..

2553


.. 2553

AW 2.indd 1

10/18/10 5:14:52 PM

.. 2553

ISBN

:

:








.
.. 2553. -- :
, 2553
1...................................... 2........................................ 3...................................... I. .
ISBN

:
(.)
120 3 2-4


10210
. 0 2141 4100 . 0 2143 9730-1
www.nhso.go.th
1
2553 5,000
:

:

AW 2.indd 2

10/18/10 5:14:52 PM

( )

2553

AW 2.indd 3

10/18/10 5:14:53 PM







2-8


.. 2548

..
2553

AW 2.indd 4

10/18/10 5:14:54 PM

AW 2.indd 5

10/18/10 5:14:54 PM

...... 1
..2553
..................................... 2
.................................................................................................... 7
.......................................................................................... 8
............................................................................................ 8
..................................................................................... 9
.......................................................................................... 9
............................................................................................ 10
...................................................................................... 11
............................................................................... 13
........................................ 13
- ...................................................... 14
....................................................................................... 15
........................................................................ 16
stable COPD................................................................ 16
...................................................................... 18
......................................................................... 22
............................................................ 24
.................................... 25
25

.................................................................................................29
.......................................................................................30

AW 2.indd 6

10/18/10 5:14:55 PM


1 ....................................... 34
2 COPD ............ 36
3 : .............. 42
4 .................................................. 61
5 .................................................... 70
6 ........................................ 72
7 ................... 75

1 ......................17


2 ........................20

1 ..................14
2 COPD.................................................15

AW 2.indd 7

10/18/10 5:14:56 PM


.. 2553

AW 2.indd 8

10/18/10 5:15:04 PM

.. 2553

AW 2.indd 1



.. 2553

10/18/10 5:15:14 PM

(Strength of Recommendation)

.. 2553

AW 2.indd 2

++

+/-

--

10/18/10 5:15:22 PM

 (Quality of Evidence)

1.1 (systematic review)

- (randomized-controlled

clinical trials)
1.2 -

1 (a well-designed, randomized-

controlled clinical trial)

2.1

- (non-randomized, controlled, clinical

trials)
2.2 -

(well-designed, non-randomized, controlled

clinical trial)
2.3

(cohort)


(case-control analytic studies)

.. 2553

AW 2.indd 3

10/18/10 5:15:29 PM


.. 2553

AW 2.indd 4

2.4 multiple time series

.. 2480

3

3.1 (descriptive studies)

3.2 -

(fair-designed, controlled clinical trial)

4

4.1

(consensus)

4.2

(anecdotal report)

10/18/10 5:15:38 PM

.. 2553


.. 2553

AW 2.indd 5

10/18/10 5:15:46 PM

 COPD
(Chronic Obstructive Pulmonary Disease)

progressive, not fully reversible airflow limitation

.. 2553

AW 2.indd 6

10/18/10 5:15:54 PM

.. 2553

(Definition)

AW 2.indd 7



.. 2553

COPD (Chronic Obstructive
Pulmonary Disease)
progressive, not fully reversible airflow limitation

abnormal inflammatory response
(multicomponent disease)
2 (chronic
bronchitis) (pulmonary emphysema)



3 2



respiratory bronchiole

10/18/10 5:16:02 PM

 (Pathogenesis)

(pulmonary vasculature)
T-lymphocyte ( CD8) neutrophil macrophage mediator
leukotriene B4, interleukin 8 tumor necrosis factor a

2 oxidative stress
proteinase antiproteinase

(Pathology)

.. 2553

AW 2.indd 8

goblet
cell mucous gland
mucus

2


respiratory bronchiole
centrilobular emphysema

10/18/10 5:16:10 PM

 (Pathophysiology)

1. mucus
cilia


2. elastic recoil
airflow limitation air trapping

3.
hypoxemia
hypercapnia pulmonary hypertension
cor pulmonale

(Epidemiology)

AW 2.indd 9



.. 2553

5
30 1
60
7.1 3.6 2 40

3.7 7.1

10/18/10 5:16:17 PM




15
.. 2550 11.03 (
..2550)
(primary prevention)
(smoking cessation)

