<33312D3420BCBAC0CEB0A3C8A320B3EDB9AE2D33C2F72E687770>

Korean Journal of Adult Nursing Vol. 31. 4, 427-438, August 2019 ORIGINAL ARTICLE eissn 2288-338X https://doi.org/10.7475/kjan.2019.31.4.427 Open Access 만성폐쇄성폐질환비입원환자와급성악화로입원, 재입원하는환자특성비교 최자윤 1 윤소영 2 전남대학교간호대학교수 1, 남부대학교간호학과조교수 2 Comparisons of the Characteristics for n-hospitalized, Hospitalized, and Rehospitalized Patients due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease Choi, Ja Yun 1 Yun, So Young 2 1 Professor, College of Nursing, Chonnam National University, Gwangju, Korea 2 Assistant Professor, Department of Nursing, Nambu University, Gwangju, Korea Purpose: This study compares the characteristics of patients with Chronic Obstructive Pulmonary Disease (COPD) according to hospitalization frequency due to Acute Exacerbation (AE) using a retrospective medical records review. Methods: From August to October 2017, COPD patients who had visited the chonnam national university hospital were classified into three groups: (1) not hospitalization (n=115), (2) hospitalized once owing to AE (n=79) and (3) hospitalized twice or more owing to AE (n=47), and their medical records were reviewed. Data were analyzed using x 2, Kruskal Wallis, and Mann-Whitney tests, and logistic regression. Results: Home oxygen therapy, metered dose inhaler use, long-acting beta 2-agonist, and Inhaled Corticosteroids (ICS) were used most in patients who were hospitalized twice or more. Symptoms of dyspnea and fever, prescription of phosphodiesterase-4 and oral corticosteroid were the least frequent in the patients who were not hospitalized, and they had the best pulmonary function test results. Home oxygen therapy (Odds Ratio [OR]=9.59, 95% Confidence Interval [CI]=2.53~36.46), and prescribed ICS (OR=2.77, 95% CI=1.14~6.77) and phosphodiesterase-4 (OR=5.35, 95% CI=1.69~16.93) were significantly associated with COPD readmission. For patients who were hospitalized once, SpO 2 (p=.016), the frequency of positive pressure ventilation therapy (p=.023) and monitoring of oxygen saturation in nursing activities (p=.022) were higher than that of patients who were hospitalized twice or more. There was no significant difference in discharge education between the two hospitalized groups. Conclusion: Regardless of the severity of illness, presence of respiratory symptoms, drug prescribed, or admission frequency, there were no differences in nursing activities and discharge education. Key Words: Pulmonary disease, chronic obstructive; Patient readmission; Medical records; Nursing, practical 서론 1. 연구의필요성 만성폐쇄성폐질환 (Chronic Obstructive Pulmonary Disease, COPD) 은현재전세계적으로 11.7% 의높은유병률을보이며 [1], 2030년도에는사망원인 4위로예측되는질환이다 [2]. 국내의경우 40세이상 COPD의성인유병률은남자 21.1%, 여자 6.6%, 사망원인은 8위를기록하고있다 [3]. 또한세계적으로인구고령화와 COPD 위험인자에대한지속적인노출에의해 주요어 : 만성폐쇄성폐질환, 재입원, 의무기록, 간호실무 Corresponding author: Yun, So Young https://orcid.org/0000-0003-2562-4592 Department of Nursing, Nambu University, 23 Chumdan Jungang-ro, Gwangsan-gu, Gwangju 62271, Korea. Tel: +82-62-970-0391, Fax: +82-62-970-0399, E-mail: yunsy@nambu.ac.kr Received: May 16, 2019 / Revised: Jun 21, 2019 / Accepted: Jul 10, 2019 This is an open access article distributed under the terms of the Creative Commons Attribution n-commercial License (http://creativecommons.org/licenses/ by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2019 Korean Society of Adult Nursing http://www.ana.or.kr

Choi, JY Yun, SY COPD로인한사회 경제적인부담은지속적으로증가될것으로보고있다 [2]. COPD의급성악화는호흡기증상이평소변동범위를넘어서치료약제의변경을필요로하는정도의급격히악화된상태를말한다 [4]. 질병의심각도가중등도에서중증인 COPD 환자는 1년에 3회이상의급성악화를경험하고, 1년간재입원율은 25~80% 까지보고되고있다 [5]. 이처럼 COPD 의급성악화는재입원율을높이고사망과의료비상승을초래하여최근에 COPD 급성악화로인한재입원을막기위한관리전략에대해관심이높아지고있다. COPD 급성악화로인한재입원예측에관한국외연구에의하면폐기능손상, 급성악화빈도, 흉막삼출물동반, 비호흡근사용, 지속성베타작용제 (Long-Acting Beta 2-Agonist, LABA) 흡입제사용, 흡입스테로이드제 (Inhald Corticosteroids, ICS) 사용, 산소치료요법, 비침습적양압호흡, 재원기간, 나이, 골다공증등이위험인자로보고되었다 [5,6]. 국내의경우재택산소치료, 폐기능검사결과, 천식의동반질환, CRP (C-Reactive Protein) 상승이위험인자로보고되었고 [7] 국내 COPD 진료지침에서는과거입원병력, 경구스테로이드사용, 장기재택요법, 삶의질저하, 일상적신체활동감소등을재입원을예측할수있는위험인자로지적하였다 [4]. 이를종합해볼때 COPD 급성악화로인한재입원은폐기능이좋지못하거나약물, 산소요법등의복합적인처치를요하는경우, 지속된증상으로개인의일상생활에영향을미치는경우에발생하는경향이있다. COPD 재입원의고위험군인급성악화로입원한환자에게퇴원전질병에대한교육, 인플루엔자백신투여, 흡입기사용법및악화증상자가인지법등을익혀급성악화를예방하고관련증상을조기에인지함으로써재입원을줄이도록권고하고있다 [4,8]. 