How should I evaluate and manage a 58‑year‑old ex‑smoker (quit 6 months ago) with a one‑week productive cough, fatigue, dyspnea, expiratory wheeze, normal vital signs except borderline oxygen saturation (95 %), no fever, and prior benefit from Ventolin?

Evaluation and Management of Suspected COPD Exacerbation in an Ex-Smoker

Immediate Clinical Assessment

This patient most likely has an acute exacerbation of previously undiagnosed COPD, and you should immediately initiate bronchodilator therapy, prescribe antibiotics for the purulent sputum, and arrange urgent spirometry once acute symptoms resolve to confirm the diagnosis. 1

The constellation of productive cough, wheeze, dyspnea, and borderline oxygen saturation (95%) in a 58-year-old with a 43 pack-year smoking history (quit only 6 months ago) strongly suggests COPD exacerbation, even without a formal diagnosis. 2 The presence of expiratory wheeze on examination with good air entry bilaterally indicates moderate airflow obstruction rather than severe disease. 2

Diagnostic Approach

Key Clinical Features Supporting COPD Exacerbation:

• Purulent sputum with increased breathlessness meets the cardinal criteria for infectious exacerbation requiring antibiotic therapy 1
• Recent smoking cessation (6 months) does not eliminate COPD risk; symptoms often persist or worsen initially after quitting 2, 3
• Previous Ventolin response suggests reversible airflow obstruction, common in COPD despite being "largely fixed" 2
• Fatigue and reduced exercise tolerance indicate at least moderate disease severity 1

Essential Immediate Investigations:

• Chest X-ray is mandatory to exclude pneumonia, malignancy, pleural effusion, heart failure, and assess for emphysema 1, 4
• Spirometry with bronchodilator testing must be performed once acute symptoms resolve to confirm COPD diagnosis (FEV1 <80% predicted, FEV1/FVC <0.70) and assess severity 2, 1, 4
• Complete blood count and inflammatory markers to assess infection severity 1
• Arterial blood gas if oxygen saturation remains ≤92% on room air to identify hypoxemia or hypercapnia 2

Immediate Management

Bronchodilator Therapy:

• Increase short-acting β2-agonist (salbutamol/Ventolin) to regular dosing every 4-6 hours or via nebulizer if severe 1, 4
• Add or increase inhaled anticholinergic (ipratropium) for combination therapy 2, 1

Antibiotic Therapy:

• Prescribe antibiotics immediately given the presence of purulent sputum, increased breathlessness, and increased sputum volume—this meets all three cardinal features of infectious COPD exacerbation 1
• Typical choices include amoxicillin-clavulanate, doxycycline, or a macrolide for 5-7 days 1

Corticosteroid Therapy:

• Consider oral prednisolone 30-40 mg daily for 5-7 days for this moderate exacerbation to improve lung function and shorten recovery time 1, 4
• The presence of wheeze, dyspnea, and borderline oxygen saturation justifies systemic corticosteroids 1

Critical Differential Diagnoses to Exclude

Lung Cancer:

This patient has multiple red flags for malignancy including 43 pack-year smoking history, age 58, persistent productive cough, fatigue, and reduced appetite—chest X-ray is essential to exclude mass or nodule. 1, 4 Weight loss inquiry should be specifically documented. 1

Heart Failure:

The normal heart sounds and absence of peripheral edema make this less likely, but chest X-ray will help exclude cardiomegaly or pulmonary edema. 1

Pneumonia:

The absence of fever and normal temperature (36.3°C) make bacterial pneumonia less likely, but chest X-ray is still mandatory to exclude consolidation. 1

Bronchiectasis:

Less likely given the relatively short symptom duration (1 week) and absence of large volumes of persistent purulent sputum, but consider if symptoms persist despite treatment. 1

Follow-Up Plan

• If no improvement within 2 weeks, obtain chest radiography (if not already done) and consider hospital referral 1
• Arrange spirometry within 4-6 weeks once acute symptoms resolve to confirm COPD diagnosis and grade severity (mild: FEV1 60-79%, moderate: 40-59%, severe: <40% predicted) 2
• Initiate smoking cessation interventions immediately—this is the single most important intervention at all disease stages 1, 3
• Reassess oxygen saturation at follow-up; persistent hypoxemia (<92%) requires arterial blood gas measurement 2

Common Pitfalls to Avoid

• Do not delay treatment waiting for spirometry—COPD diagnosis requires spirometry, but acute exacerbations should be treated empirically based on clinical presentation 2, 1
• Do not dismiss symptoms as "just a cough" in ex-smokers; COPD necessarily passes through mild phases before becoming severe, and early detection is crucial 2
• Do not assume recent smoking cessation eliminates COPD risk—6 months is insufficient time for significant lung function recovery, and symptoms may initially worsen 2, 3
• Do not forget malignancy screening—persistent cough in a heavy smoker requires chest imaging regardless of other findings 1, 4