Pulmonary Rehabilitation Nursing Interventions Promoting Self-Care in Elderly People with Chronic Obstructive Pulmonary Disease (At Home)

Abstract

Background/Objectives: Pulmonary rehabilitation is recognised as one of the most cost-effective interventions. However, patients’ adherence to these programmes remains a challenge. This systematic literature review aimed to describe pulmonary rehabilitation interventions carried out by nurses that promote self-care in elderly people with COPD (at home). Methods: The exploratory literature search was conducted to support the development of the research question and the PICO strategy. The criteria for eligibility were determined for participants, interventions, comparators, and outcomes. Research was conducted in the CINAHL, SCOPUS, and MEDLINE databases and that covered publications up to 31 December 2024 with no temporal limit identified, eight articles that included cohort studies, randomised controlled trials (RCTs), and quasi-experimental studies that met the quality standards established by JBI. Results: The identified interventions include health education, breathing training and physical exercise, the development of tailor-made plans with monitoring and follow-up, psychological support, and oxygen therapy management. Conclusions: The results highlight the importance of tailor-made interventions that can enhance self-care in elderly people with COPD in a home setting, as well as key components of respiratory rehabilitation.

1. Introduction

Population ageing is accelerating worldwide and has become a significant trend in Europe over recent decades [1,2]. In the European Union, the proportion of individuals aged 65 or over has increased from 16% in 2003 to 21% in 2023 [3]. In Portugal, this demographic trend is equally evident: in 2022, the ageing index—comparing the population aged 65 or over with those aged 0 to 14—reached 185.6 elderly individuals per 100 young people, up from 181.3 in 2021 [4]. The increase in the elderly population applies considerable pressure on healthcare and social security systems [5].

Chronic obstructive pulmonary disease (COPD) is a widespread condition among older people [6,7] and is one of the leading causes of morbidity and mortality worldwide [8,9,10]. It is defined as a prevalent, preventable, and treatable disease characterised by persistent respiratory symptoms and airflow obstruction caused by alveolar and/or airway alterations resulting from prolonged exposure to harmful particles or gases, as well as genetic predispositions [8].

People that suffer from COPD often face physical, psychosocial, and emotional hardships that limit their ability to manage self-care, including trouble breathing, eating, dressing, and maintaining personal hygiene [11]. Self-care is a central concept in Orem’s theory [12] and refers to an individual’s ability to autonomously manage their own needs [13]. In Orem’s self-care theory, self-care is understood as a learned and intentional behaviour aimed at maintaining life, health, and well-being [12]. A self-care deficit takes place when one’s self-care capacity is insufficient to meet their necessary requirements, making nursing care essential [12,13]. All nursing interventions aim to promote one’s active participation in their own self-care, ensuring the continuous fulfilment of their self-care needs [12] and emphasising the importance of maintaining independence in daily self-care activities [14].

Pulmonary rehabilitation (PR) may be one of the most cost-effective treatment methods [8,15,16] and is a key pillar of non-pharmacological interventions for people with COPD [10,17]. It stands out as a therapy that not only reduces symptoms [18] but also offers a favourable cost–benefit ratio [15]. PR is described as an essential care element in individuals with chronic respiratory disease [18]. Participating in PR reduces dyspnoea, increases exercise capacity, improves health-related and emotional-related quality of life, and provides social support [18]. PR also contributes to reducing hospital admissions and the risk of mortality after hospitalisation in people with COPD [18].

Although not limited to the mentioned therapies, the therapies included in PR involve physical training, education, and behavioural change strategies, all designed to improve the physical and psychological well-being of individuals with chronic respiratory diseases and promote adherence to practices that support their health in the long term [19].

The literature documents assigned obstacles to the acceptance and participation of individuals in PR interventions [8], including travel requirements [18,20], transportation challenges [8] and the limited availability of services in contexts where dyspnoea and reduced mobility are common [20]. Consequently, home-based PR interventions can improve adherence amongst people with COPD [21] and provide a practical alternative that is comparable to conventional outpatient rehabilitation programmes [8,22].

