Case 3: Lung function test

68 yr old male came for regular check up.

He had a lung function test last year.

He used to be a heavy smoker, quit last year. His exercise tolerance is limited to around 50m.

What is your diagnosis ?

With a long smoking history and shortness of breath, this lung function indicates Chronic Obstructive Pulmonary Disease (COPD) . COPD is confirmed by the presence of persistent airflow limitation. FEV1/FVC < 0.7.

The problem we are having now is that we over diagnose people with COPD. Around 20-30% of patients who have a diagnosis of COPD has never had spirometry. Remember, COPD is a spirometry diagnosis.

What are your differential diagnoses?

COPD has many causes including asthma, smoking, occupation exposures, and anti tripsin 1 deficiency.

Is this severe disease ?

The current classification from lung foundation Australia classify this patient with severe disease.

How would you manage this patient?

This patient requires multi-disciplinary approach. 

1. GP management plan and TCA
2. Prevention of exacerbation: flu vaccination and pneumococcal vaccination
3. Stop smoking 
4. Optimise medications: use COPD stepwise treatment flowchart (link)
5. COPD action plan 
6. Refer to lung rehabilitation or physiotherapist or exercise physiologist to improve lung function 
7. Regular review and assess inhaler techniques 

According to the latest COPD guideline, severe COPD with more than 2 exacerbations per year should be managed by LABA + Inhale corticosteroid. 

Reference:

1. COPD-X concise guideline