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International Journal of COPD
open access to scientific and medical research Clinical pathway for acute exacerbations of chronic obstructive pulmonary disease: method This article was published in the following Dove Press journal: International Journal of COPD28 June 2011Number of times this article has been viewed Background: Randomized controlled trials, evidence-based medicine, clinical guidelines, and
total quality management are some of the approaches used to render science-based health care services. The clinical pathway for hospitalized patients suffering from acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is poorly established, although a clinical pathway is an integral part of total quality management.
Kaikoukai Jousai hospital, Aichi, Japan; Aim: To evaluate the outcomes of patients hospitalized with AECOPD in Japan, treated with
a clinical pathway following published guidelines.
Methods: Prospective data were collected for patients with AECOPD admitted to a general
hospital over a 5-year period since 2003. The clinical pathway was designed to establish general rules for the entire treatment protocol. The clinical pathway indicates which treatments and
interventions should be performed, and when. In this study, health care providers were required
to check the clinical pathway sheets to determine the next step of treatment.
Results: This study analyzed 276 hospitalizations in 165 patients. The clinical pathway was
interrupted and defined as a dropout in 45 cases (16.3%). Nine patients died during hospitalization
(3.3%). Oxygen was administered in 232 hospitalizations (84.1%). Noninvasive positive pressure
ventilation (NPPV) treatment was administered in 110 hospitalizations (39.9%). The rate of
intubation in those cases where NPPV treatment had been administered was 8.2% (9 cases out
of 110). The average length of stay (LOS) was 20.3 days, and the median value was 15 days.
The LOS was longer than 30 days in 34 admissions (12.3%), mainly due to complications.
Conclusion: AECOPD can be managed using a clinical pathway. This clinical pathway could
fill the gap between guidelines and clinical practice.
Keywords: COPD, AECOPD, mortality, pulmonary rehabilitation
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is one of the
most common causes of acute hospital admission. These hospital admissions come
with a high mortality rate and an extended impairment of the health status. Similar
to diseases like pneumonia, acute myocardial infarction, and heart failure, AECOPD
is common, has high morbidity, and is costly to society. However, unlike these other
diseases, the underlying medical conditions responsible for AECOPD are generally
unknown. Clinical guidelines have been published and updated to standardize the Kaikoukai Jousai hospital, 4-1 Kitahata, management of AECOPD, with the aim of improving health care and safely reducing costs.1 However, the UK National COPD Audit 2003 reported a wide variation in both the length of stay (LOS) and mortality among hospitals in the UK.2 The contributing factors remain unclear, although it appears that some of this variation can be attributed submit your manuscript
International Journal of COPD 2011:6 365–372 2011 Nishimura et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.
to patient factors. In 2006, Lindenauer and colleagues health care mainly for the western part of the city of Kyoto. reported that only two-thirds of patients with AECOPD The clinical pathway was developed in November 2002, and received the entire set of recommended care protocols in US was implemented for the care of patients hospitalized with hospitals,3 and that numerous participants received tests or AECOPD. The clinical pathway was formalized by a multi- treatments that were considered not beneficial. Mularski and disciplinary study group made up of pulmonary specialists, colleagues also concluded in 2006 that AECOPD patients in staff nurses, physiotherapists, pharmacists, emergency staff, the US received only 60.4% of the recommended care.4 and dieticians. The clinical pathway indicates which treat- Randomized controlled trials, evidence-based medicine, ments and interventions should be performed, and when. clinical guidelines, and total quality management are In this study, the health care providers were required to check considered to be important methods to provide more science- the clinical pathway sheets to determine the next step of based health care services. Integrated care pathways or clinical treatment. The clinical pathway was approved by the clinical pathways detail tasks, sequences, timescales, and disciplines, pathway committee responsible for the medical governance and contain a checklist of all necessary actions.5 It was reported in 1998 that AECOPD should be included in the The implemented clinical pathway for AECOPD consists table of integrated care pathways in use in Britain.5 In other of the following interventions: (1) frequent evaluations words, clinical pathways may be guidelines or management and laboratory testing, (2) pharmacological treatment, rules within individual hospitals, and are part of a total (3) instructions on the method of drug administration by a quality management approach to care. They aim to facilitate ward pharmacist, (4) respiratory management, (5) pulmonary the introduction of clinical guidelines as well as systematic, rehabilitation during the acute phase, (6) nutritional support, continuing audits into clinical practice; thus, clinical pathways and (7) early discharge planning. The core therapeutic can provide a link between establishing clinical guidelines and interventions included in the clinical pathway are summarized practicing them. A clinical pathway is generally recommended in Table 1. In addition, the plan for antibiotics administra- in all common clinical settings, especially for scheduled tion was adjusted based on the results of blood tests for admissions such as elective surgery.
