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Is it really COPD?. Dr Rod Taylor Consultant Respiratory Physician Calderdale Royal Hospital. The Breathless Patient. Chest Clinic. Definition of COPD. airflow obstruction usually stable not fully reversible worsens gradually smoking main cause. Airflow obstruction.

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Is it really COPD?

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Is it really copd

Is it really COPD?

Dr Rod Taylor

Consultant Respiratory Physician

Calderdale Royal Hospital

The breathless patient

The Breathless Patient

Chest Clinic

Definition of copd

Definition of COPD

  • airflow obstruction

  • usually stable

  • not fully reversible

  • worsens gradually

  • smoking main cause

Airflow obstruction

Airflow obstruction

FEV1 < 80% predicted;

and FEV1/FVC < 70%

-NICE: post-bronchodilator

Is it really copd

No spirometry = no COPD!

Is it really copd

No spirometry,

no COPD!

Is it really copd

COPD is a



not a disease

in its own right.

Function and cause

Function and Cause

  • COPD = abnormal function

    • airflow obstruction

    • doesn’t get better

  • What disease caused it?

  • Can have two diagnoses

    • presence of COPD

    • disease responsible for it

Is it really copd

I’ve got asthma!

There will be trouble!

Where to start

Where to start?

  • History

  • Examination

  • Investigations

Sir william osler

Sir William Osler

Listen to the

patient; he is

telling you

the diagnosis.

Smoker or ex smoker

Smoker… or ex-smoker?

Once been a smoker

always an ex-smoker

nevera non-smoker

Ian Fleming

born 1908, died 1964

Smoking history

Smoking History

No. of Packs/day


No. of Years smoked


COPD patients

~ 20 pack-years


The history

The History

  • How long breathless?

  • How did it start?

  • Is it getting worse?

  • How quickly?

  • Any previous respiratory trouble?

Bucket and spoon

Bucket and Spoon?

Maximum at age 25:

start with a bucketful

Lose FEV1 at a spoonful

(about 25 ml) per year:

natural ageing process

~ 1 litre over 40 years

Poor function when old

Poor Function when Old

More than a spoonful/year

Normal size

Fletcher and peto

Fletcher and Peto

Charles Fletcher

Richard Peto

Fletcher peto diagram 1977

Fletcher-Peto Diagram: 1977

Overflowing bathtub

Overflowing Bathtub


It was that last

spoonful which decided

Quackie’s fate.

Two populations of smokers

Two Populations of Smokers?



Number of Subjects

Rate of decline in FEV1

Decline in smokers

Decline in Smokers



Number of Subjects

Rate of Decline in FEV1

Decline in lung function

Decline in Lung Function



Rate of loss of FEV1

What have you inhaled

What have you inhaled?




Clinical examination

Clinical Examination




  • airflow obstruction

    • but insensitive

    • doesn’t tell cause

  • anything else?


Is it really copd

Low resting SaO2

SaO2falls on exercise

Chest x ray

Chest X-ray

Good for structure

Bad for function

Alpha 1 antitrypsin


  • protein which ‘protects lungs’

  • hereditary pattern

  • deficiency discovered 1963

  • causes premature emphysema

  • think of it if young COPD

Breathless patient

Breathless Patient

If it’s not COPD

- is it asthma?

Is it asthma

Is it asthma?

  • May never have smoked

  • Symptoms before age 35

  • Variable breathlessness

  • Breathless at night

  • Several things bring it on

Peak flow

Peak Flow

  • serial readings

  • twice a day

  • three each time

  • variability > 20%

Bronchodilator effect

Bronchodilator Effect

  • Which bronchodilator?

  • What dose?

  • How big an effect?

    • FEV1 increases by > 400ml

  • No response: inconclusive

  • Trial of prednisolone?

Breathless patient1

Breathless Patient

  • If it’s not COPD

  • or asthma,

  • could it be

  • bronchiectasis?



  • pneumonia, whooping cough

    • in fewer than 50%

  • chronic sputum production

  • breathlessness, wheeze

  • crackles in chest

  • dilated, thickened bronchi

Sputum production

Sputum Production

I am


Physical signs

Physical Signs

Crackles in

affected areas



Copd and something else

COPD and Something Else?

  • complication of COPD

  • other disease from smoking

  • related to treatment

  • something quite different

Is it really copd

Left-sided pneumothorax

Lung cancer

Lung cancer

Compression of central airways

Pleural effusion

Pleural Effusion

Right-sided effusion

Heart failure

Heart failure

This is #>}$@*

hard work!

Aspirin and anaemia

Aspirin and Anaemia

Is it really copd

Clot blocking

pulmonary artery



  • Is it COPD?

  • If so, what is the cause?

  • Is there anything else?

  • Spirometry essential

    • confirm airflow obstruction

    • measure the severity

    • compare with previous

Consolation from confucius

Consolation from Confucius

The biggest fool can ask more than the wisest man can answer

The end

The End

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