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]

Overview

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

History

The patient may present with a chronic history (lasting for years) of progressive shortness of breath (emphysema) or productive cough (chronic bronchitis). History may involve patient doing life style modifications to deal with the shortness of breath. History of being chronic smoker (usually more than 40 pack year) is also commonly found.

Symptoms

• COPD is the umbrella term for chronic bronchitis, emphysema and a range of other lung disorders. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath (dyspnea). 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.

Acute Exacerbations of COPD

An acute exacerbation of COPD is a sudden worsening of COPD symptoms (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.

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)

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

AAT Deficient Patients

• Present earlier than other COPD patients.
• Mainly affects the lungs and the liver.
• Liver abnormalities can be seen in the first decade of life.
• Patients who are homozygous (PIZZ) have following feature:
  • Early presentation (< 50 yrs)
  • Commonly involve the lung bases
  • Panacinar emphysema.

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
• Patient may have confusion indicating an alteration of mental status.
• Depression may be seen
• Decreased fat-free mass, impaired systemic muscle function (systemic manifestation)

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)

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.

References

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