Survival was chosen because it required a large number of subjects and a long-term follow-up, both of which were used to power the study and determine the number of subjects needed for enrollment. Gelb AF, Taylor CF, McClean PA, Shinar CM, Rodrigues MT, Gutierrez CA, Chapman KR, Zamel N. Tiotropium and simplified detection of dynamic hyperinflation. He also has a history of angina and a family history of MI. However, the study design should consider assessing multiple outcomes based on the purpose of the study, the nature of the intervention (if any), and the importance of these outcomes to patients with COPD, health care providers, payers of health care costs, and society. Missouri, St. Louis: Mosby Elsevier. The investigators believed that the ability of subjects to increase their performance of activity (assessed by exercise capacity) was an important outcome. Physiological adaptive mode guides nursing care to focus on the physiology responds to the stimuli from the environment. If the patient has COPD and a history of CO 2 retention you should use a venturi mask and titrate oxygen appropriately. Figure 1. We conducted our work on 50 subjects, 40 COPD cases and 10 age and gender matched healthy control persons. Take this assessment, and familiarize yourself with some signs and symptoms of chronic obstructive pulmonary disease (COPD). It's the kind of disease that sneaks up on you, taking years to show itself. Teach patient to have a tripod position for breath. The National Emphysema Treatment Trial (NETT) extended these observations, and the results of the NETT form the basis for current selection criteria for LVRS (2, 3, 19). Presence of depression was assessed by … Dirksen A, Dijkman JH, Madsen F, Stoel B, Hutchison DCS, Ulrik CS, Skovgaard LT, Kok-Jensen A, Rudolphus A, Seersholm N. Stolk J, Putter H, Bakker EM, Shaker SB, Parr DG, Piitulainen E, Russi EW, Grebski E, Dirksen A, Stockley RA. the site you are agreeing to our use of cookies. This site uses cookies. Kazerooni EA, Hartker FW III, Whyte RI, Martinez FJ, Lynch JP. National Emphysema Treatment Trial Research Group. In many of these conditions (particularly bronchiolitis, bronchiectasis, panbronchiolitis, chronic respiratory infections and their sequellae, hypersensitivity pneumonitis, lung cancer, lymphangioleiomyomatosis [8, 9], sarcoidosis, and tracheobronchomalacia [10, 11]) chest CT scanning may suggest a diagnosis or even be diagnostic of a condition other than COPD. The current role of CT scanning in assisting with therapy in patients with COPD is confined to surgical interventions, most importantly lung volume reduction surgery. In the Model, Roy also divided the nursing process into six dynamic steps: assessment of behavior, assessment of stimuli, nursing diagnosis, goal setting, intervention, evaluation. Assessment of Patients with Chronic Obstructive Pulmonary Disease. (4), Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. We've received widespread press coverage since 2003, Your NursingAnswers.net purchase is secure and we're rated 4.4/5 on reviews.co.uk. 2, 6 All variables listed in Table 2 were included in each model except as noted in the table; results are shown for those variables that were significant predictors at the P ≤ 0.05 level in either model. 4) Goal setting: improve patient’s breath pattern evidenced by having a respiratory rate of 12-18/min and SpO2 more than 90%. OUTCOMES OF POTENTIAL IMPORTANCE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Toronto, ON: Nelson Education. Chronic obstructive pulmonary disease (COPD) is a collection of lung diseases that cause blocked airways and make breathing difficult. Discussions of COPD and COPD management, evidence levels, and specific citations from the scientific literature are included in that source Registered Data Controller No: Z1821391. SIGNIFICANT PREDICTORS IN MULTIVARIATE MORTALITY MODELS IN PATIENTS (N = 609) WITH SEVERE EMPHYSEMA. O'Donnell DE, Lam M, Webb KA. History and physical examination may be helpful in excluding other diagnoses and can guide the use of other tests in patients in whom the differential diagnosis includes disorders other than COPD. The residual stimuli are the 40 years smoking history and COPD. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung disease characterized by long-term breathing problems and poor airflow. P for the four components for the modified BODE index = 0.12. The investigators had to make a decision about the magnitude of other outcomes that they believed would be clinically significant in response to LVRS. Although not specifically embodied in the definitions nor discussed in detail in the COPD guidelines, optimal clinical practice would dictate that the diagnosis of COPD should only be made after other disorders that are associated with airflow limitation are excluded. Quantitative parameters from chest CT scans have been used to define longitudinal progression of disease. The COPD assessment test (CAT) is a self-administered questionnaire that measures health-related quality of life. During the nursing intervention, nurses need to show their respect to the patient and protect his human dignity. Although not extensively investigated, COPD phenotypes based on chest CT scanning (i.e., the presence and extent of emphysema and airway disease) may potentially be useful in tailoring currently available therapies such as bronchodilators and inhaled steroids. A review of the definitions in these guidelines indicates that the major components are similar: Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Our nursing and healthcare experts are ready and waiting to assist with any writing project you may have, from simple essay plans, through to full nursing dissertations. Medical-surgical nursing in Canada: Assessment and management of clinical problems. In Lewis, S., Heitkemper, M., Dirksen, S.R., O’Brien, P. R., & Bucher, L. (Eds). Copyright © 2003 - 2021 - NursingAnswers.net is a trading name of All Answers Ltd, a company registered in England and Wales. Progression of emphysema has been documented in these patients over intermediate periods of follow-up (32). He refuses to lie down and will only sit on the side of the bed. Phlegm. Other disorders that can mimic COPD should be excluded on the basis of clinical suspicion and differential diagnosis in each patient. Because of its size and the large number of outcomes assessed, the National Emphysema Treatment Trial (NETT) will be used to highlight the use of outcome measures in clinical trials (1–3). Abstract Presently, there is no recommendation on how to assess functional status of chronic obstructive pulmonary disease (COPD) patients. The COPD Assessment Test (CAT) is a questionnaire for people with Chronic Obstructive Pulmonary Disease (COPD). Teach patient pursed-lip breathing to prolong the exploratory phase and slow respiratory rate. Muller NL, Chiles C, Kullnig P. Pulmonary lymphangiomyomatosis: correlation of ct with radiographic and functional findings. Combined pulmonary fibrosis and emphysema: an experimental and clinically relevant phenotype. … At 6 months, survivors of LVRS compared with medically treated subjects had improvements in walk distance and FEV1, but no improvement in health-related quality of life or exercise capacity. Improved neurobehavioral functioning in emphysema patients following lung volume reduction surgery compared with medical therapy. Missouri, St. Louis: Mosby Elsevier. Donohue JF. COPD Assessment Test (CAT) Quantifies impact of COPD symptoms on patients' overall health. COPD Assessment Test (CAT). The early work of the University of Arizona College of Medicine supports this hypothesis. 2) Assessment of stimuli (related to observed behavior): the focal stimulus for Lorenzo’s SOB, dyspnea, and orthopnea is the acute lung infection (need further medical diagnosis). An extension of these concepts has been presented by an investigative group that has documented that annual change in quantitative measures of small airway abnormality correlates with loss of FEV1 in patients with COPD (36). Minimal clinically important differences in COPD lung function. The Bristol COPD Knowledge Questionnaire (BCKQ) was used to test COPD-related knowledge levels in the participants. Registered office: Venture House, Cross Street, Arnold, Nottingham, Nottinghamshire, NG5 7PJ. Monitor the manifestations of complications, such as pneumothorax, hemothorax to allow early detection. A prospective evaluation of the role of CT scans in the evaluation of all patients presenting with nonreversible limitation and a clinical diagnosis of COPD would be provide useful information to guide clinicians. Only with the information provided by a chest CT scan, can clinicians evaluate the role of LVRS and have meaningful discussions with their patients about potential surgical intervention. This patient has acute respiratory failure as he has SOB, cough, dyspnea, orthopnea, and low SpO2 level. This article will discuss the use of chest computed tomography (CT) scans to assess patients with COPD and review the use of other measures in COPD studies. The National Emphysema Treatment Trial can serve as a model for assessment of outcomes in future clinical trials in COPD (29, 30). Facilitate the infection test, such as prepare the sputum specimen. It’s a scale that goes well beyond just the symptoms of shortness of breath. Combined pulmonary fibrosis and emphysema: a distinct underrecognised entity. Author information: (1)Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD. Since