Download Case based discussion of COPD guidelines 2004

Case based discussion of COPD
guidelines 2004
Diagnosis
Dr Anne McGown
Mar 2008
Case 1
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Mrs J.W
Aged 81
complaining about SOB on 50-100yards
SOB 1 flight of stairs
no cough or sputum
no antibiotics for chest
Hypertension, no IHD, no childhood asthma
What associated
symptoms/factors should you ask
about
What associated
symptoms/factors should you ask
about
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Weight loss
waking at night
ankle swelling
fatigue
occupational hazards
chest pain*
haemoptysis*
How can you grade
breathlessness?
MRC Dyspnoea scale
• 1 Not troubled by breathlessness except on strenuous
exercise
• 2 Short of breath when hurrying or walking up a slight
hill
• 3 Walks slower than contemporaries on level ground
because of breathlessness, or has to stop for breath when
walking at own pace
• 4 Stops for breath after walking about 100m or after a
few minutes on level ground
• 5 Too breathless to leave the house, or breathless when
dressing or undressing
SH
• Lives alone
• Ex-waitress/barmaid
• gave up smoking aged 65, started in her
teens and smoked 10/day = 25 pack years
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Eprosartan
Aspirin
Omacor
bendrofluazide
doxazosin
serevent
Examination
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No clubbing or oedema
pulse 72 and regular
heart sounds normal
chest clear
CXR - NAD
FEV1 1.13 53% pred
FVC 1.5l 64% pred, ratio FEV1/FVC 74%
Differential diagnosis?
Differential diagnosis?
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Respiratory - asthma/COPD
Cardiac
Anaemia
Other rare
Flow volume loop
Case 1
Main differential
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Asthma
COPD
Peak flow chart no variation
Mild COPD
Improved with addition of tiotropium (could
walk and talk at the same time which was
what she wanted)
• Discharged.
Spirometry
• (a) - normal
• (b) - obstructive
– dashed - asthma after
bronchodilator
• (c) - restrictive
compared to normal
– From Johns Pocket
Guide to Spirometry
Spirometry
• Airflow obstruction if FEV1/FVC <0.7
– FEV1<80% predicted
• Severity of airflow obstruction
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mild - FEV1 50-80% predicted
moderate - FEV1 30-49% predicted
severe - FEV1 <30% predicted
spirometry predicts prognosis in COPD, but not
disability or quality of life
Spirometry in COPD
• COPD definition - presence of airflow
limitation that is not fully reversible and
does not change markedly over several
months.
• Distinguish from asthma on basis of history,
examination, longitudinal observation (+/reversibility testing and PEFR charts).
• Chest pain and haemoptysis, or
disproportionate SOB/cyanosis in mild
cases - look for alternative diagnosis
Spirometry in COPD
• The pitfalls (a) normal
• (b) obstructive
– From Johns Pocket
Guide to Spirometry
Flow volume loops
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(a) Normal
(b) - asthma
(c) - emphysema
(d) - restrictive
(e) - upper airway
obstruction
Spirometry summary
• Obstructive useful
• May miss diagnosis if technique poor or
severe disease
• Restrictive less useful as more sensitive to
technique, and cannot distinguish intrinsic
lung disease from extrinsic lung disease
(esp. obesity also chest wall, muscle)
Spirometry does not predict
disability
• Other prognostic factors
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Frequency of exacerbation
FEV1 and TLCO
MRC breathlessness
Health status
Exercise capacity
BMI
Arterial pO2
Cor pulmonale
Case 2
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Mr CG
Age 66
Admitted acutely SOB
No chest pain or palpitations
History of wheeze with chest infections for
several years
• Ex smoker
Examination findings
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Tachypnoea
Saturations 85% on air
Tachycardia 150bpm AF
Raised JVP and peripheral oedema
Widespread wheeze
Bilateral inspiratory crackes
What are the possible causes of
SOB?
What are the possible causes of
SOB?
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LVF
Decompensation from fast AF
COPD
Cor pulmonale
How can you distinguish cardiac and
respiratory causes?
How can you distinguish cardiac and
respiratory causes?
• Echo – good biventricular function, LVEF
65%, normal valves, mild TR
• ECG – no ischaemic changes
• Spirometry – FEV1 1.62 (38% predicted),
FVC 3.09, ratio FEV1/FVC 52%
• ABG when not acutely SOB – pH 7.426,
pO2 6.31, pCO2 7.19 SaO2 82%
• CXR
Treatment at discharge
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Combivent
Ramipril
Furosemide
Bisoprolol
Digoxin
Spironolactone
Treatment of cor pulmonale
• LTOT assessment
• Diuretics
• No evidence for ACEI, calcium channel
blockers, alpha blockers or digoxin unless
AF,
Follow up
• Definite symptomatic improvement when
ramipril dose increased
• Still SOB on short distances
• Minor improvement in spirometry – still
obstructive
• Sats improved to 92% on air – not keen on
ambulatory oxygen assessment
Case 3
• Age 46 female
• Admitted with wheeze, productive cough,
fever
• Quite slow to recover – 4-5days as IP
• Smoker
• Operation for scoliosis aged 12
• Discharged on combivent and becotide
• Seen in OPD in 6 weeks
• Felt back to normal, but still SOBOE
What sort of defect do you think
her spirometry showed?
What sort of defect do you think
her spirometry showed?
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Mixed defect
FEV1 1.10 (41% pred)
FVC 1.54 (49% pred)
FEV1/FVC 71%
After ventolin
FEV1 1.45l (132%)
PEFR from 170 to 240
sats 97% on air
How would you distinguish
asthma and COPD in this
patient?
How would you distinguish
asthma and COPD in this
patient?
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Spirometry alone cannot separate
clinical features
longitudinal variation
bronchodilator response (>400ml)
Steroid response (>400ml)
PEFR variability >20%
Clinical features
COPD
Asthma
Smoker or ex smoker Nearly all
Possibly
Symptoms under age
35
Rare
Often
Chronic productive
cough
Common
Uncommon
Breathlessness
Persistent and
progressive
Variable
Night time waking
Uncommon
Common
Diurnal/day to day
variability
Uncommon
Common
Spirometric reversibility testing
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Not required routinely
May be inconsistent, not reproducible
Misleading unless change in FEV1 >400ml
Arbitrary definition of significant change
Response to long term therapy not predicted
by acute reversibility testing
COPD vs asthma
• Clinically significant COPD not present if FEV1
and FEV1/FVC ratio return to normal with drug
therapy
• Imaging and TLCO may help resolve difficult
cases
• TLCO (gas transfer) may be reduced in COPD and
may be increased in asthma.
• Clinical history as good as bronchial biopsies……
Opportunistic case finding
• Knowledge of abnormal lung function as part of a
motivational package significantly affects the
success of smoking cessation therapy.
• Cost effectiveness depends on prevalence of
undetected COPD and smoking cessation success
rate.
• Over 35 current or ex smokers with a chronic
cough.
Specialist referral - 1
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Diagnostic uncertainty
Suspected severe COPD
Patient requests second opinion
Onset of cor pulmonale
Assessment for oxygen therapy
Assessment for nebuliser
Assessment for long term oral steroids
Specialist referral - 2
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Bullous lung disease
Rapid decline in FEV1
Assessment for pulmonary rehab
Assessment for thoracic surgery
Dysfunctional breathing
Aged under 40
Frequent infections
Haemoptysis
Summary
• Spirometry – pitfalls
• Assessing severity
• Main differentials – asthma and cardiac
failure
• Reasons for specialist referral