COPD

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Dr Gerard Meachery
2
 The objectives of the pre-anaesthetic
assessment

• Evaluate the patients medical condition from
  medical history, physical examination,
  investigations and, when appropriate, past
  medical records
•  
• Optimise the patients medical condition for
  anaesthesia and surgery
• Determine and minimise risk factors for
  anaesthesia
• Plan anaesthetic technique and peri-operative
  care
• Develop a rapport with the patient to reduce
  anxiety and facilitate conduct of anaesthesia
• Inform and educate the patient about anaesthesia,
  peri-operative care and pain management
• Obtain consent for anaesthesia

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Guidelines on the radical management of patients
with lung cancer

• Lim E, Baldwin D, Beckles M, et al. Thorax 2010,
  65 Suppl III, iii1-iii27
• A joint initiative by the British Thoracic
  Society and the Society for Cardiothoracic
  Surgery in Great Britain and Ireland undertaken
  to update the 2001 guidelines for the selection
  and assessment of patients with lung cancer who
  can potentially be managed by radical treatment

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Guidelines on the radical management of patients
with lung cancer

• 2.1.3 Assessment of lung function
• 43. Offer surgical resection to patients with low
  risk ofpostoperative dyspnoea. C
• 44. Offer surgical resection to patients at
  moderate to high riskof postoperative dyspnoea
  if they are aware of and accept therisks of
  dyspnoea and associated complications. D
• 47. Consider using shuttle walk testing as
  functional assessmentin patients with moderate
  to high risk of postoperativedyspnoea using a
  distance walked of gt400 m as a cut-off forgood
  function. C
• 48. Consider cardiopulmonary exercise testing to
  measure peakoxygen consumption as functional
  assessment in patients withmoderate to high risk
  of postoperative dyspnoea using gt15 ml/kg/min as
  a cut-off for good function. D

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Guidelines on the radical management of patients
with lung cancer

• 49. RR Further studies with specific outcomes are
  required to define the role of exercise testing
  in the selection of patients for surgery
• 51. Avoid taking pulmonary function and exercise
  tests as sole surrogates for quality of life
  evaluation. C

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Pulmonary Function Testing
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Objectives

• Categorise PFTs according to specific purposes
• Identify at least one indication for spirometry,
• lung volumes, and diffusing capacity
• Obstructive and restrictive ventilatory defects
• Relate respiratory history to indications for
• performing pulmonary function tests

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Pulmonary Function Testing

• Establish baseline lung function and evaluate the
  presence or absence of lung disease
• Evaluate symptoms of dyspnoea
• Evaluate if the lung disease is primarily an
  obstructive, restrictive or mixed ventilatory
  defect
• Quantify the respiratory impairment and monitor
  the extent of known disease on lung function
• Monitor effects of therapies used to treat
  respiratory disease

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Pulmonary Function Testing

• Evaluate operative risk
• Perform surveillance for occupational-related
  lung disease
• Evaluate disability or impairment
• Assess for reversible components to optimise a
  patients clinical status

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Spirometry

• Forced expiratory volume in 1 second (FEV1)
• Volume exhaled in the first second of an FVC
  manoeuvre
• (forced exhalation from maximal inspiration)
• Vital capacity (VC)
• Total volume exhaled by a exhalation from maximal
  inspiration
• Can be a forced exhalation (FVC) or a relaxed
  exhalation (RVC) best one taken as VC
• FEV1/VC
• Ratio between FEV1 and VC

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Pulmonary Function Testing

• In normal spirometry, FVC, FEV1, and FEV1 -to-FVC
  ratio are above the lower limit of normal
• The lower limit of normal is defined as the
  result of the mean predicted value
• (based on the patient's sex, age, and height)

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Spirometry
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Reduction in FEV1

• Airway obstruction is the most common cause of
  reduction in FEV1
• Airflow obstruction may be secondary to
• Bronchospasm (Asthma/ COPD)
• Airway inflammation (Asthma/ COPD/
  Bronchiectasis)
• Loss of lung elastic recoil (Emphysema)
• Increased secretions in the airway (Bronchitis/
  Bronchiectasis/ Infection)

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Assessing reversibility in airway obstruction

• Response of FEV1 to inhaled bronchodilators is
  used to assess the reversibility of airway
  obstruction (Post Bronchodilator challenge)
• Methacholine Challenge used to assess possible
  underlying asthma, (ie reversible airway
  obstruction).
• Baseline lung function may be normal when the
  patient is clinically stable.

