الفهرس 
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Abstract
In Egypt, smoking is a common habit prevalent in both urban and rural areas. Cigarette smoking has extensive effects on respiratory function and is clearly implicated in the etiology of a number of respiratory diseases; particularly chronic Obstructive Pulmonary Disease (COPD) which is a preventable and a treatable disease characterized by progressive airflow limitation and represent one of the most prevalent human health disorders in the world. The prevalence of COPD in the general population is estimated to be around 1% of the adult population, but rises sharply among those 40 years and older. Despite significant public health efforts aimed to better understand and prevent the burden of this disease, the World Health Organization (WHO) has predicted that COPD will become the third most common cause of death in the world by 2020.
chronic obstructive pulmonary disease is a complex condition that presents with various symptoms, imposes physiologic, psychological and functional limitation on patients and is commonly associated with comorbidities. Smoking worsens the functional and physiologic impairments seen in patients with COPD. So, Smoking cessation is a vital intervention in COPD which will preserve lung function and improve survival. It is recommended for all smokers patients with COPD. But there are few data concerning changes in pulmonary functional parameters as pulmonary function test and oxygen saturation and in clinical parameters as activities of daily living, functional exercise capacity, anxiety level and respiratory symptoms in smokers with chronic obstructive pulmonary disease (COPD) weeks to months after quitting smoking. So, the researcher conducted this present study.
The aim of study
The aim of this study was to compare between pulmonary functional and clinical parameters among smokers versus ex-smokers chronic obstructive pulmonary disease patients.
Materials and method
Materials
Study design
A descriptive comparative research design was utilized to conduct this study.
Setting
This study was carried out at the Outpatient and Inpatient Chest Departments of the Alexandria Main University Hospital.
Subjects
Subjects of this study were consisted of a convenience sample of 60 male and female adult patients from 40-60 years old currently diagnosed with chronic obstructive pulmonary disease. Sample was assigned randomly into two equal groups according to criteria of smokers and ex-smokers each consist of 30 patients.
Tools of the study
Tool (I) Pulmonary function assessment tool.
This tool assessed pulmonary functions for COPD patients. It was composed of three parts:
Part1: Biosocio-demographic, clinical data and anthropometric measurements:
It was used to elicit general characteristics of the patients including: age, sex and educational level, occupation, medical history, previous hospitalization, length of stay, previous exacerbations treated at home, condition of smoking, number of cigarettes smoked / day, number of years smoked and pack year index (smoking index), weight, height, BMI.
Part 2: Pulmonary Function Test (PFT):
It was used to evaluate and compare the obstructive ventilatory defect among COPD patients who were smokers and ex-smokers through three parameters: FEV1, FVC and FEV1% to diagnose and assess the severity or staging of COPD.
Part 3: Oxygen Saturation (SPO2) assessment:
It was used to measure and compare the percentage of hemoglobin bound oxygen compared to total capacity of hemoglobin among COPD patients who are smokers and ex-smokers by using portable pulse oximeter.
Tool (II) Clinical parameters assessment tool. It includes:
Part 1: Activities of Daily Living (ADL) assessment: it assessed patient’s level of independency in activities of daily living.
Part 2: Functional Exercise Capacity assessment: it was done using 6 Minutes Walking Distance (6MWD) Or 6 Minutes’ Walk Test (6MWT).
Part 3: Anxiety level assessment: it was done using State-Trait Anxiety Inventory (STAI) to assess and compare anxiety level between smokers versus ex-smokers COPD patients.
Part 4: Respiratory symptoms assessment: it included assessment and comparison of respiratory symptoms as cough, sputum production, shortness of breath and wheezing among smokers versus ex-smokers COPD patients.
Assessment of breathlessness severity (dyspnea) by modified Medical Research Council (mMRC) scale: it consisted of 5 grades of dyspnea.
Method
- An official letter was issued from the Faculty of Nursing, Alexandria University to the director of the Alexandria Main University Hospital and head of the Outpatient and Inpatient Chest Departments to obtain their permission to collect necessary data after explanation of the aim of the study.
- Tool I was developed by the researcher based on recent review of relevant literatures. Tool II was adapted by the researcher and necessary modifications were done. Part 1 and part 3 were translated into the Arabic language by the researcher.
- The tools were tested for content validity by 5 experts in the field of Medical Surgical Nursing and Chest diseases specialists in Alexandria University and necessary modifications in wording, statement and sequencing were done accordingly.
The reliability of the tools was tested using cronbach’s alpha test. The correlation coefficient was (α = 0.905)
- A pilot study was conducted on 6 patients out of the sample who diagnosed with COPD and fulfilled the inclusion criteria before starting the data collection to test clarity, feasibility, validity, reliability and applicability of the tools and determine obstacles that may be encountered during the period of data collection. The necessary modifications were done accordingly and final tool was reconstructed.
- After securing the administrative approval, the data collection was started which covered a period of 6 months (from September 2018 to February 2019).
- Patients were assigned randomly into two equal groups according to criteria of smokers and ex-smokers each consist of 30 patients.
- Every patient in the two groups was interviewed individually once for 30-45 minutes at his inpatient room by the researcher to collect the needed data.
- Biosocio- demographic, clinical data was collected and the anthropometric parameters then measured using tool I part 1.
- Clinical parameters of every COPD patient in the two groups were assessed by the researcher as follows:
• Level of anxiety using tool II part 3.
• Activity of daily living using tool II part 1.
• Respiratory symptoms including grade of dyspnea, using tool II part 4.
