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 2nd 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.