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COPD

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

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COPD

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  1. COPD Or Chronic Bronchitis That Was Dr Bruce Davies

  2. Possible Areas to Cover • Diagnosis • Initial investigation • Management plans • Referral criteria • Follow plans • Troubleshooting • The evidence base

  3. Possible Areas to Cover • Ideas for Audit • Sources of further information • Case Histories • Future developments • Prevalence • Risk factors • Prevention

  4. Labels encompassed by COPD • Chronic bronchitis • Emphysema • COAD • Chronic airflow restriction • Some cases of chronic asthma

  5. Definition • Chronic slowly progressive airways obstruction, not fully reversible • FEV1 <80% predicted • FEV1/FVC ratio <70% • Impairment largely fixed

  6. 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

  7. Risk Factors • Smoking • Asthma • Genetic • Social class (Independent ? Of other factors) • Pollution • Occupational dust exposure • Recurrent infection

  8. Symptoms • “Smokers cough” - Mild • Breathlessness on exertion - Moderate • Cough +/- sputum - Moderate • Breathlessness on any exertion - Severe • Peripheral oedema - Severe

  9. 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

  10. Management Plans Essential at all stages Quit rates improved by: • Active cessation programmes • NRT

  11. Management Plans Exercise. Encouraged where at all possible, evidence that graded programmes are beneficial is growing.

  12. Management Plans • Obesity and poor nutrition make things worse

  13. Management Plans Depression • Common concurrent problem Social problems • Also common

  14. Management Plans Vaccination Influenza for all ? Pneumococcal

  15. Management Plans • Short acting Bronchodilator PRN • or • Anticholinergic MDI, PRN • Regular use of above • Combination of two

  16. Management Plans • ? Steroid trial • ? Regular inhaled steroid, if positive response to trial • Assess for home nebuliser • Assess for LTOT

  17. Management Plans Probably useless • Xanthines • Long acting beta agonists

  18. Steroid Trial 30mg prednisolone daily for 2 weeks • + = 200ml increase in FEV1 from baseline • Subjective improvement is negative • Objective improvement in 10-20%

  19. 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

  20. Referral Criteria • ? Nebuliser therapy • To exclude inappropriate prescriptions • Assessment for oral steroids • To justify long term use / withdrawal supervision • Bullous lung disease • ? Surgery

  21. 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

  22. Referral Criteria • Uncertain diagnosis • To make one! • Symptoms disproportionate to lung function • To look for other explanations

  23. Acute Exacerbations Or Help

  24. Features • Worsening of previously stable state • Increased dyspnoea • Chest tightness • Fluid retention • Increased wheeze • Increased sputum • Increased sputum purulence

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

  26. Home Treatment • Increase bronchodilators • 7 day course of Abx • Steroids for 1 week Consider: CXR, admission or referral if not back to “normal” in 2 weeks

  27. Other Stuff

  28. Evidence ? • Rather good for these suggestions • Very much a EBM field • British Thoracic Society

  29. References • Thorax, 1997; 52(suppl 5): S1-S32 • Common Diseases, Fry, MTP, 1995.

  30. Prevention • Fags • Fags • Fags • Pollution • Occupational factors • ? Housing

  31. 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?

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