Understanding and Managing Chronic Obstructive Pulmonary Disease as a Long-Term Condition

Introduction

A long-term condition (LTC) is referred to illness that are incurable but can be controlled with treatment and regular use of effective medication by the patients (Extance, 2020). In the UK, nearly 15 million people are suffering from LTC among which 58% of people with LTC are 60 years and above (Kingsfund, 2021). It indicates that LTC is a prevalent health condition among elderly people in UK. Thus, the current case study is explored to understand the impact and treatment of COPD as LTC condition in an elderly patient.

The chronic obstructive pulmonary disorder (COPD) is third leading LTC responsible for causing death. According to WHO, in 2019, nearly 3.23 million people are considered to have died from COPD (WHO, 2021). The exact worldwide number for COPD prevalence is not available but, in the UK, nearly three million people are mentioned to have COPD with two million people been undiagnosed for the disease (NICE, 2015). In Essex, UK, it is mentioned that 2,734 people are mentioned to be suffering from COPD in 2020 (Essex gov, 2021). This indicates the disease is widespread and effective focus regarding it pathophysiology, impact and management is to be understood for controlling well-being of the affected patients. Therefore, the case study of a patient suffering from chronic obstructive pulmonary disease (COPD) as LTC is to be described. The pathophysiology of COPD is to be mentioned related to the patient. Thereafter, physical, social and psychological challenges faced by the patient due to COPD is to be discussed. The nursing care and integrated care developed in managing COPD as LTC is to be explained. The health promotion, patient education and empowerment to be managed for COPD management is also to be discussed.

Confidentiality Statement

According to NMC Code of Conduct 2018, the personal details of the patient is not to be revealed publicly under any condition and their confidentiality along with privacy is to be maintained. The details of the patient could be revealed with their prior permission and in the condition of health emergencies particularly to the individuals who are responsible for taking care of the patient (NMC, 2018). In this case study, the pseudonym Yasmin is to be used to indicate the patient so that her confidentiality along with privacy is ensured.

Case Study

The patient named Yasmin who is 67-years-old is admitted to the emergency department due to acute onset of intense breathlessness. On admission, she mentioned of chest pain with increased palpitations along with increased sputum production, wheezing and difficulty in breathing while even at rest. She also mentioned being feeling confused and fatigued out of shortness of breath. The vital signs recorded for Yasmin by nurses are BMI 24, BP 139/89 mm Hg, heart rate 110 bpm, breathing 28 breaths/min and oxygen saturation is 85%. The normal BMI rate is 18.5-24.9 indicating Yasmin has normal BMI rate (Sun et al., 2019). The normal heart rate in individual is 60-100 betas/min and blood pressure are 120/90 mmHg (Esmer et al., 2019). However, Yasmin’s blood pressure and heart beat are found to be high indicating she may be suffering from hypertension. Moreover, the normal oxygen saturation is above 90% whereas the level below 88% is considered to be dangerous (Echevarria et al., 2021). Thus, it indicates Yasmin’s oxygen saturation is at dangerous level and required to be immediately cared. The current medication used by Yasmin include 100-25mg of fluticasone-vilanterol daily for overcoming troubled breathing and wheezing and 50mg of hydralazine 3 times a day for managing hypertension. The family history of Y mentions that his mother used to suffer from COPD and high blood pressure. She has a 30-year-old married daughter living in the city who visit her once a month and calls her each day to remain in contact.

Yasmin has a steady history of smoking 30 cigarettes a day for last 35 years which has been reduced to 5 cigarettes a day till now indicating she has not entirely overcome her smoking habit. She mentions to feel lonely as she no more goes out due to breathing problem after COPD and in the absence of her husband who died in an accident 2 years ago. Her past medical history mentions she has high blood pressure and her COPD been identified in the last 5 years for which steady medication are been already provided. At home, she executes her own livelihood activities with the help of a carer to assist her doing duties as she often feels fatigue. She mentions avoiding exercise and walking long distance because of breathlessness which is leading her develop sedentary life as her carer do all the groceries, cooking and cleaning at home. However, Yasmin express no assistance required for bathing and dressing or eating from the carer. Her only daughter lives out of town and calls weekly to check on her.

