Bakgrund: Kronisk obstruktiv lungsjukdom är en folkhälsosjukdom som drabbar miljontals människor och är det tredje vanligaste dödsorsaken i världen. För att kunna bemöta patienterna som drabbas av sjukdom krävs stort ansvar av sjukvården och främst sjuksköterskor som har en betydande roll av att främja hälsa och minska symtomlidande. Patienter behöver kontinuerlig uppföljning och utbildning kring sjukdomen för att kunna få en förståelse av innebörden samt utveckla egenvårdsåtgärder. Syfte: Syftet var att belysa individens upplevelser av att leva med kronisk obstruktiv lungsjukdom. Metod: Litteraturöversikt som utgick från 13 kvalitativa originalartiklar. Resultat: I resultatet presenterades patientupplevelsen med hjälp av övergripande teman som: “fysiska utmaningar”, “psykologiska utmaningar hos patienter med KOL", “Självkänsla och Stigma”, “Acceptans och Hanteringsstrategier” samt “Förlust och begränsningar”.   Slutsats: Litteraturöversikten om kroniskt obstruktiv lungsjukdom (KOL) visar komplexa fysiska och psykologiska utmaningar. Fysiska hinder som trötthet och andnöd påverkar vardagslivet, medan psykologiska utmaningar som självkänsla och stigma kan leda till depression och social isolering. Vikten av socialt och psykologiskt stöd framhävs för att komplettera medicinsk vård och underlätta hanteringen av KOL:s påverkan på livskvaliteten. / Background: Chronic obstructive pulmonary disease is a public health ailment affecting millions of people and is the third leading cause of death worldwide. To effectively address patients affected by the disease, a significant responsibility falls on healthcare, particularly on nurses who play a crucial role in promoting health and alleviating symptoms. Patients require continuous monitoring and education about the disease to gain an understanding of its implications and develop self-care measures. Aim: The aim was to illustrate individuals' experiences of living with chronic obstructive pulmonary disease. Method: Literature review based on 13 qualitative original articles. Results: In the results, patient experiences were presented using overarching themes such as: “physical challenges”, “psychological challenges in COPD patients”, “Self-esteem and Stigma”, “Acceptance and Coping Strategies” and “Loss and Limitation”. Conclusions: The literature review on chronic obstructive pulmonary disease (COPD) highlights complex physical and psychological challenges. Physical barriers, such as fatigue and breathlessness, impact daily activities, while psychological challenges, including self-esteem and stigma, may lead to depression and social isolation. The importance of social and psychological support is emphasized to complement medical care and facilitate coping with the impact of COPD on quality of life.

Background: Advancements in machine learning (ML) techniques and voice technology offer the potential to harness voice as a new tool for developing decision-support tools in healthcare for the benefit of both healthcare providers and patients. Motivated by technological breakthroughs and the increasing integration of Artificial Intelligence (AI) and Machine Learning (ML) in healthcare, numerous studies aim to investigate the diagnostic potential of ML algorithms in the context of voice-affecting disorders. This thesis focuses on respiratory diseases such as Chronic Obstructive Pulmonary Disease (COPD) and explores the potential of a decision support tool that utilizes voice and ML. This exploration exemplifies the intricate relationship between voice and overall health through the lens of applied health technology (AHT. This interdisciplinary nature of research recognizes the need for accurate and efficient diagnostic tools. Objective: The objectives of this licentiate thesis are twofold. Firstly, a Systematic Literature Review (SLR) thoroughly investigates the current state of ML algorithms in detecting voice-affecting disorders, pinpointing existing gaps and suggesting directions for future research. Secondly, the study focuses on respiratory health, specifically COPD, employing ML techniques with a distinct emphasis on the vowel "A". The aim is to explore hidden information that could potentially be utilized for the binary classification of COPD vs no COPD. The creation of a new Swedish COPD voice classification dataset is anticipated to enhance the experimental and exploratory dimensions of the research. Methods: In order to have a holistic view of a research field, one of the commonly utilized methods is to scan and analyze the literature. Therefore, Paper I followed the methodology of an SLR where existing journal publications were scanned and synthesized to create a holistic view in the realm of ML techniques employed to experiment on voice-affecting disorders. Based on the results from the SLR, Paper II focused on the data collection and experimentation for the binary classification of COPD, which was one of the gaps identified in the first study. Three distinct ML algorithms were investigated on the collected datasets through voice features, which consisted of recordings collected through a mobile application from participants 18 years old and above, and the most utilized performance measures were computed for the best outcome.  Results: The summary of findings from Paper I reveals the dominance of Support Vector Machine (SVM) classifiers in voice disorder research, with Parkinson's Disease and Alzheimer's Disease as the most studied disorders. Gaps in research include underrepresented disorders, limited datasets in terms of number of participants, and a lack of interest in longitudinal studies. Paper II demonstrates promising results in COPD classification using ML and a newly developed dataset, offering insights into potential decision support tools for COPD diagnosis. Conclusion: The studies covered in this dissertation provide a comprehensive literature summary of ML techniques used to support decision-making on voice-affecting disorders for clinical outcomes. The findings contribute to understanding the diagnostic potential of using ML on vocal features and highlight avenues for future research and technology development. Nonetheless, the experiment reveals the potential of employing voice as a digital biomarker for COPD diagnosis using ML.

