浙江大学 文本 Management of stable COPD_生理学

Patient Education and Counseling ELSEVIER PucIt Edason uNl Courxelitg 52 (2004)225-229 wwwelsevierooculocate'pateduoou Management of stable COPD Paul van der Valk Evelyn Monninkhof',Job van der Palen" Gerhard Zielhuis Cees van Herwaarden Deparnew of PNoonary Medicive.MesA Specm 7wene.PO.Bo J069.7500 KA Echerte.The Nertertdr Drpunne af Epegr an Bu Satauer.Inmeray Mnitcaf Cecne Nyerge Numnger.Ti Neherldh Epormuenr y /uory Mediciue.Uurrarsiry Mvdcal Cnme Nyugen Mifuegsn.The Matarldr Roo:iol 28 May 2002.trrrived in irvinal fom 15 Sepanber 2002,aooepled 22 Deeemls 2002 Ahsiract Chranic pbstructive pulmonary disease (COPD]is a systemic disease with major impact worldwide.In the treatmert of COPD a holistic approoch shoud be taken.In oder to reach this,an individual treutment plan should be made which includesa least elemensofsmking cessation,optimisation of'pulntonary status hy pharmacothempy and exereise ebedded in n new lifestyle Furthentore,more research on nutntioral and memabolic imervention strategies for COPD panents is needed With the mmilabily of'all these treatment optons,a nihilistic altide lonserd the patint with COPD is no lnger justificd. 2003 Elsevicr Scikcnoe Ircland Lid.All righis rescrwd. .COPD.:Heth-rclalol qulity of lif:,of lang function,,Self-urensl of exoe butioro; Smoknz cessation 1.Introduction cemic corsequences 7 In particular,there is accumulating evidence of skeletal muscle impairment contrbuting to ex- Chronic obstructive pulmonary disease (COPD)is a dis- ereise anoleranoe.a frequent complaint in COPD 81.Also. case characterised by the propresswve development of airtlow up to 35%of clinically stable patients with COPD experi- limitation that is not fully reversible.COPD is caused by ence involuntary weipht loss as the seventy ot the disease nn abnomal intlammatory response of the lurgs to noxious progresses 19.which is not only related to n disturbed en- particles or gases [in particular cigarette smoking COPD ergy balance but also to altered metabolism 7 Theretore.a constitutes a major publie health burden worldwide [1 holistie appronch shoul be taken in the trentmer of'COPD. The World Ifealth Organisation [2]estimates COPD to be As patients beoome symptomatie from COPD.the most 止e world's五fhme城ommon diseas and fourth lesding common complaints arre hreathlessness with exercise intol- cause of death.Both prevalence and mortality are expected erance.cough with or without sputum production and fa to increase in the coming decades The economic im tigue.Dyspnea leads to inactivity.which leads to physical pact of COPD is huge,with an annal cost in the United decondibioning,and a victous circle ensues with serious con- States alooe of more than 23 billion dollars.due to medical sequences such as depressoon [10] expenditures and to indirect costs of morbidity and prema- The clinical course of COPD is one of gradual progres- ture mortaluty among COPD patients 4].There is no doubt sive pulmonary impairment which may eventually lead to that the main risk factor for developing COPD is cigarette respiratory falure.An acute exacerbation of COPD is de- smoking Inhaled smoke acts in conjunction with underly. fined as a sustained worsening of a patient's condition,from ing host susceptihility and erwironmental fictors and results stahle stare and hevond rormal day-to-day varintions that in COPD in 10-20%of chronic smokers [5,6].Apart from is acute in anset and recessitates a change in regular medi- the ireversihle respiratory impairment,COPD has also sys- cation[li】 The frequency of these exacerbations increases with the severity of COPD [5].Exacerbatians have a major impact The is sponsored by Te Netherds Asthma Foud on health-related quality of life [12].Early identification on,Amicon Hodl山Cae lpuarce Compury,Bocl在ngr lngdlcin u- GbroeSnithKline RV of patients at particular risk for exacerbations may redie ·0 amesponding ather.Td:+31-5-472610:6a+31-5343g127 morbidity ard moctality from complications assuciated with GwW adeesr:valkpopa iknngnl (P van der Valk COPD exncerbations. ÷r1i010167译-99105XH5-3

Patient Education and Counseling 52 (2004) 225–229 Management of stable COPD
