Symptoms

  Treatment Guidelines / Chronic Obstructive Pulmonary Disease Overview / Symptoms

Symptoms

Signs & Symptoms Of COPD

  • COPD should be suspected in any patient who has chronic cough, sputum production or dyspnea w/ or w/o history of risk factors for the disease
A diagnosis of COPD should be considered in patients over 40 yr of age who have a suggestive medical history (ie presence of risk factors) & who present w/ any of the following:
  • Chronic cough (present intermittently or daily) & sputum production of at least 3 mth in each of 2 consecutive yr
    • Does not reflect the major impact of airflow limitation on the morbidity & mortality in patients w/ COPD
    • Cough may be unproductive
  • Exertional breathlessness, wheezing, pursed-lip breathing, dyspnea w/ or w/o wheezing
  • Rhonchi, prolonged expiratory phase of respiration, chest hyperinflation, use of accessory muscles for respiration, decreased breath sounds
  • Signs of cor pulmonale: Neck vein distention, increased pulmonic component of 2nd heart sound, lower extremity edema, hepatomegaly
  • The absence of wheezing or chest tightness does not rule out a diagnosis of COPD

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Diagnosis

Spirometry
  • Recommended measurement of airflow limitation that confirms the diagnosis of COPD
    • A useful tool in the assessment of the severity of the pathological changes in COPD
  • Also recommended for patients at risk of COPD, especially smokers >45 yrs old w/ cough, sputum or dyspnea & for regular follow-up of patients w/ documented COPD
  • Measures forced vital capacity (FVC) & forced expiratory vol in 1 sec (FEV1)
    • A decreased FEV1/FVC ratio is typically seen in patients w/ COPD
    • A post-bronchodilator FEV1/FVC <70% confirms the presence of airflow limitation
  • Spirometry services should be supported by quality control processes
  • Lung volumes are affected by process of aging & FEV1/FVC ratio depends on age, height & sex
    • The use of fixed ratio may lead to underdiagnosis in patients <45 yr esp of mild disease & overdiagnosis in patients >50 yr
    • There’s a proposal that diagnosis of obstructive pulmonary disease should be based on an FEV1/FVC ratio below the lower limit of normal
  • If there is no access to spirometry, COPD diagnosis may be suspected based on history, symptoms & physical signs
    • Peak flow measurements may be used to rule out asthma, but not to diagnose COPD
      • Has good sensitivity rate but weak specificity
    • A forced expiratory time (FET) is the time for a patient to forcefully exhale through open mouth from total lung capacity until air flow is inaudible [≥6 sec is abnormally prolonged & >6 sec is an acceptable guide to presence of FEV1/FVC <50% (obstructive disease)]
    • Modified Medical Research Council (mMRC) Dyspnea Scale is useful for classification, which can be used to assist in the evaluation of disease severity & functional disability
MEDICAL RESEARCH COUNCIL DYSPNEA SCALE*
Grade Description
0 Only experience breathlessness w/ strenuous exercise
1 There’s shortness of breath when walking up a slight hill or hurrying on the level
2 Walks slower than people of the same age on the level because of breathlessness or has to stop to catch a breath when walking at own pace on the level
3 Stops to catch a breath after walking about 100 meters or after a few min on the level
4 Too breathless to leave the house or breathless when dressing or undressing

*Adapted from Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2015.

  • COPD Assessment Test (CAT) is a short questionnaire used in routine clinical practice to gauge the health status of COPD patients
    • Measures patients’ disease severity using 8 symptoms, w/ scores ranging from 0-40:
      • Frequency of cough
      • Chest tightness
      • Limitations w/ home activities
      • Presence of sleep disturbance
      • Degree of presence of phlegm
      • Breathlessness when climbing stairs/walking uphill
      • Confidence w/ outdoor activities even if w/ COPD
      • Level of energy
Other Lab Tests
Bronchodilator Reversibility Testing
  • Usually performed only once at the time of diagnosis
  • May help rule out asthma, establish best attainable lung function, evaluate prognosis & guide treatment decisions
  • However, it may not reliably predict response to long-term bronchodilator therapy
Chest X-ray
  • Useful mainly in ruling out alternative diagnoses
  • May show signs of lung hyperinflation (eg flattened diaphragm), lungs hyperlucency & rapid tapering of the vascular markings
Computed Tomography (CT)
  • Not routinely used but may help in excluding other possible diagnosis
  • Recommended if surgical management is being contemplated
Pulse Oximetry & Arterial Blood Gas (ABG) Measurement
  • Pulse oximetry should be performed in stable patients w/ FEV1 <35% predicted or w/ signs of resp failure or right heart failure
  • ABG should be assessed when the peripheral saturation is <92%; should be obtained by arterial puncture
Alpha-1 Antitrypsin Deficiency Screening
  • May be useful in young patients (<45 yr) who develop COPD
  • Positive results may lead to family screening & counseling
  • Alpha-1 antitrypsin serum concentration of <15-20% of the normal value is highly suggestive of homozygous alpha-1 antitrypsin deficiency