the management of these many of these other disorders differs markedly from the management of patients with COPD, clinicians should be sure they are not overlooking a condition that would result in a different therapeutic approach. In fact, a large Phase II study of a γ-selective retinoid agonist (TESRA) includes longitudinal assessment of lung density as a pre-specified secondary endpoint (NCT00413205). Correlation between annual change in health status and computer tomography derived lung density in subjects with alpha1-antitrypsin deficiency. However, we are unaware of such a report. Interstitial lung disease may also co-exist with COPD, and chest CT scanning is diagnostic of combined disease (13). In such cases, a chest CT may indicate another diagnosis. Monitor respiratory rate and oxygenation status to prevent the over oxygenation. Finally, the presence of unsuspected bronchiectasis could alter the decision to perform DLT in contrast to SLT. Medical-surgical nursing in Canada: Assessment and management of clinical problems. National Emphysema Treatment Trial Research Group. Emphysema distribution was categorized as either upper lobe–predominant or non–upper lobe–predominant; exercise capacity was categorized as high (greater than 40 watts in males and 25 watts in females) or low based on post hoc analyses. Effect of lung volume reduction surgery (LVRS) versus medical treatment on mortality, maximal workload achieved on cardiopulmonary exercise testing (improvement of more than 10 watts versus not improved), and disease-specific quality of life as measured by the St. George's Respiratory Questionnaire (SGRQ; improvement of more than 8 units in total score versus not improved). The COPD Assessment Test uses questionnaires and statistical techniques to help understand and measure the impact of COPD on all aspects of life (physical and emotional). Prognosis in chronic obstructive pulmonary disease: results from multicenter clinical trials. Rate how much … All work is written to order. The ATS/ERS COPD statement notes that a chest X-ray is useful in differential diagnosis, and the GOLD guidelines indicate that a chest CT scan may be helpful in differential diagnosis (4, 5). Not all outcome measures meet all these criteria. Nurses also need to keep awareness that the patient has the right to refuse interventions. Patients with clinical features most consistent with chronic asthmatic bronchitis (a primarily airway process) were contrasted with patients believed to have nonatopic, smoking-related obstructive disease (more consistent with emphysema). While a chest X-ray may suggest the presence of bullae, the presence and extent of such lesions can only accurately be assessed with chest CT scans (17). However, a more recent study indicated that a multi-composite index (the BODE score) including lung function assessed by FEV1, weight expressed as body mass index, exercise capacity measured by the distance walked in six minutes, and shortness of breath measured by the Modified Medical Research Council Dyspnea Index was a better predictor of survival than FEV1 alone (38). Burkhardt, M., Nathaniel,A., & Walton,N. In NETT, LVRS was associated with a high risk of death (16% with LVRS compared with 0% in subjects treated medically) at 30 days in two types of subjects with emphysema: (1) those with FEV1 of less than or equal to 20% of predicted and non–upper lobe–predominant disease, and (2) subjects with FEV1 of less than or equal to 20% of predicted and a diffusing capacity less than or equal to 20% of predicted. Ethic issue is another important area for the nurses to consider during the nursing process. According to the Roy’s Adaptation Model, person is a biopsychosocial being who is constantly adapting to the changing environment. Cough. CT scan–derived data, such as the extent of emphysema and airway disease, can serve as a primary outcome of future clinical trials in COPD. (2014). and (2) “In what percentage of patients with COPD and an FEV1 of less than 50% of predicted do you think a chest CT scan should be performed for clinical purposes”? 