Characterized by progressive airflow obstruction (which has little/no reversibility) and abnormal inflammatory response in lungs commonly due to cigarette smoke


The disease is staged according to the severity of airflow obstruction (GOLD staging): mild (FEV1 >80% and symptomatic), moderate (FEV1 50-79%), severe (FEV1 30-49%) or very severe (FEV1 <30%)



  • SOB
    • Exertional breathlessness
    • Chronic cough with sputum production
    • Wheeze
  • Frequent infections
  • Fatigue

    Clinical signs:

On inspection:

  • Inhaler devices, nebulisers
    • Sputum pot
    • Oxygen
  • Cigarettes
    • Cachectic
    • Tachypnoea
    • Barrel shaped chest
    • Pursed lip breathing
    • Use of accessory muscles of breathing
    • Tar staining
    • Peripheral +/- central cyanosis
    • Bronchodilator tremor
    • CO2 retention flap
  • Audible wheeze

    On examination:

  • Hyperinflated chest
  • Reduced chest expansion
    • Hyperresonant percussion note
    • Bounding pulse
    • Prolonged expiratory phase of respiration
    • Expiratory wheeze
    • Reduced breath sounds over bullae


Tell the examiner that you suspect the patient has COPD due to smoking NB: consider alpha-1 antitrypsin deficiency if patient is young/non-smoker/Fx of emphysema or bronchitis/icteric with hepatomegaly
Comment on whether there is evidence of complications such as respiratory failure (oxygen, cyanosis, CO2 retention flap) or cor pulmonale (RV heave, loud P2, raised JVP, peripheral oedema) or infection (bronchial breathing, creps, antibiotics at bedside, fever) or malignancy (cachectic, lymphadenopathy, radiation tattoo)


Comment on whether there are signs of treatment:


  • Steroid usage: Cushingoid, thin skin, bruising, proximal myopathy
  • Oxygen
  • Scars- eg. from lung volume reduction surgery


Comment that your differential diagnosis for wheeze includes:


  • Asthma
  • Heart failure
  • Bronchiectasis and mucus plugging




Bedside tests:

Arterial blood gas: hypoxia, hypercapnia, acidosis, respiratory failure

ECG: right heart strain


Laboratory tests:
Anaemia of chronic disease, polycythaemia

Raised WCC if infection/steroid use
Raised inflammatory markers if infection present
Alpha 1 antitrypsin level if young/non-smoker/Fx of emphysema or bronchitis

Theophylline level
Sputum MC+S

Functional tests:

Lung function tests- airflow obstruction FEV1/FVC ratio <0.70

Mild (FEV1 >80% and symptomatic), moderate (FEV1 50-79%), severe (FEV1 30-49%) or very severe (FEV1 <30%)
Minimal reversibility with bronchodilator
Increased total lung capacity and residual volume
Reduced transfer factor

CXR: hyperinflation, flat hemidiaphragms, bullae, large heart/pulmonary arteries, evidence of complications e.g. infection, pneumothorax, malignancy
CT scan: if severity of symptoms outweighs severity of COPD on spirometry
Echo: to evaluate possible cor pulmonale




Multidisciplinary team approach
Smoking cessation

Optimize nutrition
Pulmonary rehab
Vaccinations (influenza and pneumococcal)
Social support

Inhaler technique



Inhaled therapy: inhalers (SABA, SAMA, LABA, LAMA, combination therapy with steroid if FEV1<50%) and nebulisers

Oral therapy e.g. steroids, theophylline, carbocystiene

Oxygen therapy:

  • LTOT i.e. oxygen given for > 15 hours a day with aim of achieving Pa02 8kpa
    • Patients with Pa02 <7.3 kpa on two consecutive readings at least three weeks apart in stable patient
    • Pa02 7.3-8kpa in patients with pulmonary hypertension, polycythaemia, nocturnal hypoxaemia, peripheral oedema
  • Ambulatory oxygen

Non-invasive ventilation

Manage complications e.g. depression, infection, cor pulmonale



Lung volume reduction surgery

Lung transplant

Written by Dr Amna Shah

Edited by Dr Sarah Kennedy


Resources used to make this document include the references listed on the PACES webpage