Introduction: There is a growing interest in how technology can be used in order to provide efficient healthcare. Aim: The aim is to explore perceptions on the use of home telemonitoring in patients with COPD.                                                                                                                             Method: Semi-structured individual interviews were carried out with eight women and five men who were part of a larger project aiming to develop and evaluate a telemonitoring system. Participants were interviewed after having used the system for two to four months. Interview transcripts were analysed with qualitative content analysis. Results: The analysis resulted in the theme a transition towards increased control and security and the categories: facing enablers or barriers, increasing control over the disease, providing easy access to care and affecting technical confidence or concern. Participants expressed initial feelings of insecurity, both in practical aspects using the telemonitoring system as well as regarding their disease. The telemonitoring system could reinforce and confirm the participants´ feelings of their current state of health, and the practical management of the telemonitoring system became easier with time.     Conclusion: Telemonitoring can be a valuable complement to healthcare with the potential to contribute to equity in care. However, in order to improve further development and implementation of telemonitoring, several actions are needed such as improved patient education and the use of co-creation. Additional research is needed particularly in the design of user-friendly systems as well as tools to predict which patients are most likely to find the equipment useful as it may result in reduced costs and increased empowerment. / Introduktion: Intresset för hur teknologi kan användas för att erbjuda effektiv sjukvård ökar. Syfte: Syftet är att utforska KOL-patienters upplevelse av att använda ett webbaserat rapporteringssystem i hemmet. Metod: Semi-strukturerade individuella intervjuer med åtta kvinnor och fem män som deltog i ett större projekt med syfte att utveckla och utvärdera ett webbaserat rapporteringssystem. De intervjuades efter att ha använt systemet två till fyra månader. Intervjuerna analyserades med kvalitativ innehållsanalys. Resultat: Analysen resulterade i temat en övergång till ökad kontroll och trygghet samt kategorierna: möta möjligheter eller hinder, ökad kontroll över sjukdomen, skapar lättillgänglig vård samt påverkar teknisk självkänsla eller oro. Deltagarna uttryckte till en början osäkerhetskänslor, både vad gäller praktiska aspekter i användandet av rapporteringssystemet samt kring själva sjukdomen. Det webbaserade rapporteringssystemet kunde förstärka och bekräfta deltagarnas egna känsla av mående och det praktiska hanterandet av rapporteringssytemet blev lättare med tiden. Konklusion: Webbaserade rapporteringssystem kan vara ett värdefullt komplement till sjukvården med potential att bidra till jämlik vård. I syfte att förbättra fortsatt utveckling och implementering bör förbättrad patientinformation samt vikten av att ta med användarna i utformningen beaktas. Mer forskning behövs för att optimera användarvänlighet samt att identifiera de patienter som har bäst nytta av systemet då det kan ge hälsoekonomiska vinster och inte minst öka patienters delaktighet.

No / The English End of Life Care Strategy promises that all patients with advanced, life limiting illness will have the opportunity to participate in Advance Care Planning (ACP). For patients with Chronic Obstructive Pulmonary Disease (COPD), the barriers to this being achieved in practice are under-explored. Five focus groups were held with a total of 39 health care professionals involved in the care of patients with COPD. Participants reported that discussions relating to ACP are very rarely initiated with patients with COPD and identified the following barriers: inadequate information provision about the likely course of COPD at diagnosis; lack of consensus regarding who should initiate ACP and in which setting; connotations of comparing COPD with cancer; ACP discussions conflicting with goals of chronic disease management; and a lack of understanding of the meaning of 'end of life' within the context of COPD. The findings from this study indicate that, for patients with COPD, significant service improvement is needed before the objective of the End of Life Care Strategy regarding patient participation in end of life decision-making is to be achieved. Whilst the findings support the Strategy's recommendations regarding an urgent for both professional education and increased public education about end of life issues, they also indicate that these alone will not be enough to effect the level of change required. Consideration also needs to be given to the integration of chronic disease management and end of life care and to developing definitions of end of life care that fit with concepts of 'continuous palliation'.

