*4.1.2 Other early possible signs and symptoms that are coming before cannot breathe*

COPD patients have early possible signs and symptoms that are coming before cannot breathe different individually. There were twenty-three other early possible signs and symptoms, included: (1) edgy/nervous/moody, (2) difficult breathing, (3) increasing cough, (4) cough with sputum, (5) sticky sputum, (6) a lot of sticky clear white mucus, (7) runny nose, (8) sneeze, (9) stuffy nose, (10) feeling tight like something obstructing in the throat, (11) wheezing, (12) inspiratory wheezing, (13) breathe not all over the stomach, (14) dry cough, (15) tinnitus, (16) hoarse voice, (17) change color in sputum, (18) agitation, (19) sick at heart/heart pain, (20) unsettledness, (21) sweating, (22) frequent cough, and (23) leg pain.

Because COPD patients have different durations of illness and comorbidities, they have early possible signs and symptoms that are coming before cannot breathe differently.

### **4.2 Signs and symptoms that make the patients worse**

There are two categories of signs and symptoms that make the patients worse, included: 1) common signs and symptoms that make the patients worse and 2) signs and symptoms that make the patients decide to go to the hospital.

### *4.2.1 Common signs and symptoms that make the patients worse*

There are four signs and symptoms that make AECOPD patients worse: (1) coughing, (2) wheezing, (3) tightness, and (4) difficulty breathing. Coughing is the sign that most participants have experienced before getting worse but some study said that difficulty breathing is the sign of respiratory system illness which will impact COPD patients' immediate response because it results in airflow limitation and air being trapped which are the cause of increased dyspnea until exacerbation occurs.

### *4.2.2 Signs and symptoms that make the patients decide to go to the hospital*

Seven signs and symptoms make AECOPD patients need to receive the treatment from the doctor at the hospital, included: (1) still dyspnea, (2) cannot exhale, (3) cannot inhale, (4) after receiving bronchodilator therapy, still dyspnea, (5) dyspnea until the body shakes, (6) tinnitus, and (7) when wheezing results in dyspnea. Still dyspnea was the most symptom which the participants decided to go to the hospital to receive treatment from the doctor. It is the symptom that AECOPD patients usually unable to control or manage because they have pulmonary function test (PFT); forced expiratory volume in one second/forced vital capacity (FEV1/FVC) < 0.70% (confirms the presence of airflow limitation). Thus, they have difficulty to control dyspnea.

## *A Compendium of Chronic Obstructive Pulmonary Disease*

#### **Figure 1.**

*The characteristics of warning signs and prodromal symptoms of AECOPD.*
