Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with ...

Nursing Best Practice GuidelineNon-invasive and Invasive Ventilation ModalitiesNon-invasive positive pressure ventilation (NIPPV) (e.g., bi-level positive airway pressure) is indicated forthe treatment of both acute hypercapneic and hypoxemic respiratory failure. In patients with COPD,respiratory muscle fatigue with increased airway resistance or decreased compliance often leads torespiratory distress and failure. Bi-level positive airway pressure via nasal oral, oronasal, full and total facemask provides alternating levels of inspiratory pressure to keep the airway open as a patient breathes in,and expiratory pressure to reduce the work of exhalation.A meta-analysis of seven randomized trials showed that NIPPV is associated with lower rates of death andendotracheal intubation, in patients with acute respiratory failure compared with usual practice, with thegreatest benefit in patients with exacerbation of acute COPD (Keenan, Kernerman, Cook, Martin, McCormack &Sibbald, 1997).Invasive ventilation is used for hypercapneic failure in those patients who do not tolerate or benefit fromnon-invasive pressure ventilation or cannot sustain NIPPV effort. Further discussion of invasive ventilationis beyond the scope of this guideline.Energy Conserving StrategiesSome work has been done to address the importance of pacing activities to conserve energy for individualsliving with COPD. Carrieri, Janson-Bjerklie, & Jacobs (1984) report on two studies by Fagerhaugh (1973) andBarstow (1974), in which patients describe the strategies they use to cope with dyspnea resulting fromemphysema. Both authors describe careful planning to minimize energy expenditure.Pacing was identified as one of the main strategies to conserve energy in several qualitative studies (Brown,Carrieri, Janson-Bjerklie & Dodd, 1986; Carrieri & Janson-Bjerklie, 1986; Leidy & Haase, 1996; Roberts, Thorne & Pearson, 1993);however, little quantitative research was found related to this topic. One randomized controlled trial byBredin, Corner, Krishnasamy, Plant, Bailey and A’Hern (1999) demonstrated significant improvement inpatients with breathlessness due to lung cancer when they were taught a range of strategies includingactivity pacing. However, there is no way of identifying which strategy caused the improvement.Breslin (1992a) acknowledges that nurses commonly teach patients to pace the performance of activitiesof daily living in relation to their respiratory cycle. She contends, however, that there are breath-pacingdifferences between activities involving lower body motor activity such as walking and upper body armactivities such as eating, dressing and teeth and hair brushing. Breslin (1988) suggests that, to minimizedyspnea, individuals living with severe breathlessness should be encouraged to perform leg exercise duringthe expiratory phase of respiration, however, perform unsupported arm activities during the inspiratoryphase of the cycle. According to Breslin (1992a), doing lower body activity during the exhalation phase ofrespiration is thought to reduce the respiratory rate and prolong the duration of exhalation leading to adecrease in dyspnea. Although the mechanism of reduced dyspnea with alternate respiratory pacing forarm activity has not been reported, Breslin states that individuals do report less breathlessness with thealternate pacing, suggesting that the chest wall muscles recruited by individuals during inspiration are ableto rest during the expiratory phase.29