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ERS-ATS COPDGuidelines
Copyright European Respiratory Society 2005
These slides can be used freely
for non-commercial purposes.
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Document authors
B.R. C lli W. M N
A.Anzuet A.Agusti .Austergaard W. Bailey
C. B lliger B. Berg A.S. Buist N.H. C avannes
R. Carter P. Calverley T. Dillard E.W.Ely
B. Fahy M.Estenne A. Fein M. Fi reN. Gross R. Gross an J.Heffner L.Hoffman
J.C.Hogg R.M. Kotloff S.C.Lareau N.M.Lazar
J.Lynn W.McNicholas F.J.Martinez P.M.Meek
M.Myramoto J.W.M.Muris J.B. Orens R.Pauw els
J.J. Reilly S. Rennard R. Rodriguez-Roisin A. Rossi
A.M.W.J.Schols L.Sicilian N.Siafakas G.L.Snider
B.L.Tiep J.van Noord J. Vestbo W.Weder
I.M.Weisman M.E.Wew ers E.F.M.Wouters R.D. Yusen
J. Zielinski R. ZuWallack
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Document Goals and O jectives (1)
The Standards for the Diagnosis and Treatment ofPatients withCOPD document updates the position papers on COPDpu lished y the ATS and the ERS in 1995.
Both organisations acknowledge the recent dissemination of theGlo al Initiative ofO structive Lung Disease (GOLD) as a majorcontri ution against COPD.
However, an adaptation ofGOLD was deemed necessary tomatch specific requirements of the mem ers of oth societies.
Those requirements include specific recommendations onoxygen therapy, pulmonary reha ilitation, noninvasiveventilation, surgery in and for COPD, sleep, air travel, and end-of-life.
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Document Goals and O jectives (2)
These guidelines aim at:
Improving the quality ofcare provided to patients
with COPD.
Promoting the use ofa disease-oriented approach.
aintaining a synchronous flowwith the wider
o jectives ofGOLD.
Using an electronic, we - ased format which can
e updated any time a modification is deemed
necessary.
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Definition ofCOPD
Chronic O structive Pulmonary Disease (COPD)
is a preventa le and treata le disease state
characterised y airflow limitation that is not fully
reversi le.
The airflow limitation is usually progressive and
associated with an a normal inflammatory
response of the lungs to noxious particles orgases, primarily caused y cigarette smoking.
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Epidemiology (1)
COPD is a leading cause ofmor idity and
mortality worldwide, and results in an economic
and social urden that is oth su stantial and
increasing.
Prevalence and mor idity data greatly
underestimate the total urden ofCOPD ecause
the disease is usually not diagnosed until it isclinically apparent and moderately advanced.
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Epidemiology (2)
COPD is the fourth leading cause ofdeath in the USA
and Europe, and COPD mortality in females has more
than dou led over the last 20 years.
Leading causes ofdeath in the USA, 1998 Num er
Heart disease 724,269
Cancer 538,947
Cere rovascular disease (stroke) 158,060
Respiratory diseases (COPD) 114,381
Accidents 94,828Pneumonia and influenza 93,207
Dia etes 64,574
Suicide 29,264
Nephritis 26,265
Chronic liver disease 24,936
All other causes ofdeath 469,314
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Epidemiology (3) COPD is a more costly disease than asthma and, depending on
country, 5075% ofthe costs are for services associated withexacer ations.
To acco smoke is y far the most important riskfactorfor COPD
worldwide.
Other important riskfactors are:
Host factors Exposures
Genetic factorsSex
Airway hyperreactivity,
IgE and asthma
SmokingSocio-economic status
Occupation
Environmental pollution
Perinatal events and childhood illness
Recurrent ronchopulmonary infections
Diet
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Pathogenesis and Pathophysiology
Pathogenesis To acco smoking is the main riskfactorfor COPD, although
other inhaled noxious particles and gases may contri ute.
In addition to inflammation, an im alance ofproteinases and
antiproteinases in the lungs, and oxidative stress are alsoimportant in the pathogenesis ofCOPD.
Pathophysiology The different pathogenic mechanisms produce the pathological
changes which, in turn, give rise to the physiologicala normalities in COPD:
mucous hypersecretion and ciliary dysfunction,
airflow limitation and hyperinflation,
gas exchange a normalities,
pulmonary hypertension,
systemic effects.