Pathophysiology

Chronic obstructive pulmonary disease (COPD) is referred to chronic inflammation of the lungs which obstructs the smooth airflow leading to create difficulty in breathing among people. In case of Yasmin, she is mentioned facing intense breathlessness for which she required to be immediately hospitalised. The study by Hopkinson et al. (2019) mentions that in COPD increased breathlessness occurs due to obstructive airflow as a secondary action for airway inflammation, remodelling and hypersecretion of sputum in patients. It is evident as alveoli are damaged in the COPD due to cigarette smoke or intake of polluted air which rupture them to create large spaces reducing the surface area of gas exchange leading to shortness of breath (David et al., 2021). Luckett et al., (2021) mentioned that during COPD exacerbation, the increased dynamic hyperinflammation hinders the efficiency of the respiratory muscles to enhance the intrathoracic pressure on response to increased drive in breathing. The reduced intrathoracic pressure leads the lungs to collapse and unable to fill in supporting increased inspiration capacity during exercise (Luckett et al., 2021). Thus, it explains the mechanism of the lung function which may be currently faced by Yasmin as she is experiencing intense breathlessness.

In COPD, apart from dyspnoea, wheezing and coughing with sputum are symptoms which is also mentioned to be faced by Yasmin. The wheezing sound in COPD patients is mainly developed due to forced air exhalation through the obstructed or narrowed air passage within the lungs where the obstruction is mainly caused by excess mucus and muscle tightening of the airways due to damage cells (Bellou et al., 2019). In the study by Hanlon et al., (2018), it is informed that increased sputum is developed in COPD patients because of increased mucus secretion and production as a result of the overabundance of goblet cells and oversized mucus glands present in the airways. The cigarette contains harmful chemical agents that cause profound alteration by damaging the air sacs leading to inflaming them and creates hindered condition for exchange of air leading the individual with COPD to develop breathlessness (Hopkinson et al., 2019). In case of Yasmin, it is seen that she still smokes 5 cigarettes a day which may have caused her condition with COPD to be exacerbated.

In the case study, Yasmin is mentioned to be feeling the tightness of the chest and lack of energy as she mentioned to hiring help in assisting in her everyday activities. According to Ali et al., (2021), chest tightness in COPD patients is common condition because patients with COPD face spam of the bronchi out of damaged cells and elasticity of the lungs which leads the individuals to face hindered expansion of the lungs. The study by Prieur et al. (2020) mentions that troubled oxygen intake and build-up of carbon dioxide on the body due to hindered breathing leads the patients to develop low energy and fatigue. Thus, the health condition of Yasmin contributed to her feeling of lack of energy.

Physical, Social and Psychological Challenges

The presence of COPD creates wide number of physical, social and psychological challenges in people. As asserted by Hanlon et al. (2018), COPD patients face physical challenge of executing any intense physical activity such as long walk, exercise, running and others. This is because of the ventilatory limitation in COPD patients caused by their damaged air sacs and reduced elasticity of the lungs. The muscle atrophy along with weakness of muscles of the lungs as mentioned acts as co-factor towards the limitation of exercise in people (Schneider et al., 2018). It is similar for Yasmin who mentioned experiencing challenges with long walks or performing everyday activities like cleaning, washing and others at home due to which she has hired a care provider to support her at home. As argued by Ramos et al. (2019), limited physical activity and sedentary behaviour in COPD patients makes them develop weaker lower limb muscles. It makes the individual develop physical challenge of maintaining effective balance during walking and it result them developing risk of fall. In case of Yasmin, it is seen that she is already showing sedentary behaviour with no physical activity which may gradually led her to develop muscle weakness and develop challenges with walking or balancing leading her to be risk of fall. It would also impact the carer and family members feel fear of risk of fall for Yasmin which would make them develop increased responsibility in supporting her.

The study by Hanlon et al. (2018) informs that loss of energy and fatigue are common physical challenge among COPD patients which makes them dependent on others for care and supporting them in everyday activities of life. This is evident as in case of Yasmin it is seen that she is experiencing challenge with everyday actions like cooking and cleaning due to which she must depend on the carer is executing the activities. However, her personal activities such as bathing, and dressing are still able to be managed by Yasmin indicating she requires partial assistance in executing her everyday activities. It would make the carer develop increased physical responsibility in doing the chores of Yasmin. The repeated hospitalisation and relapse of Yasmin’s condition would make the family member develop doubts regarding the care provided to her and unsure of her health improvement.

