pulmonary disorders
Chronic Obstructive Pulmonary Disease (COPD)
Symptoms and Signs of COPD
COPD takes years to develop and progress. Most patients have smoked≥20 cigarettes/day for>20 years. Productive cough usually is the initial symptom, developing among smokers in their 40s and 50s. Dyspnea that is progressive, persistent, exertional, or worse during respiratory infection appears when patients are in their late 50s or 60s. Symptoms usually progress quickly in patients who continue to smoke and in those who have a higher lifetime tobacco exposure. Morning headache develops in more advanced disease and signals nocturnal hypercapnia or hypoxemia. Signs of COPD include wheezing, a prolonged expiratory phase of breathing, lung hyperinflation manifested as decreased heart and lung sounds, and increased anteroposterior diameter of the thorax (barrel chest). Patients with advanced emphysema lose weight and experience muscle wasting that has been attributed to immobility, hypoxia, or release of systemic inflammatory mediators, such as TNF-alpha. Signs of advanced disease include pursed-lip breathing, accessory respiratory muscle use, paradoxical inward movement of the lower rib cage during inspiration (Hoover sign), and cyanosis. Signs of cor pulmonale include neck vein distention, splitting of the 2nd heart sound with an accentuated pulmonic component, tricuspid insufficiency murmur, and peripheral edema. Right ventricular heaves are uncommon in COPD because the lungs are hyperinflated. Spontaneous pneumothorax may occur (possibly related to rupture of bullae) and should be suspected in any patient with COPD whose pulmonary status abruptly worsens. The symptoms can be graded according to which activities cause dyspnea (see table Breathlessness Measurement Using the Modified British Medical Research Council (mMRC) Questionnaire ). Grade Shortness of Breath 0 None except during strenuous exercise 1 Occurring when hurrying on level ground or walking up a slight incline 2 Resulting in walking more slowly than people of the same age on level ground or Resulting in stopping for breath when walking at own pace on level ground 3 Resulting in stopping for breath after walking about 100 meters or after a few minutes on level ground 4 Preventing the person from leaving the house or Occurring when dressing or undressing Adapted from Mahler DA, Wells CK: Evaluation of clinical methods for rating dyspnea.Chest93:580–586, 1988. Acute exacerbations occur sporadically during the course of COPD and are heralded by increased symptom severity. The specific cause of any exacerbation is almost always impossible to determine, but exacerbations are often attributed to viral upper respiratory infections, acute bacterial bronchitis, or exposure to respiratory irritants. As COPD progresses, acute exacerbations tend to become more frequent, averaging about 1 to 3 episodes/year. 