NURS FPX 4025 Assessment 3

Name

Capella university

NURS-FPX4025 Research and Evidence-Based Decision Making

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Date

Title

Chronic Obstructive Pulmonary Disease (COPD) is a lung disease that continuously worsens and makes breathing difficult and susceptible to exacerbation. The treatment effectively manages the symptoms and prevents the disease’s progress. COPD is one of the main reasons for death in the U.S., and about 16 million adults are affected (CDC, 2024). The proper treatment choice can influence patient results. This assessment compares Long-Acting Beta-Agonist (LABA) therapy to triple therapy (LABA/LAMA/ICS) for treating moderate to severe COPD for three months. It compares efficacy in reducing exacerbation frequency and controlling symptoms.

Explaining a Diagnosis

COPD is a chronic and disabling disease with obstructed airflow, chronic mucus plugging, and chronic shortness of breath due to airway distortion. The prevalence of COPD among U.S. adults has remained fairly consistent over the past decade, with an overall rate of about 6.0% in 2021 (CDC, 2024). COPD is managed by preventing exacerbation, controlling signs and symptoms, and improving the patient’s quality of life. Stable COPD patients do not necessarily have any short-term complications, but uncontrolled COPD has severe complications such as respiratory failure, pulmonary hypertension, and increased susceptibility to infection, such as pneumonia (Lea et al., 2023).

With declining lung function, patients with frequent exacerbations are at higher risk of mortality and hospitalization. Vulnerable groups, including low-income patients and elderly patients, are at higher risk of COPD complications due to lower access to specialist care, smoking cessation, and advanced pharmacotherapy (Lea et al., 2023). For instance, rural residents may have lower access to pulmonary rehabilitation, lower physical performance, and more exacerbations. 

Moreover, patients of lower socioeconomic status are likely to struggle with paying for maintenance medication, such as long-acting bronchodilators. They will hence have more opportunities for uncontrolled symptoms and disease progression. For example, in stable COPD patients, inappropriate use of inhaled corticosteroids (ICS) due to withdrawal anxiety is prevalent, and inappropriate use of ICS is likely to increase the risk of pneumonia, particularly in older patients and immunocompromised patients. Where appropriate, LABA treatment optimization and ICS withdrawal can reduce complications and enhance health equity in COPD management (Lee et al., 2021). 

PICO(T) Research Question

A well-structured PICO(T) research question guides evidence-based practice in optimizing COPD treatment. The research question is: “In COPD patients (P), how does LABA therapy (I), compared to triple therapy with ICS (C), affect the frequency of exacerbations and symptom control (O) over a period of 3 months (T)?”

Each component of PICO(T) is defined as follows:

• P (Patient/Population): Patients diagnosed with COPD who are at risk of exacerbations and may be prescribed long-term inhaled therapy.
• I (Intervention): Long-acting beta-agonist (LABA) therapy, which is used to improve airflow, reduce symptoms, and enhance lung function in COPD patients.
• C (Comparison): Triple therapy (LABA/LAMA/ICS) is a commonly used approach that includes an inhaled corticosteroid. However, it may not be necessary for all patients and carries risks such as pneumonia.
• O (Outcome): The focus is reducing exacerbation frequency and improving symptom control, key indicators of effective COPD management.
• T (Timeframe): A 3-month period allows for assessing short-term treatment efficacy and potential differences between LABA monotherapy and triple therapy.

This question enables a systematic search for evidence, helping clinicians determine whether LABA alone is sufficient or if triple therapy is necessary for optimal COPD management.

Literature Search

This search thoroughly searched for evidence on optimal COPD management, comparing LABA therapy with triple therapy (LABA/LAMA/ICS). Multiple academic databases, including PubMed, CINAHL, Cochrane Library, and Google Scholar, were used to search, as they form a wide range of high-quality sources. The keywords used at the first stage of the search were COPD, LABA therapy, triple therapy, ICS withdrawal, exacerbation prevention, symptom management, and long-term COPD treatment. The search was refined with Boolean operators (AND, OR) so that the studies compare LABA and triple therapy in COPD management rather than in the general COPD treatment approaches.

The CRAAP criteria (Currency, Relevance, Authority, Accuracy, and Purpose) were used to assess the credibility of the studies (Dehkordi et al., 2024). Systematic reviews met meta-analyses listed in the last five years, and peer-reviewed articles received priority. Also considered were sources from recognized organizations, such as the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and other studies, such as Fukuda et al. (2023), which had a clinical base.

Finally, filters were applied for publications in full text, in English, and studies about adult COPD patients to refine the search process. First, a large volume of general COPD management literature was retrieved. Still, by adding specific terms like “ICS step-down in COPD” and “effectiveness of dual bronchodilator therapy,” the results were narrowed to studies directly relevant to the research question (GOLD, 2023). This approach ensured that only the most credible and applicable evidence was selected to inform evidence-based practice in COPD treatment strategies.

Relevant Articles

A comprehensive review of four high-quality sources evaluated the effectiveness of LABA therapy compared to triple therapy (LABA/LAMA/ICS) for moderate to severe COPD. As a result, credibility, relevance, and applicability to the research question were assessed in these sources. Fukuda et al. (2023) examined randomized controlled trials comparing LABA therapy to triple therapy. This updated review expands the 2017 version, increasing included studies from 11 to 19 (22,354 participants), with a median of 700 participants per study, 70% male, and an average age of 64 years with a median predicted FEV1 of 51.5%. However, findings showed that triple therapy reduced exacerbation rates, but LABA therapy alone was similar to triple therapy in reducing symptoms in patients with no history of frequent exacerbations.