inflammatory markers, a sputum test, and signs of pneumonia Few reports exist on the use of clinical pathways in the at 4 and 8 days after beginning the treatment. Intravenous infu- management of AECOPD. The lack of established clinical sions of aminophylline and the administration of expectorants pathways for AECOPD patients may be due to the difficulty were not included in the clinical pathway. As a general rule, associated with setting up a clinical pathway for acute or when the patients were under respiratory management, such severe illnesses and critical care medicine, and to concerns as oxygen administration and noninvasive positive pressure about treatment failure. In addition, the number of patients ventilation (NPPV) treatment, arterial blood gas analysis hospitalized with AECOPD is still relatively low in Japan, was performed every morning and at 30–120 minutes after although the prevalence of COPD in Japan has been reported changing the oxygen dose or NPPV setting. To respond to to be similar to that of Western countries, based on general acute exacerbations of the patient’s condition, the nurses were population studies.6 This low incidence might be another instructed to change the applied concentration of oxygen as reason for the lack of an organized effort to establish a clini- follows: if a saturation of peripheral oxygen (SpO ) ,88% continues for over 30 minutes, then increase the fraction We hypothesized that AECOPD could be treated using a of inspired oxygen (FiO ) one step at a time using the clinical pathway, and that it could fill the gap between guide- Ventimask®; if a SpO . 93% continues over 30 minutes, lines and clinical practice. In the present study, we developed then decrease the FiO one step at a time using the Ventimask. a clinical pathway and applied it to treat patients hospital- The initial setting for NPPV was an inspiratory positive ized with AECOPD in a general hospital in Japan. We then airway pressure (IPAP) of 8 cm H O, an expiratory positive analyzed the results of 5 years of prospective observations airway pressure (EPAP) of 4 cm H O, a backup respiratory on AECOPD patients treated with this clinical pathway.
rate of 12 breaths per minute, and oxygen supplementation to maintain the oxygen concentration before NPPV therapy. Materials and methods
Hypercapnia was managed by an increase in the IPAP from 2 to 4 cm H O after every arterial blood gas analysis. The The present study was conducted at the Respiratory Division final IPAP was 14–20 cm H O in most hypercapnic subjects. of Kyoto-Katsura Hospital, a general hospital that provides The nurses were responsible for changing the oxygen dose submit your manuscript |
Clinical pathway for acute exacerbations of COPD Table 1 Therapeutic interventions included in the clinical pathway
performed the pulmonary rehabilitation as early as possible for the management of hospitalized patients with acute exacerbation after the vital signs became stable. The Barthel index was recorded prior to pulmonary rehabilitation,8 and the 6-minute 1. Frequency of the evaluations and testing: walking test was performed as much as possible before and   • Blood tests, chest x-rays, and ABG analyses on the first, fourth, after the pulmonary rehabilitation. Although there is no   • ABg analysis every morning if necessary evidence for nutritional interventions to manage AECOPD,   • Pulmonary function tests after inhalation of 200 μg salbutamol a high-calorie diet was provided for all subjects, with nutri- using an MDI with a spacer on the day after completion of the oral tional counseling as necessary. Early discharge was carefully glucocorticosteroid course, or before discharge planned in all cases. At the time of discharge, the patients   • high-dose, frequent inhalation of a bronchodilator under were further educated by instructional videos.
