Likely Diagnosis: Acute Exacerbation of COPD (or Acute Bronchitis in Underlying COPD)
The most likely diagnosis is an acute exacerbation of chronic obstructive pulmonary disease (COPD), presenting with infectious bronchitis, given the combination of wheezing, exertional dyspnea, productive cough with purulent (yellow) sputum, and sinus congestion in what is presumably a patient with smoking history or environmental exposure risk factors. 1, 2
Diagnostic Reasoning
Why COPD Exacerbation is Most Likely
COPD should be considered in any patient presenting with dyspnea, chronic cough, or sputum production, particularly with exposure to risk factors like smoking. 1 The constellation of wheezing, shortness of breath with exertion, and productive cough are cardinal symptoms of COPD. 1, 2
The presence of yellow (purulent) sputum strongly suggests an infectious exacerbation. 3 Development of purulent sputum is one of the three cardinal features of COPD exacerbation (along with increased breathlessness and increased sputum volume). 3
Normal chest X-ray does not exclude COPD or its exacerbations. 1 Physical examination and chest radiography are often normal in mild to moderate COPD, and spirometry is required for definitive diagnosis. 1
Absence of fever does not rule out infectious exacerbation. 3 Many COPD exacerbations with bacterial or viral triggers occur without systemic fever.
Clinical Pattern Analysis
The patient exhibits the classic triad suggesting infectious COPD exacerbation: 3
- Increased breathlessness (SOB with exertion)
- Increased sputum volume (productive cough)
- Development of purulent sputum (yellow color)
When at least two of these three features are present, antibiotic therapy is indicated. 3 This patient has all three.
Alternative Diagnoses to Consider (Less Likely)
Cough-variant asthma: While possible, this typically presents with chronic cough as the sole symptom, normal baseline pulmonary function, and absence of sputum production. 4 The presence of yellow sputum and sinus congestion makes this less likely.
Acute bronchitis alone: Possible in a patient without underlying lung disease, but the combination of wheezing, exertional dyspnea, and the clinical pattern suggests underlying chronic airway disease (COPD) with acute exacerbation.
Immediate Management Approach
Confirm Risk Factors
- Document detailed smoking history (pack-years), occupational exposures, and age. 1, 2 Most COPD patients are long-term smokers over age 40. 2
- Assess for history of recurrent respiratory infections, especially during winter months. 2
Treatment Without Spirometry
While spirometry is required for definitive COPD diagnosis (post-bronchodilator FEV1/FVC <0.70), treatment should not be delayed. 1, 2
For this acute exacerbation: 3
- Increase dose or frequency of short-acting bronchodilators (if already on them, or initiate if not)
- Prescribe antibiotic therapy given the presence of purulent sputum with increased volume and breathlessness 3
- Consider systemic corticosteroids for moderate exacerbations to improve lung function and shorten recovery time 3
Follow-Up Strategy
- Arrange spirometry once acute symptoms resolve to confirm COPD diagnosis and assess severity. 1, 2 This remains essential for guiding long-term treatment decisions. 2
- If no improvement within two weeks, obtain chest radiography and consider hospital referral. 3
- Initiate smoking cessation interventions immediately if applicable, as this is essential at all disease stages. 3
Common Pitfalls to Avoid
- Do not rely on physical examination alone. Physical signs are poor predictors of COPD severity, and their absence does not exclude the diagnosis. 2
- Do not wait for spirometry to treat an acute exacerbation. Clinical diagnosis based on symptoms, smoking history >40 pack-years, and examination findings (wheezing) can guide initial management. 2
- Do not dismiss the diagnosis because of normal chest X-ray. Radiographic changes lag behind functional impairment in COPD. 1