A recent systematic review and meta-analysis of randomised controlled trials on the effectiveness of pulmonary rehabilitation in older adults with COPD [23] concluded that more comprehensive pulmonary rehabilitation programmes should be made available for this population, whether in community hospitals, large public hospitals, or at home. The importance of evidence-based nursing practices in guiding interventions and treatments for older adults with respiratory disorders was also emphasised in another recent systematic review [24]. Furthermore, according to a recent study [7], the long-term survival effects of continuous nursing interventions, combined with guided respiratory training in elderly patients with COPD, still warrant further investigation.

Given these challenges, it is essential to optimise the outcomes of healthcare interventions for patients and to reduce the overall burden on healthcare systems worldwide [25]. Therefore, this systematic review aimed to describe pulmonary rehabilitation interventions carried out by nurses that promote self-care in elderly people with COPD at home.

2. Materials and Methods

2.1. Study Design

The systematic literature review was chosen, keeping in mind the study’s objective and the state-of-the-art phenomenon under analysis. This systematic review followed the recommendations outlined by the JBI criteria, ensuring research rigour in study design, bibliographic research, and data analysis [26]. The study protocol was previously registered and published in the PROSPERO database (CRD42022308062).

2.2. Research Question and Eligibility Criteria

The research question that was formulated using the PICO search strategy was “What are the pulmonary rehabilitation interventions carried out by nurses that promote self-care in elderly people with COPD at home?”

Based on the research question, eligibility criteria were defined and used in the process of searching, selecting, and analysing the scientific evidence (Table 1).

The selected articles were limited to those for which full-text access was available, regardless of the publication’s access policy, and were published up until 31 December 2024 in Portuguese, English, or Spanish.

This review opted to exclude studies that used devices or technological applications in respiratory rehabilitation. The decision was made to ensure that the analysed interventions were exclusively those carried out in a home setting with face-to-face interaction. Albeit technology plays an increasing role in respiratory rehabilitation, priority was given to the analysis of strategies that could be implemented in an approachable manner across different contexts without the need for advanced technological resources.

2.3. Research Strategy

The research was conducted in the following databases: MEDLINE (via PubMed) (Table 2), CINAHL (Table 3), and SCOPUS.

The preliminary research strategy combined natural language terms with indexed language, and it is important to note that the indexed terms were appropriately adapted to the specifics of each database, particularly standardised medical descriptors (MeSH) or standardised subject headings (subject headings). To structure the research, the terms were combined with Boolean operators OR and AND, following the PICO approach.

2.4. Data Extraction, Quality Appraisal, and Data Synthesis

Data extraction and coding were carried out independently by two reviewers. Any discrepancies were addressed by consulting with a third reviewer.

After identifying relevant articles in the selected databases, they were exported in “.ris” format to the Rayyan web application (available online https://www.rayyan.ai) to facilitate collaboration amongst reviewers during the study selection process. Initially, duplicates were removed. After that, the titles and abstracts were examined, and relevant studies were selected for full-text review.

After an initial review of titles and abstracts, studies that were deemed to be irrelevant were excluded. Full texts were read and examined according to the inclusion and exclusion criteria for potentially eligible studies.

For the selected studies, two researchers extracted key study characteristics into a table independently, including the study’s identification (author, year of publication, and country of origin), study design, objective, participants, and interventions. Data extraction was conducted by two researchers. Any discrepancies were addressed by consulting with a third reviewer.

Both the methodological quality and risk of bias of the included studies were independently assessed by two reviewers using JBI’s critical appraisal tools. Any discrepancies were addressed by consulting with a third reviewer.

3. Results

The database searches resulted in 257 articles (Figure 1). After removing duplicates, 186 articles remained. Title and abstract screening led to the exclusion of 144 articles. A total of 42 articles were read in full, of which 34 were excluded (Figure 1). As a result, eight articles were included in this study (Table 4).

The methodological quality of the included studies was assessed using JBI’s critical appraisal tools. The assessment included cohort studies (Table 5), randomised controlled trials (RCTs) (Table 6), and quasi-experimental studies (Table 7).

