To date, patients with chronic obstructive pulmonary disease (COPD) have a fourfold in-creased risk of developing severe forms (1) and are more likely to be affected by COVID-19 (2). Patients with COPD are known to be more susceptible to respiratory viral infection and virus-induced exacerbations caused by influenza, rhinovirus, and seasonal coronaviruses (3, 4). The incidence of hospitalization and severity of illness in patients with COPD are much higher in patients with COVID-19 than in those with seasonal influenza (5). Awatade et al. (3) in their systematic review show that people with COPD do not have a higher prevalence of hospital admission. Therefore, this could indicate that there is no increased susceptibility to SARS-CoV-2 infection or it may reflect a change in community behavior – which benefits from social isolation. Also the implementation of infection control measures during the COVID-19 pandemic has reduced the number of respiratory infections, which is the most common cause of COPD exacerbations (6).

Despite this, studies show that the number of COPD patients admitted at hospital for SARS-CoV-2 infection ranges from 2 to 7.7% and in intensive care units, this prevalence does not exceed 5% (7, 8). These results may be due to the protective effect of inhaled drugs, due to the underdiagnosis of COPD, which reaches 74.7% in Spain (9), and the strict compliance with isolation measures (10). The “lockdown” that the worldwide population has been forced to endure during the first COVID-19 outbreak has led to the emergence of a situation of psychosocial instability that may have worsened due to the mass quarantine (11). These aspects have several consequences in the natural history of the patient’s disease, with high psychiatric morbidities such as depression and anxiety.

Therefore, efforts should be made to maintain a situation of low clinical impact over time in individuals with COPD, since clinical management in COPD is an integrative, dynamic and useful tool (12) where the patient’s perception is key to their treatment. In Italy, feelings of terror, fear and/or apprehension were reported in 58.22% of COPD patients during the first months of the pandemic (13). The result of COPD patients suffering from COVID-19 is that the patient reports increased shortness of breath and worse quality of life and sleep, combined with mood disturbances. However, previous studies had shown how the “lockdown” and confinement had a low impact on COPD patients, albeit many clinical consultations and tests were cancelled, patients were very satisfied with the telephonic care provided (14).

During the COVID-19 pandemic it has been shown how COPD patients experienced an increase in their feeling of fragility (15) and, faced with the fear of becoming infected and dying (6), patients adopted restrictive protective measures (16, 17), by changing their perception of risk (17). As a consequence, there was an increase in protective measures against contagion, but also a decrease in social contact and isolation in their homes (10, 16, 17). New technologies and virtual platforms and chats helped to maintain contact with professionals and continue with COPD treatment (18, 19).

Therefore, the aims of this study were: (a) to describe the perspectives of a group of Spanish patients with COPD during the first outbreak of Covid-19 pandemic regarding confinement, restrictive measures, protective strategies adopted, and clinical care during the pandemic, and (b) to narrate the emotions and polarity (acceptance-rejection) of their perspectives regarding living with COPD during the pandemic applying a novel lemmatize and thematic analysis of participants’narratives.

The sample of the present study consisted of eight patients with COPD (five women) with a mean age of 65.12 years (SD 6.87). Six patients had moderate COPD, one had severe COPD, and one had very severe COPD. Two participants continued to smoke (P1 and P7), the number of packs of tobacco per year that they continued to consume were 45, and 35, respectively for P1 and P7. The characteristics of the participants are shown in Table 4.

Our thematic results showed that patients with COPD did not have a major negative experience of confinement during the first wave of COVID-19 outbreak, following the recommendations to avoid the infection. They had many difficulties with face masks, particularly FFP2 type, and half of them refused the vaccine. Ultimately, they feel safe and protected by the health care professionals in the COPD unit of their hospital.

