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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
Is it really COPD?

Dr Rod Taylor

Consultant Respiratory Physician

Calderdale Royal Hospital



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



No spirometry,

no COPD!


COPD is a

pathophysiological

diagnosis,

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


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

X

No. of Years smoked

…………………………

COPD patients

~ 20 pack-years

20


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



Overflowing bathtub
Overflowing Bathtub

Gulp!

It was that last

spoonful which decided

Quackie’s fate.


Two populations of smokers
Two Populations of Smokers?

Normal

COPD

Number of Subjects

Rate of decline in FEV1


Decline in smokers
Decline in Smokers

Smokers

Nonsmokers

Number of Subjects

Rate of Decline in FEV1


Decline in lung function
Decline in Lung Function

Frequency

COPD

Rate of loss of FEV1


What have you inhaled
What have you inhaled?

Work

Hobbies

Pets


Clinical examination
Clinical Examination

Hmm…

Hmm…

Hmm…

  • airflow obstruction

    • but insensitive

    • doesn’t tell cause

  • anything else?

Gulp!


Low resting SaO2

SaO2falls on exercise


Chest x ray
Chest X-ray

Good for structure

Bad for function


Alpha 1 antitrypsin
Alpha1-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?


Bronchiectasis
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

disgusting


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



Lung cancer
Lung cancer

Compression of central airways


Pleural effusion
Pleural Effusion

Right-sided effusion


Heart failure
Heart failure

This is #>}[email protected]*

hard work!



Clot blocking

pulmonary artery


Conclusion
Conclusion

  • 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



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