Paul van der Valk a,∗, Evelyn Monninkhof a, Job van der Palen a, Gerhard Zielhuis b, Cees van Herwaarden c a Department of Pulmonary Medicine, Medisch Spectrum Twente, P.O. Box 50000, 7500 KA Enschede, The Netherlands b Department of Epidemiology and Bio Statistics, University Medical Centre Nijmegen, Nijmegen, The Netherlands c Department of Pulmonary Medicine, University Medical Centre Nijmegen, Nijmegen, The Netherlands Received 28 May 2002; received in revised form 15 September 2002; accepted 22 December 2002 Abstract Chronic obstructive pulmonary disease (COPD) is a systemic disease with major impact worldwide. In the treatment of COPD a holistic approach should be taken. In order to reach this, an individual treatment plan should be made which includes at least elements of smoking cessation, optimisation of pulmonary status by pharmacotherapy and exercise embedded in a new lifestyle. Furthermore, more research on nutritional and metabolic intervention strategies for COPD patients is needed. With the availability of all these treatment options, a nihilistic attitude toward the patient with COPD is no longer justified. © 2003 Elsevier Science Ireland Ltd. All rights reserved. Keywords: COPD; Treatment; Exacerbations; Health-related quality of life; Optimisation of lung function; Self-management; Self-treatment of exacerbations; Smoking cessation 1. Introduction Chronic obstructive pulmonary disease (COPD) is a dis￾ease characterised by the progressive development of airflow limitation that is not fully reversible. COPD is caused by an abnormal inflammatory response of the lungs to noxious particles or gases [1] in particular cigarette smoking. COPD constitutes a major public health burden worldwide [1]. The World Health Organisation [2] estimates COPD to be the world’s fifth most common disease and fourth leading cause of death. Both prevalence and mortality are expected to increase in the coming decades [3]. The economic im￾pact of COPD is huge, with an annual cost in the United States alone of more than 23 billion dollars, due to medical expenditures and to indirect costs of morbidity and prema￾ture mortality among COPD patients [4]. There is no doubt that the main risk factor for developing COPD is cigarette smoking. Inhaled smoke acts in conjunction with underly￾ing host susceptibility and environmental factors and results in COPD in 10–20% of chronic smokers [5,6]. Apart from the irreversible respiratory impairment, COPD has also sys-
The COPE study is sponsored by The Netherlands Asthma Founda￾tion, Amicon Health Care Insurance Company, Boehringer Ingelheim and GlaxoSmithKline BV. ∗ Corresponding author. Tel.: +31-53-4872610; fax: +31-53-4308127. E-mail address: valkpapa@knmg.nl (P. van der Valk). temic consequences [7]. In particular, there is accumulating evidence of skeletal muscle impairment contributing to ex￾ercise intolerance, a frequent complaint in COPD [8]. Also, up to 35% of clinically stable patients with COPD experi￾ence involuntary weight loss as the severity of the disease progresses [9], which is not only related to a disturbed en￾ergy balance but also to altered metabolism [7]. Therefore, a holistic approach should be taken in the treatment of COPD. As patients become symptomatic from COPD, the most common complaints are breathlessness with exercise intol￾erance, cough with or without sputum production and fa￾tigue. Dyspnea leads to inactivity, which leads to physical deconditioning, and a vicious circle ensues with serious con￾sequences such as depression [10]. The clinical course of COPD is one of gradual progres￾sive pulmonary impairment, which may eventually lead to respiratory failure. An acute exacerbation of COPD is de- fined as a sustained worsening of a patient’s condition, from stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medi￾cation [11]. The frequency of these exacerbations increases with the severity of COPD [5]. Exacerbations have a major impact on health-related quality of life [12]. Early identification of patients at particular risk for exacerbations may reduce morbidity and mortality from complications associated with COPD exacerbations. 0738-3991/$ – see front matter © 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0738-3991(03)00095-8

226 尺nt dky Fi量d星./atenr Fdaion avd Co5ew32422-229 The goals of eflectnve COPD management [1]are to with oral NAC may reduce the risk of exaoerbabons and prevent disease progression.relieve sympoms,improve improve sympooms in putients with COPD [28.291. exercise tolerance.improve health statu3.prevent and treal Finally.patients with severe COPD and hypovemia may complications,prevert and treat exacerbations ard reduce reed long-term oxygen therapy. mortalily.The mangement strategy is based on an indi- Long-term admimistration of oxygen 1o patirts with vidualised assessment of disease severty and resporse to severe COPD and hypoxema pulmonary hypertension, various therapies [1].In order to reach this goul an indi- congestive heart failure or polycythemia has been shown to vidual treatment plan should he made with the following increase survival [30]. impartant elements:smoking cessation,optimistion of pulmunary status by pharmacotherpy,physical activity, nutrition,and self management. 4.Physical activity Exercise intolerance is a characteristic and disturbing 2.Smokding cessution manifestation of COPD.The pathephysiological basis of exercise intolerance is often multifactorial.Dyspnea leads Smoking eessation 13.14]is the mainstay of the man- to inactivity.which leads to physical deconditioning.and agement of COPD beeause it reduees the declire in pul- a viseious circle ensues with devastating resporses 10]. monary function,improves the prognosis [13.15]and en- Exercise tmining.undertnken alone or in the contet of pul- hnnces quality oflife [16]As COPD pntients penerally hmve monary rehahilitation,can improve the exereise intolerance a lone smoking history.they are considered strongly addicted of patients with COPD).Exercise trnining is considered to to smoking.both physically and psychologically A strong be n mandatory part of pulmorary rehabilitation A pul- nicotine addiction is likely to require stnctured counselling monary rehabilitation programme is a multidisciplinary to achieve cessntion success [17] programme of enre for COPD patients that is individu- Various smcking cessation programs including phamsco- ally tailored snd designed to optimise physical and social logical and'or behavioural elemerts hae been applied,but performance and autonomy [311.Several simple designed, most of them are urstructured and not espectally developed primarily bome based or near bome programmes of exercise for COPD patients [13,18.191.There is an urgent need to training also achieved improvement in exereise tolerance develop a smoking cesssion programme targeted at COPD and health-related quality of life (HRQoL)[32-35].Pul- patients,because there is evdence that thes group is part- monary rehabililaton as well s more simple primarily ularly heavily addicted. bome based oe near home programmes of exercise traiming have shown to produce short-term beneticial ellects on exer- cise tolerance and quality of life i COPD-patnts [36-41]. 3.Optimisation of pulmonary status by Maintenance of these initial improvements,however,is pharmacotherapy disappeinting as many of the initial improvements tend to disappear [32,33,37]in most studies.There is a need far Noce of the existing medicatinnes for COPD has been developing programs which focus on the implementation shown to modify the long-term decline in lungg furxtion of exercise in the nurmal daily pattern,in order to maintain Therefure,pharmacotherapy is only used to decrease symp long-term improvement in exercise capacicy. toms and complications [1].Standards fur phammacologi cal treatment of COPD recommend a stepwise approuch guided by the severity of the disease 1201 Bronchodilator 5.Nutrition therspy 14]is the first step and remains [13]the mainstay of the maregement of COPD This may significanly re- Up to 33%of elinically stable 42,43]potients with mod- duce symptoms of dyspnen by reducing hyperintintion.and erate to severe COPD experienee imvoluntary weight loss may also improve evercise tolernnce [21].A second step their condition progresses 9]Those who do lose weighe is a tnial with of inhaled corticosteroids (ICS)since it is have more dyspnea nnd less exercise capacity than those not clear whether or not ICS are heneficinl in all COPD who do noc,even when their underlying levels of pulmonary patients (22 23] impairmert are similar Morerwer,hody weight has an inde- Several studies have indicaed beneficial effects on res pendert effect on survival in COPD [44] piratory symptoms [24].decressed frequency [25]or sever- The coessequences of weight loss in COPD patients par- ity 26]of exscerbations and bealth-related quality of life ticularly relale to the decrease in muscle mass and can be (HRQoL)[25].but ICS have shown to be ineffective in ar- measured indirectly in clinically stable patients by assess- resting long-term decline in lung function [21.Safety of memt of fat-free mass (FFM)[45].In COPD.tissue depletion lorgg-term,high-dose ICS has not been well established 271. s indicalted by a body mass index (BMI)below 22 kg'm2 An alternative step is a trial trestment wiht N-acetyleysteine or a fat-free mass index below 16 m males and 15 in fe- (NAC)for patnts with recurrent exacerbations.Treatment males.Nutritional depletion cortributes to resparalory and

