Effects of traditional Chinese medicine nursing combined with conventional nursing in patients with chronic obstructive pulmonary disease: a meta-analysis

1. Introduction

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation resulting from airway and/or alveolar abnormalities that are usually caused by significant exposure to noxious particles or gases, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).1 Globally, because of continued exposure to COPD risk factors and population aging, the COPD burden is expected to increase in the coming decades.2 COPD is a systemic disease that is associated with a wide variety of symptoms and affects patients’ physical, psychological, and social conditions.3 COPD presents high morbidity and mortality but can be decreased by proper treatment and conventional care or traditional Chinese medicine (TCM)nursing.

With the development of TCM, TCM nursing is becoming increasingly widely used in clinical practice, including in patients with COPD. Chinese medical care researchers have explored involving TCM nursing theory, education, management, practice, and so on to promote the development of TCM nursing. Currently,the clinical efficacy of conventional nursing has been recognized. There are a considerable number of nonrandomized trials and randomized controlled trials (RCTs)involving the comparison of TCM nursing combined with conventional nursing and conventional nursing alone.The sample size in current studies is limited and multicenter trials are lacking, making the evidence of TCM nursing combined with conventional nursing unreliable and lacking power.

The aim of this study was to compare the effects of TCM nursing combined with conventional nursing with conventional nursing alone in patients with COPD. The meta-analysis allows clinical outcomes to be quantified for evaluating the advantages of TCM nursing combined with conventional nursing.

由于观光采摘节是利用果树的花期或果期作为依托的节庆活动，如果没有果品资源以外的其他资源优劣势、人们的需求情况、政府和地方的重视程度等因素的作用，观光采摘节应具有明显的淡旺季之分。

2. Materials and methods

2.1 Inclusion and exclusion criteria

Criteria for inclusion and exclusion of studies were established according to the participants, interventions,comparisons, outcomes, and study design (PICOS)principles. The inclusion criteria were as follows: (1) participants: all of the included participants had a diagnosis of COPD, according to the guidelines for the diagnosis and treatment of COPD and received conventional Western medicine; (2) interventions: the participants in the study group were treated with TCM nursing combined with conventional nursing. Conventional nursing involves daily care, dietary nursing, activity nursing, oxygen therapy, assistance with coughing, condition observation, medication care, and health education. TCM nursing, characterized as dialectical nursing, includes dietetic care, emotional nursing, physical therapy of TCM, TCM health education, and TCM rehabilitation training; (3) comparisons: participants in the control group received conventional nursing; (4) outcomes: the study should have reported at least one of the following clinical outcomes: St. George’s Respiratory Questionnaire (SGRQ) score, pulmonary function index (forced expiratory volume in 1 second [FEV1], FEV1/forced vital capacity [FVC], FEV1%, and FEV1 predicted value),hospital stay, and clinical efficacy; and (5) study design:RCTs aimed at studying the effect of TCM nursing intervention on the clinical outcome of patients with COPD.Exclusion criteria were as follows: (1) literature was not designed rigorously; (2) the control group was not designed in the literature; (3) data in the literature were unknown; or (4) relevant data could not be extracted from the literature. For literature that was duplicated or reported by the same research institution, publications with higher quality or more detailed data were included.

2.2 Search strategy

Because of the significant heterogeneity of the eligible studies, random-effects models were used during pooling of data. Significant heterogeneity persisted during the sensitivity analysis, especially when comparing the FEV1 value, FEV1/FVC value, and FEV1% value between the two groups. The significant heterogeneity was likely a result of the differences in some potentially confounding variables that were not specifically considered, such as disease type, demographic characteristics, or methodology differences among studies.6-10,12-17 In addition, the studies did not use the same TCM nursing methods, and the severity of illness was also different, leading to potential heterogeneity. COPD severity might affect the rehabilitation of lung function, so there was a significant heterogeneity, especially in comparing the FEV1 value, FEV1/FVC value, and FEV1% value.Thus, more rigorous RCTs should be conducted to evaluate the parameters that have significant heterogeneity in this meta-analysis.

