What are the signs and symptoms of a chronic obstructive pulmonary disease (COPD) exacerbation in an older adult patient with a history of smoking and underlying health conditions such as cardiovascular disease or diabetes?

Signs and Symptoms of COPD Exacerbation

A COPD exacerbation is defined as an acute worsening of baseline dyspnea, cough, and/or sputum production beyond day-to-day variability that is sufficient to warrant a change in management. 1

Cardinal Respiratory Symptoms

The primary manifestations of a COPD exacerbation include:

• Increased dyspnea (shortness of breath) - This is the most prominent symptom and represents worsening beyond the patient's baseline breathlessness 1, 2
• Increased cough - Cough becomes more frequent and troublesome compared to the patient's stable state 1, 3
• Increased sputum production - Greater volume of sputum than usual 1, 3, 4
• Change in sputum purulence - Sputum becomes more discolored (yellow or green), indicating possible bacterial infection 1, 3, 4

These symptoms typically worsen over a period of days to 2 weeks and represent acute deterioration from the patient's stable baseline. 5, 3

Classification by Symptom Severity

Exacerbations are traditionally classified into three types based on symptom presentation 4:

• Type 1 (most severe): All three cardinal symptoms present - increased dyspnea, increased sputum volume, AND increased sputum purulence 4
• Type 2 (moderate): Any two of the three cardinal symptoms 4
• Type 3 (mild): One cardinal symptom plus additional symptoms such as wheeze, cough, or upper respiratory tract infection symptoms 4

Signs of Severe Exacerbation Requiring Hospitalization

The following clinical features indicate a severe exacerbation that warrants immediate hospitalization or ICU admission: 1, 6

Respiratory Distress Signs

• Marked increase in dyspnea - Inability to speak in full sentences or perform basic self-care 1, 6
• Respiratory rate >24-35 breaths per minute 6
• Use of accessory respiratory muscles - Visible recruitment of neck and chest wall muscles for breathing 6
• Paradoxical breathing pattern - Inward movement of abdomen during inspiration 6
• Inability to eat or sleep due to breathlessness 1

Gas Exchange Abnormalities

• Worsening hypoxemia - Declining oxygen saturation below baseline 1, 6
• Worsening hypercapnia - Rising carbon dioxide levels 1, 6
• Respiratory acidosis - Arterial blood gas showing pH <7.35 with elevated PaCO2 6, 7

Neurological Signs

• Changes in mental status - Confusion, somnolence, or altered consciousness indicating severe hypoxemia or hypercapnia 1, 6

Cardiovascular Signs

• Hemodynamic instability - Abnormal blood pressure, heart rate, or presence of arrhythmias 1, 6
• Signs of right heart failure - Peripheral edema, elevated jugular venous pressure, hepatomegaly 6
• Cardiac arrhythmias - New or worsening irregular heart rhythms 1, 6

Additional Clinical Features

Associated Symptoms

• Wheeze - Audible or auscultated wheezing, though this is a poor predictor of severity 1, 4
• Chest tightness - Sensation of constriction in the chest 3
• Upper respiratory symptoms - Sore throat, nasal congestion, suggesting viral trigger 4

Physical Examination Findings in Moderate to Severe Cases

• Cyanosis - Blue discoloration of lips or extremities indicating severe hypoxemia 1
• Clinical signs of hyperinflation - Barrel chest, decreased breath sounds 1
• Tachycardia - Elevated heart rate 6

Important Clinical Context

Patients with underlying cardiovascular disease (such as heart failure, arrhythmias) or diabetes represent high-risk populations who require more aggressive monitoring and earlier hospitalization. 1 The presence of these comorbidities can complicate the clinical presentation and worsen outcomes 1, 6.

Common Pitfalls to Avoid

• Do not assume all acute dyspnea in COPD patients is an exacerbation - The cardinal symptoms are nonspecific and can result from pneumonia, pulmonary embolism, acute heart failure, or cardiac arrhythmias 3, 6
• Do not rely solely on patient reporting - Approximately 50% of exacerbations go unreported by patients who are accustomed to frequent symptom changes 4
• Do not underestimate exacerbations in patients with severe baseline COPD - These patients may have poor perception of breathlessness despite severe physiologic deterioration 1
• Inadequate response to outpatient management is itself a sign requiring hospitalization - Failure to improve with initial bronchodilator therapy indicates more severe disease 1