What are the cardinal signs of Chronic Obstructive Pulmonary Disease (COPD)?

Cardinal Signs of COPD

The cardinal signs of COPD are breathlessness (dyspnea), chronic cough, and sputum production, often accompanied by wheezing. 1

Primary Symptoms

• Breathlessness (Dyspnea): Progressive dyspnea is the most characteristic symptom of COPD, typically developing gradually over many years and eventually limiting daily activities 1
• Chronic Cough: Often productive and worse in the morning, present in most patients and sometimes dominating the clinical picture 1
• Sputum Production: Regular sputum production for 3 months or more in 2 consecutive years is the classic definition of chronic bronchitis, a common feature in COPD 1
• Wheezing: May vary between days and throughout a single day 1

Physical Findings

• Wheezing during tidal breathing: A useful indicator of airflow limitation 1
• Prolonged forced expiratory time (>5 seconds): Another useful indicator of airflow limitation 1
• Diminished breath sounds: May be elicited but is a poor guide to the degree of airflow limitation 1
• Reduced ribcage expansion and diaphragmatic excursion: Indicates hyperinflation 1
• Hyperresonance on percussion: Indicates air trapping 1

Signs of Severe Disease

• Use of accessory respiratory muscles (e.g., sternomastoid): Implies severe airflow obstruction 1
• Pursed-lip breathing: Usually indicates severe airflow obstruction 1
• Central cyanosis: Seen with significant hypoxemia, though sensitivity is low 1
• Weight loss and anorexia: Common in advanced COPD 1
• Signs of cor pulmonale: Peripheral edema, raised jugular venous pressure, hepatic enlargement, and signs of pulmonary hypertension 1

Diagnostic Confirmation

It's important to note that while these signs and symptoms suggest COPD, the diagnosis must be confirmed by spirometry showing:

• Post-bronchodilator fixed FEV1/FVC ratio <0.70 1, 2
• The sensitivity of physical examination for detecting or excluding moderately severe COPD is poor, and reproducibility of physical signs is variable 1

Clinical Patterns During Exacerbations

• Increased breathlessness: A key indicator of exacerbation 3
• Increased sputum volume: Suggests an exacerbation 3
• Development of purulent sputum: Indicates an infectious exacerbation requiring antibiotic therapy 3
• Tachypnea and tachycardia: Used to assess exacerbation severity 1
• Respiratory muscle dysfunction or fatigue: Evidenced by uncoordinated ribcage motion or paradoxical movement of the abdominal wall during inspiration 1

Risk Factors to Consider

• Smoking history: Most patients are long-term cigarette smokers 1, 2
• Age: Patients are typically more than 40 years of age when presenting with breathlessness 1
• History of repeated respiratory infections: Especially during winter months 1

Common Pitfalls

• Physical signs alone are poor guides to the severity of airflow limitation 1
• The absence of wheezing or other physical signs does not exclude COPD 1
• Historically, patients were classified as "pink puffers" and "blue bloaters," but these terms are not clearly related to specific functional or pathological features and their use is not encouraged 1
• COPD may be confused with chronic asthma in older subjects; a history of heavy smoking, evidence of emphysema on imaging, decreased diffusing capacity, and chronic hypoxemia favor the diagnosis of COPD 1

Remember that COPD is often diagnosed late in its course because patients may lack symptoms even at low FEV1, making frequent routine spirometry important for earlier detection 1.