History and exam

Key diagnostic factors

A sustained increase from the baseline level of dyspnoea beyond day-to-day variation is the key symptom of an exacerbation.[1][83]

  • Document the current degree of shortness of breath and exercise tolerance.

    • Use a score validated for exacerbations or refer back to previous score results taken in the stable condition, such as the extended Medical Research Council dyspnoea (eMRCD) scale, which is used in stable COPD to grade the degree of breathlessness according to level of exertion.[86] 

    • Define how this has changed from the patient’s baseline and/or the rate of deterioration, if possible, using previous results or by asking the patient or family/carers.

      • This helps determine the escalation strategy and what level of functionality to aim for upon discharge.

Practical tip

Patients may describe breathlessness in terms of reduced exercise capacity. For example, they might report only being able to walk 10 metres for the last couple of days when they would usually be able to walk 50 metres before feeling short of breath.

The patient might report an increase in frequency or severity of cough;[1][83] often productive. 

  • An increase or change in character compared with the patient’s day-to-day cough.

  • Sputum quality may change with exacerbations or superimposed infection.[1][83]

Ask if there is a change to the volume, thickness, or colour of the sputum.

  • Investigate for bronchiectasis in patients who repeatedly present with exacerbations with purulent sputum.[1]

An increase in sputum purulence may indicate the presence of bacteria.[1]

  • The presence of green sputum has been found to be 94.4% sensitive and 77% specific for the yield of a high bacterial load, identifying a distinct subset of patients in whom bacteria are strongly associated with the exacerbation.[87] 

  • The most frequently identified bacterial pathogens include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.[31][51] 

  • Viral infection may also cause increased sputum production alone or lead to an altered environment that may promote secondary bacterial infection.[87] 

    • Co-infection with viruses and bacterial pathogens is not uncommon.

Practical tip

It may be difficult to evaluate sputum production as some patients swallow rather than expectorate it.[1] This will vary from patient to patient, but be aware of this possibility when asking patients about changes to volume or thickness. Ideally ask for a sample to assess the colour and thickness yourself.

Auscultate to check for presence of a wheeze.[1] Beware a 'silent chest' (decreased breath sounds), which may indicate impending respiratory failure. 

  • May present as prolongation of the expiratory phase of breathing on examination.

  • Consider cardiac causes for wheeze or the presence of asthma.[88]

Practical tip

Transmitted upper airway noise 'wheeze' is common both as a symptom and as a sign. Be aware that patients or relatives may describe 'wheeze', especially on exertion, that is actually upper airway transmitted noise and not wheeze. Consider this on auscultation. Likewise wheeze heard at the end of the bed is often from the upper airway rather than small airways and may not improve with usual COPD treatment. 

Ask if the patient feels 'tightness' in the chest. 

  • May result from worsened airflow limitation and chest hyperinflation.[14]

  • Chest pain is common secondary to coughing and/or increased work of breathing (respiratory muscle discomfort).

  • Consider the possibility of an asthma exacerbation, myocardial infarction, or pneumothorax if marked chest tightness or other chest discomfort/pain is present. Involve senior colleagues for appropriate investigation and management.

Practical tip

Many patients with COPD are elderly and frail, and may have comorbidities with abnormal baseline parameters. When assessing severity, consider any changes in symptom status relative to the patient’s baseline level rather than using absolute cut-offs. 

Use an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess the patient. In hospital, involve your senior team when needed.

  • Observe for tachypnoea.

  • Be alert for the presence or imminent onset of respiratory failure.

Note pulse rate and rhythm.

  • Atrial fibrillation is a common comorbidity and forms part of the DECAF (Dyspnoea, Eosinopenia, Consolidation, Acidaemia, and atrial Fibrillation) score, a prognostic score that is used to predict in-hospital mortality.[92] 

Take a history covering the likely risk factors for an exacerbation of COPD, including:

Spirometry-confirmed diagnosis of COPD 

Ask about previous exacerbations and previous use of non-invasive ventilation, as patients with a history of two or more exacerbations in the preceding year, or those with a history of hospitalisation due to exacerbation in the previous year, are considered to be at high risk of subsequent exacerbations.[24][55] 

  • Review the patient’s notes to check for recent spirometry results confirming a diagnosis of COPD.[85] If there is no recorded spirometry result, and the patient is admitted to hospital for an exacerbation, arrange spirometry to confirm diagnosis of COPD.[85] 

  • Ask about a change in symptoms: did existing symptoms worsen, or are there new symptoms? How long have the symptoms been present?

