COPD Or Chronic Bronchitis That Was Dr Bruce Davies

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

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

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

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

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

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

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

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

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

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

Management Plans Obesity and poor nutrition make things worse

Management Plans Depression Common concurrent problem Social problems Also common

Management Plans Vaccination Influenza for all ? Pneumococcal

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

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

Management Plans Probably useless Xanthines Long acting beta agonists

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

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

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

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

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

Acute Exacerbations Or Help

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

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

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

Other Stuff

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

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

Prevention Fags Pollution Occupational factors ? Housing

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?