ATS/ ERS TASK FORCE

Standards for the diagnosis and treatment of patients with COPD:a summary of the ATS/ERS position paper

B.R. Celli* , W. MacNee* , and committee members

Committee members: A Agusti, A Anzueto, B Berg, A S Buist, P M A Calverley, N Chavannes, T Dillard, B Fahy, A Fein, J Heffner,S Lareau, P Meek, F Martinez, W McNicholas, J Muris, E Austegard, R Pauwels, S Rennard, A Rossi, N Siafakas, B Tiep, J Vestbo,

E Wouters, R ZuWallack

*P ulmonaryand Critical C are D ivision , St Elizabeth ’s Medical Center, Tufts U niv ersity School of Medicine, Boston, Massachusetts, USA

# Respirato ry Medicine ELE GI, Colt R esearch Lab Wilk ie Building, Medical Schoo l, T eviot Place, Edinburgh, UKCONTENTS

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 932

Goals and objectives 933Participants 933Evidence, methodology and validation 933Concept of a "live", modular document 933Organisation of the document 933

De® nition of COPD . . . . . . . . . . . . . . . . . . . . . . . 933Diagnosis of COPD . . . . . . . . . . . . . . . . . . . . . . . 933

Epidemio ogy, risk factors and natura history

of COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934

Patho ogy and pathophysio ogy in COPD . . . . . . . . 934

C inica assessment, testing and differentia diagnosis of

COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934

Medical history 935Physical signs 935

Smoking cessation. . . . . . . . . . . . . . . . . . . . . . . . . 935

Brief intervention 935Management of stab e COPD: pharmaco ogica therapy 936

Bronchodilators 936Glucocorticoids 936Outcomes of frequently used drugs 936Combination therapy 937

Management of stab e COPD: ong-term oxygentherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937

Management of stab e COPD: pu monary

rehabi itation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937

Management of stab e COPD: nutrition . . . . . . . . . 938

Management of stab e COPD: surgery in and for

COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938

Surgery in COPD 938Surgery for COPD 938

Management of stab e COPD: s eep . . . . . . . . . . . . 938

Management of stab e COPD: air-trave . . . . . . . . . 939

Exacerbation of COPD: de® nition, eva uation andtreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939

De® nition 939Assessment 940Indication for hospitalisation 940Indications for admission to specialised or intensivecare unit 940

Treatment of exacerbations 940Exacerbation of COPD: inpatient oxygen therapy. . . 940

Setting and adjusting oxygen ¯ ow 941Monitoring following hospital discharge 941

Exacerbation of COPD: assisted venti ation . . . . . . . 942

Indications for mechanical ventilation 942Modes of mechanical ventilation 942Criteria for hospital discharge 942Follow-up evaluation 943

Ethica and pa iative care issues in COPD . . . . . . . 943Integrated disease management for primary care in

COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 943

Referral indications 943Conc usions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 944

Background

The Standards for the Diagnosis and Treatment of Patientswith COPD document 2004 updates the position papers onchronic obstructive pulmonary disease (COPD) published bythe American Thoracic Society (ATS) and the EuropeanRespiratory Society (ERS) in 1995 [1, 2] Both societies feltthe need to update the previous documents due to thefollowing 1) The prevalence and overall importance ofCOPD as a health problem is increasing 2) There have

been enough advances in the ® eld to require an update,especially adapted to the particular needs of the ATS/ERSconstituency 3) It allows for the creation of a "live" modulardocument based on the web; it should provide healthcareprofessionals and patients with a user friendly and reliableauthoritative source of information 4) The care of COPDshould be comprehensive, is often multidisciplinary andrapidly changing 5) Both the ATS and the ERS acknowledgethe recent dissemination of the Global Initiative of Obstruc-tive Lung Disease (GOLD) [3] as a major worldwide

Correspondence: B R Celli, St Elizabeth’ s Medical Center, 736 Cambridge St, Boston MA 02135, USA Fax: 1 6175627756 E-mail:bcelli@cchcs org

*Pulmonary and Critical Care Division, St Elizabeth’ s Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA#Respiratory Medicine ELEGI, Colt Research Lab Wilkie Building, Medical School, Teviot Place, Edinburgh, UK

CONTENTS

Eur Respir J 2004; 23: 932–946DOI: 10.1183/09031936.04.00014304Printed in UK – all rights reserved

Copyright #ERS Journals Ltd 2004European Respiratory Journal

ISSN 0903-1936

contribution to the battle against COPD However, somespeci® c requirements of the members of both societies requireadaptation of the broad GOLD initiative Those requirementsinclude speci® c recommendations on oxygen therapy, pulmo-nary rehabilitation, noninvasive ventilation, surgery in andfor COPD, sleep, air travel, and end-of-life In addition,special emphasis has been placed on issues related to the habitof smoking and its control

Goals and objectives

The main goals of the updated document are to improvethe quality of care provided to patients with COPD and todevelop the project using a disease-oriented approach Toachieve these goals, both organisations have developed amodular electronic web-based document with two compo-nents 1) A component for health professionals that intendsto: raise awareness of COPD; inform on the latest advances inthe overall pathogenesis, diagnosis, monitoring and manage-ment of COPD; and promote the concept that COPD is atreatable disease 2) A component for the patient that intendsto: provide practical information on all aspects of COPD; andpromote a healthy lifestyle to all patients af¯ icted with thedisease

Participants

The committee members who were involved in the produc-tion of this document are clinicians, nurses, respiratory thera-pists and educators interested in the ® eld of COPD The currentStandards for the Diagnosis and Treatment of Patients withCOPD document is unique in that it also had input frompatients suffering from COPD The committee members wereproposed and approved by the ATS and ERS The memberswere selected because of their expertise and willingness toparticipate in the generation of the document A uniquefeature of this project was the development of a patientdocument that could serve as a formal source of informationfor the patients, thereby making them partners in the effort todecrease the burden of the disease

Evidence, methodology and validation

Several well-accepted guidelines served as the blueprint forthe document Namely, the ATS and the ERS standards of1995 [1, 2] and the GOLD initiative published in 2001 [3] Atthe initial meeting, each member of the committee wasassigned a speci® c section of the document and was asked toselect a subcommittee to gather literature and review theexisting evidence The document was discussed in four groupmeetings, and the content and validity of each section wasthoroughly reviewed The ® nal statement is the product ofthose discussions and has been approved by all the membersof the committee Several of the basic source documentsreviewed have used an evidence-based approach, and thecommittee utilised those references as a source of evidencewherever appropriate

The draft document was reviewed by a diverse group ofexperts whose input was also considered Peer review wasidenti® ed by the ATS and ERS, and the ® nal document wassubmitted for review and approval by the Board of Directorsof the ATS and the Executive Committee of the ERS

Concept of a "live", modular document

Understanding that medicine and, in particular, the area ofCOPD is constantly undergoing changes, the ATS and theERS considered that it was time to develop new instrumentscapable of adjusting to the changes As such, this is the ® rststatement conceived to be primarily based on the web andcapable of being changed as needed To achieve this goal, theorganisations have developed a COPD task force composedof three members from each society whose of® ce will last for3 yrs The main task of the members is to constantly reviewadvances in the ® eld of COPD and to propose changes to themodules of the document As is customary in both organisa-tions, the need to do so may arise from the membershipthrough the current existing mechanisms One of the membersof the task force from each society will represent the societyon the executive GOLD committee The overall goal is toattempt to maintain a synchronous ¯ ow with the wider objec-tives of GOLD

Organisation of the document

The document has two distinct components The ® rst,directed at patients and their needs, which can be accessedfrom the ATS/ERS website (www copd-ats-ers org) and fromthe website of each society (www ersnet org and www thoracicorg), is not the subject of this summary The second isdirected at healthcare practitioners and all those interested inthe professional issues related to COPD This summaryhighlights the contents of the document for health practi-tioners, but the readers are encouraged to access thedocument via the website, where an easy navigational toolwill allow you to explore its contents The reader is alsoencouraged to access the patient document in order tofamiliarise themselves with its content It was designed forand with patients so as to serve as a reliable resource foreveryone

De® nition of COPD

Chronic obstructive pulmonary disease (COPD) is apreventable and treatable disease state characterised byair¯ ow limitation that is not fully reversible The air¯ owlimitation is usually progressive and is associated with anabnormal in¯ ammatory response of the lungs to noxiousparticles or gases, primarily caused by cigarette smokingAlthough COPD affects the lungs, it also produces signi® cantsystemic consequences

Diagnosis of COPD

The diagnosis of COPD should be considered in anypatient who has the following: symptoms of cough; sputumproduction; or dyspnoea; or history of exposure to risk fac-tors for the disease

The diagnosis requires spirometry; a post-bronchodilatorforced expiratory volume in one second (FEV1)/forced vitalcapacity (FVC) 40 7 con® rms the presence of air¯ owlimitation that is not fully reversible (table 1) Spirometryshould be obtained in all persons with the following history:exposure to cigarettes; and/or environmental or occupationalpollutants; and/or presence of cough, sputum production ordyspnoea Spirometric classi® cation has proved useful inpredicting health status [4], utilisation of healthcare resources[5], development of exacerbations [6, 7] and mortality [8] in

933ATS/ERS COPD STANDARDS

COPD It is intended to be applicable to populations [9] andnot to substitute clinical judgment in the evaluation of theseverity of disease in individual patients

It is accepted that a single measurement of FEV1 incom-pletely represents the complex clinical consequences of COPDA staging system that could offer a composite picture ofdisease severity is highly desirable, although it is currentlyunavailable However, spirometric classi® cation is useful inpredicting outcomes such as health status and mortality, andshould be evaluated In addition to the FEV1, the body massindex (BMI) [10, 11] and dyspnoea [12] have proved useful inpredicting outcomes such as survival, and this documentrecommends that they be evaluated in all patients