No / Prognosis in COPD is poor and many patients perceive shortcomings in the education they receive about aspects of their condition. This study explores the experiences of patients with COPD, particularly fears surrounding death and dying. Semi-structured interviews were conducted with 21 patients with moderate or severe COPD. Findings revealed that patient understanding of COPD was poor, most patients were unaware of the progressive nature of the condition, and few were aware they could die of COPD. Despite this, patients often expressed concerns that their condition might deteriorate. Patients had particular concerns regarding the manner of their death; the overriding fear was dying of breathlessness or suffocation. None of the patients' had discussed these fears with a health care professional. Improved patient education is needed in order to improve patients understanding of their condition and prognosis. Open communication regarding death, as advocated in a palliative care approach, is also appropriate to alleviate patients fears and to allow them to make decisions regarding the management of their care at the end of life.

No / We report patients, family members and health professionals' experiences of Chronic Obstructive Pulmonary Disease (COPD) in Barnsley, northern England. A widespread belief that having "bad lungs" is part of normal ageing shapes everyday experience in this former mining town. People with COPD, and their families, link its cause to the areas industrial past and are sceptical of a medical orthodoxy that attributes cause to smoking. They doubt doctors' objectivity. Encouraging uptake of care, promoting smoking cessation, and developing care planning would be enhanced by engaging with the significance of place in the social narrative of health evident in this town.

Made available in DSpace on 2016-06-02T20:18:12Z (GMT). No. of bitstreams: 1 2946.pdf: 2432239 bytes, checksum: 38088e144c053efcf31c8e90a089b74f (MD5) Previous issue date: 2010-04-07 / Universidade Federal de Sao Carlos / Patients with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) present significant exertional dyspnea. The peripheral muscle dysfunction appears to be the greatest impact on the inability to perform physical exercise. Additionally, there is respiratory muscle weakness caused by a limited supply of O2 and alteration of mechanical ventilation. In this context, in order to better understand the manifestations of these disorders and to establish management strategies, we have proposed the development of three studies. The first study was entitled Deep breathing heart rate variability is associated with respiratory muscle weakness in patients with chronic obstructive pulmonary disease . The purpose of the present investigation was to evaluate the influence of respiratory muscle strength on autonomic control of heart rate variability (HRV) in these patients. Ten COPD patients (69±9 years; forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) 59±12% and FEV1 41±11% predicted) and nine age-matched healthy male volunteers (64±5 years) participated in this study. The maximal inspiratory pressure was obtained in the sitting position. Then, electrocardiography signal was obtained in three conditions: 1) lying position for 15 min; 2) lying position during the respiratory sinusal arrhythmia maneuver (RSA-M) for 4 min; and 3) sitting position for 15 min. Data was analyzed by the time (RMSSD and SDNN indexes) and the frequency domains, in total power, low frequency (LF), high frequency (HF) absolute (ab) and normalized (nu) units and LF/HF ratio. Regarding the RSA-M indexes, the expiratory/inspiratory ratio (E/I) and the inspiratory/expiratory difference (&#916;IE) were calculated. The patients with COPD demonstrated significantly impaired cardiac autonomic modulation at rest and during RSA-M when compared with healthy subjects (ratio E/I: 1.1±0.06 vs. 1.2±0.1 e &#916;IE: 7.0±3.5 vs 12.7±4.2, respectively). Moreover, significant and positive correlations between maximal inspiratory pressure (MIP) and the inspiratory-expiratory difference (&#916;IE) (r = 0.60, p<0.01) were found. In conclusion, patients with COPD presented impaired sympathetic-vagal balance at rest and during RSA-M. In addition, cardiac autonomic control of heart rate was associated with inspiratory muscle weakness in chronic obstructive pulmonary disease. Based on this evidence, future research applications of respiratory muscle training may bring to light a potentially valuable target for rehabilitation. The second study was entitled to Deep breathing heart rate variability xviii is able to reflect the respiratory muscle weakness in chronic heart failure . The purpose of the present investigation was to evaluate the influence of respiratory muscle strength on autonomic control in these patients. Ten CHF (62 ± 7 years left ventricle eject fraction of 40 ± 5% and NYHA class I-III) and nine matched-age healthy volunteers (64±5 years) participated in this study. Heart rate variability (HRV) was obtained at rest and during RSA-M by electrocardiograph (as previously described). CHF patients demonstrated impaired cardiac autonomic modulation at rest and during RSA-M when compared with healthy subjects (p<0.05). Moreover, significant and positive correlations between MIP and IE-differences (r: 0.79), E/I ratio (r: 0.83), RMSSD (r: 0.77), SDNN (r: 0.77), LFab (r: 0.77), HFab (r: 0.70) were found during RSA-M. At rest, significant correlations were also found. Patients with CHF presented impaired sympathetic-vagal balance at rest. In addition, cardiac autonomic control of heart rate was associated with inspiratory muscle weakness in CHF. Based on this evidence, recommendations for future research applications of respiratory muscle training can bring to light a potentially valuable target for rehabilitation. Finally, the third study: "Behavior of heart rate on determination of anaerobic threshold in healthy men: comparison with cardiopulmonary exercise testing and near-infrared spectroscopy" aimed to identify the anaerobic threshold (AT) obtained from the V-slope method , visual method on oxihemoglobin (O2Hb) and deoxihemoglobin (HHb) and compare the method with heteroscedastic (HS) applied to VCO2, HR and HHb data. Secondly, to assess the degree of agreement between the methods for determination of AT. Fourteen healthy men were subjected to incremental cardiopulmonary test (CPT) in the electromagnetic cycle-ergometer until physical exhaustion. At the same time they obtained the following biological signals: (i) ventilatory and metabolic variables - a breath to breath - measured by the Cardio2 System (Medical Graphics Corporation, St. Paul, MO, USAI), (ii) spectroscopy, quasiinfrared rays - NIRS (NIRO 300 - Hamamatsu Photonics, Japan), and (iii) heart rate through cardiofrequencymeter (Polar S810i). We observed temporal equivalence and similar values of power (W), absolute O2 consumption (mL/min) and relative O2 consumption (mL/kg/min) and HR (bpm) on determination of AT by the methods performed. In addition, by the Bland-Altman plot, HR (bpm) confirmed the good agreement between the methods with biases between -1.3 and 3.5. In conclusion: (i) all methods were sensitive in identifying the AT1, including the HS applied to FC, and (ii) the methods showed a good correlation in the identification of AT1. Thus the xix results support the FC, a methodology that is simple and economically feasible, seems to be a valid parameter in determining the AT of the individuals in our study. Therefore it remains to be clarified if these results can be replicated in patients with chronic cardiopulmonary disorders, contributing in safe, individualized and adequate prescribing physical exercise in rehabilitation programs. / Pacientes com insuficiência cardíaca crônica (ICC) e doença pulmonar obstrutiva crônica (DPOC) apresentam significativa dispnéia exercional. A disfunção muscular periférica parece ser a causa de maior impacto na incapacidade de realização de exercício físico. Adicionalmente, pode coexistir a fraqueza muscular respiratória provocada pela limitada oferta de O2 e a alteração da mecânica ventilatória. Neste contexto, com intenção de compreender melhor as manifestações dessas disfunções e estabelecer estratégias de manejo, foi proposto o desenvolvimento de três estudos. O primeiro intitulado por Deep breathing heart rate variability is associated with respiratory muscle weakness in patients with chronic obstructive pulmonary disease teve como objetivo, avaliar a influência da fraqueza muscular inspiratória sobre a o controle autonômico da frequência cardíaca (FC) de homens com DPOC. Foram estudados 10 pacientes (69±9 anos; FEV1/FVC 59±12% and FEV1 41±11% do predito) e 9 homens saudáveis (64±5 anos). Na posição sentada, foi medida a pressão inspiratória máxima (PIMax) dos voluntários. Na sequência, em repouso, o sinal eletrocardiográfico foi obtido em três situações: 1) 15 min na posição supina; 2) quatro min durante a manobra de acentuação da arritmia sinusal respiratória (MASR) na posição supina; e 3) 15 min na posição sentada. Os dados foram analisados no domínio do tempo (índices RMSSD e SDNN) e da freqüência, pela densidade espectral total (DET), bandas de baixa (BF) e alta freqüências (AF) - absolutas (ab) e normalizadas (un), e a razão BF/AF. Durante M-ASR foram calculadas a razão expiração/inspiração (E/I) e a diferença inspiração/expiração (&#916;IE). Os pacientes com DPOC apresentaram valores significativamente menores da variabilidade da frequência cardíaca (VFC) quando comparados ao grupo controle em repouso e durante a M-ASR (razão E/I: 1,1±0,06 vs. 1,2±0,1 e &#916;IE: 7,0±3,5 vs 12,7±4,2, respectivamente). Adicionalmente, foi observado correlação positiva entre PIMax e &#916;IE (r = 0.60, p<0.01). Em conclusão: (i) pacientes com DPOC apresentam prejuízos da modulação autonômica da FC em repouso e durante a M-ASR; e (ii) a fraqueza muscular inspiratória parece influenciar no desbalanço simpato-vagal desses pacientes. Em