• Functional exercise capacity by doing 6 Minutes’ Walk Test (6MWT).
- Pulmonary functional parameters of every COPD patient in the two groups were assessed by the researcher as follows:
• Pulmonary function test was done by the researcher using portable spirometry.
• Oxygen saturation was measured by the researcher using portable pulse oximeter.
The main results of the study showed that:
- In relation to biosociodemographic data, the results revealed that, 66,7% were in the age group between (50-60 years) in the both smoker and ex-smoker patients. All patients 100% were males in the both groups. Concerning residence, (70% & 56.7%) respectively were from rural areas in smoker and ex-smoker groups. As for level of education, 50% of the patients in smoker group were illiterate, while in ex-smoker group, 40% of them had secondary education. Concerning occupation, 66.7% were manual workers in smoker group, while in ex-smoker group, 50% of the patients were occupying a manual work and another half 50% were occupying a clerical work. Regarding marital status, (73.3%, 83.3%) respectively in smoker and ex-smoker groups were married.
- Regarding clinical data, 83.3% in smoker group had a frequency of previous hospitalization during the last 6 months as compared to 56.7% of the ex-smoker group. (66.7%, 76.7%) respectively of smoker and ex-smoker group had previous exacerbations treated at home during the last 6 months. 80.0% of smoker group had (7 – <14 days) length of stay at hospital as compared to 80.0% of ex-smoker group stay (<7 days) at hospital.
- In relation to Body Mass Index (BMI), 56.7% of ex-smoker group were overweight as compared to 30.0% of smoker group.
- According to smoking history, all patients smokers and ex-smokers had a history of cigarette smoking, hubble bubble or both of them with pack year index=30. In relation to intention to stop smoking, all patients in smoker group intended to stop smoking. Concerning presence of smokers in patients home or work (passive smoker), 53.3% of smoker group had passive smokers in their home or work as compared to 80.0% in ex-smoker group. In relation to reasons of smoking cessation in ex-smoker group, 63.3% in stopped smoking due to health problems, 26.7% had stopped smoking for economic reasons and 10.0% stopped for social reasons.
- As for pulmonary function assessment, there were statistical significant differences among smoker and ex-smoker group regarding FVC and oxygen saturation and there was no statistical significant difference regarding FEV1 and FEV1/FVC ratio.
- In relation to clinical parameters, there were statistical significant differences among smoker and ex-smoker group regarding Activities of daily living (ADL), functional exercise capacity that were assessed by (6MWT), respiratory symptoms (cough, sputum production, wheezing and grade of dyspnea that was assessed by mMRC) and there was no statistical significant difference regarding anxiety level.
- In ex-smoker group, spirometry variables (FEV1, FVC and FEV1% (FEV1/FVC ratio)) had a positive significant correlation with oxygen saturation (SPO2), Activities of daily living (ADL) and functional exercise capacity by 6 Minutes Walking Distance (6MWD) and had a negative significant correlation with respiratory symptoms, breathlessness severity (dyspnea) by mMRC and Anxiety level.
- In smoker group, spirometry variables (FEV1 and FVC) had a positive significant correlation with oxygen saturation (SPO2), Activities of daily living (ADL) and functional exercise capacity by 6 Minutes Walking Distance (6MWD) and had a negative significant correlation with respiratory symptoms, breathlessness severity (dyspnea) by mMRC and Anxiety level. While FEV1% (FEV1 /FVC ratio) had a positive correlation with Respiratory symptoms, Breathlessness severity (dyspnea) by MMRC and Activities of daily living (ADL) and had a negative correlation with Oxygen saturation (SPO2), Functional exercise capacity by 6 Minutes Walking Distance (6MWD) and Anxiety level.
from the findings of the present study, it can be concluded that:
Smoking cessation prevents further deterioration of lung function and further alteration in physical and psychosocial well-being for COPD patients as follows:
• As for pulmonary function assessment, there were statistical significant differences among smoker and ex-smoker group regarding FVC and oxygen saturation and there was no statistical significant difference regarding FEV1 and FEV1/FVC ratio and this is possible due to smokers and ex-smokers COPD patients already had a mild-to-severe degree of disease and COPD is a progressive and irreversible disease.
• In relation to clinical parameters, there were statistical significant differences among smoker and ex-smoker group regarding Activities of daily living (ADL), functional exercise capacity that were assessed by (6MWT), respiratory symptoms (cough, sputum production, wheezing and grade of dyspnea that was assessed by mMRC). Anxiety level is declined in ex-smoker COPD patients as compared to smoker COPD patients but this result wasn’t statistically significant may be due to the majority 80% of ex-smokers had passive smokers in their home or work or this is possible due to anxiety is a withdrawal symptom after quitting smoking.
The main recommendations are:
Recommendations for patients:
- Developing a structured educational program for behavioral change using films, video tapes for smoker COPD patients and educational program about how to use portable spirometer for all COPD patients.
- Community programs for patients should be developed to increase awareness about smoking hazardous and prevention of further complications of the COPD disease especially in rural areas.
Recommendations for nurses:
- In – service training to all nurses and health care providers in hospital and outpatients clinics to update their knowledge and increase their ability to care for patients with COPD and help smoker COPD to quit smoking.
- In-service education program should be instituted for nurses about patients’ rehabilitation and development of Arabic colored educational booklet concerning types and hazardous of smoking.
Recommendations for future researches:
- Study the similarities and differences between smokers and ex-smokers severe and very severe COPD patients.
- Study the psychological impact of smoking cessation of COPD patients.
- Smoking cessation measures for smokers COPD patients.