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                             COPD 
 
 
 
                                      Version 2 Final
EBM – COPD 
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Document control 
 
Version history 
Version Date 
Comments 
2 Final 
19 March 2007 
Signed off by MSCMT 
2f (draft) 
17 March 2007 
Comments from customer incorporated 
2d (draft) 
16 January  2007 
Formatting 
2c (draft) 
5 December 2006 
External review by Dr J Munro 
2b (draft) 
26 September 2006 
Internal QA by Dr G Buchanan 
2a (draft) 
12 September 2006 
Initial Draft 
 
 
 
Changes since last version 
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Introduction 
Definition 
 
Chronic Obstructive Pulmonary Disease (COPD) is a chronic, progressive disorder 
characterised by airflow limitation. 
 
It may be accompanied by airway hyper-reactivity, and may be partly reversible (i.e. 
have an additional asthmatic element). 
 
The GOLD (Global Initiative for Chronic Obstructive Lung Disease) definition is: 
 
A disease state characterised by airflow limitation that is not fully reversible.  The 
airflow limitation is usually both progressive and associated with an abnormal 
response of the lungs to noxious particles or gases.
 [1] 
 
Although the previous definition chronic bronchitis and emphysema no longer forms 
part of this definition of the disease state, these conditions are still associated with 
COPD. 
Indeed most patients with COPD, who by definition have airflow obstruction, have 
features of chronic bronchitis and emphysema.  [2] 
 
COPD is disabling because of the reduced exercise tolerance resulting from 
impaired exchange of oxygen and carbon dioxide between the atmosphere and the 
pulmonary circulation. 
 
Due to the evolution of the definition of COPD and historical diagnostic labels 
some people who fulfil the criteria may report themselves as having: 
 
 
Chronic obstructive airways disease 
 
Chronic airflow limitation 
 Chronic 
bronchitis 
 Emphysema 
 Chronic 
asthma 
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Description 
Aetiology 
 
The development of COPD is associated with the inhalation of atmospheric 
pollutants. 
 
The condition usually results from an inflammatory response to noxious particles 
and gases, causing irreversible increased airflow resistance in the smaller airways.  
[1] 
 
The main cause is cigarette smoking.  However, not all smokers develop COPD and 
some non-smokers develop the disease. 
 
Additional aetiological factors include environmental exposure and genetic 
susceptibility. 
The inherited deficiency of anti-protease enzyme alpha1-antitrypsin is associated 
with development of COPD.  The affected gene has been identified and a number of 
variants described.  95% of people with severe deficiency have a greatly increased 
risk of emphysema especially in smokers.  [2] 
 
There is evidence that dusty occupations and air pollution lead to COPD.  
Occupational exposure to coal dust, grain, and various airborne chemicals is 
associated with COPD.  [3]   
 
Prevalence 
 
COPD is one of the greatest causes of death in the world, ranking fourth in the year 
2000 global mortality table.  [1] 
              In the UK it is currently ranked sixth.  [4] 
 
     COPD is an important cause of morbidity and mortality in the United Kingdom  
               ( 30,000 + deaths per annum ). There are an estimated 3 million people in the U.K.  
                suffering from the disease (of whom 900,000 are diagnosed and 2.1 million             
               undiagnosed ) and GP consultation rates for COPD are up to four times that for       
               Ischaemic Heart Disease.  [5] 
 
 
The prevalence of COPD is closely linked to the prevalence of smoking.  The habit 
of cigarette smoking is becoming generally less common in wealthy countries and 
more common in developing countries. 
 
Even within a single country prevalence and mortality from COPD reflect differences 
in smoking habits.  They are generally higher in the North and West of England than 
in the South and East. 
 
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Over recent decades there has been a relative increase in smoking in women 
compared to men.   
 
The smoking rate among UK secondary schoolgirls continues to rise, and in some 
age groups the figure is higher than that for boys. 
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Diagnosis 
History 
 
The airflow limitation causes a history of gradually progressive breathlessness, 
which may be associated with wheeze, although this may not become apparent until 
the later stages of the disease. 
The irreversible component of COPD is associated with loss of lung tissue elasticity, 
causing bronchioles to “collapse”.  The resultant “air trapping” causes hyperinflation 
which increases the effort of breathing.  
 
Chronic bronchitis is associated with COPD and is defined by a history of symptoms 
of productive cough on most days for at least three months of two successive years 
(having excluded other causes of chronic productive cough).  In COPD coughing is 
usually associated with the production of small quantities of mucoid sputum. 
 
