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2nd edition
Pocket Guide
Edition
Committee for the Second Edition of
the COPD Guidelines of The Japanese Respiratory Society
2004 The Japanese Respiratory Society
Shibata Building 2F, 2-6-4, Uchikanda, Chiyoda-ku, Tokyo,
101-0047, JAPAN
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Guidelines for
the Diagnosis and
Treatment of COPD
Chronic Obstructive Pulmonary Disease
2nd edition
Pocket Guide
Edition
Committee for the Second Edition of
the COPD Guidelines of The Japanese Respiratory Society
Foreword
Yoshinosuke Fukuchi
Committee Chairman
Committee for the Second Edition of the COPD Guidelines
of The Japanese Respiratory Society
iii
Index
Guidelines for the Diagnosis and Treatment of COPD
Chronic Obstructive Pulmonary Disease2nd. ed., Pocket Guide
Foreword iii
Committee Members vi
1 Definition 1
2 Epidemiology of COPD in Japan 2
3 Risk factors 4
4 Etiology 5
5 Diagnosis 6
1. Diagnostic criteria 6
2. Stage classification 8
3. Clinical findings 10
4. Diagnostic imaging 12
5. Pulmonary function test 14
6. Exercise tests, respiratory muscle function tests, sleep
studies 16
7. Arterial blood gas measurement 16
8. Evaluation of pulmonary hypertension and cor pulmonale 17
9. QOL assessment 17
6 Treatment and management 18
1. Smoking cessation 18
2. Management of stable COPD 20
A. Pharmacologic treatment 21
B. Comprehensive pulmonary rehabilitation 24
C. Patient education 26
D. Nutrition management 27
E . Oxygen therapy 28
F. Ventilatory support 28
G. Lung volume reduction surgeryLVRS 29
H. Lung transplantation 29
I . Home management 30
3. Management during exacerbations 31
A. Evaluation of exacerbations and indications for hospital-
ization 31
B. Pharmacologic therapy of exacerbations 32
C. Elimination of airway secretions 33
D. Ventilatory support 33
E. Prognosis 34
7 Ethical issues 35
v
Guidelines for the Diagnosis and Treatment of COPD Chronic Obstructive Pulmonary Disease2nd. ed., Pocket Guide
Committee for the Second Edition of the COPD Guidelines of The Japanese Respiratory Society
in alphabetical order
Hiroshi KAWANE The Japanese Red Cross Hiroshima College of Nursing Takayuki SHIRAKUSA Second Department of Surgery, Fukuoka University,
School of Medicine
Kozui KIDA Respiratory Care Clinic, Nippon Medical School
The 4th Department of Internal Medicine, Nippon Medical School Keiji TAKAHASHI Department of Respirology, Shiseido General Hospital
Kentaro KIMURA National Hospital OrganizationNHOKinki-chuo Chest Medical Jun UEKI Department of Respiratory Medicine, Juntendo University School of Medicine
Center, Clinical Research Center
Kazuhiro YAMAGUCHI Department of Medicine, Keio University School of
Keishi KUBO Internal Medicine1, Shinshu University School of Medicine Medicine
Takayuki KURIYAMA Department of RespirologyB2, Graduate School of Mutsuo YAMAYA Department of Geriatric and Respiratory Medicine, Tohoku
Medicine, Chiba University University School of Medicine
vi vii
COPD POCKET GUIDE
1Definition
COPDChronic Obstructive Pulmonary Diseaseis a
disease displaying progressive airflow limitation
caused by inflammatory reaction in lungs resulting
from inhalation of noxious particles or gas. The airflow
limitation has various degrees of reversibility, both its
onset and progress are gradual, and it can cause dysp-
nea on exertion.
