Chronic Obstructive Pulmonary Disease (COPD) Clinical Presentation

Updated: Sep 24, 2017
  • Author: Zab Mosenifar, MD, FACP, FCCP; Chief Editor: John J Oppenheimer, MD  more...
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Presentation

History

Most patients with chronic obstructive pulmonary disease (COPD) seek medical attention late in the course of their disease. Patients often ignore the symptoms because they start gradually and progress over the course of years. Patients often modify their lifestyle to minimize dyspnea and ignore cough and sputum production. With retroactive questioning, a multiyear history can be elicited.

Patients typically present with a combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease. These include cough, worsening dyspnea, progressive exercise intolerance, sputum production, and alteration in mental status. Symptoms include the following:

  • Productive cough or acute chest illness

  • Breathlessness

  • Wheezing

Systemic manifestations (decreased fat-free mass, impaired systemic muscle function, osteoporosis, anemia, depression, pulmonary hypertension, cor pulmonale, left-sided heart failure

A productive cough or an acute chest illness is common. The cough usually is worse in the mornings and produces a small amount of colorless sputum.

Breathlessness is the most significant symptom, but it usually does not occur until the sixth decade of life (although it may occur much earlier). By the time the FEV1 has fallen to 50% of predicted, the patient is usually breathless upon minimal exertion. Despite the fact that FEV1 is the most common variable used to grade the severity of COPD, although it is not the best predictor of mortality.

Wheezing may occur in some patients, particularly during exertion and exacerbations.

The value of patient history and physical examination was addressed in the 2011 update to the American College of Physicians/American College of Chest Physicians/American Thoracic Society/European Respiratory Society (ACP/ACCP/ATS/ERS) guideline for diagnosis and management of stable COPD. According to the 2011 guideline, a history of more than 40 pack-years of smoking was the best single predictor of airflow obstruction; however, the most helpful information was provided by a combination of the following 3 signs [34] :

  • Self-reported smoking history of more than 55 pack-years

  • Wheezing on auscultation

  • Self-reported wheezing

If all 3 signs are absent, airflow obstruction can be nearly ruled out. [34]

With disease progression, intervals between acute exacerbations become shorter, and each exacerbation may be more severe. The rate of COPD exacerbations appears to reflect an independent susceptibility phenotype. [35]

COPD is now known to be a disease with systemic manifestations, and the quantification of these manifestations has proved to be a better predictor of mortality than lung function alone. Many patients with COPD may have decreased fat-free mass, impaired systemic muscle function, osteoporosis, anemia, depression, pulmonary hypertension, cor pulmonale, and even left-sided heart failure. Depression is not uncommon in subjects with COPD. [36]

In a study by Spitzer et al in Germany, airflow limitation as measured by spirometry was significantly more common in adults with posttraumatic stress disorder than in controls. Results were adjusted for lifestyle, clinical, and sociodemographic factors. [37]

In addition, COPD appears to increase the risk for mild cognitive impairment (MCI). Investigators from the Mayo Clinic Study of Aging—a population-based, cross-sectional study of 1,927 participants—reported an association between COPD and an increased risk of having MCI, MCI subtypes, and memory loss in elderly patients. [38, 39] They also observed a dose-response relationship between COPD duration and an increased risk for cognitive problems.

The prevalence of MCI was significantly higher in patients with COPD (n = 288) (27%) than in those without COPD (15%), and there was a nearly twofold higher odds ratio (1.87) for MCI in patients with COPD. Moreover, the odds ratio increased from 1.6 in patients with COPD for 5 years or less to 2.1 in those who had COPD for longer than 5 years. [38, 39]

Some important clinical and historical differences may help distinguish between the types of COPD. Classic findings for patients with chronic bronchitis include productive cough with gradual progression to intermittent dyspnea; frequent and recurrent pulmonary infections; and progressive cardiac/respiratory failure with edema and weight gain. Classic findings for patients with emphysema include a long history of progressive dyspnea with late onset of nonproductive cough; occasional mucopurulent relapses; and eventual cachexia and respiratory failure.

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Physical Examination

The sensitivity of a physical examination in detecting mild to moderate COPD is relatively poor; however, physical signs are quite specific and sensitive for severe disease. Patients with severe disease experience tachypnea and respiratory distress with simple activities.

The respiratory rate increases in proportion to disease severity. Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign). In advanced disease, cyanosis, elevated jugular venous pulse (JVP), and peripheral edema can be observed.

Thoracic examination reveals the following:

  • Hyperinflation (barrel chest)

  • Wheezing – Frequently heard on forced and unforced expiration

  • Diffusely decreased breath sounds

  • Hyperresonance on percussion

  • Prolonged expiration

In addition, coarse crackles beginning with inspiration may be heard.

Certain characteristics allow differentiation between disease that is predominantly chronic bronchitis and that which is predominantly emphysema.

Chronic bronchitis characteristics include the following:

  • Patients may be obese

  • Frequent cough and expectoration are typical

  • Use of accessory muscles of respiration is common

  • Coarse rhonchi and wheezing may be heard on auscultation

  • Patients may have signs of right heart failure (ie, cor pulmonale), such as edema and cyanosis

Emphysema characteristics include the following:

  • Patients may be very thin with a barrel chest

  • Patients typically have little or no cough or expectoration

  • Breathing may be assisted by pursed lips and use of accessory respiratory muscles; patients may adopt the tripod sitting position

  • The chest may be hyperresonant, and wheezing may be heard

  • Heart sounds are very distant

  • Overall appearance is more like classic COPD exacerbation

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Staging

The severity of airflow obstruction was the primary means of staging COPD until the American Thoracic Society (ATS) provided criteria for staging COPD based on the presence of obstruction (ratio of FEV1 to forced vital capacity [FEV1/FVC] < 70%) and its severity as measured by percent of predicted FEV1.

ATS and Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for assessing the severity of airflow obstruction (based on the percent predicted postbronchodilator FEV1 when the FEV1/FVC is < 70%) are as follows:

  • Stage I (mild) - FEV1 80% or greater of predicted

  • Stage II (moderate) - FEV1 50-79% of predicted

  • Stage III (severe) - FEV1 30-49% of predicted

  • Stage IV (very severe) - FEV1 less than 30% of predicted or FEV1

However, these staging systems have limited utility in predicting mortality. The recognition that COPD is a systemic disease has helped in developing criteria that are better at predicting mortality than is assessment of airway obstruction alone. A widely used system for COPD prognosis is the BODE index (body mass index, obstruction [FEV1], dyspnea [modified Medical Research Council dyspnea scale], and exercise capacity [6MWD]). [28]

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