Is it really COPD?

1. Is it really COPD? Dr Rod Taylor Consultant Respiratory Physician Calderdale Royal Hospital

2. The Breathless Patient Chest Clinic

3. Definition of COPD • airflow obstruction • usually stable • not fully reversible • worsens gradually • smoking main cause

4. Airflow obstruction FEV1 < 80% predicted; and FEV1/FVC < 70% -NICE: post-bronchodilator

5. No spirometry = no COPD!

6. No spirometry, no COPD!

7. COPD is a pathophysiological diagnosis, not a disease in its own right.

8. Function and Cause • COPD = abnormal function • airflow obstruction • doesn’t get better • What disease caused it? • Can have two diagnoses • presence of COPD • disease responsible for it

9. I’ve got asthma! There will be trouble!

10. Where to start? • History • Examination • Investigations

11. Sir William Osler Listen to the patient; he is telling you the diagnosis.

12. Smoker… or ex-smoker? Once been a smoker always an ex-smoker nevera non-smoker Ian Fleming born 1908, died 1964

13. Smoking History No. of Packs/day X No. of Years smoked ………………………… COPD patients ~ 20 pack-years 20

14. The History • How long breathless? • How did it start? • Is it getting worse? • How quickly? • Any previous respiratory trouble?

15. Bucket and Spoon? Maximum at age 25: start with a bucketful Lose FEV1 at a spoonful (about 25 ml) per year: natural ageing process ~ 1 litre over 40 years

16. Poor Function when Old More than a spoonful/year Normal size

17. Fletcher and Peto Charles Fletcher Richard Peto

18. Fletcher-Peto Diagram: 1977

19. Overflowing Bathtub Gulp! It was that last spoonful which decided Quackie’s fate.

20. Two Populations of Smokers? Normal COPD Number of Subjects Rate of decline in FEV1

21. Decline in Smokers Smokers Nonsmokers Number of Subjects Rate of Decline in FEV1

22. Decline in Lung Function Frequency COPD Rate of loss of FEV1

23. What have you inhaled? Work Hobbies Pets

24. Clinical Examination Hmm… Hmm… Hmm… • airflow obstruction • but insensitive • doesn’t tell cause • anything else? Gulp!

25. Low resting SaO2 SaO2falls on exercise

26. Chest X-ray Good for structure Bad for function

28. Alpha1-antitrypsin • protein which ‘protects lungs’ • hereditary pattern • deficiency discovered 1963 • causes premature emphysema • think of it if young COPD

29. Breathless Patient If it’s not COPD - is it asthma?

30. Is it asthma? • May never have smoked • Symptoms before age 35 • Variable breathlessness • Breathless at night • Several things bring it on

31. Peak Flow • serial readings • twice a day • three each time • variability > 20%

32. Bronchodilator Effect • Which bronchodilator? • What dose? • How big an effect? • FEV1 increases by > 400ml • No response: inconclusive • Trial of prednisolone?

33. Breathless Patient • If it’s not COPD • or asthma, • could it be • bronchiectasis?

34. Bronchiectasis • pneumonia, whooping cough • in fewer than 50% • chronic sputum production • breathlessness, wheeze • crackles in chest • dilated, thickened bronchi

35. Sputum Production I am disgusting

36. Physical Signs Crackles in affected areas

37. Bronchiectasis

38. COPD and Something Else? • complication of COPD • other disease from smoking • related to treatment • something quite different

39. Left-sided pneumothorax

40. Lung cancer Compression of central airways

41. Pleural Effusion Right-sided effusion

42. Heart failure This is #>}$@* hard work!

43. Aspirin and Anaemia

44. Clot blocking pulmonary artery

45. Conclusion • Is it COPD? • If so, what is the cause? • Is there anything else? • Spirometry essential • confirm airflow obstruction • measure the severity • compare with previous

46. Consolation from Confucius The biggest fool can ask more than the wisest man can answer

47. The End