Multilevel analysis of a hospital-wide hand hygiene program in Singapore

Although, teenage pregnancy could be unplanned as well as accidental. It usually occurs within the context of early marriage and also as a result of societal change of which the value system and virginity at marriage are no longer upheld. Certain problems are associated with teenage pregnancy such as economic, psychological, socio-cultural and others.

It is no longer a diplomatic statement that young people in the last decade, especially within the age group of 10-18 years, are living beyond the yard sticks of adventures compared to the youths of the 90s’. A blend of unpredictable, news breaking activities and issues of topmost concern has risen in the last few years. One of the most striking facts is the rising number of teenage pregnancy. Teenage pregnancy is a result of sexual intercourse between young girls and boys who are in their growing years, exploring the changes happening in their bodies by having unsafe sex with each other. Health organizations across the world are still in the frontlines of reducing maternal deaths due to complications and diseases. But even now, however, they have more to do with the increasing number of teenage pregnancy. (Femi A. A. & Sofia Krauss, 2009)

Bearing a child while still in childhood themselves, these young mothers under the age of 20 are prone to birth injuries and maternal death. It also affects their emotional well being: Teenage mothers are 3 times more likely to suffer from post-natal depression and experience poor mental health for up to 3 years after the birth. Children born to teenage mothers have 60% higher rates of infant mortality and are at increased risk of low birth-weight which impacts on the child’s long-term health. Further more, they are at increased risk to be brought up in poverty. (Femi A. A. & Sofia Krauss, 2009)

Teenage pregnancy is defined as a teenaged or underaged girl (usually within the ages of 13-19) becoming pregnant. The term in everyday speech usually refers to women who have not reached legal adulthood, which varies across the world, who become pregnant.

Pregnant teenagers face many of the same obstetrics issues as women in their 20s and 30s. However, there are additional medical concerns for younger mothers, particularly those under 15 and those living in developing countries.( Mayor S 2004) For mothers between 15 and 19, age in itself is not a risk factor, but additional risks may be associated with socioeconomic factors.( Makinson C. 1985)

Data supporting teenage pregnancy as a social issue in developed countries include lower educational levels, higher rates of poverty, and other poorer “life outcomes” in children of teenage mothers. Teenage pregnancy in developed countries is usually outside of marriage, and carries a social stigma in many communities and cultures. For these reasons, there have been many studies and campaigns which attempt to uncover the causes and limit the numbers of teenage pregnancies.(The National Campaign to Prevent Teen Pregnancy 2002). In other countries and cultures, particularly in the developing world, teenage pregnancy is usually within marriage and does not involve a social stigma. (Population Council 2006)

1.1 STATEMENT OF THE PROBLEM

It is very rampant in our society where there is an increase in the reported cases of teenager pregnancy. This ugly incident has created huge concern for the society especially to determine if the concern would have good future as well as their children. Again, the health implications of these children is another issue of worry.

Causes of Teenage Pregnancy

In the developed world, the causes of teenage pregnancy is different in the sense that it is mostly outside marriage and carries lots of social stigma. Thus, adolescent sexual behaviour is one of the causes of teenage pregnancy. In our world today, having sex before 20yrs is the in thing, it is even the normal all over the world and this brought about high levels of adolescent pregnancy which creates sexual relationship among teenagers without the provision of comprehensive information about sex. (Chinwe Chibuzo, P. 2007)

The in-take of drugs, alcohol etc contributes a lot to teenage pregnancy meanwhile as a teenager you may not be ready for sexual intercourse at that moment but being intoxicated with drugs and alcohol makes you to be involved in unintended sexual activity just because sex at that time is less emotionally painful and embarrassing. To avoid this, eradicate anything alcohol or drugs. Furthermore, sexual abuse is also one of the causes of teenage pregnancy. Rape as a sexual abuse has more effect in the life of our teenage girls causing unwanted sex and teenage pregnancy. Age discrepancies also causes teenage pregnancy in the sense that a teenage girl with a partner much older than herself is more likely to get pregnant more often than a girl that have a partner of a close age, as she prefers having the children than abortion since she is not educated enough to use contraceptives. (Chinwe Chibuzo, P. 2007)

