Diagnosis

• RED FLAG: haemoptysis
• Excertional breathlessness (progressive whereas asthma variable)
• No diurnal variation or night time symptoms (unlike asthma)
• >35 (if under likely asthma)
• Smoker (possibly asthma but likely COPD)
• Regular sputum
• Chronic cough (asthma rarely)
• Wheeze
• Winter bronchitis
• Cor pulonale: peripheral oedema, raised venous pressure (JVP), loud 2^nd heart sound

Investigation

• Spirometry: FEV1 & FEV1/FVC–note does not correlate to disability (heterogeneous disease)
  • FEV1/FVC <0.7
  • FEV1 vs % predicted
  • 50-80 Mild
  • 30–50 Moderate
  • <30 % Severe
• Reversibility: post bronchodilator spirometry to exclude asthma, or domiciliary PEFR if doubt remains. Don’t over-rely on single measure, nor test routinely, unless change in FEV1 >400 mls
• Consider alternate diagnoses if asymptomatic elderly and FEV1/FVC <0.7, or symptomatic young and >0.7
• Chest X ray to exclude other pathology
• FBC exclude anaemia or polycythaemia
• BMI
• Alpha 1 anti-trypsin if early onset
• TLCO and CT if symptoms disproportionate to spirometry impairment
• ECG and Echo cardiography to elicit symptoms of cor pulmonale
• Pulse Oximetry
• Sputum Culture

Management

• MDT approach: Assessment, rapid access units, respiratory nurse specialist, physiotherapy with positive expiratory mask for sputum clearance and breathing techniques, anxiety and depression, GP assessment at least annually

Conservative

• Smoking cessation, offer NRT Bupropion or Varenicline
• Vaccination: Pneumoncoccal and annual influenza
• Advice regarding air travel if FEV1 vs predicted <50%

Pharmacological

• STEP 1: SABA or SAMA, oral steroid should NOT be used for reversibility testing
• STEP 2: Stable COPD who remain breathless
• If FEV1 ≥ 50% predicted: either long-acting beta2 agonist (LABA) or LAMA, if still breathless + ICS
• If FEV1 <50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA
• If decline ICS then LABA + LAMA
• Inhaler best method, train patient and regularly assess ability to use
• Spacer single actuation, followed by breath or tidal breathing
• Nebuliser in distress or disabling breathlessness
• Oral corticosteroids: not recommended for long term maintenance, but for acute exacerbation in hospital
• Theophylline: only used following trial of SABA, LABA and unable to use inhaler OR in combination if symptomatic on monotherapy
• Mucolytics: chronic productive sputum cough

Oxygen:

• Assess need for Long term oxygen therapy (LTOT) if:
• Severe obstruction FEV1 <30% predicted
• Cor pulmonale
• Polycythaemia
• Peripheral oedema
• Cyanosis
• Raised JVP
• Sats <=92% on room air
• LTOT is indicted if PaO2 <7.3 kpa (2 x ABG 3 wks apart) when stable, or <8 kpa if nocturnal hypoxaemia, sats <90% for 30% time, and has one of:
• Secondary polycythaemia
• Nocturnal hypoxaemia (sats <90% for 30% time)
• Peripheral oedema
• Pulmonary hypertension
• LTOT: to get benefit needed >15 hrs a day, ambulatory oxygen offered if exercise desaturation

Cor pulmonale: LTOT and diuretics but NOT ACE, alpha blockers, digoxin nor CCB

Non invasive ventilation

• Type 2 respiratory failure PaCO2 >7.3 kpa

Surgery

• Bullectomy if apparent on CT and FEV1 <50%
• Lung volume reduction if PaCO2 <7.3 kpa and upper lobe predominant disease

Exacerbation

• GP: pulse oximetry, not routine sputum culture
• Hospital: chest X-ray, ABG, FBC, U+E, culture sputum if purulent, blood cultures if pyrexial

NICE Source: CG101 Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.