Answer & Explanation:For this assignment please write a 2 pages literature review
on the articles uploaded to related to the information provided in highlight. Please
follow these rubric for literature review.

reviewed represents a comprehensive review of the research topic.


of the literature is a critical, analytical summary. 


of the literature illustrates a synthesis of the current knowledge of
research topic.


APA guidelines for writing style, spelling and grammar, and citation of


Include a introductions that tides the information provided
with the conceptual map in 2-3 paragraph. Then construct a conceptual map Use
Microsoft Word or Microsoft PowerPoint defined the concepts and included
relational statements in a separate attachment, based on the information
provided below.
Based on the articles of evidences collected for the
proposed study of management of exacerbation of COPD via Nonpharmacologic
treatments such as pneumococcal/ influenza vaccine/ or smoking cessation
counseling. Which theories have others cited? Please use Health promotion theories by
Bonnie Raingruber and the Grand theory as the common theme of self- management
to reduce acute COPD exacerbations. Are you seeing a common theme? Self-management along with
severity of disease is the common theme for success in prevention of
reoccurrences of exacerbations with the outcome of better quality of life and
decrease admission into hospital for acute exacerbations. Next construct
a conceptual map (see p. 133 in your textbook). Provided below. 
Use Microsoft Word or Microsoft PowerPoint and include this as an
attachment. Be sure you have defined the concepts and included relational
This is example of what the conceptual map should be and
Constructing a Conceptual Map
A conceptual map is a visual
representation of a research framework. With the concepts defined and the
relational statements diagrammed, you are ready to visually represent the
framework for your study. The framework may be limited to only the concepts
that you are studying or may be inclusive of other related concepts that are
not going to be studied or measured. When the framework includes concepts that
are not included in the specific
study being proposed, you must clearly identify the portion of the framework
being used.
From a practical standpoint,
first arrange the relational statements you have diagrammed from left to right
with outcomes located at the far right. Concepts that are elements of a more
abstract construct can be placed in a frame or box. Sets of closely
interrelated concepts can be linked by enclosing them in a frame or circle.
Second, using arrows, link the concepts in a way that is consistent with the
statement diagrams you previously developed. Every concept should be linked to
at least one other concept. Third, examine the framework diagram for
completeness by asking yourself the following questions:
  1Are all of
the concepts in the study also included on the map?
  2Are all
the concepts on the map defined?
  3Does the
map clearly portray the phenomenon?
  4Does the
map accurately reflect all the statements?
  5Is there a
statement for each of the links portrayed by the map?
  6Is the
sequence of links in the map accurate?
Developing a well-constructed
conceptual map requires repeated tries, but persistence pays off. You
Figure 7-13
Conceptual model of the effects of heart failure on quality of life whereby
symptoms depend on pathology and mediate the effects on quality of life.

(From Rector, T. S., Anand, I. S., &
Cohn, J. H. (2006). Relationships between clinical assessments and
patients’ perceptions of the effects of heart failure on their quality of life.
Journal of Cardiac Failure, 12(2), 88.
The picture uploaded is example of conceptual map.




Unformatted Attachment Preview
All rights reserved 2055-1010/15
Four patients with a history of acute exacerbations of COPD:
implementing the CHEST/Canadian Thoracic Society
guidelines for preventing exacerbations
Ioanna Tsiligianni1,2, Donna Goodridge3, Darcy Marciniuk4, Sally Hull5 and Jean Bourbeau6
The American College of Chest Physicians and Canadian Thoracic Society have jointly produced evidence-based guidelines for the
prevention of exacerbations in chronic obstructive pulmonary disease (COPD). This educational article gives four perspectives on
how these guidelines apply to the practical management of people with COPD. A current smoker with frequent exacerbations will
benefit from support to quit, and from optimisation of his inhaled treatment. For a man with very severe COPD and multiple
co-morbidities living in a remote community, tele-health care may enable provision of multidisciplinary care. A woman who is
admitted for the third time in a year needs a structured assessment of her care with a view to stepping up pharmacological and
non-pharmacological treatment as required. The overlap between asthma and COPD challenges both diagnostic and management
strategies for a lady smoker with a history of asthma since childhood. Common threads in all these cases are the importance
of advising on smoking cessation, offering (and encouraging people to attend) pulmonary rehabilitation, and the importance of
self-management, including an action plan supported by multidisciplinary teams.
