CPD CONTINUING

PROFESSIONAL
DEVELOPMENT

Chronic obstructive pulmonary

disease part 2: non-pharmacological
therapy
NS790 Jones D (2015) Chronic obstructive pulmonary disease part 2: non-pharmacological therapy.
Nursing Standard. 29, 34, 53-58. Date of submission: October 11 2014; date of acceptance: January 23 2015.

Aims and intended learning outcomes

Abstract
Chronic obstructive pulmonary disease (COPD) is a common, progressive
and disabling disease that causes significant burden to patients, their
families, and the NHS. Research suggests that the complexity of factors
contributing to the disease requires a deeper understanding of the patient
experience and a more holistic approach to care provision. This, the second
of two articles, discusses the non-pharmacological therapies for managing
patients with COPD and explores the concept of mindfulness as a therapy
in the management of breathlessness.
Author
Donna Jones District nursing sister, Shropshire Community Health NHS
Trust, Shrewsbury, England.
Correspondence to: donnajones8@nhs.net
Keywords
Anxiety, breathlessness, chronic obstructive airways disease,
chronic obstructive pulmonary disease, COPD, dyspnoea, mindfulness,
relaxation therapy
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The aim of this article is to increase readers’
knowledge of chronic obstructive pulmonary
disease (COPD), while also encouraging
critical thinking and a reflective approach to
non-pharmacological management options for
patients. It explores mindfulness as a new concept
in the treatment of COPD. After reading this
article and undertaking the time out activities,
you should be able to:
Explain the importance of effective health
promotion and symptom management in
relation to the provision of high quality care
and efficient use of resources.
Develop a holistic approach to address the
biological, social and psychological care
needs of patients with COPD who have
extensive and complex health problems.
Discuss non-pharmacological interventions
for the management of COPD.
Analyse and present the evidence for
mindfulness as a therapy for breathless
patients.
Psychological distress
Although pulmonary dysfunction is the
underlying cause of COPD-related distress,
breathlessness, fatigue and their psychological
consequences dominate patients’ perceptions
of quality of life (Barnett 2005, Seamark
et al 2007). Patients with advanced COPD
experience distress, encompassing complex and
interwoven physical, emotional and spiritual
aspects (Taylor 2007). Fear, anxiety, panic
disorder and depression are major problems
in COPD, yet they tend to be under-diagnosed
and under-treated, especially in the context of
concurrent physical illness (Wagena et al 2005,
Adams et al 2007, Seamark et al 2007).

