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



  • 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
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


Assessment Of Severity

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

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 

Patient Category Airflow Limitation Classification Characteristics
  • mMRC 0-1
  • Low risk, less symptoms
  • CAT (COPD Assessment Test) <10
  • ≤1 exacerbations/yr
    (w/o hospitalization)
  • mMRC ≥2
  • Low risk, more symptoms
  • CAT ≥10
  • ≤1 exacerbations/yr
    (w/o hospitalization)
  • mMRC 0-1
  • High risk, less symptoms
  • CAT <10
  • ≥2 exacerbations/yr
    (w/ hospitalization)
  • 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


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


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


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