BMI is easily obtained by dividing weight (in kg) overheight (in m2) Values 521 kg·m-2 are associated with incre-ased mortality

Functional dyspnoea can be assessed by the MedicalResearch Council dyspnoea scale as follows 0: not troubledwith breathlessness except with strenuous exercise 1: troubledby shortness of breath when hurrying or walking up a slighthill 2: walks slower than people of the same age due tobreathlessness or has to stop for breath when walking at ownpace on the level 3: stops for breath after walking about100 m or after a few minutes on the level 4: too breathless toleave the house or breathless when dressing or undressing

Poorly reversible air¯ ow limitation associated with bronch-iectasis, cystic ® brosis and ® brosis due to tuberculosis are notincluded in the de® nition of COPD, and should be consideredin its differential diagnosis

Patients presenting with air¯ ow limitation at a relativelyearly age (4th or 5th decade) and particularly those with afamily history of COPD should be tested for a1-antitrypsinde® ciency

Epidemio ogy, risk factors and natura history of COPD

COPD is a leading cause of morbidity and mortality world-wide, and results in an economic and social burden that isboth substantial and increasing The prevalence and morbid-ity data greatly underestimate the total burden of COPDbecause the disease is usually not diagnosed until it isclinically apparent and moderately advanced In peopleaged 25± 75 yrs in the USA, the estimated prevalence ofmild COPD (de® ned as FEV1/FVC 570% and FEV1 580%predicted) was 6 9% and of moderate COPD (de® ned asFEV1/FVC570% and FEV1 480% pred) was 6 6%, accordingto National Health and Nutrition Examination Survey(NHANES) COPD is the fourth-leading cause of death inthe USA and Europe, and COPD mortality in females hasmore than doubled over the last 20 yrs [13] Currently, COPDis a more costly disease than asthma and, depending on

country, 50± 75% of the costs are for services associated withexacerbations Tobacco smoke is by far the most importantrisk factor for COPD worldwide Other important risk factorsare occupational exposures, socio-economic status and gene-tic predisposition

COPD has a variable natural history and not all individualsfollow the same course [14] The often-quoted statistic thatonly 15± 20% of smokers develop clinically signi® cant COPDmay underestimate the toll of COPD

It is increasingly apparent that COPD often has its rootsdecades before the onset of symptoms [15] Impaired growthof lung function during childhood and adolescence, caused byrecurrent infections or tobacco smoking, may lead to lowermaximally attained lung function in early adulthood [16, 17]This abnormal growth will, often combined with a shortenedplateau phase in teenage smokers, increase the risk of COPD

The risk factors for COPD are shown in table 2 and theyare separated into host factors and exposures

Patho ogy and pathophysio ogy in COPD

COPD comprises pathological changes in four differentcompartments of the lungs (central airways, peripheral air-ways, lung parenchyma and pulmonary vasculature), whichare variably present in individuals with the disease [18± 22]

Tobacco smoking is the main risk factor for COPD,although other inhaled noxious particles and gases may contri-bute This causes an in¯ ammatory response in the lungs,which is exaggerated in some smokers, and leads to thecharacteristic pathological lesions of COPD In addition toin¯ ammation, an imbalance of proteinases and antiprotei-nases in the lungs, and oxidative stress are also important inthe pathogenesis of COPD [23] The different pathogenicmechanisms produce the pathological changes which, in turn,give rise to the following physiological abnormalities inCOPD: mucous hypersecretion and cilliary dysfunction;air¯ ow limitation and hyperin¯ ation; gas exchange abnormali-ties; pulmonary hypertension; and systemic effects [24, 25]

C inica assessment, testing and differentia diagnosis ofCOPD

COPD runs an insidious course, measured over years, withan often undiagnosed initial phase Its presence can besuspected after a directed clinical evaluation and then con-® rmed physiologically with simple spirometry Chest radio-graphy helps in differential diagnosis (table 3), and other testsmay be useful to better determine the phenotype and physio-logical characteristics of individual patients

Some patients with asthma cannot be distinguished from

Table 2. – Risk factors for chronic obstructive pulmonarydisease

Host factors Exposures

Genetic factors SmokingSex Socio-economic statusAirway hyperreactivity,

IgE and asthmaOccupationEnvironmental pollutionPerinatal events and childhood illnessRecurrent bronchopulmonary infectionsDiet

Ig: immunoglobulin

Table 1. – Spirometric classication of chronic obstructivepulmonary disease (COPD)

Severity PostbronchodilatorFEV1/FVC

FEV1 % pred

At risk# 40 7 580Mild COPD 40 7 580Moderate COPD 40 7 50± 80Severe COPD 40 7 30± 50Very severe COPD 40 7 530

FEV1: forced expiratory volume in one second; FVC: forced vitalcapacity

#: patients who smoke or have exposure to pollutants, have

cough, sputum or dyspnoea

934 B R CELLI ET AL

COPD with the current diagnostic tests The management ofthese patients should be similar to that of asthma

Medical history

A directed medical history should assess the followingissues: symptoms of cough, sputum production and dyspnoea;past medical history of asthma, allergies and other respiratory

diseases; family history of COPD or other respiratory diseases;co-morbidities; any unexplained weight loss; and exposure his-tory, smoking, and occupational and environmental exposures

Physical signs

A normal physical examination is common in early COPD[13] As the disease progresses, some signs become apparentand in advanced stages many are almost pathognomonicExamination should aim at eliciting the presence of respiratoryand systemic effects of COPD All patients should have theirrespiratory rate, weight and height, and BMI measured

Smoking cessation

Cigarette smoking is an addiction and a chronic relapsingdisorder, and is regarded as a primary disorder by theDepartment of Health and Human Services Guidelines in theUSA [26, 27] and by the World Health Organization (WHO)Therefore, treating tobacco use and dependence should beregarded as a primary and speci® c intervention Smokingshould be routinely evaluated whenever a patient presents to ahealthcare facility and all smokers should be offered the bestchance to treat this disorder

The most comprehensive of the guidelines prepared onsmoking cessation is "Treating Tobacco Use and Depen-dence", an evidence-based guideline sponsored by the USDepartment of Health and Human Services and released in2000, which updates the previous evidence-based guideline"Smoking Cessation" released in 1996 The guideline and themeta-analyses on which it is based are available online [28]The key ® ndings of this report are summarised in table 4

Brief intervention

The key steps in brief intervention are as follows Ask:systematically, identify all tobacco users at every visit,implement an of® ce-wide system that ensures that tobaccouse is queried and documented for every patient at every clinicvisit Advise: strongly urge all tobacco users to quit, in a clear,strong and personalised manner Assess: determine will-ingness to make a quit attempt Assist: help the patient witha quit plan, provide practical counselling, provide treatmentand social support, help the patient obtain extra treatmentand social support, recommend the use of approved pharma-cotherapy (except in special circumstances), and providesupplementary materials Arrange: schedule follow-up contact,either in person or via the telephone

Permanent remissions can be achieved in a substantialpercentage of smokers with currently available treatmentsSuccessful treatment of this disorder can have a substantialbene® t in reducing many secondary complications of whichCOPD is one All patients willing to make a serious attempt

Table 3. – Differential diagnosis of chronic obstructivepulmonary disease (COPD)

Diagnosis Suggestive features

COPD Mid-life onsetSlowly progressing symptomsLong history of smoking

Asthma Early onsetVarying symptomsSymptoms during the night/early

morningPresence of allergy, rhinitis and/or

eczemaA family historyAir¯ ow limitation that is largely

reversibleCongestive heart failure Fine basilar crackles on auscultation

Dilated heart on chest radiographyPulmonary oedemaVolume restriction not air¯ ow

limitation on pulmonary functiontests

Bronchiectasis Large volume of purulent sputumCommonly associated with bacterial

infectionCoarse crackles/clubbing on

auscultationBronchial dilation and bronchial wall

thickening on chest radiography/CTTuberculosis Onset at all ages

Lung in® ltrate on chest radiographyMicrobiological con® rmationHigh local prevalence of tuberculosis

Obliterative bronchiolitis ounger onset and in nonsmokersHistory of rheumatoid arthritis/fume

exposureHypodense areas on expiration on

CT suggestive of bronchiolitisDiffuse panbronchiolitis Effects mostly male nonsmokers

Almost all have chronic sinusitisDiffuse small centrilobular nodular

opacities and hyperin¯ ation onchest radiography and HRCT

CT: computed tomography; HRCT: high resolution computed to-mography

Table 4. – Key points of the Treating Tobacco Use and Dependence guidelines

Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achievedEffective treatments for tobacco dependence exist and all tobacco users should be offered these treatmentsClinicians and healthcare delivery systems must institutionalise the consistent identi® cation, documentation and treatment of every tobacco

user at every visitBrief tobacco dependence intervention is effective and every tobacco user should be offered at least brief interventionThere is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectivenessThree types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social

support arranged outside treatmentFive ® rst-line pharmacotherapies for tobacco dependence are effective: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal

spray and nicotine patch, and at least one of these medications should be prescribed in the absence of contraindicationsTobacco-dependence treatments are cost effective relative to other medical and disease prevention interventions

935ATS/ERS COPD STANDARDS

to quit should be offered pharmacological support (nicotinereplacement therapy and/or bupropion) [26, 27] Smokingcessation activities and support for its implementation shouldbe integrated into the healthcare system

Management of stab e COPD: pharmaco ogica therapy

Effective medications for COPD are available and allpatients who are symptomatic merit a trial of drug treatment[1± 3] The medications for COPD currently available can reduceor abolish symptoms, increase exercise capacity, reduce thenumber and severity of exacerbations, and improve healthstatus At present, no treatment has modi® ed the rate ofdecline in lung function The inhaled route is preferred