npj Primary Care Respiratory Medicine (2015) 25, 15023; doi:10.1038/npjpcrm.2015.23; published online 7 May 2015
A 63-year-old self-employed plumber makes a same-day appointment for another ‘chest infection’. He caught an upper respiratory
tract infection from his grandchildren 10 days ago, and he now
has a productive cough with green sputum, and his breathlessness and fatigue has forced him to take time off work.
He has visited his general practitioner with similar symptoms
two or three times every year in the last decade. A diagnosis of
COPD was confirmed 6 years ago, and he was started on a shortacting β2-agonist. This helped with his day-to-day symptoms,
although recently the symptoms of breathlessness have been
interfering with his work and he has to pace himself to get
through the day. Recovering from exacerbations takes longer than
it used to—it is often 2 weeks before he is able to get back to
work—and he feels bad about letting down customers. He cannot
afford to retire, but is thinking about reducing his workload.
He last attended a COPD review 6 months ago when his FEV1
was 52% predicted. He was advised to stop smoking and given a
prescription for varenicline, but he relapsed after a few days and
did not return for the follow-up appointment. He attends each
year for his ‘flu vaccination’. His only other medication is an ACE
inhibitor for hypertension.
Managing the presenting problem. Is it a COPD exacerbation?
A COPD exacerbation is defined as ‘an acute event characterised
by a worsening of the patient’s respiratory symptoms that is
beyond normal day-to-day variation and leads to change in
medications’.1,2 The worsening symptoms are usually increased
dyspnoea, increased sputum volume and increased sputum
purulence.1,2 All these symptoms are present in our patient who
experiences an exacerbation triggered by a viral upper respiratory
tract infection—the most common cause of COPD exacerbations.
Apart from the management of the acute exacerbation that could
include antibiotics, oral steroids and increased use of short-acting
bronchodilators, special attention should be given to his on-going
treatment to prevent future exacerbations.2 Short-term use of
systemic corticosteroids and a course of antibiotics can shorten
recovery time, improve lung function (forced expiratory volume in
one second (FEV1)) and arterial hypoxaemia and reduce the risk of
early relapse, treatment failure and length of hospital stay.1,2
Short-acting inhaled β2-agonists with or without short-acting antimuscarinics are usually the preferred bronchodilators for the
treatment of an acute exacerbation.1
Reviewing his routine treatment
One of the concerns about this patient is that his COPD is
inadequately treated. The Global Initiative for Chronic Obstructive
Lung Disease (GOLD) suggests that COPD management be based
on a combined assessment of symptoms, GOLD classification of
airflow limitation, and exacerbation rate.1 The modified Medical
Research Council (mMRC) dyspnoea score3 or the COPD Assessment Tool (CAT)4 could be used to evaluate the symptoms/health
status. History suggests that his breathlessness has begun to
interfere with his lifestyle, but this has not been formally asssessed
since the diagnosis 6 years ago. Therefore, one would like to be
certain that these elements are taken into consideration in future
Agia Barbara Health Care Center, Heraklion, Crete, Greece; 2Department of Thoracic Medicine, Clinic of Social and Family Medicine, University of Crete, Heraklion, Crete, Greece;
Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada; 4Division of Respirology, Critical Care and Sleep Medicine, University of
Saskatchewan, Saskatoon, SK, Canada; 5Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK and 6Respiratory Epidemiology
and Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montréal, QC, Canada.