Emphysema is defined histopathologically as the dilatation of the terminal airspaces 
of the lung distal to the terminal bronchiole with destruction of their walls, without 
obvious fibrosis.  Consequently, there are no aspects of the history referable to 
emphysema. 
 
 
 
 
Centri-acinar alveolar 
Stenotic bronchiole in 
Panacinar dilatation in 
dilatation in 
chronic bronchitis 
emphysema 
emphysema 
 
The presentation may therefore be of: 
 
1.  Cough and sputum. 
2.  Progressive breathlessness affecting activities of daily living.   
3.  A combination of the two. 
 
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Observation 
 
Informal observation of the patient’s activities gives a good indication of the stage of 
the disease and of its disabling effects. 
 
Early stages of the disease will show little evidence of exercise intolerance, but as 
the disease progresses, gasping tachypnoea, mouth breathing, and the use of 
accessory muscles of respiration are induced at lower and lower levels of effort 
progressing from walking uphill and climbing stairs, to walking on the flat, and then 
to dressing and undressing. 
 
When the condition has progressed even further these clinical signs will be 
observable at rest. 
 
A sub-group of individuals do not have good ventilatory drive and tend to become 
drowsy and cyanosed with right ventricular failure (RVF) and peripheral oedema in 
the later stages of the disease, (formerly known as “blue bloaters”).  The terms “blue 
bloater” and “pink puffer” are now rarely used and have little relevance to diagnosis 
or the assessment of disability. 
Examination 
 
There may be no abnormalities in the early stages of the disease.  Abnormal clinical 
findings will become apparent in the later stages. 
 
Respiratory Features. 
The clinical features primarily affect the respiratory system. 
 
Inspection:  The chest may be “barrel shaped” with increased AP diameter and held 
in the position of near full inflation.  The shoulders are held in a “shrugged” attitude.   
 
Measurement of expansion: Reduced expansion may be detected with a tape 
measure.  The normal change in chest circumference between full inspiration and 
full expiration is approximately 5 cms in the average male. 
 
Percussion: Resonance may be increased and drum-like as the chest is continually 
hyper-inflated .   
 
Auscultation: Breath sounds may be quieter than normal due to reduced airflow and 
the expiration phase is prolonged. There may be added wheezy sounds (high 
pitched expiratory rhonchi)  
 
Abdominal palpation: The overexpansion of the lungs may make the liver appear 
larger by downward displacement.  
 
 
 
 
 
 
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Cardiovascular Features. 
Central cyanosis from polycythaemia and hypoxia may be present.  Progressive 
lung damage results in pulmonary hypertension.  This may progress to signs of right 
ventricular failure with raised jugular venous pressure (J.V.P.), peripheral oedema, 
right parasternal pulsation from a hypertrophied right ventricle, increased splitting of 
the 2nd. heart sound and true hepatomegaly (cor pulmonale). 
 
Systemic Features. 
With severe COPD many patients show evidence of poor nutrition, muscle wasting 
and weight loss, though this may be masked by the development of peripheral 
oedema. 
 
Special tests 
 
The gold standard for diagnosis is by spirometry with reversibility testing (British 
Thoracic Society and GOLD).  [1] [6] 
              Similarly the NICE guidelines for COPD (February 2004) recommend that all health  
              care professionals managing patients with COPD should have access to spirometry 
              and be competent in the interpretation of the results. 
 
 
Chest X-ray findings correlate poorly with physiological findings.  CXR can be 
CXR 
useful to exclude other causes of dyspneoa. 
High-resolution computerised tomography can demonstrate the parenchymal 
CT 
lung destruction of emphysema.  (This investigation is rarely performed). 
This is measured by spirometry – and is the Forced Expiratory Volume in the first 
second of expiration.  It is the single best diagnostic test in patients with airflow 
FEV1 
limitation.  FEV1 measured/FEV1 predicted shows some correlation with effort 
intolerance.[6] 
This measures the Forced Expiratory Vital Capacity in the first 4 seconds of 
expiration. The ratio FEV/FVC remains normal in restrictive lung disease but is 
FVC 
less than 75% in diffuse airflow obstruction.  The FEV/FVC ratio is the single 
best indicator of airflow limitation. 
Peak expiratory flow rate (also known as PFR) measured with a standard peak 
flow meter.  PEF (measured) /PEF (predicted) correlates fairly well with effort 
PEF 
intolerance but not as well as FEV1.  PEF underestimates the degree of airway 
resistance.[7] 
The diffusing capacity of carbon monoxide is a special test providing information 
DCO 
on gas transfer from the alveoli to the pulmonary circulation.  Emphysema 
causes a reduction in the transfer factor and coefficient (KCO). 
PaO2 
Arterial oxygenation is reduced in severe disease 
The maximum rate of oxygen uptake on exercise testing on a treadmill or bicycle 
VO2 max 
ergometer is the best measure of effort tolerance.[8] 
This is a measure of energy expenditure as a multiple of resting energy 
MET 
expenditure.  For example a 70kg man while sitting may expend 1.2 kcal/min, 
when walking at 4 kph he expends 3.6 kcal/min – i.e. 3 METs. 
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Table of diagnostic features and terms 
 