Upon triangulation of the thematic results with textual content analysis, participants showed a positive polarity of their discourse regarding the first wave of the COVID-19 pandemic. Our results coincided with the work of Pleguezuelos et al. (14) on the experience of patients with COPD during their confinement in the COVID-19 pandemic, where they described how most of the patients stated that their feeling regarding lung disease and their general health was similar or even better during confinement, and how it had little impact on their life. This contrasts with previous studies of COPD patients during the pandemic, which described negative feelings, along with anxiety, and stress (10, 16, 49). The psychological and emotional impact described in previous studies due to the pandemic were a consequence of the fear of dying, fear of becoming infected, feeling abandoned by the health system, difficulty of access to health professionals, and lack of support and care, despite being vulnerable patients (10, 15, 16, 49). The positive polarity of our participants’ perspective, identified in their narratives, can be explained by the fact that the patients belong to a specialized COPD cohort/unit of a regional hospital, where specific treatment and follow-up protocols were in place, where the Referring professionals (physicians and nurses) have not changed, and where care protocols have continued to be applied in the same way as before the pandemic. Previous studies have shown how the involvement and proactivity of professionals minimized the adverse effects of the COVID-19 pandemic on patients with COPD (10, 18, 19).

Regarding home confinement, our participants did not experience it in a negative or distressing way. On the contrary, they recounted how these measures were particularly beneficial to vulnerable patients with chronic conditions. These results agree with an observational study (14) conducted in Spain, where 100 COPD patients were interviewed by telephone. The Hospital Anxiety and

Depression, the COPD Assessment Test, and the 5-Dimension Euro Quality-of-Life questionnaire were administered. The interviews also included questions about the lockdown, missed clinical

appointments, and fears of the disease. In this study, Pleguezuelos et al. (14) showed that, in general, the worldwide lockdown had a low impact on COPD patients. In contrast, in Italy, during the

confinement, COPD patients described feeling terror, anguish, and apprehension (13). This difference compared to our results could be explained by the fact that the restrictive measures were applied to

all people, decreasing the exposure of COPD patients to other non-vulnerable people, and therefore decreasing the risk of contagion. Moreover, prior to the pandemic, patients had adapted their habits and lifestyle to the restrictions caused by COPD symptoms. Whereas Philip et al. (49) described the concerns and difficulties of patients with COPD regarding obtaining food, money, supplements, and medication, keeping their distance from their social and family environment, and in those living alone, in our results these difficulties were not reported because they were performed by the partner, or the family (in the case of those who lived alone).

Our results showed how patients with COPD felt more vulnerable, and they strictly adopted protective measures (avoiding going to the doctor, using masks and gloves, hydroalcoholic gel, etc.) due to fear (of contagion, of COPD progressing and worsening, of intubation). Moreover, agreed with previous studies (10, 16) that reported how patients with COPD during the pandemic, due to the fear of becoming infected, have implemented strict measures of social distancing, self-isolation, and distancing from family and friends. Measures such as wearing face masks, social distancing, washing or sanitizing hands, and avoiding public or crowded places, were largely followed and applied and in a higher proportion by patients with chronic diseases compared to the healthy population (50). However, Kusk et al. (16) described how patients with COPD, by applying strict precautionary measures, experienced a feeling of loneliness and an alteration of the life-illness balance, since they were protecting a life while losing another. Conversely, previous studies (51, 52) showed how the application of these measures reduced the number of severe COPD exacerbations during the COVID-19 Pandemic. On the other hand, our results showed that as a consequence of using the mask, patients with COPD felt suffocated, with shortness of breath as if they were in a prison. The increased feeling of shortness of breath could be damaging for COPD patients, easing protective measures and increasing the risk of contagion. Tomán et al. (15) showed how for patients with COPD, dyspnea was the most terrifying symptom of progressive lung disease, and how patients tried to minimize it at all costs.

Previous studies described how patients experience denial of care, discrimination, or inequity in health care (49), and even oblivion by health authorities and health professionals (10). Our results did not show that patients with COPD have experienced lack of clinical care or inequity in access to health care. They described difficulties in accessing clinical consultations in primary care; however, similar to the rest of the people in their environment. In addition, they feel protected and safe by their healthcare professionals and by the measures taken by the health authorities to protect the population (including the most vulnerable) such as the strict confinement during the first wave of the COVID-19 outbreak for a period of 3 months (14).