The change in lung function after brief treatment with anydrug does not help in predicting other clinically relatedoutcomes Changes in FEV1 following bronchodilator thera-py can be small but are often accompanied by larger changesin lung volumes, which contribute to a reduction in perceivedbreathlessness Combining different agents produces a greaterchange in spirometry and symptoms than single agents alone

Bronchodilators

Three types of bronchodilator are in common clinical use:b-agonists, anticholinergic drugs and methylxanthines Despitesubstantial differences in their site of action within the celland some evidence for nonbronchodilator activity with someclasses of drug, the most important consequence of broncho-dilator therapy appears to be airway smooth muscle relaxa-tion and improved lung emptying during tidal breathing Theresultant increase in FEV1 may be relatively small but is oftenaccompanied by larger changes in lung volumes [29], with a

reduction in residual volume and/or a delay of the onset ofdynamic hyperin¯ ation during exercise Both of these changescontribute to a reduction in perceived breathlessness [30, 31]In general, the more advanced the COPD, the more importantthe changes in lung volume become relative to those in FEV1The clinical use of bronchodilator drugs is illustrated in® gure 1

Short-acting bronchodilators can increase exercise tole-rance acutely [30, 31] Long-acting inhaled b-agonists improvehealth status possibly to a greater extent than regular short-acting anticholinergics [32], reduce symptoms, rescue medica-tion use and increase time between exacerbations comparedwith placebo [33± 35] Combining short-acting bronchodilatoragents (salbutamol (albuterol)/ipratropium) produces agreater change in spirometry than either agent alone [34]Combining long-acting b-agonists and ipratropium leads tofewer exacerbations than either drug alone No good com-parative data between different long-acting b-agonists arepresently available, although it is likely that their effects willbe similar Combining long-acting b-agonists and theophyl-line appears to produce a greater spirometric change thaneither drug alone [35] Tiotropium improves health status andreduces exacerbations and hospitalisations compared withboth placebo and regular ipratropium [36, 37]

Theophylline is a weak bronchodilator, which may havesome anti-in¯ ammatory properties Its narrow therapeuticindex and complex pharmacokinetics make its use dif® cult,but modern slow-release preparations have improved thisproblem and lead to more stable plasma levels Generally,therapeutic levels should be measured and patients should bekept on the lowest effective dose (recommended serum level8± 14 mg·dL-1)

Glucocorticoids

Glucocorticoids act at multiple points within the in¯ am-matory cascade, although their effects in COPD are moremodest as compared with bronchial asthma Data from largepatient studies suggest that inhaled corticosteroids can pro-duce a small increase in postbronchodilator FEV1 and a smallreduction in bronchial reactivity in stable COPD [38± 40] Inpatients with more advanced disease (usually classi® ed as anFEV1 550% pred) there is evidence that the number ofexacerbations per year and the rate of deterioration in healthstatus can be reduced by inhaled corticosteroids in COPD[38] Evidence from four large prospective 3-yr studies hasshown no effect of inhaled corticosteroids on rate of changeof FEV1 in any severity of COPD [38± 41]

When therapy is thought to be ineffective, a trial of with-drawing treatment is reasonable Some patients will exacer-bate when this occurs, which is a reason for re-instituting thistherapy [42] The results of forthcoming large randomisedtrials with mortality as an outcome will help clarify the role ofinhaled glucocorticoids in COPD

Outcomes of frequently used drugs

Table 5 summarises the effects of frequently used medica-tions in patients with COPD The evidence level was obtainedfrom the GOLD document [3] using the same grade ofevidence, as follows Grade A: randomised clinical trial (RCT),rich body of data Grade B: RCT, limited body of dataGrade C: nonrandomised trials, observational studies GradeD: panel consensus

Confirm diagnosisof COPD

Intermittent symptoms cough, wheeze, exertional dyspnoea

Persistent symptomsdyspnoea, night

waking

SA-BD as needed . inhaled -agonist, anticholinergic

LA-BD/SA-BD Æ Ç + as neededreliever

Limited benefit?

Alternative class/combine classes LA-BD+ICS

Limited benefit?Side-effects?

Add/substitue oral theophylline

Yes

Yes

Fig 1 ± Algorithm for pharmacological treatment of chronic obstruc-tive pulmonary disease (COPD) SA-BD: short-acting bronchodilator;LA-BD: long-acting bronchodilator; ICS: inhaled corticosteroidAssess effectiveness by treatment response criteria If forced expira-tory volume 550% predicted and exacerbations of COPD requiring acourse of oral corticosteroid or antibiotic occurred at least oncewithin the last year, consider adding regular ICS Always ensure thepatient can use an inhaled device effectively and understands itspurpose If an ICS and a long-acting b-agonist are used, prescribe acombination inhaler

936 B R CELLI ET AL

Combination therapy

Combining medications of different classes seems a con-venient way of delivering treatment and obtaining betterresults This includes better lung function and improvedsymptoms [43± 45]

Data from trials combining long-acting inhaled b-agonistsand inhaled corticosteroids show a signi® cant additionaleffect on pulmonary function and a reduction in symptoms inthose receiving combination therapy compared with its com-ponents [45] The largest effects in terms of exacerbations andhealth status are seen in patients with an FEV1 550% pred,where combining treatment is clearly better than eithercomponent drug used alone

Management of stab e COPD: ong-term oxygen therapy

Supplemental long-term oxygen therapy (LTOT) improvessurvival, exercise, sleep and cognitive performance in hypox-aemic patients [1± 3, 45± 50] Reversal of hypoxaemia super-sedes concerns about carbon dioxide (CO2) retention

Arterial blood gas (ABG) assessment is the preferredmethod to determine oxygen need because it includes acid-base information Arterial oxygen saturation as measured bypulse oximetry (Sp,O2) is adequate for trending Physiologicalindications for oxygen include a arterial oxygen tension(Pa,O2) 57 3 kPa (55 mmHg) The therapeutic goal is tomaintain Sp,O2 490% during rest, sleep and exertion Ifoxygen is prescribed during an exacerbation, ABG should berechecked in 30± 90 days Withdrawal of oxygen because ofimproved Pa,O2 in patients whose need for oxygen wasdetermined when in a stable state may be detrimental

Active patients require portable oxygen Oxygen sourcesinclude gas, liquid and concentrator; while oxygen deliverymethods include nasal continuous ¯ ow, pulse demand, reser-voir cannulae and transtracheal catheters [51] Patient educa-tion improves compliance

Figure 2 shows a ¯ ow chart for prescribing home oxygentherapy

Management of stab e COPD: pu monary rehabi itation

Pulmonary rehabilitation is de® ned as "a multidisciplinaryprogramme of care for patients with chronic respiratoryimpairment that is individually tailored and designed tooptimise physical and social performance and autonomy"[52]

Pulmonary rehabilitation results in improvements in multi-ple outcome areas of considerable importance to the patient,including dyspnoea, exercise ability, health status andhealthcare utilisation [53± 57] These positive effects occur

despite the fact that it has a minimal effect on pulmonaryfunction measurements This re¯ ects the fact that much of themorbidity from COPD results from secondary conditions,which are often treatable if recognised Examples of thesetreatable conditions are cardiac deconditioning, peripheralmuscle dysfunction, and a reduction in total and lean bodymass, anxiety and poor coping skills Elements of compre-hensive pulmonary rehabilitation, including promoting ahealthy lifestyle, stressing adherence to therapy and encourag-ing physical activity, should be incorporated into the careof all patients with COPD Pulmonary rehabilitation is amultidisciplinary programme of care that is individuallytailored and designed to optimise physical and socialperformance, and autonomy

Pulmonary rehabilitation should be considered for patientswith COPD who have dyspnoea or other respiratory symp-toms, reduced exercise tolerance, a restriction in activitiesbecause of their disease, or impaired health status There are

Table 5. – Effect of commonly used medications on important clinical outcomes in chronic obstructive pulmonary disease

FEV1 Lung volume Dyspnoea HRQoL AE Exerciseendurance

Diseasemodi® erby FEV1

Mortality Side-effects

Short-acting b-agonists es (A) es (B) es (A) NA NA es (B) NA NA SomeIpratropium bromide es (A) es (B) es (A) No (B) es (B) es (B) No NA SomeLong-acting b-agonists es (A) es (A) es (A) es (A) es (A) es (B) No NA MinimalTiotropium es (A) es (A) es (A) es (A) es (A) es (B) NA NA MinimalInhaled corticosteroids es (A) NA es (B) es (A) es (A) NA No NA SomeTheophylline es (A) es (B) es (A) es (B) NA es (B) NA NA Important

FEV1: forced expiratory volume in one second; HRQoL: health-related quality of life; AE: exacerbation of COPD; NA: evidence not availableGOLD grade levels are indicated in brackets (see text for explanation)

Hypoxaemia from disease progressionor recovering from acute exacerbation

Ê a,O2 90%)

during rest, sleep and exertion

Titrate flowrest ( a,O2 >90%)

exertion add 1 L·min-1sleep add 1 L·min-1

Hypoxaemia identifiedduring exacerbation?