226 P. van der Valk et al. / Patient Education and Counseling 52 (2004) 225–229 The goals of effective COPD management [1] are to prevent disease progression, relieve symptoms, improve exercise tolerance, improve health status, prevent and treat complications, prevent and treat exacerbations and reduce mortality. The management strategy is based on an indi￾vidualised assessment of disease severity and response to various therapies [1]. In order to reach this goal an indi￾vidual treatment plan should be made with the following important elements: smoking cessation, optimisation of pulmonary status by pharmacotherapy, physical activity, nutrition, and self-management. 2. Smoking cessation Smoking cessation [13,14] is the mainstay of the man￾agement of COPD because it reduces the decline in pul￾monary function, improves the prognosis [13,15] and en￾hances quality of life [16]. As COPD patients generally have a long smoking history, they are considered strongly addicted to smoking, both physically and psychologically. A strong nicotine addiction is likely to require structured counselling to achieve cessation success [17]. Various smoking cessation programs including pharmaco￾logical and/or behavioural elements have been applied, but most of them are unstructured and not especially developed for COPD patients [13,18,19]. There is an urgent need to develop a smoking cessation programme targeted at COPD patients, because there is evidence that this group is partic￾ularly heavily addicted. 3. Optimisation of pulmonary status by pharmacotherapy None of the existing medications for COPD has been shown to modify the long-term decline in lung function. Therefore, pharmacotherapy is only used to decrease symp￾toms and complications [1]. Standards for pharmacologi￾cal treatment of COPD recommend a stepwise approach guided by the severity of the disease [20]. Bronchodilator therapy [14] is the first step and remains [13] the mainstay of the management of COPD. This may significantly re￾duce symptoms of dyspnea by reducing hyperinflation, and may also improve exercise tolerance [21]. A second step is a trial with of inhaled corticosteroids (ICS) since it is not clear whether or not ICS are beneficial in all COPD patients [22,23]. Several studies have indicated beneficial effects on res￾piratory symptoms [24], decreased frequency [25] or sever￾ity [26] of exacerbations and health-related quality of life (HRQoL) [25], but ICS have shown to be ineffective in ar￾resting long-term decline in lung function [21]. Safety of long-term, high-dose ICS has not been well established [27]. An alternative step is a trial treatment wiht N-acetylcysteine (NAC) for patients with recurrent exacerbations. Treatment with oral NAC may reduce the risk of exacerbations and improve symptoms in patients with COPD [28,29]. Finally, patients with severe COPD and hypoxemia may need long-term oxygen therapy. Long-term administration of oxygen to patients with severe COPD and hypoxemia, pulmonary hypertension, congestive heart failure or polycythemia has been shown to increase survival [30]. 4. Physical activity Exercise intolerance is a characteristic and disturbing manifestation of COPD. The pathophysiological basis of exercise intolerance is often multifactorial. Dyspnea leads to inactivity, which leads to physical deconditioning, and a viscious circle ensues with devastating responses [10]. Exercise training, undertaken alone or in the context of pul￾monary rehabilitation, can improve the exercise intolerance of patients with COPD. Exercise training is considered to be a mandatory part of pulmonary rehabilitation. A pul￾monary rehabilitation programme is a multidisciplinary programme of care for COPD patients that is individu￾ally tailored and