The other physical challenge faced by COPD patients is high blood pressure because the condition leads the airways to be inflamed which reduces the amount of oxygen to be delivered from the lungs to the surrounding arteries. It causes the arteries to be narrowed so that oxygen supply could be controlled under the minimised situation causing high blood pressure in individuals (Briggs et al., 2019). In case of Yasmin, she is seen to regular take hydralazine that is the medication used for treating high blood pressure as it acts as a vasodilator (Brewster, 2019). Moreover, her blood pressure is 139/89 mmHg which is pre-hypertension as the normal level is 120/90 mmHg (Fox, 2021). Patients with COPD experience psychological challenges of depression and stress due to the long-term condition and hindered efficiency in managing everyday life. It is evident as physical and social challenges caused by the disease leads individuals develop hindered mood and emotional health (Luckett et al., 2021). Yasmin retired from her job of as a clerk seven years ago and due to the exacerbated COPD condition has limited ability to move around without feeling breathlessness in travelling to other places to meet people. She has avoided to interacting with the neighbours due to their discriminatory attitude towards her being a Muslim and lack of daily interaction with her daughter has made her feel isolated and depressed.

The reduced functional ability along with the need of frequent hospitalisation leads the patients with COPD develop anxiety-disorder. This is because the poor health condition makes them fear and sad regarding their efficiency to lead life (Maddocks, 2018). In case of Yasmin, no instance of anxiety was mentioned but she is seen to be hospitalised for second time in 2 years which may gradually led her develop anxiety in later years out of the hindered disease management. Thus, effective intervention is required to improve her physical, social and emotional health so that her ability to execute physical duties can be achieved by her and she can develop a stable mental health.

Nursing Care

The nursing care to be provided to Yasmin is to be determined by nurses through APIE (assessment, planning, intervention and evaluation) approach. This is because the process allows the nurses to deliver support systematically and ensure greater management of the health incidence of the patient (Piccoli et al., 2018). In case of Yasmin, the initial care provided by the nurses with consultation from the health professional is supplement oxygen delivery. This is because supplement oxygen helps in increasing the oxygen saturation in the blood and gradually improve breathing ability (Fuller et al., 2020). In COPD patients during exacerbation, they are to be provided oxygen in 24-28% concentration through a venturi mask for reaching the oxygen saturation level of more than 90% (Nicholson et al., 2020). The 24-28% level of mask are to be used as they helps in providing fixed oxygen to the patient to resolve the hypoxic drive without creating risk of hyperoxygenation (Wagley et al., 2022). In Yasmin’s case, her health assessment mentions oxygen saturation level is 85% which is dangerous, and her breathing rate is too high that is 28 breaths per min (normal= 16-20 breaths/min) (Marzocchi et al., 2021). Therefore, the nursing care of providing her supplement oxygen is planned and implemented.

According to NICE, the oxygen therapy in COPD patients is essential for improving oxygen saturation level (92% or less) (NICE, 2019). This is because the supplementary oxygen helps in increasing the oxygen saturation of the blood which the COPD patients are unable to manage due to breathlessness in which enough oxygen in unable to be inspired from the air (Echevarria et al., 2021). In case of Yasmin, she is seen to face severe airflow obstruction and oxygen saturation at dangerous level due to which supplement oxygen therapy is appropriate action followed by the nurses. In delivering supplementary oxygen to Yasmin, the nurses evaluated and monitored her oxygen saturation level through use of pulse oximeter. This is to avoid over oxygenation of the patient which harmful and leads to further deterioration of health symptoms of COPD (O'Driscoll et al., 2017). The nurse on assessing the medication history of Yasmin identified she is not on any corticosteroids needed for COPD patients. It led them to plan by consulting with the health professional that Yasmin is to be put under long-acting bronchodilators as her COPD condition is poor. Yasmin is currently provided albuterol-ipratropium along with fluticasone-vilanterol on regular basis for treating the air blockage and enhancing the efficiency of the lungs in COPD patients (NICE, 2018). This is because albuterol-ipratropium are beta-2-agonists which stimulated the beta-2-receptors lining smooth muscle cells in the airways leading the muscle cells to relax and open airways for enhancing breathing (Wilkinson et al., 2019).