그러나재입원하는만성질환자들의자가간호및약물이행도가낮고 [9,10] 재입원여부에따라교육요구도가다르므로 [11] COPD 악화로재입원을반복하는환자를대상으로환자특성에맞는간호중재와퇴원관리를개발할필요가있다 [12]. 또한과거입원력은급성악화로인한입원빈도증가를설명하는변수이므로재입원이잦은환자뿐만아니라첫번째입원한환자역시향후재입원을예방할수있는예방적치료및간호중재가필요하다. GOLD (The Global Initiative for Chronic Obstructive Lung Disease)[13] 에서는 COPD 환자의 FEV1% pred (predicted % Forced Expiratory Volume in 1 minute) 와 1년동안급성악화횟수, 주관적증상경험정도에따라환자군을나누어각단계별약물치료방법을권고하고있다. 심한급성악화로입원한경험이있는환자를대상으로운동요법위주의가정 기반호흡재활치료요법을시행하였을때재입원율을줄일수있었고 [14], GOLD 분류상 III, IV 단계인환자를대상으로질병관련교육, 자가관리법, 통신기기를통한건강상태모니터링및의료진과의의사소통을통합한관리방법이 COPD 환자의삶의질을향상시켰다 [15] 는보고가있다. 그러나현재까지급성악화를자주경험하는군과그렇지않는군간의어떤차이로인해급성악화를경험하는가에대한고찰이부족하고, 급성악화로인한재입원이잦은 COPD 환자를위한약물처방이외에차별화된치료및간호중재의개발이미흡하다. 국내연구에서 1년이내급성악화로응급실방문이나재입원하는관련요인이천식의동반질환, 재택산소치료, CRP 상승이었고, 90일이내급성악화로인한병원재방문은폐기능검사결과와관련이있다고하였다 [7]. 국민건강보험공단의 COPD 환자자료를활용한연구에서재택산소치료는심한저산소혈증 (PaO2 55 mmhg) 일때재입원빈도를낮추지만저산소혈증이아닐경우에는관련이없었다 [16]. 그러나이러한연구들이치료중심의환자자료에집중되어있고급성악화를경험하지않은환자자료와의비교나간호중재관련특성들을확인하기어려웠다. 의무기록지조사를통한후향적연구를통해급성악화로입원한환자들과급성악화를경험하지않는환자들의특성을파악하고, 급성악화로재입원을반복하는환자들을고려한간호중재제공여부를확인하여이를바탕으로재입원을줄이기위한방안을모색할수있을것이다. 따라서본연구는 COPD 환자의급성악화로인한재입원을예방하기위한기초연구로서 COPD 비입원군, 급성악화로인한 1회입원군및급성악화로인한 2회이상입원군의특성을비교하고자시행되었다. 2. 연구목적본연구의목적은 COPD 비입원군과급성악화로인한 1회입원군, 급성악화로인한 2회이상입원군의일반적, 질병관련, 입원관련특성을비교하기위함이다. 연구방법 1. 연구설계 본연구는의무기록지조사를통해 COPD의급성악화로입원하는빈도에따른일반적, 질병관련특성을파악하고의료기관입원시제공된입원관련특성을비교하기위한후향적서 428 http://kjan.or.kr

A Study on the Medical Records of COPD AE 술적조사연구이다. 2. 연구대상연구대상은 2017년 8월부터 10월까지광주광역시소재 1개상급종합병원호흡기내과외래를방문한 COPD 환자를대상으로하였다. 대상자선정기준은 COPD를진단받은지 6개월이상인환자, 질병의중증도가 GOLD II단계이상인만 40세이상성인환자이다. 제외기준은주진단이천식과심장질환인환자, 입원원인이급성악화가아닌환자이다. 선정및제외기준에해당하는대상자중 2012년 8월에서 2017년 8월까지입원하지않고외래진료만받은환자는비입원군, 급성악화로인해응급실이나입원치료를 1회받은환자는급성악화 1회입원군, 급성악화로인한입원을 2회이상한환자를급성악화 2회이상입원군의세군으로분류하였다. 자료수집기간인 3개월간호흡기내과외래를방문한호흡기질환자총 6,246명중선정기준에해당하는환자는 241명이었다. 이중비입원군은 115 명, 급성악화 1회입원군은 79명, 급성악화 2회이상입원군은 47명이었다. 3. 연구도구의무기록지조사표의개발을위해국내 COPD 환자관련특성에대한인터넷을활용한문헌검색, 참고문헌조사, 의무기록지사전조사를시행하였다. 인터넷을활용한문헌검색으로 KMbase database를이용하여키워드 chronic obstructive pulmonary disease, 발행연도 2007~2017년으로검색하였다. 검색결과도출된 115개의문헌중, 연구팀이제목과초록의내용을확인하여 COPD 환자특성파악과관련이없는논문 87개를배제하여총 28개의문헌고찰을시행하였다. 호흡기질환환자간호경험이있는임상경력 8년이상의 2명의전문가가선정된문헌에서 COPD 환자에의미있는항목을추출하였고합의를통해추출된항목을일치시키는과정을거쳤다. 추출된항목은성별, 나이, 흡연력, 음주력, 동반질환, Body Mass Index (BMI), 질병기간, 재택산소치료, Metered Dose Inhaler (MDI) 사용, 주증상, COPD Assessment Test (CAT), modified Medical Research Council dyspnea scale (mmrc), 폐기능검사결과 (predicted % forced expiratory volume in 1 minute, FEV1%pred; divided by forced vital capacity, FEV1/FVC), GOLD 단계, 처방약물, 재원기간, 입원경유지, 입원중호소증상, 중환자실입원여부, 활력징후, 말초산소포화 도 (Peripheral capillary oxygen saturation, SpO 2), 동맥혈가스분석검사 (Arterial Blood Gas Analysis, ABGA), 혈액검사중백혈구수 (White Blood Cell, WBC), CRP이었다. COPD 급성악화입원환자에게제공된간호활동을조사하기위하여선행문헌 [17,18] 에제시된호흡기계간호활동중 SpO 2 모니터, 심호흡권장, 호흡기증상관찰, 기침및가래뱉기권장, 효과적인기침법설명, 자세, 불안완화, 흡인, 흉부타진, 흡입기사용법교육의 10가지항목을추출하였다. COPD 급성악화입원환자들에게제공된퇴원교육내용을조사하기위해의무기록지사전조사를시행하였다. 연구자는의무기록지에기록된 COPD 환자에게시행된퇴원교육항목을조사하였으며교육내용이포화에이를때까지총 12명의의무기록지사전조사를시행하였다. 도출된퇴원교육내용은자가관리, 식이, 금연, 예방접종, 운동, 흡입기사용법의 6가지항목이었다. 최종추출된항목은특성별로일반적특성, 질병관련특성, 입원관련특성으로분류하여의무기록지조사표의예비문항을작성하였다. 예비항목중 CAT, mmrc는의무기록지에기록되지않아최종조사표에서제외하였다. 최종개발한의무기록지조사표는호흡기내과전문의 2인과성인간호학전공교수 2인의전문가집단을통한내용타당도검증을받았으며 I-CVI (Item-level Content Validity) 는모두.80 이상이었다. 4. 자료수집자료수집은전자의무기록지를통하여후향적방법으로 2017년 8월 1일부터 2017년 10월 31일까지진행하였다. 자료수집에포함된기록지는간호정보조사지, 간호기록지, 활력징후기록지, 외래경과기록지, 퇴원간호계획, 의사처방전, 입퇴원기록지, 임상병리결과지였다. 급성악화 2회이상입원군의자료는최종입원시의자료를조사하였으며모든임상검사자료는입원당일혹인입원후첫번째측정자료를사용하였다. 자료수집은연구자가사전조사를시행하면서두명의연구보조원을 2시간동안훈련하였는데두명의훈련된연구보조원이각각조사하여일치도가 r=.80 이상이되었음을확인한후본조사를시행하였다. 연구자는간호학박사소지자로자료수집대상병원에서간호사로근무한경력이있고연구보조원은자료수집병원의실습경험이있는간호대학졸업생으로전자의무기록지의활용및해석이가능한자이다. 본조사에서불일치부분에대해서는합의를하여일치를이루도록하였다. 수집된자료는훈련된연구보조원에의해코딩이이루어졌다. Korean J Adult Nurs. 2019;31(4):427-438 429

Choi, JY Yun, SY 5. 윤리적고려본연구는의무기록자료수집에관한교육을받고대상병원의연구윤리위원회심의 (. CNUH- 2017-042) 를받아진행되었다. 자료수집을위해대상병원의의무기록실과해당진료과에연구목적과방법, 진행절차를설명하고협조를구하였으며전자의무기록에대해공식적인자료열람승인절차를거쳐시행하였다. 비교는 x 2 test (Fisher s exact test), Mann-Whitney 검정을이용하여분석하였다. COPD 환자의입원빈도에영향을미치는요인은로지스틱회귀분석을이용하여분석하였으며비입원군이기준이었다. 연속변수의정규성검정은 Shapiro-Wilk 검정을시행하였고정규성을만족하지못하여각군간의평균비교는비모수검정방법을사용하였다. 연구결과 6. 자료분석수집된자료는 SPSS/WIN 22.0 프로그램을이용하여분석하였고연구대상자의일반적특성은빈도, 실수, 백분율로나타내었다. 세군에대한특성비교는 x 2 test (Fisher s exact test) 와 Kruskal Wallis 검정, 추가검정및두군에대한특성 1. COPD 비입원군, 급성악화 1회입원군, 급성악화 2회이상입원군의일반적특성비교본연구에포함된연구대상자는남성이 197명 (81.7%) 이었고평균나이는 72.6세이었다. 성별, 나이, 흡연력, 음주력, 동반질환, BMI에서세군간차이가없었다 (Table 1). Table 1. Comparison of General Characteristics among Three Groups (N=241) Variables Categories Total t hospitalized (n=115) Hospitalized once (n=79) Hospitalized twice or more (n=47) x 2 or F p Gender Men Women 197 (81.7) 44 (18.3) 94 (81.7) 21 (18.3) 62 (78.5) 17 (21.5) 41 (87.2) 6(12.8) 1.51.469 Age (year) 59 60~69 70 16 (6.6) 63 (26.2) 162 (67.2) 72.58±8.70 7 (6.1) 34 (29.6) 74 (64.3) 72.43±8.73 8 (10.1) 14 (17.7) 57 (72.2) 72.75±9.56 1 (2.1) 15 (31.9) 31 (66.0) 72.62±7.50 6.64 0.03.156.968 Smoking state Smoking Quit smoking n-smoking 33 (13.7) 114 (47.3) 94 (39.0) 22 (19.1) 52 (45.2) 41 (35.7) 7 (8.8) 36 (45.6) 36 (45.6) 4 (8.5) 26 (55.3) 17 (36.2) 6.85.144 Alcohol consumption 45 (18.7) 179 (74.3) (n=100) 21 (21.0) 79 (79.0) (n=78) 19 (24.4) 59 (75.6) (n=46) 5(10.9) 41 (89.1) 3.37.185 Comorbidity Cardiovascular 106 (44.0) 135 (56.0) 57 (49.6) 58 (50.4) 29 (36.7) 50 (63.3) 20 (42.6) 27 (57.4) 1.20.203 Diabetes 37 (15.4) 204 (84.6) 17 (14.8) 98 (85.2) 10 (12.7) 69 (87.3) 10 (21.3) 37 (78.7) 1.74.419 Musculoskeletal 5 (2.1) 236 (97.9) 3 (2.6) 112 (97.4) 1 (1.3) 78 (98.7) 1 (2.1) 46 (97.9) 0.55.854 Lung cancer 13 (5.4) 228 (94.6) 5 (4.3) 110 (95.7) 7 (8.9) 72 (91.1) 1 (2.1) 46 (97.9) 2.66.245 Esophageal reflux 33 (13.7) 208 (86.3) 14 (12.2) 101 (87.8) 10 (12.7) 69 (87.3) 9(19.1) 38 (80.9) 1.48.477 BMI 22.59±3.75 22.79±3.34 22.82±3.65 21.70±4.65 1.64.196 BMI=body mass index; Fisher's exact test. 430 http://kjan.or.kr

A Study on the Medical Records of COPD AE 2. COPD 비입원군, 급성악화 1회입원군, 급성악화 2회이상입원군의질병관련특성비교급성악화 2회이상입원군은비입원군, 1회입원군보다재택산소치료를가장많이시행하였고 (x 2 =29.96, p<.001) 급성악화 1회입원군또한비입원군보다재택산소치료횟수가많았다. 그리고 MDI 사용도급성악화 2회이상입원군에서비입원군, 1회입원군보다가장많이시행하였고 (x 2 =8.95, p=.011) 비입원군과 1회입원군에서는사용횟수에차이가없었다. 증상의경우급성악화 1회입원군과 2회이상입원군모두비입원군에비해호흡곤란 (x 2 =11.86, p=.003), 발열증상 (x 2 =13.60, p=.001) 이많았다. FEV1% pred 와 FEV1/FVC 는비입원군에서가장높았고 (F=25.78, p<.001; F=6.45, p=.040) GOLD 단계는비입원군과 1회입원군에서 II단계 (68.7%, 53.2%), 2회이상입원군에서는 III단계 (53.2%) 가가장많았으며세군간차이가있었다 (x 2 =24.53, p<.001). 처방약물에서지속성베타작용제와흡입스테로이드제는 2회이상입원군에서가장많이처방되었고 (x 2 =9.34, p=.009; x 2 =16.91, p<.001), 포스포디에스터라제 4 (Phosphodiesterase-4) 와경구용스테로이드제 (oral corticosteroid) 는비입원군에서가장적게처방되었다 (x 2 =14.08, p=.001; x 2 =8.90, p=.011). 질병기간, 기침과가래증상, 지속성항콜린제 (Long-Acting Muscarinic-Antagonist, LAMA), 메틸잔틴 (Theophylline), 항생제의처방은세군간에유의한차이가없었다 (Table 2). 3. COPD 입원빈도에영향을미치는일반적및질병관련특성 COPD 입원빈도 ( 비입원 : 비교기준그룹, 1회입원, 2회이상입원 ) 를종속변수로일반적및질병관련특성중단변량검증에서유의한변수를설명변수로하는다항로지스틱회귀분석을 5% 의유의수준에서실시하였다. 단 FEV1% pred, FEV1/ FVC 및 GOLD stage 중나머지두변수를반영하는 GOLD stage를선택하였다. 통계적으로모형은적합하였고 (x 2 (24, N=241)=109.22, Nagelkerke R 2 =.42, p<.001), 재택산소치료, 증상중호흡곤란, 처방약물중흡입스테로이드제및포스포디에스터라제 4가통계적으로유의한변수였다. 재택산소치료를시행한경우는비입원군에비해급성악화 1회입원군의승산비가 4.68 (CI=1.28~17.12) 배높았고급성악화 2회이상입원군의승산비가 9.59 (CI=2.53~36.46) 배높았다. 증상중호흡곤란이있는경우는비입원군에비해급성악화 1회입원 군의승산비가 2.55 (CI=1.25~5.18) 배높았다. 처방약물중흡입스테로이드제를사용한경우는비입원군에비해급성악화 2 회이상입원군의승산비가 2.77 (CI=1.14~6.77) 배높았다. 처방약물중포스포디에스터라제 4를복용한경우는비입원군에비해급성악화 1회입원군의승산비가 3.21 (CI=1.15~8.94) 배높았고, 급성악화 2회이상입원군의승산비가 5.35 (CI=1.69~ 16.93) 배높았다 (Table 3). 4. COPD 급성악화 1회입원군과급성악화 2회이상입원군의입원관련특성비교 COPD 급성악화 1회입원군의 SpO 2 수치와양압환기법치료빈도가급성악화 2회이상입원군보다높았고 (Z=-2.41, p=.016; x 2 =7.17, p=.023) 입원기간, 입원경로, 입원시호소증상, 중환자실입원, 활력징후, WBC, CRP, ABGA 는두군간에유의한차이가없었다. 가장빈번하게수행한간호활동은 SpO 2 모니터 (84.1%) 이었고, SpO 2 모니터는급성악화 1회입원군에서급성악화 2회이상입원군보다더자주시행되었다 (x 2 =5.24, p=.022). 퇴원교육빈도는두군간에유의한차이가없었다 (Table 4). 논의 본후향적서술적조사연구에서는의무기록지검토를통해 COPD 급성악화로입원하는빈도 ( 비입원, 1회입원, 2회이상입원 ) 에따른일반적, 질병관련특성과입원관련특성을비교하였고급성악화로인한재입원의영향요인에대해분석하였다. 연구결과 2회이상입원군의높은재택산소치료, MDI 사용, 호흡곤란, 발열빈도와폐기능감소를확인하였고, 비입원군과 2회이상입원군의처방약물차이를확인하였다. 입원군간의특성차이는 SpO 2 수치와양압환기법이었고 SpO 2 모니터를제외하고간호활동과퇴원교육빈도에차이가없었다. 질병관련특성에서재택산소치료, MDI 사용, 호흡곤란과발열증상발현, 폐기능검사수치와 GOLD 단계, 지속성베타작용제, 흡입스테로이드제의사용, 포스포디에스터라제 4와경구용스테로이드제사용이세군간에차이가있었다. MDI 사용여부는급성악화 2회이상입원군에서가장많이 MDI를처방받아사용하였고, 비입원군, 급성악화 1회입원군과각각비교했을때도유의하게처방빈도가높았다. COPD 환자의증상관리와약물치료는일반적으로 MDI를사용하여이루어지고있지만 [4] 고령의환자들은사용방법을잘기억하지못하거나잘못된방법으로사용하기도한다. 실제 COPD 환자에서 MDI Korean J Adult Nurs. 2019;31(4):427-438 431

