COPD summary

Main phenotypes

• Chronic bronchitis: chronic productive cough due to mucus hypersecretion and airway inflammation.
• Emphysema: alveolar wall destruction, loss of elastic recoil, air trapping and hyperinflation.
• Most patients have features of both.

Risk factors

• Cigarette smoking, including pack-year exposure
• Biomass-fuel smoke, occupational dusts/fumes, air pollution
• Recurrent respiratory infections, impaired lung growth
• Family history or early-onset disease: consider alpha-1 antitrypsin deficiency
• Asthma can coexist, but is a separate diagnosis

Typical symptoms

• Progressive exertional breathlessness
• Chronic cough, with or without sputum
• Wheeze, chest tightness
• Reduced exercise tolerance, fatigue
• Recurrent lower respiratory infections or exacerbations

Diagnosis

FEV1/FVC < 0.70

Complications and comorbidities

• Exacerbations
• Respiratory failure, hypercapnia
• Pulmonary hypertension and cor pulmonale
• Pneumothorax
• Weight loss/cachexia, osteoporosis
• Anxiety/depression
• Cardiovascular disease, arrhythmia, heart failure
• Lung cancer

Core management principles

• Smoking cessation and avoidance of inhaled exposures
• Vaccination, inhaler technique and adherence review
• Bronchodilators: short-acting for relief; long-acting LAMA and/or LABA for maintenance
• Inhaled corticosteroid only in selected patients, mainly those with recurrent exacerbations and features predicting benefit
• Pulmonary rehabilitation, exercise and nutrition support
• Long-term oxygen only for documented severe chronic resting hypoxemia
• Exacerbations: assess severity, give short-acting bronchodilators, systemic corticosteroid and antibiotics when indicated, and consider non-invasive ventilation if acidotic hypercapnic respiratory failure.

COPD OSCE station

Opening and structure

“Hello, I’m [name], one of the medical students. I’ve been asked to ask you about your breathing and perform an examination. Is that okay? This may involve examining your chest, hands and legs. Please tell me if you become uncomfortable or breathless at any point.”

• Confirm identity
• Wash hands
• Ensure patient is comfortable, ideally sitting at 45 degrees
• Ask about pain and acute breathlessness
• Observe before touching the patient
• At the end, thank the patient, ensure comfort, wash hands and summarize.

Focused COPD history

1. Presenting complaint and timeline

“What breathing problem has brought you in today?”
“When did it begin?”
“Has it been gradual or sudden?”
“How has it changed over time?”

• A stable chronic presentation
• A possible acute exacerbation
• A new or abrupt symptom that might be something else, for example pulmonary embolism, pneumonia, pneumothorax, acute coronary syndrome or heart failure.

2. Dyspnea

“Do you get short of breath?”
“What can you do before you need to stop?”
“Can you walk on the flat? Climb stairs? Wash and dress yourself?”
“Do you get breathless at rest?”
“Do you sleep with extra pillows or wake at night short of breath?”

• Only strenuous exertion
• Hurries on flat ground or walking uphill causes breathlessness
• Walks slower than peers or stops on the flat
• Stops after around 100 m or a few minutes
• Too breathless to leave home or breathless while dressing

“Does leaning forward or pushing a trolley make breathing easier?”

3. Cough and sputum

“Do you have a cough?”
“Is it dry or productive?”
“How much sputum do you bring up, and what colour is it?”
“Has the amount or colour changed recently?”
“Any blood in the sputum?”

4. Wheeze, chest symptoms and infection

“Do you wheeze or feel chest tightness?”
“Any fever, shivering or recent chest infection?”
“Any pleuritic chest pain?”
“Have you noticed ankle swelling, palpitations or blackouts?”

• Childhood asthma, atopy, eczema, allergic rhinitis
• Marked day-to-day or seasonal variability
• Clear triggers and reversibility

5. Exacerbation history

“Have your breathing symptoms suddenly worsened before?”
“How many flare-ups have you had in the past year?”
“Did any need antibiotics, steroids, an emergency visit, hospital admission, ICU care or a breathing machine?”