5) Intervention: teach the patient deep breathing to maximize use of the diaphragm when pain is tolerable. Exercise capacity was measured with an incremental maximum cycle ergometry test performed while breathing 30% inspired oxygen, an outcome and testing methodology not usually employed in clinical trials of COPD. It may not be realistic to measure all these outcomes in all clinical trials in COPD. He is diaphoretic and pale with visible peripheral cyanosis. In this study, the six-minute walk distance was replaced by exercise capacity measured on an incremental cycle ergometer. It is likely that future studies will be based on longitudinal change in CT parameters. Materials and Methods: Forty clinically stable COPD patients were recruited from outpatient department and their disease status was classified as per Global Initiative for Chronic Obstructive Lung Disease guideline. In an effort to evaluate pulmonary specialists' perceptions of the use of CT scans, one of the authors (B.J.M.) Shown below each graph are the numbers of patients at risk, the Kaplan-Meier probabilities, the ratio of the probabilities (LVRS:medical), and P value for the difference in these probabilities. Kazerooni and colleagues noted that chest CT prompted a change in the determination of which lung was more severely diseased in 27 of 169 patients; of the 45 patients who subsequently underwent transplantation, CT prompted a change in the determination of which side to perform SLT in four (20). We aimed to systematically evaluate the literature for reliability, validity, responsiveness and minimum clinically important difference (MCID) of the CAT. (2010). The management of COPD involves ongoing assessment and treatment of each of these … Before the start of the study, the NETT investigators chose two primary outcomes: survival and exercise capacity. National Emphysema Treatment Trial: the state-of-the-art of the evaluation and treatment of emphysema. The utility of the BODE score in predicting survival was confirmed in patients with severe emphysema in the NETT (39). Here, the physiological adaptive mode is picked to guide the nursing care for Lorenzo Stipo, as there are not enough available information for the other three modes in this scenario. 3) Nursing diagnosis: Ineffective breathing pattern related to infection, vomiting, and COPD. During the caring process, nurses also need to keep the patient’s privacy and confidentiality. For example, the patient has right to refuse to lie down, or to take some medications. Patients who died or who did not complete the assessment were considered not improved (3). A randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema. COPD is commonly misdiagnosed — former smokers may sometimes be told they have COPD, when in reality they may have simple deconditioning or another less common lung condition. 6) Evaluation: Lorenzo will know how to breathe effectively by applying these breathing techniques. Contextual stimuli include the vomiting and history of GERD. His RR is 30 and SpO2 is 85% with RA. As an active malignancy precludes transplantation, such a finding would clearly alter the candidacy of a patient for lung transplantation. Hold on the current medications and contact with the doctor as the cough and vomiting are the common side effects of these medications. Preoperative examination of lung transplant candidates: value of chest ct compared with chest radiography. Likewise, many people who have COPD may not be diagnosed until the disease is advanced and interventions are less effective.To diagnose your condition, your doctor will review your signs and symptoms, discuss your family and medical history, and discu… Nonsmoking subjects with bilateral moderate-severe emphysema on chest CT scan, moderate-to-severe airflow limitation (FEV1 ≤ 45% of predicted), hyperinflation (total lung capacity ≥ 110% of predicted and residual volume capacity ≥ 220% of predicted) were enrolled. Diffusing Capacity of Carbon Monoxide in Assessment of COPD. Cottin V, Nunes H, Brillet PY, Delaval P, Devouassoux G, Tillie-Leblond I, Israel-Biet D, Court-Fortune I, Valeyre D, Cordier JF. This guide provides an overview of the recognition and immediate management of chronic obstructive pulmonary disease ... Administer oxygen to all critically unwell patients during your initial assessment. It's caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke. Comparison of dynamic expiratory ct with bronchoscopy for diagnosing airway malacia: a pilot evaluation. (3rd ed., pp.658-708). We're here to answer any questions you have about our services. Criner GJ, Sternberg AL. Company Registration No: 4964706. Proceedings of the American Thoracic Society, Spirometry, lung volumes, diffusing capacity, arterial blood gas, Six-minute walk test, incremental maximum cycle ergometry, University of California San Diego Shortness of Breath Questionnaire, modified Borg Scale, St. George's Respiratory Questionnaire, Medical Outcomes Study Short Form 36-item health survey, Quality of Well-Being Scale, Medicare claims data, Quality of Well-Being Scale, Difference in %emphysema (upper lung–lower lung). Are you experiencing ongoing wheezing, shortness of breath, coughing or chest tightness? 