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Diagnosis ofCOPD (1) Diagnosis ofCOPD should e considered in any patient
who has the following: symptoms ofcough
sputum production
dyspnoea history ofexposure to riskfactors for the disease
Spirometry should e o tained in all persons with thefollowing history:
exposure to cigarettes and/or environmental or occupationalpollutants
family history ofchronic respiratory illness
presence ofcough, sputum production or dyspnoea
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Diagnosis ofCOPD (2)
Spirometry
Spirometric classification of COPD:
Post- ronchodilator E 1/forced vital capacity 0.7 u80
Mild COPD e0.7 u80
Moderate COPD e0.7 5080
Severe COPD e0.7 3050
Very severe COPD e0.7
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Diagnosis ofCOPD (3)
B I and dyspnoea Body Mass Index (BMI) and dyspnoea have proved useful in predicting
outcomes such as survival, and should thus e evaluated in all patients.
BMIvalues < 21 kgm-2 are associated with increased mortality.
Functional dyspnoea can e assessed y the Medical Research Council dyspnoeascale:
0 Not trou led with reathlessness except with strenuous exercise.
1 Trou led y shortness of reath when hurrying orwalking up aslight hill.
2 Walks slower than people ofthe same age due to reathlessnessor has to stop for reath when walking at own pace on the level.
3 Stops for reath afterwalking a out 100 m or after a few minuteson the level.
4 Too reathless to leave the house or reathless when dressing orundressing.
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Diagnosis ofCOPD (4)
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Smoking cessation (1) To acco is the most important riskfactorfor COPD.
Cigarette smoking is an addiction and a chronic relapsing disorder.
Treating to acco use and dependence should e regarded as a primary andspecific intervention.
Smoking cessation activities and support for its implementation should eintegrated into the healthcare system.
The key steps in intervention are:
Ask Identify all to acco users at every visit
Advise Strongly urge all to acco users to quit
Assess Determine willingness to make a quit attempt
Assist Help the patient with a quit plan, provide practical counselling,
treatment and social support, recommend the use ofapproved
pharmacotherapy
Arrange Schedule follow-up contact
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Smoking cessation (2) Key points ofthe Treating To acco Use and Dependence
guidelines:
To acco dependence is a chronic condition that warrants repeatedtreatment until long-term or permanent a stinence is achieved.
Effective treatments for to acco dependence exist and all to acco usersshould e offered these treatments.
Clinicians and healthcare delivery systems must institutionalise theconsistent identification, documentation and treatment ofevery to accouser at every visit.
Briefto acco dependence intervention is effective and every to accouser should e offered at least rief intervention.
There is a strong dose-response relationship etween the intensity ofto acco dependence counselling and its effectiveness.
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Smoking cessation (3) Key points ofthe Treating To acco Use and Dependence guidelines
(continued):
Three types ofcounselling were found to e especially effective:practical counselling, social support as part oftreatment, and
social support arranged outside treatment.
Five first-line pharmacotherapies for to acco dependence areeffective: upropion SR, nicotine gum, nicotine inhaler, nicotinenasal spray, and nicotine patch, and at least one of thesemedications should e prescri ed in the a sence of
contraindications.
To acco-dependence treatments are cost-effective relative toother medical and disease prevention interventions.
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary reha ilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary reha ilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Pharmacological therapy (1)
The medications for COPD currently availa le can reduceor a olish symptoms, increase exercise capacity, reducethe num er and severity ofexacer ations, and improvehealth status.
At present, no treatment has een shown to modify therate ofdecline in lung function.
The change in lung function after rief treatment with any
drug does not help in predicting other clinically relatedoutcomes.
The inhaled route is preferred.
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Pharmacological therapy (2)
Changes in forced expiratory volume in one second
(FE 1) following ronchodilator therapy can e small ut
are often accompanied y larger changes in lung
volume, which contri ute to a reduction in perceived
reathlessness.
Com ining different agents produces a greater change in
spirometry and symptoms than single agents alone.
Three types of ronchodilators are in common clinicaluse: -agonists, anticholinergic drugs and
methylxanthines.
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Pharmacological therapy (3)
Bronchodilators
LA-BD: long-acting bronchodilator; ICS: inhaled corticosteroid. Assess effectiveness by treatmentresponse criteria. If forced expiratory volume
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Pharmacological therapy (4)
Bronchodilators Short-acting ronchodilators can increase exercise tolerance acutely in
COPD.
Anticholinergics given q.i.d. can improve health status over a 3-monthperiod.
Long-acting inhaled -agonists improve health status, possi ly more than
regular ipratropium. Additionally, these drugs reduce symptoms, rescuemedication use and increase the time etween exacer ations.
