Chronic Obstructive Pulmonary Disease (COPD)

Introduction

This real-life case study discusses the occurrence of Chronic Obstructive Pulmonary Disease (COPD) in a patient. It explicates the patient’s profile, guarantees his confidentiality, and describes the pathophysiology and the physical, social and psychological challenges of this life-threatening condition. The paper also outlines the public health policies and drivers related to COPD as well as the effectiveness of integrated care for COPD patients accessing health and social care services. Furthermore, it outlines the role of nurses in undertaking patient-centred care in promoting the well-being and preventing ill health and presents evidence-based person-centred care for COPD patients within a hospital or community setting. It finally describes an appropriate care and compassion to the changing needs of COPD patients, their families, and carers in accessing services and provides conclusion and recommendations for evidence-based nursing care in relation to the case discussed in this paper.

There are various obstructive lung diseases for which Chronic Obstructive Pulmonary Disease (COPD) is inclusive. COPD is associated with restricted or obstructed airflow leading to protracted breathing problems. The typical symptoms that are characteristic of the condition include a sputum-producing cough as well as shortness of breath (WHO, 2016). The condition is irreversible and since there is no cure for COPD, the impacts of the disease take effect with time in a progressive manner thus capable of reaching a chronic stage. Tobacco smoking is the primary cause of COPD with a slight contribution from, occupational dust and chemicals, polluted air, and hereditary factors (Tidy, 2015). As the agent of tobacco smoke and polluted air continue to irritate the lung surface, the body’s immunity agents mount an inflammatory response that results in lung tissue breakdown and consequently narrowing of the lung airways. As a preventive measure, it is important to promote efficient ventilation especially in areas where air pollution is rife (WHO, 2016). Individuals are also encouraged to quit smoking as a way of helping to prevent the aggravation of the illness. As stated earlier, COPD has no cure and available remedies are only meant to decelerate acute worsening (exacerbated occurrences). Such remedies may include the use of Inhalers (bronchodilators), antibiotics, steroids, oxygen therapy, and mucus-thinning medications (Tidy, 2015). 

Globally, the occurrence of COPD by the year 2010 was estimated at around 384 million of the global population (Adeloye et al., 2015). A common occurrence has been witnessed in men more than in women and mostly in people above the age of 40 years (Tidy, 2015). Most associated deaths are reported in the developing countries. The importance of probing the subject of COPD within the context of the United Kingdom (UK) as described in this paper is due to the commonness of the condition in that about three million people suffer from COPD in the UK  with at least 25,000 reported annual deaths making it a significant public health issue (Tidy, 2015). Considering its irreversibility the cost of managing COPD can really be high. COPD can also lead to premature deaths (Adeloye et al., 2015).

Confidentiality Statement

In adherence to the code of conduct prescribed by the NMC, the patient’s name, the location of residence as well as his age and other confidential details have been made anonymous as an aspect of respecting his confidentiality and privacy (Nursing and Midwifery Council, 2016). The patient, in this case, will be referred to as John (not his real name).

The Patient’s Profile in the Case study

John is a 61 year (not his real name and age) old man who is suffering from Chronic Obstructive Pulmonary Disease. He had been diagnosed with COPD two years earlier at the time of his recent admission. He confessed that he had been living as a widower with his two sons who were above the age of 20 considering that his wife had passed on 5 years ago. When he reported to the hospital, he was accompanied by his eldest son. Upon initial probe, it was established that John was a heavy smoker even in the present has been unable to quit successfully, sometimes being able to smoke over 20 cigarettes in a day. He is not used to cooking and relies heavily on fast foods purchased from convenience eateries. 

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During the past two years, John had had 4 histories of exacerbated COPD events. At the time of his hospital visit and admission, he had complained of increasing shortness of breath that was severe which was making him feel very weak and exhausted. The problem with his breathing was possibly due to the reduced amount of normal airflow in the lungs (Harvey et al., 2015). The low amount of normal airflow resulted in the need for extra energy to allow for a forceful form of breathing. He also experienced a severe productive cough. Although his two sons often took care of him, he was also of a routine use of medications such as salbutamol and often used the tiotropium inhaler to ease his breathing. Upon assessment, it was established that the patient exhibited the occurrence of decreased airflow characterized by the notable wheezing sound in his chest (Huang et al., 2015). One of the assessments that were carried out was the chest auscultation which revealed that there was the presence of a protracted extended forceful exhalation pattern arising from a minimum amount of air available in the lungs. In addition, an illness level detection using the spirometry indicated a FEV1/FVC value of 52%. Considering the acceptable value of a spirometry which is expected to be at least 70%, a value of 52% in airflow limitation may have been indicative of a stage two progression of the disease (Shaw et al., 2014; Tidy, 2015; Waschki et al., 2015).