According to NICE, long-acting bronchodilators such as Formoterol is prescribed for Yasmin (NICE, 2018). This is because they bind with the adrenergic receptors in the lungs to stimulate bronchodilation for long-term through cyclic AMP secondary messenger system (Voorham et al., 2018). Thus, to provide long-term relief and avoiding repeated intake of medication, the nurse determined to prescribe long-acting bronchodilators to Yasmin. The bronchodilators are also important for Yasmin as it would help her in overcoming chest tightness created by exacerbated COPD condition. It is evident as bronchodilation leads the trapped air from the alveoli to the released which allow the lungs to support improved breathing and reduce chest tightness (Sicras-Mainar et al., 2022). The side-effects of long-acting bronchodilators in COPD patients are nausea, headache, dry mouth and others (NICE, 2019). The NICE mentions that long-acting bronchodilators are to be provided to patients with the combination of corticosteroid such as salbutamol (Parkin et al., 2021). This is because corticosteroids help in lowering the swelling of the air passage while bronchodilators help in opening the air passage thus acting as complementary to one another (Gonem et al., 2019). The side-effects are informed to Yasmin by the nurses to make the patient remain aware of the condition.

The NICE guidelines mention that mucolytic drug therapy is to be provided to COPD patients in helping them manage hypersecretion of sputum (NICE, 2018). This is because the mucolytic drug therapy helps in making the sputum less thick and sticky leading to assist it to be easily coughed up (Juergens et al., 2020). The side-effect of mucolytic drug is diarrhoea, rash, vomiting and others which are rare (Dobler et al., 2018). Since Yasmin is showing increased sputum production, the mucolytic drug therapy is to be provided by the nurses to ensure him better health. In case of Yasmin, she is mentioned to be involved in active smoking even after the diagnosis of COPD and is currently seeking assistance from nurses to overcome the habit. Thus, the nurses determine that she is involved in Smoking Cessation intervention where talk therapies along with nicotine replacement therapy are to be provided to help her overcome the addiction towards smoking. This is important as smoking in COPD is life-threatening as harmful chemical elements from the cigarette smoke leads to cause damage to the airways that exacerbates the condition and uncontrolled management of COPD (Sonnex et al., 2020).

The Smoking cessation intervention including talk therapy is effective in making the patients understand the need of avoiding smoking as per their health condition and offer them develop strong emotional consideration in quitting to smoke (Murray et al., 2020). The nicotine replacement therapy helps in providing substituting compounds of nicotine to smokers to make them gradually overcome the affinity to smoke (Hartmann-Boyce et al., 2018). A dietician is provided to Yasmin and the nurses worked in collaboration with the dietician to determine the diet and drinks to be taken by the patient in maintaining stable COPD condition. This is because eating diet with low carbohydrates assist COPD patient to breath faster as higher carbohydrates produces increased carbon dioxide for the oxygen used leading to cause hindrance in breathing (Fischer et al., 2019).

In discharging Yasmin from the hospital, the nurse requires to ensure that she is stable for 24 hours and more, require less bronchodilators per hour and oxygen delivery is ceased for 24 hours and more. During discharge, Yasmin is to be informed regarding the details of the medication to be taken after discharge and written instructions is to be provided to her for using inhalation and oxygen devices. This is to ensure Yasmin is aware of the way medication is to be taken and feel empowered in taking care of her after the discharge. An outreach program allowing Yasmin to contact the physicians and nurses at anytime in emergency is to be created so that she feels safe and secured of being effectively cared even after the discharge if required in any condition (Fairview, 2021).

Integrated Care

The NHS mentions Integrated Care is providing people with the required support with collaborative approach from health professionals and nurses along with NHS and council services (NHS, 2021). The integrated care provided to Yasmin with the help of multi-disciplinary team members such as dieticians, smoking cessation service providers and others while working with the health professional and nurses caring for Yasmin is effective to improve the quality of care. This is because it helped in involving experts from different field of medicine in deciding the best possible treatment as per the specific needs and health condition of Yasmin (Kingsfund, 2021a). The benefit of integrated care for the patient Yasmin is that it ensured holistic support to avoid further exacerbation of COPD condition in patient and controlled the cost of care by avoiding rehospitalisation (Kingsfund, 2021a).