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Assessing reversibility in airway obstruction

• Gibson Resp Med
• 12 or 200ml

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Reversible Airway Obstruction
Spirometry Predicted Measured Post BD
FEV 1 (l) 2.8 2.43
VC (l) 3.79 3.75
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Reversible Airway Obstruction
Spirometry Predicted Measured Post BD
FEV 1 (l) 2.8 2.43 2.73
VC (l) 3.79 3.75 4.02
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Indications for Lung Volume Tests

• Diagnose or assess the severity of restrictive
  lung disease
• Differentiate between obstructive and restrictive
  disease patterns
• Assess the response to therapy
• Make preoperative assessments of patients with
  compromised lung function

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Static lung volumes

• Total lung capacity (TLC)
• Total volume of air in the lungs at the end of an
  maximal inspiration
• Residual volume (RV)
• Volume of air remaining in the lungs at the end
  of a maximal expiration
• Functional residual volume (FRC)
• Volume of air remaining in the lungs at the end
  of tidal expiration

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Lung Volumes
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Reduction in FVC

• A reduced FVC on spirometry in the absence of a
  reduced FEV1 -to-FVC ratio suggests a restrictive
  ventilatory defect
• An inappropriately shortened exhalation during
  spirometry can (and often does) result in a
  reduced FVC
• (i.e. Patient effort is important)

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Causes of Abnormal Lung Volumes

• Raised TLC
• COPD esp. emphysema
• Transiently raised during an asthma exacerbation
  or in the recovery phase of an asthma
  exacerbation
• Increased RV
• Airways disease (air-trapping), e.g. asthma or
  emphysema
• Reduced TLC/ FVC/ RV
• Restrictive defect
  (intrapulmonary or extrapulmonary)

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Diffusion Capacity/ Transfer Factor

• The diffusing capacity is a measure of the
  conductance of the CO molecule from the alveolar
  gas to Haemoglobin in the pulmonary capillary
  blood
• CO (and oxygen) must pass through the alveolar
  epithelium, tissue interstitium, capillary
  endothelium, blood plasma, red cell membrane and
  cytoplasm before attaching to the Haemoglobin
  molecule

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Diffusion Capacity
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Indications for Diffusion Capacity

• Evaluate or follow the progress of parenchymal/
  interstitial lung disease
• Evaluate pulmonary involvement in systemic
  disease
• Evaluate obstructive lung disease
• Quantify disability associated with interstitial
  lung disease
• Evaluate pulmonary hemorrhage

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Diffusion capacity

• TLCO transfer factor for the lung for carbon
  monoxide i.e. Total diffusing capacity for the
  lung
• Same as DLCO
• KCO transfer coefficent i.e. Diffusing capacity
  of the lung per unit volume, standardised for
  alveolar volume (VA)
• VA Lung volume in which carbon monoxide
  diffuses into during a single breath-hold
  technique

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Abnormal Diffusion Capacity

• Low TLC
• Low TLCO
• Low/normal KCO
• Intrapulmonary restrictive defect
• Interstitial lung diseases
• Pulmonary oedema
• High TLC
• Low TLCO
• Low KCO
• emphysema

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Abnormal Diffusion Capacity

• Low TLCO
• but high/N KCO
• extrapulmonary restrictive defect
• Obesity
• Neuromuscular disease (respiratory muscle
  weakness)
• Pleural disease e.g. effusion, thickening, tumor
• Skeletal deformity
• Post pneumonectomy

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Abnormal Diffusion Capacity

• Normal/raised TLCO
• Raised KCO
• Asthma
• Pulmonary haemorrhage

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Obstructive Lung Disease

• Chronic Obstructive Pulmonary Disease (COPD)
• Chronic Bronchitis
• Excessive mucus production, with a productive
  cough on most days, for at least 3 months for 2
  years or more.
• Emphysema
• Primarily caused by cigarette smoking.
• Alpha -1-antitrypsin deficiency
• Environmental pollutants

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Working Definition of COPD
Chronic obstructive pulmonary disease (COPD) is
characterised by airflow obstruction. The airflow
obstruction is usually progressive, not fully
reversible and does not change markedly over
several months. The disease is predominantly
caused by smoking. Airflow obstruction is defined
as a reduced FEV1 (forced expiratory volume in 1
second) and a reduced FEV1/FVC ratio (where FVC
is forced vital capacity), such that FEV1 is less
than 80 predicted and FEV1/FVC is less than 0.7.
(www.nice.org.uk/CG012NICEguideline)
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Chronic Obstructive Pulmonary Disease (COPD)

• Characterized by
• Dyspnoea at rest or with exertion
• Productive cough
• Barrel-chest (?AP to Transverse diameter)
• Chest percussion Hyper resonant
• Chest auscultation Breath sounds distant or
  absent
• Chest X-Ray
• Flattened diaphragms
• Hyperinflated lung fields/ bullae

