Documentation of Lung Findings in Acute COPD Exacerbation
When documenting lung findings in an acute COPD exacerbation, describe the specific adventitious sounds you hear using standard medical terminology: document "diffuse expiratory wheezes," "rhonchi" (for low-pitched continuous sounds suggesting secretions), "decreased breath sounds," and note the use of accessory muscles and respiratory rate—these objective findings reflect the inflamed, noisy airways characteristic of exacerbations. 1
Standard Physical Examination Findings to Document
Respiratory Sounds
- Wheezes: Document as "diffuse expiratory wheezes" or "polyphonic wheezes throughout lung fields"—these reflect bronchospasm and airway inflammation typical of exacerbations 2, 1
- Rhonchi: Low-pitched, continuous sounds that change with coughing; document as "coarse rhonchi" or "sonorous rhonchi"—these indicate secretions in larger airways 2
- Decreased breath sounds: Note "generally reduced breath sounds" or "diminished air entry bilaterally"—this reflects hyperinflation and air trapping 2
- Crackles: If present, document as "bibasilar crackles" but note these are less common in pure COPD exacerbations and should raise concern for pneumonia or heart failure 3
Work of Breathing
- Respiratory rate: Document the exact rate—tachypnea is a key severity indicator 1
- Accessory muscle use: Specifically note "use of sternocleidomastoid muscles" or "intercostal retractions" 1
- Paradoxical breathing: A critically important finding—document "paradoxical abdominal motion" or "abdominal paradox" as this suggests respiratory muscle fatigue and impending respiratory failure 1
Additional Objective Findings
- Cyanosis: Document "central cyanosis" (lips, tongue) if present—this indicates significant hypoxemia 1
- Heart rate: Note tachycardia as part of severity assessment 1
- Mental status: Document any altered consciousness—"alert and oriented" versus "drowsy" or "confused"—as changes indicate severe exacerbation 1
Avoid These Common Documentation Pitfalls
Do not use vague terms like "lungs sound inflamed" or "rugging"—these are not standard medical terminology and do not convey specific clinical findings 2
Do not rely on physical examination alone to determine severity—physical signs have poor sensitivity and reliability in COPD exacerbations 1. Always correlate with:
- Pulse oximetry (document SpO2 value) 1
- Arterial blood gas if severe (document pH, PaCO2, PaO2) 1
- Chest X-ray to exclude pneumonia, pneumothorax, or heart failure 1, 3
Severity Classification Based on Your Findings
Document severity using this framework 1:
- Mild exacerbation: Increased dyspnea, cough, and sputum production; wheezes present; no accessory muscle use; normal mental status
- Moderate exacerbation: More pronounced dyspnea; tachypnea; wheezes and rhonchi; possible accessory muscle use; tachycardia
- Severe exacerbation: Marked dyspnea at rest; significant tachypnea or paradoxically low respiratory rate (warning sign); accessory muscle use; possible cyanosis; altered mental status; requires hospitalization
Critical Warning Signs to Document
A paradoxically low respiratory rate in a patient who appears distressed is a medical emergency—document this immediately as it suggests respiratory muscle fatigue with impending respiratory arrest 1
Altered mental status (drowsiness, confusion, agitation) requires immediate documentation and hospitalization—this indicates severe hypercapnia or hypoxemia 1