supervision (introduce  and change to  in a few days)    Repeated inhalation of 0.5 mL salbutamol using a nebulizer This study examined those patients who were hospitalized    Repeated inhalation of four puffs of salbutamol (400 μg) + four puffs of oxitropium bromide (400 μg) using an MDI and a spacer during the 5½-year period between January 2003 and June 2008, and who were treated according to the clinical pathway   • Oral administration of 0.5 mg/kg of prednisolone every morning for for AECOPD. The inclusion criteria for this clinical pathway were: (1) a clinical diagnosis of COPD, (2) a history of smok- Antibiotics administration until the inflammatory markers disappear (cefazolin or piperacillin 1– 2 g × 2 div) ing (10 pack-years or greater), (3) a forced expiratory volume   • Starting inhaled corticosteroids as maintenance therapy after the in one second to forced vital capacity ratio (FEV /FVC) , 0.7 completion of systemic corticosteroid administration on or before the first day of the clinical pathway, (4) the absence of previous inflammatory changes on chest radio-   • Oxygen administration at the lowest concentration possible to maintain a PaO $ 60 mm hg (start with a Ventimask®) graphs that influenced pulmonary function (for example,   • Start NPPV therapy if PaCO $ 45(–50) mm hg or if ph drops to previous thoracoplasty or tubercular sequelae), and (5) the below 7.35, regardless of the oxygen concentration presence of aggravated symptoms of COPD compatible with 4. Pulmonary rehabilitation during the acute phase: exacerbations. Since the confirmation of airflow limitation as   • Visit by a physical therapist and rehabilitation at an early stage5. Instructions on the methods of administration by a ward pharmacist defined by a FEV /FVC , 0.7 was necessary for inclusion, the   • In the case of breathing difficulties, a single dose of salbutamol by results of previous spirometric tests were obtained whenever nebulizer, or 400 μg salbutamol and 400 μg oxitropium bromide by possible. Spirometry was required for admission even if the condition was severe, unless previous compatible spirometric   • When changing to therapy using an MDI and a spacer to maintenance therapy including inhaled corticosteroids results were available before admission.
  • Inhalation techniques to be supervised by nurses following a The exclusion criteria were: (1) intubation on the first day of disease, (2) tracheotomy prior to the first day of disease, (3) exacerbation due to pneumothorax, and (4) exacerbation 7. Provision of a high-calorie diet and nutrition counseling when necessary due to cardiac failure alone. When continuous treatment with Abbreviations: ABg, arterial blood gas; MDI, metered-dose inhaler; NPPV,
noninvasive positive pressure ventilation; PaCO , pressure of carbon dioxide in
a clinical pathway became impossible due to progression arterial blood; PaO , pressure of oxygen in arterial blood.
of the disease or complications, the case was defined as a dropout (variance).
during NPPV therapy as follows: if an SpO , 88% continues It is well known that COPD patients suffer from the compli- over 30 minutes, then increase the FiO by 5% or increase cation of community-acquired pneumonia at a high frequency. the oxygen supplementation by 0.5 L/min; if a SpO . 93% It is believed that therapeutic management of AECOPD with continues over 30 minutes, then decrease the FiO by 5% or no clinical signs of pneumonia should be the same as that lower the oxygen supplementation by 0.5 L/min.
for an exacerbation of COPD as a result of pneumonia.9 In The use of pulmonary rehabilitation during the acute addition, it would be under-treatment if those patients with phase of AECOPD is still controversial. Evidence is accumu- exacerbated COPD due to pneumonia were treated only for lating for the effectiveness of pulmonary rehabilitation during their pneumonia. Therefore, in the current clinical pathway, the recovery phase of AECOPD.7 However, the optimal we decided to widen the selection criteria in this regard, and time to start pulmonary rehabilitation has not been clearly included not only AECOPD patients due to respiratory infection, established. In the present clinical pathway, a physiotherapist but also patients with COPD complicated by pneumonia.
submit your manuscript
In addition, we retrospectively examined as many hospital from 70.6% to 94.5%). These patients were diagnosed with records as possible during the study period, and collected a reversible airflow limitation whose initial presentation was information on COPD patients who were not included in similar to AECOPD. We believe that these cases could not be excluded initially due to the difficulty in distinguishing an asthma exacerbation from an AECOPD in some patients.
