Chronic Obstructive Pulmonary Disease (COPD): Clinical Signs

00:00 What are the clinical signs of COPD? Well, with mild disease, in fact, there will be very little to find when they examine the patient, but more moderate, more severe disease, it may be evident that they have respiratory difficulty. They may be breathless moving around the examination room, they may have an increased respiratory rate at rest. They may have to use their accessory muscles to breathe and there might be excessive abdominal movement. And patients with more severe disease and exacerbations could show pursed lip breathing. When you look at the chest, it may obviously be hyperexpanded with a horizontal angle to the ribs and increased anterior-posterior diameter, the so-called 'barrel chest'. There may be tracheal tug with the cricoid cartilage coming down on inspiration towards the sternal notch.

00:41 And when you examine the chest directly, the expansion will be reduced bilaterally on inspiration and there will be loss of the normal dull percussion note that you normally find over the liver and the heart, and the lungs might be expanded below the level of the 10th vertebra posteriorly. When you listen to the lungs actually wheeze, although it is a sign of the COPD and airways disease, is not universally present. In fact, it's probably present in fewer patients, than no wheeze. What they do have, is a prolonged expiratory phase and they have quiet breath sounds all over their chest, that's a very common sign. Patients with very severe disease may have the signs of complicating cor pulmonale, raised JVP, oedema etc. There's often a description of clinical phenotypes of COPD. As I mentioned earlier, there's an admixture of different pathologies that patients with COPD have and that might dictate the clinical phenotype they present with.

01:44 The two extremes of this phenotype is the blue bloater and the pink puffer. Now there are probably not terribly useful clinical terms but they are useful with illustrating the different types of pathology mixtures you may get in somebody with COPD.

02:00 So, for example, a pink puffer, the emphysema component may be dominant in their pathology and that's associated with a lot of muscle wasting and cachexia and a rapid respiratory rate, using accessory muscles with pursed lips breathing, but with no real cyanosis or oedema, because the patient is maintaining their respiratory function without tipping over into type 2 respiratory failure or significant hypoxia by compensating with a high respiratory rate. The blue bloater on the other hand, airways obstruction is dominant, there is not much emphysema and they seem to have chronic type 2 respiratory failure with hypercapnia and some cor pulmonale. And that means they're cyanosed, they have a relatively low respiratory rate, they tend to be overweight, and they have peripheral oedema. But this a spectrum and patients frequently have a mixture of these features and even can go from one to the other to a certain extent. So many patients with emphysema, although they are not hypoxic initially, eventually they will develop hypoxia and cor pulmonale and will present with cyanosis and oedema etc etc. So how do we confirm the suspected diagnosis of COPD? Well that's easy enough. We need to do some lung function tests, we need to record an FEV1 and FVC. Both will be reduced at a significant airways obstruction, but the FEV1 will be reduced proportionately further than the FVC because of the airflow obstruction, and that means the ratio of the two will fall. So for example in the spirometry shown here on this slide, the expected value for this patient will be 3.9 and 4, and that gives a ratio of FEV1 to FVC over the high 70s. However, the obtained values was 0.9 and 1.6.

03:44 Those are both much lower than they should be, but also the ratio of FEV1 to FVC is closer to 50%, around 60% there. And the thing about the airways obstruction in COPD is that it's largely irreversible, there might be a small uplift with bronchodilators, but often there is no change at all in FEV1, and there's always a persisting level of airways obstruction.

04:11 The peak flow records are not so useful in patients with COPD as they are of asthma, because the peak flow does not vary as much, and therefore is not a useful way of analyzing whether the patient is in exacerbation or is deteriorating in some way. A very important point which follows from the slides that we discussed earlier is that the FEV1 over time tells you how the patient is doing. And if the patient has an FEV1 less than 50%, that's probably severe COPD.