.. 2553

10

AW 2.indd 10

2
1.
2.
l

75.4 COPD 4
l

(biomass

fuel) (diesel

exhaust)

10/18/10 5:16:25 PM

spirometry





/



(bronchiectasis)





airflow
limitation air trapping prolonged expiratory phase,
increased chest A-P diameter, hyperresonance on percussion
diffuse wheeze

11

.. 2553

AW 2.indd 11

10/18/10 5:16:33 PM


.. 2553

12

emphysema
hyperinflation
cor pulmonale
pulmonary trunk peripheral vascular marking





Spirometry
spirometry
(stable) 1

airflow limitation FEV1/FVC
70 4
FEV1 ( 1)

residual volume (RV), total lung capacity (TLC), RV/TLC
diffusing capacity carbon monoxide (DLCO)

AW 2.indd 12

10/18/10 5:16:41 PM

AW 2.indd 13

13

.. 2553

(exacerbation)
spirometry ( 1)
FEV1 spirometry







BODE index ( 7)

spirometry

10/18/10 5:16:49 PM

 1

4 : Very Severe


3 : Severe


2 : Moderate





1 : Mild
exacerbation

exacerbation

exacerbation FEV < 30 %

1

exacerbation



FEV < 50 %
FEV1 50-79%
1 80% FEV1 30-49% 1
FEV









l

.. 2553

14

l

l


l exercise tolerance


l


l

l

l

AW 2.indd 14

10/18/10 5:16:57 PM

AW 2.indd 15

15

.. 2553

( 2) 4


1.

2. stable COPD

3.

4. (acute exacerbation)





2 COPD

COPD

10/18/10 5:17:05 PM

1.



( 2)

2. stable COPD

spirometry


(health status)
( 1)




(end of life plan)

.. 2553

16

AW 2.indd 16

10/18/10 5:17:13 PM

 1


1 : Mild

l

l exacerbation

l FEV 80%
1

( 2 )
l

1-2
l
1

2 : Moderate

l

l exacerbation


l FEV 50-79%
1

1
l

1-2 + sustained-
release theophylline
l
rehabilitation

( 4)


2-3
3
17

.. 2553

AW 2.indd 17

10/18/10 5:17:23 PM

 3 : Severe

l


l exacerbation

l FEV 30-49%
1

2
l

1-2
/
l
severe exacerbation
> 1 12 :
ICS combination
LABA / ICS
l

( 5)

4 : Very severe


l

l 3
l exacerbation
l

(end of life plan) (

6)
l FEV < 30%
1
l FEV
< 50%

.. 2553

18

2.1

AW 2.indd 18

10/18/10 5:17:33 PM

AW 2.indd 19

19

.. 2553

2.1.1

( 1)

spirometry

3 b2-agonist, anticholinergic xanthine derivative ( 2)



3 4
4
( 1)

(metereddose dry-powder inhaler)
5 ( 1,
++) (
3) ( +/-)
nebulization


( ++)

10/18/10 5:17:41 PM

b2-agonist anticholinergic
FEV1 6
tachyphylaxis ( 1)
2
2


1.
1.1 b2-agonist
1.1.1

.. 2553

20

AW 2.indd 20

salbutamol
terbutaline
salbutamol

2 .
2.5 .
100, 200 .
(MDI&DPI)


1.1.2



10 .
bambuterol

procaterol
25, 50 .
salmeterol
25-50 .


(MDI&DPI)
12 . (DPI)
formoterol

1.2 Anticholinergic
0.02 .+0.05
1.2.1 ipratropium+
b2-ago- fenoterol .(MDI)
nist
ipratropium+
21 .+120 .
(MDI)
salbutamol

( )



4-6
4-6
4-6


24
8-12
12+

12+

68

68

10/18/10 5:17:51 PM


1.2.2

1.3 Xanthine
derivative

tiotropium

sustainedrelease
theophylline
2. beclomethasone


budesonide

fluticasone
3. b2agonist

formoterol +
budesonide
salmeterol +
fluticasone

18 ./
(DPI)
< 400 ./
1,000-2,000
./
800-1,600 ./

500-1,000 ./

9/320-18/640
./
100/500-100/1000
./

( )
24+
1224
12

12

12
12

12

AW 2.indd 21

21

.. 2553

2.1.2 ICS

ICS
FEV17-9 10
11-14

( 1 )( 1, ++)