John had a notable high blood pressure value with a reading of 168/84 mmHg and with a weight of 246 pounds and height of 4.9 feet indicating his body mass index (BMI) at 50.2 was indicative that John was obese.  Other vital signs recorded at the time of his admission showed that his rate of respiration was 26 breaths per minute, heart rate as 97 beats per minute and finally a breathing room air that was at 79 %. With these assessment drawn and under close monitoring, the patient was put on 40mg prednisolone, 500mg of clarithromycin given after every half day check up to prevent chances of infections and 2.5 mg salbutamol as well as a 60% oxygen therapy to help with breathing. After two days of continued therapy and medication, the patient indicated improvement although his airflow was still problematic. Fortunately, upon the continuation of the treatment, John appeared more comfortable on the third day. He was allowed to rest at the hospital for one extra day for the need of further observation and was discharged at the end of the fourth day after his condition was determined as very improved with the guideline that he visits the facility after 4 weeks for review.

Pathophysiology

As a type of obstructive lung disease, COPD is characterised by limited airflow (Hoff et al., 2016). The condition is irreversible and its cure is yet to be determined (Vestbo, 2014, p.1). The occurrence of COPD is typical to an elevated inflammatory response on the surface of the lung as a result of the presence of irritants such as gases or other solid micro-particles. Such irritants may originate primarily from cigarette smoking and other secondary origins such as polluted air and occupational gases (Dadvand et al., 2014; Song et al., 2014 Pope et al., 2015). John was a heavy smoker sometimes being able to smoke more than 20 cigarettes in a day a situation which was greatly associated with his COPD condition. When these noxious agents are inhaled, their irritation on the lung surface elicits an abnormal inflammatory response which consequently results in both pathological and physiological consequences. The common pathological and physiological impacts include chronic bronchitis characterized by hypersecretion of mucus, apparent inflammation, emphysema which is the destruction of lung tissues, and the occurrence of fibrosis on small lung airways (Trojanek et al., 2014; Angelis et al., 2014; Trimmer, 2017, p.2). Preliminary assessment of john’s airways revealed that there were abnormal hyperplasia and hypertrophy of his mucus glands and goblet cells which led to the hypersecretion of mucus that caused the clogging and thus obstruction of his airways leading to his noted difficulty in breathing. Evaluation of the inflammatory markers also revealed a high degree of inflammation on the surface of the lungs of the patient. The compounded impacts of all these pathological and physiological changes resulted into constricting of john’s lung airways which in essence obstructed and hence diminished his normal airflow. The narrow airways can also lead to trapping of air within the lungs that was characteristic of the notable wheezing sound in his chest. The patient was also coughing excessively. 

The continued irritation of the glands and goblet cells on the surface of the lungs that function in mucous secretion by the irritants mentioned above lead to their abnormal swelling and functioning which means that there is excessive production of mucus which is not easily cleared (Ramos, Krahnke, & Kim, 2014). The excess mucous then become obstructive to normal airflow within the larger airways and triggers excessive coughing. The obstructive mucous can also facilitate a favourable breeding ground for agents of infection such as bacteria. In addition, due to its obstructive nature, the excessive and obstructive mucous within the larger airways may results to hypoxemia since it affects the normal ventilation and air supply within the lungs.

The continued inflammatory response on the surface of the lung due to reaction to the irritating gaseous agents such as those found in cigarette smoke may causes an imbalance in the protease-antiprotease equilibrium resulting in instances of increase in the immunological actions of both neutrophil and macrophages elastases which further leads to destruction of alveolar and other lung tissue damage which is a phenomenon known as emphysema (Kukkonen et al., 2013; Hentschel et al., 2015). Clinical evaluation of John’s lungs did not manifest any occurrence of damaged lung tissues and thus the illness had not progressed to the onset of emphysema. Destruction of lung tissues such as alveolar walls reduces their elasticity and consequently their function in lung ventilation and oxygen supply.  With decreased oxygen supply, the activity of the heart may be reduced leading to a reduced blood circulation (de Paiva Azevedo et al., 2016, p.1899). 

An immunological assessment of the patient (John) indicated a high proportion of inflammatory cells that included macrophages, neutrophils, lymphocytes, and dendritic cells. As stated earlier, the action of the irritants on the lung’s surface elicits an inflammatory response. The activation of the associated inflammatory cells such as neutrophils, macrophages, dendritic cells, lymphocytes and B-cells as well as other agents of inflammation such as  interleukin 6 (IL-6), interleukin 8 (IL-8) and tumour necrosis factor (TNFα) is the genesis of occurrence of bouts of inflammation on the affected surfaces of the lungs such as the trachea, bronchi, and the bronchioles (Dancer & Sansom, 2013, p.1176-1178; Rovina, Koutsoukou, & Koulouris, 2013, p.2; Dima et al., 2015, p.313). The compounded impacts of chronic bronchitis (mucous obstruction of lung airways), emphysema (lung tissue damage) and inflammatory responses lead to an increased limitation of gaseous exchange in the lungs characterized by decreased lung capacity.

Upon an acute occurrence, COPD may be characterized by a significant onset of excessive coughing, sputum production as well as difficulty in breathing (dyspnoea). Such an occurrence is referred to as COPD exacerbation (Wedzicha & Donaldson, 2012). The manifestation of the acute form of COPD on the patient was evident through the typical signs of exacerbation which included dysponea which actually made him very uncomfortable, excessive coughing and production of thick sputum. An exacerbated event may take place due to environmental changes such as temperature, increased contact with irritants, as well as pathogens (Wilson et al., 2013; Wedzicha, Mackay, & Singh, 2013; Clark et al., 2015). For a patient already suffering from COPD, the baseline pathophysiology associated with COPD may be magnified to life-threatening levels and as such may require an abrupt change in the normal therapeutic measures. An instance of exacerbation is characterized by increased narrowing of small airways, excessive dilation of the mucosal lining, and abnormal production of very viscous mucus. These three elements further increase the difficulty in lung ventilation which is the characteristic presented as dyspnoea.

In notable instances where genetic factors are involved, a lack of the Alpha–1 anti-trypsin (AAT) gene may trigger the onset of COPD (Brode, Ling, & Chapman, 2012). AAT functions in such a way that its residence in the bloodstream and the lungs prevent the possible damage that may arise from inflammatory response witnessed in the lungs as a result of the presence of gaseous or solid irritants on the surface of the lungs. Therefore, their action prevents possible lung tissue damage due to the actions of neutrophils, macrophages, dendritic cells, lymphocytes and B-cells, interleukin 6 (IL-6), interleukin 8 (IL-8) and tumour necrosis factor (TNFα). A deficiency in AAT is more likely to lead to the ease of occurrence of COPD and the resultant emphysema (Rahaghi & Miravitlles, 2017). Therefore, a family history of the occurrence of COPD could be an important element of assessment of a suspected COPD patient. However, the patient’s history did not reveal any notable occurrence of COPD among any members of his family or relatives.  In addition, a notable consumption of more than 20 packets of cigarettes in a single year as was witnessed in John’s lifestyle is a serious precursor of the occurrence of COPD (Anjamo, Tegene, & Tadesse, 2015). 

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Physical, Social and Psychological Challenges

Psychological Impact of COPD

Bouts of COPD manifest conspicuous psychological and social effects on a patient as well as their carers who may include their family members or friends.  Most COPD patients have to contend with social challenges such as diminished mobility, social isolation and stigma, as well as possibility of becoming increasingly dependent. For example, John narrated how he had lost many close friends he had associated very closely with in the past and now had appeared to have been avoiding him. He believed that people avoided him possibly because he would be dependent on them. Compounded with the inability to make a living for himself, the psychological implications that John faced as a COPD patient were depressing. For example, the loss of financial independence, as well as the inability to fend for himself, may have lead John to experience a diminished self-worth and self-esteem which made him avoid going out and interacting with other people freely. Such a state of hopelessness and depression normally tends to make the situation worse and only increases the progression of the disease (Alexopoulos et al., 2014; Yohannes & Alexopoulos, 2014). It is possible that due to the several incidences of dyspnoea, a COPD patient may develop increased levels of anxiety as well as depression as noted in at least 6 in 10 people in the UK (Tidy, 2015). John said that in most cases and especially when he experiences episodes of dysponea, he is always anxious and would often which to be accompanied by a close family member such as one of his two sons to the hospital just in case the condition grew worse on his way. However, with early detection anxiety and depression can be treated (Yohannes & Alexopoulos, 2014; Ouellette & Lavoie, 2017) 

Socioeconomic Impact of COPD

Amplified COPD events exert an elevated laden of healthcare both at an individual, family and government levels. There are over 100,000 medical admissions cases of COPD reported in the UK every year (Hull et al., 2017). Since his diagnosis with COPD, John had experienced multiple hospital admission than any other time in his life. Furthermore, most of those admitted with COPD are associated with extended stays and occupancy at the hospital which cumulatively amplifies the cost of health care at almost every level of the society. The overall cost of admission and treatment results to an increased financial burden to the healthcare system in the UK. Furthermore, the progressive nature of COPD leads to a decline in the lung function of COPD patients which with time renders them sedentary and unable to engage in active socio-economic activities that can grant them financial independence. Since the onset of the disease, John had become progressive economically unproductive meaning that he was not even able to raise enough resources for his health care needs.  The resultant financial dependence puts a strain on their family members and other carers.  His eldest son who held a job with a local contributed greatly to his father’s medical bills.  With the reported cases of COPD mortality reported in the UK, the impact to the economy are also high since it affects a very economically productive age group. 

Physical Impact of COPD

The continued narrowing of the lung airways, obstruction by mucus, and damage to lung tissues increases the progressive difficulty in breathing which most COPD patients find disabling. With time such patient becomes increasingly sedentary due to poor mobility as well as diminished strength for activities of daily living (Vaz Fragoso et al., 2014). What this means is that caring responsibility of sedentary COPD patients will fall heavily on family members/carers. During the exacerbated episodes, John would feel exceedingly disabled and would be heavily hindered in carrying out his activities of daily living in which case, his sons would be very supportive.  

Medical/ Nursing Care (Chronic or Acute Care)

A patient-centered approach to care requires that the care and clinical interventions on the patient adhere to strict consideration on the needs and preferences of the patient (Mirzaei et al., 2013). It is imperative for a COPD patient to be part of the decision making process on the kind and treatment and care he or she should receive. Therefore, for the patient to contribute productively to the care decision making process he or she should do so from an informed perspective. It is, therefore, the duty of the nurse to ensure that the patient understands the associated implications of using a given therapeutic approach (Elwyn et al., 2014). A point of view that is based on knowledge will help the patient make an informed decision and thus give an informed rather than a coerced consent. 

Considering that there is no cure for COPD, the basis of medical/ nursing care is to manage the exacerbated episodes with the aim of stabilising the condition of the patient from the acute attacks. In such a state, the immediate response is always to try and improve gaseous exchange in the patient before any other medication or therapy is commenced. Such therapies usually involve the employment of approaches such as the use of bronchodilators and the oxygen therapy.   Other important remedies include antibiotics and corticosteroids. 

The oxygen therapy is a fundamental remedy in the clinical management of COPD. The process is importantly functional in promoting body oxygen supply as well as reducing the difficulty experienced in breathing (Okuda et al., 2014; Nishi et al., 2015). As described in the patient’s profile, John was put on 60% oxygen therapy to facilitate oxygen supply to the peripheral tissues and to maintain normalcy between the arterial blood gases. Medications such as salbutamol are helpful in effecting bronchodilation consequently reducing the effects of narrowed airwaves in the lungs.  The physiological functioning of bronchodilators is to effect the relaxation of muscles associated with broncho-constriction and thus permitting an increased flow of air through the airwaves (Nardini et al., 2014). It is the reason why 2.5 mg salbutamol in combination with tiotropium was prescribed for John. 

COPD is associated with increased immunological reaction on the surface of the lungs resulting in inflammation. As a way of countering the impacts of inflammatory markers and agents, a prescription of corticosteroids is a primary medical necessity in managing COPD exacerbations since they help in reducing airway obstruction and thus reduce recovery time (Ernst, Saad, & Suissa, 2015). The commonly used corticosteroid in managing inflammation in the body is prednisolone (Abroug et al., 2014).  A 40mg prednisolone was prescribed to the patient as a useful medication in reducing inflammation. 

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The accumulation of excessive mucus within the airwaves, occurrence of inflamed surfaces and damaged lung tissues provide a favourable environment for the onset of bacterial infections. An antibiotic therapy such as the use of clarithromycin may be important in preventing invasion by opportunistic pathogens such as Streptococcus pneumonia and Haemophilus influenza (Zhang et al., 2016). With a prescription of 500mg clarithromycin, the prevention of bacterial infection was put on course as part of the pharmacological management of the patient. 

Patient-centred care is entwined in good and transparent communication between the patient and the caregiver that illuminates the needs of the patient and must be evidence-based to ensure that it does not result in harming the patient (Kitson et al., 2013, p.5). The involvement of the family members/ carers must also be incorporated in the care process to allow for holistic decision making. When there are no contraindications to the approaches discussed above especially regarding the history of the patient, the informed consent of the patient as well as the contribution of the family members/ carers such as John’s son, their implementation can be very effective in managing exacerbation. However, what may be vital in the management of COPD is the prevention of episodes of exacerbation since it reduces the counts of hospital visits and admissions. Possible preventive measures may involve vaccination, regular use of bronchodilators as well as regular use of corticosteroids (Gnatiuc et al., 2015). 

Integrated Care

Integrated care according to the World Health Organization refers to the holistic approach to care that incorporates both “inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion” (Williams et al., 2016, p.2). Its aim is to ensure that the healthcare services that are provided are easily accessible, are the highest standards possible, are efficient and are able to satisfy the needs of the patient. In other words, all aspects of integrated care must be patient-centred in its entire entirety. In some instances, it may be necessary to carry out multi-sectoral coordination to promote access to care. The basis of integrated care for a COPD patient must achieve the benefit of the patient being able to attend to and manage their activities of daily living optimally and independently as well as improvement in the patient’s health status (Nici, & ZuWallack, 2012, p.2).   

Clinically integrated care for the COPD patient requires that the caregiver make a clinical determination of symptoms as well as a possible comorbidity (Williams et al., 2016, p.2). Interventions targeted at the disease may include the need to commit to effective pharmacological and non-pharmacological therapies,  undertake cessation from smoking, regular physical activities, assisted self-management, proper nutrition, as well as palliative and hospice care where necessary (Williams et al., 2016, p.2). The care approaches should be well coordinated among caregivers to prevent possible confusion or possible medication errors.  

A well implemented integrated care should be able to achieve cost containment while improving health outcomes in the management of the disease in that where possible community-based care can be adopted. The inference of community-based care can be from the perspective of home based-maintenance patient-tailored pulmonary rehabilitation, provision of self-management education, prevention of admissions or readmissions, as well as facilitation of remote diagnosis (Williams et al., 2016, p.3). Other elements may include enhanced communication and effective coordination of care amongst all individuals, systems, and levels involved in the COPD patient’s care. However, in most cases, it is not always absolute to provide the ideal patient-centered medical home considering the difficulty in achieving the requisite balance in integrating both primary and subspecialist interventions in the management of the condition. Such a difficulty is mostly notable in episodes of exacerbations (Williams et al., 2016, p.4). As much as such a balance is fundamentally desirable its achievability is more often than not hindered. 

The components of integrated care that were useful for John included his active involvement as well as that of his sons in the decision making the process of the care that he received. For instance, the nurses found it important to educate him and his sons on the significance of the different patient-tailored pulmonary rehabilitation pharmacological remedies that were prescribed for him. This way it would be easy for the patient and his carers to promote consistency in the use of such medication as a means of avoiding preventable readmissions. Furthermore, as a remedy to help with his struggles in the cessation of smoking, the healthcare professional’s empowered the patient and his sons on the use of nicotine patches as an alternative to smoking. There was effective coordination between the caregivers who attended him and who also ensured that the components of care were clear to him through enhanced positive communication. 

The UK government like many other governments across the world has put concerted efforts in alleviating inequality with respect to access to quality healthcare (Department of Health, 2011, p.18). This means that John would be able to access quality healthcare in a similar manner as any other individual in the society without the discrimination of affluence or race. The government’s public health initiatives involve conduction of public health intelligence, interventions geared at primary prevention, issuance of vaccines, quality assurance screening programmes, as well as public awareness campaigns to encourage recognition of early signs of the disease thus fostering early intervention (Department of Health, 2011, p.19). The government is also supportive of innovative resources to help patients and their carers manage COPD remotely and effectively. For instance through the Government supported online resource termed MyCOPD, patients are able to improve their breathing especially in bouts of exacerbation and enhance remote care (Clark, 2017). Remote access to disease management resources would also help John to avoid preventable visits to the healthcare facility.

According to the key recommendations in the Wanless report, the 5 years projected Government strategies on dealing with preventable maladies arising from unhealthy lifestyles such as smoking and physical inactivity include aspects such as regulation of smoking (Imison et al., 2016, p.20). Such approaches include the enacting and implementation of policies to counter unhealthy behaviour such as smoking through the introduction of higher taxes on cigarettes. Such an approach will ensure that John is not able to afford his routine excessive smoking. It, therefore, helps the patient to develop a personal behavioural approach in overcoming his unhealthy lifestyle. Other government spearheaded initiatives in tackling preventable lifestyles diseases such as COPD include the assessment of the strength of employing the approach of electronic patient records as a way of monitoring the possible health risks that an individual such as John may encounter (Imison et al., 2016, p.73). The recommendations also focuses on the government’s ability to provide remote advice possibly through the implementation of online (website based) and telephone advisory services and resources in addition to the nurse-led advice services provided by NHS nurses (Imison et al., 2016, p.31).

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Health Promotion and Patient Empowerment

The Nursing and Midwifery Council’s (NMC) code emphasises four priority themes in centred on health promotion when handling patients. These themes include the need to prioritise people, promote professionalism and trust, preserve safety and practise effectively (Nursing and Midwifery Council, 2016). Health promotion and patient empowerment in COPD cases largely involve collaborative self-management as a fundamental aspect of integrated care (Williams et al., 2016, p.3). Supported self-management involves empowerment programs such as providing patient-centered education and behavioural change promotions aimed at enhancing health outcomes. Behavioural change may include among many things encouragement to cease smoking, adherence to disease management action plans, routine physical exercise, breathing management techniques, bronchial hygiene management, proper nutrition, overcoming stress as well as respiratory muscle training (Williams et al., 2016, p.3). 

While sometimes nurses may experience instances of patients relapsing back to smoking especially after quitting is recommended as was the case of John and thus exacerbating their condition, it may be important to continue encouraging such a person or finding a possible remedy to smoking. A possible alternative may be the use of nicotine patches in the place of active smoking. In essence, according to the NMC code, patient–centred care would encompass prioritising his needs, ensuring the care given is effective and safe, and promoting a mutual yet professional and trustworthy relationship between the healthcare professionals and the patient. In addition, the NHS constitution promotes a 6Cs framework that aims to put the patient cared at the heart of the provided care. 6Cs framework is a vision for nurses to exhibit communication, care, competence, compassion, courage and commitment when attending to their patients (Baillie, 2017, p.558). While care is the primary service that the patient receives, the level of kindness through which it is given manifests compassion while high skills in its provision show competence (Baillie, 2017, p.558). A mutual informed decision-making process between the patient and the caregiver is enhanced through effective communication and the absoluteness in making the right decision at the right time is guided by courage (Baillie, 2017, p.558). Finally, the nurse has to exhibit the drive and commitment in ensuring the patient experiences improved health outcomes. 

Conclusion

With respect to the case provided in this study, an integrated patient centred approach to care is fundamental towards the patient being able to experience improved health outcomes and thus achieve his normal daily functioning optimally and independently. It is imperative to undertake care planning from a wholesome point of view through a holistic patient assessment both at an individual and community level as well as the provisions of the available policies so as to align care with available and accessible care resources. Care must be implemented from an integrated perspective that takes into account uptake of the correct medication, patient-tailored pulmonary rehabilitation, prevention of admissions or readmissions, facilitation of remote diagnosis, coordinated care among healthcare professionals as well as the patient’s family/carers, and collaborative self-management.

Apart from the standard nurse-led care, it is vital to promote supported self-management as a way of empowering John as a patient through patient-centered education and behavioural change approaches that may help improve his health outcomes. It is important to guide the patient through behavioural change approaches that may include smoking cessation, routine physical exercise, disease management action plans, bronchial hygiene management, respiratory muscle training, stress management, proper nutrition, and breathing management techniques. Adherence to the NMC code will ensure that the patient is prioritised, he is cared for effectively through safe interventions in a professional and trustworthy manner.  Furthermore, it is important for healthcare professionals to always adopt the NHS 6Cs framework when attending to their patients.