Choi, JY Yun, SY Table 2. Comparison of Disease-related Characteristics among Three Groups (N=241) Variables Categories Total t nospitalized a (n=115) Hospitalized once b (n=79) Hospitalized twice or more c (n=47) χ² or F p (additional test) Disease duration (month) 62.31±52.50 57.71±54.66 64.25±53.78 70.29±44.15 5.91.052 Home oxygen therapy 34 (14.1) 207 (85.9) 4 (3.5) 111 (96.5) 13 (16.5) 66 (83.5) 17 (36.2) 30 (63.8) 29.96 <.001 (a b, b c, a c) MDI use 212 (88.0) 29 (12.0) 100 (87.0) 15 (13.0) 65 (82.3) 14 (17.7) 47 (100.0) 8.95.011 (a b, b c, a c) Symptoms Dyspnea 160 (66.4) 81 (33.6) 64 (55.7) 51 (44.3) 62 (78.5) 17 (21.5) 34 (72.3) 13 (27.7) 11.86.003 (a b, b c, a c) Sputum 120 (49.8) 121 (50.2) 49 (42.6) 66 (57.4) 44 (55.7) 35 (44.3) 27 (57.4) 20 (42.6) 4.58.101 Cough 101 (41.9) 140 (58.1) 43 (37.4) 72 (62.6) 37 (46.8) 42 (53.2) 21 (44.7) 26 (55.3) 1.90.387 Fever 14 (5.8) 227 (94.2) 115 (100.0) 9(11.4) 70 (88.6) 5 (10.6) 42 (89.4) 13.60.001 (a b, b c, a c) Pulmonary function test FEV1 % pred 52.30±16.63 57.00±14.86 51.57±16.88 42.04±15.78 25.78 <.001 (a b, b c, a c) FEV1/FVC 50.48±12.02 52.46±11.83 49.37±10.86 47.48±13.62 6.45.040 (a b, b c, a c) GOLD stage II III IV 134 (55.6) 85 (35.3) 22 (9.1) 79 (68.7) 30 (26.1) 6 (5.2) 42 (53.1) 30 (38.0) 7 (8.9) 13 (27.7) 25 (53.2) 9 (19.1) 24.53 <.001 (a b, b c, a c) Prescription drug LABA 185 (76.8) 56 (23.2) 83 (72.2) 32 (27.8) 58 (73.4) 21 (26.6) 44 (93.5) 3 (6.4) 9.34.009 (a b, b c, a c) LAMA 164 (68.0) 77 (32.0) 70 (60.9) 45 (39.1) 60 (75.9) 19 (24.1) 34 (72.3) 13 (27.7) 5.39.067 ICS 97 (40.2) 144 (59.8) 36 (31.3) 79 (68.7) 30 (38.0) 49 (62.0) 31 (66.0) 16 (34.0) 16.91 <.001 (a b, b c, a c) Oral theophylline 86 (35.7) 155 (64.3) 42 (36.5) 73 (63.5) 25 (31.6) 54 (68.4) 19 (40.4) 28 (59.6) 1.06.590 Antibiotics 42 (17.4) 199 (82.6) 14 (12.2) 101 (87.8) 17 (21.5) 62 (78.5) 11 (23.4) 36 (76.6) 4.29.117 PDE4 inhibitor 34 (14.1) 207 (85.9) 7 (6.1) 108 (93.9) 14 (17.7) 65 (82.3) 13 (27.7) 34 (72.3) 14.08.001 (a b, b c, a c) Oral corticosteroid 7 (2.9) 234 (97.1) 115 (100.0) 3 (3.8) 76 (96.2) 4 (8.5) 43 (91.5) 8.90.011 (a b, b c, a c) FEV1 % pred=forced expiratory volume in 1 second % predictive; FEV1/FVC=ratio of forced expiratory volume in 1 second to forced vital capacity; GOLD=global initiative for chronic obstructive lung disease; ICS=inhalded corticosteroids; LABA=long-acting beta 2-agonist; LAMA=long-acting muscarinic-antagonist; MDI=metered dose inhaler; PDE4 inhibitor=phosphodiesterase-4; Fisher's exact test. 432 http://kjan.or.kr

A Study on the Medical Records of COPD AE Table 3. Factors Influencing Hospitalization in Patients with Chronic Obstructive Pulmonary Disease Frequency B SE Wald p Exp (B) Hospitalization =1 (n=194) Intercept -0.89 0.78 1.31.252 95% CI for Exp (B) Home oxygen therapy=yes 1.54 0.66 5.43.020 4.68 1.28~17.12 MDI use=yes -0.60 0.48 1.54.214 0.55 0.21~1.42 Dyspnea=yes 0.93 0.36 6.67.010 2.55 1.25~5.18 Fever=yes 18.30 2,322.26 0.00.994 88,996,747.17 0.00~NA GOLD stage=2-0.17 0.70 0.06.810 0.85 0.21~3.33 GOLD stage=3 0.36 0.71 0.26.612 1.43 0.35~5.73 LABA=yes -0.15 0.39 0.14 705 0.86 0.40~1.60 ICS=yes 0.18 0.37 0.25.620 1.19 0.59~2.46 PDE4 inhibitor=yes 1.16 0.52 4.92.026 3.21 1.15~8.94 Corticosteroid=yes 18.01 3,599.84 0.00.996 65,981,051.59 0.00~NA Hospitalization 2 (n=162) Intercept -18.80 0.96 386.57.000 Home oxygen therapy=yes 2.26 0.68 11.02.001 9.59 2.53~36.46 MDI use=yes 16.35 0.00 NA NA 12,559,316.26 12,559,316.26 ~12,559,316.26 Dyspnea=yes 0.07 0.46 0.02.879 1.07 0.44~2.63 Fever=yes 18.20 2,322.26 0.00.994 80,205,163.99 0.00~NA GOLD stage=2-0.92 0.77 1.46.227 0.40 0.09~1.78 GOLD stage=3 0.17 0.74 0.05.825 1.18 0.27~5.07 LABA=yes 0.86 0.72 1.43.232 2.35 0.58~9.54 ICS=yes 1.02 0.46 5.02.025 2.77 1.14~6.77 PDE4inhibitor=yes 1.68 0.59 8.15.005 5.35 1.69~16.93 Corticosteroid=yes 18.52 3,599.84 0.00.996 11,088,2181.41 0.00~NA CI=confidence interval; GOLD=the global initiative for chronic obstructive lung disease; ICS=inhalded corticosteroids; LABA=long-acting beta 2-agonist; MDI=metered dose inhaler; NA=not available; PDE4 inhibitor=phosphodiesterase-4; SE=standard error; FEV1 % pred and FEV1/FVC was excluded. 의부정확한사용은흡입기의종류에따라 53% 까지보고되었고 MDI를부정확하게사용한군은정확하게사용하는군보다 CAT 점수가높았으며호흡기증상을더호소하는것으로나타났다 [19]. MDI를정확하게사용하지않으면약물의효과가떨어져증상관리에성공하지못하기때문에약물복용순응도가떨어질수있다. COPD 환자의약물순응도는재입원까지의걸리는시간에영향을미치므로 [10] 기존에 MDI 를처방받아사용하고있는환자들의사용법에대한점검과효과적인교육방법을적용한교육이필요하다. 그러나입원관련특성에서급성악회 2회이상입원군의 MDI 사용법에대한교육은입원중 1.6%, 퇴원시 35.7% 로그빈도가낮았다. 특히입원중 MDI 사 용법에대한교육빈도가 1.6% 로매우낮은이유는입원환경에서기관지확장제의급성기약물치료가 MDI 보다네뷸라이저를통해시행되기 [4] 때문인것으로보인다. 발열증상은비입원군에서는없었고입원경험이있는나머지두군에서는각각 11.4%, 10.6% 에서호소하는것으로나타났으며세군간단변량검정에서유의한차이가있었다. COPD 급성악화의가장일반적인원인은기도감염 [20] 이므로입원을경험했던두군에서기도감염의증상인발열을주증상으로호소한빈도가높은것으로보인다. 추가검정에서발열증상이두입원군에서차이가없었고, 입원관련특성비교에서도입원을경험했던두군의발열증상은차이가없었다. GOLD 분류 III Korean J Adult Nurs. 2019;31(4):427-438 433

