COMPREHENSIVE MANAGEMENT OF

Chronic Obstructive
Pulmonary Disease

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 ANNE CATHCART, MSW, RSW

Professor of Medicine Social Worker
University of Manitoba Respiratory Program
Winnipeg, Manitoba Riverview Health Centre
Winnipeg, Manitoba
BARBARA BARNETT, BA, BMin
Canon, Coordinator of Spiritual Care DAWN CHAITRAM, BSW
Deer Lodge Centre Social Worker
Winnipeg, Manitoba Department of Social Work
Deer Lodge Centre
DANIELLE BEAUCAGE, RN, BScN
Winnipeg, Manitoba
Clinical Instructor
Department of Nursing JOSÉE DAGENAIS, RN, MSc
McGill University Health Centre Clinical Nurse Specialist
Montreal, Quebec Department of Nursing
Maisonneuve-Rosemont Hospital
ALAIN BEAUPRE, MD, FRCPC
Montreal, Quebec
Professor of Medicine
University of Montreal TANYA DUTTON, BScPT, MscA
Montreal, Quebec Clinical Manager of Rehabilitation Services
Physiotherapy and Occupational Therapy Department
ELIZABETH BORYCKI, RN, HBScN, MN, GNC (c)
Queen Elizabeth II Health Science Centre
Clinical Informatics Specialist
Halifax, Nova Scotia
Department of Informatics
Mount Sinai Hospital GORDON FORD, MD, FRCPC, FACP, FCCP
Toronto, Ontario Professor of Medicine
University of Calgary
MARTIN BOULÉ, BPharm, MSc
Calgary, Alberta
Clinical Assistant Professor
Faculty of Pharmacy ANDRÉ GERVAIS, MD, FRCPC
Laval University Assistant Professor of Medicine
Quebec City, Quebec University of Montreal
Montreal, Quebec
JEAN BOURBEAU, MD, MSc, FRCPC
Assistant Professor of Medicine and Epidemiology ROGER S. GOLDSTEIN, MD, FRCP (C)
McGill University Professor of Medicine
Montreal, Quebec University of Toronto
Toronto, Ontario
SHIRLEY BRYAN, MKin
Research Kinesiologist CATHERINE GRAY-DONALD, PhD
Department of Medicine Associate Professor of Dietitics and Human Nutrition
University of Calgary McGill University
Calgary, Alberta Montreal, Quebec
vi Contributors

ANN HATZOGLOU, Pht, BSc CINDE LITTLE, RRT, CAE

Physiotherapist Clinical Trial Coordinator
Physiotherapy and Occupational Therapy Department of Medicine
Montreal Chest Institute/McGill University Health Centre University of Calgary
Montreal, Quebec Calgary, Alberta
DOUGLAS HELMERSEN, MD, FRCPC BRENDA LOVERIDGE, BPT, PhD
Respirologist Professor of Medical Rehabilitation
Department of Medicine University of Manitoba
University of Calgary Winnipeg, Manitoba
Calgary, Alberta
JOSIAH LOWRY, MD, CCFP, FCFP
PAUL HERNANDEZ, MDCM, FRCPC Assistant Professor of Community and Family Medicine
Assistant Professor of Medicine University of Toronto
Dalhousie University Toronto, Ontario
Halifax, Nova Scotia
FRANÇOIS MALTAIS, MD
EARL S. HERSHFIELD, BSc, MD, FRCPC Assistant Professor of Medicine
Professor of Medicine Laval University
University of Manitoba Montreal, Quebec
Winnipeg, Manitoba
DARCY MARCINIUK, MD, FRCP (C)
ANGELA JONE, BN, RN, CAE Professor of Medicine
Clinical Trial Coordinator University of Saskatchewan
Department of Medicine Saskatoon, Saskatchewan
University of Calgary
SUNITA MATHUR, BSc (PT), MSc
Calgary, Alberta
Coordinator
MARCEL JULIEN, MD Cardiopulmonary program
Associate Professor of Medicine Atlantic Health and Wellness Institute
University of Montreal Halifax, Nova Scotia
Montreal, Quebec
MAUREEN MCGUIRE, BSc, (PT)
JOHN KAYSER, RN, BSc Adjunct Staff
Instructor Health Sciences Faculty
Department of Nursing Queen’s University
McGill University Kingston, Ontario
Montreal, Quebec
ANDREW MCIVOR, MD, MSc, FRCP (C), FRCP (E)
R. JOHN KIMOFF, MD, FRCP (C) Associate Professor of Medicine
Associate Professor of Medicine Dalhousie University
McGill University Halifax, Nova Scotia
Montreal, Quebec
DENISE MELANSON, BSW
YVES LACASSE, MD, MSc, FRCP (C) Social Worker
Assistant Professor of Medicine Social Services
Laval University Montreal Chest Institute/McGill University Health Centre
Quebec City, Quebec Montreal, Quebec
JUDY LAMB, OT, MA, BSc DIANE NAULT, RN, MScN
Guest Lecturer Head Nurse
Department of Occupational Therapy Ambulatory Services
McGill University Montreal Chest Institute/McGill University Health Centre
Montreal, Quebec Montreal, Quebec
MARLÈNE LEMIEUX, BSc, RD SUZANNE NESBITT, RRT
Clinical Dietitian Respiratory Therapist
Department of Clinical Nutrition Respiratory and Anesthesia Technology
McGill University Health Centre McGill University Health Centre
Montreal, Quebec Montreal, Quebec
 Contributors vii

