Ask an answerable question (PICO)：
Chronic obstructive pulmonary disease (COPD) reduces patients' quality of life. Traditional care is mostly based on medications, pursed-lip breathing, upper limb exercises, and oxygen therapy. Past research has shown that singing and performing breathing exercises can improve the quality of life of COPD patients. However, there is no consistent conclusion thus far. Given the high safety profile of singing and its suitability for home-based care of stable moderate-to-severe COPD in the elderly, this gap in knowledge has motivated the author to further explore this area.
The Method and Analysis of Literature Review：
According to empirical nursing methodology, PICO questions were formulated with the following elements: [P] older elderly patients with chronic obstructive pulmonary disease (COPD), [I] singing interventions, [C] routine care, [O] quality of life. MeSH terms were used to find synonyms, and Boolean logic searches were performed in the Cochrane Library, PubMed, MEDLINE, and Airiti Online Library, as well as the National Digital Library of Theses and Dissertations in Taiwan.
This yielded 72 relevant documents. These were screened to exclude non-elderly cases and inconsistent intervention measures. 28 articles were excluded for being irrelevant to the topic. An additional 30 articles were removed due to duplication. The search was limited to the past 10 years (January 1, 2013 - August 20, 2023) with no restrictions on language. Priority was given first to systematic reviews (SRs) and meta-analyses (MAs), followed by randomized controlled trials (RCTs). A total of 14 articles were reviewed in full, resulting in the final inclusion of 1 SR and 1 RCT for the literature review.
Critical Appraisal：
The literature was reviewed using the Critical Appraisal Skills Programme (CASP) 2020 as an appraisal tool, and the Oxford Centre for Evidence-Based Medicine (CEBM) 2011 guidelines for ranking clinical research evidence levels.
For the first SR, the SF-36 Physical Component Summary (PCS) for the singing group showed an overall effect at p=0.0005, indicating low-quality evidence that singing may improve physical health in COPD patients (evidence level 1). The RCT found that group singing improved depressive symptoms and quality of life in patients with stable periodic COPD. There were no significant between-group differences at baseline and 1 month, but significant differences were achieved at p < 0.001 at 3 and 6 months (evidence level 2).
Results, Conclusions and Recommendations：
Based on the two studies, singing may improve physical health and quality of life for COPD patients. Group singing can provide interactive and emotional support through activities, thereby reducing anxiety and depressive symptoms, and thus improving mental health. Although tentative, singing can raise the patient's diaphragm, promote breathing motion, and produce effective deep inhalation and exhalation, enhancing expectoration ability. In addition, singing facilitates more relaxed breathing. Thus, it is recommended as a non-pharmacological therapy for clinical COPD patients. Future proposed research should investigate whether singing can improve quality of life for COPD patients through more randomized controlled trials.