Correspondence: J Bourbeau ([email protected])
Received 22 February 2015; accepted 24 February 2015
© 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited
Patients with history of acute exacerbations of COPD
I Tsiligianni et al
their relative effectiveness and the order in which they should be
prescribed. The choice of prescription should be guided by the
risk/benefit for a given individual, and drug availability and/or cost
within the health care system.
category C
category D
High risk
few symptoms
High risk
many symptoms
or ≥ 1 admission
<10 CAT score GOLD 3–4 Exacerbations ≥2/year or ≥1 admission CAT score ≥10 mMRC ≥2 mMRC 0–1 Patient category A Patient category B Low risk few symptoms Low risk many symptoms GOLD Exacerbations CAT score 1–2 ≤1/year <10 mMRC 0–1 GOLD Exacerbations CAT score mMRC Non-pharmacological approach A comprehensive patient-centred approach based on the chronic care model could be of great value.2,8 This should include the following elements ● 1–2 ≤1/year ≥10 ≥2 Figure 1. The four categories of COPD based on assessment of symptoms and future risk of exacerbations (adapted by GruffyddJones,5 from the Global Strategy for Diagnosis, Management and Prevention of COPD).1 CAT, COPD Assessment Tool; COPD, chronic obstructive pulmonary disease; mMRC, modified Medical Research Council Dyspnoea Scale. management by involving other members of the health care team. The fact that he had two to three exacerbations per year puts the patient into GOLD category C–D (see Figure 1) despite the moderate airflow limitation.1,5 Our patient is only being treated with short-acting bronchodilators; however, this is only appropriate for patients who belong to category A. Treatment options for patients in category C or D should include long-acting muscarinic antagonists (LAMAs) or long-acting β2-agonists (LABAs), which will not only improve his symptoms but also help prevent future exacerbations.2 Used in combination with LABA or LAMA, inhaled corticosteroids also contribute to preventing exacerbations.2 Prevention of future exacerbations Exacerbations should be prevented as they have a negative impact on the quality of life; they adversely affect symptoms and lung function, increase economic cost, increase mortality and accelerate lung function decline.1,2 Figure 2 summarises the recommendations and suggestions of the joint American College of Chest Physicians and Canadian Thoracic Society (CHEST/CTS) Guidelines for the prevention of exacerbations in COPD.2 The grades of recommendation from the CHEST/CTS guidelines are explained in Table 1. ● ● ● Vaccinations: the 23-valent pneumococcal vaccine and annual influenza vaccine are suggested as part of the overall medical management in patients with COPD.2 Although there is no clear COPD-specific evidence for the pneumococcal vaccine and the evidence is modest for influenza, the CHEST/CTS Guidelines concur with advice of the World Health Organization (WHO)9 and national advisory bodies,10–12 and supports their use in COPD patients who are at risk for serious infections.2 Smoking cessation (including counselling and treatment) has low evidence for preventing exacerbations (Grade 2C).2 However, the benefits from smoking cessation are outstanding as it improves COPD prognosis, slows lung function decline and improves the quality of life and symptoms.1,2,13,14 Our patient has struggled to quit in the past; assessing current readiness to quit, and encouraging and supporting a future attempt is a priority in his care. Pulmonary rehabilitation (based on exercise training, education and behaviour change) in people with moderate-to-very-severe COPD, provided within 4 weeks of an exacerbation, can prevent acute exacerbations (Grade 1C).2 Pulmonary rehabilitation is also an effective strategy to improve symptoms, the quality of life and exercise tolerance,15,16 and our patient should be encouraged to attend a course. Self-management education with a written action plan and supported by case management providing regular direct access to a health care specialist reduces hospitalisations and prevents severe acute exacerbations (Grade 2C).2 Some patients with good professional support can have an emergency course of steroids and antibiotics to start at the onset of an exacerbation in accordance with their plan. Finally, close follow-up is needed for our patient as he was inadequately treated, relapsed from smoking cessation after a few days despite varenicline, and missed his follow-up appointment. A more alert health care team may have been able to identify these issues, avoid his relapse and take a timely approach to introducing additional measures to prevent