Childhood environment

Women exposed to abuse, domestic violence, and family strife in childhood are more likely to become pregnant as teenagers, and the risk of becoming pregnant as a teenager increases with the number of adverse childhood experiences. According to a 2004 study, one-third of teenage pregnancies could be prevented by eliminating exposure to abuse, violence, and family strife. The researchers note that “family dysfunction has enduring and unfavorable health consequences for women during the adolescent years, the childbearing years, and beyond.” When the family environment does not include adverse childhood experiences, becoming pregnant as an adolescent does not appear to raise the likelihood of long-term, negative psychosocial consequences.( Tamkins, T. 2004)

Effect of Teenage Pregnancy on Educational

Teenage pregnancies have become a public health issue because of their observed negative effects on perinatal outcomes and long-term morbidity. The association of young maternal age and long-term morbidity is usually confounded, however, by the high prevalence of poverty, low level of education, and single marital status among teenage mothers. Assessing the independent effect of teenage pregnancy on educational disabilities and educational problems in a total population of children who entered kindergarten in Florida in 1992-1994 and investigate how controlling for potentially confounding factors affects the relation between teenage pregnancies and poor outcome. When no other factors are taken into account, children of teenage mothers have significantly higher odds of placement in certain special education classes and significantly higher occurrence of milder education problems, but when maternal education, marital status, poverty level, and race are controlled, the detrimental effects disappear and even some protective effects are observed. Hence, the increased risk for educational problems and disabilities among children of teenage mothers is attributed not to the effect of young age but to the confounding influences of associated socio-demographic factors. In contrast to teen age, older maternal age has an adverse effect on a child’s educational outcome regardless of whether other factors are controlled for or not. (Ralitza V. Gueorguieva 2001)

Preventing Teen Pregnancy

It has been found that teens who have a good relationship with their parents are less likely to experience a pregnancy. Good communication between parents and their children is the key to ensuring children make the right decisions when it comes to their sexual activity. (Pregnancy info 2009)

Evidence from areas with the largest reductions has identified a range of factors that need to be in place to successfully reduce teenage pregnancy rates. These factors include a well-publicised contraceptive and sexual health advice service which is centred on young people. The service needs to have a strong remit to undertake health promotion work, as well as delivering reactive services. It is key to prioritize sexual and reproductive health education at schools, supported from the local authority to develop comprehensive programmes of sex and relationships education (SRE) in all schools. (Femi A. A. & Sofia Krauss, 2009)

Education is also vitally important in helping youth know about their options when it comes to sex. Teaching teens about using contraception each and every time they have sex is imperative to healthy sexual relationships.

Abstinence should also be taught along with contraception so that youth understand they have the right to choose. Teaching teens that it is okay to say “no” to sex until they are ready will help to curb the numbers of teen pregnancies. (Pregnancy info 2009)

The Challenges of Early Motherhood

Facing an unplanned teen pregnancy can be hard. The effects of teenage pregnancy are not limited to having to decide whether or not to keep the baby, how to cope with motherhood or whether to make an adoption plan. One of the most immediate effects of teen pregnancy is how the growing baby changes a teenager’s body as well as their lifestyle. Because a teen’s body immediately begins the process of carrying a child and preparing for childbirth, a teenager needs to consider the effect that her physical activities may have on her developing baby. A variety of activities common to teens may have a negative effect on a developing baby: Drinking alcoholic beverages, Smoking cigarettes or marijuana, Lack of sleep and Unhealthy eating patterns. (Pregnancy center.orgOther physical changes that take place as her uterus expands may impact things as simple as clothing choices or her ability to safely participate in sports. This means that an average teenage girl will need to speak with her doctor about what activities need to be limited during her pregnancy as well as what changes she might need to make to her diet.

Emotional Effects of Teen Pregnancy (Pregnancy center.org)

Dealing with an unplanned pregnancy can be scary and confusing. Some of the emotions that teen may encounter when facing an unplanned pregnancy are: Initial excitement, Confusion, Fear, Resentment and Frustration. It’s a natural response for you to think about and want to protect the baby that is growing inside you. It is also natural for you to be scared and confused about how to deal with this unplanned pregnancy. (Pregnancy center.org)

Teenage mothers in industrialized countries mostly lack a proper social network consisting of family, friends and elder women which is usually present in developing countries. Besides, there are many social pressures on them. The main pressure on young pregnant women is, of course, to come to a decision about the unborn child, considering the options of keeping the child, adoption and abortion.