Diagnostic 
Term Definition criteria 
Chronic 
Cough and sputum for 3 months in 2 successive 
History of 
Bronchitis 
years 
symptoms 
Airways 
Diffuse peripheral airway narrowing with 
 FEV1 
obstruction 
increased resistance to airflow 
PEF 
Reversible airways obstruction with airway 
Bronchodilator and 
Asthma 
inflammation and hyper-responsiveness 
steroid response 
Histopathology 
Dilatation of the terminal airspaces with 
Emphysema 
CT scan 
destruction of alveoli 
KCO 
Respiratory 
Failure to maintain arterial oxygen and CO2 
failure 
tensions 
 P O

a
2        PCO2 
Oedema 
Chronic lung disease causing pulmonary 
JVP 
Cor pulmonale 
hypertension and leading to right heart 
hypertrophy.  
ECG 
Echocardiography 
Measured in 
Effort tolerance 
Maximum energy expenditure 
METs 
Vo  
max 
          Diagnostic criteria for COPD (under GOLD or NICE guidelines) is post bronchodilator 
             FEV1  <80% of predicted FEV1  and  FEV1/FVC <70% of predicted FEV1/100%FVC. 
 
However, it has to be acknowledged that these definitions of levels of abnormality 
have not been supported by the American Thoracic Society (ATS) nor the European 
Respiratory Society.   [18]  [19] 
Differential Diagnoses 
 
Other causes of breathlessness and productive cough should be excluded. 
 
The most important differential diagnosis to make is between Asthma and COPD. 
 
The differentiating features are in the history and in the investigations. 
 
 
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Clinical features differentiating COPD and asthma 
 
FEATURE COPD 
Asthma 
Smoker or ex-smoker 
Nearly all 
Possibly 
Symptoms under age 35 
Rare 
Common 
Chronic productive cough 
Common 
Uncommon 
Breathlessness Persistent and progressive 
Common 
Variable 
Night time waking with breathlessness and/or wheeze 
Uncommon 
Common 
Significant diurnal or day to day variability of symptoms 
Uncommon 
Common 
Day to day variation in PEF 
Minimal 
Usual 
Response to bronchodilators 
Poor 
Good 
 
 
The table in Appendix A gives other, less common, differential diagnoses.                               
                                         
                                                                                                                                  
                            
 
 
                                                      
 
                                                  
 
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Treatment 
The first line of treatment is to advise patients to stop smoking.  They should also be 
advised to avoid occupational dusts and chemicals, and indoor and outdoor 
atmospheric pollutants. [9] 
 
Smoking cessation is the single most effective intervention to reduce the risk of 
further development of COPD. 
 
The table below indicates which interventions are likely to be beneficial and are 
currently recommended, and so may be expected to be reported, in different 
conditions 
 
 
Drug Interventions 
Treatment Effect 
 
improved exacerbation rate, symptoms, and 
Inhaled anticholinergics 
FEV1  
 
Improved FEV
Inhaled anticholinergics plus beta
1 compared with either drug 
2 agonists 
alone 
Inhaled corticosteroids plus long acting beta2  improved exacerbation rate, symptoms, 
agonists 
quality of life, FEV1 
Discontinue if no benefit after 4 weeks 
Antibiotics 
Possibly overprescribed but indicated if there 
is purulent sputum and an increase in 
respiratory symptoms with systemic upset. 
Long term domiciliary oxygen 
beneficial in people with severe hypoxaemia 
provided the pCO2 does not rise 
unacceptably 
 
 
 
Non – drug Interventions 
 
 
Psychosocial plus pharmacological 
 
interventions for smoking cessation 
Pulmonary rehabilitation  
 
General physical activity  
 
Inspiratory muscle training  
 
Peripheral muscle training  
 
 
 
 
 
 
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Pulmonary Rehabilitation 
 
Definition
 
 
A multidisciplinary programme of care for patients with chronic respiratory 
impairment that is individually tailored and designed to optimise each patient's 
physical and social performance and autonomy. 
 
