Acute exacerbation of COPD: Diagnosis and management

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Mr. B, 64, has a 10-year history of chronic obstructive pulmonary disease (COPD). He arrives at the pulmonary clinic with a 2-day history of increasing shortness of breath and sputum changing to a green color. He has “usual cough and wheezing,” but no “real increase.” Mr. B denies chest pain, an increase in volume of sputum, sore throat, or nasal discharge; he also has a history of hypertension, which is well controlled.
Mr. B has a 62-pack-year history and continues to smoke 1.5 packs per day; he and his wife are not interested in stopping. He states he has been taking tiotropium dry powder inhaler (DPI, 2 puffs, 1 capsule) once a day, and albuterol (HFA oral inhaler, 2 puffs) about once a week when he anticipates dyspnea due to impending activities. Mr. B works full time as a manager of a house painting company.
Mr. B's vital signs, including oxygen saturation, are all either at or less than 10% above baseline; his body mass index (BMI) is 23.3. He is alert and conversational. Spirometry at his last well visit (6 months earlier) was post bronchodilator: forced expiratory volume (FEV1)/forced vital capacity (FVC), 28%; FEV1, 31%; and FVC, 84%, which is considered grade 3 (severe) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD).1 His last COPD exacerbation was 18 months earlier and he was treated in the pulmonary clinic with outpatient prednisone and antibiotics. Mr. B has had at least two acute exacerbations of COPD (AECOPD) in the past, which have required ED visits. Mr. B's COPD Assessment Test (CAT) score is 9, and his COPD combined assessment is C, indicating a high risk with fewer symptoms.2 The combined COPD assessment tool (ABCD) from yearly GOLD reports (2011 to 2016) was found to be no better than just using the spirometric grade for mortality predictions or other important health outcomes. Therefore, a refinement of the ABCD assessment tool in GOLD 2017 separates spirometric grades from the ABCD groups. According to the 2017 GOLD revised combined assessment, Mr. B would be labeled GOLD grade 3 (spirometrics) group C (assessment of symptoms and exacerbation history).1
A chest exam reveals a barrel chest; on physical exam he has hyperresonance to percussion, scattered wheezes bilaterally with no bronchial breath sounds, no intercostal retractions, and no egophony or whispered pectoriloquy.
Mr. B exemplifies a typical individual with AECOPD. However, if a patient is unknown to the provider and has no spirometry records, the diagnosis is not as clear. The provider may see a patient who was given a COPD diagnosis based only on a long smoking history and signs and symptoms.
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