Differential Diagnosis of Suspected Chronic Obstructive Pulmonary Disease Exacerbations in the Acute Care Setting: Best Practice

Abstract

Patients with chronic obstructive pulmonary disease (COPD) may suffer from acute episodes of worsening dyspnea, often associated with increased cough, sputum, and/or sputum purulence. These exacerbations of COPD (ECOPDs) impact health status, accelerate lung function decline, and increase the risk of hospitalization. Importantly, close to 20% of patients are readmitted within 30 days after hospital discharge, with great cost to the person and society. Approximately 25% and 65% of patients hospitalized for an ECOPD die within 1 and 5 years, respectively. Patients with COPD are usually older and frequently have concomitant chronic diseases, including heart failure, coronary artery disease, arrhythmias, interstitial lung diseases, bronchiectasis, asthma, anxiety, and depression, and are also at increased risk of developing pneumonia, pulmonary embolism, and pneumothorax. All of these morbidities not only increase the risk of subsequent ECOPDs but can also mimic or aggravate them. Importantly, close to 70% of readmissions after an ECOPD hospitalization result from decompensation of other morbidities. These observations suggest that in patients with COPD with worsening dyspnea but without the other classic characteristics of ECOPD, a careful search for these morbidities can help detect them and allow appropriate treatment. For most morbidities, a thorough clinical evaluation supplemented by appropriate clinical investigations can guide the healthcare provider to make a precise diagnosis. This perspective integrates the currently dispersed information available and provides a practical approach to patients with COPD complaining of worsening respiratory symptoms, particularly dyspnea. A systematic approach should help improve outcomes and the personal and societal cost of ECOPDs.

Keywords: COPD; algorithms; differential diagnosis; symptom flare-up.

Figure 1.

Diseases in patients with chronic obstructive pulmonary disease (COPD) presenting with acute worsening of dyspnea/chest discomfort that may mimic or contribute to the clinical presentation of an exacerbated COPD.

Figure 2.

A practical algorithm to help direct evaluation of a patient with chronic obstructive pulmonary disease (COPD) presenting with symptoms consistent with an exacerbated COPD. Recommendations are on the basis of the most recent available guidelines, consensus documents, and/or original studies referenced in the manuscript. ABG = arterial blood gases; CRP = C-reactive protein; CTPA = computed tomography pulmonary angiogram; ECG = electrocardiogram; ECOPD = exacerbation of chronic obstructive pulmonary disease; GDMT = guideline-directed medical treatment; HF = heart failure; ILDs = interstitial lung diseases; PE = pulmonary embolism; VAS = visual analog scale.

Figure 3.

Algorithm reflecting the clinical features of a patient with chronic obstructive pulmonary disease (COPD) presenting with increased respiratory symptoms and suspected acute heart failure. Recommendations are on the basis of the most recent European and American Guidelines on heart failure (19, 20). *The thresholds for N-terminal pro-brain natriuretic peptide (NT-proBNP) and BNP are intended for the diagnosis of acute heart failure (HF) (20) and may need correction with age. Thresholds for new onset stable HF are much lower (i.e., NT-proBNP >125 pg/ml and BNP >35 pg/ml) (19) and should be used outside the context of an exacerbation of COPD. Note that the presence of COPD may raise these values. Please see text for further details. ECG = electrocardiogram; ECOPD = exacerbation of chronic obstructive pulmonary disease; GDMT = guideline-directed medical treatment; HJ reflux = hepatojugular reflux; JVD = jugular vein distention; PND = paroxysmal nocturnal dyspnea; WBC = white blood cell count.

Figure 4.

Algorithm reflecting the clinical features of a patient with COPD presenting with increased respiratory symptoms and suspected pulmonary embolism (PE). Recommendations are on the basis of Konstantinides and colleagues (35) and Couturaud and colleagues (36). *PE probability assessed using Geneva or Wells scores. COPD = chronic obstructive pulmonary disease; CRP = C-reactive protein; CTPA = computed tomography pulmonary angiogram; DVT = deep-vein thrombosis; ECOPD = exacerbation of chronic obstructive pulmonary disease; GDMT = guideline-directed medical treatment; WBC = white blood cell count.

Figure 5.

Algorithm reflecting the clinical features of a patient with chronic obstructive pulmonary disease presenting with increased respiratory symptoms and when potential pneumonia is considered. Recommendations are on the basis of European guidelines (Woodhead and colleagues [43]), consensus documents, and/or relevant original studies quoted in the text. COPD = chronic obstructive pulmonary disease; CRP = C-reactive protein; CT = computed tomography; ECOPD = exacerbation of chronic obstructive pulmonary disease; GDMT = guideline-directed medical treatment.