ICS 15
( 1) ICS
ICS
2

10/18/10 5:18:01 PM


.. 2553

22

2.1.3 ICS LABA

LABA
ICS
16
( 1)

2.1.4 Xanthine derivatives


5
sustained-release ( 2)

2.1.5

1) ( +/-)

2) anti-oxidant carbocisteine 17, N-acetyl
cysteine18 :
( 2, +/-)


2.2

2.2.1 1
19 (
1, ++) pneumococcal vaccine


2.2.2 (pulmonary rehabilitation)

AW 2.indd 22

10/18/10 5:18:09 PM

AW 2.indd 23

23

.. 2553

( 4)
3 4
4

1) (dyspnea score)

2) (exercise capacity)

3) (quality of life)

4) / (BMI)

5) (patient education)

6)
(muscle strength)



2.2.3 ( 5)

2.2.4 /

10/18/10 5:18:17 PM


1) Bullectomy

2) (lung volume reduction
surgery)
3) (endobronchial valve)
4)

4.5 (end of life plan) (
6)

3.

.. 2553

24

(subjective) (objective) 1-3



3.1
( MMRC scale ( 7) visual analogue scale)
(actual daily activity)



3.2 1 spirometry
BODE Index, 6 minute walk
distance ( 7), oxygen saturation arterial
blood gases

AW 2.indd 24

10/18/10 5:18:25 PM

4.
(acute exacerbation)


() /
(purulent sputum)
pulmonary embolism,
pneumonia, pneumothorax

AW 2.indd 25

25

.. 2553

prednisolone 20-30 ./ 5-7






1. (accessory muscle)
abdominal
paradox respiratory alternans

10/18/10 5:18:32 PM


.. 2553

26

2. 120 / hemodynamic
instability

3. Peak expiratory flow 100 /

4. Oxygen saturation 90% PaO2
60 .

5. PaCO2 45 . pH 7.35

6.

7.




1.

2. 4

3.


4.

5.



1.
oxygen saturation 90%
(CO2 narcosis)

2. b2-agonist b2-agonist
anticholinergic metered dose inhaler

AW 2.indd 26

10/18/10 5:18:40 PM

AW 2.indd 27

27

.. 2553

spacer 4-6 puffs nebulizer

20

3. hydrocortisone
100-200 . dexamethasone 5-10 .
6 prednisolone 30-60 ./

7-14

4.



5. aminophylline



6.

6.1 Non-invasive positive pressure ventilation (NIPPV)



PaCO2 45-60 . pH 7.25-7.35
NIPPV

1)

2)


3)

4)

10/18/10 5:18:48 PM


.. 2553

28

5)

6)

7)


NIPPV

/ pH PaCO 2



6.2 Invasive mechanical ventilation



1) NIPPV

2) NIPPV

3) Acute respiratory acidosis (pH < 7.25)

4)

1.

2. Hemodynamic status 24

3.


4.

AW 2.indd 28

10/18/10 5:18:56 PM







Disability Adjusted
Life Year (DALY) 3 15

29

.. 2553

AW 2.indd 29

10/18/10 5:19:04 PM

.. 2553

30

1. Regional COPD Working Group. COPD prevalence in 12 Asia-Pacific

countries and regions: projections based on the COPD prevalence

estimation model. Respirology 2003; 8:192-8.

2. Maranetra N, Chuaychoo B, Dejsomritrutai W, et al. The prevalence

and incidence of COPD among urban older persons of Bangkok

Metropolis. J Med Assoc Thai 2002; 85:1147-55.

3. Pothirat C, Petchsuk N, Pisanthanaphan S, et al. (Abstract)

Prevalence, smoking risk factor and severity of COPD in community:

a comparative study between an urban and a rural area in Chiang

Mai. In the proceedings of Annual meeting of Thoracic Society of

Thailand 2007, Pang Saunkaew Hotel, Chiang Mai

4. Pothirat C, Petchsuk N, Deesomchok A, et al. Clinical characteristics

and long-term survival among COPD patients of Northern Thailand

COPD club members. J Med Assoc. Thai 2007; 90: 653-62.

