Common presenting symptoms to the ED for patients with an exacerbation of COPD may be:

  • Breathlessness
  • Cough
  • Wheeze
  • Chest tightness
  • Increased or change in sputum production
  • Inability to cope at home
  • Reduced exercise tolerance
  • Fatigue
  • Confusion
  • Ankle swelling

Patients will often have an established diagnosis of COPD but there will be a proportion who have not been formally diagnosed so it is important to consider the diagnosis in those >35 years with risk factors for the disease.

Other important aspects of the history to consider are:

  • Past medical history especially any previous respiratory disease
  • Medication history including recent use of corticosteroids
  • Home oxygen use
  • Nebuliser use
  • Previous hospital admissions
  • Use of any invasive or non-invasive ventilation
  • Exercise tolerance – normal and current
  • Social history – especially housing, stairs, mobility, care support
  • Smoking history – ideally the number of pack years should be determined
  • Previous ITU admissions

Exacerbations of COPD are more likely in winter and in those with previous exacerbations of their disease [8].

NICE [4] advocates asking about chest pain and haemoptysis in patients with a potential diagnosis of COPD as these symptoms are seldom seen in COPD and should prompt consideration and investigation for alternative diagnoses.

When asking patients about their baseline breathlessness when well, a recognised scoring system is recommended. NICE advocates the use of the MRC breathlessness scale [4].

Table 3: MRC dyspnoea scale [4]

Grade Degree of breathlessness related to activities
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
4 Stops for breath after walking about 100 metres or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing