“女性、肥満、軽症COPD”の管理さてどうするか？

Pulmonary Rehabilitation for Management of Chronic Obstructive Pulmonary Disease
N Engl J Med. Vol. 360:(13) 1329-1335 Mar. 26, 2009

61歳女性、４５年間喫煙、1年前禁煙、ここ2年間労作性呼吸苦自覚
運動不足・“sedentary”となり、体重６．８Kg（１５lb)増加、BMI３２
聴診上肺音減弱
心エコー上左室運動性良好
スパイロメトリー上、軽度気道狭窄

“女性、肥満、軽症COPD”の事例・・・さて、どう管理するか？

“Sedentary”とわざわざ書かれているので、筆者らの意図はすぐわかる・・・

The patient in the vignette is an appropriate candidate for pulmonary rehabilitation, and we would recommend that she be enrolled in an outpatient, hospital-based program.


Before she begins treatment, a stress test for cardiovascular evaluation, perhaps in the form of a cardiopulmonary exercise test, should be performed.

Useful, but not mandatory, preprogram assessments include initial measurements of functional capacity (e.g., by means of a 6-minute walk test) and health-related quality of life (e.g., with the CRQ(（Thorax 1987;42:773-778.）)).

She should then begin an 8-week program consisting of 24 sessions held for 3 hours each 3 times a week. In the exercise component of the program, we would include relatively high-intensity treadmill and stationary-cycle ergometer training as well as lower-intensity calisthenics.
A self-management strategy for future COPD exacerbations should also be formulated, focusing on early recognition and treatment of exacerbations.
At the end of the program, the 6-minute walk test and CRQ might be readministered and reassessed.
After the patient has completed the formal program, we would strongly advise her to attend maintenance exercise sessions and to participate in a support group for patients with COPD.

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重点項目を、赤字なり、下線で指摘した。

すなわち、運動負荷試験は必須で、６分間歩行距離・HR-QOLチェックを適宜行い、週3回・3時間の２４回セッションを含む8週間プログラムで、評価としては６分間歩行距離・HR-QOLチェック。急性悪化指導もこのプログラムに含むというもの


American Thoracic Society–European Respiratory Society Statement on Pulmonary Rehabilitation（Am J Respir Crit Care Med 2006;173:1390-1413）

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文献

Pulmonary Rehabilitation: Joint American College of Chest Physicians–American Association of Cardiovascular and Pulmonary Rehabilitation Evidence-Based Clinical Practice Guidelines（Chest 2007;131:4S-42S.）

State of the Art: Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease（Am J Respir Crit Care Med 2005;172:19-38.）

British Thoracic Society Statement on Pulmonary Rehabilitation（Thorax 2001;56:827-834.）

CRQ　：A measure of quality of life for clinical trials in chronic lung disease.　（Thorax 1987;42:773-778.）

ステートメントの結論としては、呼吸リハビリテーションは呼吸苦軽減効果、肺機能改善、QOL改善につながるというもの（GOLD:　Am J Respir Crit Care Med 2007;176:532-555. ）

呼吸リハビリテーションは、有症状COPD患者にも推奨されている（ Global Initiative for Chronic Obstructive Lung Disease・American Thoracic Society–European Respiratory Society Statement on Standards for Diagnosis and Treatment of Patients with COPD.（Eur Respir J 2004;23:932-946. [Erratum, Eur Respir J 2006;27:242.] ）

日本で、メリハリのきいた呼吸リハビリテーションが行われているかはなはだ疑問である。