his recurrent acute exacerbations. Pharmacological approach In patients with moderate-to-severe COPD, the use of LABA or LAMA compared with placebo or short-acting bronchodilators is recommended to prevent acute exacerbations (Grades 1B and 1A, respectively).2,6,7 LAMAs are associated with a lower rate of exacerbations compared with LABAs (Grade 1C).2,6 The inhaler technique needs to be checked and a suitable device selected. If our patient does not respond to optimizing inhaled medication and continues to have two to three exacerbations per year, there are additional options that offer pulmonary rehabilitation and other forms of pharmacological therapy, such as a macrolide, theophylline, phosphodieseterase (PDE4) inhibitor or N-acetylocysteine/carbocysteine,2 although there is no information about CASE STUDY 2: A 74-YEAR-OLD MAN WITH VERY SEVERE COPD LIVING ALONE IN A REMOTE COMMUNITY A 74-year-old man has a routine telephone consultation with the respiratory team. He has very severe COPD (his FEV1 2 years ago was 24% of predicted) and he copes with the help of his daughter who lives in the same remote community. He quit smoking the previous year after an admission to the hospital 50 miles away, which he found very stressful. He and his family managed another four exacerbations at home with courses of steroids and antibiotics, which he commenced in accordance with a selfmanagement plan provided by the respiratory team. His usual therapy consists of regular long-acting β2-agonist/ inhaled steroid combination and a long-acting anti-muscarinic. He has a number of other health problems, including coronary heart disease and osteoarthritis and, in recent times, his daughter npj Primary Care Respiratory Medicine (2015) 15023 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Patients with history of acute exacerbations of COPD I Tsiligianni et al 3 Patient with COPD (greater than 40 years of age, previous or current smoker, post bronchodilator FEV1/FVC <0.70) At risk for acute exacerbation of COPD (AECOPD) e.g., acute event that requires antibiotic and/or systemic corticosteroids (moderate: at home, doctor’s office or ER; severe: in hospital) PICO 1: Non-pharmacological therapies Recommended -Annual influenza vaccine -Pulmonary rehabilitation (AECOPD ≤4 wks) -SM education and case management with monthly follow-up Suggested Not suggested -Pneumococcal -Pulmonary rehabilitation vaccine (AECOPD >4 wks)
-Education or
case management
-SM education
and action plan
-SM education
and case
with action plan
but without case
PICO 2: Pharmacological inhaled therapies
PICO 3: Pharmacological oral therapies
-LABA vs. placebo
-LAMA vs. placebo,
vs. placebo
-ICS (with LABA) vs.
placebo, LABA or
ICS alone
-SAMA + SABA vs.
-SAMA + LABA vs.
-Long-term macrolides
corticosteroids to
prevent AECOPD in
the 30 days after
initial event
-PDE4 inhibitors
Not recommended
corticosteroids in the
first 6 months
following the initial
Figure 2. Decision tree for prevention of acute exacerbations of COPD (reproduced with permission from the CHEST/CTS Guidelines for the
prevention of exacerbations in COPD).2 This decision tree for prevention of acute exacerbations of COPD is arranged according to three key
clinical questions using the PICO format: non-pharmacologic therapies, inhaled therapies and oral therapies. The wording used is
‘Recommended or Not recommended’ when the evidence was strong (Level 1) or ‘Suggested or Not suggested’ when the evidence was weak
(Level 2). CHEST/CTS, American College of Chest Physicians and Canadian Thoracic Society; COPD, chronic obstructive pulmonary disease;
FEV1, forced expiratory volume in one second; FVC, forced vital capacity; LABA, long-acting β-agonist; LAMA, long-acting muscarinic
antagonist; ICS, inhaled corticosteroids; SAMA, short-acting muscarinic antagonist; SABA, short-acting β-agonist; SM, self-management.
Table 1.
Summary of the grading system used in the CHEST/CTS guidelines for preventing exacerbations of COPD
Strength of recommendation
Strength of evidence
1—Strong recommendation A—High quality
C—Low quality
2—Weak recommendation A—High quality
C—Low quality
Balance of benefits versus risk
Implication for clinicians
Benefits clearly outweigh risks and Strong recommendation, applies to most patients in most
burdens (or vice versa)
May change if higher quality evidence becomes available
Benefits closely balanced with
risks and burden
Weak recommendation, best action may differ depending
on circumstances
Other alternatives may be equally reasonable
Abbreviations: CHEST/CTS, American College of Chest Physicians and Canadian Thoracic Society; COPD, chronic obstructive pulmonary disease.
