2. COPD Or Chronic Bronchitis That Was Dr Bruce Davies

3. Possible Areas to Cover Diagnosis Initial investigation Management plans Referral criteria Follow plans Troubleshooting The evidence base

4. Possible Areas to Cover Ideas for Audit Sources of further information Case Histories Future developments Prevalence Risk factors Prevention

5. Labels encompassed by COPD Chronic bronchitis Emphysema COAD Chronic airflow restriction Some cases of chronic asthma

6. Definition Chronic slowly progressive airways obstruction, not fully reversible FEV1 <80% predicted FEV1/FVC ratio <70% Impairment largely fixed

7. Prevalence Depends on where you work! Male:Female = 4:1 Urban:Rural = 2:1 5-25% of population Declining, or being redefined! 1-4 consultations per GP per week Strongly social class related Increases with age

8. Risk Factors Smoking Asthma Genetic Social class (Independent ? Of other factors) Pollution Occupational dust exposure Recurrent infection

9. Symptoms Smokers cough - Mild Breathlessness on exertion - Moderate Cough +/- sputum - Moderate Breathlessness on any exertion - Severe Peripheral oedema - Severe

10. 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

11. Management Plans Essential at all stages Quit rates improved by: I.Active cessation programmes II.NRT

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

13. Management Plans Obesity and poor nutrition make things worse

14. Management Plans Depression Common concurrent problem Social problems Also common

15. Management Plans Vaccination Influenza for all ? Pneumococcal

16. Management Plans i.Short acting Bronchodilator PRN or Anticholinergic MDI, PRN ii.Regular use of above iii.Combination of two

17. Management Plans ii.? Steroid trial iii.? Regular inhaled steroid, if positive response to trial iv.Assess for home nebuliser v.Assess for LTOT

18. Management Plans Probably useless Xanthines Long acting beta agonists

19. Steroid Trial 30mg prednisolone daily for 2 weeks + = 200ml increase in FEV1 from baseline Subjective improvement is negative Objective improvement in 10-20%

20. 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

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

22. Referral Criteria <10 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

23. Referral Criteria Uncertain diagnosis To make one! Symptoms disproportionate to lung function To look for other explanations

24. Acute Exacerbations Or Help

25. Features Worsening of previously stable state Increased dyspnoea Chest tightness Fluid retention Increased wheeze Increased sputum Increased sputum purulence

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

27. Home Treatment a.Increase bronchodilators b.7 day course of Abx c.Steroids for 1 week Consider: CXR, admission or referral if not back to normal in 2 weeks

28. Other Stuff

29. Evidence ? Rather good for these suggestions Very much a EBM field British Thoracic Society

30. References Thorax, 1997; 52(suppl 5): S1-S32 Common Diseases, Fry, MTP, 1995.

31. Prevention Fags Pollution Occupational factors ? Housing

32. 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?