Com ining short-acting agents (sal utamol/ipratropium) produces a greaterchange in spirometry over 3 months than either agent alone.
Com ining long-acting inhaled -agonists and ipratropium leads to fewerexacer ations than either drug alone.
Com ining long-acting -agonists and theophylline produces a greaterspirometric change than either drug alone.
Tiotropium improves health status and reduces exacer ations andhospitalisations compared with oth place o and regular ipratropium.
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Pharmacological therapy (5)
Glucocorticoids
Glucocorticoids act at multiple points within the
inflammatory cascade, although their effects in
COPD are more modest compared with
ronchial asthma.
In patients with more advanced disease (usually
classified as an FE 1
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary reha ilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Long-term oxygen therapy (1)
Long-term oxygen therapy (LTOT) improves survival,
exercise, sleep and cognitive performance.
Reversal ofhypoxaemia supersedes concerns a out
car on dioxide (CO2) retention.
Arterial lood gas (ABG) is the preferred measure and
includes acid- ase information.
Oxygen sources include gas, liquid and concentrator. Oxygen delivery methods include nasal continuous flow,
pulse demand, reservoir cannulas and transtracheal
catheter.
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Long-term oxygen therapy (2)
Physiological indications for oxygen include an arterialoxygen tension (Pa,O2) 90% during rest,sleep and exertion.
Active patients require porta le oxygen.
Ifoxygen was prescri ed during an exacer ation,recheck ABGs after 3090 days.
Withdrawal ofoxygen ecause of improved Pa,O2 inpatients with a documented need for oxygen may edetrimental.
Patient education improves compliance.
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Long-term oxygen therapy (3)
Home treatment
Pa,O2: arterial oxygen
tension; Sa,O2: arterial
oxygen saturation; ABG:
arterial lood gases.
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary rehabilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Pulmonary reha ilitation Pulmonary reha ilitation is a multidisciplinary programme ofcare
that is individually tailored and designed to optimise physical andsocial performance and autonomy.
Pulmonary reha ilitation should e considered for patients withCOPD who have dyspnoea or other respiratory symptoms, reducedexercise tolerance, a restriction in activities ecause oftheirdisease, or impaired health status.
Pulmonary reha ilitation programmes include:
exercise training,
education,
psychosocial/ ehavioural intervention, nutritional therapy,
outcome assessment,
promotion of long-term adherence to the reha ilitationrecommendations.
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary reha ilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Nutrition Weight loss and a depletion offat-free mass (FFM) may e o served in
sta le COPD patients.
Being underweight is associated with an increased mortality risk.
Criteria to define weight loss are:
Weight loss >10% in the past 6 months or >5% in the past month.
Nutritional therapy may only e effective ifcom ined with exercise or otherana olic stimuli.
Underweight BMI 50 yrs
Normal weight BMI
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary reha ilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Surgery in COPD (1)
Patients with a diagnosis ofCOPD have a 2.74.7-foldincreased risk ofpost-operative pulmonarycomplications.
The further the procedure from the diaphragm, the lowerthe pulmonary complication rate.
Smoking cessation at least 48 weeks pre-operativelyand optimisation of lung function can decrease post-
operative complications. Early mo ilisation, deep reathing, intermittent positive-
pressure reathing, incentive spirometry and effectiveanalgesia may decrease postoperative complications.
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Surgery in COPD (2)
Algorithm for pre-operative testing forlung resection.DL,CO: car on dioxide
diffusing capacity of the lung; FE 1:
forced expiratory volume in one
second; ppo: predicted postoperative;
VO2,max: maximum oxygen
consumption.
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Surgery for COPD (1)
Bullectomy and lung volume reductionsurgery may result in improved spirometry, lungvolume, exercise capacity, dyspnoea, health-
related quality of life and possi ly survival inhighly selected patients.
Lung transplantation results in improvedpulmonary function, exercise capacity, quality of
life and possi ly survival in highly selectedpatients.
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Surgery for COPD (3)
Lung Volume Reduction SurgeryParameter Favourable Unfavourable
Clinical Age 7580 yrs
Clinical picture consistent with emphysema
Co-morbid illness which would increase surgical
mortality
Not actively smoking (>36 months) Clinically significant coronary artery disease
Severe dyspnea despite maximal medical treatment
including pulmonary rehabilitation
Pulmonary hypertension (PA systolic >45, PA mean
>35 mmHg)
Requiring 140 m
Low post-rehabilitation maximal achieved cycle ergometry
watts#
Radiographical
High-resolution computed tomography confirming severe
emphysema, ideally with upper lobe predominance Homogeneous emphysema and FEV1
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Surgery for COPD (4)
Lung Volume Reduction Surgery
Schematic algorithm from theNational Emphysema Therapy
Trial for Lung Volume ReductionSurgery (LVRS).FEV1:forcedexpiratory volume in one second;DLCO: car on dioxide diffusingcapacity ofthe lung.