COPD
1
COPD POCKET GUIDE 2 Epidemiology of COPD in Japan
12.2
10
Diagnosis was
8 8.5 given
6 10%
4 5.1 24
2 3.1
0
40 - 49 50 - 59 60 - 69 70 Total
Age
Age group
Diagnosis was not given
90%
Figure 2COPD prevalence according to ageNICE study 227
Reference 1
2 3
COPD POCKET GUIDE COPD POCKET GUIDE
3Risk factors 4Etiology
Risk factors for COPD include exogenous factors such The main hypothesis explaining the etiology of COPD
as smoking and air pollution, as well as endogenous involves imbalance of protease / antiprotease and
factors of the patients themselves Table 1. The imbalance of oxidant / antioxidantFigure 5.
greatest exogenous factor for COPD is smoking, but New hypotheses are appearing due to the results of
since this condition occurs only in some smokers, it is recent animal experiments producing pulmonary emphy-
considered that it is easy to develop in patients who sema. Apoptosis of lung cells may also be involved.
are more sensitive to cigarette smoke.
The most definite endogenous risk factor is the geneti-
cally inherited 1 -antitrypsin deficiency, but this is
extremely rare in Japan. In addition, there are several Noxious particles and gas
candidate genes related to the cause of COPD, but suf-
Endogenous
ficient evidence is lacking. patient risk
The main exogenous factor is smoking. In addition, Antioxidants factors
there are occupational dusts and chemical materials Pulmonary inflammation Antiprotease
vapors, irritant substances, smoke, passive smoking
and respiratory infectious diseases.
Oxidative stress Protease
Air pollution
Passive smoking Figure 5Etiology of COPD Reference 2
Exogenous Exposure to
Smoking Infection This shows the process of COPD lesion formation due to inflammation
factors occupational dusts of the lung as a result of smoking.
and chemical
Airway inflammation and destruction of alveolar walls occurs as a
materials
result of what can be termed pulmonary disorder attack factors such
Endogenous 1-AT Airway hypersensitivity as various proteases or oxidative stress overwhelming the protective
related to host genetic
factors deficiency polymorphism factors of antiprotease or antioxidative materials either quantitatively
or qualitatively.
1-AT1-antitrypsin
4 5
COPD POCKET GUIDE 5 Diagnosis
5Diagnosis
Table 4Reversibility test for airflow limitation
1. Diagnostic criteria
In the presence of clinical symptoms such as cough, 1. The examination should be performed with the patient in
sputum, or dyspnea on exertion, or middle aged or a stable clinical state. The absence of acute respiratory
older people who have risk factors such as a history of infection should be confirmed.
smoking, COPD must always be suspectedTable 2. 2. Patients must not take short-acting bronchodilators in the
Spirometry is essential for diagnosis of COPD. Airflow previous 6 hours, or long-acting bronchodilators in the
limitation is judged to be present when the FEV 1 previous 24 hours.
Forced Expiratory Volume in one second/ FVC
3. The bronchodilator used for the reversibility test is usually
Forced Vital Capacityratio is less than 70% after
a short-acting inhaled 2stimulator. Anticholinergic
administration of bronchodilatorsTable 3, 4.
agents or both can be used.
For a definitive diagnosis, it is necessary to exclude
various other diseases by means of diagnostic imaging 4. Administration can be with either metered dose inhaler
and detailed pulmonary function examinations. One of MDIinhalation using a spacer or a nebulizer.
the most problematic differential diagnoses is 5. The examination should be performed 30 to 60 minutes
bronchial asthmaTable 5. after inhalation of the bronchodilator.
Table 2Diagnostic reference 6. The airflow limitation is considered reversible when FEV1
after administration are at least 12% and 200mL or more
COPD must be always thought of as a possibility, and
greater than the pre-bronchodilator FEV1.