Choi, JY Yun, SY Table 4. Comparisons of Hospitalization-related Characteristics between Two Hospitalized Groups Variables Categories Total Hospitalized once (n=79) Hospitalized twice or more (n=47) χ² or Z p Length of stay (day) 10.71±6.33 9.91±5.81 12.04±6.98-1.95.051 Route of hospitalized 1.88.208 Symptoms Dyspnea Sputum Cough Fever ICU admission Outpatient ER 11 (8.7) 115 (91.3) 71 (56.3) 55 (43.7) 17 (13.5) 109 (86.5) 10 (7.9) 116 (92.1) 26 (20.6) 100 (79.4) 5 (4.0) 121 (96.0) 9(11.4) 70 (88.6) 40 (50.6) 39 (49.4) 13 (16.5) 66 (83.5) 8(10.1) 71 (89.9) 16 (20.3) 63 (79.7) 5 (6.3) 74 (93.7) 2 (4.3) 45 (95.7) 31 (66.0) 16 (34.0) 4 (8.5) 43 (91.5) 2 (4.3) 45 (95.7) 10 (21.3) 37 (78.7) 47 (100.0) (N=126) 2.81.093 1.59.207 1.39.391 0.02.891 1.83.293 SBP (mmhg) 124.33±12.76 123.96±18.64 124.94±16.12-0.04.705 DBP (mmhg) 75.75±9.00 76.00±12.73 75.75±12.16-0.16.873 Pulse (rate per min) 92.33±12.18 91.92±17.89 93.01±15.19-0.38.705 Respiration (rate per min) 21.17±1.60 21.24±2.50 21.01±1.87-0.50.618 Temperature ( ) 36.87±2.00 36.63±0.62 37.27±4.47-0.27.786 SpO 2 (%) 91.80±4.62 92.14±7.60 90.90±3.93-2.41.016 WBC*109/L 11.13±3.44 11.09±5.14 11.37±5.42-0.82.411 CRP (mg/l) 7.33±5.09 7.92±7.64 7.78±6.58-0.21.830 ABGA Positive pressure ventilation Nursing activities SpO 2 monitoring Encourage deep breathing Observation of respiratory symptoms Encourage cough & expectoration Explain effective cough Positioning Relieve anxiety Suction Chest percussion Training MDI use Education at discharge Self-management Diet Smoking cessation Vaccination Excercise MDI use Arterial ph PaCO 2 (mmhg) n-invasive Invasive ne (n=92) 7.43±0.06 42.02±12.62 7 (5.5) 4 (3.2) 115 (91.3) 106 (84.1) 20 (15.9) 91 (72.2) 35 (27.8) 81 (64.3) 45 (35.7) 72 (57.1) 54 (42.9) 25 (19.8) 101 (80.2) 9 (7.1) 117 (92.9) 7 (5.6) 119 (94.4) 5 (4.0) 121 (96.0) 4 (3.2) 122 (96.8) 2 (1.6) 124 (98.4) 101 (80.2) 25 (19.8) 94 (74.6) 32 (25.4) 63 (50.0) 63 (50.0) 60 (47.6) 66 (52.4) 52 (41.3) 74 (58.7) 45 (35.7) 81 (64.3) (n=59) 7.42±0.06 40.63±10.60 7 (8.8) 4 (5.1) 68 (86.1) 71 (89.9) 8(10.1) 53 (67.1) 26 (32.9) 48 (60.8) 31 (39.2) 40 (50.6) 39 (49.4) 17 (21.5) 62 (78.5) 5 (6.3) 74 (93.7) 3 (3.8) 76 (96.2) 3 (3.8) 76 (96.2) 1 (1.3) 78 (98.7) 2 (2.5) 77 (97.5) 63 (79.7) 16 (20.3) 57 (72.2) 22 (27.8) 40 (50.6) 39 (49.4) 34 (43.0) 45 (57.0) 32 (40.5) 47 (59.5) 27 (34.2) 52 (65.8) (n=33) 7.44±0.06 44.51±15.46 47 (100.0) 35 (74.5) 12 (25.5) 38 (80.9) 9(19.1) 33 (70.2) 14 (29.8) 32 (68.1) 15 (31.9) 8(17.0) 39 (83.0) 4 (8.5) 43 (91.5) 4 (8.5) 43 (91.5) 2 (4.3) 45 (95.7) 3 (6.4) 44 (93.6) 47 (100.0) 38 (80.9) 9(19.1) 37 (78.7) 10 (21.3) 23 (48.9) 24 (51.1) 26 (55.3) 21 (44.7) 20 (42.6) 27 (57.4) 18 (38.3) 29 (61.7) -0.87.388-1.42.205 7.17.023 5.24.022 2.78.095 1.15.284 3.66.056 0.37.540 0.21.726 1.25.423 0.02 >.999 2.51.146 1.21.529 0.02.881 0.67.412 0.03.854 1.78.182 0.05.821 0.22.641 ABGA=arterial blood gas analysis; CRP=C-reactive protein; DBP=diastolic blood pressure; ER=emergency room; ICU=intensive care unit; MDI=metered dose inhaler; PaCO 2=arterial carbon dioxide tension; SBP=systolic blood pressure; SpO 2=peripheral capillary oxygen saturation; Fisher's exact test. 434 http://kjan.or.kr

A Study on the Medical Records of COPD AE 과 IV단계의 COPD 환자를대상으로한연구에서기도감염으로급성악화가발생하여입원하는위험요인중발열증상이유의한변수로밝혀졌는데 [21] 이러한결과는발열증상이급성악화로인한입원과비입원을구별할수있는중요한변수라고생각된다. 본연구의대상자인급성악화 2회이상입원군의 72.3% 가중증도 III단계 (GOLD의 COPD 중증도분류 ) 이상이었으나비입원군과급성악화 1회입원군은각각 31.3%, 46.9% 만이중증도 III단계이상에해당되어급성악화로입원을반복하는군일수록질병의심각도가나쁜것으로나타났다. 폐기능검사에서도 FEV1% pred 와 FEV1/FVC는급성악화 2회이상입원군에서가장낮았고비입원군에서가장높은결과를보였으며세군간에유의한차이를보인것으로나타났다. 이는폐기능이 COPD 중증도를평가하는주요한지표가되며급성악화시기도협착이발생하여폐기능이떨어지는경향을보인결과이기도하다 [10]. 실제 COPD의급성악화를반복하는환자들에대한연구 [22] 에서도재입원을반복할수록 COPD의중증도가높은것으로나타났다. 폐기능은 COPD 의중증도와질병과정을대변하며급성악화로인한입원횟수와도관련이있으므로지속적폐기능모니터를통한 COPD 환자의중증도평가가중요하다. 그러나로지스틱회귀분석에서는질환의중증도가입원빈도에영향을미치는것으로나타나지않았다. COPD 환자의지식, 태도, MDI 사용및자가관리이행간의관계를확인한연구에서 COPD 중증도에따라지식, 태도 MDI 사용및자가관리이행에차이가없었고 [23], COPD 중증도에따른자가관리, 증상경험, 삶의질에대한연구에서질병의중증도와자가관리정도가관련이없고, 오히려중증도가심한환자군에서질환의심각성을인식하지못하고자가관리정도가낮았다 [24]. 