similaridade, no segundo estudo, intitulado com Deep breathing heart rate variability is able to reflect the respiratory muscle weakness in chronic heart failure o objetivo foi avaliar a influência da PIMax no controle autonômico da FC de pacientes com ICC. Foram estudados 10 pacientes com ICC xv (62±7 anos Fração de Ejeção do ventrículo esquerdo de 40 ± 5% e classificação IIII da NYHA). Seguindo a metodologia descrita no estudo anterior, os resultados mostraram que os pacientes com ICC também apresentaram menores valores da VFC em repouso e durante a M-ASR e correlações positivas e significativas entre PIMax e diferença expiração-inspiração (r: 0,79), razão expiração/inspiração (r: 0,83), RMSSD (r: 0,77), SDNN (r: 0,77), BF (r: 0,77), AF (r: 0,70). Em conclusão: (i) pacientes com ICC apresentam prejuízos da modulação autonômica da FC em repouso e durante a M-ASR; e (ii) a fraqueza muscular inspiratória parece influenciar no desbalanço simpato-vagal desses pacientes. Por fim, o terceiro estudo: Comportamento da frequência cardíaca na determinação do limiar de anaerobiose em homens saudáveis: análise comparativa com o teste cardiopulmonar e a espectroscopia por raios quasi-infravermelhos objetivou identificar do limiar de anaerobiose (LA) obtido pelo método padrão-ouro, método visual pelo comportamento da oxihemoglobina (O2Hb) e deoxihemoglobina (HHb) e comparar com o método heteroscedástico (HS) aplicado aos dados de VCO2, HHb e da FC. Secundariamente, avaliar o grau de concordância entre os métodos de determinação do limiar de LA. Quatorze homens saudáveis foram submetidos ao teste cardiopulmonar (TCP) incremental em cicloergômetro de frenagem eletromagnética até a exaustão física. Concomitantemente foram obtidos os seguintes sinais biológicos: (i) variáveis ventilatórias e metabólicas respiração a respiração - medida pelo sistema CardiO2 System (Medical Graphics Corporation, St. Paul, MO, USAi); (ii) espectroscopia por raios quasi-infravermelhos - NIRS (NIRO 300 Hamamatsu Photonics, Japan); e (iii) frequência cardíaca por meio do cardiofreqüencímetro (Polar S810i). Foram observadas equivalências temporais e das variáveis potência (W), consumo de O2 absoluto (mL/min) e relativo (mL/kg/min) e FC (bpm) na determinação do LA pelos métodos empregados. Em adição, pela análise de Bland-Altman, a FC (bpm) confirmou a boa concordância entre os médotos com viéses entre -1,3 e 3,5. Em conclusão: (i) todos os métodos mostraram-se sensíveis na identificação do LA1, inclusive o HS aplicado a FC; e (ii) os médotos apresentaram boa correlação na identificação do LA1. Assim os resultados suportam que a FC, uma metodologia mais simples e economicamente viável, parece ser um parâmetro válido na determinação do LA dos indivíduos do nosso estudo. Agora, basta saber se estes resultados podem ser replicados em pacientes com disfunções cardiorrespiratórias crônicas, contribuíndo na prescrição xvi segura, individualizada e adequada de exercício físico em programas de reabilitação.

Limited data exists describing the long-term prognosis of patients with acute decompensated heart failure (ADHF) further stratified according to currently recommended ejection fraction (EF) findings. In addition, little is known about the magnitude of, and factors associated with, long-term prognosis for these patients. Based on previously validated and clinically relevant criteria, we defined HF-REF as patients with an EF value ≤40%, HF-PEF was defined as an EF value > 50%, and HF-BREF was defined as patients with an EF value during their index hospitalization between 41 and 49%. The hospital medical records of residents of the Worcester (MA) metropolitan area who were discharged after ADHF from all 11 medical centers in central Massachusetts during the 5 study years of 1995, 2000, 2002, 2004, and 2006 were reviewed. Follow-up was completed through 2011 for all patient cohorts. The average age of this population was 75 years, the majority was white, and 44% were men. Patients with HF-PEF experienced higher post discharge survival rates than patients with either HF-REF or HF-BREF at 1, 2, and 5-years after discharge. Advanced age and lower estimated glomerular filtration rate findings at the time of hospital admission were important predictors of 1-year death rates, irrespective of EF findings. Previously diagnosed chronic obstructive pulmonary disease, chronic kidney disease, and atrial fibrillation were associated with a poor prognosis in patients with PEF and REF whereas a history of diabetes was an important prognostic factor for patients with REF and BREF. In conclusion, although improvements in 1-year post-discharge survival were observed for patients in each of the 3 EF groups examined to varying degrees, the post- 7 discharge prognosis of all patients with ADHF remains guarded. In addition, we observed differences in several prognostic factors between patients with ADHF with varying EF findings, which have implications for more refined treatment and surveillance plans for these patients.

