JEAN BOURBEAU, MD, MSc, FRCPC

Assistant Professor
Medicine and Epidemiology
McGill University
Montreal, Quebec
DIANE NAULT, RN, MSc
Head Nurse
Ambulatory Services
McGill University Health Centre
Montreal, Quebec
ELIZABETH BORYCKI, RN, HBScN, MN, GNC (c)
Clinical Informatics Specialist
Informatics
Mount Sinai Hospital
Toronto, Ontario
2002
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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of
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CONTRIBUTORS
NICHOLAS ANTHONISEN, MD, PhD
Professor of Medicine
University of Manitoba
Winnipeg, Manitoba
BARBARA BARNETT, BA, BMin
Canon, Coordinator of Spiritual Care
Deer Lodge Centre
Winnipeg, Manitoba
DANIELLE BEAUCAGE, RN, BScN
Clinical Instructor
Department of Nursing
McGill University Health Centre
Montreal, Quebec
ALAIN BEAUPRE, MD, FRCPC
Professor of Medicine
University of Montreal
Montreal, Quebec
ELIZABETH BORYCKI, RN, HBScN, MN, GNC (c)
Clinical Informatics Specialist
Department of Informatics
Mount Sinai Hospital
Toronto, Ontario
MARTIN BOUL, BPharm, MSc
Clinical Assistant Professor
Faculty of Pharmacy
Laval University
Quebec City, Quebec
JEAN BOURBEAU, MD, MSc, FRCPC
Assistant Professor of Medicine and Epidemiology
McGill University
Montreal, Quebec
SHIRLEY BRYAN, MKin
Research Kinesiologist
Department of Medicine
University of Calgary
Calgary, Alberta
ANNE CATHCART, MSW, RSW
Social Worker
Respiratory Program
Riverview Health Centre
Winnipeg, Manitoba
DAWN CHAITRAM, BSW
Social Worker
Department of Social Work
Deer Lodge Centre
Winnipeg, Manitoba
JOSE DAGENAIS, RN, MSc
Clinical Nurse Specialist
Department of Nursing
Maisonneuve-Rosemont Hospital
Montreal, Quebec
TANYA DUTTON, BScPT, MscA
Clinical Manager of Rehabilitation Services
Physiotherapy and Occupational Therapy Department
Queen Elizabeth II Health Science Centre
Halifax, Nova Scotia
GORDON FORD, MD, FRCPC, FACP, FCCP
Professor of Medicine
University of Calgary
Calgary, Alberta
ANDR GERVAIS, MD, FRCPC
Assistant Professor of Medicine
University of Montreal
Montreal, Quebec
ROGER S. GOLDSTEIN, MD, FRCP (C)
Professor of Medicine
University of Toronto
Toronto, Ontario
CATHERINE GRAY-DONALD, PhD
Associate Professor of Dietitics and Human Nutrition
McGill University
Montreal, Quebec
vi Contributors
ANN HATZOGLOU, Pht, BSc
Physiotherapist
Physiotherapy and Occupational Therapy
Montreal Chest Institute/McGill University Health Centre
Montreal, Quebec
DOUGLAS HELMERSEN, MD, FRCPC
Respirologist
Department of Medicine
University of Calgary
Calgary, Alberta
PAUL HERNANDEZ, MDCM, FRCPC
Assistant Professor of Medicine
Dalhousie University
Halifax, Nova Scotia
EARL S. HERSHFIELD, BSc, MD, FRCPC
Professor of Medicine
University of Manitoba
Winnipeg, Manitoba
ANGELA JONE, BN, RN, CAE
Clinical Trial Coordinator
Department of Medicine
University of Calgary
Calgary, Alberta
MARCEL JULIEN, MD
Associate Professor of Medicine
University of Montreal
Montreal, Quebec
JOHN KAYSER, RN, BSc
Instructor
Department of Nursing
McGill University
Montreal, Quebec
R. JOHN KIMOFF, MD, FRCP (C)
Associate Professor of Medicine
McGill University
Montreal, Quebec
YVES LACASSE, MD, MSc, FRCP (C)
Assistant Professor of Medicine
Laval University
Quebec City, Quebec
JUDY LAMB, OT, MA, BSc
Guest Lecturer
Department of Occupational Therapy
McGill University
Montreal, Quebec
MARLNE LEMIEUX, BSc, RD
Clinical Dietitian
Department of Clinical Nutrition
McGill University Health Centre
Montreal, Quebec
CINDE LITTLE, RRT, CAE
Clinical Trial Coordinator
Department of Medicine
University of Calgary
Calgary, Alberta
BRENDA LOVERIDGE, BPT, PhD