The Integrated Care Pathway (ICP) by NHS informs multi-disciplinary team is to be included for delivering anticipated care in proper timeframe to the patient for helping the individual overcome health complication (BMA, 2021). In the integrated care for Yasmin there are no differences with the ICP as similarly multi-disciplinary team is included by the nurses to develop care for the individual. The NHS Long Term Plan mentions that in the next 10 years effective improvement among all patients is to be achieved so that a fit future could be developed (NHS Long-term Plan, 2021). In caring for Yasmin, the plan is effectively followed as enhanced analysis of holistic health needs of Yasmin is done by the nurses and accordingly treatments are accurately provided for creating a fit future. The following of the NHS Long Term plan is beneficial for patient care as it would lower prevalence of relapse of long-term condition like COPD among the patients and ensure them better health and well-being (NHS Long-term Plan, 2021).

The House of Care (HoC) model is referred to as the framework of coordinated services which allows the clinicians and patients with long-term condition to work collaboratively for determining and supporting the needs of well-being for the patient’s condition (NHS, 2021a). The benefit of HoC model is that it helps in providing person-centred care with collaboration from the multi-disciplinary team and ensures greater satisfactory care to the patient (NHS, 2021a). In caring for Yasmin, the HoC model is followed as her needs are identified and person-specific care is provided to Yasmin. Moreover, the clinical worked with Yasmin to determine her needs and shaped the support with the help of the multi-disciplinary team.

Health Promotion, Patient Empowerment and Education

The NMC Code of Conduct mentions the nurses to determine the physical, social and psychological needs of the patients and provide them care in meeting the needs as well as in the best interest of the patient (NMC, 2018). The nurse caring for Yasmin is seen to have followed holistic needs identification and has arranged care as per the demands of the patients ensuring the care delivered in patient’s best interest. The NMC Code of Conduct also mentions that in promoting health of patients, the nurses are to act professionally and work within their competence to avoid any error in care (NMC, 2018). The Code is effectively followed by nurse caring for Yasmin as she interacted with health professionals for prescribing medication and contacted the multidisciplinary team in collaboratively delivering expert care that are beyond their competence. The NMC Code of Conduct for health promotion of patients mentions nurses to act ethically and avoid any harm to the patient (NMC, 2018). In case of Yasmin, the nurses effectively followed the Code as no harm was done to her and effective actions are taken to ethically delivery care by ensuring confidentiality and privacy of the patients.

The 6 C’s of nursing inform the nurse’s role in health promotion of the patients. The 6 C’s are care, compassion, competence, communication, courage and commitment (Barchard et al., 2017). In support for Yasmin, the nurses expressed enhanced care as her holistic needs are identified and accordingly diver care is arranged for Yasmin. The compassion leads the nurses to show they understand the patients and share their pain (Baillie, 2017). However, without compassion from the nurses, the patient feels lack of value and dignity as they feel their health condition is not understood by others (Kline, 2019). In taking care of Yasmin, the nurse expressed enhanced compassion by showing effective understanding of the pain and discomfort faced by Yasmin as well as she assured ways in which they are trying to resolve her pain to show value towards her. The nurse caring for also expressed competence as she involved with multi-disciplinary team and consulted with clinicians in deciding her care by avoiding to work beyond their expertise.

The nurse support Yasmin is seen to show effective communication ability as she developed clear past and present health history of the patients to be analysed to understand the reason behind her exacerbation of COPD and further actions to be taken to resolve it. The nurse also expressed courage and commitment by doing the right action needs for health improvement of Yasmin in a professional manner without violating any rules to overcome COPD exacerbations. The Transtheoretical model mentions the different stages of behaviour expressed by individuals in making change (Nakabayashi et al., 2020). According to Yasmin’s condition, she is currently in the Preparation Stage. The preparation stage indicate individual who are intending to take action in immediate future for making behaviour change (AmacTraining, 2021). In case of Yasmin, she personally asked the nurses for involving her is smoking cessation services. This is because she wishes to entirely leave smoking which she has been trying to do on her own but have failed even after knowing it is harmful for her current COPD condition. It indicates she is ready to take actions in making behaviour change that is smoking cessation needed for controlling her COPD condition.

