COPD

1. COPD Alex Gibbins

2. Contents • Numbers • Assessment • Management – NICE guideline CG101 June 2010 • When to refer

3. Numbers • 835000 in UK have COPD • Up to 2 million un-diagnosed • 2nd commonest cause of emergency hospital admission • 30,000 deaths per year • 60% of NHS costs due to unscheduled care

4. Consider it in people who… • Over 35, smoker / ex-smoker with: • Exertional SoB • Chronic cough • Regular sputum production • Frequent winter ‘bronchitis’ • Wheeze • AND do not have features of asthma (variability, nocturnal dry cough etc)

5. Investigations • Spirometry • CXR • FBC

6. Assessment of severity Degree of airflow obstruction (FEV1/ FVC ratio <0.7): Stage 1 — mild: FEV1 80% of predicted value or higher (symptoms must be present). Stage 2 — moderate: FEV1 50–79% of predicted value. Stage 3 — severe: FEV1 30–49% of predicted value. Stage 4 — very severe: FEV1 less than 30% of predicted value.

7. MRC dyspnoea scale • Not troubled by breathlessness except during strenuous exercise • Short of breath when hurrying or walking up a slight hill • Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace • Stops for breath after walking about 100 m or after a few minutes on the level • Too breathless to leave the house, or breathless when dressing or undressing

8. Calculate BMI • Assess for Cor Pulmonale: • Peripheral oedema. • Raised jugular venous pressure. • Systolic parasternal heave. • A loud pulmonary second heart sound (over the second left intercostal space). • Widening of the descending pulmonary artery on chest X-ray. • Right ventricular hypertrophy on electrocardiography. • Smoking history • Screen for depression

9. Management

10. http://cks.nice.org.uk/chronic-obstructive-pulmonary-disease#!scenariorecommendation:13http://cks.nice.org.uk/chronic-obstructive-pulmonary-disease#!scenariorecommendation:13 • http://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease#path=view%3A/pathways/chronic-obstructive-pulmonary-disease/inhaled-therapy-in-copd.xml&content=view-index

11. Referrals

12. Pulmonary Rehab • If MRC dyspnoea or above 3 or above • If admitted with an exacerbation • BUT NOT if: • Recent MI / Unstable angina / Poor mobility

13. Oxygen Oxygen saturation less than or equal to 92% breathing air. • Very severe airflow obstruction (forced expiratory volume in 1 second [FEV1] less than 30% predicted). • Cyanosis. • Secondary polycythaemia (erythrocytosis). • Peripheral oedema. • Raised jugular venous pressure. • Consider referring people with severe airflow obstruction (FEV1 30–49% predicted) for assessment for the need for LTOT. • Optimize medical treatment before referral. • Warn people using oxygen not to smoke because of the risk of fire or explosion.

14. Respiratory • Diagnostic uncertainty. • Referral may be needed for this reason for black and Asian people, for whom normal ranges for forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) are not known. • COPD that is very severe (for example FEV1 less than 30% predicted) or worsening (rapid decline in FEV1). • Continued smoking, if the primary healthcare professional considers that referral would increase the likelihood of smoking cessation. • The person with COPD requests a second opinion. • Cor pulmonale.

15. Dysfunctional breathing (abnormal breathing patterns associated with anxiety). • Onset of symptoms at an age younger than 40 years, or a family history of alpha1-antitrypsin deficiency. • Frequent infections. • Symptoms disproportionate to lung function. • For pulmonary rehabilitation (for a person who considers themselves functionally disabled by COPD), if direct referral is not possible. • For assessment of the need for: • Long-term oxygen therapy , ambulatory oxygen therapy, or short-burst oxygen therapy. • Nebulizer therapy or long-term oral corticosteroids. • Lung surgery (for example, for a person with bullous lung disease who is still symptomatic on maximal therapy).