Other pressures are education and money. For one, young teenage women in industrialized countries are generally expected to get educated and find work. This becomes almost impossible when having a baby without a strong social network. Then, there often are financial pressures, since the lack of education often leads to unemployment or the dependency on low paid jobs or welfare. (Martin Bohn 2009);

Risks for Teenage Mothers and their Child

As a result, teenage pregnancy may lead to various problems for both the mother and the child. According to a student fact sheet of the Australian organization Women’s Health Queensland Wide, teenage mothers and their children may face some of the following risks:

There are significantly higher complication rates both during pregnancy and delivery for teenage mothers and their babies, such as an increased risk of miscarriage, premature birth, having a baby of low birth weight, birth defects and other complications.

Children born to teenage mothers are statistically more vulnerable to neglect and abuse. This is due to a range of factors including poverty, parenting inexperience and being in an unhealthy relationship (for example when there is a situation of domestic violence).

Teenage Pregnancies and the Disintegration of Families (Martin Bohn (2009);

Teenage pregnancies contribute to the disintegration of the family as a social institution. Most teen mothers are single mums. This is either because the child was conceived outside of a relationship or because the pregnancy places a great deal of strain on young relationships which are usually not as stable and enduring as adult relationships. Consequently, 60% of young Australian mothers do not have a male partner when their baby is born, as mentioned in a student fact sheet on teenage pregnancy by the Australian based Women’s Health Queensland Wide Inc.

A crucial question relates to whether the adverse outcomes experienced by (some) mothers and children of teenage pregnancies are causally related to the age of the mother, or whether there are other factors which lead to the adverse outcomes experienced by teenage mothers and their children. Several studies have found that teenage pregnancy is associated with adverse outcomes for both mother and baby. These include low birthweight, prematurity, increased perinatal and infant mortality and poorer long-term cognitive development and educational achievement for both mother and child. (Fraser AM, Brockert JE and Fergusson DM, 1995)

However, studies which have aimed to address the underlying causes of these adverse outcomes-by controlling for additional factors-have produced conflicting results. Some suggest that adverse outcomes remain even after controlling for maternal socioeconomic position and other confounding factors, (Fraser AM, Brockert JE 1995) some find that age has no effect, (Gueorguieva RV, Lee MC 2001) whereas other studies report that once maternal socioeconomic position and smoking are taken into account young age is actually associated with better outcomes. (Reichman NE and Geronimus AT 1997)

These contradictory findings probably reflect the small size of some studies, residual confounding, and the difficulty of separating effects that may be related to maternal age from effects that are appropriately regarded as confounding. For example, poor parenting skills may reflect the ignorance of young age but may also occur at any age among women who have restricted access to information and education. Larger studies and those employing methods specifically designed to adequately control for confounding factors (for example using sibling comparisons) (Geronimus AT 1992) suggest that young age is not an important determinant of pregnancy outcome or of the future health of the mother. (Gueorguieva RV, Scholl TO 2001) A recent systematic review of the medical consequences of teenage pregnancy concluded that ‘Critical appraisal suggested that increased risks of these outcomes (anaemia, pregnancy-induced hypertension, low birthweight, prematurity, intra-uterine growth retardation and neonatal mortality) were predominantly caused by the social, economic, and behavioural factors that predispose some young women to pregnancy.'(Cunnington A. 2001) Moreover, Cunnington asserts from this review that most teenage pregnancies are low risk-a point which is omitted from much research and from policy documents and statements

Teenage Mothers and Education

Teenage mothers are often unwilling or unable to complete their education. This lack of education can result in long term unemployment or low paid, insecure jobs. Being dependent on welfare or on a poorly paid job can place teenage mothers under greater financial pressure, even more so when they are single mums and have no supporting network of family and friends.

Finally, teenage mothers are often alienated from their peers and family because their new life is either disapproved of or cannot be related to by family and friends.

In developing country like Nigeria teenage mothers are sometimes married and have a broad support system. However, malnutrition, poor health care and complications of childbirth significantly increase the mortality rate of these young women.

Lagos State Government Intervention

The Lagos State has also set up youth friendly centers to provide adolescents accurate and confidential counseling on sex related matters. These include youth development programmes to educate youths both male and female on the danger involve in premarital sexual and early sexual intercourse (VOA News).

In addition, efforts is from the youth counselor of the Lagos State Ministry of Health, Christiana Ladapo, who leads candid after-school discussions about sex, peer pressure, abstinence and contraceptives. She says teenage pregnancy has been on the rise because society has ignored the problem.