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CPD respiratory disease

Anxiety was found to be the leading cause of
hospital admission, in one study of patients
with COPD (Burgess 2005). Patients vividly
describe feelings of uncertainty, profound
anxiety and fear of death at times of markedly
worsening breathlessness (Kunik et al 2005).
Rates of anxiety disorders are higher among
patients with COPD than among the general
population (Gudmundsson et al 2005,
Cully et al 2006), which suggests a need for
effective models of care to assess and address
breathlessness-related anxiety disorders in
these patients (Kunik et al 2005).
Breathlessness is a common and distressing
symptom in advanced COPD (Bruera et al
2000, Nordgren and Sorensen 2003, Solano
1 Discuss with a et al 2006) and is defined as ‘a subjective
physiotherapist how experience of breathing discomfort that
you could educate and consists of qualitatively distinct sensations
encourage breathless that vary in intensity’ (American Thoracic
patients to exercise Society 1999). Breathlessness is known to
to improve their increase as death approaches (Lynn et al 2000),
health, independence particularly in the last days of life; this is
and quality of life. one of the most difficult symptoms health
Identify the pulmonary professionals will manage (Taylor 2007).
rehabilitation, exercise Breathlessness often causes people with
and empowerment COPD to abandon activities that require
services in your area and exertion. This occurs through a ‘cycle of
share this information dyspnoea’ (Figure 1), where breathlessness on
with your team. moderate exertion causes anxiety. This results
in individuals limiting their activity, which
FIGURE 1
The cycle of dyspnoea
Shortness
of breath
Increased
anxiety
Shallow
breathing
Activities
limited
Tense
muscles
Increased
shortness
of breath
Anxiety
decreases their exercise tolerance. This, in
turn, results in further breathlessness on mild
exertion and subsequently during activities of
daily living. This process contributes to the
physical disability, psychological stress and
decrease in the quality of life experienced by
people with COPD (Carrieri-Kohlman 1993).
Therefore, the role of the nurse is to provide
education, advice and support, and co-ordinate
the involvement of professionals from
appropriate disciplines to manage anxiety and
breathlessness and encourage exercise. This can
improve physical ability, psychological status
and quality of life for patients with COPD.
Complete time out activity 1
Non-pharmacological treatments for
breathlessness
It is recognised that COPD should be treated
with a combination of pharmacological and
non-pharmacological interventions (Guthrie
et al 2001, Bausewein et al 2008). This is
important, especially since pharmacological
interventions such as opioids and oxygen rarely
help the person to achieve adequate relief from
breathlessness (Bausewein et al 2008). Patients’
self-efficacy in this area is increased following
education or a combination of education and
exercise programmes aimed at managing
dyspnoea (Zimmerman et al 1996, Scherer
et al 1998). Beliefs about personal efficacy
are known to influence a person’s motivation,
course of action, perseverance, thought
patterns, emotional response and attribution of
accomplishment and failure (Bandura 1997).
The use of patient positioning in the relief of
breathlessness is not well supported by evidence
(Jantarakupt and Porock 2005). However,
anecdotal reports support the benefits of
positioning to relieve breathlessness (Davis
2005). Leaning forward, sitting on the edge
of a chair or bed with the arms folded on a
table, is a comfortable position that reduces
trans-diaphragmatic pressure. This position
allows the abdominal wall to move outwards
more easily, providing greater space for lung
expansion and gaseous exchange (Jantarakupt
and Porock 2005).
The use of a fan or open window should be
offered before oxygen is prescribed (Jantarakupt
and Porock 2005). This is because of the risk
of adverse effects with oxygen therapy, such as
physical limitations, impaired communication,
psychological dependence, fire hazard,
hypercapnic respiratory failure and the cost
of oxygen (Booth et al 2004). The evidence is

