COPD - PowerPoint

							         COPD
Or Chronic Bronchitis That Was

       Dr Bruce Davies
www.bradfordvts.co.uk
       Possible Areas to Cover
•   Diagnosis
•   Initial investigation
•   Management plans
•   Referral criteria
•   Follow plans
•   Troubleshooting
•   The evidence base
       Possible Areas to Cover
•   Ideas for Audit
•   Sources of further information
•   Case Histories
•   Future developments
•   Prevalence
•   Risk factors
•   Prevention
Labels encompassed by COPD
•   Chronic bronchitis
•   Emphysema
•   COAD
•   Chronic airflow restriction
•   Some cases of chronic asthma
              Definition
• Chronic slowly progressive airways
  obstruction, not fully reversible
• FEV1 <80% predicted
• FEV1/FVC ratio <70%
• Impairment largely fixed
               Prevalence
•   Depends on where you work!
•   Male:Female = 4:1
•   Urban:Rural = 2:1
•   5-25% of population
•   Declining, or being redefined!
•   1-4 consultations per GP per week
•   Strongly social class related
•   Increases with age
             Risk Factors
• Smoking
• Asthma
• Genetic
• Social class (Independent ? Of other
  factors)
• Pollution
• Occupational dust exposure
• Recurrent infection
                Symptoms
•   “Smokers cough” - Mild
•   Breathlessness on exertion - Moderate
•   Cough +/- sputum - Moderate
•   Breathlessness on any exertion - Severe
•   Peripheral oedema - Severe
               Diagnosis
• Spirometry preferred to PEFR
• If PEFR used then it needs to be done
  over several weeks to confirm lack of
  variability
• CXR to exclude other problems
• Bronchodilators only give limited
  improvement of PEF
          Management Plans

Essential at all stages

Quit rates improved by:
I. Active cessation
   programmes

II. NRT
        Management Plans
Exercise.

 Encouraged where
 at all possible,
 evidence that
 graded
 programmes are
 beneficial is
 growing.
Management Plans
        • Obesity and poor
          nutrition make
          things worse
       Management Plans
Depression
• Common concurrent
  problem


Social problems
• Also common
Management Plans
        Vaccination

        Influenza for all

        ? Pneumococcal
Management Plans
     i. Short acting
        Bronchodilator PRN
       or
       Anticholinergic MDI,
       PRN
     ii. Regular use of above
     iii. Combination of two
Management Plans
      ii. ? Steroid trial
      iii. ? Regular inhaled
           steroid, if positive
           response to trial
      iv. Assess for home
          nebuliser
      v. Assess for LTOT
       Management Plans

Probably useless
• Xanthines
• Long acting beta
  agonists
Steroid Trial
   30mg prednisolone daily
     for 2 weeks
   • + = 200ml increase in
     FEV1 from baseline
   • Subjective improvement
     is negative
   • Objective improvement
     in 10-20%
          Referral Criteria
• Suspected severe COPD
To confirm diagnosis & optimise therapy

• Onset of Cor pulmonale
To confirm diagnosis & optimise therapy

• ? Need for oxygen therapy
To measure blood gasses
          Referral Criteria
• ? Nebuliser therapy
To exclude inappropriate prescriptions

• Assessment for oral steroids
To justify long term use / withdrawal
  supervision

• Bullous lung disease
? Surgery
        Referral Criteria
• <10 pack years of smoking
To confirm or exclude the diagnosis

• Rapid decline in FEV1
To encourage early intervention

• Aged less than 40
? Alpha 1 anti-trypsin deficiency
       Referral Criteria

• Uncertain diagnosis
To make one!

• Symptoms disproportionate to lung
  function
To look for other explanations
Acute Exacerbations

         Or
        Help
                 Features
•   Worsening of previously stable state
•   Increased dyspnoea
•   Chest tightness
•   Fluid retention
•   Increased wheeze
•   Increased sputum
•   Increased sputum purulence
              Assessment
•   Able to cope at home?
•   Good social circumstances?
•   Cyanosis?
•   Consciousness?
•   Degree of breathlessness
•   General condition?
•   LTOT?
•   Level of activity?
Home Treatment
      a. Increase
         bronchodilators
      b. 7 day course of Abx
      c. Steroids for 1 week

      Consider: CXR,
        admission or referral
        if not back to
        “normal” in 2 weeks
Other Stuff
            Evidence ?

• Rather good for these suggestions
• Very much a EBM field
• British Thoracic Society
             References
• Thorax, 1997; 52(suppl 5): S1-S32
• Common Diseases, Fry, MTP, 1995.
          Prevention
•   Fags
•   Fags
•   Fags
•   Pollution
•   Occupational factors
•   ? Housing
              Questions
• Should practices have spirometers?
• Or open access to lung function clinics?
• Should practice nurses run regular
  follow-up clinics?
• How should a practice audit this area?
• Should practices have smoking cessation
  clinics?