2.3 Quality assessment

The Jadad scale4 was used to assess the quality of the selected publications that met the inclusion criteria. All of the eligible RCTs were assessed by three reviewers(Chenyang Li, YuNan Ji, and ZhenHua Hou) independently. The criteria of Jadad were as follows: (1) Generation of random sequences (appropriate: 2 points; unclear:1 point; inappropriate: 0 points); (2) Allocation concealment(appropriate: 2 points; unclear: 1 point; inappropriate: 0 points; unused: 0 points); (3) Double blinding (appropriate: 2 points; unclear: 1 point; inappropriate: 0 points); and(4) Withdrawal (describes the number and rationale for the withdrawal: 1 point; The number and rationale of withdrawal are not described: 0 points). Four aspects of the evaluation quality were used: 1–3 points were regarded as low quality, and 4–7 points were regarded as high quality.

2.4 Data extraction

Two investigators (Chenyang Li and Lingli Xie) extracted the data independently. The following data were extracted from each publication: first author, year of publication, type of study, selection criteria, age, number of participants, randomness in method, SGRQ scores,pulmonary function, hospital stay, and clinical efficacy.

2.5 Statistical analysis

Meta-analysis was performed using Stata12.0 software(StatCorp, College Station, TX, USA). Weighted mean differences (WMDs) were used to compare SGRQ scores,pulmonary function, and hospital stay. Clinical efficacy was compared using odds ratios (ORs), and subgroup analysis was performed. Statistical heterogeneity was evaluated by the use of Cochran Q and I2 statistics. A value of P≤0.10 was considered statistically significant, and a randomeffect model was used. Otherwise, a fixed-effect model was used. Begg’s test and Egger’s linear regression test were performed to evaluate the publication bias.

3. Results

3.1 Study selection and characteristics

Using the search strategies described, 753 potential articles were initially retrieved, and 662 studies were excluded after screening the titles. Fifty studies(reviews or case reports) were excluded after assessing the abstracts. Upon full-text review, 18 reports were excluded because the control groups were missing.Therefore, 23 studies were eligible for this meta-analysis (Figure 1); the characteristics and quality assessment of eligible studies are shown in Table 1. These eligible articles involved 3116 participants (TCM nursing combined with conventional nursing group: 1559,conventional nursing group: 1557). All included studies were reported in the Chinese language.

3.2 Statistical results

通过上述方法获取的保护装置多维度信息，并不能直接实现与WDT中的装置整机测试能力描述模块进行对应，还需要通过一定的转换规则将装置板卡组成信息转换成唯一测试能力描述ID号，然后再根据整机测试能力唯一描述ID号在WDT的整机测试能力映射数据库中进行搜索，如该整机测试能力唯一描述ID号存在，WDT将存在信息反馈给ITCC。最后有ITCC下发测试指令给WDT，从而实现ITCC对保护装置整机测试的自动控制。详见图2。

Four studies5-8 reported indications for SGRQ scores,and a fixed-effect model was used for studying interstudy heterogeneity (I2 = 0.0%, P=0.990). TCM nursing combined with conventional nursing was associated with lower SGRQ scores than conventional nursing(WMD = –15.06, 95% confidence interval [CI]: –16.56 to–13.55, P=0.000) (Table 2).

TCM nursing combined with conventional nursing can achieve maximum optimization by integrating the advantages of TCM nursing with conventional nursing.This meta-analysis shows that for patients with COPD,TCM nursing combined with conventional nursing emphasized that dialectical nursing can be preferably performed. However, because there is significantly high heterogeneity among studies, further studies should be undertaken to confirm this evidence.

Significant heterogeneity was observed in six studies8-13 that reported data on the FEV1 value (I2 = 95.7%, P=0.000),11 studies6-10,12-17 that reported data on the FEV1/FVC value (I2 = 96.2%, P=0.000), and four studies8,14,15,18 that reported data on the FEV1% value (I2 = 97.8%, P=0.000);a random-effect model was used for analysis. There was a higher FEV1 value (WMD = 0.29, 95% CI: 0.13–0.45,P=0.000), a higher FEV1/FVC value (WMD = 4.95, 95% CI:2.71–7.19, P=0.000), and a higher FEV1% value (WMD =9.20, 95% CI: 4.71–13.68, P=0.000) compared with those with conventional nursing (Table 2). Four studies6,7,16,17 reported data on the FEV1 predicted value; the FEV1 predicted value in TCM nursing combined with conventional nursing was higher than that in conventional nursing alone(WMD = 4.13, 95% CI: 3.44–4.82, P=0.000) with interstudy heterogeneity (I2 = 0.0%, P=0.725) (Table 2).

Figure 1. Flow chart of eligible studies.

