Clinical features

Patients may not have any symptoms or may present with minimal symptoms during the early stages of COPD (1).

Usually, patients seek medical help either because of chronic respiratory symptoms or because of an acute transient episode of exacerbated respiratory symptoms (2)

Typical clinical features of COPD include:

• chronic progressive dyspnoea
  • cardinal symptom of COPD
  • is persistent
  • the patient may describe it as an “increased effort to breathe”, “heaviness”, “air hunger” or “gasping” (2)
  • in advanced disease, breathlessness may occur on minimal exercise, e.g. dressing
  • the Medical Research Council (MRC) dyspnoea scale should be used to grade the breathlessness according to the level of exertion required to elicit it
• chronic cough
  • is often the first symptom of COPD
  • may be intermittent and may be unproductive but subsequently may be present every day, throughout the day
  • significant airflow limitation may be present even in the absence of cough
• regular sputum production
  • often difficult to evaluate since patients may swallow sputum rather than expectorate it
  • can be intermittent with periods of flare-up interspersed with periods of remission
• frequent winter “bronchitis”
• wheezing and chest tightness
  • may vary between days and over the course of a single day
  • audible wheeze may arise at laryngeal level (in the absence of abnormalities on auscultation) or alternatively widespread inspiratory or expiratory wheezes can be present on auscultation
  • chest tightness is often seen after exertion, is poorly localized, is muscular in character, and may arise from isometric contraction of the intercostals muscles (1,2)

Other symptoms which should be considered in severe COPD patients:

• fatigue
• weight loss
• anorexia
• syncope during cough
• rib fractures due to coughing (sometimes asymptomatic)
• ankle swelling – may indicate presence of cor pulmonale
• depression and/or anxiety (2)

The following signs may be present in COPD patients (although they are not helpful in making a diagnosis of COPD)

• hyperinflated chest
• wheeze or quiet breath sounds
• purse lip breathing
• use of accessory muscles
• paradoxical movement of lower ribs
• peripheral oedema
• cyanosis
• raised JVP
• cachexia (1)

Historically, a distinction has been made between "pink puffers" and "blue bloaters". The reasons for the existence of these two clinically recognisable groups is not known, but probably reflects premorbid ventilatory drive rather than underlying lung pathology. The distinction is no longer considered clinically useful.

Note:

• fatigue, weight loss and anorexia may indicate presence of other diseases such as TB or lung cancer (2)

Reference:

1. National Institute for Health and Clinical Excellence (NICE) 2019. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care.
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease