Further research is undoubtedly needed to strengthen the results of the positive studies on which current guidelines are mainly based. Research needs to be carried out to gain insight on health behavior change interventions in COPD in order to design more effective self-management programs. For future studies it is imperative to realize that a self-management strategy must enhance self-efficacy and behavior modification before it can affect exacerbation outcomes. Therefore, self-efficacy and behavior modification should be measured as outcomes. Future clinical trials need to be planned and designed more carefully; studies should be powered properly.
Furthermore, future studies must avoid the methodological pitfalls, which might have caused equivocal and inconclusive results in previous studies. Benefits of a self-management program on health care utilization and health status are more likely to be observed in a study population consisting of patients with moderate to severe COPD, and previous hospitalization due to exacerbations. Only few studies consider comorbidities as possible confounders, whereas depression and anxiety can inhibit self-management.44 A recent review on the effects of action plans demonstrated that exacerbation severity and duration were not used as outcomes in any of the reviewed trials.42 This is conspicuous, as early symptom recognition and prompt treatment of exacerbations affect health care utilization and health status by decreasing the severity and length of an exacerbation. If we are to progress in the management of acute exacerbation, it is evident that the effect of early interventions on symptom recovery and health status should be considered as an essential component of clinical trials.
The use of action plans to help patients recognize symptom changes, to implement self-care, and to self-initiate a customized prescription (antibiotics and corticosteroids) in the event of an exacerbation has been suggested as a promising strategy. So far, there is growing evidence that self-management influences COPD
5
Table 2
Structure of the educational session on the action plan (Living Well with COPD): Interventions and suggested questionsInterventions Suggested questions
1. Explore present patient’s knowledge and behaviors
According to you, what is a COPD exacerbation? What do you usually do when your symptoms get worse?
2. i. Present/demonstrate technique/discuss topic
Why should you use an action plan? What is included in an action plan? ii. Evaluate patient’s
comprehension
Who are your resource persons, how and when should you contact them?
Could you describe your daily symptoms? What should you do to keep your health condition stable?
Which changes in your COPD symptoms tell you that you may have a respiratory infection? When should you start your additional treatment? How do you know that your symptoms improved? What should you do if you feel you are in danger? 3. Explore possible barriers
to integration of skills and behaviors learned
What prevents you from using your action plan?
4. Evaluate patient’s level of self- efficacy
Do you believe that you will be able to use your action plan to prevent or manage an exacerbation at home?
Do you believe that an action plan can help to prevent or manage a worsening of COPD symptoms?
5. Reference to other health professionals if needed
Did you get your prescription from your physician? Is your action plan prescription on file at the pharmacy?
78 79
CHAPTER 5 SELF-MANAGEMENT IN PREVENTION AND EARLY INTERVENTION OF EXACERBATIONS
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