DENIS E. O’DONNELL, MD, FRCP (I), FRCP (C) JUDITH SOICHER, BSc (PT), MSc
Professor of Medicine Doctoral Candidate
Queen’s University Epidemiology and Biostatistics
Kingston, Ontario McGill University
Montreal, Quebec
GISELE PEREIRA, BPT
Senior Instructor DAVID STUBBING, MD, BS, FRCPC
Department of Medical Rehabilitation Associate Professor of Medicine
University of Manitoba McMaster University
Winnipeg, Manitoba Hamilton, Ontario
VITALIE PERREAULT, RN, MSc MICHÈLE TREMBLAY, MD
Nurse Team Coordinator
Ambulatory Services Montreal Regional Public Health Department
Montreal Chest Institute/McGill University Health Centre Montreal, Quebec
Montreal, Quebec
RENY VAUGHAN, RRCP, RRT
GINETTE POULIN, MSC, RN Clinical Coordinator/COPD Educator/Faciltator
Clinical Nurse Department of Respiratory Therapy
Heart Failure Clinic The Michener Institute for Applied Health Sciences
Institute of Cardiology Montreal Toronto, Ontario
Montreal, Quebec
PETER WARREN, MB, MA, FRCPC
KATHY RICHES, RN, BScN Professor of Medicine
Nurse Clinician University of Manitoba
Ambulatory Services Winnipeg, Manitoba
Royal Victoria Hospital/McGill University Health Centre
KATHERINE WEBB, MSc
Montreal, Quebec
Research Associate
MICHEL ROULEAU, MD Department of Medicine
Clinical Professor of Medicine Queen’s University
Laval University Kingston, Ontario
Quebec City, Quebec
PETER J. WIJKSTRA, MD, PhD
LOUIS ROUSSEAU, MD, RRCP (C) Chest Physician
Liaison Psychiatrist Department of Pulmonary Diseases
Department of Psychiatry University Hospital of Groningen
Laval University Groningen, Netherlands
Quebec City, Quebec
MARY ANN SIOK, RN, BScN, MScA
Nurse Clinician
Ambulatory Services
Montreal Chest Institute/McGill University Health Centre
Montreal, Quebec
 PREFACE

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 first-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 find 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
 FOREWORD

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 first 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 affliction and that
the team’s 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 dosages—with 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 find 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 qualified 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 financial 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 field 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 scientific 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 fitness 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 patient’s condition is improved to
ultimately attain a higher quality of life.

Henri Tremblay, Patient

 ACKNOWLEDGMENTS

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 significant 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 Hélène 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 refine
and finalize many of the illustrations; and, finally, 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 book’s 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 santé du
Québec (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 sacrifice on their part. I am
truly fortunate and grateful beyond words.

Jean Bourbeau
 CONTENTS
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, Michèle 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 Long–Term 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. O’Donnell, 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
François Maltais, Earl S. Hershfield, 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, Josée 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