Professor of Medical Rehabilitation
University of Manitoba
Winnipeg, Manitoba
JOSIAH LOWRY, MD, CCFP, FCFP
Assistant Professor of Community and Family Medicine
University of Toronto
Toronto, Ontario
FRANOIS MALTAIS, MD
Assistant Professor of Medicine
Laval University
Montreal, Quebec
DARCY MARCINIUK, MD, FRCP (C)
Professor of Medicine
University of Saskatchewan
Saskatoon, Saskatchewan
SUNITA MATHUR, BSc (PT), MSc
Coordinator
Cardiopulmonary program
Atlantic Health and Wellness Institute
Halifax, Nova Scotia
MAUREEN MCGUIRE, BSc, (PT)
Adjunct Staff
Health Sciences Faculty
Queens University
Kingston, Ontario
ANDREW MCIVOR, MD, MSc, FRCP (C), FRCP (E)
Associate Professor of Medicine
Dalhousie University
Halifax, Nova Scotia
DENISE MELANSON, BSW
Social Worker
Social Services
Montreal Chest Institute/McGill University Health Centre
Montreal, Quebec
DIANE NAULT, RN, MScN
Head Nurse
Ambulatory Services
Montreal Chest Institute/McGill University Health Centre
Montreal, Quebec
SUZANNE NESBITT, RRT
Respiratory Therapist
Respiratory and Anesthesia Technology
McGill University Health Centre
Montreal, Quebec
Contributors vii
DENIS E. ODONNELL, MD, FRCP (I), FRCP (C)
Professor of Medicine
Queens University
Kingston, Ontario
GISELE PEREIRA, BPT
Senior Instructor
Department of Medical Rehabilitation
University of Manitoba
Winnipeg, Manitoba
VITALIE PERREAULT, RN, MSc
Nurse
Ambulatory Services
Montreal Chest Institute/McGill University Health Centre
Montreal, Quebec
GINETTE POULIN, MSC, RN
Clinical Nurse
Heart Failure Clinic
Institute of Cardiology Montreal
Montreal, Quebec
KATHY RICHES, RN, BScN
Nurse Clinician
Ambulatory Services
Royal Victoria Hospital/McGill University Health Centre
Montreal, Quebec
MICHEL ROULEAU, MD
Clinical Professor of Medicine
Laval University
Quebec City, Quebec
LOUIS ROUSSEAU, MD, RRCP (C)
Liaison Psychiatrist
Department of Psychiatry
Laval University
Quebec City, Quebec
MARY ANN SIOK, RN, BScN, MScA
Nurse Clinician
Ambulatory Services
Montreal Chest Institute/McGill University Health Centre
Montreal, Quebec
JUDITH SOICHER, BSc (PT), MSc
Doctoral Candidate
Epidemiology and Biostatistics
McGill University
Montreal, Quebec
DAVID STUBBING, MD, BS, FRCPC
Associate Professor of Medicine
McMaster University
Hamilton, Ontario
MICHLE TREMBLAY, MD
Team Coordinator
Montreal Regional Public Health Department
Montreal, Quebec
RENY VAUGHAN, RRCP, RRT
Clinical Coordinator/COPD Educator/Faciltator
Department of Respiratory Therapy
The Michener Institute for Applied Health Sciences
Toronto, Ontario
PETER WARREN, MB, MA, FRCPC
Professor of Medicine
University of Manitoba
Winnipeg, Manitoba
KATHERINE WEBB, MSc
Research Associate
Department of Medicine
Queens University
Kingston, Ontario
PETER J. WIJKSTRA, MD, PhD
Chest Physician
Department of Pulmonary Diseases
University Hospital of Groningen
Groningen, Netherlands
T
he idea for this book, Comprehensive Management of Chronic Obstructive Pulmonary Disease (COPD),
started a few years ago when I was leading a multicenter randomized clinical trial assessing the
effectiveness of a newly developed education and self-management tool, Living well with COPD

,
for patients with COPD and their families. It became clear from this study that self-care and medical care are
enhanced by effective collaboration. However, certain conditions have to be in place if we want to achieve
effective collaborative management. For instance, it is essential that patients and care providers have shared
goals, a sustained working relationship, mutual understanding of roles, and, furthermore, skills for carrying
out their roles.