The studies were analysed independently by two reviewers, and any discrepancies were addressed by consulting with a third reviewer.

The analysed cohort studies showed variations in methodological quality. Study [30] met all established methodological criteria, ensuring good reliability of its results. However, study [29] showed weaknesses in essential criteria (items 4, 5, and 10), suggesting the need for cautious interpretation of its results.

The clinical trials included in the review, namely [27,28], revealed methodological weaknesses, especially in the blinding of subjects and evaluators (items two, four, and five). This limitation may compromise the internal validity of the studies, requiring caution in extrapolating the results.

The quasi-experimental studies showed variable methodological quality. Studies [32,33] met almost all methodological criteria, suggesting good bias control. By contrast, studies [31,34] showed weaknesses in bias control (item eight) and methodological clarity (item two).

Despite some limitations, most quasi-experimental studies can be considered methodologically robust.

This systematic review identified and analysed eight studies investigating interventions in pulmonary rehabilitation for older adults with COPD in a home setting. The identified interventions were categorised into five main areas (Table 8). When it was possible to clearly attribute an intervention to nursing professionals, a check mark (✓) was placed in the corresponding cell. When the intervention was delivered within a multidisciplinary team and the role of the nurse was not specifically distinguishable, the cell was marked with an “M”, indicating a multidisciplinary delivery involving nurses. This approach ensures clarity while respecting the methodological limitations of the primary studies.

4. Discussion

As identified in the analysis of the included studies, in studies [29,30], the interventions were carried out within the scope of multidisciplinary pulmonary rehabilitation programmes. However, it was not possible to clearly determine which interventions were specifically delivered by nurses. The lack of this distinction in the articles limits the direct attribution of certain practices to the nursing profession. Nevertheless, all the interventions analysed in this review were described as being performed by nurses in at least one of the included studies. Therefore, the following section presents a discussion of the identified interventions based on the available evidence.

To define pulmonary rehabilitation programmes for older adults with COPD, it is first necessary to identify the relevant rehabilitation interventions. According to Orem’s nursing theory, nursing interventions aimed at individuals with COPD should promote the development of self-care skills, specifically the following [16]: cognitive (knowing), instrumental (knowing how to do), and personal (knowing how to be). The findings of this systematic review identify five key areas in the development of programmes for older adults with COPD: health education, breathing training and physical exercise, personalised planning with monitoring and follow-up, psychological support, and oxygen therapy management. These findings align with the existing literature, which highlights the effectiveness of these approaches in promoting self-care and improving quality of life [8,35,36,37].

Health education is widely recognised as a fundamental pillar in the treatment of COPD, giving patients the necessary knowledge and skills for effective self-management of the disease [17]. The review identified five key topics commonly addressed in COPD education: understanding the condition, correct use of medication, smoking cessation, symptom and exacerbation management, and nutrition.

The incorrect use of inhalers is common, and it compromises therapy effectiveness, making continuous education by specialised nurses essential [36]. Recent publications highlight that education on the correct use of pharmacological therapy, particularly inhalers, is a priority intervention, as incorrect use is widespread and negatively impacts treatment efficacy [36,37]. This education should be ongoing, ideally provided during each visit, and it should include demonstrations and technique verification [8]. Recent studies suggest that this intervention should be carried out by specialised nurses, which would significantly improve patients’ performance [36].

The reviewed studies (approximately 87.5%) reinforce the need for interventions focused on the early identification of exacerbations and symptom management. Recent publications highlight these aspects as fundamental for reducing exacerbations and preventing hospitalisation, underlining their importance in minimising disease progression and healthcare burden [38].

Smoking cessation was also widely addressed in the reviewed studies (approximately 87.5%), as around 40% of people with COPD continue to smoke even after being diagnosed [39]. Nurses play a crucial role in supporting smoking cessation, using strategies and setting goals with patients [40].

