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Guidelines for

the Diagnosis and

Treatment of COPD
Chronic Obstructive Pulmonary Disease

2nd edition

Pocket Guide

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

Guidelines for the Diagnosis and Treatment of COPDChronic

Obstructive Pulmonary Disease, 2nd ed., Pocket Guide

First published 2004

All rights reserved. No part of this publication may be repro-

duced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, record-
ing or otherwise without the prior permission of the copyright

Published by
The Japanese Respiratory Society
Shibata Building 2F, 2-6-4, Uchikanda, Chiyoda-ku, Tokyo,
101-0047, JAPAN

English translation with the assistance of

J. Patrick Barron
Keiko Yamamoto
Kozue Iijima
International Medical Communications Center, Tokyo Medical
6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, JAPAN

Printed by
Medical Review Co., Ltd.
Itopia Yushima Building, 3-19-11, Yushima, Bunkyo-ku, Tokyo,
113-0034, JAPAN
Guidelines for
the Diagnosis and
Treatment of COPD
Chronic Obstructive Pulmonary Disease

2nd edition

Pocket Guide

Committee for the Second Edition of
the COPD Guidelines of The Japanese Respiratory Society

It is recognized throughout the world that in order to

overcome the problem of the under diagnosis of COPD,
it is important for clinicians to correctly understand it.
To achieve this, it would be valuable to have a pocket
guidebook which can provide clinicians with rapidly
absorbed and practically applicable information cover-
ing all the main points about COPD. This guidebook
has been created as a distillation of the essential
aspects of the Second Edition of the Guidelines for the
Diagnosis and Treatment of Chronic Obstructive
Pulmonary Disease. I earnestly hope that it will serve
that purpose and will be useful in the early diagnosis
and treatment of this disease.

I would like to express my gratitude to all the mem-

bers of the Committee for the Second Edition of the
COPD Guidelines who have worked so hard on produc-
ing both the Guidelines and its pocket guide. In partic-
ular, I would like to thank Dr. Jun Ueki and Dr.
Kuniaki Seyama, who served as the central coordina-
tors of the project, also the staff of Medical Review Co.
Concerning the English edition, I would also like to
thank Professor J. Patrick Barron, Ms. Keiko Yamamoto
and Ms. Kozue Iijima of the International Medical
Communications Center of Tokyo Medical University,
for their producing the English edition so rapidly in
cooperation with Dr. Ueki.

Yoshinosuke Fukuchi
Committee Chairman
Committee for the Second Edition of the COPD Guidelines
of The Japanese Respiratory Society

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

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

Chairman Committee members

Yoshinosuke FUKUCHI Department of Respiratory Medicine, Juntendo University Takeshi MATSUSE Division of Respiratory Medicine, Department of Internal
School of Medicine Medicine, Yokohama City University Medical Center

Masakazu MATSUZAKI Higashi Matsuyama Municipal Hospital

Committee members
Michiaki MISHIMA Department of Respiratory Medicine, Graduate School of
Hisamichi AIZAWA 1st. Department of Internal Medicine, Kurume University School
Medicine, Kyoto University
of Medicine
Akira MURATA Respiratory Care Clinic, Nippon Medical School
Nobuyuki HARA National Hospital OrganizationNHOFukuoka-Higashi Medical
The 4th Department of Internal Medicine, Nippon Medical School
Atsushi NAGAI Respiratory Center, Pulmonology, Tokyo Women s Medical
Kazuto HIRATA Department of Respiratory Medicine, Graduate School of Medicine,
University Hospital
Osaka City University
Takahide NAGASE Department of Respiratory Medicine, Graduate School of
Masakazu ICHINOSE Third Department of Internal Medicine, Wakayama Medical
Medicine, University of Tokyo
Masaharu NISHIMURA Division of Respiratory Medicine, Department of Internal
Hideki ISHIHARA Department of Respiratory Medicine and Intensive Care, Osaka
Medicine, Hokkaido University Graduate School of
Prefectural Medical Center for Respiratory and Allergic Diseases
Shinichi ISHIOKA ISHIOKA Internal Medicine Clinic
Shuichi OKUBO OKUBO Chest Clinic
Harumi ITOH Division of Radiology, Department of Radiology and Laboratory
Kuniaki SEYAMA Department of Respiratory Medicine, Juntendo University School
Medicine, Faculty of Medical Sciences, University of Fukui
of Medicine
Tomoaki IWANAGA Division of Clinical ResearchRespiratory Medicine, National
Nobuyoshi SHIMIZU Department of Cancer and Thoracic Surgery, Okayama
Hospital OrganizationNHOFukuoka-higashi Medical Center
University Graduate School of Medicine and Dentistry
Yoshio KASUGA Saitama Social Insurance Hospital
Kaoru SHIMOKATA Division of Physiological Medicine, Department of Medicine,
Masataka KATO KATO clinic Nagoya University Graduate School of Medicine

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
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.