Table 1. Study characteristics and inclusion criteria

Notes: a1= SGRQ scores; 2= FEV1 Value; 3= FEV1/FVC Value; 4= FEV1% value; 5= FEV1 predicted value; 6= hospital stay; 7= clinical efficacy.

Articles Study period Case Number in study group group Outcomesa Quality assessment Dai 20165 2012/11–2015/12 COPD 20 20 1 3 Li 20156 2013/6–2015/6 Stable COPD 50 50 1, 3, 5 3 He 20147 2010/12–2013/10 Stable COPD 60 60 1, 3, 5 3 Zheng et al 20148 Number in control 2011/1–2012/12 Stable COPD 143 143 1, 2, 3, 5 4 Peng 20099 2007/1–2009/1 Stable COPD 50 50 2, 3 3 Chen et al 201510–Stable COPD 53 53 2, 3, 7 4 Li 201511 2014/1–2014/12 Stable COPD 43 43 2 4 Zuo et al 201512 2013/4–2014/3 COPD 36 36 2, 3 3 Pei et al 201513 2014/6–2015/6 Stable COPD 46 46 2, 3, 7 4 Shi et al 201414 2013/5–2013/12 Acute exacerbation COPD 15 15 3, 4 4 Liu 201415 2013/1–2014/1 COPD 53 53 3, 4 4 Wang et al 201516 2013/7–2014/7 COPD 40 38 3, 5 4 Huang 201617 2012/10–2014/10 Stable COPD 42 42 3, 5 3 Li et al 201318 2008/1–2013/2 Stable COPD 300 300 4, 7 3 Fu et al 201419 2012/1–2013/12 Acute exacerbation COPD 50 50 6 4 Lei 201420 2012/8–2014/2 COPD 100 100 6, 7 4 Liang et al 201021 2008/1–2009/1 Acute exacerbation COPD 45 45 6 4 Pan 201322 2011/4–2012/3 Acute exacerbation COPD 64 64 6, 7 4 Fan 201523 2013/5–2015/5 COPD 40 40 7 3 Zhang et al 201324 2011/1–2013/1 Acute exacerbation COPD 27 27 7 4 Nie et al 201225 2011/1–2011/11 Acute exacerbation COPD 120 120 7 3 Han 201526 2013/9–2014/10 Acute exacerbation COPD 60 60 7 4

Table 2. Results of meta-analysis of outcomes

Outcomes Number of studies WMD P Heterogeneity Study group Control group I2 (%) P Number of patients Pooled WMD 95% CI of pooled SGRQ scores 4 273 273 –15.06 –16.56 to 13.55 0.000 0.0 0.990 FEV1 value 6 371 371 0.29 0.13 to 0.45 0.000 95.7 0.000 FEV1/FVC value 11 588 586 4.95 2.71 to 7.19 0.000 96.2 0.000 FEV1% value 4 511 511 9.20 4.71 to 13.68 0.000 97.8 0.000 FEV1 predicted value 4 192 190 4.13 3.44 to 4.82 0.000 0.0 0.725 Hospital stay 4 259 259 –3.96 –5.79 to 1.94 0.000 95.9 0.000

3.2.3 Hospital stay

Four studies19-22 recorded hospital stay. There was significant heterogeneity (I2 = 95.9%, P=0.000), and a random-effect model was used. There was a shorter hospital stay in the TCM combined with conventional nursing group (WMD = –3.96, 95% CI: –5.79 to –1.94,P=0.000) (Table 2).

This meta-analysis suggests that for the treatment and rehabilitation of COPD, TCM nursing combined with conventional nursing can be performed preferably. We attempted to search the literature as thoroughly as possible to minimize publication bias. Begg’s test and Egger’s linear regression test, as well as the funnel plots,showed that there was no publication bias, indicating that this meta-analysis approximated the actual results.However, there are some limitations as follows. First,the study of the application of Chinese and Western medicine nursing care in patients with COPD is limited to Chinese language texts; relevant English literature was not retrieved. Second, because some evaluation indicators that were included in the studies are not uniform, data extraction was limited and further subgroup analysis could not be performed. Third, the sample size of the studies was relatively small; a large-scale multicenter RCT comparing TCM nursing integrated with conventional nursing with conventional nursing alone in patients with COPD is warranted.

