What is the examination protocol for a patient with Chronic Obstructive Pulmonary Disease (COPD)?

COPD Examination Protocol

The examination protocol for COPD requires a structured approach combining detailed history, targeted physical examination, and mandatory spirometry confirmation, as physical examination alone is neither sensitive nor specific for diagnosis. 1

Medical History Assessment

Obtain a comprehensive smoking and exposure history as the foundation of your evaluation. 1, 2

Key Historical Elements to Document:

• Smoking history: Calculate pack-years (>40 pack-years is the strongest predictor of airflow obstruction; >55 pack-years combined with wheezing has a likelihood ratio of 156 for obstruction) 2, 3

• Occupational and environmental exposures: Document exposure to dusts, vapors, fumes, gases, and home cooking/heating fuels 1

• Symptom characterization: 1

  • Dyspnea that is progressive over time, worse with exercise, and persistent
  • Chronic cough (may be intermittent and unproductive)
  • Chronic sputum production (note: regular production for 3+ months in 2 consecutive years defines chronic bronchitis; large volumes suggest bronchiectasis) 1
  • Recurrent lower respiratory tract infections
  • Wheezing and chest tightness (varies day-to-day)

• Exercise tolerance: Specifically quantify limitation in activities of daily living using standardized questionnaires (mMRC dyspnea scale, COPD Assessment Test) 1, 2

• Past medical history: Asthma, allergies, sinusitis, nasal polyps, childhood respiratory infections 1

• Family history: COPD or other chronic respiratory diseases 1

• Exacerbation history: Previous hospitalizations for respiratory disorders 1

• Comorbidities: Heart disease, osteoporosis, musculoskeletal disorders, malignancies 1

• Systemic symptoms in severe disease: Fatigue, weight loss, anorexia 1

Physical Examination

Physical examination is rarely diagnostic in COPD and is typically normal until significant lung function impairment exists, but specific findings can support the diagnosis. 1

Vital Signs and Anthropometrics (Mandatory):

• Respiratory rate 1
• Oxygen saturation at rest and with exertion 1
• Weight, height, and BMI (weight loss is common in advanced disease and correlates with severity) 1

Respiratory System Examination:

Early/Mild COPD (often normal examination): 1

• Wheezing during tidal breathing (useful indicator but poor guide to severity) 1
• Prolonged forced expiratory time (>5 seconds suggests obstruction) 1

Moderate to Severe COPD (progressive findings): 1

• Diminished breath sounds (positive likelihood ratio >5.0 when combined with hyperresonance) 1
• Signs of hyperinflation: 1
  • Loss of cardiac dullness
  • Decreased cricosternal distance (<3 cm)
  • Increased anteroposterior chest diameter
  • Hyperresonance on percussion
  • Reduced ribcage expansion and diaphragmatic excursion 1
• Accessory muscle use (sternomastoid activity) or pursed-lip breathing (implies severe obstruction) 1
• Prolonged expiration 1
• Rhonchi, especially on forced expiration 1

Advanced/Severe COPD (signs of complications): 1

• Central cyanosis (indicates significant hypoxemia, though sensitivity is low) 1
• Signs of cor pulmonale: Peripheral edema, raised jugular venous pressure, hepatic enlargement 1
• Weight loss 1

Functional Assessment:

• Exercise testing: Perform timed walking distances or walking speed measurement (strongly predicts mortality) 1
• Breathlessness scoring: Use mMRC dyspnea scale 1, 2

Diagnostic Confirmation

Spirometry is absolutely required to establish the diagnosis—COPD cannot be diagnosed on history and physical examination alone. 1, 4

Spirometric Criteria:

• Post-bronchodilator FEV1/FVC ratio <0.70 confirms airflow limitation 1, 2
• Perform spirometry in any individual >40 years with key indicators (dyspnea, chronic cough, sputum production, smoking history, recurrent infections) 1, 2

Severity Classification (based on FEV1 % predicted): 2

• Mild: FEV1 ≥80% predicted
• Moderate: FEV1 50-79% predicted
• Severe: FEV1 30-49% predicted
• Very severe: FEV1 <30% predicted

Additional Diagnostic Testing

Chest radiography should be performed during initial evaluation to exclude alternative diagnoses and identify comorbid conditions, though it is frequently normal in early COPD. 1

• Radiographic findings may include hyperinflation and hyperlucent areas with peripheral vascular trimming 1
• Not performed during routine follow-up of stable patients 1

Common Pitfalls to Avoid

• Do not rely on history and physical examination alone—they are neither sensitive nor specific for COPD diagnosis 1, 4, 5
• Do not assume normal examination excludes COPD—physical signs are rarely present until significant impairment exists 1
• Do not use "pink puffer" and "blue bloater" terminology—these terms are not clearly related to specific functional features and should be avoided 1
• Do not overlook active questioning about daily activities—patients may deny symptoms because they've restricted activities to avoid triggering them 1
• Do not diagnose COPD without post-bronchodilator spirometry—approximately two-thirds of patients with a clinical diagnosis lack spirometric confirmation 4