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary reha ilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Sleep Sleep in COPD is associated with oxygen desaturation, which is
predominantly due to the disease itselfrather than to sleep apnoea.The desaturation during sleep may e greater than during maximumexercise.
Sleep quality is markedly impaired in COPD, oth su jectively and
o jectively.
Clinical assessment in all patients with COPD should includequestions a out sleep quality and possi le co-existing sleep apnoeasyndrome.
Management ofsleep pro lems in COPD should particularly focus onminimising sleep distur ance y measures to limit cough anddyspnoea, and nocturnal oxygen therapy is rarely indicated forisolated nocturnal hypoxaemia.
Hypnotics should e avoided, ifpossi le, in patients with severeCOPD.
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Management ofsta le COPD
Pharmacological therapy
Long-term oxygen therapy
Pulmonary reha ilitation
Nutrition
Surgery in and for COPD
Sleep
Air travel
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Exacer ation ofCOPD
Definition, evaluation and treatment
In-patient oxygen therapy
Assisted ventilation
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Exacer ation ofCOPD
Definition, evaluation and treatment
In-patient oxygen therapy
Assisted ventilation
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Definition, evaluation and
treatment (1)
The definition ofCOPD exacer ation is an acutechange in a patients aseline dyspnoea, coughand/or sputum eyond day-to-day varia ilitysufficient to warrant a change in therapy.
Causes ofexacer ation can e oth infectiousand non-infectious.
Medical therapy includes ronchodilators,corticosteroids, anti iotics and supplementaloxygen therapy.
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Definition, evaluation and
treatment (2)
Indications for hospitalisation ofpatients with a COPDexacer ation Presence ofhigh-risk co-mor id conditions, including
pneumonia, cardiac arrhythmia, congestive heart failure,dia etes mellitus, renal or liverfailure
Inadequate response ofsymptoms to outpatient management Marked increase in dyspnoea
Ina ility to eat or sleep due to symptoms
Worsening hypoxaemia
Worsening hypercapnia
Changes in mental status
Ina ility of the patient to care for her/himself
Uncertain diagnosis
Inadequate home care
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Definition, evaluation and
treatment (3) The Operational Classification ofSeverity is as follows: am ulatory (Level I), requiring
hospitalisation (Level II) and acute respiratory failure (Level III).
Level I Level II Level III
Clinical history
Co-mor id conditions
History offrequent exacer ationsSeverity ofCOPD
+
+
Mild/moderate
+++
+++
Moderate/severe
+++
+++
Severe
Physical findings
Haemodynamic evaluation
Use accessory respiratory muscles, tachypnoea
Persistent symptoms after initial therapy
Sta le
Not present
No
Sta le
++
++
Sta le/unsta le
+++
+++
Diagnostic procedures
Oxygen saturation
Arterial lood gases
Chest radiograph
Blood tests
Serum drug concentrations
Sputum gram stain and culture
Electrocardiogram
es
No
No
No
Ifapplica le
No
No
es
es
es
es
Ifapplica le
es
es
es
es
es
es
Ifapplica le
es
es
+: unlikely to be present; ++: likely to be present; +++: very likely to be present
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Definition, evaluation and
treatment (4)
Level I: outpatient treatmentPatient education
Check inhalation technique
Consider use ofspacer devices
Bronchodilators
Short-acting 2-agonist and/or ipratropium MDIwith spacer or hand-held ne uliser as neededConsider adding long-acting ronchodilator ifpatient is not using it
Corticosteroids (the actual dose may vary)
Prednisone 3040 mgper os q day for 10 days
Consider using an inhaled corticosteroid
Antibiotics
May e initiated in patients with altered sputum characteristics
Choice should e ased on local acteria resistance patterns
Amoxicillin/ampicillin, cephalosporins
Doxycycline
Macrolides
If the patient has failed prior anti iotic therapy consider:
Amoxicillin/clavulanate
Respiratory fluoroquinolones
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Definition, evaluation and
treatment (5)
Level II: treatment for hospitalised patient
Bronchodilators
Short acting 2-agonist (al uterol, sal utamol) and/or
Ipratropium MDIwith spacer or hand-held ne uliser as needed
Supplemental oxygen (ifsaturation
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Definition, evaluation and
treatment (6)
Level III: treatment in patients requiring special or intensive care unit
Supplemental oxygen
Ventilatory support
Bronchodilators
Short-acting 2-agonist (al uterol, sal utamol) and ipratropium MDIwith spacer, two puffs every 24 hIfthe patient is on the ventilator, consider MDI administration, consider long-acting -agonist
Corticosteroids
Ifpatient tolerates oral medications, prednisone 3040 mgper os q day for 10 days
Ifpatient can not tolerate, give the equivalent dose i.v.for up 14 days
Consider use inhaled corticosteroids y MDI or hand-held ne uliser
Antibiotics ( ased on local acteria resistance patterns)Choice should e ased on local acteria resistance patterns
Amoxicillin/clavulanate
Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin)
IfPseudomonas spp. and or otherEnterobactereaces spp. are suspected consider com ination therapy
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Exacer ation ofCOPD
Definition, evaluation and treatment
In-patient oxygen therapy
Assisted ventilation
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In-patient oxygen therapy The goal is to prevent tissue hypoxia y maintaining arterial oxygen
saturation (Sa,O2) at >90%.