While taking care of our patients with COPD, we should keep in mind this statement of the World Health
Organization: If you treat your patient, you have helped him for today. If you teach him, you have helped
him for a whole lifetime. This is essentially the philosophy of this book.
This book was written to help physicians and the allied health care professionals improve their skills in
managing patients with COPD. As physicians or the allied health care professionals, we also have to learn to
be facilitators and educators. We must recognize that our patients, who are often elderly, can be complex, with
multiple medical and psychosocial problems affecting the way in which they adapt to their COPD. Success
in managing these patients depends on the ability of allied health care professionals to create a culture of
cooperation among all of the members of the health care team. Furthermore, we have to facilitate the shift
from reactive, acute care to planned care, the goal of which is COPD self-management and disease control,
for patients to be at their maximum capacity in terms of physical, mental, and social functioning.
This book goes beyond patients lung function management, beyond pharmacologic intervention, and
beyond standard care. One of the unique features of this book is that each chapter has been written by a
multidisciplinary team composed of experts and peoples with rst-hand experience involved in providing
and coordinating patient care. Another feature of the book is the way in which chapters are organized. Each
chapter includes the following divisions: objectives and what physicians and the allied health care professionals
can expect to learn, introduction, chapter main content, when to refer, summary, case study, key points,
references, and suggested readings.
The book is addressed to a large audience: respirologists, physicians, and allied health care professionals
who care for patients with COPD. It is not encyclopedic but comprehensive. It integrates knowledge into
daily practice, giving health care professionals the information necessary to understand and modify their own
activities at a detailed, operational level. The book can be used as a reference or for teaching students, physicians,
or allied health care professionals.
I hope you nd this book useful. I sincerely believe that implementing the management strategies outlined
in this book will improve the care and the quality of life of our patients and optimize health service use. I also
hope that this book will provide a framework for future research and innovation to improve COPD care.
Jean Bourbeau
March, 2002
PREFACE
I
t is a pleasure to introduce a new text, Comprehensive Management of Chronic Obstructive Pulmonary
Disease (COPD). The topic is important because COPD is a leading cause of mortality in the Western
world; furthermore, it is an even more important cause of morbidity, whether or not the latter is calcu-
lated in terms of medical costs, lost productivity, or poor life quality. Chronic obstructive pulmonary disease
is a catchall term that describes the clinical manifestations of several abnormalities of the lung, including
chronic bronchitis (cough and sputum), small airways obstruction, and pulmonary emphysema. All three of
these abnormalities are associated with tobacco use; COPD develops over decades, during which time the
disease is often without symptoms severe enough to cause the smoker to seek help. In the vast majority of
cases, medical attention is sought only after major, irreversible damage has occurred. Patients with established
COPD endure years of gradually progressive shortness of breath with a progressive worsening of exercise
capacity and life quality. Their course is often punctuated by exacerbations of their symptoms necessitating
medical intervention that can vary all the way from added medication to admission to intensive care units.
Recognition of COPD as a major health problem rst occurred about 50 years ago. In the intervening time,
a great deal has been learned about its cause and its course, and an armamentarium of management techniques
has been developed. It is my belief that these techniques have substantially increased the life expectancy of
the average patient. The fact that COPD is caused by smoking has been established beyond question, and
one can hope that as smoking decreases, so will the COPD problem. However, even in the most enlightened
societies, smoking remains prevalent, and COPD is often a disease of ex-smokers who quit too late to avoid
lung damage. These factors ensure that the COPD problem will not disappear soon.
People with COPD have the disease 24 hours a day, 7 days a week for many years. It has only recently been
recognized that a team best carries out the medical management of patients with this kind of afiction and that
the teams most important member is the patient himself/herself. Although physicians are necessarily part of
the team, they are not necessarily the primary contact between the patient and the health care system. Nurses,
pharmacists, respiratory therapists, nutritionists, social workers, and physical and occupational therapists all have
key roles in COPD care that is truly comprehensive.
