Edward is a 55 year old builder who has smoked cigarettes since his teens. He presents with a productive cough, says he is breathless when carrying bricks at work and this is the third winter when he has felt wheezy in the cold weather. He has a history of hay fever.

  1. Why might you suspect he has COPD rather than Asthma?

  1. What tests might you do to confirm that Edward has COPD?

Edward's FEV1is 68% of that predicted, and his FEV1/FVC ratio is 0.65.

  1. According to NICE guidance, would his airway obstruction be classified as mild, moderate or severe?

  1. Should Edward also have reversibility testing?
  1. What additional investigations would you like to carry out on Edward?
  1. What is the single most important thing, which will help Edward’s symptoms and improve his prognosis (and what options does Edward have to achieve this)?

  1. What other extra-pulmonary symptoms might Edward complain of?

Depression/anxiety, weakness/lethargy, Cor Pulmonale (and associated symptoms)

  1. What treatment will you start Edward on?

Edward initially does well on inhaled salbutamol. Twelve months later, he is invited for a review with the practice nurse. He has not yet managed to stop smoking. Lung function has declined a little but his airflow limitation is still mild.

Edward's symptoms are becoming more troublesome (he has a chronic cough, and his breathlessness is more apparent) and so you consider stepping up his treatment.

9.Which treatment would you start Edward on next?

  1. Should he be offered an inhaled corticosteroid?
  1. Would Edward benefit from a mucolytic?

Edward is stabilised on his regular long-acting bronchodilator with short-acting bronchodilator when required, and he also takes a mucolytic. You have arranged a pneumococcal immunisation and offered Edward annual influenza immunisation.

Some months later, Edward presents with much worsened breathlessness and cough, and increased production of sputum, which is green and purulent. He feels unwell and has been like this for a couple of days. Symptoms started fairly swiftly - he had been well (for him) up to about a week ago.

  1. How should this acute exacerbation be managed?
  1. Once Edward has recovered should he be referred for Pulmonary Rehabilitation?
  1. Would Edward benefit from oxygen therapy?