History

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.

Complications

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

Differential Diagnoses

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Pierson DJ. Indications for mechanical ventilation in adults with acute respiratory failure. Respir Care. 2002 Mar. 47(3):249-62; discussion 262-5. [QxMD MEDLINE Link].
[Guideline] Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2018 Report. Goldcopd.org. Available at https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf. 2018; Accessed: October 23, 2018.
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[Guideline] Global Initiative for Chronic Obstructive Lung Disease. Global strategy for diagnosis, management, and prevention of COPD: 2016. Available at http://goldcopd.org/gold-reports/. Accessed: June 8, 2017.
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Media Gallery

Chronic obstructive pulmonary disease (COPD). Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells.
Chronic obstructive pulmonary disease (COPD). Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells (high-powered view).
Posteroanterior (PA) and lateral chest radiograph in a patient with severe chronic obstructive pulmonary disease (COPD). Hyperinflation, depressed diaphragms, increased retrosternal space, and hypovascularity of lung parenchyma is demonstrated.
Chronic obstructive pulmonary disease (COPD). A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragms on lateral chest radiograph.
Chronic obstructive pulmonary disease (COPD). A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragms on posteroanterior chest radiograph.
Subcutaneous emphysema and pneumothorax.