designed to optimise physical and social performance and autonomy [31]. Several simple designed, primarily home based or near home programmes of exercise training also achieved improvement in exercise tolerance and health-related quality of life (HRQoL) [32–35]. Pul￾monary rehabilitation as well as more simple primarily home based or near home programmes of exercise training have shown to produce short-term beneficial effects on exer￾cise tolerance and quality of life in COPD-patients [36–41]. Maintenance of these initial improvements, however, is disappointing as many of the initial improvements tend to disappear [32,33,37] in most studies. There is a need for developing programs which focus on the implementation of exercise in the normal daily pattern, in order to maintain long-term improvement in exercise capacity. 5. Nutrition Up to 35% of clinically stable [42,43] patients with mod￾erate to severe COPD experience involuntary weight loss as their condition progresses [9]. Those who do lose weight have more dyspnea and less exercise capacity than those who do not, even when their underlying levels of pulmonary impairment are similar. Moreover, body weight has an inde￾pendent effect on survival in COPD [44]. The consequences of weight loss in COPD patients par￾ticularly relate to the decrease in muscle mass and can be measured indirectly in clinically stable patients by assess￾ment of fat-free mass (FFM) [45]. In COPD, tissue depletion is indicated by a body mass index (BMI) below 22 kg/m2 or a fat-free mass index below 16 in males and 15 in fe￾males. Nutritional depletion contributes to respiratory and

P.rat der Falk er al/Pomenr Ediuiont anf Cowutiuny 52 (2004)125-229 227 peripheral skeletal muscle weakness and to decreased ex- 51-54].There is very little known so far,about the effec- ercise performance.independent of impaired lung finction tiveness of self-management and self-treatment of COPD Recent studies bave shown that nutritional abnormalites in A Cochrane review of published studies demonstrates in- COPD patients not cnly relate to a disturbed energy balance sulficient evidence to conclude aboul the eflectnveness of but also to altered regulation of substrate metabolism caused self-mangement programmes for COPD-patients [55].In- by changes in arabolic and catabolic sumuli [451.In a re- deed.pulmonary rehabilitation has been proven to increase cen meta-analysis[9]nutritional supplementation (2 weeks exercise tolerance and quility of life [40]in COPD patierts or more)has not been demonstrated to be successful in im- but pulmonary rehahilitation is expensive and time consum- proving arthropometric measures,lungfunction or exercise ing for both professionals and patients Self-manzgement capucity in stable COPD patients.But mamy fictors were programmes combined with a low-intersity exercise pro not optimally fulfilled in those irerventions such as dura gramme may be more easily implemented and more tion of the intervention,adsquate composition of the supple. cost-effective.New studies with sufficient size and follow-up tion,lack of an anabolic stimulus such as exercise training to are initiated to fill the knowledge gup on the effect of these noid an expansion of fat mass only and compliance with the programmes therapy.Not in all patients with COPD the negative effect of low body weight can be reversed by appropriate therapy 441.More knowledge of'the pathopenesis of weight loss 7.Conclusion and practice implication nnd muscle wasting is essental to dewclop new nutrtional nnd metnbolc intervention strntegies for COPD potients. COPD is a systemie disense with major impact world- wide.In the treatment of COPD n holistic approach should be taken In order to rench this.an individual treatment 6.Self-management olnn should be mnde which includes at lenst clements of smoking cessarion.optimisntion of pulmonnry status by Self-management of COPD is defined as effective be- phammacothempy and exercise emhedded in n new lifesryle havicr,based on sufficient knowledge about COPD and its Furthermore,more research on nutritionnl nnd metabolie provoking fctors,adequale coping behaniour,compliance intervention stnitegies for COPD patients is needed With with inhaled medication,atlention to changes in the severity the availabdity of all these treatment opticr,a nihilistic of the disease,and adequate inhalation