse oximetry when delivering oxygen therapy are outlined. Nurses working in the community are responsible for conducting respiratory assessments, specifically in relation to triage and decisions concerning whether or not to treat patients at home or transfer them to hospital. It is hoped that the article will provide nurses with the knowledge to improve their practice in relation to oxygen therapy.

Strategies to help adolescents stop smoking

Since most people who smoke begin doing so during adolescence, there is a need for an effective intervention aimed at this age group. This article looks at the factors that increase the probability of smoking and tobacco addiction during adolescence, and concludes with some useful approaches to smoking cessation.

Diagnosis and management of patients with COPD in primary care

This article discusses the diagnosis and management of chronic obstructive pulmonary disease in primary care, in the light of recent updates to national guidelines. It describes the use of spirometry, differential diagnosis, treatment options such as pharmacological management, oxygen therapy, pulmonary rehabilitation and the management of exacerbations.

Domiciliary oxygen therapy: assessment and management

This article examines assessment and management strategies for all categories of domiciliary oxygen therapy for adult patients. It highlights the evidence underpinning each category, and enables dissemination of good practice to colleagues, patients and carers.

Psychological effects of chronic lung disease

Carol Kelly and Dave Lynes outline the potential psychological consequences of living with a chronic respiratory disease and how nurses can assess problems and implement strategies to help patients to adjust and cope.

Reversibility testing in patients with asthma and COPD

This article examines the difference between chronic obstructive pulmonary disease and asthma, the use of reversibility testing and the various guidelines available to help healthcare professionals diagnose and treat patients with these conditions.

The use of domiciliary oxygen therapy

Carol Kelly and Dave Lynes discuss the evidence and assessment for domiciliary oxygen, as well as considering oxygen therapy in palliative care.

Difficult asthma: people's perspectives on taking corticosteroid therapy

AIMS AND OBJECTIVES

This study aimed to explore the experiences of patients with difficult asthma, who take corticosteroid therapy, and provide insight into why some patients comply with therapy, whilst others do not.

BACKGROUND

Asthma is growing in prevalence and affects more than 100 million people worldwide. Corticosteroids are the mainstay treatment but, despite considerable risk to the individual in terms of morbidity and mortality, compliance is low. Previous research has been mainly quantitative and analysed variables associated with compliance, doing little to increase professional understanding of the patient's perspective on taking corticosteroid treatment.

METHODS

A hermeneutic phenomenological approach was selected as most appropriate for this study. Unstructured interviews were undertaken with a purposive sample of 10 participants. Interviews were taped, transcribed and the data were analysed using a multi-step technique described by Holloway.

FINDINGS

Fear of side effects was the strongest theme to emerge; illustrated by the negative images participants described such as weight gain, anxiety, irritability and depression. Participants related control and power over their condition to knowledge and information. They wanted more information, but believed that health professionals assumed they were already well informed. Costs and benefits of treatment were weighed up before decisions were made. Participants described feelings of 'not being themselves' and personality changes resulting in the loss of their role within relationships. Routine, time and opinions of significant others, also impacted on taking steroids.

CONCLUSION

Decision-making was a complex process, involving evaluation of the personal costs and benefits of treatment; fear of side effects was the dominant concern. Compliance with treatment saves lives in this population.

RELEVANCE TO CLINICAL PRACTICE

This study uncovers issues participants consider when making decisions regarding adherence and highlights the importance of the nurse's role in eliciting patients' concerns and the providing appropriate information to allay fears and misconceptions.

The psychological needs of patients with chronic respiratory disease

Recent developments in medical management have improved symptom control and life expectancy of patients with chronic respiratory disease (CRD). However, this presents new challenges to patients, their relatives and friends, and health professionals.

An introduction to blood gas analysis

Blood gas analysis is a procedure that is associated with high dependency, intensive care and respiratory units, but equipment used to carry out blood gas analysis is now commonplace on hospital wards and in some community services. It is, therefore, important for nurses in primary and secondary care to understand the significance of blood gas analysis.

Managing hypoxia and hypercapnia

The main objective when treating hypoxia (a deficiency of oxygen in the tissues) and hypercapnia (a high concentration of carbon dioxide in the blood) is to give sufficient oxygen to ensure that the patient is safe and his or her condition does not deteriorate. However, while giving too little oxygen can result in hypoxia, which can result in death, excessive oxygen therapy can also be dangerous for some patients.

Using observation for data collection

Observation is a term that describes several methodological techniques, and can be used to collect qualitative or quantitative data. Non-verbal behaviour and tactile skills are particularly amenable to observation. The presence of an observer may affect the behaviour of subjects. Data collection may be influenced by the observers' expectations and motives.

Health problems of sheltered homeless children using mobile health services

Homeless families are an increasing problem in the United States, with children representing 34% of the total homeless population. This retrospective study describes the demographic characteristics and health care problems and concerns of sheltered homeless children who used the services of a mobile health van over a 1-year period in a midwestern metropolitan area. The patterns of utilization, medications prescribed, and referrals are also described. Medical records of 175 sheltered homeless children who sought care from a mobile health van were reviewed. Forty-eight percent of the children were female; 52% were male. The majority were under 6 years of age (15% infants, 22% toddlers, 22% preschoolers, 23% school-age children, and 18% adolescents). The major reasons for seeking health care, the primary diagnoses, and treatments are presented. Recommendations for using a mobile van to provide efficient, quality health care for this population are discussed.