Thus, the remaining 276 hospitalizations of 165 patients The present clinical pathway was applied to a total of 300 were analyzed in the present study. The results are summarized in hospitalizations for 189 patients. Although we screened Table 2. The average age of the patients, calculated with the total the patients based on the exclusion criteria before the clinical number of hospitalizations as the denominator, was 74.6 years. pathway was initiated, we found 11 cases where the clinical In 97 cases (35.1%), the patients were taken to the hospital by pathway for AECOPD was inappropriately applied. The most ambulance, and in 83 cases (30.0%), since the chest radiographs frequent reason for an error in the initial screening was that revealed infiltration compatible with pneumonia, they were the patient was a never-smoker, and the attending physician diagnosed with a pneumonic exacerbation of COPD.
applied the clinical pathway without confirming the smoking Spirometry was performed in 248 out of 276 episodes history. The second reason was that the spirometric results after completing the treatment, and disease severity of COPD were not available, and that the airflow limitation was not was unknown in 28 hospitalizations (10.1%). According to confirmed before the initiation of the clinical pathway. These the GOLD (Global Initiative for Chronic Obstructive Lung cases were excluded from our analysis.
Disease) criteria,1 there were 29 (10.5%), 81 (29.3%), 89 In addition, 13 subjects were excluded from further (32.2%), and 49 (17.8%) episodes, respectively, of stage I, analysis due to a disappearance of their airflow limitation. II, III, and IV. The post-bronchodilator FEV was 0.99 L on These patients successfully passed the initial screening, and an average, and the FEV /FVC was 44.4%. The average LOS airflow limitation was confirmed at the initiation of the clinical was 20.3 days, and the median value was 15 days. The length pathway. Nevertheless, the spirometry performed before of stay was longer than 30 days in 34 admissions (12.3%), discharge revealed that the FEV /FVC was over 0.7 (ranging Table 2 Characteristics of a total of 276 episodes from 165 patients treated by the clinical pathway for acute exacerbations of chronic
obstructive pulmonary disease
Arterial blood gas before beginning treatment with variable concentration of oxygena
Pulmonary function tests after treatmentb
Notes: an = 275; bn = 248; cn = 245; dn = 210; en = 210.
Abbreviations: 6MWD, 6-minute walk distance; FeV , forced expiratory volume in one second; FVC, forced vital capacity; PaCO , pressure of carbon dioxide in arterial
blood; PaO , pressure of oxygen in arterial blood; SD, standard deviation.
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Clinical pathway for acute exacerbations of COPD The clinical pathway was completed in 231 out of 276 even though all other procedures scheduled in the clinical hospitalizations (83.7%), but was interrupted and regarded pathway were completed. The other reasons for the dropouts as a dropout in 45 hospitalizations (16.3%), see Table 3. were complications that appeared during the clinical pathway, Nine patients (3.3%) died during hospitalization due to the including pneumonia in five cases, pleural effusion in three following reasons: two cases each of pneumothorax-related cases, a pneumothorax in two cases. Nine cases that required deaths, septic shock, and cerebral infarction; one case each intubation and the use of a mechanical ventilator following of nosocomial pneumonia, unconsciousness of unknown unsuccessful NPPV treatment were also included in the cause, and sudden death of unknown cause. One of the two pneumothorax-related deaths occurred in a subject that had a Oxygen was administered to 232 hospitalizations bilateral pneumothorax that developed just after the introduc- with a pressure of oxygen in arterial blood (PaO ) , tion of NPPV; he received subsequent mechanical ventilation 60 mm Hg (84.1%). NPPV treatment was administered in with intubation, but the treatment was unsuccessful. In the 110 hospitalizations with a pressure of carbon dioxide in second pneumothorax-related death, an autopsy revealed a arterial blood (PaCO ) $45(–50) mm Hg or a pH , 7.35 collapse of the left lung in a patient who died unexpectedly on (39.9%). Forty-four hospitalizations without respiratory the third day after hospitalization. All of the fatal cases were failure (15.9%) were treated without oxygen administration due to complications after the initiation of the treatment, and and without NPPV treatment, and 122 hospitalizations with a were difficult to predict. Seven patients (2.5%) were trans- PaO , 60 mm Hg but without a PaCO $ 45(–50) mm Hg or ferred to other long-term care facilities; four had families a pH , 7.35 (44.2%) were treated with oxygen administration who refused their discharge to home, and the remaining three but without NPPV treatment. There were only three dropouts were transferred due to complications (intertrochanteric hip (6.8%) among these 44 hospitalizations without oxygen fracture, cerebral infarction, and interstitial pneumonia).