따라서폐기능의모니터와함께질병진행상태에따른증상조절과자가관리전략의수립과이행을도움으로써재입원을막는전략이필요하다. 재택산소치료, 호흡곤란증상, 포스포디에스터라제 4 사용이비입원군에비해급성악화 1회입원군의승산비가높았고, 재택산소치료, 흡입스테로이드제, 포스포디에스터라제 4 사용이비입원군에비해급성악화 2회이상입원군의승산비가높았다. 재택산소치료는기도폐쇄나폐의파괴가심한진행된 COPD 환자에서저산소혈증을완화하고자시행되는데본연구에서비입원군에서 3.5% 로그빈도가낮았고급성악화 1회입원군과 2회이상재입원군에서각각 16.5%, 36.2% 로비입원군보다빈도가높았다. 본연구결과는 COPD 급성악화횟수가잦을수록재택산소치료가요구된다는연구결과 [23] 와일치하 였다. 호흡곤란증상은증상중유일하게로지스틱회귀분석에서비입원군에비해급성악화 1회입원군의승산비가높았다. 비입원군의 FEV1% pred가다른군보다상대적으로높아호흡곤란을주증상으로보고한빈도가낮았던것으로판단된다. FEV1% pred가낮을수록호흡곤란이심해지지만실제폐기능검사결과가 COPD 환자의호흡곤란정도와일치율이높지않은데 [4] 이는호흡곤란증상이환자의주관적표현이기때문이며종종 COPD 환자에게서급성호흡곤란이불안을표현하는방법이되기때문이다 [25]. 본연구결과에서도 1회입원군이급성악화를처음경험하면서급성호흡곤란과함께불안이함께표현됨으로써 2회이상입원군보다호흡곤란을더호소한것으로생각된다. 흡입스테로이드제, 포스포디에스터라제 4는 COPD 약물단계치료가이드라인에서 FEV1% pred 가 60% 미만이거나지난 1년동안 2회이상급성악화가있었거나 COPD로입원할정도로심한악화가 1회이상있었던경우에해당하는대상자에게지속성베타작용제, 흡입스테로이드제가포함된처방 (LABA+LAMA, ICS/LABA, ICS+LABA+LAMA) 을사용하도록권장하고, 급속악화의병력이있거나충분한치료후에도증상이지속되는경우포스포디에스터라제 4, 구강스테로이드를처방하는약물치료가이드라인 [13] 에부합하는결과였다. 입원관련특성에서급성악화 1회입원군이 2회이상입원군보다 SpO 2 와양압환기치료빈도가높았으며급성악화 1회입원군에서 SpO 2 모니터가더자주시행되었다. SpO 2 수준의차이는두군의폐기능차이로인해폐환기수준이다르기때문이다. 2회이상입원군에서 SpO 2 가더낮음에도불구하고 SpO 2 모니터빈도가급성악화 1회입원군보다낮게나타났는데 2회이상입원군은 GOLD 분류상다른군보다중증도가높고다른군보다가스교환장애가악화되어저산소혈증으로인해평소 SpO 2 가낮은특징을보이므로 [4] 급성악화 1회입원군환자보다 SpO 2 수준에민감하게반응하지않은것으로생각된다. SpO 2 감소는특히낮은 FEV1% pred와매우밀접한관련이있고 [26], 급성악화시에관찰할수있는신체적변수이다 [27]. FEV1 % pred의평균이 50% 미만으로나타난급성악화 2회이상입원군에서폐기능상태를반영하는가장간편한방법이 SpO 2 모니터이므로 SpO 2 감소여부를지속적으로모니터하는중재가필요하다. 급성악화 2회이상입원군은침습적 비침습적양압환기치료를받지않는것으로나타났는데이는본연구가외래환자를대상으로하여타병원전원및사망환자의자료가포함되지않았고, 자료수집기간이호흡기내과외래를방문한환자를대상으로 3개월인점, 폐기능이심하게떨어져있 Korean J Adult Nurs. 2019;31(4):427-438 435

Choi, JY Yun, SY 는 COPD 환자의기계환기에대한의존성으로기계환기이탈이어렵거나사망률이높아선호하지않는등 [4,28] 의이유로양압환기치료의적용빈도가적은것으로판단된다. 비침습적양압환기법은 COPD 급성악화로입원한환자에서사망률을낮출수있는표준치료로알려져있지만 [4], 최근시행된체계적문헌고찰에서는비침습적양압환기가 COPD 환자의가스교환능력, 운동능력, 폐기능, 장기간사망률에효과가없는것으로나타나 [29] COPD 급성악화에서비침습적양압환기적용효과에대한연구들이더필요하다고생각된다. 급성악화로인한 1회입원과 2회이상입원환자의경우고위험군에해당된다. 우리나라는 COPD로입원하는비율이 OECD (Organization for Economic Cooperation and Development) 국가평균에비해매우높은수준 ( 우리나라 214.2명 vs. OECD 국가평균 190.6명 / 인구 10만명 ) 인데, COPD는외래에서효과적으로진료가이루어지면질병악화와입원을예방할수있는대표적인외래민감성질환이다 [30]. 따라서입원시적절한간호활동과퇴원시환자맞춤형퇴원교육이급성악화를예방하여다빈도재입원을줄일수있는매우중요한전략중하나이다. 그런데본연구에서입원특성을비교한결과 1회입원환자와 2회이상입원환자에서간호중재중 SpO 2 모니터에서만차이가있었고, 퇴원교육에서는전혀차이가없었다. 또한불안완화에대한간호활동이두군에서각각 3.8%, 8.5% 로시행빈도가낮음을알수있었다. 본연구가의무기록을분석한연구의제한점에따라불안완화간호활동빈도가낮은이유가기록의누락일수도있지만불안은 COPD의호흡곤란발생에기여하고생명을위협하는급성악화시에더두드러지며건강관련삶의질을저하시키고사망위험을증가시키므로 [31] 기록을누락시킬정도의간호활동은아니라고생각된다. COPD 입원환자의건강결과에영향을미치는불안을인식하고침상에서적용할수있는이완요법등을활용한간호중재의개발및적용에대한연구가필요하다 [32]. 퇴원교육에서각항목의교육빈도는두군간에유의한차이가없었다. 입원군의퇴원교육내용에서운동과 MDI 교육이 41.3%, 35.7% 에서만시행되었고금연교육과예방접종에대한내용은 50%, 47.6% 에서시행되었다. 자가관리, 식이, 금연교육, 예방접종, 운동, MDI 교육에대한항목이 COPD 환자의비약물적관리방법에있어모두포함해야할내용이지만연구결과퇴원교육내용이충분하지않은것으로확인되었다. 게다가급성악화로입원한환자대상조기호흡재활요법이재입원위험을줄이는데효과적이나 [33] 본연구결과에서는퇴원교육시호흡재활요법의시행이나의뢰가제공되지않은것으로나 타났다. COPD 환자의퇴원교육은일방적인정보제공보다는교육의질을고려해서체계적으로접근해야하며 [34] 급성악화로인한재입원가능성을개별적으로평가한후지식, 증상관리방법, 생활습관등을강화시키거나개선시켜나가야한다고생각된다. 이러한퇴원교육을환자맞춤형으로접근하여질높은교육을시행하기위해서는해당업무를독립적으로관장하고전문화되어있는전문간호사의활용도필요하다 [34,35]. 또한다학제적인호흡재활요법이지역사회건강프로그램안에서보편적으로시행될수있는제도적장치나관련전문가집단의인식변화, 우리나라실정에맞는호흡재활프로그램의개발이필요하다. 본연구의제한점은일지역의상급종합병원을대상으로하였고연구기간동안외래방문환자를대상으로의무기록지를조사하여전원및사망한환자에대한자료가배제되었다. 추후연구에서는이를고려하여지역과대상병원을확대하고다양한환자자료가포함되도록할필요가있다. 그리고 COPD 환자들에게입원중제공된간호활동및퇴원교육에대한의무기록지조사가질적수준을파악하기어려운점이있으므로실제간호사를대상으로 COPD 재입원환자들에대한인식과제공되는간호활동및퇴원교육의차이점에대해조사해볼필요가있다고생각한다. 결론및제언 만성폐쇄성폐질환의재입원은보건의료비용상승과사망률및삶의질과관련된요인으로써이를예방하기위한노력이필요하다. 본연구는급성악화로재입원을하는빈도에따라관련특성이있는지의무기록지조사를통하여실시하였다. 각군들의질병관련특성을비교하였고재택산소치료법, 흡입스테로이드제, 포스포디에스터라제 4 사용은비입원군에비해재입원의가능성을높이는것으로나타났다. 입원시제공되는간호활동과퇴원간호중재내용에대하여알아보았으나급성악화로인한입원빈도에따라제공되는간호활동과퇴원간호중재의서로다른특성은확인하지못하였다. COPD 급성악화로재입원을반복하는환자에게낮아진폐기능에적응하고재택산소치료에대한관리법과 SpO 2 모니터에대한교육이필요하며 MDI 에대한올바른사용, 약물교육과급성악화시호흡곤란, 발열을비롯한증상발현시행동중재에대한교육이필요할것으로생각된다. 급성악화로인해반복되는재입원을막기위하여급성악화로인한입원위험군을대상으로외래나병동에서불안중재, 폐재활요법등자가관리법을재점검할필요가 436 http://kjan.or.kr

