History and exam
Key diagnostic factors
common
dyspnea
A sustained increase from the baseline level of dyspnea beyond day-to-day variation is usually observed in patients with an acute exacerbation.[10]
cough
wheeze
All patients with COPD have expiratory flow limitation, and this may lead to wheezing. Patients experiencing an acute exacerbation may be found to have greater severity of wheezing and prolongation of the expiratory phase of breathing on examination. However, wheezing is not identified in many patients.
Auscultation sounds: Expiratory wheeze
Auscultation sounds: Polyphonic wheeze
changes in sputum volume/color/thickness
tachypnea
Tachypnea is frequently seen and may be severe. It is important to observe the patient for signs of respiratory failure.
uncommon
cyanosis
Possible sign of impending respiratory failure.
Other diagnostic factors
common
past medical history of COPD
A past medical history of COPD should be sought, as well as of other conditions that may impact the likelihood of another acute problem considered in the differential diagnosis. People with a history of two or more exacerbations in the preceding year or those with history of hospitalization due to exacerbation in the previous year are considered at high risk of subsequent exacerbations.[1]
tobacco dependence
It is important to determine if patients have a history of significant exposure to tobacco or other smoke, and whether they are currently smoking, using e-cigarette/vaping products, or other inhaled substances (e.g., marijuana, cocaine, hookah/shisha).
past medical history of gastroesophageal reflux/swallowing dysfunction
It is important to determine if patients have a history of heartburn, bitter/sour taste in the mouth, coughing or choking after eating, hiatal hernia, and/or gastroesophageal reflux or difficulty swallowing.[18][19][20][21][22] However, GERD should be considered as a potential cause of recurrent exacerbations even if the patient lacks the above-noted typical symptoms and signs of gastroesophageal reflux. Nighttime episodes of coughing may also signal the presence of GERD.
No available studies guide whether the treatment of reflux improves exacerbations of COPD.
malaise and fatigue
These symptoms and other nonspecific symptoms such as insomnia, decreased activity level and loss of appetite are commonly identified in people with an acute exacerbation of COPD.[116][130]
While these symptoms have great impact on the quality of life of the patient, they are generally not used to determine whether an exacerbation is present.
chest tightness
This may result from worsened airflow limitation and chest hyperinflation.[13] However, the possibility of a myocardial infarction or pneumothorax should be considered if marked chest tightness or other chest discomfort is present.
features of cor pulmonale
This may develop as a result of increased hypoxic vasoconstriction due to exacerbation-induced hypoxemia. The resulting increase in pulmonary vascular resistance and/or pulmonary artery pressure can lead to acute right heart failure. Elevated jugular venous pressure, hepatojugular reflux, peripheral edema, and relative hypotension may be present.
uncommon
environmental/occupational exposure to pollutants or dust
It should be determined whether the patient has a history of significant exposure to black smoke, such as wood smoke, dust, pesticides, and/or other pollutants, such as chemicals or small particulate matter.
change in mental status
Including drowsiness, confusion, and/or personality change.
fever
accessory muscle use
Sign of impending respiratory failure.
paradoxical movements of abdomen
Sign of impending respiratory failure.
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