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

2. The Breathless Patient Chest Clinic

3. 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

4. Airflow obstruction

5. No spirometry = no COPD!

8. 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

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

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

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

12. 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

13. 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

14. 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?

15. 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

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

17. Fletcher and Peto Charles Fletcher Richard Peto

18. Fletcher-Peto Diagram: 1977

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

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

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

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

23. What have you inhaled? Work Hobbies Pets

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

25. Low resting SaO 2 SaO 2 falls on exercise Low resting SaO 2 SaO 2 falls on exercise

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

28. 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

29. Breathless Patient If it’s not COPD - is it asthma? 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 May never have smoked Symptoms before age 35 Variable breathlessness Breathless at night Several things bring it on

31. 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%

32. 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?

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

34. 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

35. Sputum Production I am disgusting disgusting

36. Physical Signs Crackles in affected areas Crackles in affected areas

37. Bronchiectasis

38. COPD and Something Else? complication of COPD 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 #>}$@* hard work! This is #>}$@* hard work!

43. Aspirin and Anaemia

44. Clot blocking pulmonary artery 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