Noxious particles / gas

tobacco smoke, air pollution,
indoor biomass fuel smoke

Alveoli Peripheral airways Central airways

destruction of small bronchi with less mucous gland
than 2 mm in internal
alveolar walls diameter, bronchioles hypertrophy

Emphysema Airway lesion

predominant type predominant type


Figure 1Diagram of the clinical phenotype of COPD

The clinical phenotype of COPD can be understood by studying the fig-
ure above:
The main cause related to airflow limitation is peripheral airway
There are cases in which primarily destruction of the alveolar system
leads to conditions favoring emphysema : Emphysema predominant
In some cases, primarily progression of central airway lesions leads to
a preponderance of airway lesions : Airway lesion predominant type.
The concept of COPD encompasses all such alveolar-peripheral air-
way-central airway lesions.
Accompanying the progression of these pulmonary lesions, dyspnea
on exertion, airway hypersecretions, and various systemic symptoms
can appear.
Effective prevention and management can be achieved by the elimina-
tion of risk factors and appropriate treatment.

COPD POCKET GUIDE 2 Epidemiology of COPD in Japan

2Epidemiology of COPD in Japan

From the 1960s, the sales and consumption of ciga-
rettes have increased and about 20 years after that
trend was seen, there was an increase in mortality
in Japan due tochronic bronchitis and pulmonary Severe Very severe
emphysema*. COPD COPD
4% 2%
According toTrends in public health, COPD did not Moderate 96
appear among the ten leading causes of death through COPD 15%
1999. In the year 2000, however, it became ranked as 38
the 10th highest cause of death.
Based on the data concerning the prevalence of COPD Mild COPD
obtained by the Nippon COPD EpidemiologyNICE 79%
study, it is estimated that about 5.3 million Japanese
suffer from COPDFigures 2, 3 and 4.

Figure 3Degree of severity of

patients given a diagnosis of COPD
17.4 in the NICE study Reference 1

Diagnosis was
8 8.5 given
6 10%
4 5.1 24
2 3.1
40 - 49 50 - 59 60 - 69 70 Total
Age group
Diagnosis was not given
Figure 2COPD prevalence according to ageNICE study 227
Reference 1

Figure 4Past clinical history of

cases given a diagnosis of COPD
in the NICE study Reference 1
The termchronic bronchitis and pulmonary emphysemawas used
in epidemiological surveys up to the year 2000, but that concept is
generally the same as the present COPD.

2 3
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-
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

Table 1Risk factors of COPD Repair mechanisms

Most Important
important Possible factors Pathology of COPD
factors factors

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
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.

4 5

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

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

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

MRCThe British Medical Research CouncilMRCproduced this

internationally widely used scale. There are three commonly used
forms: the five-grade scale from 1 to 5, the five-grade scale with
grade 0 added, the five-grade scale from 1 to 5 converted to grades
0 to 4, which is commonly used by the American Thoracic Society.

10 11

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
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.

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.

Table 8Visual evaluation of pulmonary emphysema

Right and left lungs are divided into six areas consist of
the upper, middle and lower lung fields on both sides. The
Figure 6Plain chest x-ray film of COPD patient degree of severity of pulmonary emphysema is evaluated
using a five-point scale for each lesion.
P-A view Lateral view
1Enhanced radiolucency of the lung fields 1Flattening of the diaphragm 0 pointNo emphysematous lesions
2Decrease of peripheral blood vessel shad- 2Increase in the intercostal space 1 pointOccupying less than 25% of the entire lung field
ows in the lung fields 3Increase in the retrocardiac space 2 pointsOccupying from 25 to less than 50% of the entire lung field
3Flattening of the diaphragm 3 pointsOccupying from 50 to less than 75% of the entire lung field
4Decrease in the cardio-thoracic ratio 4 pointsOccupying more than 75% of the entire lung field
CTRdue to teardrop heart
Scores from all fields are totaled
maximum total24 points
5Increase in the intercostal space
Reference 4
12 13

