Signs and Symptoms of COPD

Diagnosing COPD requires a structured systematic approach in all cases. The person with symptoms should be able to access a responsive system with a diagnostician who has a clear path to follow and has referral options for objective tests by someone trained to do them.

Think about symptoms first (e.g. cough, breathlessness) and what might cause them and explore these with an open mind. Avoid pre-determined diagnoses, e.g. do not assume that a smoker with cough or breathlessness has COPD but collect the evidence to confirm any suspicion. Existing COPD diagnoses need to be validated/confirmed and not taken for granted at each review. 

Breathlessness, also described as dyspnoea, is a key feature of COPD. There are a number of tools which can be used to assess the degree of breathlessness. PCRS recommends the use of the modified MRC scale in primary care. The mMRC (Modified Medical Research Council) Dyspnoea Scale is used to assess the degree of baseline functional disability due to dyspnoea. It is useful in characterising baseline dyspnoea in patients with respiratory disease such as COPD. Whilst it moderately correlates with other healthcare-associated morbidity, mortality and quality of life scales (particularly in COPD) the scores are only variably associated with patients' perceptions of respiratory symptom burden. 

What you need to know

Symptoms of COPD are varied and differ from patient to patient: they include exertional breathlessness, recurrent bouts of “chest infections” (probably the most common reason for patients to present), recurrent wheeze, cough or sputum production. Less common symptoms include weight loss, effort intolerance, night time wakening, ankle oedema, and fatigue. There tends to be little variation in the symptoms on a daily basis but there will be deterioration over time. 

Clinical examination of patients with COPD may not be helpful in making a firm diagnosis as it may be normal or signs may be non-specific and shared with other conditions. People with possible COPD are at high risk from bronchial cancer for example or heart failure because the causation and symptomatology are similar. Some specific findings of people with COPD can include barrel chest, hyper-resonance on percussion, distant breath sounds, wheezing and air movement on auscultation and coarse crackles. COPD that has progressed shows additional features common to other conditions, such as tachypnoea, distended neck veins, peripheral oedema, weight loss, muscle loss, pursed lip breathing, cyanosis and clubbing though the latter sign should be a red flag for other conditions such as lung cancer and pulmonary fibrosis where respiratory symptoms feature most prominently. Sometimes exam findings may be present according to patient’s clinical presentation, for example cyanosis may be present during an exacerbation but absent when stable. 

COPD should not be diagnosed with history, symptoms and signs alone. Confirmatory testing, which for the majority is full spirometry should be performed. Anyone without a positive confirmatory test should be reviewed with a specialist colleague before being added to the COPD register. 

• Cough: About one in ten patients present in primary care with chronic cough and the majority of cases can be dealt with in primary care. In Managing cough in primary care Kevin Gruffydd-Jones explains that COPD is a common cause of chronic cough but only a systematic approach to diagnosis will ensure alternative causes are not missed. The article takes you through a process that will help decide whether the cough is acute or chronic and to avoid red flags. Check out the video presentation on cough in primary care featuring Kevin Gruffydd-Jones and Professor Adam Hill
• Breathlessness: About two thirds of chronic breathlessness is caused by cardiopulmonary disorders and a number of other conditions take up the remaining third. In The differential diagnosis of the breathless patient those features on history and exam that can help decisions about possible cause are explored. In this recent review, the recent challenge arising from the Covid-19 pandemic of making a diagnosis using telephone or video is considered and an evidence-based approach is recommended. When assessing how breathlessness impacts on the person’s function the Modified MRC dyspnoea scale should be used.  Achieving an understanding of how the breathlessness symptom impacts on the patient day to day then enables a further discussion of how this can be mitigated. The mMRC score has its limitations but is a helpful way to start a discussion that helps connect with the patient’s experience.
• Recurrent chest infections: Text to include here or link
• Sputum Production

Key factors to consider when personalising care

• Patients may experience embarrassment about symptoms /hide symptoms
• Patients may have delayed consulting about their symptoms due to feelings of guilt from smoking 
• Symptoms of breathlessness can be described or conbceptualised differently because of language and culture
• When a patient describes their "chest infection" they could be talking about COPD, heart failure, pulmonary fibrosis, lung cancer and more