COPD

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COPD

• Or Chronic Bronchitis That Was
• Dr Bruce Davies

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Possible Areas to Cover

• Diagnosis
• Initial investigation
• Management plans
• Referral criteria
• Follow plans
• Troubleshooting
• The evidence base

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Possible Areas to Cover

• Ideas for Audit
• Sources of further information
• Case Histories
• Future developments
• Prevalence
• Risk factors
• Prevention

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Labels encompassed by COPD

• Chronic bronchitis
• Emphysema
• COAD
• Chronic airflow restriction
• Some cases of chronic asthma

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Definition

• Chronic slowly progressive airways obstruction,
  not fully reversible
• FEV1 lt80 predicted
• FEV1/FVC ratio lt70
• Impairment largely fixed

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Prevalence

• Depends on where you work!
• MaleFemale 41
• UrbanRural 21
• 5-25 of population
• Declining, or being redefined!
• 1-4 consultations per GP per week
• Strongly social class related
• Increases with age

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Risk Factors

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

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Symptoms

• Smokers cough - Mild
• Breathlessness on exertion - Moderate
• Cough /- sputum - Moderate
• Breathlessness on any exertion - Severe
• Peripheral oedema - Severe

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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

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Management Plans

• Essential at all stages
• Quit rates improved by
• Active cessation programmes
• NRT

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Management Plans

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

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Management Plans

• Obesity and poor nutrition make things worse

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Management Plans

• Depression
• Common concurrent problem
• Social problems
• Also common

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Management Plans

• Vaccination
• Influenza for all
• ? Pneumococcal

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Management Plans

• Short acting Bronchodilator PRN
• or
• Anticholinergic MDI, PRN
• Regular use of above
• Combination of two

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Management Plans

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

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Management Plans

• Probably useless
• Xanthines
• Long acting beta agonists

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Steroid Trial

• 30mg prednisolone daily for 2 weeks
• 200ml increase in FEV1 from baseline
• Subjective improvement is negative
• Objective improvement in 10-20

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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

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Referral Criteria

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

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Referral Criteria

• lt10 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

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Referral Criteria

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

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Acute Exacerbations

• Or
• Help

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Features

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

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Assessment

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

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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

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Other Stuff
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Evidence ?

• Rather good for these suggestions
• Very much a EBM field
• British Thoracic Society

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References

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

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Prevention

• Fags
• Fags
• Fags
• Pollution
• Occupational factors
• ? Housing

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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?