Continue LTOT

Recheck ABG30–90 days

Ê a,O2

no speci® c pulmonary function inclusion criteria that indicatethe need for pulmonary rehabilitation, since symptomsand functional limitations direct the need for pulmonaryrehabilitation

The pulmonary rehabilitation programme includes exercisetraining, education, psychosocial/behavioural intervention,nutritional therapy, outcome assessment and promotion oflong-term adherence to the rehabilitation recommendations

Management of stab e COPD: nutrition

Weight loss, as well as a depletion of fat-free mass (FFM),may be observed in stable COPD patients, irrespective of thedegree of air¯ ow limitation, and being underweight is associ-ated with an increased mortality risk [58]

Nutritional screening is recommended in the assessment ofCOPD Simple screening can be based on measurements ofBMI and weight change Patients are considered under-weight (BMI 521 kg·m-2; age 450 yrs), normal weight (BMI21± 25 kg·m-2), overweight (BMI 25± 30 kg·m-2) or obese(BMI 530 kg·m-2) Criteria to de® ne weight loss are weightloss 410% in the past 6 months or 45% in the past month

Weight loss and particularly muscle wasting contributesigni® cantly to morbidity, disability and handicap in COPDpatients Weight loss and loss in fat mass is primarily theresult of a negative balance between dietary intake and energyexpenditure, while muscle wasting is a consequence of animpaired balance between protein synthesis and protein break-down In advanced stages of COPD, both energy balance andprotein balance are disturbed Therefore, nutritional therapymay only be effective if combined with exercise or otheranabolic stimuli [59, 60]

Management of stab e COPD: surgery in and for COPD

Surgery in COPD

Patients with a diagnosis of COPD have a 2 7± 4 7-foldincreased risk of postoperative pulmonary complications[61± 63] However, COPD is not an absolute contraindicationto any surgery The most important concept determining therisk of surgery is that the further the procedure from thediaphragm, the lower the pulmonary complication rateAlthough the value of pre-operative pulmonary functiontesting in general surgery is debatable, pre-operative pulmo-nary function studies have a well-documented role in theevaluation of patients undergoing lung surgery [64± 67]

Smoking cessation at least 4± 8 weeks pre-operatively andoptimisation of lung function can decrease post-operativecomplications In addition, early mobilisation, deep breath-ing, intermittent positive-pressure breathing, incentive spiro-metry and effective analgesia may decrease post-operativecomplications

An algorithm for pre-operative evaluation of patientsundergoing lung resection is shown in ® gure 3

Surgery for COPD

Bullectomy, lung volume reduction surgery and lungtransplantation may result in improved spirometry, lungvolumes, exercise capacity, dyspnoea, health-related qualityof life and possibly survival in highly selected patients [68± 69]Factors associated with a favourable or unfavourable out-come in bullectomy are shown in table 6

The recently completed National Emphysema Therapy

Trial (NETT) showed bene® ts for a subset of patientswith nonhomogenous emphysema Figure 4 summarises thestrati® cation of the patients and the results of the trial foreach of the groups Group B is comprised of those patientswith nonhomogenous emphysema of upper lobe predomi-nance and limited exercise performance after pre-operativecomprehensive rehabilitation Group C corresponds topatients with predominant upper lobe emphysema and goodpost-rehabilitation exercise capacity Group D corresponds tothose patients with homogenous emphysema and low post-rehabilitation exercise capacity Group E was characterisedby homogeneous emphysema and good post-rehabilitationexercise capacity Finally, group A corresponds to those patientswith a very high risk for lung reduction surgery [70]

The results of this trial showed that patients in group Bwho underwent surgery had a lower mortality, better exercisecapacity and health status than patients randomised tomedical therapy The operated patients in groups C and Ddid not bene® t from improved survival but had signi® cantimprovements in exercise capacity and health status com-pared to patients randomised to medical therapy The patientsin group E had higher mortality and would, therefore, not becandidates for LVRS The results in this group are similar tothose observed in the highest risk group (A) who should notbe considered for surgery

Lung transplantation results in improved pulmonaryfunction, exercise capacity and quality of life, however, itseffects on survival remain controversial [71] Speci® c guide-lines for lung transplantation in COPD are shown in table 7

Management of stab e COPD: s eep

Sleep in COPD is associated with oxygen desaturation,which is predominantly due to the disease itself rather than tosleep apnoea [72] The desaturation during sleep may begreater than during maximum exercise [73] In COPD, sleepquality is markedly impaired, both subjectively and objec-tively [74] However, sleep apnoea syndrome is about asprevalent in COPD as in a general population of similar age,but oxygen desaturation during sleep is more pronouncedwhen the two conditions co-exist [75]

The clinical assessment in all patients with COPD shouldinclude questions about sleep quality and possible co-existingsleep apnoea syndrome Sleep studies are not indicated inCOPD except in special circumstances These include: a clinical

Spirometry, Í L,CO

FEV1 60% pred

ppo FEV1 >40% predand

ppo Í L,CO >40% pred

Considersurgery

ppo FEV1 10 mL·kg-1·min-1

orstair climb >3 flights (54 steps)

Fig 3 ± Algorithm for pre-operative testing for lung resection DL,CO:carbon dioxide diffusing capacity of the lung; FEV1: forced expira-tory volume in one second; ppo: predicted postoperative; V’O2,max:maximum oxygen consumption

938 B R CELLI ET AL

suspicion of sleep apnoea or complications of hypoxaemiathat are not explained by the awake arterial oxygen levels, andpulmonary hypertension out of proportion to the severity ofpulmonary function derangement

Management of sleep problems in COPD should particu-larly focus on minimising sleep disturbance by measures tolimit cough and dyspnoea, and nocturnal oxygen therapy maybe indicated for nocturnal hypoxaemia [76] Hypnotics shouldbe avoided, if possible, in patients with severe COPD

Management of stab e COPD: air-trave

Commercial airliners can cruise at 412,192 m (440,000feet), as long as the cabin is pressurised from 1,829± 2,438 m(6,000± 8,000 feet) This is equivalent to an inspired oxygenconcentration at sea level of ~ 15% [77]

Patients with COPD can exhibit falls in Pa,O2 that average3 3 kPa (25 mmHg) [78] Pre-¯ ight assessment can helpdetermine oxygen needs and the presence of co-morbidities[79] Oxygen needs can be estimated by using the hypoxiainhalation test or through the use of regression formulaeHowever, it is currently recommended that the Pa,O2 duringair travel should be maintained above 6 7 kPa (50 mmHg)[80] Treatment with 2± 3 L·min-1 of oxygen by nasal cannulawill replace the inspired oxygen partial pressure lost at2,438 m (8,000 feet) compared to sea level [81] For high-riskpatients, the goal should be to maintain oxygen pressureduring ¯ ight at the same level at which the patient is clinicallystable at sea level Most airlines will provide supplementaloxygen on request

Exacerbation of COPD: de® nition, eva uation andtreatment

De® nition

An exacerbation of COPD is an event in the natural courseof the disease characterised by a change in the patient’s

Table 6. – Factors associated with favourable or unfavourable outcome in classical bullectomy

Parameter Favourable Unfavourable

Clinical Rapid progressive dyspnoea despite maximal medical therapy Older ageEx-smoker Co-morbid illness

Cardiac diseasePulmonary hypertension410% weight lossFrequent respiratory infectionsChronic bronchitis

Physiological Normal FVC or slightly reduced FEV1 535% predFEV1 440% pred Low trapped gas volumeLittle reversibility Decreased DL,COHigh trapped lung volumeNormal or near normal DL,CONormal Pa,O2 and Pa,CO2

ImagingCXR Bulla 41/3 hemithorax Vanishing lung syndrome

Poorly de® ned bullaeCT Large and localised bulla with vascular crowding and

normal pulmonary parenchyma around bullaMultiple ill-de® ned bullae in underlying lung

Angiography Vascular crowding with preserved distal vascular branching Vague bullae; disrupted vasculature elsewhereIsotope scan Well-localised matching defect with normal uptake and

washout for underlying lungAbsence of target zones, poor washout in

remaining lung

CXR: chest radiography; CT: computed tomography; FVC: forced vital capacity; FEV1: forced expiratory volume in one second; DL,CO: carbonmonoxide diffusing capacity of the lung; Pa,O2; arterial oxygen tension; Pa,CO2; arterial carbon dioxide tension Table modi® ed from [68]

Í L,CO 20%pred?

Yes FEV1 20%pred?

Homogenousemphysema?

Group A

Upper lobepredominantemphysema?

Low post-rehabilitation

exercisecapacity?

Group B Group C Group D Group E

Yes Yes

YesYes No No

No

No

NoNo

Yes

Candidatefor LVRS

Low post-rehabilitation

exercisecapacity?

Fig 4 ± Schematic algorithm from the National Emphysema TherapyTrial for Lung Volume Reduction Surgery (LVRS) (see text) FEV1:forced expiratory volume in one second; DL,CO: carbon dioxidediffusing capacity of the lung Modi® ed from [69]

Table 7. – Disease-specic guidelines for candidate selectionfor lung transplantation in chronic obstructive pulmonarydisease patients

FEV1 425% pred (without reversibility) and/orResting room air Pa,CO2 47 3 kPa (55 mmHg) and/orElevated Pa,CO2 with progressive deterioration requiring long-term

oxygen therapyElevated pulmonary arterial pressure with progressive deterioration

FEV1: forced expiratory volume in one second; Pa,CO2: arterial carbondioxide tension

939ATS/ERS COPD STANDARDS

baseline dyspnoea, cough and/or sputum beyond day-to-dayvariability suf® cient to warrant a change in management

There is no agreed classi® cation of exacerbations Thefollowing operational classi® cation of severity can help rankthe clinical relevance of the episode and its outcome Level I:treated at home Level II: requires hospitalisation Level III:leads to respiratory failure

Assessment

Several clinical elements must be considered when evaluat-ing patients with exacerbations These include the severity ofthe underlying COPD, the presence of co-morbidity and thehistory of previous exacerbations The physical examinationshould evaluate the effect of the episode on the haemody-namic and respiratory systems The diagnostic procedures tobe performed depend on the setting of the evaluation [82, 83]

The pharmacological treatment of patients with an exacer-bation of COPD is based on the same medications utilised inthe management of the stable patient [1± 3] However, theevidence supports the use of systemic glucocorticosteroids[84± 88]

Table 8 shows the elements of the clinical evaluation anddiagnostic procedures that are usually informative in patientswith exacerbations according to the severity of the episode