5. Global Initiative for Chronic Obstructive Lung Disease. Global strategy

for the diagnosis, management and prevention of chronic obstructive

pulmonary disease. NHLBI/WHO workshop report. Bethesda, National

Heart, Lung and Blood Institute, Date updated: November 2008.

6. Gross N, Tashkin D, Miller R, et al. Inhalation by nebulization of

albuterol-ipratropium combination (Dey combination) is superior to

either agent alone in the treatment of chronic obstructive pulmonary

disease. Dey Combination Solution Study Group. Respiration 1998;

65: 354-62.
7. Burge PS, Calverley PM, Jones PW, et al. Randomised, double blind,

placebo controlled study of fluticasone propionate in patients with

moderate to severe chronic obstructive pulmonary disease: the

ISOLDE trial. BMJ 2000; 320: 1297-303.

8. Lung Health Study Research Group. Effect of inhaled triamcinolone on

the decline in pulmonary function in chronic obstructive pulmonary

disease: Lung Health Study II. N Engl J Med 2000; 343: 1902-09.
9. Pauwels RA, Lofdahl CG, Laitinen LA, et al. Long-term treatment with

inhaled budesonide in persons with mild chronic obstructive pulmonary

disease who continue smoking. European Respiratory Society Study on

Chronic Obstructive Pulmonary Disease. N Engl J Med 1999; 340:

1948-53.

AW 2.indd 30

10/18/10 5:19:12 PM


.. 2553

10. Spencer S, Calverley PM, Burge PS, et al. Impact of preventing

exacerbations on deterioration of health status in COPD. Eur Respir J

2004; 23: 698-702.

11. Mahler DA, Wire P, Horstman D, et al. Effectiveness of fluticasone

propionate and salmeterol combination delivered via the Diskus device

in the treatment of chronic obstructive pulmonary disease. Am J

Respir Crit Care Med 2002; 166: 1084-91.

12. Jones PW, Willits LR, Burge PS, et al. Disease severity and the effect

of fluticasone propionate on chronic obstructive pulmonary disease

exacerbations. Eur Respir J 2003; 21: 68-73.

13. Calverley P, Pauwels R, Vestbo J, et al. Combined salmeterol and

fluticasone in the treatment of chronic obstructive pulmonary disease:

a randomized controlled trial. Lancet 2003; 361: 449-56.

14. Szafranski W, Cukier A, Ramirez A, et al. Efficacy and safety of

budesonide/formoterol in the management of chronic obstructive

pulmonary disease. Eur Respir J 2003; 21: 74-81.

15. Singh S, Amin AV, Loke YK. Long-term use of inhaled corticosteroids

and the risk of pneumonia in chronic obstructive pulmonary disease: a

meta-analysis. Arch Intern Med. 2009;169: 219-29.

16. Calverley PM, Anderson JA, Celli B, et al. Salmeterol and fluticasone

propionate and survival in chronic obstructive pulmonary disease. N

Engl J Med 2007; 356: 775-89.

17. Zheng JP, Kang J, Huang SG, et al. Effect of carbocisteine on acute

exacerbation of chronic obstructive pulmonary disease (PEACE Study):

a randomized placebo-controlled study. Lancet. 2008; 371: 2013-8.

18. Decramer M, Rutten-van Molken M, Dekhuijzen PN, et al. Effects of

N-acetylcysteine on outcomes in chronic obstructive pulmonary disease

(Bronchitis Randomized on NAC Cost-Utility Study, BRONCUS): a

randomised placebo-controlled trial. Lancet 2005; 365: 1552-60.

31
19. Wongsurakiat P, Maranetra KN, Wasi C, et al. Acute respiratory illness

in patients with COPD and the effectiveness of influenza vaccination:

a randomized controlled study. Chest 2004; 125: 2011-20.