administration and without NPPV treatment. There were In 29 out of 45 dropouts, the patients did not complete 13 cases (10.7%) of dropouts among the 122 hospitalizations the clinical pathway but were discharged home from the with oxygen administration but without NPPV treatment. hospital after receiving various subsequent therapies. Among On the other hand, there were 29 dropouts (26.4%) out of the 29 dropouts who were discharged from the hospital, in 110 hospitalizations with oxygen administration and NPPV nine hospitalizations, the reason for the dropout was only treatment. Therefore, the clinical pathway completion rates because the pulmonary rehabilitation was not performed, were 93.2%, 89.3%, and 73.6%, respectively, for these Table 3 Outcomes of COPD-related hospitalizations during the study period
The clinical pathway applied
n = 11
Disappearance of airflow limitation after discharge Transferred to other long-term care facilities Discharged to home from the hospital alive Treatment with the clinical pathway completedn = 44 COPD-related hospitalizations outside the clinical pathway
n = 25
Intubations on the first day of exacerbation Tracheotomy prior to the first day of exacerbation exacerbations due to cardiac failure alone Prompt discharge because of very mild exacerbations Abbreviations: AeCOPD, acute exacerbation of chronic obstructive pulmonary disease; COPD, chronic obstructive pulmonary disease; NPPV, noninvasive positive
pressure ventilation.
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hospitalization groups. The rate of intubation in those cases among patients with stable COPD. A comprehensive where NPPV treatment had been administered once was approach, including the use of drugs known to reduce the frequency of AECOPD episodes, is necessary.10 As the second Pulmonary rehabilitation was administered in 262 step, if AECOPD does occur, then it is important to promptly cases, and started on average 3.5 days (median 3 days) change the therapeutic regimen, and, if necessary, facilitate after admission. The Barthel index was recorded in 245 the patient’s access to medical services. Patient education episodes, and the mean ± standard deviation index value was and self-management involving action plans and behavior 60.1 ± 31.3, ranging from 0 to 100. The six-minute walking modification are among the critical issues associated with the distance was 199 ± 533 and 268 ± 660 meters in 210 episodes second step.11 Studies designed to include these approaches before versus after pulmonary rehabilitation, respectively.
as a part of integrated care have resulted in favorable We examined the hospital records and found a total of outcomes.12,13 The third step for managing AECOPD is the 62 COPD-related hospitalizations that were not treated using actual treatment itself. For mild symptoms of AECOPD, the clinical pathway. Among these 62 episodes, we could patients can be treated by unscheduled or emergency visits. identify the reason why the clinical pathway was not applied Patients suffering from moderate-to-severe symptoms of in 25 AECOPD episodes. In the remaining 37 episodes, it AECOPD need to be hospitalized, and our study was designed was not clear from the medical records whether the COPD to improve the quality of treatment at this final stage of the was stable or not, and it was difficult to identify the reason why the clinical pathway was not applied, even though these Some clinicians may feel an aversion to the uniform cases appeared to match the criteria for AECOPD.