Indication for hospitalisation

Table 9 provides reasonable guidelines for patient hospita-lisation Based on expert consensus, they consider the severityof the underlying respiratory dysfunction, progression ofsymptoms, response to outpatient therapy, existence of co-morbid conditions and the availability of adequate home care

Indications for admission to specialised or intensive careunit

The severity of respiratory dysfunction dictates the need foradmission to an intensive care unit (ICU) Depending on theresources available within an institution, admission ofpatients with severe exacerbations of COPD to intermediateor special respiratory care units may be appropriate if

personnel, skills and equipment exist to identify and manageacute respiratory failure successfully

Indications for ICU or special care unit admission includethe following: impending or actual respiratory failure; pre-sence of other end-organ dysfunction, i e shock, renal, liveror neurological disturbance; and/or haemodynamic instability

Treatment of exacerbations

The treatment of exacerbations has to be based on theclinical presentation of the patient, as shown in tables 10, 11and 12

Exacerbation of COPD: inpatient oxygen therapy

During a severe exacerbation, ABGs should be monitoredfor Pa,O2, arterial carbon dioxide tension (Pa,CO2) and pHThe Sp,O2 should be monitored for trending and adjustingoxygen settings The goal of inpatient oxygen therapy is tomaintain Pa,O248 kPa (60 mmHg) or Sp,O2490% in order toprevent tissue hypoxia and preserve cellular oxygenation Dueto the shape of the oxyhaemoglobin dissociation curve, increa-sing the Pa,O2 to values much greater than 8 kPa (60 mmHg)confers little added bene® t (1± 2 vol %) and may increase therisk of CO2 retention, which may lead to respiratory acidosis

Table 8. – Clinical history, physical ndings and diagnostic procedures in patients with exacerbation of chronic obstructivepulmonary disease (COPD)

Level I Level II Level III

Clinical historyCo-morbid conditions# + +++ +++History of frequent exacerbations + +++ +++Severity of COPD Mild/moderate Moderate/severe Severe

Physical ® ndingsHaemodynamic evaluation Stable Stable Stable/unstableUse accessory respiratory muscles, tachypnoea Not present ++ +++Persistent symptoms after initial therapy No ++ +++

Diagnostic proceduresOxygen saturation es es esArterial blood gases No es esChest radiograph No es esBlood tests¶ No es esSerum drug concentrations+ If applicable If applicable If applicableSputum gram stain and culture No§ es esElectrocardiogram No es es

+ : unlikely to be present;++ : likely to be present;+++ : very likely to be present#: the more common co-morbid conditions associated with poor

prognosis in exacerbations are congestive heart failure, coronary artery disease, diabetes mellitus, renal and liver failure; ¶: blood tests include cellblood count, serum electrolytes, renal and liver function; +: serum drug concentrations, consider if patients are using theophylline, warfarin,carbamezepine, digoxin; §: consider if patient has recently been on antibiotics

Table 9. – Indications for hospitalisation of patients with aCOPD exacerbation

The presence of high-risk co-morbid conditions, includingpneumonia, cardiac arrhythmia, congestive heart failure,diabetes mellitus, renal or liver failure

Inadequate response of symptoms to outpatient managementMarked increase in dyspnoeaInability to eat or sleep due to symptomsWorsening hypoxaemiaWorsening hypercapniaChanges in mental statusInability of the patient to care for her/himself (lack of home support)Uncertain diagnosisInadequate home care

940 B R CELLI ET AL

[89, 90] The main delivery devices include nasal cannula andventuri masks Alternative delivery devices include nonre-breather masks, reservoir cannulae, nasal cannulae or transtra-cheal catheters

As a general principle, prevention of tissue hypoxiasupercedes CO2 retention concerns If CO2 retention occurs,monitor for acidemia If acidemia occurs, consider noninva-sive or invasive mechanical ventilation

Setting and adjusting oxygen ¯ ow

Figure 5 shows an algorithm for correcting hypoxaemia inthe COPD patient

Monitoring following hospital discharge

Patients may be started on oxygen for the ® rst time duringhospitalisation for an acute exacerbation and discharged before

recovery is complete Patients with hypoxaemia at dischargemay require short-term oxygen therapy as the effects of theexacerbation are clearing After 30± 90 days, oxygen may nolonger be required; thus re-evaluation of the patient’s oxygen

Table 10. – Level I: outpatient treatment

Patient educationCheck inhalation techniqueConsider use of spacer devices

BronchodilatorsShort-acting b2-agonist

# and/or ipratropium MDI with spaceror hand-held nebuliser as needed

Consider adding long-acting bronchodilator if patient is notusing one

Corticosteroids (the actual dose may vary)Prednisone 30± 40 mg orally·day-1 for 10± 14 daysConsider using an inhaled corticosteroid

AntibioticsMay be initiated in patients with altered sputum characteristics+

Choice should be based on local bacterial resistance patternsAmoxicillin/ampicillin¶, cephalosporinsDoxycyclineMacrolides§

If the patient has failed prior antibiotic therapy consider:Amoxicillin/clavulanateRespiratory ¯ uoroquinolonesƒ

MDI: metered-dose inhaler #: salbutamol (albuterol), terbutaline; +:purulence and/or volume; ¶: depending on local prevalence of bacterialb-lactamases; §: azithromycin, clarithromycin, dirithromycin, roxithro-mycin; ƒ: gati¯ oxacin, levo¯ oxacin, moxi¯ oxacin

Table 11. – Level II: treatment for hospitalised patient

BronchodilatorsShort-acting b2-agonist and/orIpratropium MDI with spacer or hand-held nebuliser as needed

Supplemental oxygen (if saturation 590%)Corticosteroids

If patient tolerates, prednisone 30± 40 mg orally·day-1 for10± 14 days

If patient can not tolerate oral intake, equivalent dose i v forup to 14 days

Consider using inhaled corticosteroids by MDI or hand-heldnebuliser

Antibiotics (based on local bacteria resistance patterns)May be initiated in patients that have a change in their sputum

characteristics#

Choice should be based on local bacteria resistance patternsAmoxicillin/clavulanateRespiratory ¯ uoroquinolones (gati¯ oxacin, levo¯ oxacin,

moxi¯ oxacin)If Pseudomonas spp and/or other Enterobactereaces spp are

suspected, consider combination therapy

MDI: metered-dose inhaler #: purulence and/or volume

Table 12. – Level III: treatment in patients requiring special orintensive care unit

Supplemental oxygenVentilatory supportBronchodilators

Short-acting b2-agonist (salbutamol (albuterol)) and ipratropiumMDI with spacer, two puffs every 2± 4 h

If the patient is on the ventilator, consider MDI administrationConsider long-acting b-agonist

CorticosteroidsIf patient tolerates oral medications, prednisone 30± 40 mg

orally·day-1 for 10± 14 daysIf patient cannot tolerate, give the equivalent dose i v for up to

14 daysConsider using inhaled corticosteroids by MDI or hand-held

nebuliserAntibiotics (based on local bacteria resistance patterns)

Choice should be based on local bacteria resistance patternsAmoxicillin/clavulanateRespiratory ¯ uoroquinolones (gati¯ oxacin, levo¯ oxacin,

moxi¯ oxacin)If Pseudomonas spp and/or other Enterobactereaces spp are

suspected, consider combination therapy

MDI: metered-dose inhaler

Assess patientObtain ABG

Begin O2

Assure Pa,O2 >8 kPaAdjust O2 to Sa,O2 90%

Hypercapnia?(Pa,CO2 >6.7 kPa)

No change inoxygen setting

Reassess ABG in1–2 h

Hypercapnia?Pa,CO2 >6.7 kPa

Maintain O2Sa,O2 90%

pH 8 kPa)

Maintain O2Sa,O2 90%

Reassess ABGin 2 h

pH 8 kPa)

No change inoxygen setting

Considermechanical ventilationNPPV or intubation

No Yes

Yes

No

No

Yes

Yes

No

F ig 5 ± Algorithm to correct hypoxaemia in an acutely ill chronicobstructive pulmonary disease patient ABG: arterial blood gas; Pa,O2:arterial oxygen tension; O2: oxygen; Sa,O2: arterial oxygen saturation;Pa,CO2: arterial carbon dioxide tension; NPPV: noninvasive positivepressure ventilation

941ATS/ERS COPD STANDARDS

and medical status should be completed If the patient nolonger meets the prescribing criteria for LTOT, oxygen shouldbe discontinued, as there is no proven survival bene® t forpatients with mild hypoxaemia [91] Patients recovering froman exacerbation may bene® t from pulmonary rehabilitation

Some patients who needed oxygen prior to hospitalisationmay, over time, increase their Pa,O2 to the point that they nolonger qualify for oxygen This phenomenon is thought to bedue to a reparative effect of LTOT Withdrawing oxygenfrom these patients may negate the reparative effect and causethe patient’s status to deteriorate to the point of meeting thephysiological requirement for oxygen Consequently, thesepatients should continue their oxygen therapy without inter-ruption, as withdrawing their oxygen might be detrimental[92, 93]

Exacerbation of COPD: assisted venti ation

Mechanical ventilation can be administered via noninvasiveor invasive ventilation Noninvasive is preferred wheneverpossible Mechanical ventilation, either "invasive" or "non-invasive", is not a therapy but it is a form of life support untilthe cause underlying the acute respiratory failure is reversedwith medical therapy [94± 96] Patients considered for mechan-ical ventilation should have a measurement of ABGs

Indications for mechanical ventilation

The institution of mechanical ventilation should be consi-dered when, despite optimal medical therapy and oxygenadministration there is acidosis (pH57 35) and hypercapnia(Pa,CO2 46± 8 kPa (45± 60 mmHg)) and respiratory frequency424 breaths·min-1