spirometry performed, in the presence of any one of items 1
to 3 below, or even in cases in which there is no clinical
Table 5Differential diagnoses
symptoms but risk factors for COPD are present, especially
a long history of smoking. Spirometry is the most basic 1. Bronchial asthma
examination to establish a diagnosis of COPD. 2. Diffuse panbronchiolitis
3. Congenital sinobronchial syndrome
1. Chronic cough
4. Obstructive bronchiolitis
2. Chronic sputum production
5. Bronchiectasis
3. Dyspnea on exertion
6. Pulmonary tuberculosis
4. Long-term exposure to tobacco smoke or occupational dusts
7. Pneumoconiosis
Table 3Diagnostic criteria 8. Pulmonary lymphangiomyomatosis
9. Congestive heart failure
Using the diagnostic references given in Table 2 above,
1. FEV1 / FVC 70% on spirometry after bronchodilator administration.
2. Eliminate the possibility of other diseases causing airflow limitation.
6 7
COPD POCKET GUIDE 5 Diagnosis
2. Stage classification
Stage classification of COPD uses FEV1 value which Table 6COPD staging classification
expresses the degree of airflow limitation. The classifi- Stage Characteristic features
cation reflects the severity of the disease. The FEV1 /
FVC ratio is not used because it does not appropriate- Stage 0 Results of spirometry are normal.
ly reflect the degree of severity in cases of moderate group at risk for COPD Presence of chronic symptoms
or more severe COPD. The stage classification uses cough, sputum)
the post-bronchodilator FEV1. Stage I FEV1/FVC70%
The stages of COPD are stage 0 : the group at risk,
mild COPD FEV180%predicted
stage I : mild COPDFEV1 80% of predicted value,
Regardless of the presence or
stage II : moderate COPD50% FEV1 < 80% pre-
absence of chronic symptoms
dicted, stage III : severe COPD30% FEV1 < 50%
cough, sputum
predicted, stage IV : very severe COPD : FEV1 <
30% predicted or FEV1 < 50% predicted accompanied Stage II FEV1/FVC70%
with chronic respiratory failure or right heart failure moderate COPD 50%FEV180%predicted
Table 6. Regardless of the presence or
The special features of these staging system are the absence of chronic symptoms
addition of stage 0 : group at risk, stage I : mild COPD, cough, sputum
and also addition of the chronic respiratory failure or
right heart failure to the classification of stage IV : very Stage III FEV1/FVC70%
severe COPD. severe COPD 30%FEV150%predicted
Regardless of the presence or
absence of chronic symptoms
cough, sputum
Stage IV FEV1/FVC70%
very severe COPD FEV130%predicted or
FEV1 50% predicted accom-
panied with chronic respiratory
failure or right heart failure
N.B. The post-bronchodilator FEV1 should be used for the classification.
8 9
COPD POCKET GUIDE 5 Diagnosis
3. Clinical findings
Many patients are smokers, and the main symptoms Table 7MRC* breathlessness scale
are dyspnea on exertion and chronic cough and spu- Grade 0 No breathlessness
tum productionTable 7.
Typical physical findings in COPD usually do not Grade 1 Breathless with strenuous exercise
appear until the disease is severe. Short of breath when hurrying on the level
On visual inspection, pursed-lip breathing, barrel chest Grade 2
or walking up a slight hill
i.e. increase in the anteroposterior dimension of the
chest, paradoxical movement of the chestHoover s Walk slower than people of the same age on the
signare recognized. level
Grade 3
Percussion reveals tympanic resonance due to hyperin- or stop for breath while walking at own pace on
flation of the lung, and palpation reveals overall reduc- the level
tion in the movement of the chest during breathing.
Auscultation frequently reveals decrease in respirato- Stop for breath after walking about 100 yards
Grade 4
ry sounds and extended expiration, and forced expira- or after a few minutes on the level
tion sometimes produces wheezing.
Too breathless to leave the house
With progression of the disease, loss of weight and Grade 5
anorexia can become problematic and these are poor or breathless when dressing or undressing
prognostic factors. In cases accompanied by hypercap- Reference 3
nia, patients complain of headache in the morning.
Cases of exacerbation of right heart failure can show
exacerbation of dyspnea and sometimes edema of the
whole body or nocturnal polyuria can be observed. In
cases accompanied by cor pulmonale, exacerbation of
right heart failure should be considered when body
weight increases rapidly. Furthermore, psychological-
ly, depression and anxiety symptoms are frequently
noted.
10 11
COPD POCKET GUIDE 5 Diagnosis
4. Diagnostic imaging A B
A chest X-ray film is used to exclude other diseases or
to diagnose relatively advanced pulmonary emphyse-
ma or airway lesionsFigure 6.
