COPD

Or Chronic Bronchitis That Was

Dr Bruce Davies

Possible Areas to Cover

• Diagnosis

• Initial investigation

• Management plans

• Referral criteria

• Follow plans

• Troubleshooting

• The evidence base

Possible Areas to Cover

• Ideas for Audit

• Sources of further information

• Case Histories

• Future developments

• Prevalence

• Risk factors

• Prevention

Labels encompassed by COPD

• Chronic bronchitis

• Emphysema

• COAD

• Chronic airflow restriction

• Some cases of chronic asthma

Definition

• Chronic slowly progressive airways obstruction, not fully reversible

• FEV1 <80% predicted

• FEV1/FVC ratio <70%

• Impairment largely fixed

Prevalence

• Depends on where you work!• Male:Female = 4:1• Urban:Rural = 2:1• 5-25% of population• Declining, or being redefined!• 1-4 consultations per GP per week• Strongly social class related• Increases with age

Risk Factors

• Smoking

• Asthma

• Genetic

• Social class (Independent ? Of other factors)

• Pollution

• Occupational dust exposure

• Recurrent infection

Symptoms

• “Smokers cough” - Mild

• Breathlessness on exertion - Moderate

• Cough +/- sputum - Moderate

• Breathlessness on any exertion - Severe

• Peripheral oedema - Severe

Diagnosis

• Spirometry preferred to PEFR

• If PEFR used then it needs to be done over several weeks to confirm lack of variability

• CXR to exclude other problems

• Bronchodilators only give limited improvement of PEF

Management Plans

Essential at all stages

Quit rates improved by:

I. Active cessation programmes

II. NRT

Management Plans

Exercise.

Encouraged where at all possible, evidence that graded programmes are beneficial is growing.

Management Plans

• Obesity and poor nutrition make things worse

Management Plans

Depression• Common concurrent

problem

Social problems• Also common

Management Plans

Vaccination

Influenza for all

? Pneumococcal

Management Plans

i. Short acting Bronchodilator PRN

or

Anticholinergic MDI, PRN

ii. Regular use of above

iii. Combination of two

Management Plans

ii. ? Steroid trial

iii. ? Regular inhaled steroid, if positive response to trial

iv. Assess for home nebuliser

v. Assess for LTOT

Management Plans

Probably useless• Xanthines• Long acting beta

agonists

Steroid Trial

30mg prednisolone daily for 2 weeks

• + = 200ml increase in FEV1 from baseline

• Subjective improvement is negative

• Objective improvement in 10-20%

Referral Criteria

• Suspected severe COPD To confirm diagnosis & optimise therapy

• Onset of Cor pulmonale To confirm diagnosis & optimise therapy

• ? Need for oxygen therapy To measure blood gasses

Referral Criteria

• ? Nebuliser therapy To exclude inappropriate prescriptions

• Assessment for oral steroids To justify long term use / withdrawal supervision

• Bullous lung disease ? Surgery

Referral Criteria

• <10 pack years of smoking To confirm or exclude the diagnosis

• Rapid decline in FEV1 To encourage early intervention

• Aged less than 40 ? Alpha 1 anti-trypsin deficiency

Referral Criteria

• Uncertain diagnosisTo make one!

• Symptoms disproportionate to lung functionTo look for other explanations

Acute Exacerbations

Or

Help

Features

• Worsening of previously stable state

• Increased dyspnoea

• Chest tightness

• Fluid retention

• Increased wheeze

• Increased sputum

• Increased sputum purulence

Assessment

• Able to cope at home?• Good social circumstances?• Cyanosis?• Consciousness?• Degree of breathlessness• General condition?• LTOT?• Level of activity?

Home Treatment

a. Increase bronchodilators

b. 7 day course of Abxc. Steroids for 1 week

Consider: CXR, admission or referral if not back to “normal” in 2 weeks

Other Stuff

Evidence ?

• Rather good for these suggestions

• Very much a EBM field

• British Thoracic Society

References

• Thorax, 1997; 52(suppl 5): S1-S32

• Common Diseases, Fry, MTP, 1995.

Prevention

• Fags

• Fags

• Fags

• Pollution

• Occupational factors

• ? Housing

Questions

• Should practices have spirometers?

• Or open access to lung function clinics?

• Should practice nurses run regular follow-up clinics?

• How should a practice audit this area?

• Should practices have smoking cessation clinics?