Modes of mechanical ventilation

Mechanical ventilation can be delivered as follows 1)Through an endotracheal tube, by passing the upper airway,i e "conventional" or "invasive" mechanical ventilation 2)Without the use of an endotracheal tube, i e "noninvasive"mechanical ventilation or NIMV, which can be instituted intwo modes: noninvasive positive pressure ventilation (NPPV)(nasal or face masks); or negative pressure ventilation (e giron lung, not recommended)

Noninvasive positive pressure ventilation NPPV is by far themost popular mode of providing noninvasive ventilation It istypically administered as a combination of continuous positiveairway pressure (CPAP) plus pressure support ventilation(PSV) [94± 98] ABG improve because of an increase in alveolarventilation without signi® cant modi® cations in the alveolarventilation/perfusion mismatching and gas exchange in thelungs [99]

ABGs are fundamental for the correct assessment andguidance of therapy Once baseline ABGs are obtained, if thepH is 57 35 in the presence of hypercapnia, NPPV should bedelivered in a controlled environment such as intermediateICUs and/or high-dependency units If the pH is57 25, NPPVshould be administered in the ICU and intubation should bereadily available The combination of some CPAP (e g4± 8 cmH2O) and PSV (e g 10± 15 cmH2O) provides the mosteffective mode of NPPV

Patients meeting exclusion criteria should be considered forimmediate intubation and ICU admission In the ® rst hours,

NPPV requires the same level of supervision as conventionalmechanical ventilation

Contraindications for NPPV include the following: respira-tory arrest; cardiovascular instability (hypotension, arrhyth-mias, myocardial infarction); impaired mental status,somnolence, inability to cooperate; copious and/or viscoussecretions with high aspiration risk; recent facial or gastro-oesophageal surgery; craniofacial trauma and/or ® xed naso-pharyngeal abnormality; burns; and extreme obesity

NPPV can be considered successful when ABGs and pHimprove, dyspnoea is relieved, the acute episode resolveswithout the need of endotracheal intubation, mechanicalventilation can be discontinued and the patient is dischargedfrom the hospital

One-year mortality was reported to be lower in patientsreceiving NPPV for exacerbations of COPD, as compared toboth conventional mechanical ventilation [100] and optimalmedical therapy alone [101]

Figure 6 illustrates a useful ¯ ow-chart for the use of NPPVin exacerbation of COPD complicated by acute respiratoryfailure

Invasive ventilation Intubation should be considered inpatients with the following 1) NPPV failure: worsening ofABGs and or pH in 1± 2 h; lack of improvement in ABGs andor pH after 4 h 2) Severe acidosis (pH57 25) and hypercapnia(Pa,CO248 kPa (60 mmHg)) 3) Life-threatening hypoxaemia(arterial oxygen tension/inspiratory oxygen fraction526 6 kPa(200 mmHg)) 4) Tachypnoea 435 breaths·min-1

Criteria for hospital discharge

As a general rule, patients hospitalised for an acuteexacerbation can be considered for discharge once the reasons

Exacerbation of COPD requiring ventilatory support

Contraindicationfor NPPV?

Yes No

Weaning

IntubateMV

NPPV withmonitoring

Improvement inpH, Ê a,CO2

clinical status

Yes No

Wean to completedisconnection

Continue NPPVIntubateMV 48 h

2-h T-tube trial

Success Failure

Discontinue MV NPPV

Fig 6 ± Flow-chart for the use of noninvasive positive pressureventilation (NPPV) during exacerbation of chronic obstructive pulmo-nary disease (COPD) complicated by acute respiratory failure MV:mechanical ventilation; Pa,CO2: arterial carbon dioxide tension

942 B R CELLI ET AL

for admission are controlled and/or reversed Based onconsensus, conditions that need to be met when consideringpatients for discharge include: symptoms returning to base-line, including eating, sleeping, etc ; haemodynamic stability;oxygenation returning to baseline; inhaled b-agonist therapyrequired less frequently; ability to resume ambulation; abilityto eat and sleep without frequent awakening by dyspnoea;off-parenteral therapy for 12± 24 h; patient (or home care-giver) understands correct use of medications; follow-up andhomecare arrangements have been completed (e g visitingnurse, oxygen delivery, meal provisions etc )

Follow-up evaluation

Once discharged, the patient should be followed There areno studies that have addressed the speci® c schedules morelikely to result in a positive outcome, but patients withfrequent exacerbations are more likely to relapse Likewise,patients who have developed respiratory failure requiringadmission to an ICU carry a very high mortality risk Basedon this, the guidelines for the re-evaluation of patientsadmitted for exacerbation of COPD should include: reassess-ment within 4 weeks; evaluation of improvement in symptomsand physical exam; assessment of need for supplementaloxygen; repeat examination if previous abnormalities werepresent; assessment of ability of the patient to cope with theenvironment; an understanding and re-adjustment of thetreatment regimen

Ethica and pa iative care issues in COPD

Patients with COPD experience acute exacerbations of theirdisease, which may produce respiratory failure and a possibleneed for either ventilatory support or accepting death Noclinical features can identify patients with respiratory failurewho will experience more burden than bene® t from life sup-portive care

If the patient has, or can have, clear preferences abouttreatment, respect for the patient requires that care providersgive effect to the patient’ s views Autonomy of the patient isthe predominant ethical principle that drives end-of-lifedecision-making in many societies

All healthcare providers should assist patients during stableperiods of health to think about their advance care planningby initiating discussions about end-of-life care These discus-sions should prepare patients with advanced COPD for alife-threatening exacerbation of their chronic disease, whileassisting them to go on living and enjoying life Pulmonaryrehabilitation provides an important opportunity to assistadvance care planning for patients with moderate-to-severeCOPD Educational programmes on advance care planningwithin pulmonary rehabilitation increase the adoption rate forinstruments of advance care planning and patient-physiciandiscussion about end-of-life care [102] Patients who choose torefuse life supportive care or have it withdrawn require expertdelivery of palliative care

Patients with COPD sometimes qualify for formal hospiceservices, especially when they are having repeated exacerba-tions and very poor measures on tests of pulmonary functionNevertheless, many patients will have a fatal exacerbationwithin a short time of having fairly good function, so onecannot wait to consider using hospice until death is nearlycertain Opportunities for hospice care are frequently neg-lected for patients coming to the end of life with COPD

[103, 104] Neglect in offering patients and their familiesappropriate resources for supportive end-of-life care results inunnecessary admissions to acute care hospitals for worseningrespiratory symptoms

Integrated disease management for primary care inCOPD

Disease management can be regarded as an integrated andsystematic approach in which healthcare providers worktogether in a coordinated and cooperative manner to producean optimal outcome for a particular patient with COPD,throughout the entire continuum of care [105] The concept ofthe disease as a continuum is depicted in ® gure 7 This ® gurealso represents the navigation tool for the web-basedStandards for the Diagnosis and Treatment of Patients withCOPD document 2004

Integrated care for COPD involves the patient and a teamof clinical professionals working in primary care, cooperatingwith secondary care and rehabilitation services Optimaldisease management involves redesigning standard medicalcare to integrate rehabilitative elements into a system ofpatient self-management and promotion of a healthy lifestyle

The following aspects are important: smoking cessation forall patients who smoke; early diagnosis and secondaryprevention (healthy lifestyle, vaccinations, exercise); educa-tion and self-management; pulmonary rehabilitation; mon-itoring and early recognition of exacerbation; implementationof rapid action plan; careful attention to end-of-life issues;palliative care

Referral indications

Referral to specialist care is indicated for COPD patientswith the following: disease onset at age 540 yrs; frequentexacerbations (two or more per year) despite adequatetreatment; rapidly progressive course of disease (decline inFEV1, progressive dyspnoea, decreased exercise tolerance,unintentional weight loss; severe COPD (FEV1550% pred)despite optimal treatment; need for LTOT; onset of co-morbid illness (osteoporosis, heart failure, bronchiectasis,lung cancer); evaluation for surgery

Clinical presentation

At risk Symptomatic Exacerbations Respiratoryfailure

Interventions

Smoking cessation

Disease management

Pulmonary rehabilitation

Other options

SymptomsFEV1

Disease progression

F ig 7 ± Continuum of care for chronic obstructive pulmonary disease(COPD) FEV1: forced expiratory volume in one second

943ATS/ERS COPD STANDARDS

Conc usions

This summary presents an overview of the entire documentfor the health practitioner, which is readily available online(www copd-ats-ers, www ersnet org and www thoracic org)This summary does not include any reference to the patientdocument, which, due to its inherent characteristics, cannotbe presented in a conventional format The readers areencouraged to visit the website to access both full documents

The committee that developed this document fully under-stands that the ® eld is rapidly changing and that individualcomponents of this document need to be updated periodicallyas the need arises However, the modular and ¯ exible designallows for this to occur easier than ever before The challengefor the future is to develop mechanisms to permit the updated¯ ow of valid scienti® c information to reach all who need it

References

1 American Thoracic Society Standards for the diagnosis andcare of patients with chronic obstructive pulmonary diseaseAm J Respir Crit Care Med 1995; 152: S77± S121

2 Siafakas NM, Vermeire P, Pride NB, et al Optimalassessment and management of chronic obstructive pulmo-nary disease (COPD) The European Respiratory SocietyTask Force Eur Respir J 1995; 8: 1398± 1420

3 Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS,the GOLD Scienti® c Committee Global strategy for thediagnosis, management, and prevention of chronic obstruc-tive pulmonary disease NHLBI/WHO Global Initiative forChronic Obstructive Lung Disease (GOLD) Workshopsummary Am J Respir Crit Care Med 2001; 163: 1256± 1276

4 Ferrer M, Alonso J, Morera J, et al Chronic obstructivepulmonary disease and health related quality of life Ann IntMed 1997; 127: 1072± 1079