3.2.4 Clinical efficacy

Clinical efficacy was reported by ten studies.10,13,18,20,22-27 The analysis of clinical efficacy did not exhibit heterogeneity (I2 = 0.0%, P=0.606). The difference in clinical efficacy was statistically significant between the groups,and there was a preferable clinical efficacy in the TCM combined with conventional nursing group (OR = 4.41,95% CI: 2.85–6.82, P=0.000) (Figure 2). Subgroup analysis was conducted to compare the clinical efficacy of TCM nursing combined with conventional nursing between patients with acute exacerbation of COPD(AECOPD) and patients with stable COPD. There was no significant heterogeneity (I2 = 0.0%, P=0.448), and a fixed-effect model was used. For patients with AECOPD,TCM nursing combined with conventional nursing had greater clinical efficacy (OR = 10.42, 95% CI: 4.11–26.42, P=0.000), relative to patients with stable COPD(OR = 2.89, 95% CI: 1.43–5.86, P=0.003) (Figure 3).

综合管廊监控系统管理一体化设计的基础是监控中心。在对监控中心进行设计的过程中，采用的设计方式是分布式设计和集中化存储方式。随着云计算和云数据在各个行业的广泛应用，监控中心设计的过程中，也逐渐向云端存储的方向发展。随着业务数据的逐渐增多，后期可通过分类的方式，如按区域分类或者按照业务类别进行分类等方式，建设云数据中心，以为市政管廊的运营和维护提供保障。

试验温度分别为室温20 ℃、40 ℃以及55 ℃。在每种温度条件下，分别秤取(270±1)g，3种润滑油加入到3个烧杯中，在每个烧杯上做好记号。用不锈钢丝将试样悬挂在支架上，保证试样完全浸没在油中，且试样之间及与杯壁间不接触，试样表面无气泡。试验时间按照国家标准GB/T 1690-2010的要求，选取24 h的整倍数168 h，在试验时间达到后将试样取出，将试样表面残留液体完全擦干，在规定时间内完成硬度(Hi)、体积(Vi)以及拉伸性能的测试，并将浸泡之后的O型密封圈放置待用。

Evaluation of publication bias was performed using Begg’s test and, based on clinical efficacy, showed no significance (P=0.325). Figure 4 shows that there is no publication bias and depicts the distribution of ORs comparing the clinical efficacy for the ten studies included in this meta-analysis.

Figure 2. Forest plots of analysis of study group versus control group for clinical efficacy. The results are presented as individual and pooled ORs and 95% CIs. CI = confidence interval; OR = odds ratio.

Figure 3. Forest plots of subgroup analysis of stable COPD versus AECOPD for clinical efficacy. The results are presented as individual and pooled ORs and 95% CIs. AECOPD = acute exacerbation of COPD; CI = confidence interval; COPD = chronic obstructive pulmonary disease; OR = odds ratio.

Figure 4. Funnel plots of the evaluation of potential publication bias in the efficacy of TCM nursing combined with conventional nursing in patients with COPD. COPD = chronic obstructive pulmonary disease; s.e. = standard error; TCM = traditional Chinese medicine.

4. Discussion

To our knowledge, this comprehensive and detailed meta-analysis is the first to evaluate the association between TCM nursing combined with conventional nursing and conventional nursing alone in treating COPD.This meta-analysis presents us with the evidence that TCM nursing combined with conventional nursing can provide patients with COPD a higher life quality, better lung function, preferable clinical efficacy, and a shorter hospital stay. Furthermore, subgroup analysis indicates that TCM nursing combined with conventional nursing has greater clinical efficacy in patients with AECOPD and stable COPD.

3.2.1 SGRQ scores

According to the TCM syndrome differentiation standard,28 COPD can be divided into several types, such as exterior cold and interior heat, obstructed lung-Qi by retention of phlegm, stagnated lung-Qi, stagnation of phlegm-heat in the lung, and so on. TCM nursing is based on the theoretical system of TCM, which mainly embodies the concept of wholism and treatment determination based on syndrome differentiation. Tuinaology of TCM is a form of Chinese manipulative therapy that prevents and treats diseases. Currently, it is best known as “Tuina” and “Anmo”. The active principles of Tuina therapy can be considered to keep the balance of Yin and Yang, dredge the meridians and collaterals, regulate the Qi and blood, regulate the Zang-Fu organ function, restore and treat injured soft tissue to reduce the displacement, and lubricate joints. For regulation on the material level, Tuina can regulate the respiration system. When conducting Tuinaology, Feishu, Fenglong, Neiguan, Pishu, Qihai, Zhongji, and Tiantu can be selected to treat patients with COPD.Each procedure is performed for 3 minutes, once a day, until a local acid bilge feeling is reported. Studies29 suggest that Tuina can improve lung function and the quality of life of patients with COPD; this finding is consistent with the results of this meta-analysis. Apart from Tuinaology, acupuncture treatment is also important for COPD patients’ rehabilitation.30 The COPD rehabilitation guideline recommends that effective exercise can be ensured with moderate intensity.31 Traditional rehabilitation exercises such as six words, eight brocade, and Tai chi are relevant to improvements in exercise capacity, respiratory function, and respiratory muscle strength. Additionally, because COPD is a prolonged disease, patients with COPD are prone to be depressed and anxious. TCM emotional care is necessary.