5. Pulmonary function test

In COPD, it is essential to establish a diagnosis of the FlowL/S FlowL/S
presence of airflow limitation by spirography. 10 10
A post-bronchodilator FEV1/FVC less than 70% is con- 8 8
sidered to indicate the presence of airflow limitation.
6 6
Decrease in the gas exchange function of COPD
patients can be grasped by examining the decrease in 4 4
the diffusing capacity for CODLco.
2 2

0 0 0
1 2 3 4 5 6 1 2 3 4 5 6
VolumeL VolumeL
1 2 2

2 4 4
Severe COPD
Figure 9Flow volume curve
4 FEV1 AHealthy subjectBSevere COPD patient
healthy subject
0 1 2 3 4 5 6 7
Volume time curve
Figure 8Spirograms of a healthy individual and a severe
COPD patientFEV1 and FVC

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.
FEV1% = FEV1 / FVC 100%
%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

6. Exercise tests, respiratory muscle 8. Evaluation of pulmonary hyper-

function tests, sleep studies tension and cor pulmonale
The exercise test is useful for evaluating the degree of In respiratory diseases primarily affecting ventilation
severity, clarifying the exercise limiting factors of the such as COPD, the pulmonary hypertension is consid-
respiratory and circulatory systems, deciding on the ered to be indicated by an mean pulmonary arterial
therapeutic strategy and its effectiveness, and also for pressure of 20 Torr.
prognostic evaluating. Cases of COPD usually do not have severe pulmonary
In COPD, the ventilation system is the major limiting hypertension and the pattern of progression is grad-
factor of exercise. In severe cases, hypoxemia during ual, but it can increase transiently on episodes of exac-
exercise, pulmonary circulation disturbance and erbation, under exercise loading, or during sleep in
decreased oxygen transport capability may also limit sleep-related respiratory disorders.
the exercise capacity.
Both inspiratory and expiratory muscle strength is 9. QOL assessment
reduced in COPD, but the degree of decrease is
greater in inspiratory muscle strength. The purpose of treatment for COPD is to improve
There is a tendency toward marked decrease in the QOL by alleviating respiratory symptoms, reducing
arterial blood oxygen saturation during sleep in the chronological decrease in pulmonary function, and
patients who show a decrease in the partial oxygen avoiding exacerbation.
pressurePaO2when awake. In these patients, a ten- In COPD, QOL should be quantitatively assessed using
dency towards hypoxemia is particularly marked dur- standardized questionnaires which evaluate the effects
ing REM sleep. of disease on the activities of daily living, and the
degree of well-being.
7. Arterial blood gas measurement Disease-specific HRQL instrument for COPD
PaO2 value of a 60 Torr or less at rest breathing room Items Japanese version
air is diagnosed as respiratory failure. If the PaCO2 is St. George
s Respiratory QuestionnaireSGRQ 76 Available
45 Torr or more, it is judged to indicate the accumula- Chronic Respiratory Disease QuestionnaireCRQ 20 Available
tion of carbon dioxide.
When considering QOL to examine the relationship between health and disease
Measurement of SpO2 using a pulse oxymeter allows in the field of medicine, two types of assessments are madegeneral QOL and
continuous non-invasive measurement, but it is neces- health-related QOLHRQL. The QOL assessment skills can be largely divided
sary to understand all points requiring caution for the into scalesinstrumentsfor assessment of general healthgeneric HRQL
measurement. and disease-specific HRQL, aimed specifically at COPD. The generic HRQL
assessment scales can also be effective in comparing the degree of disorder in
COPD and other respiratory diseases or diseases affecting other organs.
Disease-specific HRQL assessment scales developed for COPD are more reliable
and sensitive than generic HRQL scales, and are suited for evaluation of changes
in HRQL after medical intervention, including prospective clinical trials.
16 17
COPD POCKET GUIDE 6 Treatment and management