COPD patients with breathlessness often avoid exercise and become unfit and 
de-motivated. They become anxious, depressed and socially isolated. 
Pulmonary rehabilitation (PR) addresses all these issues. 
 
The general indication is any patient who considers him or herself to be 
functionally disabled by COPD (usually modified MRC dyspnoea scale 2 or 
greater  [Appx. B])  irrespective of lung function.  
It is not suitable for patients unable to exercise. 
 
Those who lack motivation need encouragement. 
 
Pulmonary rehabilitation is effective in improving: 
  quality of life 
 exercise 
capacity 
 dyspnoea 
 
There is some evidence of reduced bed days and healthcare consumption. There 
is strong evidence that it is cost-effective. 
Despite its proven benefits, it is estimated that it is only available to a minority of 
suitable patients. 
 
The components of Pulmonary rehabilitation are: 
 
Exercise 
  Individually tailored and increased during the programme 
  Involves supervised exercises preferably twice weekly, although once 
weekly can be effective 
  upper- and lower-limb exercises 
  usually in a group with an exercise regime to be followed at home 
 
Education - main topics include: 
 
 Relaxation 
 Breathing 
control 
 Pathophysiology 
 Drug 
treatment 
 Self-management 
  Benefits, social services 
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Setting 
 
In the past PR was mainly hospital based, but increasingly it is performed in the 
community. This has advantages for patients in terms of access, but it is 
important that location and the 
programme are risk-assessed.  Most programmes comprise 2 or 3 sessions per 
week and last for 6 – 12 weeks. 
 
Assessment 
 
It is important that formal assessment of health status and exercise capacity is 
measured before and after pulmonary rehabilitation. 
Widely used are:  
  The Incremental Shuttle Walking Test [10] 
  “Guyatt’s” Chronic Respiratory Questionnaire  (CRQ)  [11] 
  St. Georges Respiratory Questionnaire  (SGRQ)   [12] 
  Clinical COPD Questionnaire  (CCQ)  [13]  
 
Other useful questionnaires include  
  London Chest Activity of Daily Living Scale  (LCADL)  
  Hospital anxiety Depression Score  (HAD)  [14] 
  Lung Information Needs Questionnaire  (LINQ).    [Appx. B] 
 
Follow-up 
 
It is important to offer a means of continuing the exercise programme. 
Some have regular follow-up sessions, some refer to exercise on prescription 
Schemes, and some to the local patient support group, e.g. Breathe Easy.  [5] 
 
 
 
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Prognosis 
The prognosis is profoundly influenced by smoking habit. Continuation of smoking in 
COPD leads to a continuous steady decline in lung function. 
 
With the cessation of smoking the decline in lung function reverts to its normal 
gradient within a relatively short time. 
 
120
100
Never
smoked

80
60
Smoker
40
stopping at
age 55

20
Smoker not
0
stopping
25
40
55
70
Age
Graph of decline of lung function with age and smoking with COPD. 
 
Pulmonary rehabilitation can lead to significantly improved effort tolerance in COPD 
patients, even though lung function tests are not improved. [15] [16] 
                          
Severely dyspnoeic patients benefit less from rehabilitation than moderately 
dyspnoeic patients.  [17] 
 
 
Main Disabling Effects 
 
The primary disablement from COPD is due to reduced exercise tolerance.   
 
Initially there is minimal disablement, which may only be apparent when running. 
 
As the disease progresses there is limitation in walking quickly and climbing flights 
of stairs. 
 
This progresses to limitation in walking at a normal pace and in climbing a flight of 
stairs. 
 
Later the effort of mild exertion limits activities, such as dressing and undressing, 
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washing, rising from sitting and walking even a few steps. 
 
Eventually even minimal effort is not tolerated and there will be breathlessness at 
rest. 
 