AW 2.indd 31

10/18/10 5:19:20 PM

AW 2.indd 32

10/18/10 5:19:20 PM

AW 2.indd 33

10/18/10 5:19:20 PM

(Screening for COPD)

60 1,2
peak expiratory flow (PEF) mini
peak flow meter

2

PEF
PEF 62 (%
predicted value) 72.7
81.1 (cost-effectiveness) 2,3

spirometry


l
l

.. 2553

34

AW 2.indd 34

10/18/10 5:19:28 PM



1. Maranetra N, Chuaychoo B, Lertakyamanee, et al. The

cost-effectiveness of a questionnaire as a screening

test for chronic obstructive pulmonary disease among

the Bangkok elderly. J Med Assoc Thai 2003; 86:

1033 - 41.

2. Maranetra N, Chuaychoo B, Naruman C, et al. The

cost-effectiveness of mini peak expiratory flow as a

screening test for chronic obstructive pulmonary

disease among the Bangkok elderly. J Med Assoc Thai

2003; 86: 1133 - 9.

3. Chuaychoo B, Maranetra N, Naruman C, et al. The

most cost-effective screening method for chronic

obstructive pulmonary disease among the Bangkok

elderly. J Med Assoc Thai 2003; 86 : 1140 - 8.

35

.. 2553

AW 2.indd 35

10/18/10 5:19:36 PM

.. 2553

36

COPD
(Smoking cessation)


COPD

(5A)


1. ASK :

active problem


2. ADVISE :

3. ASSESSMENT :

(motivation
counseling)

AW 2.indd 36

10/18/10 5:19:43 PM


4. ASSIST :



1



5. ARRANGE : (follow up)

AW 2.indd 37

37

.. 2553

2

1.

(brief counseling)



( 1600)

2. (smoking cessation
medications)
2 1

10/18/10 5:19:51 PM


1) nicotine supplement nicotine
nicotine withdrawal 2
nicotine patch nicotine gum

2) non-nicotine medication bupropion
SR nortriptyline antidepressant

varenicline partial agonist
partial antagonist nicotinic receptor central nervous
system

(<10 )

.. 2553

38

AW 2.indd 38

10/18/10 5:19:59 PM

.. 2553

AW 2.indd 39

Estimated
() Odds Ratio
(95%CI)*
l > 10 / :
616
1.9

21 ./ x 6-8

(1.72.2)
(Nicotine
;

14 ./ & 7 ./

patch)
2-4
l < 10 / :

14 ./ x 6

7 ./ x 2-4

l > 25 / :

614
1.5
4 . 0-6

(1.21.7)
1 1-2 .

( 9 /) ;

7-9 1

2-4 .;

10-12 1 4-8

.
l < 25 / :

2 .

(craving)

(50%)
l

l

(Chew Temporo-

and Park
mandibular

technique) joint (TMJ)

disease

39

10/18/10 5:20:09 PM

AW 2.indd 40

Estimated



() Odds Ratio
(95%CI)*
12-24
2.0 l
l
l

Bupropion 1-2

SR
(1.8-2.2)
(1:1,000)
150 .

l eating
l

3
l

disorders
150 .

l

2

(35-40%) MAOI
l

Varenicline 1-2
12-24
3.1
l l

l

(2.5-3.8) l positive
(30%)
0.5 .

reinforcement
l abnormal
l
3

dreams

0.5 . 2
l

(5%)
l

- 4-7

1. 2
psychiatric

- 8
disorders

.. 2553

40

10/18/10 5:20:19 PM

..2552
*

Estimated

Odds
Ratio
()
(95%CI)*
Nortriptyline 10-28
12
1.8


(1.3-2.6)
25 .

3-5
75-100 .

.. 2553

AW 2.indd 41

41

10/18/10 5:20:30 PM

MAOI

.. 2553

42

:
(Inhalers : techniques & devices)

1

1. : Metered-dose inhaler (MDI),
MDI with spacer, Dry powder inhaler (DPI), Nebulizer (NB)

2. :
1


3. (accessibility)

(MDI) (MDI
with spacers) (DPI) (NB)


2
(coordination)

AW 2.indd 42

10/18/10 5:20:38 PM

AW 2.indd 43

43

.. 2553

1. (close mouth technique)

2. (open mouth technique)

3. (MDIs with spacers)


(drug
deposition) 10-20%
(distal airways) 3

(oral candidiasis and dysphonia)

1

30-60 /
2,3 2

1
14% 2

10/18/10 5:20:46 PM


.. 2553

44

10 3 (driving gas flow)

10%


(tidal breathing)



2
(nebulizing
chamber, mouth piece and face mask)
(mild soap/detergent and water) (rinse)
(air dry)

:



metered dose inhaler (MDI)

1.

