1. COPD – making the diagnosis
Dr Maxine Hardinge
Consultant respiratory physician, Oxford University Hospitals NHS Trust

2. Management of Stable COPD
Once COPD has been diagnosed, effective management should be based on an individualized assessment to reduce both current symptoms and future risks of exacerbations.
© 2017 Global Initiative for Chronic Obstructive Lung Disease

3. Getting the basics right
Diagnosis – quality assured spirometry
Vaccination
Smoking cessation
Physical activity – pulmonary rehabilitation
Diet
Self management
Depression/ anxiety

4. Diagnosis of COPD Symptoms in COPD Quality assured spirometry
Lung function testing
X-rays and CT scans
Alpha 1 anti-trypsin levels

5. Symptoms in COPD Different phenotypes – pink puffer and blue bloater
Chronic and progressive dyspnoea
Cough
Sputum production
Wheezing and chest tightness
Others – including fatigue, weight loss, anorexia, syncope, chest pains, ankle swelling, depression, anxiety.

6. The last year of life of COPD: a qualitative study of symptoms and services Elkington H et al Resp Med 2004: 98;
In-depth interviews with carers of 25 COPD patients who had died in preceding 3-10 months
98% were breathless
77% had low mood and poor sleep quality
53% experienced panic attacks
72% experienced pain

7. Diagnosis and Initial Assessment
© 2017 Global Initiative for Chronic Obstructive Lung Disease

8. Symptom scores Self administered questionnaires
COPD Assessment Test (CAT TM )
Clinical COPD Questionnaire (CCQ® )
St George’s Respiratory Questionnaire (SGRQ)
Interviewer administered/ assessed
Chronic Respiratory Questionnaire (CRQ)
Modified Medical Research Council (mMRC) questionnaire
relates well to other measures of health status and predicts future mortality risk.

10. indoor/outdoor pollution
GOLD: Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
tobacco
sputum
occupation
dyspnoea
indoor/outdoor pollution è
Alpha -1 antitrypsin
SPIROMETRY

11. NICE 2010: Diagnosis of COPD
Post-bronchodilator spirometry
Record absolute and % predicted values
Assess severity
Consider alternative diagnoses in
older people without typical symptoms of COPD and FEV1/FVC ratio < 0.7,
younger people with symptoms of COPD and FEV1/FVC ratio >0.7

12. What do the results mean?
Obstructive
FEV1/FVC less than 70%
because FEV1 reduced and usually FVC maintained due to hyperinflation, until airflow obstruction is severe and the FVC also falls.
COPD, Asthma, bronchiectasis, cystic fibrosis, obliterative bronchiolitis
Restrictive
FEV1/FVC greater than 70%
because FEV1 reduced and FVC reduced
Lung fibrosis, sarcoid, kyphoscoliosis, obesity

13. © 2017 Global Initiative for Chronic Obstructive Lung Disease
Spirometry
© 2017 Global Initiative for Chronic Obstructive Lung Disease

15. Improving the quality of diagnostic spirometry in adults: the National Register of certified professionals and operators
The framework describes:
how healthcare professionals performing and/or interpreting diagnostic spirometry should be trained, assessed and certified
Experienced Practitioner Scheme, which recognises prior experience and competence without need for training
how to join the National Register and process of recertification (every 3 years)
National Register of certified healthcare professionals - phased implementation over 4 years up to 31 March Three levels of competency assessment:
Foundation: assessed as competent to perform safe, accurate and reliable spirometry tests without interpretation
Full: assessed as competent to perform and interpret spirometry in terms of physiological changes
Interpretation only: assessed as competent in interpretation only

16. Why do spirometry? Essential in diagnosis of obstructive lung disease
Useful in categorising patients:
FEV1 (% predicted) mild/moderate/severe very severe
monitor rate of decline of individual patients
use in monitoring a response to treatment
use of spirometry in reversibility trials
Spirometry is easily measurable
less variablity than other measures of dynamic hyperinfalation
more accurately predicatble from age, sex, height
Post bronchodilatorFEV1 has prognositc value, but does not predict the symptom limitation.