Malnutrition is common among people with COPD [41,42] and it is associated with a worse prognosis [8]. A significant proportion of the reviewed studies (50%) highlighted the importance of nutritional counselling. According to recent studies, this should focus on increasing caloric and protein intake to improve nutritional status and quality of life in people with COPD [41].

Not only that, but still within the scope of health education, some studies (25%) included the importance of educating family members and caregivers.

The decline of physical activity and reduced exercise tolerance pose a challenge for individuals with COPD [43], as inactivity leads to a vicious cycle of exercise deconditioning, worsening dyspnoea, and muscle weakness [21,44].

Respiratory training and physical exercise are widely acknowledged in the literature as essential components of pulmonary rehabilitation [8] and were identified in the majority of the analysed studies. This review identified the following effective interventions: endurance (aerobic) and strength (anaerobic) training, functional respiratory retraining techniques, and energy conservation techniques.

The recent literature points to aerobic and strength training as essential strategies in pulmonary rehabilitation [35], as did some other studies (37,5%). Guided exercise sessions are recommended at least twice a week and may include a variety of programmes, e.g., resistance training, strength training, and interval training. Upper and lower limb exercises should be included, as well as walking exercises; flexibility exercises, inspiratory muscle training, and neuromuscular electrical stimulation may also be incorporated [8].

The most recent Global Initiative for Chronic Obstructive Lung Disease reinforces the importance of structured, supervised, and individualised pulmonary rehabilitation programmes [45]. These should ideally include exercise sessions at least twice per week, combining endurance and strength training, inspiratory muscle training, flexibility exercises, and, when appropriate, neuromuscular electrical stimulation. GOLD 2025 also emphasises the need to tailor these programmes to patients’ physical capabilities, preferences, and social contexts [45]. Furthermore, it recognises the role of home-based rehabilitation as a practical and equally effective alternative to traditional outpatient settings, particularly in populations with reduced mobility or limited access to healthcare services [45].

Functional respiratory retraining techniques such as diaphragmatic breathing and pursed-lip breathing are essential for optimising adaptation to exercise [17], with 50% of the studies highlighting their importance. On the other hand, as exacerbations in individuals with COPD often involve mucus hypersecretion, managing sputum retention is crucial [46]. This issue was also addressed in some studies (n = 4; 50%) that highlighted the importance of airway clearance techniques. Most international guidelines recommend the use of Positive Expiratory Pressure (PEP), which has achieved the greatest consensus [45]. In clinical practice, the recent literature indicates that the most frequently used techniques include the Active Cycle of Breathing, Positive Expiratory Pressure (PEP), Oscillating Positive Expiratory Pressure, Forced Expiratory Technique, and Postural Drainage, Percussion, and Vibration [46].

Individuals with COPD often experience severe dyspnoea, which significantly impacts their ability to perform activities of daily living (ADLs) [47]. In this regard, approximately 50% of the articles emphasised energy conservation techniques in their studies. The recent literature suggests that training in energy conservation techniques is a valuable approach to improving both the tolerance and execution of these ADLs [47].

The results of this study also highlight the importance of a tailor-made plan or at least one tailored intervention, as emphasised in all the articles. The literature points to the need for tailor-made programmes [35,48] to maximise the benefits of pulmonary rehabilitation [8], tailored to the individual needs and preferences of patients [48].

The importance of monitoring was also highlighted in the reviewed articles (50%). In this context, the continuous monitoring of people with COPD should include the assessment of symptoms, exacerbations, objective measurements through spirometry, the 6 min walk test or resting oxygenation assessment [8], as well as continuous home follow-ups and phone contact [28,34].

Anxiety and depression are common in people with COPD, worsened by the fear of exacerbations [36]. In this study, 75% of the articles addressed the relevance of psychological support. The recent literature states that therapies such as cognitive–behavioural interventions and counselling have been shown to be effective in reducing these symptoms, promoting greater emotional stability [36].

