History

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]