Recent infection[1][83]

Ask the patient if they have had increased cough, breathlessness, or mucopurulent sputum in the last 5 days. Ask if they have had a fever or noticed changes in sputum.

  • Viral infections are the main cause of an exacerbation, with human rhinovirus the most common causative agent.[1]

  • Viral infection may also cause increased sputum production alone or lead to an altered environment that may promote secondary bacterial infection.[87] 

  • The most frequently identified bacterial pathogens in exacerbations of COPD include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.[31][51] 

  • Co-infection with viral and bacterial pathogens is not uncommon.

Practical tip

When asking a patient about previous exacerbations, bear in mind that they may not think in terms of 'exacerbations', but might instead explain that they received antibiotics and corticosteroids for a previous 'chest infection'. 

It might help to ask about the constellation of symptoms experienced (increased cough, breathlessness, and mucopurulent sputum) or to ask specific questions about previous:

  • Hospital visits

  • GP visits

  • Courses of oral corticosteroids or antibiotics.

    • Some patients keep corticosteroids as stand-by medication at home and therefore will be able to take a course without seeing a healthcare provider.

Symptoms of an exacerbation usually last 7 to 10 days, though may be longer.[1] 

Smoking

Check if the patient currently smokes and/or they have had significant exposure to tobacco smoke.[83] 

Exposure to pollution[83]

Ask about wood smoke, dust, and other pollutants.

  • This may include biofuel exposure from cooking over an open fire indoors.

  • Check the patient’s occupation. It may expose them to pollutants or irritants that would cause an exacerbation.

  • Short-term exposure to fine particulate matter is associated with increased hospitalisations for acute exacerbations and increased mortality.[1]

Cor pulmonale may develop as a result of increased pulmonary artery hypoxaemic vasoconstriction due to exacerbation-induced hypoxaemia. The resulting increase in pulmonary vascular resistance and/or pulmonary artery pressure can lead to acute right heart failure.

If you suspect cor pulmonale, exclude other causes of peripheral oedema and make a clinical diagnosis based on the presence of:[83]

  • Peripheral oedema 

  • Elevated jugular venous pressure

  • Hepatojugular reflux

  • Systolic parasternal heave

  • Relative hypotension

  • Loud pulmonary second heart sound.

These signs may be difficult to define in practice due to the presence of a hyperinflated chest.

Other diagnostic factors

Assess for signs suggestive of respiratory failure. In consultation with your senior team, arrange admission to a higher-level care facility (high-dependency unit or intensive care unit) if the exacerbation is severe and you detect signs of acute respiratory failure. 

Change in mental status[1]

Look for drowsiness, confusion, personality change, irritability.

Morning headaches

Sign of worsening hypercapnic ventilatory failure.

  • This may be accompanied by increased daytime somnolence.

Malaise and fatigue

These symptoms and other non-specific symptoms such as insomnia, decreased activity level, and loss of appetite are commonly identified in people with an acute exacerbation of COPD.[102][103] 

  • These symptoms have a great impact on quality of life, but are not on their own diagnostic of an exacerbation. 

Accessory muscle use

Sign of impending respiratory failure.

  • This may be accompanied by pursed lip breathing.

Paradoxical movements of abdomen

Sign of impending respiratory failure.

  • More common when there is respiratory muscle weakness.

May be a sign of bacterial infection meaning antibiotic therapy is required.

  • Consider a bacterial pneumonia or influenza virus infection if there is a high and/or persistent fever.

A possible trigger for exacerbations of COPD.[65][66] 

  • No available studies guide whether the treatment of reflux improves exacerbations of COPD.

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