Regarding vaccination, our results showed the experience of a small group of patients. However, it is paradoxical that despite the high risk of death of COPD patients in the event of contracting the SARS-CoV-2 virus and the vaccination recommendations (53), half of the participants did not wish to be vaccinated. We find these results surprising, as all the participants reported having been informed of the vaccination by their physicians and feeling very satisfied with the clinical care, trusting the professionals of the COPD unit, and confirmed having a very good professional-patient relationship. Previous studies (54, 55) reported evidence of a COVID-19 vaccine hesitancy among chronic patients. This hesitancy or distrust towards COVID-19 vaccination is not a local phenomenon but rather is widespread throughout the world (54). Factors that facilitate refusal include possible side effects, fears that the vaccine may not be safe, fear of injections, belief in natural or traditional remedies, need for more information, anti-vaccine attitudes or beliefs, believing that the vaccine will serve to those who produce this virus, i.e., conspiracy beliefs of the vaccine (55).

The qualitative design allowed us to explore and describe in depth the perspectives of patients with COPD during the COVID-19 pandemic (10, 15–19, 49). Compared to previous studies (10, 15–19), our study added these new findings: (a) The confinement measures did not cause limitation of their daily activities since they were previously limited by the illness; (b) confinement was perceived as a measure that protected them since they were more vulnerable; (c) they strictly adopted personal protection measures (masks, gloves, etc.) but they had problems adapting to the masks since they felt suffocated as if they were in a prison; (d) when walking and moving outside they tended to remove the mask to minimize the feeling of suffocation; (e) the COVID-19 vaccine was not accepted, the reasons included fear that it would further damage their lungs, the fact that the information provided by politicians was confusing and they preferred to wait getting vaccinated; (f) the professionals and the care from their reference hospital made them feel safe (unlike primary care) as they continued to monitor COPD by maintaining the in-person visit, regardless of the pandemic.

Regarding the integration of the results, the use of two analytical proposals (thematic and content) allowed us to obtain and understand the perspective of patients with COPD, as well as deepening the emotions and the tendency of polarity (acceptance/rejection) of their discourses. This did not mean that the results of both analyses coincided, but rather that they showed nuances of perspective, which only one type of analysis could not identify. Thus, in the present work, using thematic analysis, patients with COPD described important negative aspects of experiencing the first wave of the pandemic from their perspective. However, in the content analysis of his speech, through lemmatization, the polarity of his speech had a positive final result.

An important novelty of this work was the use of lemmatization as a complementary analysis proposal to other qualitative tools (such as thematic analysis), and in this way increased the credibility of the results and also the depth of the perspective analysis of the participants.

First, regarding sample size sufficiency, previous studies (33, 34) reported that the sample size justification in qualitative health research was limited and defining sample size a priori is inherently problematic. Also, Sebele-Mpofu (56) describes how the definition of the concept of saturation can vary, depending on the qualitative design chosen, sampling strategy and the data collection instrument used. Due to this great variability of criteria, the authors opted for a proposal to establish the sample size based on pragmatic considerations (difficulty of access to participants due to confinement and social isolation measures) and on the information power to achieve sample size saturation (35). The inclusion of a small sample with 8 participants was in line with existing research: (a) on the sample size in qualitative studies (qualitative sample size), which described how the sample could be reached by saturation between 5–12 interviews (56–63); and (b) on qualitative studies conducted in patients with COPD during the COVID-19 pandemic, using samples of eight (15) and 10 participants (19). However, as a result of using this pragmatic consideration, along with the qualitative nature of this study, gathering the perspective of a group of COPD patients concerning a certain phenomenon and the small number of patients with COPD, this study has limitations in terms of generalizability. Finally, data collection was carried out in December 2020, time after the first wave of the COVID-19 pandemic in Spain (March 14, 2020 to June 21, 2020) (64). This could have influenced the narratives and results obtained.

Our results showed that COPD patients narrated how the confinement and restrictive measures of the first wave did not have a negative impact on their lives. On the contrary, fear (in all areas and situations) forced them to adopt strict protective measures to avoid contagion and impacted their daily lives. Moreover, they have experienced barriers in access to primary care, great difficulty in the use of masks, and the refusal of some patients to the COVID-19 vaccine was relevant. The content analysis showed how the main emotion was fear, and how the global polarity of the speech of patients with COPD was positive.

Future studies should analyze adherence and the use of face masks in COPD patients, and the reasons for accepting or refusing vaccination. These results may help managers to understand the impact that confinement rules and the adoption of protection measures against contagion had on the daily life of patients, as well as the importance of maintaining and the developing specialized COPD monitoring units.