5 Friedman M, Serby C, Menjoge S, Wilson J, Hilleman D,Witek T Pharmacoeconomic evaluation of a combination ofipratropium plus albuterol compared with ipratropium aloneand albuterol alone in COPD Chest 1999; 115: 635± 641

6 Burge PS, Calverley PM, Jones PW, Spencer S, AndersonJA, Maslen TK Randomised, double blind, placebocontrolled study of ¯ uticasone propionate in patients withmoderate to severe chronic obstructive pulmonary disease:the ISOLDE trial BMJ 2000; 320: 1297± 1303

7 Dewan N, Ra® que S, Kanwar B, et al Acute exacerbation ofCOPD Factors associated with poor treatment outcomeChest 2000; 117: 662± 671

8 Anthonisen NR, Wright EC, Hodgkin JE, the IPPB TrialGroup Prognosis in chronic obstructive pulmonary diseaseAm Rev Respir Dis 1986; 133: 14± 20

9 Celli B, Halbert R, Isonaka S, Schau B Population impact ofdifferent de® nitions of airway obstruction Eur Respir J 2003;22: 268± 273

10 Schols AM, Slangen J, Volovics L, Wouters EF Weight lossis a reversible factor in the prognosis of chronic obstructivepulmonary disease Am J Respir Crit Care Med 1998; 157:1791± 1797

11 Landbo C, Prescott E, Lange P, Vestbo J, Almdal TPPrognostic value of nutritional status in chronic obstructivepulmonary disease Am J Respir Crit Care Med 1999; 160:1856± 1861

12 Nishimura K, Izumi T, Tsukino M, Oga T Dyspnea is abetter predictor of 5-year survival than airway obstruction inpatients with COPD Chest 2002; 121: 1434± 1440

13 Mannino DM, Homa DM, Akinbami LJ, Ford ES, ReddSC Chronic obstructive pulmonary disease surveillance ±United States, 1971± 2000 MMWR 2002; 51: 1± 16

14 Prescott E Tobacco-related diseases: the role of gender DanMed Bull 2000; 47: 115± 131

15 Anto JM, Vermeire P, Vestbo J, Sunyer J Epidemiology ofchronic obstructive pulmonary disease Eur Respir J 2001;17: 982± 994

16 Fletcher CM, Tinker CM, Peto R, Speizer FE The naturalhistory of chronic bronchitis and emphysema Oxford,Oxford University Press, 1976

17 Gold DR, Wang X, Wipyj D, Speizer FE, Ware JH, DockeryDW Effects of cigarette smoking on lung function inadolescent boys and girls N Engl J Med 1996; 335: 931± 937

18 Saetta M, Di Stefano A, Turato G, et al CD8+T-lymphocytes in peripheral airways of smokers with chronicobstructive pulmonary disease Am J Respir Crit Care Med1998; 157: 822± 826

19 Rennard SI In¯ ammation and repair processes in chronicobstructive pulmonary disease Am J Respir Crit Care Med1999; 160: S12± S16

20 Peinado VI, Barbera JA, Abate P, et al In¯ ammatoryreaction in pulmonary muscular arteries of patients withmild chronic obstructive pulmonary disease Am J RespirCrit Care Med 1999; 159: 1605± 1611

21 Rodriguez-Roisin R, MacNee W Pathophysiology ofchronic obstructive pulmonary disease Eur Respir Mono1998; 3: 107± 126

22 O’Shaughnessy TC, Ansari TW, Barnes NC, Jeffery PKIn¯ ammation in bronchial biopsies of subjects with chronicbronchitis: inverse relationship of CD8+ T lymphocytes withFEV1 Am J Respir Crit Care Med 1997; 155: 852± 857

23 Repine JE, Bast A, Lankhorst I Oxidative stress in chronicobstructive pulmonary disease Oxidative Stress StudyGroup Am J Respir Crit Care Med 1997; 156: 341± 357

24 Matsuba K, Wright JL, Wiggs BR, Pare PD, Hogg JC Thechanges in airways structure associated with reduced forcedexpiratory volume in one second Eur Respir J 1989; 2: 834± 839

25 O’Donnell DE, Revill SM, Webb KA Dynamic hyperin¯ a-tion and exercise intolerance in chronic obstructive pulmo-nary disease Am J Respir Crit Care Med 2001; 164: 770± 777

26 Fiore MC, Bailey WC, Cohen SJ Smoking cessationGuideline technical report no 18 Publication No AHCPR97-Noo4 Rockville, MD, US Department of Health andHuman Services, Public Health Service, Agency for HealthCare Policy and Research, October 1997

27 Fiore MC US public health service clinical practice guide-line: treating tobacco use and dependence Respir Care 2000;45: 1200± 1262

28 Of® ce of the Surgeon General Tobacco Cessation Guidelinewww surgeongeneral gov/tobacco/default htm Data lastupdated: continuous

29 Celli B, ZuWallack R, Wang S, Kesten S Improvement inresting inspiratory capacity and hyperin¯ ation with tiotro-pium in COPD patients with increased static lung volumesChest 2003; 124: 1743± 1748

30 O’Donnell DE, Lam M, Webb KA Spirometric correlates ofimprovement in exercise performance after anticholinergictherapy in chronic obstructive pulmonary disease AmJ Respir Crit Care Med 1999; 160: 542± 549

31 Belman MJ, Botnick WC, Shin JW Inhaled bronchodilatorsreduce dynamic hyperin¯ ation during exercise in patientswith chronic obstructive pulmonary disease Am J RespirCrit Care Med 1996; 153: 967± 975

32 Dahl R, Greefhorst LA, Nowak D, et al Inhaled formoteroldry powder versus ipratropium in chronic obstructivepulmonary disease Am J Respir Crit Care Med 2001; 164:778± 784

33 Jones PW, Bosh TK Quality of life changes in COPDpatients treated with salmeterol Am J Respir Crit Care Med1997; 155: 1283± 1289

34 Combivent trialists In chronic obstructive pulmonarydisease, a combination of ipratropium and albuterol ismore effective than either agent alone An 85-day multicentertrial COMBIVENT Inhalation Aerosol Study Group Chest1994; 105: 1411± 1419

35 Zuwallack RL, Mahler DA, Reilly D, et al Salmeterol plus

944 B R CELLI ET AL

http://www.surgeongeneral.gov/tobacco/default.htmhttp://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^281995^298L.1398[aid=1414969]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^282001^29163L.1256[aid=1881672]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-4819^281997^29127L.1072[aid=2292147]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281999^29115L.635[aid=1881886]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0959-8138^282000^29320L.1297[aid=1487124]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^282000^29117L.662[aid=1486922]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-0805^281986^29133L.14[aid=1487132]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282003^2922L.268[aid=5228825]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281998^29157L.1791[aid=2229922]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29160L.1856[aid=1817362]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^282002^29121L.1434[aid=3356308]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0907-8916^282000^2947L.115[aid=4834685]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282001^2917L.982[aid=2292388]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^281996^29335L.931[aid=1487162]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281998^29157L.822[aid=1486982]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29159L.1605[aid=2292780]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281997^29155L.852[aid=2275496]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281997^29156L.341[aid=819126]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^281989^292L.834[aid=5002811]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^282001^29164L.770[aid=1882115]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0020-1324^282000^2945L.1200[aid=5835434]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^282003^29124L.1743[aid=5835335]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29160L.542[aid=1882110]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^282001^29164L.778[aid=2724520]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281997^29155L.1283[aid=1496595]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281994^29105L.1411[aid=2054403]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-4819^281997^29127L.1072[aid=2292147]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282003^2922L.268[aid=5228825]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281998^29157L.1791[aid=2229922]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29160L.1856[aid=1817362]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0907-8916^282000^2947L.115[aid=4834685]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282001^2917L.982[aid=2292388]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281998^29157L.822[aid=1486982]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29159L.1605[aid=2292780]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0020-1324^282000^2945L.1200[aid=5835434]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29160L.542[aid=1882110]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^282001^29164L.778[aid=2724520]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281997^29155L.1283[aid=1496595]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281994^29105L.1411[aid=2054403]

theophylline combination therapy in the treatment ofCOPD Chest 2001; 119: 1661± 1670

36 Casaburi R, Mahler DA, Jones PW, et al A long-termevaluation of once daily inhaled tiotropium in chronicobstructive pulmonary disease Eur Respir J 2002; 19: 217± 224

37 Vicken W, Van Noord JA, Greefhorst AP, et al , on behalf ofthe Dutch/Belgian Tiotropium Study Group Improvedhealth outcomes in patients with COPD during 1 yeartreatment with tiotropium Eur Respir J 2002; 19: 209± 216

38 Burge PS, Calverley PM, Jones PW, Spencer S, AndersonJA, Maslen TK Randomised, double blind, placebocontrolled study of ¯ uticasone propionate in patients withmoderate to severe chronic obstructive pulmonary disease:the ISOLDE trial BMJ 2000; 320: 1297± 1303

39 Pauwels RA, Lofdahl C-G, Laitinen LA, et al Long-termtreatment with inhaled budesonide in persons with mildchronic obstructive pulmonary disease who continue smok-ing New Engl J Med 1999; 340: 1948± 1953

40 The Lung Health Study Research Group Effect of inhaledtriamcinolone on the decline in pulmonary function inchronic obstructive pulmonary disease New Engl J Med2000; 343: 1902± 1909

41 Vestbo J, Sorensen T, Lange P, Brix A, Torre P, Viskum KLong-term effect of inhaled budesonide in mild andmoderate chronic obstructive pulmonary disease: A rando-mised controlled trial Lancet 1999; 353: 1819± 1823