A Study on the Medical Records of COPD AE 있고이를결과를바탕으로자가관리방법의체계적이고구체적인접근이필요하다. 따라서 COPD 급성악화로인한재입원을줄이기위해증상악화에대한행동지침을포함한자가관리프로그램개발과지역사회와연계된자가관리프로그램개발및효과검증연구를제안하는바이다. CONFLICTS OF INTEREST The authors declared no conflict of interest. AUTHORSHIP Study conception and design acquisition - CJY and YSY; Data collection - YSY; Analysis and interpretation of the data - CJY and YSY; Drafting and critical revision of the manuscript - CJY. ACKNOWLEDGEMENT This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (2016R 1D 1A 3B03933227). REFERENCES 1. Adeloye D, Chua S, Lee C, Basquill C, Papana A, Theodoratou E, et al. Global and regional estimates of COPD prevalence: systematic review and meta-analysis. Journal of Global Health. 2015;5(2):020415. https://doi.org/10.7189/jogh.05.020415 2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLOS Medicine. 2006;3 (11):e442. https://doi.org/10.1371/journal.pmed.0030442 3. Statistics Korea. 2017 Annual report on the causes of death statistics [Internet]. Seoul: Statistics Korea; 2017 [cited 2018 October 29]. Available from: http://kostat.go.kr/portal/korea/kor_nw/1/6/2/index.- board 4. The Korean Academy of Tuberculosis and Respiratory Diseases. Revision committee of COPD medical guidline (2018 revision). Seoul: The Korean Academy of Tuberculosis and Respiratory Diseases; 2018. p. 3. 5. Soltani A, Reid D, Wills K, Walters EH. Prospective outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease presenting to hospital: a generalisable clinical audit. Internal Medicine Journal. 2015;45(9):925-33. https://doi.org/10.1111/imj.12816 6 Liu D, Peng S-H, Zhang J, Bai S-H, Liu H-X, Qu J-M. Prediction of short term re-exacerbation in patients with acute exacerbation of chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease. 2015;10(1):1265-73. https://doi.org/10.2147/copd.s83378 7. Jeong SH, Lee H, Carriere KC, Shin SH, Moon SM, Jeong B-H, et al. Comorbidity as a contributor to frequent severe acute exacerbation in COPD patients. International Journal of Chronic Obstructive Pulmonary Disease. 2016;11(1):1857-65. https://doi.org/10.2147/copd.s103063. 8. Ringbæk T, Green A, Laursen LC, Frausing E, Brøndum E, Ulrik CS. Effect of tele health care on exacerbations and hospital admissions in patients with chronic obstructive pulmonary disease: a randomized clinical trial. International Journal of Chronic Obstructive Pulmonary Disease. 2015;10(1):1801-8. https://doi.org/10.2147/copd.s85596 9. Gil E-H. Differences in adherence to self-care, drug compliance, and knowledge of heart failure based on rehospitalization of heart failure patients [master's thesis]. Daejeon: Eulji University; 2013. 10. Wang L, Zang X-Y, Zhang Q, Liu S-Y, Shen Y-H, Zhao Y. Study on factors influencing recrudescent time of postdischarge patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing. 2012;21(11-12):1507-14. https://doi.org/10.1111/j.1365-2702.2011.03899.x 11. Choi Y-S. Comparison in nursing needs of heart disease patients depending on whether or not readmitted. Journal of Digital Convergence. 2014;12(6):519-26. https://doi.org/10.14400/jdc.2014.12.6.519 12. Kuo C-C, Lin C-C, Lin S-Y, Yang Y-H, Chang C-S, Chen C-H. Effects of self-regulation protocol on physiological and psychological measures in patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing. 2013;22(19-20): 2800-11. https://doi.org/10.1111/jocn.12085 13. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2019 report) [Internet]. Fontana, USA: Global Initiative for Chronic Obstructive Lung Disease; 2019 [cited 2019 January 15]. Available from: https://goldcopd.org/wp-content/uploads/2018/11/gold -2019-v1.7-FINAL-14v2018-WMS.pdf 14. Lalmolda C, Coll-Fernández R, Martínez N, Baré M, Teixidó Colet M, Epelde F, et al. Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns. International Journal of Chronic Obstructive Pulmonary Disease. 2017;12:2531-8. https://doi.org/10.2147/copd.s138451 15. Koff PB, Jones RH, Cashman JM, Voelkel NF, Vandivier RW. Proactive integrated care improves quality of life in patients with COPD. European Respiratory Journal. 2009;33(5):1031-8. https://doi.org/10.1183/09031936.00063108 16. Cho KH, Kim YS, Nam CM, Kim TH, Kim SJ, Han K-T, et al. Home oxygen therapy reduces risk of hospitalisation in patients with chronic obstructive pulmonary disease: a population-based retrospective cohort study, 2005-2012. BMJ Open. 2015;5:e009065. Korean J Adult Nurs. 2019;31(4):427-438 437