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limited on the use of fans (Bausewein et al 2008).
However, Booth (2006) suggests that the relief
might come from cooling the face in the region
of the trigeminal nerve and that fans offer
patients a degree of control over their symptoms.
Breathing strategies are supported by
moderate-strength evidence (Bausewein et al
2008) and are commonly used in pulmonary
rehabilitation. A relaxed and controlled
breathing pattern minimises the work of
respiration and provides more effective
ventilation than the shallow, rapid breathing
pattern associated with dyspnoea (Twycross
et al 2009). Inhaling deeply through the nose
followed by pursed-lip exhalation improves
lung expansion and gaseous exchange. This
also re-establishes a sense of control for the
patient, promotes relaxation and breaks the
cycle of increasing breathlessness and panic
(Jantarakupt and Porock 2005).
Relaxation works by decreasing oxygen
consumption and reducing carbon dioxide
production, through muscular relaxation and
lowering the respiratory rate (Jantarakupt
and Porock 2005). There are few data on the
effectiveness of relaxation therapies (Bausewein
et al 2008); however, such therapies are
considered useful given the role of anxiety in
precipitating and exacerbating breathlessness
(Barnes 2010).
Pulmonary rehabilitation services in the
UK offer non-pharmacological individualised
interventions to improve self-management and
enhance self-efficacy (Endicott et al 2003, Booth
2006). However, attendance at a programme
may be limited by the disabling nature of COPD,
and the effectiveness of these programmes is
difficult to research (O’Donnell et al 2004).
Low-intensity psychological therapies
such as cognitive behavioural therapy (CBT)
centre on challenging thoughts and setting
behavioural goals. CBT is used to help change
the way an individual thinks and behaves. The
process involves making sense of problems by
categorising them into thoughts, emotions,
physical feelings and actions. In doing so, the
individual may understand how these features
are connected and, with this new awareness,
may challenge and change their initial thought
processes to affect their behaviour positively
(Royal College of Psychiatrics 2015).
Coventry et al (2013) found CBT to be
ineffective for people with COPD, whose
ruminative thinking and avoidance behaviours
are associated with real and meaningful
symptoms, especially breathlessness. There
is growing evidence that CBT can improve
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generalised anxiety disorder and overall mental
health in older adults with medical diagnoses.
However, psychological interventions that
promote an ‘accepting mode of response’,
such as mindfulness, may be more appropriate
and effective for managing psychological
distress in COPD patients and, in particular,
breathing-related anxiety (Coventry et al 2013).
Complete time out activity 2
Mindfulness-based interventions
Mindfulness is rooted in Eastern spiritual
and, in particular, Buddhist traditions
(Bishop et al 2004). It was first used more
than 30 years ago for the management of
patients with chronic pain, and has since
become increasingly common in treating
a range of medical and psychological
conditions. Mindfulness-based interventions
have been associated with longer-term
benefits for psychological health, compared
with stand-alone relaxation interventions
(Coventry et al 2013). Research on
mindfulness has accompanied this rise in
popularity, producing a growing body of
evidence supporting dissemination of these
interventions (Goldberg et al 2014).
Despite advances in knowledge of the benefits
of mindfulness-based interventions, there is
still limited understanding of the nature of this
phenomenon and its psychological and neuronal
causal mechanisms (Holas and Jankowski
2013). At least a dozen different definitions of
mindfulness occur in the literature (Holas and
Jankowski 2013). One article defines mindfulness
as a state of being in which individuals bring
their ‘attention to the experiences occurring in
the present moment, in a non-judgmental and
accepting way’ (Baer et al 2006).
Mindfulness is a receptive awareness and
registration of inner experiences (emotions,
thoughts, behavioural intentions) and external
events, where information is processed in
preconception – that is, individuals simply
notice what is happening without evaluating,
analysing, or reflecting on it (Bishop et al 2004).
Mindfulness practice supports the creation of
a vibrant and meaningful life because it helps
individuals to perceive more clearly what is
happening in their mind and to notice when their 2 What is your
mood is changing or becoming more negative. understanding of
Through practising mindfulness, individuals mindfulness? Do you
can mitigate negative emotions by entering into think it could be useful
present-moment living (Johnstone 2013). in managing patients’
Mindfulness can be incorporated into daily breathlessness?
life, does not require a lot of time and can be
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CPD respiratory disease
practised in many different forms. The basics,
however, are to: find a comfortable sitting
position and sit upright in a relaxed posture;
concentrate on your breathing and allow yourself
to be aware of the present moment and your
physical body in the present moment; guide your
mind back gently to the breathing if it wanders;
feel the sense of being present in the moment and
take this forward into the rest of your day. Box 1
outlines a helpful guide for practice.
Complete time out activity 3
Researchers have argued that mindfulness
is a natural human capacity that can be
undertaken by the untrained person (Brown,
Ryan et al 2011, Dane 2011). Research
investigating mindfulness in the general
population that involved participants without
any formal meditation experience has shown
that mindfulness varies between individuals
(Brown, West et al 2011, Goldberg et al 2014).
Mindfulness strategies work in several
ways that appear to be directly applicable
to breathlessness, for example decreasing
the stress response, inducing relaxation and
enabling a less distressing interpretation of
physical disorders (Mularski et al 2009).
However, research on applying mindfulness