42 Jarad NA, Wedzicha JA, Burge PS, Calverley PMA Anobservational study of inhaled corticosteroid withdrawal instable chronic obstructive pulmonary disease Respir Med1999; 93: 161± 168

43 Calverley PM, Boonsawat W, Cseke Z, et al Maintenancetherapy with budesonide and formoterol in chronic obstruc-tive pulmonary disease Eur Respir J 2003; 22: 912± 919

44 Szafranski W, Cukier A, Ramirez A, et al Ef® cacy andsafety of budesonide/formoterol in the management ofCOPD Eur Respir J 2003; 21: 74± 81

45 Calverley P, Pauwels R, Vestbo J, et al Combined salmeteroland ¯ uticasone in the treatment of chronic obstructivepulmonary disease: a randomised controlled trial Lancet2003; 361: 449± 456

46 Report of the Medical Research Council Working PartyLong-term domiciliary oxygen therapy in chronic hypoxiccor pulmonale complicating chronic bronchitis and emphy-sema Lancet 1981; 1: 681± 685

47 Nocturnal Oxygen Therapy Trial Group Continuous ornocturnal oxygen therapy in hypoxemic chronic obstructivelung disease Ann Intern Med 1980; 93: 391± 398

48 Weitzenblum E, Sautegeau A, Ehrhart M, Mammosser M,Pelletier A Long-term oxygen therapy can reverse theprogression of pulmonary hypertension in patients withchronic obstructive pulmonary disease Am Rev Respir Dis1985; 131: 493± 498

49 Oswald-Mammosser M, Weitzenblum E, Quoix E, et alPrognostic factors in COPD patients receiving long-termoxygen therapy: importance of pulmonary artery pressureChest 1995; 107: 1193± 1198

50 Zielinski J, Tobiasz M, Hawrylkiewicz I, Sliwinksi P,Palasiewicz G Effects of long-term oxygen therapy onpulmonary hemodynamics in COPD patients: a 6-yearprospective study Chest 1998; 113: 65± 70

51 Tiep BL, Barnett J, Schiffman G, Sanchez O, Carter RMaintaining oxygenation via demand oxygen delivery duringrest and exercise Respir Care 2002; 47: 887± 892

52 Pulmonary rehabilitation: of® cial statement of the AmericanThoracic Society Am J Respir Crit Care Med 1999; 159:1666± 1682

53 Goldstein RS, Gort EH, Stubbing D, et al Randomisedcontrolled trial of respiratory rehabilitation Lancet 1994;344: 1394± 1397

54 Reardon J, Awad E, Normandin E, Vale F, Clark B,ZuWallack RL The effect of comprehensive outpatient

pulmonary rehabilitation on dyspnea Chest 1994; 105: 1046±1052

55 Ries AL, Kaplan RM, Limberg TM, Prewitt LM Effects ofpulmonary rehabilitation on physiologic and psychosocialoutcomes in patients with chronic obstructive pulmonarydisease Ann Intern Med 1995; 122: 823± 832

56 Wijkstra PJ, van der Mark TW, Kraan J, van Altena R,Koeter GH, Postma DS Effects of home rehabilitation onphysical performance in patients with chronic obstructivepulmonary disease (COPD) Eur Respir J 1996; 9: 104± 110

57 Strijbos JH, Postma DS, van Altena R, Gimeno F, KoeterGH A comparison between an outpatient hospital-basedpulmonary rehabilitation program and a home-care pulmo-nary rehabilitation program in patients with COPD Afollow-up of 18 months Chest 1996; 109: 366± 372

58 Schols AMWJ, Soeters PB, Dingemans AMC, Mostert R,Frantzen PJ, Wouters EF Prevalence and characteristics ofnutritional depletion in patients with stable COPD eligiblefor pulmonary rehabilitation Am Rev Respir Dis 1993; 147:1151± 1156

59 Schols AM, Soeters PB, Mostert R, et al Physiologic effectsof nutritional support and anabolic steroids in patients withchronic obstructive pulmonary disease: A randomisedcontrolled trial Am J Respir Crit Care Med 1995; 152:1248± 1274

60 Creutzberg EL, Wouters EFM, Mostert R, et al Ef® cacy ofnutritional supplementation therapy in depleted patientswith chronic obstructive pulmonary disease Nutrition 2003;19: 120± 127

61 Arozullah AM, Khuri SF, Henderson WG, Daley JDevelopment and validation of a multifactorial risk indexfor predicting postoperative pneumonia after major non-cardiac surgery Ann Intern Med 2001; 135: 847± 857

62 Smetana GW Preoperative pulmonary evaluation N EnglJ Med 1999; 340: 937± 944

63 Trayner E Jr, Celli BR Postoperative pulmonary complica-tions Med Clin North Am 2001; 85: 1129± 1139

64 Weisman IM Cardiopulmonary exercise testing in thepreoperative assessment for lung resection surgery SeminThorac Cardiovasc Surg 2001; 13: 116± 125

65 Martinez FJ, Iannettoni M, Paine III R Medical evaluationand management of the lung cancer patient prior to surgery,radiation or chemotherapy In: Pass H, Mitchell J, JohnsonD, Turrisi A, eds Lung cancer: principles and practicePhiladelphia, PA, Lippincott Williams & Williams, 2000;pp 649± 681

66 Bolliger CT, Jordan P, Soler M, et al Pulmonary functionand exercise capacity after lung resection Eur Respir J 1996;9: 415± 421

67 Bolliger CT, Perruchoud AP Functional evaluation of thelung resection candidate Eur Respir J 1998; 11: 198± 212

68 Martinez FJ Surgical therapy for chronic obstructivepulmonary disease: conventional bullectomy and lungvolume reduction surgery in the absence of giant bullaeSemin Respir Crit Care Med 1999; 20: 351± 364

69 Snider GL Reduction pneumoplasty for giant bullousemphysema Implications for surgical treatment of nonbul-lous emphysema Chest 1996; 109: 540± 548

70 National Emphysema Treatment Trial Research Group Arandomized trial comparing lung-volume-reduction surgerywith medical therapy for severe emphysema N Engl J Med2003; 348: 2059± 2073

71 American Thoracic Society International guidelines for theselection of lung transplant candidates Am J Respir CritCare Med 1998; 158: 335± 339

72 Hudgel DW, Martin RJ, Capehart M, Johnson B, Hill PContribution of hypoventilation to sleep oxygen desaturationin chronic obstructive pulmonary disease J Appl Physiol1983; 55: 669± 677

73 Mulloy E, McNicholas WT Ventilation and gas exchangeduring sleep and exercise in patients with severe COPDChest 1996; 109: 387± 394

945ATS/ERS COPD STANDARDS

http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^282001^29119L.1661[aid=5228846]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282002^2919L.217[aid=2321088]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282002^2919L.209[aid=2320765]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0959-8138^282000^29320L.1297[aid=1487124]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^281999^29340L.1948[aid=1487231]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^282000^29343L.1902[aid=2724275]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0140-6736^281999^29353L.1819[aid=1487230]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0954-6111^281999^2993L.161[aid=3367823]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282003^2922L.912[aid=5392145]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^282003^2921L.74[aid=4834979]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0140-6736^282003^29361L.449[aid=4932130]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0140-6736^281981^291L.681[aid=1437591]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-4819^281980^2993L.391[aid=1436327]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-0805^281985^29131L.493[aid=2359867]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281995^29107L.1193[aid=3156530]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281998^29113L.65[aid=2359873]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0020-1324^282002^2947L.887[aid=5835436]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29159L.1666[aid=2523604]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0140-6736^281994^29344L.1394[aid=1817335]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281994^29105L.1046[aid=2991091]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-4819^281995^29122L.823[aid=1414952]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^281996^299L.104[aid=2275513]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281996^29109L.366[aid=2275525]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281995^29152L.1248[aid=3279012]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0899-9007^282003^2919L.120[aid=5835437]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-4819^282001^29135L.847[aid=5835438]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^281999^29340L.937[aid=5835439]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0025-7125^282001^2985L.1129[aid=4128556]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1043-0679^282001^2913L.116[aid=5835440]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^281996^299L.415[aid=3255542]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^281998^2911L.198[aid=2054724]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281996^29109L.540[aid=2447985]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^282003^29348L.2059[aid=5269075]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281998^29158L.335[aid=5835442]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/8750-7587^281983^2955L.669[aid=1487479]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281996^29109L.387[aid=1487490]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^282000^29343L.1902[aid=2724275]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0954-6111^281999^2993L.161[aid=3367823]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0140-6736^282003^29361L.449[aid=4932130]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0003-0805^281985^29131L.493[aid=2359867]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281999^29159L.1666[aid=2523604]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0140-6736^281994^29344L.1394[aid=1817335]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0012-3692^281994^29105L.1046[aid=2991091]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281995^29152L.1248[aid=3279012]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0899-9007^282003^2919L.120[aid=5835437]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^281999^29340L.937[aid=5835439]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1043-0679^282001^2913L.116[aid=5835440]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0903-1936^281996^299L.415[aid=3255542]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/0028-4793^282003^29348L.2059[aid=5269075]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/1073-449X^281998^29158L.335[aid=5835442]http://www.ingentaselect.com/rpsv/cgi-bin/linker?ext=a&reqidx=/8750-7587^281983^2955L.669[aid=1487479]

74 Klink M, Quan S Prevalence of reported sleep disturbancesin a general population and their relationship to obstructiveairways diseases Chest 1987; 91: 540± 546

75 Sanders MH, Newman AB, Haggerty CL, et al Sleep andsleep-disorderedbreathing in adults with predominantly mildobstructive airway disease Am J Respir Crit Care Med 2003;167: 7± 14

76 Fletcher EC, Luckett RA, Goodnight-White S, Miller CC,Qian W, Costarangos-Galarza C A double-blind trial ofnocturnal supplemental oxygen for sleep desatura