This study is credible as it has many RCTs and is done rigorously. Davidescu et al. (2023) focused on the effect of ICS withdrawal in COPD patients. The study showed that a patient with eosinophil count < 300 cells/mm3 does not have an increased exacerbation rate when stepping down to LABA therapy. This is a relevant study in evaluating patient-specific treatment decisions. This source is credible because of its peer review and clinical trial data. A study by Zhang et al. (2024) analyzed the safety and efficacy of triple therapy versus LABA therapy.

It found that stable patients with COPD do not suffer from loss of efficacy with LABA therapy but frequently exacerbate the benefit from triple therapy. The inclusion criteria for the Cochrane Library ensure credibility. According to GOLD (2023) guidelines, expert consensus provided treatment recommendations. The guidelines emphasized personalized treatment, and it is noted that LABA should be chosen over triple therapy based on the patient’s specific needs. This is a highly credible source, given that the leading COPD experts have developed it. These sources provide an evidence-based approach to COPD management that is risk stratification-based.

Analyzing Evidence

The effectiveness of LABA therapy compared to triple therapy (LABA/LAMA/ICS) for moderate to severe COPD was evaluated using four high-quality sources. Credibility, relevance, and applicability to the research question were assessed. A study by Fukuda et al. (2023) analyzed randomized controlled trials comparing LABA therapy to triple therapy, finding that while triple therapy reduced exacerbation rates, LABA provided similar symptom control in patients without frequent exacerbations. Davidescu et al. (2023) examined ICS withdrawal, revealing that patients with eosinophil counts below 300 cells/mm³ did not experience increased exacerbations when stepping down to LABA therapy.

Another study by Zhang et al. (2024) found that stable COPD patients maintained efficacy with LABA, while frequent exacerbators benefited from triple therapy. The Cochrane Library ensured credibility in this analysis. Lastly, the GOLD (2023) guidelines emphasized personalized treatment, recommending LABA over triple therapy based on patient-specific needs. These sources support the assumption that treatment should be individualized, balancing symptom control with the risk of ICS-related adverse effects. A key assumption is that not all COPD patients require triple therapy; instead, treatment should be individualized, with LABA therapy being sufficient for stable patients, while those with frequent exacerbations benefit more from triple therapy.

Conclusion

Optimal COPD management involves customized treatment that equilibrates symptom control with prevention of exacerbations. While evidence indicates the adequacy of LABA for stable patients and triple therapy in frequent exacerbators. Guidelines support that individualized care maximizes outcomes and minimizes inappropriate drug use.

References

Centers for Disease Control and Prevention (CDC). (2024, June 12). COPD. Chronic Disease Indicators. https://www.cdc.gov/cdi/indicator-definitions/chronic-obstructive-pulmonary-disease.html 

Davidescu, L., Andrei , D., Mekeres, F., Goman, A., Stefania , N., & Rajnoveanu, R. (2023). Phenotype of COPD: “Frequent exacerbator” and biomarkers use in clinical practice. Pharmacophore, 14(4), 40–49. https://doi.org/10.51847/yyzhyvtysb 

NURS FPX 4025 Assessment 3

Dehkordi, M. K., Hanson, H. M., Kennedy, M., & Wagg, A. (2024). Mapping quality indicators to assess older adult health and care in community-, continuing-, and acute-care settings: A systematic review of reviews and guidelines. Healthcare, 12(14), 1397–1397. https://doi.org/10.3390/healthcare12141397 

Fukuda, N., Horita, N., Kaneko, A., Goto, A., Kaneko, T., Ota, E., & Kew, K. M. (2023). Long-acting muscarinic antagonist (LAMA) plus long-acting beta-agonist (LABA) versus LABA plus inhaled corticosteroid (ICS) for stable chronic obstructive pulmonary disease. The Cochrane Library, 2023(6). https://doi.org/10.1002/14651858.cd012066.pub3 

GOLD. (2023). Global Initiative for Chronic Obstructive Lung Disease – GOLD. Global Initiative for Chronic Obstructive Lung Disease.org. https://goldcopd.org/ 

Lea, S., Higham, A., Beech, A., & Singh, D. (2023). How inhaled corticosteroids target inflammation in COPD. European Respiratory Review, 32(170), e230084. https://doi.org/10.1183/16000617.0084-2023 

Lee, H. W., Kim, H. J., Jang, E. J., & Lee, C.-H. (2021). Comparisons of efficacy and safety between triple (inhaled corticosteroid/long-acting muscarinic antagonist/long-acting beta-agonist) therapies in chronic obstructive pulmonary disease: Systematic review and Bayesian network meta-analysis. Respiration, 100(7), 631–643. https://doi.org/10.1159/000515133 

NURS FPX 4025 Assessment 3

Zhang, S., Wang, J., Li, X., & Zhang, H. (2024). Comparative effectiveness and safety of triple therapy and non-triple therapy interventions for COPD: An overview of systematic reviews. Therapeutic Advances in Respiratory Disease, 18. https://doi.org/10.1177/17534666241259634