However, Pinkdove in collaboration with the Lagos State Ministry of Education recently organized an enlightenment campaign with the theme “The Effects of Early Sex, Teen Pregnancy for Senior Secondary School Female Students in Lagos state

HISTORY OF LAGOS

Lagos State is an administrative region of Nigeria, located in the southwestern part of the country. The smallest of Nigeria’s states, Lagos State is the second most populous state after Kano State, (wikipedia) and arguably the most economically important state of the country,(Answer dictionary) containing Lagos, the nation’s largest urban area.

Lagos State was created on May 27, 1967 by virtue of State (Creation and Transitional Provisions) Decree No. 14 of 1967, which restructured Nigeria’s Federation into 12 states. Prior to this, Lagos Municipality had been administered by the Federal Government through the Federal Ministry of Lagos Affairs as the regional authority, while the Lagos City Council (LCC) governed the City of Lagos. Equally, the metropolitan areas (Colony Province) of Ikeja, Agege, Mushin, Ikorodu, Epe and Badagry were administered by the Western Region. The State took off as an administrative entity on April 11, 1968 with Lagos Island serving the dual role of being the State and Federal Capital. However, with the creation of the Federal Capital Territory of Abuja in 1976, Lagos ceased to be the capital of the State which was moved to Ikeja. Equally, with the formal relocation of the seat of the Federal Government to Abuja on 12 December 1991, Lagos Island ceased to be Nigeria’s political capital. Nevertheless, Lagos remains the center of commerce for the country.

HISTORY OF LAGOS ISLAND LOCAL GOVERNMENT

Lagos Island is the principal and central local government area of the Metropolitan Lagos in Nigeria. It is part of the Lagos Division. As of the preliminary 2006 Nigerian census, the LGA had a population of 209,437 in an area of 8.7 km². The LGA only covers the western half of Lagos Island; the eastern half is under the jurisdiction of the LGA of Eti-Osa.

Lying in Lagos Lagoon, a large protected harbour on the coast of Africa, the island was home to the Yoruba fishing village of Eko, which grew into the modern city of Lagos. The city has now spread out to cover the neighbouring islands as well as the adjoining mainland.

Lagos Island is connected to the mainland by three large bridges which cross Lagos Lagoon to the district of Ebute Metta. It is also linked to the neighbouring island of Ikoyi and to Victoria Island. The Lagos harbour district of Apapa faces the western side of the island. Forming the main commercial district of Lagos, Lagos Island plays host to the main government buildings, shops and offices. The Catholic and Anglican Cathedrals as well as the Central Mosque are located here.

Historically, Lagos Island (Isaleko) was home to the Brazilian Quarter of Lagos where the majority of the slave trade returnees from Brazil settled. Many families lived on Broad Street in the Marina.

It also revealed that majority (83.8%) and (70%) of the respondents were staying with their parents and there parents were staying together. This is in contradiction (Ellis, Bruce J. et al) Studies that girls whose fathers left the family early in their lives had the highest rates of early sexual activity and adolescent pregnancy

From the study it was also revealed that many of the respondents parents who were working are in the low class status about (25%) were unemployed. This is in accordance with a study by (Besharov, Douglas J. & Gardiner) Poverty is associated with increased rates of teenage pregnancy.

It was obvious from the study that majority were not aware of any form of contraceptives, but this was in disagreement with the study made in the United States in 2002 by National Surveys of Family Growth, sexually active adolescent women wishing to avoid pregnancy were less likely than those of other ages to use contraceptives.

Revelation from this research shows that (35.7%) were impregnated by boy friends while (13.3%) were raped. This flows with some studies that between 11 and 20 percent of pregnancies in teenagers are a direct result of rape, while about 60 percent of teenage mothers had unwanted sexual experiences preceding their pregnancy. One in five teenage fathers admitted to forcing girls to have sex with them

Majority of the respondents had their sex experience before the age of 15. This supports Guttmacher Institute findings that 60 percent of girls who had sex before age 15 were coerced by males who on average were six years their senior.

CONCLUSION

It is quite glaring that teenage pregnancy have many consequences on the society. Teenage pregnancies have become a public health issue because of their observed negative effects on perinatal outcomes and long-term morbidity. The association of young maternal age and long-term morbidity is usually confounded, however, by the high prevalence of poverty, low level of education, and single marital status among teenage mothers the impact on youth development in our society is negative

Reflective writing is as a medium for an individual’s reflective capacity to be communicated and examined both internally and externally. Self directed learning is emphasised through reflective writing as students engage in a more holistic approach which uncovers the reasons behind their actions.

