**7.2 Physical findings**

132 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

With advanced disease, obvious exertional dyspnea, cough and frequent acute exacerbations dominate the picture. Morbidity and mortality increases with declining FEV1. Primary cause of mortality is cardiac events, however with advanced age and disease, pulmonary complications causing death, increase in proportion. Each exacerbation and the following recovery stage makes the patient most vulnerable to adverse outcomes as shown by the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments), which demonstrated a 49% 2-year mortality rate after hospital admissions

Various therapeutic and supportive medical and surgical intervention combined with rehabilitative measures help in alleviation of symptoms, slowing of pace of progression of disease and reduction of disability. Individualized plans for each patient based on the

COPD is a gradually progressive chronic disease presenting with clinically obvious symptoms late in the course, usually in their fifth decade of life with productive cough or breathlessness or acute chest illness. A1PI-deficient patients present earlier than other COPD patients usually in 3rd-4th decades and by then they have significant liver disease, which

Early COPD results in gradual progressive worsening of pulmonary function, which results in patients unknowingly avoiding exertional dyspnea (the most common early symptom of COPD) and fatigue by shifting their expectations and limiting their activity. Patients who have an extremely sedentary lifestyle but few complaints require further evaluation for possibility of underlying COPD as many patients reset their expectations with regard to health, termed "response shift"(Rennard et al,2002 as cited in Shapiro SD,2010). Generalised

Most patients usually present in the fifth or sixth decade of life by when they have dyspnea with mild exertion and usually the forced expiratory volume in 1 second (FEV1) has fallen to 50% of predicted. Moderate to severe COPD patients report variability in symptoms over the course of the day or week-to-week; morning is typically the worst time of day. Dyspnea is related to both respiratory (hyperinflation and impaired gas exchange) and extrarespiratory (like muscle dysfunction, heart disease, anaemia and depression) features of

The chronic cough is characterized by the insidious onset of sputum production, which occurs in the morning initially, but may progress to occur throughout the day. The sputum is usually mucoid, but becomes purulent during exacerbations. Hemoptysis complicating chronic bronchitis usually occurs in association with acute exacerbation. Lung cancer and tuberculosis needs to be ruled out in this scenario(Thompson et al,1992 as cited in Shapiro SD,2010). Wheezing may also be found in some patients due to co-existence of asthma or

Acute exacerbations are characterized by increased cough, sputum, dyspnea, and fatigue, are increasingly frequent as the disease worsens. Each exacerbation may last for a few weeks

with COPD exacerbation with CO2 retention(Connors et al.,1996).

**7. Clinical presentation** 

usually starts in childhood.

**7.1 History** 

COPD.

COPD alone.

characteristic and stage of disease is important to achieve optimal results.

muscle weakness found in COPD patients can also contribute to this finding.

Physical findings in early COPD is highly non-specific and unreliable. Early stage patients may have coarse crackles and rhonchi. Wheezing may be found occasionally especially associated with asthma or acute exacerbations.

The hallmark finding is obstruction of expiratory airflow. Measurement of the forced expiratory time maneuver is a simple bedside test and most consistent finding in symptomatic COPD. A forced expiratory time greater than 4 seconds indicates severe expiratory airflow obstruction. Objective measurement of airflow by spirometry, which is simple and accurate forms the basis of staging and follow-up of disease progression(Petty,2001).

As the airway obstruction worsens, physical examination may reveal hyperinflation, decreased breath sounds, wheezes, crackles at the lung bases, and/or distant heart sounds. In addition, the diaphragm may be depressed and limited in its motion, and the anteroposterior diameter of the chest may be increased.

Patients with end-stage COPD may present with barrel-shaped chest, increased span of hyperresonant lung percussion, distended neck veins, full use of the accessory respiratory muscles of the neck and shoulder girdle, purse-lipped breathing, paradoxical retraction of the lower interspaces during inspiration (ie, Hoover's sign), emaciation, and frequently, inguinal hernias. They may adopt positions that relieve dyspnea, such as leaning forward with arms outstretched and weight supported on the palms(Tripod sign). This position stabilizes the shoulder girdle and helps to maximize intrathoracic volume. Late signs may include cyanosis, clubbing, asterixis due to severe hypercapnia, and an enlarged, tender liver due to right heart failure.