It is difficult to detect early stages of COPD on plain
chest X-ray film.
High resolution CTHRCTcan be effective in the
early detection of emphysema predominant type
COPDFigure 7, Table 8.
On HRCT, pulmonary emphysema lesions appear as
C D
low attenuation areasLAA. Each LAA can be dis-
tinguished from the normal lung and they are charac-
terized by not having a capsule.
Findings suggestive of airway lesions can be detected
by HRCT, thus it can be effective in determining the
phenotype of COPD.
A B
Figure 7HRCT findings of pulmonary emphysema
-Goddard classification-1 pointScattered emphysematous lesions 1 cm or less in diameter.
-Goddard classification-2 pointsLarge size LAA due to the fusion of emphysematous lesions.
-Goddard classification-3 pointsLAA occupies an even larger area by the more pronounced
fusion of the emphysematous lesions.
-Goddard classification-4 pointsMost of the lung is occupied by emphysematous lesions and
only a small amount of normal lung remains.
VolumeL
0 0 0
1 2 3 4 5 6 1 2 3 4 5 6
VolumeL VolumeL
1 2 2
FEV1
2 4 4
Severe COPD
3
FVC
Figure 9Flow volume curve
4 FEV1 AHealthy subjectBSevere COPD patient
healthy subject
FVC
5
0 1 2 3 4 5 6 7
TimeS
Volume time curve
150
Figure 8Spirograms of a healthy individual and a severe
COPD patientFEV1 and FVC
TLCpredicted
An FEV1% volume less than 70% after bronchodilator administration indicates the 100 TLC
presence of airflow limitation. The ratio of the FEV1 to the predicted FEV1%FEV1
is used to determine the stagedegree of severityof the disease.
IC
FEV1% = FEV1 / FVC 100%
VC
%FEV1 = Actually measured FEV1 / Predicted FEV1 100%
The airflow limitation of COPD is not completely reversible. To evaluate that, it is 50 FRC
necessary to compare the results of spirometry before and after administration of
bronchodilator agent. To ensure uniform bronchodilator quantity administration, a RV
calibrated inhaler should be used. The FEV1 is used as the index of reversibility.
The following improvement ratio% change ratiois evaluated: 0
% change ratio = (the value after administration of bronchodilator agent the Young Elderly Advanced
healthy healthy COPD
value before administration of the bronchodilator agent / (the value before subject subject patient
administration of the bronchodilator agent) 100
If the FEV1 increase by 12 and 200mL or more than the value before administra- Figure 10Changes in lung volume in an elderly healthy
tion, the change is judged to be reversible. subject and a COPD patient
The extent of variation of the FEV1, measured in healthy subjects is reported to be
TLCTotal lung capacity, FRCFunctional residual capacity,
less than 5%. The standard predicted value of FEV1 in Japanese non-smoking
RVResidual volume, VCVital capacity, ICinspiratory capacity
healthy subjects is obtained by the following formula.
Men FEV1 (L) = 0.036 heightcm 0.028 age 1.178 Reference 5
Women FEV1 (L) = 0.022 heightcm 0.022 age 0.005
14 15
COPD POCKET GUIDE 5 Diagnosis
18 19
COPD POCKET GUIDE 6 Treatment and management
Figure 12Drugs used for the management of COPD in the stable stage
Metered dose Dry powder Nebulizer Oral Injection Patch Duration of
Drug inhaler inhaler mg/mL mg mg mg action
g g hours
I. Bronchodilators Anticholinergics
1. Anticholinergics Reversible airway constriction in COPD patients depends mainly on
1short-acting type acetylcholine deriving from the vagus nerve. Consequently, the most
Ipratropium bromide 20 68 effective single agent to dilate the airways would appear to be an anti-
Oxitropium bromide 100 79
2Long-acting type
cholinergic agent. There is no evidence of decrease in effectiveness
Tiotropium 18 24 resistancewith long-term administration. Long-acting anticholinergic
2. agonists agentsscheduled to be available commercially in Japan from winter
1Short-acting type 2004have effects for 24 hours after inhalation with significant
Salbutamol 100 5 2 46
Terbutaline 2 0.2 46
improvement in FEV1 and FVC remaining until the morning after admin-
Hexoprenaline 0.5 46 istration. There have been reports that anticholinergic agents can
Procaterol 510 0.1 2550g 810
cause urinary retention in patients with prostate hypertrophy and can
Tulobuterol 1 8
Fenoterol 100 2.5 8 exacerbate glaucoma.