17. COPD severity
According to spirometry (post bronchodilator FEV/FVC <0.7)
GOLD I FEV1 >80% MILD
GOLD II FEV % MODERATE
GOLD III FEV % SEVERE
GOLD IV FEV1 <30% or <50 + cor pulmonale V SEVERE

18. Oxon
78.3%

19. Finding the ‘missing millions’
82% cases of COPD on practice registers confirmed by spirometry (73-89%)
ratio of reported: expected COPD prevalence Oxon is 0.6
COPD measured prevalence Oxon is 1.4% and COPD estimated prevalence is 2.4%
PHE data 2013/4 Oxon

20. Lack of spirometry
64yr male, investigated for 15 months by GP for weight loss. Smoker. FEV1 0.7.
weight loss poor prognostic feature, missed opportunity treatments, now needs LTOT
68 yr old ex-smoker admitted with acute COPD, but not previously formally diagnosed despite numerous attendances with LRTIs
ineffective treatment, disease progression and risk/ cost of admission

21. Full lung function testing

22. Full lung function testing

23. X-rays and CT scans

24. Chest x-rays can’t be used to diagnose COPD

26. Alpha 1 anti-trypsin deficiency
Alpha-1 antitrypsin is a protease inhibitors which protects lower airways from damage caused by proteolytic enzymes, such as elastase
Normal alpha-1 antitrypsin (AAT) allele is the M allele. Over 150 allelic variants described: PiZZ is most common severely deficient variant
Bullous emphysema most commonly lower lobe
Patients with severe AAT deficiency have accelerated rate of lung function decline, especially with cigarette smoking and some occupational exposures.

27. Alpha-1 antitrypsin deficiency (AATD)
AATD screening
WHO recommends all patients with diagnosis of COPD should be screened once especially in areas with high AATD prevalence.
AATD patients are typically < 45 years with basal emphysema
Delay in diagnosis in older AATD patients presents as more typical distribution of apical emphysema
A low concentration of AATD (< 20% normal) is highly suggestive of homozygous deficiency.
© 2017 Global Initiative for Chronic Obstructive Lung Disease

29. Diagnosis and Initial Assessment
OVERALL KEY POINTS (1 of 2):
COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.
Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.
The goals of COPD assessment are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy.
© 2017 Global Initiative for Chronic Obstructive Lung Disease

30. Diagnosis and Initial Assessment
OVERALL KEY POINTS (2 of 2):
Concomitant chronic diseases occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer
These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently.
© 2017 Global Initiative for Chronic Obstructive Lung Disease

31. Diagnosis of COPD – why does it matter?
Early diagnosis in mild or moderate COPD - improve disease outcome and prevent progression.
Late diagnosis in severe disease - potential benefits of treatment greatly reduced and costs to healthcare system are high.
10% of all emergency COPD admissions are undiagnosed at point of admission.
Over 50% of COPD cost to the NHS is from inpatient hospitalisation

32. NICE 1.1.8 Referral for specialist advice (2004, 2010)
should be made when clinically indicated
may be appropriate at all stages and not solely in most severely disabled patients

33. Referrals for specialist advice
Diagnostic uncertainty:
Is it all COPD? Symptoms disproportionate to lung function deficit
Is it asthma or COPD?
Assessment for additional treatments;
oxygen therapy, pulmonary rehabilitation, transplantation, nebulisers, long term steroids or antibiotics
Advice about management of recurrent exacerbations
Advice about management of breathlessness
Significant disease in young person:
Alpha 1 antitrypsin deficiency
cannabis

34. Who is being referred? 69 year old woman
COPD diagnosed following hospital admission Sept 2015
Fostair and salbutamol. Tried Carbocisteine twice – rash both times.
O2 sats 95%
‘extremely SOB and afraid to out. Please advise on breathlessness’
What is her spirometry?
Why tried carbocisteine if problem is breathlessness?
Why isn’t she on a LAMA?
Has she done PR?
Is she still smoking?
Is her CXR normal?
FEV1 0.7L (51% pred), FVC 1.1L (64%)
Thoracic kyphoscoliosis
CXR normal

35. Who is being referred? 63 yr old woman COPD breathlessness grade 4
Continues to smoke
On maximal therapy
Requires frequent courses of oral steroids
O2 sats 93%
What is her spirometry?
Has she has a CXR or Hb recently?
If recurrent exacerbations what’s growing in her sputum?
Is she eosinophilic and would long term low dose steroids be appropriate?
Has she been to PR?
What's been tried for her smoking?
O2 sats 90-91%
No CXR or Fbc since 2010
Dry powder inhalers – try MDI/ mist
Declined PR or smoking advice
Sputum culture ? PSA
Discussion about smoking – prognosis and oxygen

36. Summary Symptoms Obstructive spirometry Alpha 1 anti-trypsin
breathlessness and cough
Obstructive spirometry
key test for diagnosis
Alpha 1 anti-trypsin
no replacement therapy but stop smoking essential
Radiology to exclude other causes
cannot diagnose COPD by x-ray