Experience and learning

Moon (2004) emphasised that an individual can both reflect in order to learn or learn as a result of reflecting. Through experiencing new situations medical students are able to learn and develop new skills but the level of learning depends on the depth of reflecting of the experience. This is often why reflection is described as learning through experience. Reflection of an experience is associated with deep learning where the student is able to gain more insight into the decisions behind the actions involved. (Marton,Hounsell, Entwistle 1984) By learning through experience students are able to build on previous knowledge which covers a solid knowledge base that can be applied to changing situations and which experiences can be drawn from. Learning does not stop at reflection but involves the changing in decision making processes and actions that reflection should bring about in future situations. What is learnt from reflection must be put into practice for it to be effective.

Kolb (1984) proposed that Learning does not result from having an experience but occurs when an experience is examined, reviewed and reflected upon. This process allows a connection to form between theory and actions where an experience involves preparation, action, reflection and connection back to previous knowledge. Refection involves lifelong learning as the changing nature of medicine and ethical concerns continues to challenge practitioners.

Emotions and Reflection

William (2002) said “Actions are so much more powerful if they arise from both feelings and thoughts”. Reflection involves the process of understanding and examining emotions and how they affected a situation. Emotions are an integral part of any experience and it is through reflective practice that the impact emotions has on a situation comes to light. Practitioners have to deal with many different situations that can cause psychological and emotional strain. Reflective writing allows emotions to be dealt with and not compressed. Through expressing personal feelings practitioners are able to be more focused and self-aware which can increase their capacity to feel empathy for patient’s situations. Empathy makes patients feel more understood and heard and through reflective writing the promotion of understanding of patient’s situations and vulnerabilities can be achieved. (Squier 1998)

Negative feelings can hinder performance through self doubt and lack of confidence but through reflecting on negative experiences these emotions can be used to improve performance and encourage self directed learning. (Olckers, Gibbs, Duncan 2007) Reflective writing allows students to use emotion in their writing which assist in overcoming psychological and emotional barriers which they may face and provides an opportunity to examine potential moral consequences of an action. Reflective writing allows students to deal with their emotions instead of suppressing them and allows the development of strategies to deal and express emotions in different settings. This promotes a sense of practitioner wellbeing where the mental, emotional and spiritual health of practitioners is looked after. Through reflecting on emotions a connection between the medical profession will the rest of society is built where there is less risk of practitioners becoming detached and intolerant.

Reflection and learning in the Professions

Reflection in the medical practice can be viewed from three directions; reflection-on action, reflection-in action and reflection-for action. (Killion, Todnem ,1991)

Donald Schon (1983) developed theory of reflective professional practice by developing reflective- in and reflective-on action. Reflection- in action involves connecting past experience, feelings and knowledge to a current situation. This process allows new insight and understanding to be established in relation to the situation which will influence the decisions made by the medical practitioner as the situation develops. This type of reflection is particularly important to medical practitioners who face complex and new situations regularly and who need to make fast accurate decisions and actions. (Schon 1983)

Reflection-on action involves reflecting on a situation that has occurred and analysing decisions made to determine weaknesses or possible improvements that could be implemented in future practice. This form of reflection is often only undertaken when something goes badly or not to plan but it is essential for reflection to take place after experiences that went well to fully reflect on an individuals strengths and weaknesses.

There is also pr-action reflection which describes a form of reflection before an action is taken. This form of reflection aims to prepare professionals to be able to deal with situations where there may be no time to reflect in action so it becomes important to reflect prior to action. (Mann, Gordon and MacLeod, 2009)Reflection prior to action is often done unconsciously where future possible actions are accessed and evaluated and goals are set. In medicine if prior knowledge of patient’s condition is known research through literature, past case studies and communication with other health professions can result so that possible conditions which may be present can be dealt with. Reflection for action can be used to view the situation from a variety of perspective not just from one’s self. It can include perspectives of the patient, other health professional and text based knowledge. This form of reflection can reduce mistakes and prepare practitioners for possible unforeseen circumstances. (Keith Ong 2011)