Clenbuterol 10g 1012
Mabuterol 2550g 810
2Long-acting type 2agonists
Salmeterol 2550 12 The most rapid initiation of bronchodilating effects is through the use
Formoterol
4.512 12 of short-acting 2-agonists inhalation. A single administration of
TulobuterolPatch 0.52 24
inhalation-type long-acting 2-agonists yields effects for 12 hours and
3. Methylxanthines
no decrease in effectivenessresistanceis seen with long-term
Aminophylline 250 Variable, maximum 24 hours
TheophyllineSlow release 50400 Variable, maximum 24 hours administration. Good compliance can be anticipated with the use of
II.
Inhaled glucocorticosteroids patch-type 2-agonists.
1Topical administrationinhalation
Beclomethasone 50100 Methylxanthines
Fluticasone 50100 50200 While these drugs are not as effective in improving the FEV 1 value
Budesonide100200
compared to inhaled bronchodilators, from a theoretical point of view,
2Systemic administrationoral, injection
Prednisolone 5 when these are given orally, they should have a better effect on dila-
Methylprednisolone 24 40125 tion of peripheral airways and reduce the overexpansion of the lung
III. Combined
III. Combined drugs
drugs long-acting
-agonists
in one inhaler
plus glucocorticoid and ameliorate dyspnea on exertion. It has been suggested that low-
Salmeterol/Fluticasone 50/100, 250, 500 dose theophylline reduces the amount of inflammatory cells in the air-
Formoterol/Budesonide 4.5/100, 200 way.
Mucousregulatory drugs
VI.
Bromhexine 2 4 4 Inhaled glucocorticosteroids
Carbocisteine 250500
Fudosteine 200
Inhalation of glucocorticosteroids can help reduce the number of
Ambroxol 15 episodes of exacerbation of COPD in patients with %FEV1 of less than
Acetylcysteine 200
50% of the predicted value and can reduce the rate of deterioration of
TulobuterolPatchneeds to be examined further in terms of the sequence of the bronchodilator QOL. There are few reports on dose-response relationship of inhaled
since the data is based on blood concentrations. steroids in COPD patients. In large-scale trials, high-dose inhaled
steroids have been used.
22 23
COPD POCKET GUIDE 6 Treatment and management
Induction
program
Social activities
Patient
Exercise training
Exercise capability QOL
Physiotherapy
ADL Assessment
Oxygen therapy Correct use of the Maintenance Assessment
equipment Stability of the disease
Patient / family Nutrition counseling condition program
Compliance
assessment Pharmacologic therapy Days hospitalized
Self-management ability
medically, socially
Patient education
smoking cessation,
general daily activities
Repeated
rehospitalization
Figure 15Programed development of exercise training
Understanding of the
Psychosoical support disease Anxiety Reference 8
The induction program is performed under supervision in the outpatient
department at least two times a week (three times or more in many
Figure 13Comprehensive pulmonary rehabilitation cases), normally six to eight weeks.
Basic structure and three main strings Reference 7
24 25
COPD POCKET GUIDE 6 Treatment and management
26 27
COPD POCKET GUIDE 6 Treatment and management
tiation of nutritional supplementation therapy. COPD patients. In the future, randomized clinical trials
However, there is no consensus concerning the most are necessary to determine this point.
appropriate treatment method, including prevention, For home tracheostomy intermittent positive pressure
thus this topic must be studied further. ventilationTIPPV, there is a great necessity for a
For behavioral therapy in nutritional guidance, nutri- diagnostic and therapeutic system as well as a nursing
tionists, physicians and nurses should form a team. or home help support system. Therefore, it is neces-
sary to prepare a system for the education of the
E. Oxygen therapy helpers and a system of initiation of home help and
In cases of COPD exhibiting hypoxemia, long-term home care.
oxygen therapyLTOT, 15 hours or more per day,
G. Lung volume reduction surgery (LVRS)
can improve the survival rate.
