History and exam

Key diagnostic factors

presence of risk factors (e.g., smoking)

The main risk factor is smoking. Other key risk factors include advancing age and genetic factors.


Usually the initial symptom of COPD.

Frequently a morning cough, but becomes constant as disease progresses.

Usually productive, and sputum quality may change with exacerbations or superimposed infection.

shortness of breath

Initially with exercise but may progress to shortness of breath even at rest.

Patients may have difficulty speaking in full sentences.

Other diagnostic factors

barrel chest

The anteroposterior diameter of the chest is increased.

This suggests hyperinflation and air trapping secondary to incomplete expiration.

hyper-resonance on percussion

Caused by hyperinflation and air trapping secondary to incomplete expiration.

distant breath sounds on auscultation

Caused by barrel chest, hyperinflation, and air trapping.

poor air movement on auscultation

Secondary to loss of lung elasticity and lung tissue breakdown.

wheezing on auscultation

A common finding in exacerbations. The current accepted descriptive word for a continuous musical lung sound.

Is indicative of airway inflammation and resistance.

coarse crackles

A common finding in exacerbations. A discontinuous sound referring to mucus or sputum in airways.

Indicative of airway inflammation and mucus over-secretion.


An increased respiratory rate occurs to compensate for hypoxia and hypoventilation.

May involve use of accessory muscles.


Loss of postural control in outstretched arms (commonly known as a flap) caused by hypercapnia.

This is due to impaired gas exchange in lung parenchyma, worsens with exercise, and is suggestive of respiratory failure.

distended neck veins

Occurs secondary to increased intrathoracic pressure and cor pulmonale.

lower-extremity swelling

Suggests cor pulmonale and secondary pulmonary hypertension as a complication of advanced chronic lung disease.


Occurs because of disrupted sleep secondary to constant nocturnal cough and persistent hypoxia and hypercapnia.


May occur due to vasodilation caused by hypercapnia.


Seen in the late stages of COPD, usually with hypoxia, hypercapnia, and cor pulmonale.

loud P2

Sign of advanced COPD.

Indicates secondary pulmonary hypertension as a complication of cor pulmonale.

hepatojugular reflux

Sign of advanced COPD complicated by cor pulmonale.


Sign of advanced COPD complicated by cor pulmonale.


COPD itself does not cause clubbing, but if tobacco exposure in COPD patients leads to lung cancer and/or bronchiectasis, then clubbing may occur in COPD. Clubbing is usually not present until significant impairment of lung function has occurred.

Risk factors

cigarette smoking

Most important risk factor. It causes 40% to 70% of cases of COPD. [14]

Elicits an inflammatory response and causes cilia dysfunction and oxidative injury.

advanced age

The effect of age may be related to a longer period of cigarette smoking as well as the normal age-related loss of FEV1.

genetic factors

Airway responsiveness to inhaled insults depends on genetic factors. Alpha-1 antitrypsin deficiency is a genetic disorder, mostly encountered in people of northern European ancestry, which causes panacinar emphysema in lower lobes at a young age.

white ancestry

Despite high rates of smoking among black Americans and other racial and ethnic groups, COPD is more common in white people.

exposure to air pollution or occupational exposure

Chronic exposure to dust, traffic exhaust fumes, and sulphur dioxide increases risk of COPD.

developmentally abnormal lung

Frequent childhood infection may cause scarring of lungs, decrease elasticity, and increase risk for COPD.

male sex

COPD is more common in men, but that is probably secondary to more smokers being male. However, there is a suggestion that women may be more susceptible than men to the effects of tobacco smoke. [15] [16] [17] [18]

low socio-economic status

The risk for developing COPD is increased in people with lower socio-economic status. [19] However, this may reflect exposure to cigarette smoke, pollutants, or other factors.

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