Oxygen therapy is often necessary in the treatment of COPD [49], and its correct administration is crucial to avoid complications [50]. The management of oxygen therapy in the pulmonary rehabilitation programme was also addressed by 37.5% of the articles. The recent literature states that nurses play a key role in monitoring the safe use of oxygen, ensuring its effectiveness and intervening in cases of complications [50]. And while there are no studies demonstrating the significant effect of supplemental oxygen use during physical training, many physicians provide oxygen for safety reasons and to improve patient comfort, as it reduces dyspnoea during physical training [48].

The reviewed studies show that nursing interventions in home-based pulmonary rehabilitation include multiple strategies, health education being one of the most frequently mentioned components. Recent research recommends health education to be an essential part of rehabilitation programmes [17]. Moreover, the findings of this review reinforce that the combination of multiple nursing intervention strategies tailored to the individual needs of elderly people with COPD can enhance treatment adherence, improve functionality, and reduce disease-related complications, ultimately improving their self-care.

The studies included were conducted in various countries, namely Turkey, the United States, Ireland, Italy, Australia, and Hong Kong. Most studies do not provide detailed descriptions of the healthcare systems or access mechanisms, and this diversity should be considered when interpreting the results.

Even though this review identified pulmonary rehabilitation interventions for people with COPD, several limitations should be considered, namely the inclusion of articles that were only published in specific databases, which may have limited the scope of the review, potentially excluding relevant studies available in other sources.

Additionally, this review excluded studies involving devices or mobile applications in order to maintain a clear focus on face-to-face nursing interventions delivered in the home setting. While such technologies may provide relevant benefits—particularly in remote monitoring and telehealth—their inclusion could have introduced considerable methodological variability and compromised the homogeneity of the analysis, which was centred on direct, hands-on nursing care.

Another limitation is the methodological diversity of the included studies, which presented varied designs, samples of different sizes, and heterogeneous approaches in the reviewed interventions. This heterogeneity made it difficult to draw direct comparisons between the studies and the generalisation of results.

Despite these limitations, the results of this study provide a relevant contribution to the knowledge of nursing interventions in pulmonary rehabilitation at home as a central strategy to promote self-care in elderly people with COPD. The identification of specific practices such as health education, respiratory training, physical exercise, tailor-made interventions with monitoring and follow-up of the elderly person, psychological support, and the management of oxygen therapy offers a valuable guide for nurses working in community settings.

Although recent studies have focused on promoting self-care in people with COPD [51], the World Health Organization (WHO) [52] emphasises the need for further research in this area, and the recent literature [9] advocates for the implementation of self-care adherence programmes for elderly people with COPD. This review contributes to advancing the field by proposing nursing interventions for pulmonary rehabilitation for elderly people with COPD. This review may guide the creation of more accessible and effective pulmonary rehabilitation programmes.

5. Conclusions

This systematic review identified and described home-based nursing interventions aimed at individuals with COPD, with a potential impact on self-care support. The main strategies include health education, respiratory training, physical exercise, personalised plans with monitoring and follow-up, psychological support, and the management of oxygen therapy. These interventions have been widely mentioned in the literature as strategies that are used to promote self-care and improve disease management, although the reviewed studies show differences in the adopted methodologies and approaches.

For the clinical practice, this review provides a foundation for structuring home-based pulmonary rehabilitation programmes, highlighting essential components that should be considered in the care of elderly people with COPD. Empowering nurses to implement these strategies and adapting interventions to individual needs are key aspects for optimising the provided care.

Additionally, it was found that the follow-up periods were often short, preventing the long-term sustainability of the effects of the interventions from being assessed.

In terms of research, the results highlight the need for studies that rigorously evaluate the effectiveness of these interventions for elderly people with COPD through randomised controlled trials (RCTs) with representative samples and appropriate follow-up periods to establish more robust recommendations for clinical practice, thereby strengthening the body of evidence on the effectiveness of nursing interventions in self-care for elderly people with COPD.

Moreover, it is essential that future studies identify in detail the specific needs of elderly people with COPD living at home. This knowledge will enable the design of increasingly personalised and effective pulmonary rehabilitation programmes that can meet the demands of an ageing society.

Competing interests

Conflicts of InterestThe authors declare no conflicts of interest.

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