This book is aimed at the team caring for COPD patients. It combines features of the medical text
symptoms, signs, drugs, and dosageswith practical details concerning smoking cessation, inhalation therapy,
and rehabilitation through exercise. Topics such as psychosocial, spiritual, and sexual function are covered,
and patient involvement in the care process is emphasized. I believe that these features are the most important
aspect of this book, making it unique and justifying the adjective Comprehensive. The authorship is not
only multiple but multidisciplinary, with contributions from representatives of all of the team members
enumerated above. All individuals concerned in the care of patients with COPD should nd this book useful.
It is, in other words, more than the usual medical text.
Another unique feature of this book is its Canadian content. Although many of its authors were born
elsewhere, they all currently work in Canada. Obviously, many non-Canadians are as well qualied to write
on COPD as the present authors. However, there are several factors that favor the high level of Canadian
content. First, it is fair to say that Canadians have contributed disproportionately to the accumulation of
knowledge about COPD over the past 50 years. Second, the Canadian health care system is well suited to the
team approach to care. Third and most important, Canada is a small country with a relatively small and
congenial pulmonary community, facilitating the assembly of a multiauthor text. That is not to say that I
believe that putting this book together was easy; it most assuredly was not, and I congratulate the editors and
the authors on a job done very well indeed.
Nicholas Anthonisen, Respirologist
FOREWORD
T
he need to seek medical help has always been faced with anxiety. Inevitably, it starts with a state of
vulnerability, whereby the physical environment of the hospital, clinic, and, most of all, the emer-
gency ward, are quite intimidating. Additionally, the nature of the illness itself can be a source of pain
or fear. These stresses are all added concern for the patient with chronic obstructive pulmonary disease
(COPD) who is already currently faced with the obvious state of turmoil that the medical system has been
in for several years now.
Yet somehow, through their medical innovation and against all apparent odds, a number of practitioners
have succeeded in breaking through strings of nancial cutbacks, armchaired reorganizations, and the
institutionalization of mazes of bureaucratic restraints. This new text, Comprehensive Management of Chronic
Obstructive Pulmonary Disease, is both a convincing example of that success and a tribute to the lasting values
of the qualitative practice of medicine for chronic disease.
The starting point of their collaborative effort lies in the commitment to the objective of placing the patient
at the center of the practice. This value dominates the entire work and transcends each and all of its parts.
Because this objective surpasses the reach of any one individual, it has led its authors to seek contributions from
a widened colleague base; in this case, they have gone beyond the traditional borders of their eld and have
included the patient through an innovative perspective. Here the patient is seen as more than the object of his/her
practice; he/she is perceived as a collaborator and as an active member in the application of care itself.
The entire book attests to that perspective of the patient as a colleague; in particular, there are chapters on
controlling breathlessness and cough, energy conservation and fatigue, exercise training in patients with
COPD, and patient education. The underlying strategy of enabling the patient to become as autonomous as
possible in managing his or her own medical situation is a risky step to take at a time when resources are scarce.
In addition to the highly pertinent scientic information that is being shared here, all of the sound principles
of management seem to have been brought to the forefront in conceiving this project: interdisciplinary
perspective, team work, and methodology for imparting medical and pharmaceutical knowledge to patients,
as well as new skills to help him/her retain or regain higher states of physical tness and emotional and
psychological health.
Because the patient is a natural ally, the inclusion of the patient as a member of the medical team itself
in such an innovative fashion is probably the most promising element of this project. This book fosters a
win-win strategy for which the practice of medicine is highly qualitative and the increased autonomy of the
patient helps in containing the overall cost of the system, and whereby the patients condition is improved to
ultimately attain a higher quality of life.
Henri Tremblay, Patient
FOREWORD
I
n preparing this book, I have been fortunate to have the assistance of two outstanding co-editors, Diane
Nault and Elizabeth Borycki. I wish to thank them for their critical reviews and for their many valuable
suggestions. I have also been very fortunate to have the collaboration of respirologists, both colleagues and
friends, as well as the allied health care professionals highly skilled in the management of chronic obstructive
pulmonary disease (COPD) across Canada. Without their signicant contributions, it would have been
impossible to develop a book with such great content and comprehensive value. I also wish to thank all of
my patients with COPD, who really inspired me to undertake this project and gave me the courage and
determination to make it come true.