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Emphysema

• Spirometry
• Reduction in FEV1
• Reduction in FEV1/ VC ratio
• Lung Volumes
• Increased lung volumes (air trapping)
• Diffusing Capacity
• Reduced

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Obstructive Lung Disease

• Asthma
• Airway obstruction is characterized by
  inflammation of the mucosal lining of the
  airways, bronchospasm and increased airway
  secretions
• Reversible airway obstruction

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Obstructive Lung Disease

• Asthma Triggers
• Exercise/ Cold air
• Allergic agents
• Pollens, house dust mite, animal dander, moulds
• Non-allergic agents
• Viral infections, environmental pollutants,
  medication, food additives, emotional upset
• Occupational exposure
• Cotton/ wood dusts, grains, metal salts,
  insecticides

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Obstructive Lung Disease

• Asthma
• During Attacks
• Peak Flow (PEF) is reduced/ Hypoxia
• Response to bronchodilators
• Spirometry
• Reduced FEV1
• Lung Volumes
• Increased (Hyperinflation)
• Diffusion Capacity
• Normal
• During stable state Spirometry may be normal

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Causes of Restrictive Spirometry

• Pulmonary fibrosis
• Pleural effusion
• Pleural tumors
• Lung resection (lobectomy/ pneumonectomy)
• Diaphragm weakness or paralysis
• Neuromuscular disease
• Kyphoscoliosis
• Obesity
• Inadequate respiration secondary to pain
• Congestive heart failure
• Ascites
• Pregnancy

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Restrictive Lung Disease

• Idiopathic Pulmonary Fibrosis
• Or secondary to
• Treatment with bleomycin, cyclophosphamide,
  methotrexate or amiodarone
• Autoimmune diseases Rheumatoid arthritis,
  systemic lupus erythematousus (SLE), scleroderma
• Sarcoidosis
• Pneumoconiosis
• Silicosis Silica dust
• Asbestosis Asbestos fibers

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Restrictive Lung Disease

• Idiopathic Pulmonary Fibrosis
• Increasing exertional dyspnoea
• Dry cough
• Finger clubbing
• Inspiratory crackles on auscultation
• Chest X-Ray
• Interstitial infiltrates are visible
• Honeycombing pattern

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Restrictive Lung Disease

• Idiopathic Pulmonary Fibrosis
• Spirometry
• Reduced VC
• Lung volumes
• Reduced TLC/ RV
• Diffusion capacity
• Reduced

43
Diseases of Chest Wall and Pleura

• Disorders involving the chest wall or pleura of
  the lungs result in restrictive ventilatory
  defects on pulmonary function testing. But, lung
  parenchyma is not affected.

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Diseases of Chest Wall and Pleura

• Spirometry
• Reduced FEV1 and FVC
• Lung Volumes
• Reduced TLC
• Diffusion Capacity
• Reduced
• KCo
• Normal

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Obstructive v. Restrictive
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Mixed Picture

• Bronchiectasis
• Pathologic and irreversible dilatation of the
  bronchi, resulting from destruction of the
  bronchial wall by severe, repeated infections and
  inflammation

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Bronchiectasis

• Post infective
• Whooping cough/ TB
• Genetic
• Cystic Fibrosis/ Primary Cliliary Dyskinesia
  (PCD)
• Immunodeficiency

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Bronchiectasis

• Dyspnoea
• Significant productive cough
• Purulent, foul smelling sputum
• Haemoptysis
• Frequent pulmonary infections
• Chronically unwell
• Chest X-Ray / CT Scan
• Airway Dilation

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Airway Function Tests
Flow Volume Loop (FVL)
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Airway Function Tests

• Flow Volume Loop (FVL)

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Respiratory History

• Dyspnoea Do you get short of breath at the
  following times
• At rest? On exertion? At night?
• Progression of dyspnoea
• Cough Do you ever cough?
• In the morning? At night?
• Dry or productive?
• Blood?
• Sputum/ Phlegm? (Color, volume, consistency)
• Chest pain/ Orthopnoea/ Paroxysmal Nocturnal
  Dyspnoea
• Family history of lung disease
• Past History
• TB/ Emphysema/ Chronic Bronchitis/ Asthma
• Recurrent lung infection/ Pneumonia or pleurisy
• Allergies or hay fever

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Respiratory History

• Current Medications
• Inhalers/ Steroids/ Nebulised bronchodilators or
  antibiotics/ Oxygen/ Mucolytics
• Cardiac medications
• Oncology drugs or immunosuppressives
• Smoking Habits
• Cigarettes/ Cigars/ Pipe/ Illicit drugs
• How many years?
• Current or ex smoker?
• Occupation
• Asbestos (Direct/ Bystander exposure)
• Mining, quarry, foundry

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Invisible Lives Report - BLF

• The disease is far from invisible statistically
  it is the UKs fifth biggest killer disease,
  claiming more lives than breast, bowel or
  prostate cancer (estimated 30 000 lives/ year)
• 2. The second most common cause of emergency
  admission to hospital and one of the most costly
  inpatient conditions treated by the NHS
• 3. It is estimated that the direct cost of
  providing care in the NHS for people with COPD is
  almost 500 million a year more than half of
  which relates to hospital care

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Invisible Lives Report - BLF

• The epidemiological evidence published in 2006
  suggesting that out of an estimated 3.7 million
  people in the UK with COPD, only 900,000 were
  currently diagnosed and receiving treatment and
  care
• 2. The remaining 2.8 million people were still
  unaware they had a disease which, if left
  untreated, could severely restrict their lives
  and would eventually kill them

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Diagnosis

• Clinical suspicion in patients (usually smokers
  or ex-smokers, age gt35yrs) with
• exertional breathlessness
• chronic cough
• regular sputum production
• frequent winter bronchitis
• wheeze with a risk factor (usually smoking)
• Airflow obstruction should be confirmed with
  spirometry

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Spirometry for COPD Diagnosis NICE 2010

• FEV1 lt80 predicted
• Post Bronchodilator FEV1FVC ratio lt0.7
• Stage 1 Mild FEV1 80 ( Symptoms)
• Stage 2 Moderate FEV1 50-79
• Stage 3 Severe FEV1 30-49
• Stage 4 Very Severe FEV1 lt30
• or
• Stage 4 Very Severe FEV1 lt50
• 
  (Respiratory Failure)

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General principles of management of stable COPD
NICE guidelines

• Lifestyle modification
• Smoking cessation
• (Behavioural support/ Nicotene replacement/
  Bupropion/ Varenicline)
• Pulmonary rehabilitation
• Optimisation of pharmacological therapies
• Inhalers
• Short-acting bronchodilators
• Long-acting bronchodilators regularly, often
  combined with
• Corticosteroids (FEV1 lt/ 50 with 2
  exacerbations requiring antibiotics or oral
  steroids in 1 year)

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Maintenance therapy with budesonide and
formoterol in chronic obstructive pulmonary
diseaseCalverley et al. Eur Respir J
200322912919.
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Seretide reduces the rate of exacerbations
needing medical intervention
per patient per year
mean exacerbation rate
Adapted from Calverley PM. et al.N Engl J Med
2007356775-89.
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General Principles of Guidelines

• Theophylline, oral steroids, diuretics,
  mucolytics
• Prophylaxis
• Immunisations (influenza, pneumococcus, H1N1)
• Long Term Oxygen Therapy (LTOT)
• Surgery
• Bullectomy, lung volume reduction, transplant
• Management of anxiety and depression
• Palliation and end of life support

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General Principles - in addition

• Early detection Patient education Smoking
  cessation
• Treatment of acute exacerbations
• Pulmonary Rehabilitation
• Increases threshold for perception of dyspnoea
• Improves quality of life
• Substantially reduces health care costs
• Under resourced
• NIPPV
• Reduces need for invasive ventilation
• Reduces admissions
• Bridging measure prior to surgery
• Under resourced

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Referral for Specialist advice - NICE

• Diagnostic uncertainty
• Suspected severe COPD
• Onset of cor pulmonale
• Assessment for oxygen therapy, long-term
  nebuliser
• therapy or oral corticosteroid therapy
• Bullous lung disease
• Rapid decline in FEV1
• Assessment for pulmonary rehabilitation

• Assessment for lung volume reduction surgery or
  transplantation
• Patient aged under 40 years or a family history
  of alpha-1
• antitrypsin deficiency
• Symptoms disproportionate to lung function
  deficit
• Frequent infections
• Haemoptysis

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Complications of COPD

• Respiratory failure
• Cor pulmonale
• Bullae
• Pneumothorax
• Pneumonia
• Increased risk of malignancy (shared risk factor)

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Preoperative measures

• Cessation of cigarette smoking for at least 8
  weeks before surgery
• Treat airflow obstruction
• Treat respiratory infection if present
• Educate for lung-expansion manouvres
• Mucolytics/ Physiotherapy and chest clearance
• Postoperative measures
• Epidural analgesia or intercostals nerve bloc for
  pain control
• Early mobilization
• Chest physical therapy (including deep breathing
  and incentive spirometry)
• Continuous positive airway pressure in selected
  patients

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Pre Operative Assessment

• Be wary of a presumed diagnosis of lung disease
  
• Beware of no previous diagnosis of known lung
  disease
• Evaluate lung function systematically
• Careful history and examination
• If in doubt..
• Find a friendly respiratory physician