Chronic obstructive pulmonary disease history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Philip Marcus, M.D., M.P.H. [3]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [4] Kosar Doraghi, M.D. [5]

Overview

Chronic obstructive pulmonary disease is a group of diseases (bronchitis and emphysema) that can present with symptoms such as dyspnea (shortness of breath), wheezing, persistent cough, and sputum production. Some clinical features can help distinguish between the types of COPD. Patients with chronic bronchitis present with productive cough with gradual progression to intermittent dyspnea (shortness of breath), recurrent pulmonary infections, and in later stage progressive cardiac or respiratory failure presenting with edema and weight gain. Classic findings in patients with emphysema include a long history of progressive dyspnea (shortness of breath) with late onset of productive cough, usually mucopurulent, and eventual decrease in appetite and respiratory failure.

History

The patient may present with a chronic history (spanning over years) of progressive dyspnea (shortness of breath) mainly due to emphysema, or productive cough (chronic bronchitis). Significant history of life style modifications to deal with the dyspnea (shortness of breath) may be found. History of chronic smoking (usually more than 40 pack years) is also commonly found.

The following aspects are very helpful in the diagnosis of COPD:

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

• Wheezing on auscultation

• Self-reported wheezing

Symptoms

COPD includes chronic bronchitis, emphysema, and a range of other pulmonary disorders. This leads to a limitation of the flow of air to and from the lungs, causing dyspnea (shortness of breath). In clinical practice, COPD is defined by its characteristically low airflow on lung function tests. In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time.

• Advanced COPD can lead to complications beyond the lungs, such as weight loss (cachexia), pulmonary hypertension and right-sided heart failure (cor pulmonale). Osteoporosis, heart disease, muscle wasting and depression are all more common in people with COPD.

Chronic Bronchitis

The hallmark of chronic bronchitis is dyspnea. A positive history of chronic productive cough and shortness of breath is suggestive of chronic bronchitis. Some patients describe the dyspnea as air hunger because of sensation of gasping for air.

• Productive cough with gradual progression to intermittent shortness of breath. It is possible the sputum may contain blood (hemoptysis), usually due to damage of the blood vessels of the airways. An acute exacerbation may present as productive cough or an acute chest illness. The cough usually is worse in the mornings and produces a small amount of colorless sputum. The frequency and severity of acute exacerbation usually increases as the disease progresses.
• In later stages progressive cardiac/respiratory failure may present with edema and weight gain.

Common Symptoms

• Productive cough with gradual progression to intermittent shortness of breath.
• Sputum may contain blood (hemoptysis), usually due to damage of the blood vessels of the airways.
• An acute exacerbation may present as productive cough or an acute chest illness.
• The cough typically is worse in the mornings and produces a small amount of colorless sputum.
• The frequency and severity of acute exacerbation usually increases as the disease progresses.
• In later stages progressive cardiac/respiratory failure may present with edema and weight gain.

Other Symptoms

• Chest discomfort
• Fatigue
• Fever (typically low-grade)
• Wheezing

Severe Bronchitis

In extreme cases it could lead to cor pulmonale due the extra work required by the heart to get blood to flow through the lungs which may present as:

• Chest discomfort (typically in the front of the chest)
• Exercise intolerance
• Shortness of breath
• Swelling of the feet or ankles
• Symptoms of underlying disorders (wheezing, coughing)

• Cyanosis (typically in the lips and fingers) caused by hypoxemia
• Patient may have confusion indicating an alteration of mental status
• Depression may be seen
• Decreased fat-free mass
• Impaired systemic muscle function (systemic manifestation)

COPD Patient with suspected Exacerbation(New GOLD 2024 Recommendation)

• Confirm ECOPD Diagnosis and Episode Severity:

Consider differential diagnosis including heart failure, pneumonia, and pulmonary embolism. Appropriate testing and treatment based on severity. Severity categorized into mild, moderate, and severe with variable thresholds. Mild severity:

• Dyspnea VAS < 5
• RR < 24 breaths/min
• HR < 95 bpm
• Resting SaO2 ≥92% breathing ambient air (or patient’s usual oxygen prescription) AND/OR change ≤3% (when known)
• CRP < 10 mg/L (if obtained)

Moderate severity (requires at least three of the following):

• Dyspnea VAS ≥5
• RR ≥24 breaths/min
• HR ≥95 bpm
• Resting SaO2 <92% breathing ambient air (or patient’s usual oxygen prescription) AND/OR change >3% (when known)
• CRP ≥10 mg/L

Severe severity (indicated when ABG shows new onset/worsening hypercapnia and acidosis):

• Dyspnea, RR, HR, SaO2, and CRP same as moderate
• ABG: PaCO2 >45 mmHg and pH <7.35

Determine etiology through viral testing or sputum culture.

