Investigations

Pulmonary function tests

The diagnosis and classification of COPD rest on objective demonstration of airways obstruction by spirometric testing. An abnormal FEV1 (< 80% predicted), with an FEV1/VC ratio of < 70% and little variation in serial PEF, strongly suggests COPD. A normal FEV1 excludes the diagnosis. The relationship between FEV1 and PEF is poor in COPD, and PEF in particular may under-estimate the degree of airflow obstruction in these patients.

Reversibility testing to salbutamol and ipratropium bromide is necessary to detect patients with substantial increases in FEV1 who really have asthma, and to establish the post-bronchodilator FEV1 which is the best predictor of long-term prognosis. Significant reversibility is defined as a 15% and at least 200 ml increase in FEV1. Evidence of a similar objective response to a course of oral prednisolone (30 mg daily for 2 weeks) should also be performed in all patients with COPD.

Alveolar underventilation causes a fall in PaO2 and often a permanent increase in PaCO2, especially in severe cases. Measurement of arterial blood gases should be performed in all patients with severe COPD (FEV1 < 40% predicted).

Imaging

COPD cannot be diagnosed on a chest radiograph but this investigation is useful in excluding other pathology. In moderate and severe COPD the chest radiograph typically shows hypertranslucent lung fields with disorganisation of the vasculature, low flat diaphragms or 'terracing' of the hemidiaphragms and prominent pulmonary artery shadows at both hila. Bullae may also be observed. CT can be used to quantify the extent and distribution of emphysema but its clinical value is currently restricted to the assessment of bullous emphysema and the potential for lung volume reduction surgery or lung transplantation. Patients with α1-antitrypsin deficiency typically display basal disease, compared with the predominantly apical disease seen in smokers with normal α1-antitrypsin levels

Haematology

Polycythaemia may develop but should not be assumed to be secondary without measurement of PaO2. Venesection may be considered if the haematocrit is above 0.55.

Management:

Reduction of bronchial irritation

It is of extreme importance that the patient who smokes should stop completely and permanently. Participation in an active smoking cessation programme, together with the use of nicotine replacement therapy, leads to a higher quit rate. In well-motivated patients bupropion (150 mg once daily increasing to 150 mg 12-hourly on day 7) commenced 1-2 weeks prior to stopping smoking is also a valuable adjunct to smoking cessation. Bupropion is contraindicated in those patients with a history of epilepsy or known CNS tumour and should only be used for 7-9 weeks

Dusty and smoke-laden atmospheres should be avoided; this may involve a change of occupation.

Treatment of respiratory infection

Respiratory infection should be treated promptly because it aggravates breathlessness and may precipitate type II respiratory failure in patients with severe airflow obstruction. Purulent sputum is treated with amoxicillin 250 mg 8-hourly (clarithromycin 250-500 mg 12-hourly if penicillin-sensitive) pending sputum culture results. Co-amoxiclav 375 mg 8-hourly should be used if there is no response or if a β-lactamase-producing organism is cultured. The usual causative organisms are Streptococcus pneumoniae or Haemophilus influenzae. A 5-10-day course of treatment is usually effective. Well-informed, reliable patients can be given a supply of one of these drugs and start a course of treatment on their own initiative when the need arises.

Continuous suppressive antibiotic treatment is not advised as it is apt to promote the emergence of drug-resistant organisms within the respiratory tract. Influenza immunisation should be offered to all patients each year.

Bronchodilator and anti-inflammatory therapy

Bronchodilator therapy with regular inhaled anticholinergic agents and short-acting β2-agonists taken as required provides useful symptomatic relief in the majority of patients. In moderate and severe COPD these agents should be used regularly and in combination, and low-dose inhaled steroids considered in patients with severe COPD and frequent exacerbations requiring hospital admission. These latter agents should not be used routinely (see EBM panel). Theophyllines and long-acting β2-adrenoceptor agonists are of limited value in COPD but may produce small increases in exercise tolerance and quality of life. There is no role for other anti-inflammatory drugs. It is vital to check inhaler use as many patients with COPD struggle to use metered-dose inhalers (MDIs) effectively; dry powder inhalers or large-volume spacer devices are often preferable. The use of home nebulisers to deliver high doses of bronchodilator drugs is controversial. Treatment is expensive and may have important side-effects; however, a few patients may show significant objective or subjective improvements with such treatment.

Long-term domiciliary oxygen therapy

Long-term low-concentration oxygen therapy (2 litres/min by nasal cannulae) decreases pulmonary hypertension, reduces secondary polycythaemia, improves neuropsychological health and, most importantly, prolongs life in hypoxaemic COPD patients. The most efficient method of providing oxygen in this way is by an oxygen concentrator. Low-concentration oxygen should be administered for 15 hours or more per 24 hours.

Surgical intervention

A very small group of patients are suitable for surgical intervention. Young patients, particularly those with α1-antitrypsin deficiency and severe disease, should be considered for lung transplantation (usually single-lung), and surgical removal of expanding or very large bullae may be indicated in some patients. Lung volume reduction surgery, in which the most severely affected areas of emphysematous lung are removed in order to improve pulmonary mechanics, particularly by enhancing diaphragmatic function, is currently under assessment.

4. Plan and organizational structure of educational sessions on discipline.

№ з/п	Stages of class	Time distribu-tion	Types of control	Equipment training
1.	The starting phase	15%
1.1.	Organizational matters	20-25 min.
1.2.	Formation of motivation
1.3.	Control of entry-level training		─ written computer testing; ─ oral questioning by the standardized list of questions.	─ textbooks treatment of internal diseases; ─ guidelines; ─ situational problem in therapy of internal medicine; ─ tests "Step 2";
2.	The main stage ─ demonstration of the patient - his clinical examination (history, physical examination, additional methods of investigation); ─ interpretation received symptoms	65% 120-130 mn.	─ practical skills at the bedside (collecting complaints, history of illness, physical examination, assessment of results of additional methods investigation); ─ interpretation of the results.	─ themed patients.
3.	The final stage	20%
3.1.	Control of the final level of training	25-30 min.	─ situational tasks; ─ structured written work.
3.2.	The total score of student workload
3.3.	Informing students about the topic the next lesson