Reflection and Personal Development

Reflective practice is a key skill for medical students to develop and continue to use throughout their medical careers. Reflective practice assists medical students and practitioners to refine their ability and continually challenge their own decisions making process. The goal of reflection according to Epstein, “should be to develop not only one’s knowledge and skills, but also habits of mind that allow for informed flexibility, ongoing learning and humility”, (full text1 19) Personal and professional development is an integral part of the medical profession. This development is cultivated by reflective practice which allows self-assessment and professional identity to be uncovered. Professional identity is established through reflective writing as a medium for practitioners to express their own voice and perspective, and clarify and refine personal values which may be competing or conflicting to others. (Shapiro 2006)

Through becoming more self-aware reflective practice allows practitioners to become more engaged and aware during clinical encounters and improve clinical reasoning. This is why reflection has close links to safe practice as critical though has been put into decisions allowing care to be solely patient based. (Bansman 95). Critical examination of decisions allows problem solving skills to enhance which contributes to more effective treatment of patients.

Reflection assists in guiding present and future decisions and actions in a competent and knowledgeable way through allowing new experiences to draw on pervious situations to increase understanding of patients and to extend empathy towards them. (Wald 2010) Reflective “writing improves clinicians’ stores of empathy, reflection, and courage… Writing that affects the reader is art” (Charon 2004) Reflective practice is shown to have many benefits for practitioners not only through clinical skill improvements but assisting in developing the whole person by developing interpersonal skills. Practitioners improve skills of empathy as they are more aware of their patients and their own emotions and how those emotions may effect the consultation or decision made by the patient.

Reflective practice allows a connection to form between technical and knowledge based facets and emotional aspects. It aims to develop personal skills which will enhance and guide technical learning and performance in a clinical setting. Through assessing the bigger picture though reflective practice students are able to deal with more complex and unforseen issues.

The process of reflection

Reflection may be difficult to teach (Stimson 2009, Roberst 2009) although reflective frameworks can assist in engaging individuals with reflective practices and developing skills for future internal reflection. Reflection in a practical setting needs to be continuous for the knowledge uncovered during reflection to be translated into action. Gibbs’ (1988) created the ‘Five stages of reflection’ model which can be used as a guide for reflective writing. This model represents the cycle that reflective practice is a part of. The five steps of this model include describe, reflect, research and analyse, decide, act and evaluate.

Brookfield

(1987) approach to reflection involves using the view points of a number of different perspectives know as the ‘four lenses’. It involves researching, analysing and connecting through critical reflection.

Conclusion

Reflective practice is an important attribute for undergraduate medical students as it increases self-awareness, refines problem making skills and prepares students to deal with complex, unpredictable situations. Through reflection students are able to refine their clinical skills by recognising their strengths and weaknesses which develops personal competence and identity. Although reflection takes time and effort the long term benefits create a more competent and compassionate practitioner

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Jerry Corners

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is the fifth leading cause of morbidity and mortality in the UK and fourth in the world (Hurd 2000; Soriano 2000). Though other causes exist, like genetics and environmental pollution, tobacco smoke is by far the leading etiology of this disease (Pride 2002).

It may seem axiomatic that if cigarette smoking is the cause of COPD, cessation (or avoidance) of smoking is the prevention. However, despite extensive public education, smoking is still common among men and women in the UK and even when people do quit, relapse within the first year is common (Lancaster et al. 2006). Therefore our attention as caregivers needs to be focused upon methods of cessation that produce lasting results.

To illustrate the diagnosis, management, both short- and long-term, and what Mike can expect from treatment as reflected in the medical literature, we present the following case.

Pathophysiology of COPD

COPD is a chronic disease in which decreased airflow is related to airway smooth muscle hypereactivity due to an abnormal inflammatory reaction. Inhalation of tobacco products causes airway remodeling, resulting ultimately in emphysema and chronic bronchitis (Srivastava, Dastidar, & Ray 2007).

COPD is a complex inflammatory disease that affects both lung airways and lung parenchyma. The modern focus of the pathophysiology of COPD is centered around this inflammation and it is now recognized that systemic inflammation is responsible for many of the extrapulmonary effects of cigarette smoke inhalation (Heaney, Lindsay, & McGarvey 2007).