Choi, JY Yun, SY https://doi.org/10.1136/bmjopen-2015-009065 17. Kim KS, Yun EJ, Kim SY, Kim OS, So HS, Lee MS, et al. Medical surgical nursing. 8th ed. Seoul: Soomoonsa; 2017. p. 654-63. 18. Gronkiewicz C, Borkgren-Okonek M. Acute exacerbation of COPD: nursing application of evidence-based guidelines. Critical Care Nursing Quarterly. 2004;27(4):336-52. 19. Gregoriano C, Dieterle T, Breitenstein A-L, Dürr S, Baum A, Maier S, et al. Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial. Respiratory Research. 2018;19:237. https://doi.org/10.1186/s12931-018-0936-3 20. Vogelmeier CF, Criner GJ, Martínez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report: GOLD executive summary. Archivos de Bronconeumología. 2017;53(3):128-49. https://doi.org/10.1016/j.arbres.2017.02.001 21. Yu S, Fang Q, Li Y. Independent factors associated with pneumonia among hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease. Medicine. 2018;97 (42):e12844. https://doi.org/10.1097/md.0000000000012844 22. Tomioka R, Kawayama T, Suetomo M, Kinoshita T, Tokunaga Y, Imaoka H, et al. Frequent exacerbator is a phenotype of poor prognosis in Japanese patients with chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease. 2016;11(1):207-16. https://doi.org/10.2147/copd.s98205 23. Anh MH, Choi JY. Relationship of knowledge, attitude, correct metered dose inhaler use, and self-management compliance among patients with COPD. Korean Journal of Adult Nursing. 2012;24(2):160-70. https://doi.org/10.7475/kjan.2012.24.2.160 24. Kang G-J, Kim M-H, Hwang S-K. Self-care, symptom experience, and health-related quality of life by COPD severity. Korean Journal of Adult Nursing. 2008;20(1):163-75. 25. von Leupoldt A, Dahme B. Psychological aspects in the perception of dyspnea in obstructive pulmonary diseases. Respiratory Medicine. 2007;101(3):411-22. https://doi.org/10.1016/j.rmed.2006.06.011 26. Vold ML, Aasebø U, Melbye H. Low FEV1, smoking history, and obesity are factors associated with oxygen saturation decrease in an adult population cohort. International Journal of Chronic Obstructive Pulmonary Disease. 2014;9(1):1225-33. https://doi.org/10.2147/copd.s69438 27. Al Rajeh AM, Hurst JR. Monitoring of physiological parameters to predict exacerbations of chronic obstructive pulmonary disease (COPD): a systematic review. Journal of Clinical Medicine. 2016;5(12):108. https://doi.org/10.3390/jcm5120108 28. Ai-Ping C, Lee K-H, Lim T-K. In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study. Chest. 2005;128(2):518-24. https://doi.org/10.1378/chest.128.2.518 29. COPD Working Group. ninvasive positive pressure ventilation for chronic respiratory failure patients with stable chronic obstructive pulmonary disease (COPD): an evidence-based analysis. Ontario Health Technology Assessment Series. 2012; 12(9):1-51. 30. Health Insurance Review & Assessment Service. Three promises for asthma and chronic obstructive pulmonary disease [Internet]. Seoul: Health Insurance Review & Assessment Service; 2018 [cited 2018 May 18]. Available from: https://www.hira.or.kr/bbsdummy.do?pgmid=hiraa0200 41000100&brdScnBlt=4&brdBlt=9594#none 31. Panagioti M, Scott C, Blakemore A, Coventry PA. Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease. 2014;9(1): 1289-306. https://doi.org/10.2147/copd.s72073 32. Tselebis A, Pachi A, Ilias I, Kosmas E, Bratis D, Moussas G, et al. Strategies to improve anxiety and depression in patients with COPD: a mental health perspective. Neuropsychiatric Disease and Treatment. 2016;12:297-328. https://doi.org/10.2147/ndt.s79354 33. Puhan MA, Scharplatz M, Troosters T, Steurer J. Respiratory rehabilitation after acute exacerbation of COPD may reduce risk for readmission and mortality - a systematic review. Respiratory Research. 2005;6:54. https://doi.org/10.1186/1465-9921-6-54 34. Abad-Corpa E, Royo-Morales T, Iniesta-Sánchez J, Carrillo- Alcaraz A, Rodríguez-Mondejar JJ, Saez-Soto ÁR, et al. Evaluation of the effectiveness of hospital discharge planning and follow-up in the primary care of patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing. 2013;22 (5-6):669-80. https://doi.org/10.1111/j.1365-2702.2012.04155.x 35. Kim SJ, Park E-C, Han K-T, Kim SJ, Kim T-H. Nurse staffing and 30-day readmission of chronic obstructive pulmonary disease patients: a 10-year retrospective study of patient hospitalization. Asian Nursing Research. 2016;10(4):283-8. https://doi.org/10.1016/j.anr.2016.09.003 438 http://kjan.or.kr