technique.Ore of attitude towerd the patient with COPD is ro longer justified. the components of'self-management believed to be of im portance is the self-adjustmemt of the medication by the pa- ter in case of'an excacerbation.The term "self-treatmen" References is used when COPD patients are provided with guidelines to self-adjust their dose of hronchodilators or to start a [1]Paaweb RA.Bain:AS,Culvurley PM,lmki CR,Had SS.Gubal short course of oral steroids andfr antibiotics,based on 年四re33K53r0nt,ndr3 n of chror ct山etive pulne4 wy diae.NHLBWHO gobal intiaie国 symptom perception,in case of an exacerbation.The idea chroric oberartne ling dagaoe (001.D)werkdhep amrary.Ar J of self-managemen is as follows (a)to achieve effective Respir Cre Core Med 2001:163:1256-76. self-management behaviour,COPD patients are educated 2 Th Wul Heal Report 1998 Girnv Woeld Haith Ortanixun, about the nature of their disease,the medication used and 19w the infuence of extraneous factors such as smoking and reg 3]Mutay CJ,Lopez AD.Allerlive projosus of mocully u disability hy caane 199-0 giohal hitden of dicrane dudty Lareet ular exercise;(b)in addition they are trained in the correct 19734914%-04. use of'ther inhaled medkcation and symptom pereeption. (e)by usmng the attained knowledge and practising the skills dss.B山5山MD啡Naliotad HoL Lung4 Blou!laviluc they lenmed,patients should then be able to cope with the Departmem nf Health and luman Services.PiHir leth Servire. Natiorel Irstiunes of Heaith 1998. disease in daily life.to control their symptoms and to treat themselves in cmse of'an cxacerbation.(d)in this way,ex- MedJ1971:I645-w neerhmtions could be curtailed at an early stage,quaity of 间Sal5lAU,i TD,Pue PD.Gonclie tik fact3w山uic life could be inereased and health care contnets could be ohdnictive puimerory digone Fir Raspr 1 1997.10134:-41. 「kd[4647月 7Schois AM.Wouters EF.Nuerineal abnarmalitiex and spplemnet There is a global consensus,that an increase in disense- tion in ctronig obstrucuve dsease Cln Chest Med 2002:21:753-62. 8Skeleld m dyfuin in duoc ubkuclive pulorrydi specific knowledge.is not sufficient to develop successful self-management behaviour [48.491 Education should also Rospauury Sociey.Amn J Repi Cr.Cue Med 1959.159.51-40. focus on attitude.secial support and self-efficacy accord- Femeira1.Bmaks D.Lcae Y.Godddein R.Ntritioral itervrrtim ingg to behavioural principles [49.501 In asthma.sustained n《UPDa易0aIke0e1cgCe20IIg353-63. patien education and实fgee以programmes have [0]Yipen R.Whd oucunes shoud b:meouel in pries wh COPD? eg2101:11字33 proven to be successful in improving quality of life and lung (11]Rodrigaea-Roicin R Touord a defirition for CnP) function and in reducing the econcmic burden of disese erbocons.Chest 2000,117:3985-4015

P. van der Valk et al. / Patient Education and Counseling 52 (2004) 225–229 227 peripheral skeletal muscle weakness and to decreased ex￾ercise performance, independent of impaired lung function. Recent studies have shown that nutritional abnormalities in COPD patients not only relate to a disturbed energy balance but also to altered regulation of substrate metabolism caused by changes in anabolic and catabolic stimuli [45]. In a re￾cent meta-analysis [9] nutritional supplementation (2 weeks or more) has not been demonstrated to be successful in im￾proving anthropometric measures, lungfunction or exercise capacity in stable COPD patients. But many factors were not optimally fulfilled in those interventions such as dura￾tion of the intervention, adequate composition of the supple￾tion, lack of an anabolic stimulus such as exercise training to avoid an expansion of fat mass only and compliance with the therapy. Not in all patients with COPD the negative effect of low body weight can be reversed by appropriate therapy [44]. More knowledge of the pathogenesis of weight loss and muscle wasting is essential to develop new nutritional and metabolic intervention strategies for COPD patients. 