Oxygen therapy is indicated in cases of severe chronic Indications for LVRS are as follows:1a definitive
respiratory failure in patients with a PaO2 of 55 Torr diagnosis of emphysema has been obtained based on
or less, or in cases with PaO2 of 60 Torr or less in clinical findings or spirometry,2despite fully suffi-
whom there is remarkable hypoxia during sleep or cient medicinal treatment, dyspnea has continued,3
during exercise, and in whom the physician believes Fletcher-Hugh-Jones stage III or moreMRC rate: 3 or
home oxygen therapy is necessary. The decision on more,4Chest CT and ventilatory blood flow on
the indication for the procedure can be made based on scintigraphy show inhomogeneous lesion distribution
the measurement of PaO2 by pulse oxymeter oxygen emphysematous change .
saturation measurement. The National Emphysema Treatment TrialNETT
During induction, it is important to educate not only study shows that surgical treatment contributed to
the patient, but also the family, concerning the oxygen survival in cases in which the emphysematous changes
therapy. were more predominant in the upper lobes of the lung
In cases of hypoxemia at rest or with a lower limit of and in which there was a low exercise capability.
normal PaO270 Torr or less, travel by airplane can There are data indicating that three years postopera-
result in an exacerbation of hypoxemia. tively, the physiological functions are better than
before operation.
F. Ventilatory support
H. Lung transplantation
It is important to have the support of an comprehen-
sive approach based on a multiprofessional medical COPD is the most frequent indication of lung trans-
team for the introduction and continuation of mechani- plantation worldwide.
cal ventilation therapy. In Japan, primary pulmonary hypertension has
At present, there is no persuasive evidence as to the been the greatest indication followed by idiopathic
effectiveness of noninvasive intermittent positive pres- interstitial pneumonia, while for COPD, there has
sure ventilationNIPPVtreatment for chronic stable only been one case of lung transplantation.
28 29
COPD POCKET GUIDE 6 Treatment and management
B. Pharmacologic therapy of exacerbations tion cephem drugs, carbapenem drugs, and new
quinolone drugs are recommended.
To control exacerbation of COPD, it is essential to
either increase the dose or the frequency of adminis-
tration of bronchodilators. Short-acting 2agonists are C. Elimination of airway secretions
frequently employed. Administration of anti-bacterial agents, steroids, or
Systemic administration of glucocorticosteroidsorally bronchodilators is effective in reducing airway secre-
or intravenouslycan shorten the time to recovery and tions and to improve airway clearance in the period of
can also hasten recovery of lung function. exacerbation.
Cases with increase of sputum or increase of purulence There is no consensus on the effectiveness of respirato-
are probably related to bacterial airway infections, ry physical therapy for elimination of sputum, but this
therefore administration of antibacterial agents is rec- is performed widely in cases of acute exacerbation as
ommended. well as chronic stable condition.
In the outpatient clinic, administration of oral penicillin
and new quinolone drugs are recommended, and in
hospitalized cases, injection of -lactam drugs/-lac- D. Ventilatory support
tamase inhibitors, third generation or fourth genera- NIPPV should be used initially because of the ease of
initiation, simplicity, and lack of invasiveness, but in
Exacerbation of dyspnea cases of dysphagia and in cases with viscous or copi-
ous secretions, it is necessary to first maintain the air-
Initiation or increase of bronchodilator dose
way, therefore IPPV should be performed.
Initiation of antibacterial agents in cases of sputum increase, or purulence of sputum
NIPPV has been shown to be effective in 80-85% of
cases, based on clinical evidence such as improve-
Re-evaluation within several hours ment of blood gas findings, reduction of dyspnea,
and shortening of hospitalization time. There are
Amelioration or improvement No improvement recognized
reports on improved mortality rate and reduction of
of symptoms or findings intubations due to NIPPV.