Adapted from Guyatt et al.49
has become concerned that he is becoming forgetful. He manages
at home by himself, steadfastly refusing social help and adamant
that he does not want to move from the home he has lived in for
55 years.
This is a common clinical scenario, and a number of
important issues require attention, with a view to optimising the
management of this 74-year-old man suffering from COPD. He has
very severe obstruction, is experiencing frequent acute flare-ups,
is dependent and isolated and has a number of co-morbidities. To
work towards preventing future exacerbations in this patient, a
comprehensive plan addressing key medical and self-care issues
needs to be developed that accounts for his particular context.
Optimising medical management
According to the CHEST/CTS Guidelines for prevention of acute
exacerbations of COPD,2 this patient should receive an annual
influenza vaccination and may benefit from a 23-valent pneumococcal vaccine (Grades 1B and 2C, respectively). Influenza infection is
associated with greater risk of mortality in COPD, as well as
increased risk of hospitalisation and disease progression.1 A
diagnosis of COPD also increases the risk for pneumococcal disease
and related complications, with hospitalisation rates for patients
with COPD being higher than that in the general population.10,17
Although existing evidence does not support the use of this vaccine
© 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited
specifically to prevent exacerbations of COPD,1 administration of the
23-valent pneumococcal vaccine is recommended as a component
of overall medical management.9–12
Long-term oxygen therapy has been demonstrated to improve
survival in people with chronic hypoxaemia;18 it would be helpful
to obtain oxygen saturation levels and consider whether
long-term oxygen therapy would be of benefit to this patient.
Even though this patient is on effective medications, further
optimisation of pharmacologic therapy should be undertaken,
including reviewing administration technique for the different
inhaler devices.19 Maintenance PDE4 inhibitors, such as roflumilast
or theophyllines, long-term macrolides (i.e., azithromycin) or oral
N-acetylcysteine are potential considerations. Each of these
therapeutic options has demonstrated efficacy in preventing
future acute exacerbations, although they should be used with
caution in this frail elderly man.2 This patient would benefit from a
review of co-morbidities, including a chest X-ray, electrocardiogram, memory assessment and blood tests including
haemoglobin, glucose, thyroid and renal function assessments.
Pulmonary rehabilitation, supported self-management and
tele-health care
Pulmonary rehabilitation for patients who have recently experienced an exacerbation of COPD (initiated o4 weeks following the
npj Primary Care Respiratory Medicine (2015) 15023
Patients with history of acute exacerbations of COPD
I Tsiligianni et al
exacerbation) has been demonstrated to prevent subsequent
exacerbations (Grade 1C).2 Existing evidence suggests that
pulmonary rehabilitation does not reduce future exacerbations
when the index exacerbation has occurred more than 4 weeks
earlier;2 however, its usefulness is evident in other important
patient-centred outcomes such as improved activity, walking
distance and quality of life, as well as by reduced shortness of
breath. It would be appropriate to discuss this and enable our
patient to enrol in pulmonary rehabilitation.
The patient’s access to pulmonary rehabilitation in his remote
location, however, is likely to be limited. Several reports have
noted that only one to two percent of people with COPD are able
to access pulmonary rehabilitation programmes within Canada,20
the United States21 and the United Kingdom.22 Alternatives to
hospital-based pulmonary rehabilitation programmes, such as
home-based programmes or programmes offered via tele-health,
may be options for this patient.23 Home-based pulmonary
rehabilitation programmes have been found to improve exercise
tolerance, symptom burden and quality of life.24–27 Outcomes of a
pulmonary rehabilitation programme offered via tele-health have
also been found to be comparable to those of a hospital-based
programme,28 and may be worth exploring.
Written self-management (action) plans, together with education and case management, are suggested in the CHEST/CTS
guidelines as …
Purchase answer to see full

Order your essay today and save 10% with the discount code ESSAYHELP