treatment menu of a clinical pathway, especially because the severity of disease symptoms varies greatly among individual Discussion
patients. Indeed, it would be difficult to apply a clinical Our analysis of AECOPD patients treated by a newly devel- pathway for acute medical conditions that included critically oped clinical pathway revealed two important findings. First, ill cases. It is a reasonable concern that the uniform treatment AECOPD can be effectively treated using a clinical pathway. applied by the clinical pathway might result in a failure of Since all of the participants received all of the interventions treatment for such diseases as AECOPD, in which patients listed in the clinical pathway, this pathway proved to be well suffer from acute and severe conditions. The same treatment tolerated and accepted, even in critically ill patients with under the clinical pathway may be an over-treatment for some AECOPD. The fact that we could apply all of the listed inter- patients with mild disease or an under-treatment for some ventions to all of the patients suggests that the quality of care patients with severe symptoms. Furthermore, since AECOPD provided in our hospital had improved compared with the patients manifest qualitatively different clinical conditions, level of care before the introduction of the clinical pathway. it can be argued that the treatments should be tailored to the Second, the rate of dropouts from the clinical pathway was condition of each patient. Although these concerns are valid relatively low (approximately 16%), and most of the dropouts and important to consider, it is also important to provide a were hypercapnic cases that required NPPV treatment. This simple, practical, and easily applicable plan for those prac- low dropout rate suggests that the clinical pathway was highly titioners working at the forefront of medical services. We adaptable to all patient conditions. The mortality rate during believe that our study provided evidence suggesting that a hospitalization was less than 5% in the present study, further clinical pathway for AECOPD is both useful and practical.
supporting the contention that the clinical pathway was safe One limitation of the present study is that it was not a and did not impose any significantly adverse effects, even randomized controlled trial which examined the impact of on severely ill patients. Unfortunately, it was impossible the clinical pathway as compared with AECOPD patients to compare the present study with a control group treated treated in other ways. In the UK National COPD Audit 2003, without the clinical pathway, because the present study was it was reported that the inpatient mortality rate was 7.4%, and the mean LOS for discharged patients was 8.3 days AECOPD represents an extremely severe event that can (median 6 days).2 In the 2005 Scandinavian audit of COPD occur at any point during the long course of COPD. AECOPD hospitalizations, the overall in-hospital mortality was 3.7%, can be lethal, and can impair a patient’s health-related quality and the mean LOS was 8.6 days, although the LOS was of life severely and permanently. Thus, the first important longer than 10 days in 25% of the cases.14 In the US, Stein step is to take measures to prevent AECOPD from occurring and colleagues examined the Nationwide Inpatient Sample submit your manuscript |
Clinical pathway for acute exacerbations of COPD from the years 2000–2006 using five different algorithms In some cases, we felt that the clinical pathway would be and concluded that the in-hospital mortality was 2.0%–5.1%, inappropriate due to frequent and recurrent exacerbations, and the median LOS was 4 days in patients hospitalized for and we intentionally avoided using it for the benefit of AECOPD.15 Although the inpatient mortality in the Western these specific patients. In addition, although our clinical studies can be considered comparable to our study, the LOS pathway was indicated for AECOPD inpatients, each in the hospital, which is less than 10 days in most Western physician may have used different criteria to determine who countries, is clearly longer in Japan. The LOS for all patients should be hospitalized. The absence of a uniform criterion admitted to the Kyoto-Katsura Hospital during the period of for hospitalization might have introduced a bias into the our study was around 17 days, and this value is about the outcomes of the clinical pathway in the present study.