Conclusion

The above discussion mentions that Yasmin is a COPD patient who is admitted to the hospital due to increased breathlessness out of exacerbation of the condition. Yasmin’s COPD has exacerbated as she is still smoking and mentioned she is facing challenges with retain social life, physical exercise, stable mood and others. The nursing intervention taken for Yasmin are the administration of oxygen therapy, long-acting bronchodilators, mucolytic drug therapy and others. The NHS Integrated Care Pathway is effectively followed as multi-disciplinary team including dietician and social care providers for smoking cessation are involved in caring for Yasmin. The health promotion for Yasmin is effectively followed by the nurses through performance of actions by abiding with 6 C’s of nursing and NMC Code of Conduct.

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Recommendations

The recommendation to be followed in next clinical practice as per the idea developed from the current case is that I would provide oxygen therapy to COPD patients as immediate action who are facing intense breathlessness. Moreover, it is recommended to continuously monitor health of patients in hospital, evaluate their social condition and mental condition, perform person-centred care and include the multi-disciplinary team in future care. The two things learnt regarding long-term condition (LTC) patient is that anxiety and fatigue are caused due to the continuous suffering from health issue. The one change to be implemented in my upcoming care is monitoring the patient’s health is to be effectively recorded which was not done currently. The one change recommended to registered nurses in the clinical environment is that they are to act with compassion and empathy towards patients with LTC.

References

Ali, A.A., Maaliki, N., Sottlie, E. and Schey, R., 2021. Persistent chest pain in the vomiting patient secondary to an incidental spontaneous pneumomediastinum. BMJ Case Reports, 14(5).pp.34-56.

Baillie, L., 2017. An exploration of the 6Cs as a set of values for nursing practice. British Journal of Nursing, 26(10), pp.558-563.

Barchard, F., Sixsmith, J., Neill, S. and Meurier, C., 2017. 6Cs and ten commitments: nurses’ understanding and use of courage. Nursing Management, 23(10).pp.34-78.

Bellou, V., Belbasis, L., Konstantinidis, A.K., Tzoulaki, I. and Evangelou, E., 2019. Prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease: systematic review and critical appraisal. bmj, 367.pp.90-134.

Brewster, L.M., 2019. Underuse of hydralazine and isosorbide dinitrate for heart failure in patients of African ancestry: a cross‐European survey. ESC heart failure, 6(3), pp.487-498.

Briggs, A.D., Cobiac, L.J., Wolstenholme, J. and Scarborough, P., 2019. PRIMEtime CE: a multistate life table model for estimating the cost-effectiveness of interventions affecting diet and physical activity. BMC health services research, 19(1), pp.1-19.

David, B., Bafadhel, M., Koenderman, L. and De Soyza, A., 2021. Eosinophilic inflammation in COPD: from an inflammatory marker to a treatable trait. Thorax, 76(2), pp.188-195.

Dobler, C.C., Harb, N., Maguire, C.A., Armour, C.L., Coleman, C. and Murad, M.H., 2018. Treatment burden should be included in clinical practice guidelines. Bmj, 363.pp.78-90.

Echevarria, C., Steer, J., Wason, J. and Bourke, S., 2021. Oxygen therapy and inpatient mortality in COPD exacerbation. Emergency Medicine Journal, 38(3), pp.170-177.

Esmer, M., Keser, I., Erer, D. and Kupeli, B., 2019. Acute cardiovascular responses to the application of manual lymphatic drainage in different body regions. Lymphatic Research and Biology, 17(3), pp.362-367.

Extance, A., 2020. Covid-19 and long term conditions: what if you have cancer, diabetes, or chronic kidney disease?. Bmj, 368.pp.34-78.

Feneley, A., Clarke, A. and Goldsack, N., 2017. Patient with shortness of breath. BMJ, 358.pp.90-145.

Fischer, A., Johansson, I., Blomberg, A. and Sundström, B., 2019. Adherence to a Mediterranean-like Diet as a protective factor against COPD: a nested case-control study. COPD: Journal of Chronic Obstructive Pulmonary Disease, 16(3-4), pp.272-277.

