Chronic Obstructive Pulmonary Disease (COPD) and Emphysema in Emergency Medicine Clinical Presentation

Updated: Nov 13, 2020
  • Author: Paul Kleinschmidt, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Patients with chronic obstructive pulmonary disease (COPD) present with a combination of signs and symptoms of chronic bronchitis, emphysema, and asthma. Symptoms include worsening dyspnea, progressive exercise intolerance, and alteration in mental status. In addition, some important clinical and historical differences can exist between the types of COPD.

In the chronic bronchitis group, classic symptoms include the following:

  • Productive cough, with progression over time to intermittent dyspnea

  • Frequent and recurrent pulmonary infections

  • Progressive cardiac/respiratory failure over time, with edema and weight gain

In the emphysema group, the history is somewhat different and may include the following set of classic symptoms:

  • A long history of progressive dyspnea with late onset of nonproductive cough

  • Occasional mucopurulent relapses

  • Eventual cachexia and respiratory failure


Physical Examination

Depending on the type of chronic obstructive pulmonary disease (COPD), physical examination findings may vary.

Chronic bronchitis (blue bloaters) findings may be as follows:

  • 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.

  • Because they share many of the same physical signs, COPD may be difficult to distinguish from congestive heart failure (CHF). One crude bedside test for distinguishing COPD from CHF is peak expiratory flow. If patients blow 150-200 mL or less, they are probably having a COPD exacerbation; higher flows indicate a probable CHF exacerbation.

Emphysema (pink puffers) findings may be as follows:

  • Patients may be very thin with a barrel chest.

  • They typically have little or no cough or expectoration.

  • Breathing may be assisted by pursed lips and use of accessory respiratory muscles; they may adopt the tripod sitting position. In this manner, the patient is trying to maintain a certain amount of positive end-expiratory pressure (PEEP) at the end of expiration, to help keep their lungs open, owing to the loss of lung structure from the disease.

  • The chest may be hyperresonant, and wheezing may be heard; heart sounds are very distant.

  • Overall appearance is more like classic COPD exacerbation.



Some complications that must be anticipated in COPD treatment include the following:

  • Incidence of pneumothorax due to bleb formation is relatively high; consider pneumothorax in all patients with COPD who have increased shortness of breath.

  • In patients who require long-term steroid use, the possibility of adrenal crisis is very real; at a minimum, patients with steroid-dependent COPD should receive stress dosing in the event of an exacerbation or any other stressor.

  • Infection (common)

  • Cor pulmonale

  • Secondary polycythemia

  • Bullous lung disease

  • Acute or chronic respiratory failure

  • Pulmonary hypertension

  • Malnutrition