A literature search was conducted in a variety of electronic databases, including PubMed, Embase, Cochrane Library, Web of Science, Google Scholar, China National Knowledge Infrastructure (CNKI), WanFang Data (WF)and VIP, for research published before January 2017.The following terms or keywords were used ((“pulmonary disease, chronic obstructive” [MeSH Terms] OR(“pulmonary”[All Fields] AND “disease”[All Fields] AND“chronic” [All Fields] AND “obstructive” [All Fields]) OR“chronic obstructive pulmonary disease” [All Fields] OR(“chronic”[All Fields] AND “obstructive” [All Fields] AND“lung” [All Fields] AND “disease” [All Fields]) OR “chronic obstructive lung disease” [All Fields] OR “chronic obstructive pulmonary disease” [All Fields] OR “COPD”[All Fields]))AND ((“medicine, Chinese traditional” [MeSH Terms] OR (“medicine” [All Fields] AND “Chinese” [All Fields] AND “traditional”[All Fields]) OR “Chinese traditional medicine”[All Fields] OR (“traditional” [All Fields]AND “Chinese” [All Fields] AND “medicine” [All Fields])OR “traditional Chinese medicine” [All Fields] OR “TCM”[All Fields]) AND (“nurses” [MeSH Terms] OR “nurses”[All Fields] OR “nurse” [All Fields] OR care [All Fields])).No language restrictions were followed.

3.2.5 Publication bias

简短的宣誓仪式后，我们沿路折返。抬头望去，太阳灿烂而耀眼，天空澄明而透亮，雪山纯净而巍峨，大地静默而厚实。这是真实的所在，我们不忍打破这静谧，沉默着步履匆匆地行进，却在心底涌动着爱的热流。离乡万里来援疆，我只是一位平凡的教师，是这天地中的一粒微尘，我愿在疏附二中的三尺讲台上，像那石头小屋般驻守，为我的学生们留一盏爱的心灯。

5. Conclusions

3.2.2 Pulmonary function

当一国通过法律对一家银行或者新建立的银行给予了特殊的权利，并且国家要求其余的银行和金融机构服从这家银行的规定，此时便产生了中央银行制度，我们把拥有特定授权并且承担着特定的责任的银行就叫做中央银行。

中外运-敦豪国际航空快件有限公司近日在其北京总部举行媒体发布会，宣布其珠海口岸正式落成并投入使用，成为落户珠海口岸国际快递监管中心的首家国际快递公司。此外，DHL正式宣布将持续加大在中国的战略投资，对外公开了今年以来的一系列投资举措。DHL称，借助港珠澳大桥带来的高效物流通道，DHL珠海口岸的建立将大幅提升珠江西岸地区国际物流的快递效率。随着2018年10月24日港珠澳大桥正式通车，由珠海口岸清关的国际快递转运至其香港转运中心（DHL全球三大转运中心之一）的时间将从原来的4小时缩短为45分钟，大大提升了转运时效。而这对于专业做国际限时快递服务的DHL来说，尤为重要。

Acknowledgments

We thank Tianjin University of Traditional Chinese Medicine for offering us their library for this study.

Conflicts of interest

All contributing authors declare no conflicts of interest.

实验在相同条件下采集了黑火药及液化石油气的拉曼光谱图像，且各样品图像经过多次重复。通过光谱数值比较发现：样品2#煤气罐上方木横条、样品4#煤气罐左侧储物顶面织物、样品5#煤气罐减压阀与黑火药有相近的基团；样品3#煤气罐右侧储物箱木条与液化石油气有相似近的基团。

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