Ford, J.A., Liu, X., Chu, S.H., Lu, B., Cho, M.H., Silverman, E.K., Costenbader, K.H., Camargo Jr, C.A. and Sparks, J.A., 2020. Asthma, chronic obstructive pulmonary disease, and subsequent risk for incident rheumatoid arthritis among women: a prospective cohort study. Arthritis & Rheumatology, 72(5), pp.704-713.

Fox, C., 2021. Pediatric Hypertension. Primary Care: Clinics in Office Practice, 48(3), pp.367-378.

Fuller, G., Keating, S., Goodacre, S., Herbert, E., Perkins, G., Rosser, A., Gunson, I., Miller, J., Ward, M., Bradburn, M. and Thokala, P., 2020. Is a definitive trial of prehospital continuous positive airway pressure versus standard oxygen therapy for acute respiratory failure indicated? The ACUTE pilot randomised controlled trial. BMJ open, 10(7), p.e035915.

Gonem, S., Cumella, A. and Richardson, M., 2019. Asthma admission rates and patterns of salbutamol and inhaled corticosteroid prescribing in England from 2013 to 2017. Thorax, 74(7), pp.705-706.

Hanlon, P., Nicholl, B.I., Jani, B.D., McQueenie, R., Lee, D., Gallacher, K.I. and Mair, F.S., 2018. Examining patterns of multimorbidity, polypharmacy and risk of adverse drug reactions in chronic obstructive pulmonary disease: a cross-sectional UK Biobank study. BMJ open, 8(1), p.e018404.

Hanlon, P., Nicholl, B.I., Jani, B.D., Lee, D., McQueenie, R. and Mair, F.S., 2018. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. The Lancet Public Health, 3(7), pp.e323-e332.

Hartmann-Boyce, J., Begh, R. and Aveyard, P., 2018. Electronic cigarettes for smoking cessation. Bmj, 360.pp.34-90.

Hopkinson, N.S., Molyneux, A., Pink, J. and Harrisingh, M.C., 2019. Chronic obstructive pulmonary disease: diagnosis and management: summary of updated NICE guidance. Bmj, 366.pp.99-123.

Juergens, L.J., Worth, H. and Juergens, U.R., 2020. New perspectives for mucolytic, anti-inflammatory and adjunctive therapy with 1, 8-cineole in COPD and asthma: review on the new therapeutic approach. Advances in therapy, 37(5), pp.1737-1753.

Kline, R., 2019. Leadership in the NHS. BMJ Leader, pp.leader-2019.

Leiten, E.O., Eagan, T.M.L., Martinsen, E.M.H., Nordeide, E., Husebø, G.R., Knudsen, K.S., Lehmann, S., Svanes, Ø., Bakke, P.S. and Nielsen, R., 2020. Complications and discomfort after research bronchoscopy in the MicroCOPD study. BMJ open respiratory research, 7(1), p.e000449.

Luckett, T., Roberts, M., Swami, V., Smith, T., Cho, J.G., Klimkeit, E. and Wheatley, J.R., 2021. Maintenance of non-pharmacological strategies 6 months after patients with chronic obstructive pulmonary disease (COPD) attend a breathlessness service: a qualitative study. BMJ open, 11(5), p.e050149.

Luckett, T., Roberts, M., Swami, V., Smith, T., Cho, J.G., Klimkeit, E. and Wheatley, J.R., 2021. Maintenance of non-pharmacological strategies 6 months after patients with chronic obstructive pulmonary disease (COPD) attend a breathlessness service: a qualitative study. BMJ open, 11(5), p.e050149.

Maddocks, L.E., 2018. What’s hot that the other lot got. Thorax, 73(10), pp.996-996.

Marzocchi, G., Vassallo, A. and Monteduro, F., 2021. Spontaneous pneumothorax as a delayed complication after recovery from COVID-19. BMJ Case Reports CP, 14(5), p.e243578.

Murray, R.L., Brain, K., Britton, J., Quinn-Scoggins, H.D., Lewis, S., McCutchan, G.M., Quaife, S.L., Wu, Q., Ashurst, A., Baldwin, D. and Crosbie, P.A., 2020. Yorkshire Enhanced Stop Smoking (YESS) study: a protocol for a randomised controlled trial to evaluate the effect of adding a personalised smoking cessation intervention to a lung cancer screening programme. BMJ open, 10(9), p.e037086.