Main delivery devices include nasal cannula and venturi mask.
Alternative delivery devices include nonre reather mask, reservoir
cannula, nasal cannula or transtracheal catheter.
Arterial lood gases should e monitoredfor arterial oxygen tension(Pa,O2), arterial car on dioxide tension (Pa,CO2) and pH.
Arterial oxygen saturation as measured y pulse oximetry (Sp,O2)should e monitored for trending and adjusting oxygen settings.
Prevention of tissue hypoxia supercedes CO2 retention concerns.
IfCO2 retention occurs, monitorfor acidaemia.
Ifacidaemia occurs, consider mechanical ventilation.
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In-patient oxygen therapy (2)
Algorithm to correct hypoxaemia
in an acutely ill chronic o structivepulmonary disease patient. ABG:
arterial lood gas; Pa,O2: arterial
oxygen tension; O2: oxygen;
Sa,O2: arterial oxygen saturation;
Pa,CO2: arterial car on dioxide
tension; NPPV: noninvasivepositive pressure ventilation.
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Exacer ation ofCOPD
Definition, evaluation and treatment
In-patient oxygen therapy
Assisted ventilation
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Assisted ventilation (1) Noninvasive positive pressure ventilation (NPPV) should e offered
to patients with exacer ations when, after optimal medical therapyand oxygenation, respiratory acidosis (pH
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Assisted ventilation (2) Patients meeting exclusion criteria should e considered for
immediate intu ation and ICU admission.
Exclusion criteria include:
respiratory arrest,
cardiovascular insta ility, impaired mental status,
somnolence,
ina ility to cooperate,
copious and/orviscous secretions with high aspiration risk,
recent facial or gastro-oesophageal surgery; craniofacial trauma and/orfixed naso-pharyngeal a normality,
urns,
extreme o esity.
In the first hours, NPPV requires the same level ofassistance asconventional mechanical ventilation.
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Assisted ventilation (3)
Flow-chart for the use of
noninvasive positive pressureventilation (NPPV) duringexacer ation ofCOPDcomplicated y acuterespiratory failure. MV:mechanical ventilation;
Pa,CO2: arterial car on dioxidetension.
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Ethical and palliative care
issues in COPD Patients with COPD experience acute exacer ations of their
disease, which may produce respiratory failure and a possi le needfor eitherventilatory support or accepting death.
Healthcare providers should assist patients during sta le periods ofhealth to think a out their advance care planning y initiating
discussions a out end-of-life care.
End-of-life discussions and advance care planning assist decisionsregarding life-supportive care at the end of life y providinginformation on pro a le outcomes and the existence ofpalliativeinterventions, such as dyspnoea management and terminalsedation.
Patients who choose to refuse life-supportive care or have itwithdrawn require expert delivery ofpalliative care.
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Patient section
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Patient section This updated document includes
a patient section aimed at:
Providing practical information
on all aspects ofCOPD.
Promoting a healthy lifestyle to
all patients afflicted with the
disease.
This section is availa le in
English, French, German, Italian
and Spanish.
It includes printa le files whichcan e directly distri uted to
patients.
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www.ersnet.org/copdEur Respir J2004; 23: 932946
ERS-ATS COPD Guidelines
We site Address