2.

3.

AW 2.indd 44

10/18/10 5:20:54 PM


.. 2553

4. 10

5. 30-60

2-43,4

2
(open mouth technique) mouth piece
2

(drug deposition)


45
()

AW 2.indd 45

10/18/10 5:21:02 PM


.. 2553

46

(Accuhaler)








1.

2.

3.

10

4. 2-3
5.

AW 2.indd 46

10/18/10 5:21:10 PM

AW 2.indd 47

47

.. 2553

(Turbuhaler)









1.


2.
2


3.
()


4.

5. 2-4

6.

10/18/10 5:21:18 PM


.. 2553

48

MDI








1.


2.
(mouth piece)

3. MDI

4.

5. 10
mouth piece

6.


7. 30


(air dry)
2

AW 2.indd 48

10/18/10 5:21:26 PM

AW 2.indd 49

49

.. 2553

MDI Aerochamber










1.


2.
(mouth piece)
(face mask)

3.


4. MDI
tidal breathing 5

5.

6. 2-3
2-5

10/18/10 5:21:34 PM


.. 2553

50

MDI Integra










1. (canister)


2.

3.

4. mouth piece

5.

6.

7.

8.

9. 2-3 2-7

10.

AW 2.indd 50

10/18/10 5:21:42 PM

AW 2.indd 51

51

.. 2553

MDI Jethaler










1. (canister)

2. mouth piece jet
haler

3. canister

4. mouth piece

5. canister 2-3 (
)

6.

7. jet
haler



canister

10/18/10 5:21:50 PM


(Handihaler)

.. 2553

52

AW 2.indd 52

1.




2.

( )




3.

4.

10/18/10 5:21:58 PM

5.




6.

5 6

7.

53

.. 2553

AW 2.indd 53

10/18/10 5:22:06 PM

 (Easyhaler)

.. 2553

54

AW 2.indd 54

1.




2.
2-3



3.




4.




5

10/18/10 5:22:14 PM

 (swinghaler)

AW 2.indd 55

55

.. 2553

1.
2


2.




3.


1

4.



5.

2-3

10/18/10 5:22:23 PM

6.




7.

.. 2553

56

Aerosol Cloud Enhancer (ACE)

Spacer







1. ACE spacer, valved mouth piece, coaching adapter
(whistle)

AW 2.indd 56

10/18/10 5:22:31 PM


2. valved mouthpiece,
coaching adapter (whistle) 2

AW 2.indd 57

57

.. 2553

3.

1)

2)
spacer

3) mouth piece

10/18/10 5:22:39 PM


.. 2553

58

4) 10

5)
chamber

6) 1)-5)

(Tracheostomy
tube)

tracheostomy











1. ACE (aerosol cloud enhancer) spacer

2. T-piece adapter

3. extension tube

AW 2.indd 58

10/18/10 5:22:47 PM



(1) T-piece adapter tracheostomy tube

(2)
spacer

59

.. 2553

AW 2.indd 59

10/18/10 5:22:55 PM


1. Dolovich MB, Ahren RC, Hess DR, et al. Device selection and

outcomes of aerosol therapy: evidence based guideline.

American College of Chest Physicians/American College of

Asthma, Allergy, and Immunology. Chest 2005; 127: 335-71.

2. Newman SP, Clark SW. Inhalation devices and techniques. In

Asthma 3rd ed. Clark TJH, Godfrey S, Lee TH.editers.1992

Chapman & Hall, London 469-505.

3. Canadian Asthma Consensus Group. Inhalation devices and

propellants. JAMC 1999;161s44-s52.