Nakabayashi, J., Melo, G.R.I. and Toral, N., 2020. Transtheoretical model-based nutritional interventions in adolescents: a systematic review. BMC Public Health, 20(1), pp.1-14.

NHS 2021, Integrated Care, Available at: https://www.england.nhs.uk/integratedcare/ [Accessed on: 11 December 2021]

Nicholson, T.W., Talbot, N.P., Nickol, A., Chadwick, A.J. and Lawton, O., 2020. Respiratory failure and non-invasive respiratory support during the covid-19 pandemic: an update for re-deployed hospital doctors and primary care physicians. bmj, 369.pp.34-78.

O'Driscoll, B.R., Howard, L.S., Earis, J. and Mak, V., 2017. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ open respiratory research, 4(1), p.e000170.

Parkin, L., Williams, S., Barson, D., Sharples, K., Horsburgh, S., Jackson, R. and Dummer, J., 2021. Is the use of two versus one long-acting bronchodilator by patients with COPD associated with a higher risk of acute coronary syndrome in real-world clinical practice?. BMJ open respiratory research, 8(1), p.e000840.

Piccoli, G.B., Zakharova, E., Attini, R., Ibarra Hernandez, M., Orozco Guillien, A., Alrukhaimi, M., Liu, Z.H., Ashuntantang, G., Covella, B., Cabiddu, G. and Li, P.K.T., 2018. Pregnancy in chronic kidney disease: need for higher awareness. A pragmatic review focused on what could be improved in the different CKD stages and phases. Journal of clinical medicine, 7(11), p.415.

Prieur, G., Combret, Y., Medrinal, C., Arnol, N., Bonnevie, T., Gravier, F.E., Quieffin, J., Lamia, B., Reychler, G. and Borel, J.C., 2020. Energy conservation technique improves dyspnoea when patients with severe COPD climb stairs: a randomised crossover study. Thorax, 75(6), pp.510-512.

Ramos, M., Lamotte, M., Gerlier, L., Svangren, P., Miquel-Cases, A. and Haughney, J., 2019. Cost-effectiveness of physical activity in the management of COPD patients in the UK. International journal of chronic obstructive pulmonary disease, 14, p.227.

Schneider, L.P., Furlanetto, K.C., Rodrigues, A., Lopes, J.R., Hernandes, N.A. and Pitta, F., 2018. Sedentary behaviour and physical inactivity in patients with chronic obstructive pulmonary disease: two sides of the same coin?. COPD: Journal of Chronic Obstructive Pulmonary Disease, 15(5), pp.432-438.

Sicras-Mainar, A., Rodríguez, B.G., Traseira-Lugilde, S., Fernández-Sánchez, T. and Garrido, J.L.V., 2022. Treatment persistence and exacerbations in patients with asthma initiating treatment with inhaled corticosteroids and beta-adrenergic agonists: retrospective cohort study. BMJ open, 12(4), p.e053964.

Sonnex, K., Alleemudder, H. and Knaggs, R., 2020. Impact of smoking status on the efficacy of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review. BMJ open, 10(4), p.e037509.

Sun, Y., Milne, S., Jaw, J.E., Yang, C.X., Xu, F., Li, X., Obeidat, M.E. and Sin, D.D., 2019. BMI is associated with FEV1 decline in chronic obstructive pulmonary disease: a meta-analysis of clinical trials. Respiratory research, 20(1), pp.1-10.

Voorham, J., Roche, N., Benhaddi, H., van der Tol, M., Carter, V., van Boven, J.F., Bjermer, L., Miravitlles, M. and Price, D.B., 2018. Real-world effectiveness evaluation of budesonide/formoterol Spiromax for the management of asthma and chronic obstructive pulmonary disease in the UK. BMJ open, 8(10), p.e022051.

Wagley, P., Adhikari, S., Bhattarai, M.D., Gauli, B., Gurung, S., Patel, S. and Puri, N., 2022. Study of oxygen delivery methods use in the COVID-19 patients. Journal of Chitwan Medical College, 12(1), pp.91-97.

Wilkinson, A.J., Braggins, R., Steinbach, I. and Smith, J., 2019. Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England. BMJ open, 9(10), p.e028763.