6. Self-management Self-management of COPD is defined as effective be￾haviour, based on sufficient knowledge about COPD and its provoking factors, adequate coping behaviour, compliance with inhaled medication, attention to changes in the severity of the disease, and adequate inhalation technique. One of the components of self-management believed to be of im￾portance is the self-adjustment of the medication by the pa￾tient in case of an exacerbation. The term “self-treatment” is used when COPD patients are provided with guidelines to self-adjust their dose of bronchodilators or to start a short course of oral steroids and/or antibiotics, based on symptom perception, in case of an exacerbation. The idea of self-management is as follows: (a) to achieve effective self-management behaviour, COPD patients are educated about the nature of their disease, the medication used and the influence of extraneous factors such as smoking and reg￾ular exercise; (b) in addition they are trained in the correct use of their inhaled medication and symptom perception; (c) by using the attained knowledge and practising the skills they learned, patients should then be able to cope with the disease in daily life, to control their symptoms and to treat themselves in case of an exacerbation; (d) in this way, ex￾acerbations could be curtailed at an early stage, quality of life could be increased and health care contacts could be reduced [46,47]. There is a global consensus, that an increase in disease￾specific knowledge, is not sufficient to develop successful self-management behaviour [48,49]. Education should also focus on attitude, social support and self-efficacy accord￾ing to behavioural principles [49,50]. In asthma, sustained patient education and self-management programmes have proven to be successful in improving quality of life and lung function and in reducing the economic burden of disease [51–54]. There is very little known so far, about the effec￾tiveness of self-management and self-treatment of COPD. A Cochrane review of published studies demonstrates in￾sufficient evidence to conclude about the effectiveness of self-management programmes for COPD-patients [55]. In￾deed, pulmonary rehabilitation has been proven to increase exercise tolerance and quality of life [40] in COPD patients but pulmonary rehabilitation is expensive and time consum￾ing for both professionals and patients. Self-management programmes combined with a low-intensity exercise pro￾gramme may be more easily implemented and more cost-effective. New studies with sufficient size and follow-up are initiated to fill the knowledge gap on the effect of these programmes. 7. Conclusion and practice implication COPD is a systemic disease with major impact world￾wide. In the treatment of COPD a holistic approach should be taken. In order to reach this, an individual treatment plan should be made which includes at least elements of smoking cessation, optimisation of pulmonary status by pharmacotherapy and exercise embedded in a new lifestyle. Furthermore, more research on nutritional and metabolic intervention strategies for COPD patients is needed. With the availability of all these treatment options, a nihilistic attitude toward the patient with COPD is no longer justified. References [1] Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO global initiative for chronic obstructive lung disease (GOLD) workshop summary. Am J Respir Crit Care Med 2001;163:1256–76. [2] The World Health Report 1998. Geneva: World Health Organisation; 1998. [3] Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study. Lancet 1997;349:1498–504. [4] Morbidity & mortality: chartbook on cardiovascular, lung, and blood diseases. Bethesda (MD): National Heart, Lung and Blood Institute, Department of Health and Human Services, Public Health Service, National Institutes of Health; 1998. [5] Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J 1977;1:1645–8. [6] Sandford AJ, Weir TD, Pare PD. Genetic risk factors for chronic obstructive pulmonary disease. Eur Respir J 1997;10:1380–91. [7] Schols AM, Wouters EF. Nutritional abnormalities and supplementa￾tion in chronic obstructive disease. Clin Chest Med 2002;21:753–62. [8] Skeletal muscle dysfunction in chronic obstructive pulmonary dis￾ease. A Statement of the American Thoracic Society and European Respiratory Society. Am J Respir Crit Care Med 1999;159:S1–40. [9] Ferreira I, Brooks D, Lacasse Y, Goldstein R. Nutritional intervention in COPD: a systematic overview. Chest 2001;119:353–63. [10] Yusen R. What outcomes should be measured in patients with COPD? Chest 2001;119:327–8. [11] Rodriguez-Roisin R. Toward a consensus definition for COPD exac￾erbations. Chest 2000;117:398S–401S

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