Prednisolone administration30-40 mg The indications of mechanical ventilation treatment
during episodes of exacerbation should be decided
Continuation of treatment
If possible, reduction
Re-evaluation in several hours based on the global assessment, taking into consid-
of treatment
eration the wishes of the patient, family, the clinical
Exacerbation of symptoms or findings
course, and the evaluation of the reversibility of
cases of exacerbation. It is also necessary to discuss
Re-evaluation of long term treatment Examination at hospital or admission
with the patient and family, preferably during the
Figure 17Algorithm for home and outpatient management stable period, whether NIPPV should be the maxi-
of COPD mum therapeutic effort.
32 33
COPD POCKET GUIDE COPD POCKET GUIDE
7Ethical issues
Table 13Indications of NIPPV Informed consent must be obtained before treatment.
Information must be provided to the patient and fami-
1. Severe dyspnea
ly from their point of view giving them full informa-
2. No response to pharmacologic therapy
including oxygen therapy tion concerning all the problem options, and also giv-
3. Remarkable use of accessory respiratory muscles ing them the choice of changing options during treat-
and paradoxical respiration ment.
4. Respiratory acidosis or high CO2 levels of blood Advance directives include a wide range of instruc-
pH7.35 or PaCO245 tions of living will anddo not resuscitatedirectives.
Health care providers should inform the patient about
Table 14Criteria for elimination of NIPPV objectives and also take into consideration the opinion
of the patient for terminal care. They also should
1. Respiratory arrest, or patients with extremely inform the patient about aspects of intensive care dur-
unstable respiratory circulatory condition
ing future periods of exacerbation.
2. Patient cooperation cannot be obtained
In all aspects of medical treatment, the privacy of the
3. Cases in which some kind of airway maintenance is
necessary patient must be given primary consideration. The
4. Cases of injury or burns in the head or neck region patients must also be fully informed that their privacy
is completely protected.
E. Prognosis
Cases with stage III and IV COPDsevere, very severe
cases, not only show a decrease in QOL due to exer-
tional dyspnea but also have very poor prognosis.
Studies in Japan on long-term oxygen therapyLTOT
have shown that the outcome for women is better
than that of men, and there was no difference in out-
come in relation to the level of carbon dioxide.
34 35
References
1 Fukuchi Y, Nishimura M, Ichinose M, et al : Prevalence of
chronic obstructive pulmonary disease in Japan: results from
the Nippon COPD epidemiologyNICEstudy. Eur Respir J
2001; 18suppl 33: 275s
2 Global Initiative for Chronic Obstructive Lung Disease. Global
strategy for the diagnosis, management, and prevention of
chronic obstructive pulmonary disease : National Heart, Lung
and Blood Institute, National Institutes of Health. April 2001;
Publication Number 2701
3 Jones PW : Measurement of breathlessness, Lung function
tests, physiological principles and clinical applicationseds by
Hughes JMB, Pride NB, pp121-131, WB Saunders, London,
1999
4 Goddard PR, Nicholson EM, Lasco G, et al : Computed
tomography in pulmonary emphysema. Clin Radiol 1992 ; 33 :
379387
5 Gibson GJLung volumes and elasticity, Lung function tests,
physiological principles and clinical applicationseds by
Hughes JMB, Pride NB , pp45-56, WB Saunders, London,
1999
6 The Tobacco Use and Dependence Clinical Practice Guideline
Panel, Staff, and Consortium Representatives : A clinical
practice guideline for treating tobacco use and dependence.
JAMA 2000 ; 283 : 32443254
7 Kida KComprehensive pulmonary rehabilitation - A manual for
team management- In Japanese , Medical Review, Tokyo,1998
8 Manual of pulmonary rehabilitation - exercise training- In
Japanese . Japan Society for Respiratory Care / Japanese
Respiratory Society/ Japanese Physical Therapy Association,
2003
9 Pulmonary rehabilitation guideline committee of the Japan
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321-330
36