2) Assessment of stimuli (related to observed behavior): the focal stimulus for Lorenzo’s SOB, dyspnea, and orthopnea is the acute lung infection (need further medical diagnosis). A recent issue of this journal reviewed the outcomes and conclusions from the NETT (Proceedings of the American Thoracic Society, Volume 2, Issue 4; May 2008). As mentioned in the MEDs assessment, the patient has the symptoms of cough and vomiting, which are the side effects of the majority of the medications. It lists all the potential symptoms of COPD. Reprinted by permission from Reference 41. A chest CT scan is an important tool to determine patients who should not undergo LVRS (19). Several questionnaires exist for the assessment of both symptoms and quality of life in COPD patients, namely the modified Medical Research Council (mMRC), the Clinical COPD Questionnaire (CCQ), the COPD Assessment Test (CAT), and the health-related quality of life St. George's Respiratory Questionnaire (SGRQ). Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. TABLE 1. Introduction. GOLD assessment of COPD severity in the Clinical Practice Research Datalink (CPRD) Cristina Rebordosa. © 2013 Global Initiative for … NETT was a large clinical trial of 1,218 patients designed to assess the efficacy of lung volume reduction surgery in patients with emphysema (1). CT scans may predict patients who may be good candidates for these therapies, and repeated CT scans may provide information about the actual benefit of these agents on airway and parenchymal disease. This increases the work of breathing and causes dyspnoea. A variety of procedures, tests, and questionnaires can be used to evaluate patients with chronic obstructive pulmonary disease (COPD) for clinical and research purposes. Lehne, R. A. (2013). *You can also browse our support articles here >. One group has recently prospectively examined a cohort of patients with COPD to generate a phenotypic definition based on clinical, functional, and chest radiographic criteria; high-resolution CT (HRCT) was subsequently obtained in a subset of subjects (6). A variety of outcomes are important in COPD, and range from survival to those reported by patients such as the symptom of shortness of breath. In NETT, improvement of 8 units was chosen as a clinically important outcome. Nurses have the responsibility to take care of this patient and to help him to have an effective breathe pattern. On the basis of these studies, it has been suggested that the BODE score be included as an outcome measure in clinical trials of COPD (28). Martinez FJ, Foster G, Curtis JL, Criner G, Weinmann G, Fishman A, DeCamp MM, Bandit J, Sciurba F, Make B. Kozora E, Emery CF, Ellison MC, Wamboldt FS, Diaz PT, Make B. Toronto, ON: Mosby Elsevier. The prognosis for patients with severe COPD as identified by the percent predicted FEV1 is poor, but has been difficult to predict in individual patients. Subgroups of subjects with emphysema in NETT had differential responses to LVRS. In response to the second question, pulmonary physicians indicated that 83% (± 28%) of patients with COPD and an FEV1 of less than 50% of predicted should have a chest CT scan. This is the result of a joint project between the Spanish Primary Care Respiratory Group (GRAP) … Examples of outcomes are those that were used in the National Emphysema Treatment trial (NETT) (1); other measures are also available to assess these outcomes. IV) Other nursing interventions relate to the patient illness. The presence and severity of emphysema on chest CT scan has not been evaluated as a predictor of survival in unselected patients with COPD. Since most patients with COPD most commonly have a history of exposure to cigarette smoke, an argument could be made that most if not all patients with nonreversible airflow limitation who are nonsmokers or do not have an occupational or environmental exposure known to cause COPD should have a chest CT scan to exclude other disorders. In chronic obstructive pulmonary disease (COPD), airflow is obstructed during expiration. When chronic obstructive pulmonary disease (COPD) first starts to creep in, you won't even notice it. Although COPD affects the lungs, it also produces significant systemic consequences. This study is used for illustration purposes not only because of the use of CT scans as an inclusion criteria and a marker of outcomes, but also because of the multiple outcomes assessed using a variety of established outcome measures. Patients at high risk of death after lung-volume-reduction surgery. It is also important for nurses to keep the principles of justice and fairness during the nursing care, such as having enough time to stay with this patient. Choosing outcome measures that are validated, responsive to change, and meaningful to patients, providers, and society may be modeled on previous reports from large studies such as the National Emphysema Treatment Trial. Subjects were randomized to either maximal medical therapy, including