Abstrakt: Okontrollerade symptom och upprepade sjukhusinläggningar kännetecknar den sista tiden i livet hos en del patienter med mycket svår KOL. Trots att det finns en växande insikt att tidig integration av palliativ vård förbättrar patientens symtombehandling och livskvalitet, dör majoriteten av patienter med KOL utan tillgång till palliativ vård. Sjuksköterskor i hemsjukvården har en central roll när det gäller att identifiera och hantera patienternas palliativa vårdbehov. Syfte: Syftet med denna studie är att belysa hur sjuksköterskor i hemsjukvården upplever den palliativa vården av patienter med mycket svår KOL. Metod: Kvalitativ studie där 11 semistrukturerade intervjuer bearbetats med kvalitativ innehållsanalys. Resultat: Insamlat datamaterial resulterade i tre kategorier som påvisar förutsättningar för god palliativ vård i hemmet: 1) Personella och organisatoriska resurser i hemsjuk- och primärvården där stora brister i samarbetet med primärvården samt bristande resurserna för god vård i hemmet noteras. 2) Planering och kommunikation där bristande kommunikation med patienten och mellan olika vårdinsatser samt planering kring patientens vård poängteras. 3) Kunskap där ett behov av att utöka kunskapen om KOL och palliativ vård hos alla yrkeskategorier uppmärksammas. Konklusion: Patienter med mycket svår KOL får ofta en god palliativ vård i livets absoluta slutskede. Resultatet visar dock att patientens vård under de sista månaderna i livet ofta upplevs som oklar och diffus, vilket pekar på att palliativ vård behöver integreras tidigare i vården av patienter med mycket svår KOL. I kommunikations- och planeringsprocessen med patienten har sjuksköterskor en samordnande roll som behöver specificeras och utrustas med de erforderliga personella och organisatoriska resurserna, kunskaperna och befogenheterna. / Abstract: Uncontrolled symptoms and repeated hospitalizations characterize the last period of life in some patients with very severe COPD. Although there is a growing recognition that early integration of palliative care improves the treatment of patient's symptoms and quality of life, the majority of patients with COPD dies without access to palliative care. Nurses in home care have a central role in identifying and managing patients' palliative care needs. Aim: The purpose of this study is to examine how nurses in home care and in nursing homes experience palliative care of patients with severe COPD. Method: Qualitative study in which 11 semi-structured interviews processed using qualitative content analysis. Results: Collected data resulted in three categories that indicate conditions for good palliative care in the home: 1) Human and organizational resources in home- and primary care, where serious deficits within primary care and resources for good home care is noted. 2) Planning and communication, where the lack of communication with the patient and between different health care institutions as well as care planning is emphasized. 3) Knowledge, where a need to improve knowledge of COPD and palliative care for all care professions is recognized. Conclusion: The result shows that the patient's care during the last months of life is often perceived as vague and diffuse, suggesting that palliative care needs to be integrated earlier in the care of patients with very severe COPD. In the communication process and care planning with patients, nurses have a coordinating role that needs to be specified and equipped with the requisite human and organizational resources, skills and competences.

<p>Uvod: Iz rezultata brojnih randomiziranih kliničkih studija proizi&scaron;le su smernice u koijma se navodi da je upotreba neinvazivne ventilacije (NIV), uz farmakolo&scaron;ku terapiju, indikovana kod svih bolesnika sa te&scaron;kom egzacerbacijom hronične opstruktivne bolesti pluća (HOBP), i to sa najvi&scaron;im nivoom preporuke. Dokazano je da se upotrebom NIV-a smanjuje broj intubacija, uz smanjenje mortaliteta ali i skraćenje dužine bolničkog lečenja. S obzirom da je nekada ventilatorna potpora bila pružana isključivo u jedinicama intenzivne nege, a da je kapacitet ovakvih odeljenja gotovo stalno popunjen, postavlja se pitanje adekvatnog okruženja unutar bolnice gde se bezbedno i efikasno može primeniti neinvazivna ventilacija, ali gde se i na vreme mogu prepoznati rani znakovi njene neuspe&scaron;ne primene, nakon čega trebaobezbediti pravovremenu endotrahealnu intubaciju. Stoga su rađene brojne studije u cilju izdvajanja ranih prediktora ishoda neinvazivne ventilacije - kako u cilju ranog prepoznavanja neuspeha NIV-a i omogućavanja pravovremene intubacije, tako i u cilju stratifikacije pacijenata sa različitim stepenom rizika za neuspeh, uz obezbeđivanje adekvatnog nivoa nege i monitoringa za sve bolesnike. Ciljevi: Ciljevi istraživanja su da