Patients with chronic obstructive pulmonary disease and their perceptions: How to cope with them?

Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the world, ¹ represents an important public health challenge that is both preventable and treatable. COPD is a major cause of chronic morbidity and mortality throughout the world; many people suffer from this disease for years and die prematurely due to it or its complications. Worldwide, the COPD burden is projected to increase in coming decades because of the continued exposure to risk factors and population aging. ² Menezes et al., ³ in a study including data from five Latin American countries, observed that the prevalence of COPD in the general population older than 40 years varied from 7.8% to 19.7% and that it was more prevalent among men, elderly people, and individuals exposed to tobacco. ³ The characteristic symptoms of COPD are progressive dyspnea, cough, and sputum production, associated with frequent fatigue and impairment in exercise capacity and functional performance. ^2,4

There is a large body of evidence showing that pulmonary rehabilitation (PR) is beneficial to patients with chronic respiratory disease, including COPD. ^5,6 Its benefits include increase in exercise tolerance, reduction in symptoms, and improvement of health-related quality of life.⁵ A more recent definition describes PR as a “comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviour.” ⁷

Regardless of the clear benefits provided by PR programs, there is a substantial part of the enrolled patients who do not complete the intervention. There is scant published evidence showing the factors that lead patients with COPD to nonadherence to PR. ^8,9 Young et al. ¹⁰ used an interviewer administered questionnaire and suggested that nonadherers were more likely to be depressed, widowed, or divorced, live alone, live in rented accommodation, and be smokers. More recently, another study ¹¹ showed that the referring doctor plays a key role in the uptake of PR programs. The authors discussed that a positive doctors’ approach may increase the level of adherence to PR and would be essential to an effective intervention. ¹² In addition, a systematic review performed by Keating and colleagues⁹ identified travel and transport difficulties as a predominant barrier to attendance at PR. Lack of perceived rehabilitation benefits and the influence of the doctor were also identified as reasons for nonattendance.⁹ In order to achieve better understanding of this issue and to answer simple questions about the opinions of patients enrolled in PR programs, the interest in qualitative studies has been growing in the scientific field.

In this issue of Chronic Respiratory Disease, Pinto and colleagues ¹² contributed to the scientific literature by writing a systematic review of qualitative researches in patients with COPD about their experiences related to PR.

First, the review disclosed the lived-experience from the point of view of patients who completed a PR program. Patient’s reports included a feeling of being supported by health-professionals, peer groups and family, as well as the acquisition of knowledge about their illness and how to overcome the suffering caused by disease. Patients also reported that they were able to take advantage of the opportunities given by rehabilitation to promote considerable physical and psychosocial changes. These positive impacts of PR marked the patients’ health transitions.

Second, the authors showed that patients with COPD may indeed be able to adopt a “new way to life” after PR, which was possibly the most relevant finding in this review. A valuable feature of this review is the overwhelming importance placed on the educational process that has previously been challenging to evaluate with conventional randomized controls of PR. The empowerment experienced by patients was consistent and often associated with learning opportunities in these educational sessions

A further issue identified by the authors is related to some difficulties and barriers that patients found during the rehabilitation process. The barriers were mainly related to PR access (transport and parking), professional–patient relationship, lack of motivation during the education sessions, and psychological affectation.

It is known that qualitative research aim at analyzing cases at a given time and space, seeking interpretation of a particular phenomena of the studied subject that is limited to the representation of personal characteristics and cannot be reproduced in other subjects. In this way, qualitative studies that clearly elucidate the patients’ perceptions of participation in PR programs are welcome and add important information to health professionals, helping them to cope with their patients and, consequently, improving treatment adherence and results.