to breathlessness in patients with COPD is
limited and contradictory. It has been shown
that eight-week periods of mindfulness
instruction produce measurable biological
effects such as alterations in brain structure
and function (Hölzel et al 2011). Holas and
Jankowski (2013) suggest that, over time,
there is an increasing ability to remain in this
3 Set aside some state during everyday activities. A randomised
quiet time to practise
controlled study investigating the physiological
mindfulness. You may
effects of applying guided imagery found a
find the ten-minute
significant increase in oxygen saturation in the
podcast on the following
treatment group (Louie 2004).
website useful: tinyurl.
Benzo’s (2013) study of patients with COPD
com/pvf4ulo. Reflect
who practised mindfulness therapies during
on the experience
an initial eight-week course, with monthly
and note how you felt
face-to-face visits for a year thereafter, found
afterwards. Find out if
that participants had an improved appreciation
mindfulness is used in
of life. This was achieved by viewing hardships
your local services.
as opportunities, valuing the self through
BOX 1
The RAIN acronym for mindfulness
R – Recognise what is happening in the present moment.
A – Allow your inner life to unfold just as it is.
I – Investigate your experience (sensations, emotions and thoughts).
N – Non-identify with whatever is there.
(Johnstone 2013)
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compassion and awareness, cultivating
connectedness with others, acquiring joy
and adopting healthy behaviours. Although
this study did not focus on breathlessness,
the results showed a positive effect on
participants in areas that would subsequently
affect the experience of breathlessness. This
includes reducing the negative emotions
associated with feelings of self-consciousness,
accepting one’s feelings in a non-judgmental
way through disengaging from distressing
thoughts, and focusing on goal-based actions
and the potential for smoking cessation, if the
individual smokes.
Studies by Greenfield (2010) and
Mularski et al (2009) reported no benefit
of mindfulness-based breathing therapy in
reducing breathlessness. Greenfield (2010)
remarked that the findings of his study are
puzzling, since previous studies have shown
benefits for relaxation therapies in asthma.
Although COPD is a result of irreversible lung
damage, it might be assumed that mindfulness
could be a beneficial method to reduce stress,
anxiety and panic (Greenfield 2010). The
conflicting results of research on mindfulness
in patients with COPD may reflect variation in
mindfulness between individuals (Brown, West
et al 2011, Goldberg et al 2014).
A minority (5%) of participants in Greenfield’s
(2010) study remarked that mindfulness
was ‘weird’ or ‘silly’. This may reflect a
misunderstanding of the purpose of mindfulness
and highlight a need for further education before
commencing any intervention. Participants in
the Greenfield (2010) and Mularski et al (2009)
studies were older and predominantly male.
These characteristics may reflect barriers to
mindfulness-based interventions that are rooted
in the tendency for older people to have a more
external locus of control (a belief that life events
are influenced by external factors outside of
their control), which Sarafino (2002) considers a
product of the more paternalistic attitudes of the
older generation. An external locus of control is
also found in lower socioeconomic groups where
a higher proportion of the public smoke and have
COPD (Acheson 1998).
Ogden (2000) suggested that health
behaviours correlate with health beliefs, and
several approaches have been developed as
a result. One approach, the transtheoretical
model of behaviour change (Lundh et al 2012),
suggests that the individual’s readiness to
undertake a mind-body therapy should be
assessed and strengthened to increase the
efficacy of treatment.
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 Another explanation might be that men are
reluctant to embrace mindfulness as a result of
male socialisation, where the male stereotype
is one of masculinity and dominance
(Crespi 2004). Men may be discouraged
from participating in a therapy that requires
openness and acceptance in a public
class-based delivery setting, which might
explain why participants in Greenfield’s (2010)
study considered mindfulness weird or silly.
A statement from the American Thoracic
Society in 2012 concluded that there is
insufficient evidence to recommend mindfulness
for the relief of breathlessness (Parshall
et al 2012). However, the author suggests that
mindfulness has the potential to be beneficial in
reducing the anxiety and stress associated with
breathlessness, increasing oxygen saturation
levels, promoting relaxation, disengaging with
distressing thought process, and improving and
increasing goal planning and health behaviour
change. It is, however, important that any
barriers such as low patient self-efficacy, are
identified, explored and improved before
mindfulness therapy is commenced. 4 Reflect on this
Complete time out activity 4 article and devise an
action plan on how
you can improve your
Conclusion practice in caring for
Breathlessness associated with COPD causes and supporting patients
significant anxiety, dominates activities of daily with COPD.
living, is a major cause of avoidable hospital

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CPD respiratory disease

5 Now that you have
completed the article,
you might like to write
a reflective account.
Guidelines to help you
are on page 62.
admission and results in extensive costs to the
NHS. Non-pharmacological interventions such
as education, exercise, patient positioning, use
of a fan, breathing strategies and relaxation
are recognised as important interventions
alongside pharmacological treatment.
However, evidence for psychological therapies
is limited. There is insufficient evidence to
support CBT, because the ruminative thinking
and avoidance behaviours observed in patients
with COPD are often based on real symptoms.
Mindfulness is a new concept in the
management of breathlessness in COPD
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Complete time out activity 5

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