1. Case based discussion of COPD guidelines 2004 Diagnosis Dr Anne McGown Mar 2008

2. Case 1 Mrs J.W Aged 81 complaining about SOB on 50-100yards SOB 1 flight of stairs no cough or sputum no antibiotics for chest Hypertension, no IHD, no childhood asthma

3. What associated symptoms/factors should you ask about

4. Weight loss waking at night ankle swelling fatigue occupational hazards chest pain* haemoptysis*

5. How can you grade breathlessness?

6. MRC Dyspnoea scale 1Not troubled by breathlessness except on strenuous exercise 2Short of breath when hurrying or walking up a slight hill 3Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4Stops for breath after walking about 100m or after a few minutes on level ground 5Too breathless to leave the house, or breathless when dressing or undressing

7. SH Lives alone Ex-waitress/barmaid gave up smoking aged 65, started in her teens and smoked 10/day = 25 pack years

8. TH Eprosartan Aspirin Omacor bendrofluazide doxazosin serevent

9. Examination No clubbing or oedema pulse 72 and regular heart sounds normal chest clear CXR - NAD FEV1 1.13 53% pred FVC 1.5l 64% pred, ratio FEV1/FVC 74%

10. Differential diagnosis?

11. Respiratory - asthma/COPD Cardiac Anaemia Other rare

12. Flow volume loop

13. Case 1

14. Main differential Asthma COPD Peak flow chart no variation Mild COPD Improved with addition of tiotropium (could walk and talk at the same time which was what she wanted) Discharged.

15. Spirometry (a) - normal (b) - obstructive –dashed - asthma after bronchodilator (c) - restrictive compared to normal –From Johns Pocket Guide to Spirometry

16. Spirometry Airflow obstruction if FEV1/FVC <0.7 –FEV1<80% predicted Severity of airflow obstruction –mild - FEV1 50-80% predicted –moderate - FEV1 30-49% predicted –severe - FEV1 <30% predicted –spirometry predicts prognosis in COPD, but not disability or quality of life

17. Spirometry in COPD COPD definition - presence of airflow limitation that is not fully reversible and does not change markedly over several months. Distinguish from asthma on basis of history, examination, longitudinal observation (+/- reversibility testing and PEFR charts). Chest pain and haemoptysis, or disproportionate SOB/cyanosis in mild cases - look for alternative diagnosis

18. Spirometry in COPD The pitfalls (a) normal (b) obstructive –From Johns Pocket Guide to Spirometry

19. Flow volume loops (a) Normal (b) - asthma (c) - emphysema (d) - restrictive (e) - upper airway obstruction

20. Spirometry summary Obstructive useful May miss diagnosis if technique poor or severe disease Restrictive less useful as more sensitive to technique, and cannot distinguish intrinsic lung disease from extrinsic lung disease (esp. obesity also chest wall, muscle)

21. Spirometry does not predict disability Other prognostic factors –Frequency of exacerbation –FEV1 and TLCO –MRC breathlessness –Health status –Exercise capacity –BMI –Arterial pO2 –Cor pulmonale

22. Case 2 Mr CG Age 66 Admitted acutely SOB No chest pain or palpitations History of wheeze with chest infections for several years Ex smoker

23. Examination findings Tachypnoea Saturations 85% on air Tachycardia 150bpm AF Raised JVP and peripheral oedema Widespread wheeze Bilateral inspiratory crackes

24. What are the possible causes of SOB?

25. LVF Decompensation from fast AF COPD Cor pulmonale

26. How can you distinguish cardiac and respiratory causes?

27. Echo – good biventricular function, LVEF 65%, normal valves, mild TR ECG – no ischaemic changes Spirometry – FEV1 1.62 (38% predicted), FVC 3.09, ratio FEV1/FVC 52% ABG when not acutely SOB – pH 7.426, pO2 6.31, pCO2 7.19 SaO2 82% CXR

29. Treatment at discharge Combivent Ramipril Furosemide Bisoprolol Digoxin Spironolactone

30. Treatment of cor pulmonale LTOT assessment Diuretics No evidence for ACEI, calcium channel blockers, alpha blockers or digoxin unless AF,

31. Follow up Definite symptomatic improvement when ramipril dose increased Still SOB on short distances Minor improvement in spirometry – still obstructive Sats improved to 92% on air – not keen on ambulatory oxygen assessment

32. Case 3 Age 46 female Admitted with wheeze, productive cough, fever Quite slow to recover – 4-5days as IP Smoker Operation for scoliosis aged 12 Discharged on combivent and becotide Seen in OPD in 6 weeks Felt back to normal, but still SOBOE

33. What sort of defect do you think her spirometry showed?

34. Mixed defect FEV1 1.10 (41% pred) FVC 1.54 (49% pred) FEV1/FVC 71% After ventolin FEV1 1.45l (132%) PEFR from 170 to 240 sats 97% on air

35. How would you distinguish asthma and COPD in this patient?

36. Spirometry alone cannot separate clinical features longitudinal variation bronchodilator response (>400ml) Steroid response (>400ml) PEFR variability >20%

37. Clinical features COPDAsthma Smoker or ex smokerNearly allPossibly Symptoms under age 35 RareOften Chronic productive cough CommonUncommon BreathlessnessPersistent and progressive Variable Night time wakingUncommonCommon Diurnal/day to day variability UncommonCommon

38. Spirometric reversibility testing Not required routinely May be inconsistent, not reproducible Misleading unless change in FEV1 >400ml Arbitrary definition of significant change Response to long term therapy not predicted by acute reversibility testing

39. COPD vs asthma Clinically significant COPD not present if FEV1 and FEV1/FVC ratio return to normal with drug therapy Imaging and TLCO may help resolve difficult cases TLCO (gas transfer) may be reduced in COPD and may be increased in asthma. Clinical history as good as bronchial biopsies……

40. Opportunistic case finding Knowledge of abnormal lung function as part of a motivational package significantly affects the success of smoking cessation therapy. Cost effectiveness depends on prevalence of undetected COPD and smoking cessation success rate. Over 35 current or ex smokers with a chronic cough.

41. Specialist referral - 1 Diagnostic uncertainty Suspected severe COPD Patient requests second opinion Onset of cor pulmonale Assessment for oxygen therapy Assessment for nebuliser Assessment for long term oral steroids

42. Specialist referral - 2 Bullous lung disease Rapid decline in FEV1 Assessment for pulmonary rehab Assessment for thoracic surgery Dysfunctional breathing Aged under 40 Frequent infections Haemoptysis

43. Summary Spirometry – pitfalls Assessing severity Main differentials – asthma and cardiac failure Reasons for specialist referral