6Treatment and management

1. Smoking cessation Table 9Strategy to help a patient quit smoking

Smoking is the main risk factor of COPD, causing air Ask

flow limitation and accelerating the reduction in pul- Systematically identify all tobacco users at every visit.
monary functions. There are reports that the progres- Implement an office-wide system that ensures that, for
sion of decrease in pulmonary function can be delayed EVERY patient at EVERY clinic visit, tobacco-use status is
through smoking cessation. queried and documented.
Smoking cessation is the single most important and
effective, and cost-effective, method of intervention to Advise
reduce the risk of the occurrence of COPD and to hold Strongly urge all tobacco users to quit.
back its progress. In a clear, strong and personalized manner, urge every
Smoking is considered to be a type of drug addiction, tobacco user to quit.
i.e. addiction to nicotine. To decide on the addiction,
the Fagerstrm nicotine dependence test is often used. Assess
It is reported that even with a short three-minute peri- Determine willingness to make a quit attempt.
od of smoking cessation advice from the clinician caus- Ask every tobacco user if he or she is willing to make a
es an increase in the rate of quitting smoking. quit attempt at this timee.g., within the nest 30 days.
Smoking cessation treatment is promoted by combining
an active scientific approach for behavioral therapy, Assist
and a pharmacological approach. Aid the patient in quitting.
Help the patient with a quit planprovide practical
Nicotine replacement therapyThis is performed simultaneously with counselingprovide intra-treatment social supporthelp the
smoking cessation. The patient is instructed not to smoke while using
patient obtain extra-treatment social supportrecommend
nicotine products. When using nicotine gum, the patient should be
instructed to chew the gum slowly, to place it for sometime between use of approved pharmacotherapy if appropriateprovide
the cheek and the teeth, and to allow the nicotine to be absorbed supplementary materials.
through the oral cavity membrane. When the oral cavity becomes acidic,
the absorption of nicotine is prevented, so the patient is instructed not Arrange
to drink coffee, juice or carbonated beverages for 15 minutes before or
Schedule follow-up contact.
during chewing. Even if the patient is able to stop feeling the need for
the nicotine gum in two or three months, the patient should be instruct- Schedule follow-up contact, either in person or via telephone.
ed to always carry one piece of gum in order to feel secure. Nicotine
Reference 6
patches can have high, medium, and low nicotine contents. The patient
should start with a high content patch. Generally the high content
patch is used for 4 weeks, then the medium content patch for 2 weeks,
and the low nicotine patch for 2 weeks, gradually reducing the dose.
Even if the patient begins smoking again, the clinician should encour-
age the patient to try to stop once again, and it is very important for
the clinician also, not to give up.

18 19
COPD POCKET GUIDE 6 Treatment and management

2. Management of stable COPD A. Pharmacologic treatment

Stage I mildCOPDin addition to smoking cessation, There are no effective drugs against the pulmonary
the use of short-acting bronchodilators is recommend- and airway inflammation or the accompanying progres-
ed when needed in order to alleviate symptoms. sion of airflow limitation. However, pharmacologic
Stage IImoderateCOPDin addition to decreasing treatment can reduce symptoms, prevent exacerbation,
symptoms, the main purpose should be to improve and increase QOL and exercise capacity. Therefore
QOL and improve exercise capacity. Regular treat- pharmacologic treatment should be pursued positively.
ment with long-acting bronchodilators and pulmonary Bronchodilator medications which are central to phar-
rehabilitation is recommended. macologic treatment should be given on a step-by-step
Stage IIIVmoderate to very severeCOPDthe basis in response to the degree of severity of the dis-
main strategy of pharmacotherapy is the regular use ease. The action of each individual patient should be
of long-acting bronchodilators. Depending on the effec- studied and the most appropriate drug should be
tiveness, more than one long-acting bronchodilator can selected and given continuously.
be administered. Further evaluation is necessary con- Various bronchodilators such as anticholinergics, 2-
cerning the evaluation of the effectiveness of mucolyt- agonists and methylxanthines, all have different bron-
ic agents. chodilator mechanisms. Considering the balance
Stage IIIIVsevere to very severeCOPDpreven- between effect and adverse reactions rather than
tion of exacerbation is a very important topic. In cases increasing the dose of a single agent, it is preferable to
with repeated exacerbationse.g., three episodes of use multiple agents.
exacerbations in the past three yearsdecrease in the Continuous administration of inhaled glucocorticos-
frequency of exacerbation and suppression of the dete- teroids does not suppress the deterioration of respira-
rioration of QOL can be achieved by the use of inhaled tory function, but in cases in which the %FEV1 is less
glucocorticosteroids. than 50% with frequent episodes of exacerbation, it
Long term oxygen
has been reported that such treatment can reduce the
for respiratory failure number of episodes of exacerbation and reduce the
Consider surgical
treatment speed of deterioration of QOL.
Consider inhaled glucocorticosteroids
in cases of repeated exacerbation
It has been reported that rather than single drug
Pulmonary rehabilitation
administration of inhaled glucocorticosteroids and
Regular treatment with one long-acting bronchodilatorone or more long-acting 2-agonists, the combined use of these
Use of short-acting bronchodilators as needed agents improves the FEV1 and reduces the exacerba-
Smoking cessation tion and improves QOL significantly.
Influenza vaccination
The use of influenza vaccines has been reported to
Stage Stage 0 : group at risk Stage I : mild Stage II : moderate Stage III : severe Stage IV : very severe
reduce by 50% the mortality of COPD cases due to
Normal spirometry %FEV130% or
results, chronic
80%%FEV1 50%%FEV180% 30%%FEV150%
%FEV150% plus
chronic respiratory
exacerbation of the condition, thus all COPD cases
cough, sputum
failure or right heart
cardiac failure
should be given vaccines.
Figure 11Management according to stage of chronic stable COPD
20 21
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

