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

The Breathless Patient Chest Clinic

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

Airflow obstruction

No spirometry = no COPD!

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

I’ve got asthma! There will be trouble!

Where to start? History Examination Investigations History Examination Investigations

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

Smoker… or ex-smoker? Ian Fleming born 1908, died 1964 Ian Fleming born 1908, died 1964 Once been a smoker always an ex-smoker never a non-smoker Once been a smoker always an ex-smoker never a non-smoker

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

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

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

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

Fletcher and Peto Charles Fletcher Richard Peto

Fletcher-Peto Diagram: 1977

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

Two Populations of Smokers? Number of Subjects Rate of decline in FEV 1 Normal COPD

Decline in Smokers Smokers Nonsmokers Rate of Decline in FEV 1 Number of Subjects

Decline in Lung Function Frequency Rate of loss of FEV 1 COPD

What have you inhaled? Work Hobbies Pets

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

Low resting SaO 2 SaO 2 falls on exercise Low resting SaO 2 SaO 2 falls on exercise

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

Alpha 1 -antitrypsin protein which ‘protects lungs’ hereditary pattern deficiency discovered 1963 causes premature emphysema think of it if young COPD protein which ‘protects lungs’ hereditary pattern deficiency discovered 1963 causes premature emphysema think of it if young COPD

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

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

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

Bronchodilator Effect Which bronchodilator? Which bronchodilator? What dose? What dose? How big an effect? How big an effect? FEV 1 increases by > 400ml FEV 1 increases by > 400ml No response: inconclusive No response: inconclusive Trial of prednisolone? Trial of prednisolone? Which bronchodilator? Which bronchodilator? What dose? What dose? How big an effect? How big an effect? FEV 1 increases by > 400ml FEV 1 increases by > 400ml No response: inconclusive No response: inconclusive Trial of prednisolone? Trial of prednisolone?

Breathless Patient If it’s not COPD or asthma, - could it be bronchiectasis? If it’s not COPD or asthma, - could it be bronchiectasis?

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

Sputum Production I am disgusting disgusting

Physical Signs Crackles in affected areas Crackles in affected areas

Bronchiectasis

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

Left-sided pneumothorax

Lung cancer Compression of central airways

Pleural Effusion Right-sided effusion

Heart failure This is hard work! This is hard work!

Aspirin and Anaemia

Clot blocking pulmonary artery Clot blocking pulmonary artery

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

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

The End