se utvrdi koji pokazatelji koreliraju sa neuspe&scaron;nim ishodom primene neinvazivne mehaničke ventilacije kod bolesnika sa te&scaron;kom egzacerbacijom hronične opstruktivne bolesti pluća, kako bi se kreirao prognostički model ishoda lečenja, te da se se na osnovu prognostičkog modela stratifikuju bolesnici prema stepenu rizika za neuspeh NIV-a i u skladu sa njim predloži adekvatan stepen monitoringa, odnosno kliničko okruženje za bezbedno i efikasno pružanje ventilatorne potpore. Metodologija: U Institutu za plućne bolesti Vojvodine u Sremskoj Kamenici sprovedeno je prospektivno opservaciono istraživanje u trajanju od 39 meseci, u koje je uključeno 250 konsekutivnih bolesnika hospitalizovanih zbog te&scaron;ke egzacerbacije HOBP-a sa respiratornom acidozom. NIV je primenjen u modu pritiskom podržane ventilacije ventilatorima marke Covidien tipa Airox Supportair, uz upotrebu oronazalne maske. Početni parametri su podrazumevali upotrebu ekspiratornog pozitivnog pritiska u disajnim putevima - EPAP-a od 5 cm H2O i inspiratornog pozitivnog pritiska u disajnim putevima IPAPa od 12 cm H20, koji su u potom titrirani ka ciljnim vrednostima IPAPa od 15-20 cmH2O, a u skladu sa kliničkim odgovorom. Za svakog bolesnika evidentirani su: pol, starost, ranija primena dugotrajne oksigenoterapije u kućnim uslovima, primena NIV-a tokom prethodnih hospitalizacija, komorbiditeti preko Charlson indeksa, vreme proteklo od početka hospitalizacije do započinjanja NIV-a, vrednosti pH, bikarbonata, PaCO2 i PaO2 u gasnim analizama arterijske krvi pre započinjanja NIV-a, inicijalna SpO2 i odnos PaO2/FiO2, zatim promena vrednosti pH, PaCO2 i PaO2 u gasnim analizama arterijske krvi sat vremena nakon početka primene NIV-a, inicijalni vitalni parametri - srčana frekvenca, respiratorna frekvenca, stanje svesti procenjeno Glazgov koma skalom (GCS), telesna temperatura, sistolni arterijski pritisak, diureza, a potom zbirni modifikovani ranoupozoravajući bodovni skor (MEWS-modified early warning score), prisustvo i opseg konsolidacija na radiogramu grudnog ko&scaron;a, saradnja bolesnika, te mesto primene NIV-a. Kao primarni ishod istraživanja definisan je neuspeh neinvazivne mehaničke ventilacije: intubacija ili smrtni ishod u toku hospitalizacije uzrokovan respiratornom insuficijencijom. Svaki potencijalni prediktor neuspeha je prvo evaluiran uz pomoć univarijantne analize, a potom su svi faktori rizika za koje je univarijantnom analizom utvrdjena statistička značajnost analizirani uz pomoć multivarijantne logističke regresije, u cilju utvrdjivanja adekvatnih statističkih modela. Rezultati: Od ukupno 250 bolesnika NIV je uspe&scaron;no primenjen kod 164 bolesnika (65.6%). Ukupno 139 (59.3%) bolesnika bilo je mu&scaron;kog pola, a prosečna starost svih ispitanika bila je 67 godina. Bolesnici sa neuspe&scaron;nim ishodom NIV-a imaju, prema univarijantnoj analizi: statistički značajno veće vrednosti Charlson indexa (p=0.002, OR 1.293, 95%CI 1.103-1.516), konsolidacije u &ge;2 kvadranata (p=0.000, OR 5.384, 95%CI 2.487-11.655), duže vreme od početka hospitalizacije do započinjanja NIV-a (p=0.0034, OR 1.005, 95%CI 1.000-1.009), tahikardiju (p=0.031, OR 2.292, 95%CI 1.080-4.864), vrednost GCS &le;11 (p=0.042, OR 1.000, 95%CI 0.165-0.969), veći MEWS skor (p=0.000, OR 1.708, 95%CI 1.410-2.068), niže vrednosti inicijalnog pH (p=0.004, OR 0.002, 95%CI 0.000-0.147), slabiju saradnju (p=0.000, OR 2.102, 95%CI 0.145-0.339). Mesto gde je sprovedena NIV je značajno uticalo na ishod &ndash; &scaron;anse za neuspe&scaron;an ishod su bile dvostruko veće kod bolesnika ventiliranih na op&scaron;tem odeljenju (p=0.006, OR 2.102, 95%CI 1.236-3.574). Kao nezavisni prediktori neuspeha nakon multivarijantne logističke regresije pokazali su se vrednosti Charlson-ovog indexa (p=0.043, OR 1.246, 95%CI 1.007-1.541), MEWS skora (p=0.010, OR 1.394, 95%CI 1.083-1.795), inicijalne vrednosti pH (p=0.030, OR 0.642, 95%CI 0.430-0.958) i stepena saradnje (p=0.000, OR 0.230, 95%CI 0.141-0.376). Zaključci: Bolesnici sa visokim vrednostima Charlson-ovog indeksa (preko 6 bodova) i MEWS-ovog skora (preko 4 boda), te niskom inicijalnom pH vredno&scaron;ću arterijske krvi (ispod 7.29) i niskim stepenom saradnje (manjim od 4) su bolesnici koji imaju povi&scaron;en stepen rizika za neuspe&scaron;an ishod primene neinvazivne ventilacije. Bolesnici visokog stepena rizika treba da se zbrinjavaju i neinvazivno ventiliraju na odeljenjima poluintenzivne i intenzivne nege, dok se bolesnici sa manjim stepenom rizika mogu inicijalno neinvazivno ventilirati i na op&scaron;tim odeljenjima, uz adekvatan monitoring i nadzor obučenog osoblja.