What is the clinical picture of Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

Chronic Obstructive Pulmonary Disease (COPD) presents with a clinical picture characterized by progressive airflow limitation and respiratory symptoms, with exacerbations being a critical component of the disease, often triggered by respiratory infections or air pollution, and requiring additional treatment, as noted in the 2023 Canadian Thoracic Society guideline 1.

Clinical Presentation

Patients with COPD typically exhibit chronic cough, sputum production, dyspnea (especially on exertion), and wheezing. The clinical presentation varies based on disease severity, with early stages often showing minimal symptoms while advanced disease presents with marked breathlessness even at rest, reduced exercise capacity, fatigue, and recurrent exacerbations.

• Physical examination may reveal prolonged expiration, decreased breath sounds, hyperresonance on percussion, and use of accessory respiratory muscles.
• Patients often adopt a "tripod" position to facilitate breathing and may develop barrel chest due to lung hyperinflation.
• In advanced stages, signs of right heart failure (cor pulmonale) may appear, including peripheral edema, jugular venous distension, and hepatomegaly.

Exacerbations

Exacerbations are characterized by worsening symptoms beyond normal day-to-day variations, often triggered by respiratory infections or air pollution, requiring additional treatment, as defined by the American College of Chest Physicians and Canadian Thoracic Society guideline 1.

• Exacerbations can be classified as mild, moderate, or severe, with severe exacerbations being associated with acute respiratory failure, as noted in the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
• The management of exacerbations includes the use of systemic corticosteroids, antibiotics, and bronchodilators, with the goal of minimizing the negative impact of the current exacerbation and preventing subsequent events, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.

Comorbidities and Diagnosis

Comorbidities frequently accompany COPD, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, and lung cancer, which can complicate the clinical picture and management approach.

• Diagnosis requires spirometry showing a post-bronchodilator FEV1/FVC ratio less than 0.7, confirming the presence of persistent airflow limitation, as stated in the 2023 Canadian Thoracic Society guideline 1.
• The pharmacologic management of COPD exacerbations, including the use of corticosteroids, antibiotics, and bronchodilators, is critical in improving symptoms and preventing subsequent exacerbations, as noted in the American Academy of Family Physicians guideline 1.

From the Research

Clinical Picture of COPD Exacerbation

• A COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks 2
• The clinical diagnosis of COPD exacerbation is based on changes in dyspnea, cough, and/or sputum production in a COPD patient 3
• Exacerbations are common and can cause significant morbidity and mortality, making effective management crucial for patient care 4

Symptoms and Diagnosis

• Patients presenting with an acute exacerbation may be undiagnosed or have a variety of comorbid conditions that can complicate diagnosis 3
• Arterial blood gases remain the standard approach to assessing gas exchange in patients with COPD exacerbation, while pulse oximetry, capnography, transcutaneous monitoring, and peripheral venous blood gases have limitations and should be used wisely 2
• Targeted O2 therapy improves outcomes and should be titrated to an SpO2 of 88-92% 2

Treatment and Management

• Inhaled short-acting bronchodilators can be provided by nebulizer, pressurized metered-dose inhaler, or dry powder inhaler 2
• Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines 2
• Combination bronchodilator therapy with ipratropium and albuterol is more effective than either agent alone in improving lung function in patients with COPD 5, 6
• Care coordination can improve the effectiveness of care for patients with COPD exacerbation, and evidence-based practices improve outcomes in patients with COPD exacerbation 2, 4