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Assessment Of Severity

Severity of COPD is classified based on patient’s symptoms, spirometry results, presence of complications & future risk of exacerbations

CLASSIFICATION OF AIRFLOW LIMITATION1*
Stage Characteristics
I: Mild COPD

FEV1 ≥80% predicted
II: Moderate COPD

50% ≤ FEV1 <80% predicted
III: Severe COPD

30% ≤ FEV1 <50% predicted
IV: Very Severe COPD

FEV1 <30% predicted

1Classification is based on post-bronchodilator FEV1 in patients w/ FEV1/FVC <0.7
The use of fixed ratio may lead to underdiagnosis in patients <45 yr esp of mild disease & overdiagnosis in patients >50 yr 

SYMPTOM/RISK EVALUATION OF COPD*
Patient Category Airflow Limitation Classification Characteristics
A I-II
  • mMRC 0-1
  • Low risk, less symptoms
  • CAT (COPD Assessment Test) <10
  • ≤1 exacerbations/yr
    (w/o hospitalization)
B I-II
  • mMRC ≥2
  • Low risk, more symptoms
  • CAT ≥10
  • ≤1 exacerbations/yr
    (w/o hospitalization)
C III-IV
  • mMRC 0-1
  • High risk, less symptoms
  • CAT <10
  • ≥2 exacerbations/yr
    (w/ hospitalization)
D III-IV
  • mMRC ≥2
  • High risk, more symptoms
  • CAT ≥10
  • ≥2 exacerbations/yr
    (w/ hospitalization)

*Adapted from Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2015

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Site Of Care

  • Patients belonging to category A or B may be managed on an outpatient basis during exacerbations
  • Patients belonging to category C or D may require hospitalization & more aggressive management during exacerbations

Indications for Hospital Treatment for COPD Exacerbations:

  • Significant increase in symptoms (eg sudden development of resting dyspnea)
  • Severe underlying COPD
  • Onset of new symptoms (eg cyanosis, peripheral edema)
  • Absence of response to initial medical treatment
  • Significant comorbidities (eg heart failure or newly occurring arrhythmias)
  • Frequent exacerbations
  • Older age
  • Lack of home support

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Assessment Of Severity For COPD In Acute Exacerbation

The following are used to assess the severity of a COPD exacerbation:

  • History, symptoms
  • Physical exam
  • Lab tests

Lab Tests

ABG Measurement

  • PaO2 <60 mmHg &/or SaO2 <90% w/ or w/o PaCO2 >50 mmHg on room air are indicative of resp failure
  • If there are no facilities to measure blood gases, SaO2 should be measured

Chest X-ray

  • Helpful in patients w/ suspected pneumonia
  • May be useful in identifying alternative diagnoses that can mimic symptoms of exacerbation

Electrocardiogram (ECG)

  • Helpful in diagnosing right ventricular hypertrophy, arrhythmias & ischemic episodes
  • Aids in the diagnosis of pulmonary embolism from COPD exacerbation, as right ventricular hypertrophy & large pulmonary arteries may lead to confusing radiographic & ECG findings

Complete Blood Count (CBC)

  • May show polycythemia (hematocrit >55%) or bleeding
  • White blood cells (WBC) may be elevated in patients w/ resp infection

Biochemical Tests

  • May be helpful in determining the cause of exacerbation & in diagnosing other comorbid conditions (eg electrolyte imbalances, diabetic crisis, poor nutrition, acid-base disorders)

Sputum Culture

  • Presence of purulent sputum during an exacerbation is sufficient basis for starting antibiotics
  • Culture & sensitivity testing of sputum must be done if the patient does not respond to initial antibiotic therapy

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Assess Suitability For Discharge

Prior to discharge from the hospital, check the patient based on the following criteria:

  • Able to use long-acting either beta2-agonists &/or anticholinergics w/ or w/o inhaled corticosteroids
  • Inhaled beta2-agonist is needed every 4 hr or less frequently
  • Able to walk across the room (if previously ambulatory)
  • Able to eat & sleep w/o frequent interruptions due to breathing difficulty
  • Clinically stable for 12-24 hr
  • ABG stable for 12-24 hr
  • Patient & caregiver adequately understand correct medication use
  • Home care arrangements (eg O2 delivery) are in place
  • Patient, family & physician are confident that patient can manage well

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