same as the average LOS for general acute hospitalizations Another limitation of the present study is that our limited in Japan. Any possible additional cost may be attributed to data precluded us from examining other indices often used the longer stay in Japan. The reason for this difference can in the literature, such as the re-admission rate, the rate of be attributed to the different systems of health care delivery relapses, treatment failure, and adverse effects. These param- between the Western countries and Japan. The problem in eters could be used to monitor the yearly performance of Japan is that the number of hospitals per capita is very high, each hospital, and to compare each hospital against national but the number of staff per hospital bed is extremely low, and standards. However, few studies have examined the cost of thus the shortage of employees in medical facilities poses a developing and implementing such an index, and how it may more serious problem.16 However, in Japan, there have been effectively change clinical practice to improve the outcomes no reports on the therapeutic management of AECOPD, of each hospital. The implementation of an inpatient clinical and therefore there are no references to compare the results pathway for hospitalized asthmatic children led to a decrease in the LOS and a reduction in total cost, while improving Some interventions, such as NPPV, have been shown the quality of care.21,22 Similarly, a clinical pathway for to be effective in selecting patients enrolled in clinical AECOPD should be evaluated from various viewpoints by trials. However, few studies are available on the use of comparing a group treated by the clinical pathway against NPPV as a routine standard medical protocol for patients a control group. Such a comprehensive evaluation should with respiratory failure outside of these controlled trials. provide some basis to decide how a clinical pathway should According to the report from Schettino and colleagues,17 be implemented for AECOPD. Another problem is that the 87 patients with AECOPD were treated by NPPV in 2001, present study was limited by the small number of cases and the rate of intubation associated with NPPV failure of AECOPD included in the present series. However, this was 24%.17 In our report, NPPV treatment was administered is all the patients with AECOPD admitted to this hospital in 97 hospitalizations (40%), and the rate of intubation in our during the study period. Although it has been reported that NPPV-treated cases was 8%. This favorable rate cannot be prevalence of COPD is similar to Western countries by a easily compared with the results reported by Schettino and general population sample study,6 health care providers colleagues, but evidence of the effectiveness of NPPV treat- still feel that AECOPD is not so frequent. Since the COPD ment to control hypercapnic AECOPD is gradually accumu- stage before AECOPD may affect the clinical pathway, the lating, and appears to be infiltrating clinical practice.
therapeutic interventions included in the clinical pathway Ample evidence supports the effectiveness of pulmonary could have been tailored to the disease severity of stable rehabilitation for stable COPD, but it remains controversial whether it should be applied during the acute phase In conclusion, the rate of dropouts from the clinical path- of AECOPD. Evidence is now accumulating for the way for AECOPD was low, and most of the dropouts were effectiveness of pulmonary rehabilitation during the recovery hypercapnic cases that required NPPV treatment. Although phase of AECOPD.7 However, the optimal time to start there are many differences in health care delivery between pulmonary rehabilitation has not been clearly established.18–20 Japan and Western countries, it is also important to recognize In the current clinical pathway, we implemented pulmonary that there are many issues remaining with regard to how clini- rehabilitation during the acute phase, and started interventions cal pathways should be applied. Nevertheless, the applica- with a physiotherapist immediately after the vital signs, such tion of evidence-based medicine and the establishment of a as fever, became stable. More clinical trials are needed to standard treatment protocol based on clinical guidelines will determine when to start pulmonary rehabilitation.
certainly allow us to use the clinical pathway for AECOPD submit your manuscript
as an effective strategy. We believe that the clinical pathway 9. Lieberman D, Lieberman D, Gelfer Y, et al. Pneumonic vs for AECOPD can fill the gap between the guidelines and nonpneumonic acute exacerbations of COPD. Chest. 2002;122(4): 1264–1270.
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12. Lemmens KM, Nieboer AP, Huijsman R. A systematic review of Kyoto, Japan, and partly funded by the NPO Medise in integrated use of disease-management interventions in asthma and COPD. Respir Med. 2009;103(5):670–691.
13. Wesseling G, Vrijhoef H. Acute exacerbations of COPD: recommenda- tions for integrated care. Expert Rev Resp Med. 2008;2(4):489–494.
14. Liaaen ED, Henriksen AH, Stenfors N. A Scandinavian audit of The authors declare that they have no competing interests.
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Bradley Philip Stoner Personal Information: Sex: Citizenship: Address and Telephone Numbers: Division of Infectious Diseases Washington University School of Medicine Tel. 314-935-5673 FAX 314-935-8535 e-mail: Present Position: Associate Professor of Anthropology Director, Medicine and Society Program Director, Undergraduate Minor in Public


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