</p> / <p>Introduction: Clinical guidelines that have evolved from the results of numerous randomized clinical trials state that the use of non-invasive ventilation (NIV), in addition to pharmacological therapy, is necessary in all patients wih severe exacerbation of chronic obstructive pulmonary disease (COPD) - at the highest level of recommendation. It has been proven that the use of NIV leeds to reduction in mortality, intubation rates, and the length of stay in hospitals. Since ventilatory support in past was only delivered in intensive care units, and bearing in mind that their capacities are limited, there is a question of an adequate setting within a hospital where NIV can be used safely and efficiently, and where potential early signs of failure will be timely recognized and patient intubated, if necessary. Consequently, the studies were performed in order to identify early predictors of NIV outcome &ndash; in order to recognize NIV failure and necessity for transition towards invasive ventilation, but also in order to stratify the patients according to the level of risk, which will then dictate the necessary level of care and monitoring. Goals: This research is aimed at identification of parameters that correlate with failure of non-invasive ventilation in patients with severe exacerbation of COPD, in order to create prognostic model of outcome, which will then enable stratification of patients according to the risk of NIV failure. The model is to be used in order to determine adequate level of care and monitoring, that is, a setting within a hospital, for provision of efficent and safe ventilatory support for all patients. Methods: This 39-month prospective observational study was performed at the Institute for Pulmonary Diseases of Vojvodina in Sremska Kamenica, which included 250 consecutive patients hospitalized due to severe exacerbation of COPD with respiratory acidosis. NIV was applied as pressure support mode of ventilation with the ventilators brand Covidien, type Airox Supportair, with oro-nasal mask. Initial parameters were: expiratory positive airway pressure &ndash; EPAPof 5 cm H2O and inspiratory positive airway pressure - IPAP of 12 cm H20, which were further adjusted towards the IPAP of 15-20 cmH2O, or according to the clinical response. The following data were recorded for each patient: sex, age, earlier longterm oxygen therapy, NIV episode during the previous hospitalizations, co-morbidities through Charlson index, time elapsed from admission to NIV initiation, initial blood gas values: pH, bicarbonates, PaCO2 and PaO2, initial SpO2 and PaO2/FiO2, the subsequent changes inthe blood gas values after one hour: pH, PaCO2 and PaO2, initial vital signs - heart rate, respiratory rate, consciousness level by Glasgow coma scale (GCS), body temperature, sistolic blood pressure, urine output, and then modified early warning score - MEWS, presence of consolidation on chest X-ray, tolerance, setting where NIV was applied. Primary outcome was NIV failure defined as endotracheal intubation or death during hospitalization caused by respiratory failure. All variables were first tested with univariate analysis, and those with statistical significance were further subjected to multivariate logistic regression, in order to generate an adequate statistical model. Results: Amongst the total of 250 patients, NIV was successfully applied in 164 patients (65.6 %). There were 139 (59.3%) male patients, and average age was 67. According to the univariate analysis, patients with NIV failure had: higher Charlson index (p=0.002, OR 1.293, 95%CI 1.103-1.516), consolidation in &ge;2 quadrants (p=0.000, OR 5.384, 95%CI 2.487-11.655), longer time from admission to NIV initiation (p=0.0034, OR 1.005, 95%CI 1.000-1.009), increased heart rate (p=0.031, OR 2.292, 95%CI 1.080-4.864), GCS &le;11 (p=0.042, OR 1.000, 95%CI 0.165-0.969), higher MEWS score (p=0.000, OR 1.708, 95%CI 1.410-2.068), lower initial pH (p=0.004, OR 0.002, 95%CI 0.000-0.147), poorer tolerance (p=0.000, OR 2.102, 95%CI 0.145-0.339). The setting were NIV was applied influenced the outcome &ndash; odds for NIV failure were twice as high for the patients on general wards (p=0.006, OR 2.102, 95%CI 1.236-3.574). After the multivariate logistic regression, the following variables were identified as independent predictors of outcome: Charlson index (p=0.043, OR 1.246, 95%CI 1.007- 1.541), MEWS score (p=0.010, OR 1.394, 95%CI 1.083-1.795), initial pH (p=0.030, OR 0.642, 95%CI 0.430-0.958) and tolerance (p=0.000, OR 0.230, 95%CI 0.141-0.376). Conclusions: Patients with higher Charlson index (&gt; 6 points) and MEWS score (&gt;4 points), lower initial pH (&lt;7.29) and tolerance (&lt;4) are at a higher risk for nonivasive ventilation failure. High-risk patients should be admitted and ventilated at high dependency or intensive care units, while the low-risk patients may receive non-invasive ventilatory support on general wards, with adequate monitoring and under the trained staff supervision.</p>