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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



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


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

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?


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

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


  • 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