Emphysema

Most patients seek medical attention late in the course of their disease as the disease is gradual in onset and progressive.

• The most important aspects of history taking in patients suspected for emphysema include:
  • A long history of progressive shortness of breath with late onset of nonproductive cough
  • Cough is mainly mucopurulent
  • The cough usually is worse in the morning
  • Cough is accompanied by eventual decrease in appetite (mainly due to respiratory failure)
  • Dyspnea start to manifest mostly around 60 years of age

Symptoms of Severe Emphysema

In extreme cases it could lead to cor pulmonale due the extra work required by the heart to get blood to flow through the lungs which may present as:

• Chest discomfort, usually in the front of the chest
• Shortness of breath
• Swelling of the feet or ankles
• Symptoms of underlying disorders (wheezing, coughing)
• Cyanosis (bluish decolorization usually in the lips and fingers) caused by a lack of oxygen in the blood
• Patient may have confusion indicating an alteration of mental status
• Depression may be seen
• Decreased fat-free mass, impaired systemic muscle function (systemic manifestation)

The most helpful information in diagnosis of COPD is provided by a combination of the following 3 signs:

• Self-reported smoking history of more than 55 pack-year
• Wheezing on auscultation
• Self-reported wheezing

Severe COPD

• In extreme cases it could lead to cor pulmonale due the extra work required by the heart to get blood to flow through the lungs which may present as:
  • Chest discomfort, usually in the front of the chest
  • Exercise intolerance
  • Shortness of breath
  • Swelling of the feet or ankles
  • Symptoms of underlying disorders (wheezing, coughing)
• Cyanosis (bluish decolorization usually in the lips and fingers) caused by a lack of oxygen in the blood
• May present with confusion indicating an alteration of mental status
• Depression may be seen
• Decreased fat-free mass, impaired systemic muscle function (systemic manifestation)

Acute Exacerbations of COPD

An acute exacerbation of COPD is a sudden worsening of COPD symptoms (dyspnea [shortness of breath], quantity and color of phlegm) that typically lasts for several days. It may be triggered by an infection with bacteria or viruses or by environmental pollutants. Typically, infections cause 75% or more of the exacerbations; bacteria can be found in roughly 25% of cases, viruses in another 25%, and both viruses and bacteria in another 25%. Pulmonary emboli can also cause exacerbations of COPD. Airway inflammation is increased during the exacerbation, resulting in increased hyperinflation, reduced expiratory air flow and worsening of gas transfer. This can also lead to hypoventilation and eventually hypoxia, insufficient tissue perfusion, and then cell necrosis.

Symptoms for Admission to Emergency Department

• Confusion

• Lethargy

• Labored breathing (respiratory muscle fatigue)

• Blue discoloration of skin (indicating worsening hypoxemia)

• Worsening respiratory acidosis (pH < 7.30)

New GOLD 2024 Recommendation for Vaccination of COPD Patients

Immunosenescence refers to the gradual decline of the immune system with age, reducing the body’s ability to fight infections and form long-term immunity, particularly impacting elderly individuals and those with conditions like COPD. Lifestyle choices such as not smoking, moderate alcohol intake, regular exercise, a balanced diet, and vaccination can help slow down this process. Updated recommendations include vaccinating COPD patients with new respiratory syncytial virus (RSV) vaccines, in addition to existing vaccines like flu, pneumococcus, COVID-19, pertussis, and shingles, as per GOLD 2024 guidelines aligned with the CDC.

• Vaccination for Stable COPD
• Influenza Vaccination:

Recommended for people with COPD (Evidence B).

• SARS-CoV-2 (COVID-19) Vaccination:

Recommended by the WHO and CDC for individuals with COPD (Evidence B).

• Pneumococcal Vaccination:

Options: One dose of 20-valent pneumococcal conjugate vaccine (PCV20). Or, one dose of 15-valent pneumococcal conjugate vaccine (PCV15) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23). Benefits: Reduces the incidence of community-acquired pneumonia and exacerbations in people with COPD (Evidence B).

• Respiratory Syncytial Virus (RSV) Vaccine:

Recommended for individuals over 60 years and/or with chronic heart or lung disease (Evidence B).

• Tdap (TdaP/dTPa) Vaccination:

Protects against pertussis (whooping cough) for people with COPD who were not vaccinated in adolescence (Evidence B).

• Zoster Vaccine:

Recommended for people with COPD over 50 years to protect against shingles (Evidence B).

Sources

• 2024 GOLD REPORT

GLOBAL STRATEGY FOR PREVENTION, DIAGNOSIS AND MANAGEMENT OF COPD: 2024 Report.