• Number in last 12 months
• Hospital admissions
• Prior non-invasive ventilation or intubation
• Previous blood gas evidence of hypercapnia
• Baseline exercise tolerance and oxygen requirement

6. Exposure history

Smoking

“Do you smoke or have you smoked previously?”
“How many cigarettes per day, and for how many years?”
“When did you stop?”

packs/day × years smoked

• Vaping
• Cannabis
• Passive smoking
• Previous quit attempts and readiness to stop

Other exposures

“What work have you done?”
“Any regular exposure to dust, chemicals, fumes or smoke?”
“Do you cook or heat your home using wood, coal or biomass fuel?”

7. Past medical history

• Previous diagnosis of COPD, asthma, bronchiectasis, tuberculosis, pneumonia
• Previous spirometry, chest X-ray/CT, oxygen assessment
• Obstructive sleep apnea symptoms: snoring, witnessed apneas, daytime somnolence
• Cardiac disease, hypertension, arrhythmia, heart failure, ischemic heart disease
• Gastroesophageal reflux, osteoporosis, anxiety/depression
• Unintentional weight loss, anorexia or fatigue

Alpha-1 antitrypsin deficiency clues

“Has anyone in your family developed emphysema or serious lung disease at a young age, or liver disease?”

8. Drugs, allergies and treatment review

“Which inhalers do you use, and how often?”
“Do you use a reliever inhaler more often than usual?”
“Have you been prescribed antibiotics or steroid tablets recently?”
“Do you use oxygen at home, CPAP or non-invasive ventilation?”

• SABA use
• LAMA/LABA/ICS inhalers
• Adherence and inhaler technique
• Oral steroids, antibiotic courses
• Home oxygen flow rate and duration
• Drug allergies

9. Systems review and red flags

• Fever, night sweats
• Weight loss, anorexia
• Hemoptysis
• Hoarseness
• New focal chest pain
• Unilateral calf pain/swelling
• Sudden pleuritic pain or sudden severe dyspnea
• Orthopnea, paroxysmal nocturnal dyspnea, peripheral edema

10. Social history and impact

“Who do you live with?”
“How are you coping with daily activities?”
“Do you need help washing, dressing, cooking or getting out?”
“What work or hobbies have you had to stop?”
“Do you have a support network?”

• Influenza
• Pneumococcal
• COVID-19, according to local guidance

Focused physical examination

General inspection

• Degree of respiratory distress
• Ability to speak full sentences
• Respiratory rate and work of breathing
• Oxygen delivery device and flow rate
• Inhalers, spacer, nebulizer, home NIV
• Body habitus: cachexia or obesity
• Cough, audible wheeze
• Tripod position, pursed-lip breathing
• Peripheral or central cyanosis

Hands and arms

• Nicotine staining
• Peripheral cyanosis
• Asterixis/flapping tremor: may suggest hypercapnia
• Fine tremor and tachycardia from beta-agonists
• Clubbing

• Rate and rhythm
• Atrial fibrillation or other arrhythmia
• Bounding pulse may occur with CO2 retention

Face and neck

• Central cyanosis at lips/tongue
• Conjunctival pallor
• Horner syndrome or facial swelling, if malignancy is a concern
• Raised JVP, suggesting cor pulmonale/right heart failure
• Cervical or supraclavicular lymphadenopathy

Chest inspection

• Barrel-shaped chest, increased AP diameter
• Hyperinflation
• Reduced chest movement
• Use of sternocleidomastoids/scalenes and intercostal recession
• Tripod position
• Scars, deformity, asymmetry
• Visible chest wall movement and respiratory pattern

Palpation

• Assess chest expansion bilaterally: often reduced in hyperinflation.
• Check tracheal position.
• Assess tactile vocal fremitus if concerned about consolidation/effusion.
• Palpate for chest wall tenderness, masses and surgical emphysema if clinically relevant.

Percussion

• Hyperresonance suggests hyperinflation/emphysema.
• Reduced diaphragmatic excursion may be present.
• Dullness suggests an alternative/coexisting process such as consolidation, pleural effusion or malignancy.

