College Answer

History: consider – exercise tolerance; ADLs; home O2 use; home CPAP/NIV use; respiratory medication use and compliance; steroid use; need for heart failure medication; frequency of hospitalisations or previous mechanical ventilation.

Examination: consider – steroid skin; cachexia / nutritional assessment; plethora secondary to polycythaemia.

Investigations:  consider – previous ABGs (degree of hypoxaemia/hypercapnoea/metabolic compensation); Electrolytes: especially tCO2 indicative of bicarbonate compensation of chronic hypercapnoea; previous spirometry (FEV1/FVC - degree of emphysema/hyperexpansion/evidence of left or right heart failure); formal Pulmonary Function Tests (DLCO/flow-vol loops); ECG (?chronic right heart strain pattern); Hb (polycythaemia secondary to chronic hypoxaemia).

Discussion

This question asks about the assessment of the severity of COPD.

Historical features

• exercise tolerance
• breathlessness with everyday activities
• presence of chronic cough
• high volume of sputum, suggestive of bronchiectasis
• haemoptysis, suggestive of malignancy
• home O2 requirement
• home CPAP requirement
• pattern of bronchodilator use
• pattern of steroid use
• frequency of hospitalisations
• previous mechanical ventilation
• anorexia and weight loss

Examination

• features of malnutrition
• features of obesity (sedentary lifestyle)
• features of chronic steroid use
• central cyanosis
• breathlessness at rest
• hyperexpanded chest
• degree of air entry
• signs of right heart failure

Investigations

• Bicarbonate levels
• Hb (polycythaemia)
• Spirometry, pre and post bronchodilator
• Formal lung function tests
• ABGs to determine degree of hypoxia and hypercapnea
• TTE (pulmonary pressures)
• High-resolution CT to assess the severity of emphysematous changes