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
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
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

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
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

B. Comprehensive pulmonary rehabilitation High intensity

Pulmonary rehabilitation can contribute to the Mild disease
improvement of the effectiveness of patients, even
those who have already on pharmacologic therapy.
Pulmonary rehabilitation is, in principle, a team medical Instru-
mental Endurance /
effort. An even greater positive effect can be anticipat- Moderate muscle strength
ed by having multiprofessional team working on an disease training
comprehensive programFigure 13. ADL
Exercise therapy is a central structural component of training
Severe intensity
pulmonary rehabilitation. When starting exercise train- disease
ing, it is desirable to condition patient by adjusting Conditioning
their breathing patterns and providing them with flex- Basic
ibility training to ensure efficient exercise training
Figure 14. Figure 14Structure of the program at the beginning
Exercise training should be performed continuously of the exercise training Reference 8
and regularly, as in the correct practice of regular
inhalation pharmacologic therapy. Following the induc-
tion phase of the program, the maintenance phase con- Initial assessment Conditioning
sists of central components including endurance and Assessment
ADL training
muscle strength training. By this time it is desirable
for the patients to have formed an exercise habit and Endurance training and
incorporated it into their lifestyleFigure 15. muscle strength training

Social activities
Exercise training
Exercise capability QOL
ADL Assessment
Oxygen therapy Correct use of the Maintenance Assessment
equipment Stability of the disease
Patient / family Nutrition counseling condition program
assessment Pharmacologic therapy Days hospitalized
Self-management ability
medically, socially
Patient education
smoking cessation,
general daily activities
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

C. Patient education D. Nutrition management

Patient education occupies an extremely important Approximately 25% of COPD patients with moderate
position in all processes of prevention, diagnosis and or more severe disease and approximately 40-50% of
management of COPD. very severe COPD, the percent IBWpercent ideal
Specialists from multiple fields should participate in body weighthas decreased to less than 90% or there
patient educationTable 10. The most effective edu- has been a decrease in lean-body massLBM.
cational method is to conduct patient education sys- The development of respiratory failure and cumulative
tematically in a programed comprehensive pulmonary mortality are high in patients in which loss of body
rehabilitation. weight is seen. Loss of body weightdecrease in
In the management of COPD and other chronic dis- %IBW, BMIis a prognostic factor independent of air-
eases, adherence must be enhanced. flow limitation.
In cases of %IBW < 90%, there is usually a disturbance
Table 10Structure of patient education program in COPD
in nutrition. Dietary treatment is indicated in the
1. Instruction concerning the disease cases of COPD in which %IBW < 90%. Particularly,
The structure and function of the lung
Explanation and interpretation of the respiratory disease of the individual cases in which %IBW < 80% accompany decrease in
patient LBM. This is a strong indication for a very positive ini-
2. Smoking cessation guidance and improvement of environmental factors
Explanation of the damage to health caused by smokingincluding passive
smoking Table 11Recommended evaluation items
Avoidance of occupational dust exposure and prophylaxis Essential Body weight%IBW,BMI, eating habits, the presence / absence of
3. Guidance on pharmacologic treatment evaluation item clinical symptoms when eating
Explanation of the effects and adverse reactions of the drugs prescribed to
Dietary investigationanalysis of the amount of nutrition, energy
the individual patient Desirable consumption at restresting energy expenditure; REE, % upper arm
Give information about methods, frequency and times of taking medicine or evaluation circumference%AC, %triceps muscle of arm subcutaneous fat
inhalation items thickness%TSF, %arm muscle circumference%AMC; AMC=AC
4. Guidance concerning avoiding infection TSF, serum albumin
Inform about the meaning of the prevention of respiratory infections
Evaluation items to Body component analysisLBM, FM, etc., RTP measurement, plasma
Vaccinations amino acid analysisBCAA / AAA, grip strength, respiratory muscle
be measured
5. Efforts to adapt limitations to daily lifeenergy conservation, simplification of if possible strength, immunocompetence
daily activities
Walking, washing, toilet, bathing and other aspects of daily life IBW:80%IBW90: mild decrease, 70%IBW80:moderate decrease, %IBW70: marked decrease
6. Dietary guidance BMI: low body weight18.5, standard body weight 18.5-24.9, excess body weight 25.0-29.9, FM:Fat Mass
The necessity and points of caution concerning nutrition
Adjustments to diet intake and timing Dietary treatmentGenerally, when an increase in body weight is aimed at, an REE of
7. Guidance concerning home oxygen therapy and home ventilator therapyas 1.5 times or more is necessary with non-protein energy. As a countermeasure against
the nutritious disturbance in COPD, the basic approach is a high energy, high protein
8. Patient self-management
9. Psychological support diet. The protein source should contain large quantities of branched amino acids. P, K,
Handling anxiety and panic Ca, Mg are important for the contraction of respiratory muscles, therefore a sufficient
Stress management intake of these materials is necessary. Especially, in COPD, it has been suggested
Traveling and entertainment that there is an increased incidences of osteoporosis, therefore, Ca intake is important.
10.Access to social welfare services
When it is difficult to increase the amount of diet, or in cases of moderate or more
(Reference 9) decrease in %IBW, then nutritional supplementation method can be considered.

