COPD

Chronic Obstructive
Pulmonary Disease (COPD)
In module IGCP
You are working in a GP surgery. Your next
patient is Mrs Irene Smith, who is 65 years
old. You note that she has a past medical
history of hypertension for which she takes
Ramipril, but apart from that she is an
infrequent visitor to the surgery. You note
that she had a DVT diagnosed after the birth
of her second child but has not had any
problems with blood clots since then.

COPD – Themed Case Introduction

In case Chronic Obstructive Pulmonary
Disease (COPD)
Introduction
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Case introduction
You are working in a GP surgery. Your next
patient is Mrs Irene Smith, who is 65 years
old. You note that she has a past medical
history of hypertension for which she takes
Ramipril, but apart from that she is an
infrequent visitor to the surgery. You note
that she had a DVT diagnosed after the birth
of her second child but has not had any
problems with blood clots since then.

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What are your initial thoughts about

Irene’s problems based on the
information so far? What other questions
would you like to ask Irene at this point
that might help you make a differential
diagnosis?

Irene is describing shortness of breath on

exertion. The differential diagnosis of
shortness of breath is huge, but Irene also
mentions symptoms in keeping with a chest
infection. This might prompt us to think that
she may be developing a problem with her
respiratory system.

We might therefore want to keep the

following diagnoses in mind as we ask Irene
some more questions:

· asthma, COPD
· Pulmonary embolism (given previous
history of DVT)
· Reaction to Ramipril
· Lung fibrosis
· Angina
· Restrictive lung disease, pulmonary
fibrosis
Remind yourself of which history taking
questions in a respiratory and cardiac
history will help differentiate the possible
diagnoses.

Why is it relevant to ask about Irene’s

smoking? How do you take a smoking
history?

Irene may well have a smoking-related lung

disease, therefore it is very important to take
a smoking history. Taking a detailed smoking
history entails finding out the following
information.

Are they a current smoker?

What age did they start smoking?

Do they smoke cigarettes or roll-ups?

How many cigarettes a day do they smoke?

(if they smoke roll-ups, how much tobacco is
used in a week?- half an ounce of tobacco is
around 20 cigarettes)

Have they ever smoked more or less than

they do now?

Any breaks from smoking?

Have they ever tried to give up?

Does anyone else in the house smoke i.e are

they a passive smoker?

What is a “pack year”?

A “pack year” is a way of quantifying an

individuals’ exposure to tobacco over time.

It is calculated by multiplying the number of

packs of cigarettes smoked per day by the
number of years smoked. For example, a
person who smokes 20 cigarettes per day (ie
one pack) for 10 years will have a 10 pack-
year smoking history.

A person who has smoked 40 cigarettes per

day (cpd) for 30 years will have a 60 pack-
year history.

What is Irene’s pack year smoking history?

What is Irene’s pack year smoking

history?

Irene has smoked 20 cpd from the ages of 15

to 60, and then 10 cpd from 60-65.

Therefore her pack year history will be 45 X 1

+ 0.5 X 5 = 47.5 pack years

What is your differential diagnosis?

At this stage, the differential diagnosis could

be chronic obstructive airways disease,
asthma, or extrinsic allergic alveolitis
(although the history does not reveal any
triggers for this, so makes it less likely). Heart
failure can cause wheeze, but she does not
give any symptoms of this in the history.

What investigations would you like to

request?

The most useful investigation at this point

would be lung function tests, but other
investigations should be considered such as
a chest x-ray and ECG.

Could you give any treatment at this

stage? PLEASE PAY ATTENTION TO

ETR -PLATFORM
Inhalers to treat a tight chest and wheeze
could be started, to provide Irene with some
symptomatic relief whilst we awaiting further
investigations.

You examine Irene

You find that her chest is slightly hyper
inflated, and she has a polyphonic expiratory
wheeze.

There is no clubbing and you can’t find any

enlarged lymph nodes.

Her heart sounds are normal and she

doesn’t have any pedal oedema.

After listening to Irene’s case, what is

your differential diagnosis?

The top differential diagnosis here is COPD,

but late onset asthma may also be a
possibility.

What are the indications for each of the

tests? What will they help show or
exclude?

A chest Xray will show any signs of infection

or pulmonary oedema. Lung function tests
will help determine whether Irene has an
obstructive or restrictive lung disease, and
whether there is any reversibility. An ECG
could demonstrate any evidence of
ischaemic heart disease, arrhythmia or signs
of right sided heart strain secondary to an
underlying lung condition.

What are the psychosocial issues

affecting Irene?

Irene has more than likely developed a chronic lung condition,

which is going to impact upon her everyday life. She will need to
make some changes to her lifestyle including stopping smoking,
which can be a very difficult habit to break. Her husband still
smokes which may cause more difficulty for Irene or potential
tension in the household. Her decline in lung function may be
permanent, restricting her current lifestyle. This may lead to
depression, and Irene’s GP should be vigilant for this.

COPD – Background Science

In case Chronic Obstructive Pulmonary
Disease (COPD)
There is a strong suspicion that Irene is
suffering from Chronic Obstructive
Pulmonary Disease. This is a disease almost
entirely caused by smoking. The hallmark
symptoms of COPD are:

· Shortness of breath
· Chronic cough
· Sputum production
Please watch the following video by
Professor Woodhead which gives an
excellent overview of the epidemiology,
pathophysiology, treatment and natural
progression of this disease.

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Spirometry
One of the tests used in diagnosing COPD is
spirometry. Spirometry machines measure
the volume and flow rate of inspiration and
expiration, and can therefore be used to
diagnose obstructive and restrictive lung
diseases. Modern Spirometers are portable
and available in nearly all GP practices. NICE
guidelines recommend that all patients
suspected of having COPD undergo
spirometry. It is therefore important that all
clinicians are able to interpret spirometry
results and graphs. Please look at the links
below, which explains spirometry in more
detail. It is important to have a clear
understanding of the definitions of FVC, FEV1
and FEV1/FVC

Pulmonary Function Tests – Spirometer

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Disease severity
The GOLD (Global Initiative for Chronic
Obstructive Lung disease) criteria are used
to classify the severity of COPD, according to
the degree of airflow limitation. Familiarise
yourself with the table below.

Treatment
There are pharmacological treatments
available for the management of COPD,
however the single most important
intervention is to stop smoking.

An overview of each of the pharmacological

treatments available is shown in the video
lecture below by Dr Cathy Armstrong. Please
note that this lecture also covers treatment
for asthma.

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Inhaler therapy forms an important part of
the treatment of stable COPD. Familiarise
yourself with the “Algorithm 2a: Use of
Inhaled therapies” table on page 56 of the
NICE guidelines.

What treatments are used for asthma,

COPD or both?

B2 agonists, Ipratroprium, inhaled

corticosteroids and tablet corticosteroids are
used for both asthma and COPD. In practice,
theophylline is not as commonly used for
asthma as it is for COPD, but can be
indicated in difficult cases. Magnesium
typically is used for treating an acute
exacerbation of asthma, but is also used in
an acute exacerbation of COPD.

Leukotriene receptor antagonists are only

used in asthma, whereas carbocisteine is
only used to aid sputum production in
COPD. Sodium cromoglicate is not often
used for asthma.

Can you give some examples of each of

the generic names for:

· ICS
· LABA
· LAMA
· Combination inhaler

· ICS:  Clenil, QVAR, pulmicort

· LABA: Serevent
· LAMA: Spiriva
· SAMA: Atrovent
· Combination inhaler: Seretide,
Symbicort, Fostair

COPD and Oxygen

Administration of oxygen to patients with

COPD requires careful consideration. Many
patients with COPD suffer from Type II
respiratory failure and therefore
administration of too much oxygen may be
detrimental. Arterial Blood Gases are used to
determine whether the patient is in Type I or
Type II respiratory failure, and whether it is
compensated or uncompensated.

What is the difference between Type I

respiratory failure and Type II respiratory
failure?

Type I respiratory failure is also known as

hypoxaemic failure, and is defined by a PaO2
of less than 8kPa. It indicates a serious
underlying pathology with the lungs such as
infection, oedema or a shunt.

Type II respiratory failure is also known as

ventilatory failure, results when PaCO2 is
more than 7. Reduced ventilatory effort can
be a result of gas trapping, such as in COPD
and severe asthma, due to chest wall
deformities, muscle weakness or central
causes of respiratory depression.

What is the pathological process that

leads to Type II respiratory failure in
COPD? What physiological compensatory
mechanisms occur in the body to reduce
the level of acidaemia?

In COPD the elastic recoil of the lungs is lost.

This causes gas trapping and reduced
excretion of carbon dioxide. In the blood, the
carbon dioxide combines with water to form
carbonic acid. In an acute setting, the
increased acid levels in the blood would
lower the pH levels and the patient would
become unwell very quickly. However when
carbon dioxide retention is progressive, as if
often the case in chronic COPD, the body can
compensate for this by utilising the
bicarbonate buffer system of the blood. The
kidneys are stimulated to reabsorb more
bicarbonate, which acts as a base and
neutralises the carbonic acid, thus restoring
the pH back to the normal range.

What are the clinical features of

hypercapnia?

· Dilated pupils
· Bounding pulse
· Hand flap