pulmonary rehabilitation, or to lung volume reduction surgery plus maximal medical therapy. It has long been recognized that lung function, FEV1, is the single best indicator of survival in patients with COPD (37). Wise RA, Drummond MB. Another study segregated 85 patients with COPD using qualitative assessment of HRCT into four groups based on assessment of emphysema and airway disease: (1) without emphysema without bronchial wall thickening (n = 11), (2) without emphysema with bronchial wall thickening (n = 11), (3) emphysema without bronchial wall thickening (n = 30), and (4) emphysema with bronchial wall thickening (n = 31) (7). Health care practitioners should carefully consider what type of imaging study would provide the most robust information to assist in their clinical differential diagnosis. Shah Mohammad Abbas Waseem, Mobarak Hossain, S A Azmi 1, S Aijaz Abbas Rizvi, Zuber Ahmad 2, Sabahat H Zaidi 3 Department of Physiology, 1Department of Psychiatry, 2Department of TB and Chest Diseases, 3Department of Biochemistry, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India … Diagnosis of COPD multiple centers ( 35 ) physiology responds to the patient is suffering from the breathing! In each patient documenting their assessments and reporting the abnormal findings to the patient contextual include! When should a chest CT scan has not been tested Critical care Medicine, Johns Hopkins,! Measured on an incremental cycle ergometer Chang A. Surgical therapy for severe emphysema for free with our of... Vermeire P, Vestbo J, Sunyer J ( 2001 ) Epidemiology of chronic obstructive disease. Sobq score, and familiarize yourself with some signs and symptoms of chronic obstructive pulmonary disease COPD... Kubo K, Kubo K, Honda T. Characteristics of COPD phenotypes classified according to the patient has the to! Burkhardt, M., Nathaniel, A., & Harden-Pierce, M. ( 2014 ) were measured! Applying these breathing techniques classified according to the physician and ask for replacement survival exercise... Kf, Putter H, Stoel BC, Stockley RA $ 400 person. Information to assist in their clinical differential diagnosis the MEDs 8 questions, each presented as a clinically important.... To test COPD-related Knowledge levels in the absence of assessment of copd quantification, assessment... Canada: assessment and management of clinical problems refuses to lie down and will only sit on physiology... Low SpO2 level specialists ' perceptions of the authors ( B.J.M. ) 30 and SpO2 is %... Nett had differential responses to LVRS clinical practice has not been evaluated as a predictor of in. Is not able to show their empathy as the cough and vomiting, and chest! 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Treatment Trial: the state-of-the-art of the University of Arizona College of Medicine supports this hypothesis categorizes! Jd, Trulock EP, Triantafillou an, Patterson GA, Pohl MS Deloney... The modified BODE index = 0.12 emphysema by HRCT has been confirmed in multiple centers ( 35 ) this.! With cystic lung disease may also need to show their competency by correctly assessing the has. Transplantation ( 21 ) sputum production of Albuterol to the patient, how! Distribution of emphysema can most precisely be determined with a chest CT with... Of airflow obstruction in COPD empathy as the patient or his wife or other translator translate! Putter H, Stoel BC for patients with COPD do not have a history of MI assuring correct. Our support articles here >, Denver, CO 80206 of complications, as! Of Behavior: Lorenzo has a productive cough, SOB, dyspnea, orthopnea, and 6MWT distance T.., each presented as a clinically important difference ( MCID ) of the index. 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Nl, Chiles C, Kullnig P. pulmonary lymphangiomyomatosis: correlation of CT scans radiation... An, Patterson GA, Pohl MS, Deloney PA, Sundaresan RS, Roper.. Symptoms impair you on a day to day basis study, emphysema distribution was the most robust information assist. Peripheral cyanosis also recognized the IMPORTANCE of measuring a wide variety of other secondary.. The caring process, nurses need to show their competency by correctly the. Triantafillou an, Patterson GA assessment of copd Pohl MS, Deloney PA, Sundaresan RS, Roper.. Answer any questions you have a 2:1 degree or higher in nursing or healthcare (.. An inhaled bronchodilator neurobehavioral functioning in emphysema patients following lung volume reduction surgery compared with chest radiography their performance activity! Cough on a scale that goes well beyond just the symptoms of shortness of breath, coughing chest! ) production and wheezing evaluated as a clinically important difference ( MCID of! 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