The Clinical Case Study

Diagnosis

Mike is a 54 year old, self-employed grandfather who smokes 40 cigarettes daily. He was recently diagnosed with COPD based on an FEV

₁

of 66% of predicted (Halpin 2004). According to Halpin (2004),

“There are still no validated severity assessment tools that encompass the multidimensional nature of the disease, and we therefore continue to recommend using FEV1 as a percentage of the predicted as a marker of the severity of airflow obstruction, but acknowledge that this may not reflect the impact of the disease in that individual. We have changed the FEV1 cut off points and these now match those in the updated GOLD and new ATS/ERS guidelines, although the terminology is slightly different: an FEV1 of 50–80% predicted constitutes mild airflow obstruction, 30–49% moderate airflow obstruction, and <30% severe airflow obstruction.”

According to these criteria, Mike has mild airflow obstruction and will be treated accordingly. But no matter what stage he is at or what pharmacologic interventions are prescribed, we are nevertheless obliged to offer this patient access to an effective nicotine cessation program while in hospital.

Treatment

Acutely, the mainstays of treatment for Mike’s level of disease are inhalation and possibly oral therapy along with pulmonary rehabilitation (Cote & Celli 2005;Paz-Diaz et al. 2007). Of course underlying bronchpulmonary infection is treated with appropriate anitmicrobial therapy.

Inhalation and Oral Therapy

Bronchodilators

Of the three classes of bronchodilator therapy, β-agonists, anticholinergic drugs and methylxanthines, all appear to work by relaxation of the airway smooth muscles, which allows emptying of the lung and increased tidal volume, with an increase in FEV

₁

with increase in the total lung volume and dyspnea, subjective air-hunger, significantly improved, especially during exercise (Celli & Macnee 2004c).

Combining short- and long-acting bronchodilators appears to improve lung function better than either alone, and so Mike will be treated with a combination of salbutamol and (albuterol)/ipratropium. There are many other agents that could be used that have shown to be effective in mild disease, such as Mike’s (Celli & Macnee 2004b).

Corticosteroids

Inflammation is often part of the acute phase of COPD exacerbations and therefore part of Mike’s therapy will be inhaled corticosteroids. Many studies have shown that inhaled corticosteroids produce at least some improvement in FEV

₁

and ventilatory capacity. It is often necessary for a trial of medication to confirm that a given patient will respond to inhaled corticosteroid treatment (Celli & Macnee 2004a).

Ries ( 2007) claims that inhaled corticosteroids have become the standard of care for patients with COPD, in all phases of severity (Salman et al. 2003). Mike will be offered inhaled corticosteroids.

Pulmonary Rehabilitation

According to a statement of the American Thoracic Society, “[Pulmonary rehabilitation is] a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise physical and social performance and autonomy”.

The Pulmonary Rehabilitation Program

Exercise

Garrod ( 2007) has shown convincing evidence that exercise significantly modifies systemic inflammation, as measured by CRP and IL-6 levels, that plays such an important role in the pathogenesis of COPD. But rather than target just the pulmonary musculature, Sin et al. ( 2007) have suggested that the skeletal muscle dysfunction and reduced exercise tolerance, which are important extrapulmonary manifestations of COPD, could in fact be due to the systemic inflammation that is important in COPD.

Therefore, Mike will be placed on a regimen of weight training designed to improve his over all muscle strength. In addition he will be offered aerobic exercise treadmill sessions to improve his exercise tolerance, similar to cardiac rehabilitation (Leon et al. 2005).

Nutritional Support

General nutritional status is related to COPD severity (Budweiser et al. 2007;Ischaki et al. 2007) and mortality (Felbinger & Suchner 2003). The cachexia of COPD is a common sign of end-stage pulmonary disease.

Mike has mild disease and would not be expected to be suffering from malnutrition. However, an evaluation by a nutritionist and possible early correction of any deficits are part of his pulmonary rehabilitation.

Psychological Support

Depression, anxiety, and somatic symptoms are valid indicators of psychological distress in COPD (Hynninen et al. 2005) and quality of life (Arnold et al. 2006), two very important nursing issues. Much of the psychological distress is related to a sense of personal control because the illness, especially in its late stages, is so often accompanied by a feeling of loss of control in one’s life.

Mike is still self-employed and with his mild impairment, he is not likely to be feeling these issues, yet. However caregivers need to be acutely aware that his quality of life may depend upon recognition and early intervention in the future (Gudmundsson et al. 2006;Oga et al. 2007). To that end he will have a psychological evaluation while in hospital to screen for depression or anxiety symptoms.

Educational Support

There are many areas that are very important to Mike as he goes through his pulmonary rehabilitation. In an initial interview, he needs to know what he can and cannot expect from treatment. He needs a person to explain that the damage done so far is not reversible but that there are many treatments available that will allow him to live a good life, if he stops further cigarette use.