The gold standard for diagnosis of COPD is by spirometry. The diagnosis requires a 
post-bronchodilator FEV1 of less than 80% of the predicted value accompanied by 
an FEV1 / FVC ratio of less than 70%. 
However,  functional activity limitation (disability) does not directly correlate with 
FEV1 measured/FEV1 predicted (impairment) due to other factors such as body mass 
index, general level of fitness, and psychological factors. 
 
Cardiopulmonary exercise testing is a better guide of disability although this is rarely 
performed except in experimental work.  [8] 
 
Clinical examination findings do not correlate well with functional ability and the 
assessment of claimants is best made from the evidence of: 
 
1.  The History of Activities of Daily Living (Typical Day) taking variation into 
account. 
2.  Informal Observation of the client’s activities at examination. 
3.  Medication taken and attendance at Chest Clinic. 
 
Some scales of pulmonary disability assessment are detailed in Appendix B. 
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Appendix A - Differential Diagnoses 
 
Breathlessness due to respiratory centre stimulation by hypoxia or excess CO  
2
Common causes 
Uncommon causes 
Pulmonary oedema 
Acidosis 
Pulmonary embolus 
Pregnancy 
Pneumothorax 
Cyanotic congenital heart disease 
Pneumonia High 
altitude 
Lobar collapse 
Arteriovenous fistula 
Pulmonary fibrosis 
 
Anaemia  
 
 
Breathlessness associated with an increased work of breathing (Obstructive 
ventilatory defects) 
Commoner causes 
Uncommon causes 
Asthma 
Upper airways obstruction 
Bronchiectasis Byssinosis 
Cystic fibrosis 
 
 
 
Other Common causes 
Other Uncommon causes 
Sarcoidosis Large 
tumours 
Fibrosing alveolitis 
Large hiatus hernia 
Extrinsic allergic alveolitis 
Lymphangitis carcinomatosa 
Pneumoconioses 
Connective tissue diseases 
Large pleural effusion 
Aspiration pneumonitis 
Extensive lung resection 
Infections 
Chest wall deformity.  Scoliosis etc. 
 
Pulmonary oedema 
 
Left ventricular dysfunction 
 
 
 
Conditions associated with decreased neuromuscular power  (these are all relatively 
uncommon)
More common causes 
Uncommon causes 
Myasthenia gravis 
Poliomyelitis 
Polyneuritis 
Motor neurone disease 
 Muscular 
dystrophies 
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Appendix B - Some scales used in assessment for 
other purposes 

Scales used as guidance for assessment of pulmonary dysfunction in IISB. 
Table A 
 
Symptoms and signs 
Lung Function Impairment 
(Severity Category) 
Not breathless on exercise 
Nil 
Breathless on prolonged or heavy exertion 
Mild 
Breathless on walking uphill or climbing stairs or hurrying 
Mild 
on level ground 
Breathless at normal pace for age on level ground 
Mild 
Breathless on walking 100 metres or climbing one flight of 
Moderate 
stairs at a normal pace 
Breathless on walking 100 metres at a slow pace or 
Moderate 
climbing one flight of stairs without stopping 
Breathlessness prevents walking 100 metres at a slow 
pace without stopping or climbing one flight of stairs 
Moderate 
without stopping 
Breathlessness prevents activity outside the home without 
Severe 
assistance or supervision 
Breathlessness limits activities to within the home 
Severe 
Able to walk only a few steps because of breathlessness 
Severe 
Bed and chair bound, totally dependent on carers 
Total 
because of breathlessness 
 
 
Table B 

FEV1 as a percentage of the predicted value (use 
Lung Function Impairment 
post-bronchodilator value if available) 
(Severity Category) 
>80 Nil 
60-80 Mild 
40-59 Moderate 
<40  * 
Severe 
<40  * 
Total 
 
 
Note that there is no exact correlation between FEV1 value at any level 
and functional disability.  [8] 
 
 
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Medical Research Council dyspnoea scale for grading the degree of 
a patient's breathlessness 

 
1.  Not troubled by breathlessness except on strenuous exercise  
2.  Short of breath when hurrying or walking up a slight hill  
3.  Walks slower than contemporaries on the level because of breathlessness, or has to 
stop for breath when walking at own pace  
4.  Stops for breath after about 100 m or after a few minutes on the level  
5.  Too breathless to leave the house, or breathless when dressing or undressing  
 
MRC:  22 April 2006 
 
 
Note that this scale (used by thoracic surgeons and others) measures reported 
breathlessness as a response to standard questions.  It is, again, a subjective 
assessment. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Lung Information Needs Questionnaire  (LINQ) 
 