I wish to thank Dr. Nicholas Anthonisen and Mr. Henri Tremblay, a patient with COPD, who each wrote
a foreword to the book. I would also like to thank the many external reviewers who contributed to the com-
pletion of the different chapters, namely, Dr. M.R. Becklake (Chapter 3), Dr. Frederick Bass (Chapter 4),
Vitalie Perreault and William C. Boyle (Chapter 6), Dr. Mayer Balter (Chapter 8), Mme Hlne Boutin and
Mme Louise Hagan (Chapter 17), and Dr. Francois Maltais (Chapter 13).
As I look back, I realize that I have been blessed to work with an outstanding team without whom this book
could not have been completed. I wish to thank Rame A. Taha, who has reviewed all of the medical
references; Vincent Mecca from Mecca Design, who has used his superb skills in computer graphics to rene
and nalize many of the illustrations; and, nally, the whole team from the Department of Neurophotography,
McGill University Health Centre. My deepest thanks are expressed to Ms. Erica Taylor, who has worked more
than a year doing the typing, editing, and seemingly endless revisions of the book, all of which she has done with
great skill, dedication, and care. I would also like to thank Ms. Louise Auclair and Ms. Danielle Bastien for their
secretarial assistance.
My deep appreciation goes to AstraZeneca, Bayer, Boehringer Ingelheim, and GlaxoSmithKline for their
unrestricted educational grant. Their generosity should be duly noted, especially since this books main focus
is not about drugs and they were not involved in any of the steps leading to publication.
I gratefully acknowledge the support of the respiratory network of the Fonds de la recherche en sant du
Qubec (FRSQ). I am especially thankful to the FRSQ and Boehringer Ingelheim Canada, who support, in
partnership, the development and the validation of a self-management program, Living well with COPD

,
from which many pictures have been adapted. This book was written while I was supported by a personal
research scholarship from the FRSQ.
Finally, to my wife, parents, and children, I thank you for your constant love, inspiration, encouragement,
enthusiasm, and support as I worked on the book. I have learned much from my parents about passion, hard
work, and perseverance. They have given me more than can be expressed in words with regard to the
completion of this book. The love and support of my wife and children were instrumental in making this book
a reality. They have constantly encouraged me even when this involved personal sacrice on their part. I am
truly fortunate and grateful beyond words.
Jean Bourbeau
ACKNOWLEDGMENTS
1 Optimizing Medical Care Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Jean Bourbeau, Mary Ann Siok, Diane Nault, and Elizabeth Borycki
2 Assessment of COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Andrew McIvor, Josiah Lowry, Jean Bourbeau, and Elizabeth Borycki
3 Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Douglas Helmersen, Gordon Ford, Shirley Bryan, Angela Jone, and Cinde Little
4 Managing Tobacco Use and Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Andre Gervais, Michle Tremblay, and John Kayser
5 Pharmacologic Management of Stable COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Nicholas Anthonisen and Martin Boule
6 Using Inhalation Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Danielle Beaucage and Suzanne Nesbitt
7 LongTerm Oxygen Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
David Stubbing, Alain Beaupre, and Reny Vaughan
8 Managing Acute Exacerbation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Jean Bourbeau, Michel Rouleau, Marcel Julien, Diane Nault, and Elizabeth Borycki
9 Controlling Breathlessness and Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Denis E. ODonnell, Katherine Webb, and Maureen McGuire
10 Energy Conservation and Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Judy Lamb, Elizabeth Borycki, and Darcy Marciniuk
11 Exercise Training in Patients with COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Franois Maltais, Earl S. Hersheld, David Stubbing, Peter J. Wijkstra, Ann Hatzoglou,
Brenda Loveridge, Gisele Pereira, and Roger S. Goldstein
12 Psychosocial Considerations in COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Diane Nault, Mary Ann Siok, Elizabeth Borycki, Denise Melanson, Louis Rousseau, and Yves Lacasse
13 Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Marlene Lemieux, Katherine Gray-Donald, and Jean Bourbeau
14 Sleep and COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
R. John Kimoff and Kathy Riches
15 Sexuality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Ginette Poulin and Diane Nault
16 Leisure, Recreational Activities and Travel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Paul Hernandez and Sunita Mathur
17 Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Diane Nault, Jose Dagenais, Vitalie Perreault, and Elizabeth Borycki
18 The Final Illness: Palliative Care in Terminal COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Peter Warren, Barbara Barnett, Anne Cathcart, and Dawn Chaitram
19 Program Evaluation and Outcome Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Judith Soicher, Tanya Dutton, and Jean Bourbeau
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
CONTENTS