Is it really Is it really

COPD?COPD?Is it really Is it really

COPD?COPD?

Dr Rod TaylorDr Rod TaylorConsultant Respiratory PhysicianConsultant Respiratory Physician

Calderdale Royal HospitalCalderdale Royal Hospital

Dr Rod TaylorDr Rod TaylorConsultant Respiratory PhysicianConsultant Respiratory Physician

Calderdale Royal HospitalCalderdale Royal Hospital

The Breathless The Breathless PatientPatient

Chest Clinic

Definition of COPDDefinition of COPD

• airflow obstructionairflow obstruction• usually stable

• not fully reversible

• worsens gradually

• smoking main cause

• airflow obstructionairflow obstruction• usually stable

• not fully reversible

• worsens gradually

• smoking main cause

Airflow obstructionAirflow obstruction

No spirometry = no COPD!No spirometry = no COPD!

Function and Function and CauseCause

• COPD = abnormal function• airflow obstruction• doesn’t get better

• 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

• History

• Examination

• Investigations

Sir William OslerSir William Osler

Listen to the patient; he is

telling youthe

diagnosis.

Smoker… or ex-Smoker… or ex-smoker?smoker?

Ian Flemingborn 1908, died 1964

Ian Flemingborn 1908, died 1964

Once been a smokerOnce been a smokeralways an ex-smokeralways an ex-smokernevernever a non-smokera non-smoker

Once been a smokerOnce been a smokeralways an ex-smokeralways an ex-smokernevernever a non-smokera non-smoker

Smoking HistorySmoking History

No. of Packs/dayNo. of Packs/dayXX

No. of Years smokedNo. of Years smoked……………………………………………………

COPD patientsCOPD patients~ 20 pack-years~ 20 pack-years

No. of Packs/dayNo. of Packs/dayXX

No. of Years smokedNo. of Years smoked……………………………………………………

COPD patientsCOPD patients~ 20 pack-years~ 20 pack-years

20

The HistoryThe History

• How long breathless?

• How did it start?

• Is it getting worse?

• How quickly?

• Any previous respiratory trouble?

• How long breathless?

• How did it start?

• Is it getting worse?

• How quickly?

• Any previous respiratory trouble?

Bucket and Spoon?

Maximum at age 25: start with a bucketfulMaximum 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

Lose FEV1 at a spoonful (about 25 ml) per year:natural ageing process

~ 1 litre over 40 years

Poor Function when Poor Function when OldOld

Normal sizeNormal sizeMore than a

spoonful/yearMore than a

spoonful/year

Fletcher and PetoFletcher and Peto

Charles FletcherCharles Fletcher Richard PetoRichard Peto

Fletcher-Peto Diagram: Fletcher-Peto Diagram: 19771977

Overflowing Bathtub

It was that last

spoonful which decided

Quackie’s fate.

It was that last

spoonful which decided

Quackie’s fate.

Gulp!

Two Populations of Smokers?

Nu

mb

er

of

Su

bje

cts

Rate of decline in FEV1

Normal

COPD

Decline in Smokers

Smokers Nonsmokers

Rate of Decline in FEV1

Nu

mb

er

of

Su

bje

cts

Decline in Lung Function

Frequ

ency

Rate of loss of FEV1

COPD

What have you What have you inhaled?inhaled?

WorkWork HobbiesHobbies PetsPets

Clinical Clinical ExaminationExamination

• airflow obstruction• but insensitive• doesn’t tell cause

• anything else?

• airflow obstruction• but insensitive• doesn’t tell cause

• anything else?

Hmm…

Hmm…

Hmm…

Gulp!

Low resting SaO2

SaO2 falls on exercise

Low resting SaO2

SaO2 falls on exercise

Chest X-rayChest X-ray

Good for structureGood for structureBad for functionBad for function

Good for structureGood for structureBad for functionBad for function

AlphaAlpha11-antitrypsin-antitrypsin

• protein which ‘protects lungs’

• hereditary pattern

• deficiency discovered 1963

• causes premature emphysema

• think of it if young COPD

• protein which ‘protects lungs’

• hereditary pattern

• deficiency discovered 1963

• causes premature emphysema

• think of it if young COPD

Breathless PatientBreathless Patient

If it’s not COPDIf it’s not COPD

- is it asthma?- is it asthma?

If it’s not COPDIf it’s not COPD

- is it asthma?- 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

• May never have smoked

• Symptoms before age 35

• Variable breathlessness

• Breathless at night

• Several things bring it on

Peak FlowPeak Flow

• serial readingsserial readings

• twice a daytwice a day

• three each timethree each time

• variability > 20%variability > 20%

• serial readingsserial readings

• twice a daytwice a day

• three each timethree each time

• variability > 20%variability > 20%

Bronchodilator Bronchodilator EffectEffect

• Which bronchodilator?Which bronchodilator?

• What dose?What dose?

• How big an effect?How big an effect?

• FEVFEV11 increases by > 400ml increases by > 400ml

• No response: inconclusiveNo response: inconclusive

• Trial of prednisolone?Trial of prednisolone?

• Which bronchodilator?Which bronchodilator?

• What dose?What dose?

• How big an effect?How big an effect?

• FEVFEV11 increases by > 400ml increases by > 400ml

• No response: inconclusiveNo response: inconclusive

• Trial of prednisolone?Trial of prednisolone?

Breathless PatientBreathless Patient

If it’s not COPDIf it’s not COPD

or asthma,or asthma,- could it becould it be

bronchiectasis?bronchiectasis?

If it’s not COPDIf it’s not COPD

or asthma,or asthma,- could it becould it be

bronchiectasis?bronchiectasis?

BronchiectasisBronchiectasis

• pneumonia, whooping cough• in fewer than 50%

• pneumonia, whooping cough• in fewer than 50%

• chronic sputum production• breathlessness, wheeze• crackles in chest• dilated, thickened bronchi

Sputum ProductionSputum Production

I amI amdisgustidisgusti

ngng

Physical SignsPhysical Signs

Crackles in Crackles in affected areasaffected areasCrackles in Crackles in

affected areasaffected areas

BronchiectasisBronchiectasis

COPD and Something Else?

• complication of COPD

• complication of COPD

• other disease from smoking• related to treatment

• something quite different

Left-sided pneumothoraxLeft-sided pneumothorax

Lung cancerLung cancer

Compression of central airways

Compression of central airways

Pleural EffusionPleural Effusion

Right-sided effusion

Right-sided effusion

Heart failureHeart failure

This is #>}$@*

hard work!

Aspirin and Aspirin and AnaemiaAnaemia

Clot blockingpulmonary

artery

Clot blockingpulmonary

artery

ConclusionConclusion

• 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 Consolation from ConfuciusConfucius

The biggest The biggest fool can ask fool can ask

more than the more than the wisest man can wisest man can

answeranswer

The EndThe End