4. ACCP : Inhaled Medications and Devices : American College

of Chest Physicians 2003. Tips and Techniques. www.

chestnet.org

.. 2553

60

AW 2.indd 60

10/18/10 5:23:03 PM

(Pulmonary rehabilitation)

61

.. 2553

AW 2.indd 61

10/18/10 5:23:11 PM

 (Scopes of pulmonary
rehabilitation)

1. Patient selection and assessment

2. Pulmonary rehabilitation setting
Hospital-base (in-patient, out-patient)
Community-base
Home-base

3. Program content
Patient education
Exercise training
Psychosocial and behavioral intervention
Outcome assessment
Nutritional assessment


1.
(patient selection and assessment)









pulmonary function tests arterial blood
l
l
l

l
l
l
l
l

.. 2553

62

AW 2.indd 62

10/18/10 5:23:19 PM

AW 2.indd 63

63

.. 2553

gases


2. (pulmonary rehabilitation
setting)


(hospital-base) (community-base)
(home-base)



3. (program content)

3.1 (patient education)








3.2 (breathing exercise)

3.3 (exercise training)




strength training endurance training

10/18/10 5:23:27 PM


.. 2553

64

(increase maximum work rate and exercise

endurance time) (inspiratory capacity)
(dyspnea scale)

(health-related quality of life)




. endurance exercise training
(stationary cycling) -
(treadmill or shuttle walking)

. 4-12
3-5 20-30
(intensity)
60-75% maximum oxygen consumption
60-75% maximum heart rate


3, 4
Tai Chi Qigong
pursed-lip 30 > 5
6
(increase maximum exercise capacities
and functional exercise capacities)
(inspiratory capacity)

AW 2.indd 64

10/18/10 5:23:35 PM


.. 2553

(health-related quality of life)

cycling walking


6
Suandok Exercise Training (SET)
-

(arm ergometer) (leg ergometer)
(treadmill)
dumbbell (theraband)






pursed-lip

65




(exercise capacity)

AW 2.indd 65

10/18/10 5:23:43 PM


.. 2553

66

endurance exercise training

inspiratory muscle training pursed-lip breathing



3.4 Psychosocial and behavioral intervention











3.5
(outcome assessment)


6-12



1

AW 2.indd 66

10/18/10 5:23:51 PM


.. 2553

. (exercise capacity)

6-minute walking distance (6-MWD,

meters) maximum

exercise capacities

.

Borg scale (BDI, TDI)

.

Modified Medical Research Council (MMRC)

St. George Respiratory Questionnaires (SGRQ)







3.6 (Nutritional assessment)

COPD
,
Body Mass Index (BMI) 67

AW 2.indd 67

10/18/10 5:23:58 PM

.. 2553

68

1. American Thoracic Society Statement. Pulmonary rehabilitation-

1999. Am J Respir Crit Care Med 1999; 159:1666-82.

2. Troosters T, Casaburi R, Gosselink R, et al. Pulmonary

rehabilitation in chronic obstructive pulmonary diseaseState of

the art. Am J Respir Crit Care Med 2005; 172:1938.

3. Kiatboonsri S, Vorakitvat K, Vongvivat K, et al. Effect of Tai Chi

Qigong exercise. Training in stable COPD patients. ERS Meeting

Abstracts 2006 28: 3186a.

4. Kiatboonsri S., Amornputtisathaporn N, Siriket S, et al. Tai Chi

Qigong exercise training in COPD. Chest Meeting Abstracts 2007

132: 535a.
5.

(Tai Chi Qigong exercise-based pulmonary rehabilitation)

2009

6. Chaicharn Pothirat, Kingkaew Somrit, Nittaya Petchsuke, et al.

Suandok intensive exercise training program for COPD patients: A

short and long term efficacy analysis.()

2549.

Collaborations in Pulmonary Medicine.

. , 18-20 2549 104.