LINQ is a self-complete questionnaire that has measures the information needs 
of patients with chronic obstructive pulmonary disease (COPD). LINQ can also be 
used for patients with some other chronic lung diseases. It is not suitable for 
patients with asthma. 
It has been found particularly use to be used before and after pulmonary 
rehabilitation to assess effectiveness 
 
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 References 
1.  GOLD – The Global Initiative for Chronic Obstructive Lung Disease – a joint 
committee of the World Health Organisation and the US National Heart Lung and 
Blood Institute.  www.goldcopd.com  
 
2.  The Merck Manual of Diagnosis and Therapy, 17th. Ed.  
      Sec. 6, Ch. 68, Chronic Obstructive Airways Disorders 
3.  Becklake MR.  Occupational exposures: evidence for a causal association with 
chronic obstructive pulmonary disease.  American Review of Respiratory Disease 
1989; 140: S85-91. 
4.  Office for National Statistics.  Health Statistics Quarterly, no.6.  London.  HMSO; 
2000. 
5.  Diagnosis and Management of Chronic Obstructive Pulmonary Disease in Primary 
Care.  General Practice Airways Group:  1001, 2005, Edition 1 
6.  British Thoracic Society COPD Consortium.  Spirometry in practice: a guide to using 
spirometry in primary care.  London: BTS.   
7.  Quanjer PhH, Lebowitz MD, Gregy I, Miller MR, Pederson OF.  Peak Expiratory Flow: 
conclusions and recommendations of a Working Party of the European Respiratory 
Society.  Eur Respir J 1997; 10: Suppl 24, 2s-8s http://www.ersnet.org/0/0/0.asp  
8.  Ortega F, Montemayor T, Sanchez A, Cabello F, Castillo J.  Role of cardiopulmonary 
exercise testing and the criteria used to determine disability in patients with severe 
COPD.  Am J Respir Crit Care Med 1994; 150: 747-51 
9.  Anthonisen SR, Connett JE, Kiley JP, et al.  (The Lung Health Research Group).        
Effects of smoking intervention and the use of an inhaled anticholinergic                      
bronchodilator on the rate of decline of FEV1.  The Lung Health Study.  JAMA 1994; 
272: 1497-505. 
10. Casas A, Vilaro J, Rabinovich R, Mayer A, Barbera JA, Rodriguez-Roisin R, Roca J.  
Encouraged 6-min walking test indicates maximum sustainable exercise in COPD      
patients. Chest. 2005 Jul;128(1):55-61 
 
11. Guyatt GH, Berman LB, Townsend M, et al. A measure of quality of life for clinical      
 trials in chronic lung disease.  
      Thorax 1987;42:773-778 
 
12. Jones PW, Quirk FH, Baveystock CM, Littlejohns P. A self-complete measure of         
 health status for chronic airflow limitation. Am Rev Respir Dis 1992; 145:1321-1327 
 
13. Molen van der T, Willemse BW, Schokker S, Ten Hacken NH, Postma 
      DS, Juniper EF: Development, validity and responsiveness of 
      the Clinical COPD Questionnaire. Health Qual Life Outcomes 
      2003, 1:13. 
14. Zigmond AS, Snaith RP. The hospital anxiety and depression scale.  Acta Psychiatr. 
Scand.  1983;67:361 – 370 
15. Donner CF, Muir JF.  Selection criteria and programmes for pulmonary rehabilitation 
in COPD patients.  Eur Respir J 1997; 10: 744-57. 
EBM – COPD 
Version 2 Final 
MED/S2/CMEP~0053 (f) 
 
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 Medical Services 
 
 
16. Ong KC, Wong WP, Jailani AR, Sew S, Ong YY.  Effects of a Pulmonary 
Rehabilitation Programme on Physiologic and Psychosocial Outcomes in Patients 
with Chronic Respiratory Disorders.  Ann Acad Med Singapore 2001; 30: 15-21 
17. Wedzicha JA, Bestall JC, Garrod R, Garnham R, Paul EA, Jones PW.  Randomized 
controlled trial of pulmonary rehabilitation in severe chronic obstructive pulmonary 
disease patients, stratified with the MRC dyspnoea scale.  Eur Respir J; 1998; 12
363-369 
18. http://www.spirxpert.com/controversies/controversy.html 
19. http://www.spirxpert.com/indices5.htm 
 
 
 
 
 
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