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

I. Home management 3. Management during exacerbations

Home management treatment is based on respect of the A. Evaluation of exacerbations and indications for hospitalization
wishes and hopes of the patient, and is intended to
release the patient from the restrictive environment of The appearance of exacerbation increases the frequen-
hospitalization, while enhancing the environment of the cy of hospitalization of the COPD patient, increases
home, to increase the level of QOL of the patient and the the mortality ratio and has a very seriously negative
family, enabling support for a more independent lifestyle. effect on prognosis. It is one of the most important
The indications of home management care for COPD factors in the clinical phenomena of COPD.
patients are1severe COPD,2patients requiring a There is no concrete classification of the exacerbation
of COPD or the severity of exacerbation, including in
high level of respiratory management,3patients
the GOLD classification. In the West, various defini-
requiring continued pulmonary rehabilitation.
tions of the exacerbation or severity of exacerbation
Certification as the 4th class or more disability can be
have been published.
obtained by LTOT patients and that of the 3 rd class or
The most common causes of exacerbation are respira-
more by patients on home mechanical ventilation in
tory tract infection and air pollution. However, the
Japan. In order to reduce the burden on the patient
causes are unknown in about one-third of the cases.
and the family, the disability certification should be
usedTable 12. COPD classification in the stable condition
In nursing certification, the COPD patients are not cor- Stage mild
I Stage IImoderate Stage IIIsevere Stage IVvery severe
rectly evaluated, and there is not sufficient under-
standing by the Japanese government. As a result, it COPD exacerbation
is necessary to write in as much detail as possible in
PaO2 60Torror
the section No. 5other notable itemsin the docu- SpO2 90
ment prepared by the attending physician.
Hospitalization Hospitalization Hospitalization
Table 12Respiratory function disorder level in Japan
Figure 16Indications for hospitalization for exacerbations
Activity ability FEV1 / predicted VC PaO2 of COPD according to stage classification
So difficult to breathe that the Impossible to measure / Indications of hospitalization for exacerbations of COPD
Class 1 50 Torr or less
patient cannot take care of things 20 or less 1) Hospitalization in principle on exacerbations at stage III or IV
(severe or very severe COPD
Even walking slowly bit by bit, the 2) Indications of hospitalization for exacerbations of stage I or II
Class 3 2030 5060Torr COPD (mild or moderate COPD
patient becomes breathless
Appearance of dyspnea, exacerbation
PaO2<60 Torr or SpO2<90% breathing room air
Cannot climb stairs even slowly, Appearance of symptoms suggestive of severe disease
unless stopping from time to time Use of accessory respiratory muscles, paradoxical chest movement,
Class 4 to take breath / cannot walk at 3050 6070Torr exacerbation of central cyanosis or its de
de novo
novo appearance, appearance
of peripheral edema, symptoms of right heart failure, hemodynamic unsta-
the same speed as other people, bility
but can walk slowly Uncertainty concerning treatment for exacerbation
3In elderly cases of exacerbation, hospitalization is indicated.
30 31
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
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
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