7. Chaicharn Pothirat, Nittaya Petsuk, Warawut Chaiwong. Efficacy

of Modified Suandok Exercise Training(MSET) program applied for

Advanced COPD patients in community-based hospital.()

AW 2.indd 68

10/18/10 5:24:07 PM

2550 Emerging Threats in Pulmonary Medicine

. 17-19 2550 122

69

.. 2553

AW 2.indd 69

10/18/10 5:24:14 PM

(Oxygen therapy)

.. 2553

70

non-pharmacologic
treament COPD stage III IV
arterial desaturation stable stage
oxygen long term oxygen therapy (LTOT)

LTOT stable stage COPD
(resting)

1) PaO2 < 55 mmHg SaO2 < 88%

2) PaO2 56-59 mmHg SaO2 89%
long standing hypoxia erythrocytosis
(Hct > 55%), pulmonary hypertension,



nasal cannula
(low flow)
PaO2 > 60 mmHg SaO2 > 90% ( CO2 )

15 (15-24
)
pulmonary hypertension erythrocytosis

AW 2.indd 70

10/18/10 5:24:22 PM


mental status (oxygen source)
compressed oxygen cylinder
(oxygen concentrator) (liquid
oxygen)

71

.. 2553

AW 2.indd 71

10/18/10 5:24:30 PM

(End of life plan)

.. 2553

72

COPD progressive lung function decline
FEV1 3-4
LTOT

COPD /

1. COPD ( 3 4)
spirometry



2.
LTOT

AW 2.indd 72

10/18/10 5:24:38 PM


.. 2553

3.

3.1 Frequent exacerbation

exacerbation

invasive ventilation > 2

10


3.2 desaturation

24 . bed ridden

3.3

chronic congestive

heart failure, uncontrolled malignancy, end stage

cirrhosis end stage renal disease

chronic dialysis

73


progressive

AW 2.indd 73

10/18/10 5:24:46 PM

.. 2553

74

AW 2.indd 74

10/18/10 5:24:53 PM

AW 2.indd 75

75

.. 2553

1. BODE index

BODE index



BODE index
0
1
2
3
FEV1 (%predicted)
65 50-64 36-49 35
> 350 250-349 150-249 149
6 MWD (meters)
2
3
4
MMRC dyspnea scale 0-1
BMI (Body mass index) > 21 21

BODE index

BODE index
(%)
12 24 52
0-2
2
6
19
2
8
32
3-4
2
14
40
5-6
7-10
5
31
80

10/18/10 5:25:03 PM


Celli B, Cote CG, Marin JM, et al. The Body-mass index, Airflow
Obstruction, Dyspnea, and exercise capacity index in chronic
obstructive pulmonary disease. N Engl J Med 2004; 350: 100512.

2. 6 minute walk distance

.. 2553

76

AW 2.indd 76

1.
2.
3. 2

4.
5.
6. pulse oxymeter

1. (;

)
2.
3.
4.

10/18/10 5:25:11 PM


.. 2553

1.

2. 30 (

20 )

3. 3

4.

5.

30 .




30 .
30 .

30


=




1.
77

2.

3.

4. 2

AW 2.indd 77

10/18/10 5:25:19 PM


.. 2553

78

1.

10

2. : 1) 2) 3)

Borg dyspnea score 4) oxygen saturation

3.
Absolute contraindication

Unstable angina during the previous month

Myocardial infarction during previous month
Relative contraindication

> 120

systolic > 180 mmHg

diastolic > 100 mmHg

4. (Dyspnea)

(Fatigue)

5. 0

Clipboard Borg scale

6.



6 6

AW 2.indd 78

10/18/10 5:25:27 PM

AW 2.indd 79

79

.. 2553

() ()
( 1
)

()


6



7.

8.

1 ( )
() 5

2
() 4

3
()

4

() 2

10/18/10 5:25:35 PM


.. 2553

80

5
() 1

15


()
()





9. :

1)

2)

3) Borg dyspnea scale ( 1)

fatigue ( pre-test )

4) oxygen saturation ( option)

5)

6) (

6 )


10.

AW 2.indd 80

10/18/10 5:25:43 PM

 1 Borg dyspnea scale

0

0.5

1

2

3

4

5

6
7


8

9
10

81

.. 2553

AW 2.indd 81

10/18/10 5:25:53 PM

3. (Modified Medical
Research Council Dyspnea Score; mMRC)

()
1

(0)

(1)

(2)



100
(3)

(4)



.
..2546

.. 2553

82

AW 2.indd 82

10/18/10 5:26:02 PM

83

.. 2553

10/18/10 5:26:10 PM

AW 2.indd 83


.. 2553

84

AW 2.indd 84

10/18/10 5:26:13 PM