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?