COPD – making the diagnosis Dr Maxine Hardinge Consultant respiratory physician, Oxford University Hospitals NHS Trust

Management of Stable COPD Once COPD has been diagnosed, effective management should be based on an individualized assessment to reduce both current symptoms and future risks of exacerbations. © 2017 Global Initiative for Chronic Obstructive Lung Disease

Getting the basics right Diagnosis – quality assured spirometry Vaccination Smoking cessation Physical activity – pulmonary rehabilitation Diet Self management Depression/ anxiety

Diagnosis of COPD Symptoms in COPD Quality assured spirometry Lung function testing X-rays and CT scans Alpha 1 anti-trypsin levels

Symptoms in COPD Different phenotypes – pink puffer and blue bloater Chronic and progressive dyspnoea Cough Sputum production Wheezing and chest tightness Others – including fatigue, weight loss, anorexia, syncope, chest pains, ankle swelling, depression, anxiety.

The last year of life of COPD: a qualitative study of symptoms and services Elkington H et al Resp Med 2004: 98; 439-445 In-depth interviews with carers of 25 COPD patients who had died in preceding 3-10 months 98% were breathless 77% had low mood and poor sleep quality 53% experienced panic attacks 72% experienced pain

Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease

Symptom scores Self administered questionnaires COPD Assessment Test (CAT TM ) Clinical COPD Questionnaire (CCQ® ) St George’s Respiratory Questionnaire (SGRQ) Interviewer administered/ assessed Chronic Respiratory Questionnaire (CRQ) Modified Medical Research Council (mMRC) questionnaire relates well to other measures of health status and predicts future mortality risk.

indoor/outdoor pollution GOLD: Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnoea indoor/outdoor pollution è Alpha -1 antitrypsin SPIROMETRY

NICE 2010: Diagnosis of COPD Post-bronchodilator spirometry Record absolute and % predicted values Assess severity Consider alternative diagnoses in older people without typical symptoms of COPD and FEV1/FVC ratio < 0.7, younger people with symptoms of COPD and FEV1/FVC ratio >0.7

What do the results mean? Obstructive FEV1/FVC less than 70% because FEV1 reduced and usually FVC maintained due to hyperinflation, until airflow obstruction is severe and the FVC also falls. COPD, Asthma, bronchiectasis, cystic fibrosis, obliterative bronchiolitis Restrictive FEV1/FVC greater than 70% because FEV1 reduced and FVC reduced Lung fibrosis, sarcoid, kyphoscoliosis, obesity

© 2017 Global Initiative for Chronic Obstructive Lung Disease Spirometry © 2017 Global Initiative for Chronic Obstructive Lung Disease

Improving the quality of diagnostic spirometry in adults: the National Register of certified professionals and operators The framework describes: how healthcare professionals performing and/or interpreting diagnostic spirometry should be trained, assessed and certified Experienced Practitioner Scheme, which recognises prior experience and competence without need for training how to join the National Register and process of recertification (every 3 years) National Register of certified healthcare professionals - phased implementation over 4 years up to 31 March 2021. Three levels of competency assessment: Foundation: assessed as competent to perform safe, accurate and reliable spirometry tests without interpretation Full: assessed as competent to perform and interpret spirometry in terms of physiological changes Interpretation only: assessed as competent in interpretation only

Why do spirometry? Essential in diagnosis of obstructive lung disease Useful in categorising patients: FEV1 (% predicted) mild/moderate/severe very severe monitor rate of decline of individual patients use in monitoring a response to treatment use of spirometry in reversibility trials Spirometry is easily measurable less variablity than other measures of dynamic hyperinfalation more accurately predicatble from age, sex, height Post bronchodilatorFEV1 has prognositc value, but does not predict the symptom limitation.