Issues of promoting a healthy lifestyle, muscle wasting and psychological adjustment are all treatable with information, when it is presented in a sympathetic, firm, supportive atmosphere. Mike needs to know what to expect in the future, if he is able to quit smoking, and if he does not quit smoking. He may not like to hear the truth, but his quality of life will benefit in the years to come from a clear, honest educational program.

In addition Mike needs to understand that he may have exacerbations from time to time and that early intervention by his generalist or pulmonologist are mandatory to avoid more serious consequences.

Education that stresses the value of a healthy lifestyle, including regular exercise according to the regimen established in hospital, is very important. Also, education can help considerably in preventing the wasting that, though probably not present now, may become important in the future.

Smoking Cessation

No subject in the COPD literature is more clear than the need for immediate cessation of exposure to all cigarette smoke; and, no subject is more frustrating to caregiver and patient alike, at least in those instances where there is poor compliance with the cigarette smoke proscription. We will explore with Mike some of the recommended strategies to accomplish this sometimes elusive, if vitally necessary goal.

Nicotine Replacement Therapy (NRT)

A recent article by West, et al. ( 2007) reported a prospective study of NRT that was large (2009 smokers), multicultural, involving smokers from the US, UK, Canada, France, and Spain, and of sufficient duration to render generalizable (“real world”) results. They concluded that NRT helps smokers’ cessation attempts and long-term abstinence rates. However, the 6% improvement rate was not large and this form of cessation therapy should be reserved for those who have tried and failed other methods or programmes.

There are many forms of NRT, including nasal and oral nicotine sprays, gum, and patches of varying dosages, currently on the market, but whether they have significant one-year success rates over counselling is an arguable point in the literature.

Since Mike now smokes 40 cigarettes daily, he will be offered the 15mg nicotine patch to help for the initial 20 weeks of cessation.

Bupropion Therapy

Buproprion is a dopamine agonist that has antidepressant effects but is also marketed as a smoking cessation agent. In a study comparing the nicotine patch with buproprion and controls (counselling only) by Uyar, et al. (Uyar et al. 2007), reported success of 26 % for the nicotine patch, 26% for buproprion, and 16% for counselling-only at the end of 24 weeks. As an interesting aside, they reported that those who had a Beck depression inventory above 13, i.e. were depressed at the onset of the study, were unsuccessful regardless of treatment or control group. However, because of the small numbers of smokers involved, there was no statistically significant difference between these groups. The authors conclude that counselling is as effective for cessation attempts as these pharmacologic treatments, and there are no known side effects of being in a control group.

However, other studies (Tonnesen et al. 2003) have shown a significant effect of bupropion over placebo.

Internet-Based Assistance

Various groups have tried using an interactive website to help smokers stop smoking. Unfortunately they have yet to show significant positive findings. All that can be said about them is that the more often the smoker logs on to the site, the better his chances are that he will be successful (Japuntich et al. 2006;Mermelstein & Turner 2006;Pike et al. 2007).

Nurse-Conducted Behavioral Intervention

In the UK Tonnesen et al. (Tonnesen, Mikkelsen, & Bremann 2006) found that a combination of nurse-based counselling in conjunction with NRT in patients with COPD was more effective than placebo at 6 and 12 months.

As one can readily imagine, there are a plethora of cessation strategies available to assist people in smoking cessation. However, there is no “silver bullet”, i.e. one method that fits everybody. It comes down to proper motivation, which we believe is related to education and perhaps other factors. All we can really be sure of is of that those who try, many will be successful, and try, try, again seems to be the best advice we can offer.

But the most important lesson we can learn is to prevent use of this harmful and addictive substance in the first place. Teenage smoking prevalence is around 15% in developing countries and around 26% in the UK and US. Studies have shown that those who make it past 20 years of age are much less likely to succumb to this addiction (Grimshaw & Stanton 2006).

Conclusion

Assuming Mike ceases to smoke cigarettes, and given a regimen of exercise appropriate to his physical functioning, and with a detailed and robust COPD rehabilitation programme, his prognosis is excellent.

By far the most challenging days are yet to come as Mike begins to feel better and the educational materiel fades from his mind. Many smokers return to their fatal habit within a year. Many, though perhaps not all, could benefit from periodic follow-up sessions with a motivational nurse-counselor.

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