COPD severity According to spirometry (post bronchodilator FEV/FVC <0.7) GOLD I FEV1 >80% MILD GOLD II FEV1 50-79% MODERATE GOLD III FEV1 30-49% SEVERE GOLD IV FEV1 <30% or <50 + cor pulmonale V SEVERE

Oxon 78.3%

Finding the ‘missing millions’ 82% cases of COPD on practice registers confirmed by spirometry (73-89%) ratio of reported: expected COPD prevalence Oxon is 0.6 COPD measured prevalence Oxon is 1.4% and COPD estimated prevalence is 2.4% PHE data 2013/4 Oxon

Lack of spirometry 64yr male, investigated for 15 months by GP for weight loss. Smoker. FEV1 0.7. weight loss poor prognostic feature, missed opportunity treatments, now needs LTOT 68 yr old ex-smoker admitted with acute COPD, but not previously formally diagnosed despite numerous attendances with LRTIs ineffective treatment, disease progression and risk/ cost of admission

Full lung function testing

Full lung function testing

X-rays and CT scans

Chest x-rays can’t be used to diagnose COPD

Alpha 1 anti-trypsin deficiency Alpha-1 antitrypsin is a protease inhibitors which protects lower airways from damage caused by proteolytic enzymes, such as elastase Normal alpha-1 antitrypsin (AAT) allele is the M allele. Over 150 allelic variants described: PiZZ is most common severely deficient variant Bullous emphysema most commonly lower lobe Patients with severe AAT deficiency have accelerated rate of lung function decline, especially with cigarette smoking and some occupational exposures.

Alpha-1 antitrypsin deficiency (AATD) AATD screening WHO recommends all patients with diagnosis of COPD should be screened once especially in areas with high AATD prevalence. AATD patients are typically < 45 years with basal emphysema Delay in diagnosis in older AATD patients presents as more typical distribution of apical emphysema A low concentration of AATD (< 20% normal) is highly suggestive of homozygous deficiency. © 2017 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis and Initial Assessment OVERALL KEY POINTS (1 of 2): COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation. The goals of COPD assessment are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy. © 2017 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis and Initial Assessment OVERALL KEY POINTS (2 of 2): Concomitant chronic diseases occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently. © 2017 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis of COPD – why does it matter? Early diagnosis in mild or moderate COPD - improve disease outcome and prevent progression. Late diagnosis in severe disease - potential benefits of treatment greatly reduced and costs to healthcare system are high. 10% of all emergency COPD admissions are undiagnosed at point of admission. Over 50% of COPD cost to the NHS is from inpatient hospitalisation

NICE 1.1.8 Referral for specialist advice (2004, 2010) should be made when clinically indicated may be appropriate at all stages and not solely in most severely disabled patients

Referrals for specialist advice Diagnostic uncertainty: Is it all COPD? Symptoms disproportionate to lung function deficit Is it asthma or COPD? Assessment for additional treatments; oxygen therapy, pulmonary rehabilitation, transplantation, nebulisers, long term steroids or antibiotics Advice about management of recurrent exacerbations Advice about management of breathlessness Significant disease in young person: Alpha 1 antitrypsin deficiency cannabis

Who is being referred? 69 year old woman COPD diagnosed following hospital admission Sept 2015 Fostair and salbutamol. Tried Carbocisteine twice – rash both times. O2 sats 95% ‘extremely SOB and afraid to out. Please advise on breathlessness’ What is her spirometry? Why tried carbocisteine if problem is breathlessness? Why isn’t she on a LAMA? Has she done PR? Is she still smoking? Is her CXR normal? FEV1 0.7L (51% pred), FVC 1.1L (64%) Thoracic kyphoscoliosis CXR normal

Who is being referred? 63 yr old woman COPD breathlessness grade 4 Continues to smoke On maximal therapy Requires frequent courses of oral steroids O2 sats 93% What is her spirometry? Has she has a CXR or Hb recently? If recurrent exacerbations what’s growing in her sputum? Is she eosinophilic and would long term low dose steroids be appropriate? Has she been to PR? What's been tried for her smoking? O2 sats 90-91% No CXR or Fbc since 2010 Dry powder inhalers – try MDI/ mist Declined PR or smoking advice Sputum culture ? PSA Discussion about smoking – prognosis and oxygen

Summary Symptoms Obstructive spirometry Alpha 1 anti-trypsin breathlessness and cough Obstructive spirometry key test for diagnosis Alpha 1 anti-trypsin no replacement therapy but stop smoking essential Radiology to exclude other causes cannot diagnose COPD by x-ray