Auscultation

• Reduced air entry
• Prolonged expiratory phase
• Expiratory wheeze
• Rhonchi, particularly if secretions are present
• Quiet heart sounds due to hyperinflated lungs

• Focal crackles/bronchial breathing: pneumonia
• Coarse crackles: retained secretions/bronchiectasis
• Unilateral absent breath sounds with marked hyperresonance: pneumothorax
• Fine basal crackles: consider heart failure or interstitial lung disease

Complete with cardiovascular and peripheral examination

• JVP
• Heart sounds and rhythm
• Peripheral edema
• Sacral edema if bedbound
• Calf swelling/tenderness if pulmonary embolism is a concern
• Peripheral pulses

OSCE summary example

“This patient has clinical features consistent with COPD, including [progressive exertional dyspnea/chronic productive cough], a significant [smoking or occupational] exposure, and examination findings of [hyperinflation, reduced expansion, hyperresonance, reduced air entry, prolonged expiration and wheeze]. I would check observations including oxygen saturation and perform post-bronchodilator spirometry to confirm persistent airflow obstruction. I would also assess exacerbation frequency, inhaler technique, smoking cessation needs, vaccination status, functional status and comorbidities. I would arrange a chest X-ray and consider ECG, full blood count, urea and electrolytes, blood gas if unwell or hypoxemic, and alpha-1 antitrypsin testing when indicated.”

COPD OSCE History Checklist

1. Introduction

• Wash hands, introduce yourself, confirm patient identity
• Explain: “I’d like to ask some questions about your breathing. Is that okay?”
• Check comfort and whether the patient is currently very breathless or in pain
• Establish presenting complaint

2. Presenting complaint and history

• Main symptom: breathlessness, cough, wheeze, sputum, chest tightness
• Onset: when did it start?
• Progress: gradual, stable, or worsening?
• Acute deterioration: when did it worsen and any trigger?
• Previous similar episodes or known COPD diagnosis?

3. Dyspnea

• At rest or only on exertion?
• Exercise tolerance:
  • Flat-ground walking distance
  • Stairs/hills
  • Washing, dressing, shopping, housework
• Compare with usual baseline
• Nocturnal symptoms, orthopnea or paroxysmal nocturnal dyspnea
• Does leaning forward or using a shopping trolley help?
• Breathlessness severity, for example mMRC grade

4. Cough and sputum

• Cough: dry or productive?
• Duration and timing, for example morning cough
• Sputum:
  • Volume
  • Colour
  • Consistency
  • Any recent increase or purulence?
• Hemoptysis

5. Associated respiratory symptoms

• Wheeze
• Chest tightness
• Fever, rigors, malaise
• Pleuritic chest pain
• Recurrent chest infections
• Weight loss, night sweats, fatigue
• Hoarseness

6. Exacerbation history

• Number of flare-ups in the last 12 months
• Need for rescue inhalers, oral steroids or antibiotics
• Emergency department attendance or hospital admissions
• ICU admission, non-invasive ventilation or intubation
• Previous sputum culture results, if known
• Baseline versus current inhaler use

7. Smoking and exposure history

Smoking

• Current, ex-smoker or never-smoker
• Cigarettes/day and years smoked
• Calculate pack-years: packs/day × years smoked
• Vaping, cannabis, passive smoke exposure
• Previous quit attempts and readiness to stop

Other exposures

• Occupational dust, chemicals or fumes
• Biomass fuel, coal or wood smoke exposure
• Air pollution
• Previous tuberculosis or significant respiratory infections

8. Past medical history

• COPD diagnosis and previous spirometry
• Asthma or atopy
• Bronchiectasis, tuberculosis, pneumonia
• Obstructive sleep apnea symptoms
• Ischaemic heart disease, heart failure, hypertension, arrhythmia
• Gastroesophageal reflux
• Osteoporosis or fractures
• Anxiety/depression
• Cancer history

Consider alpha-1 antitrypsin deficiency

• Young patient or minimal smoking exposure?
• Family history of early emphysema, COPD or liver disease?

9. Drug history and treatment

• Reliever inhaler, frequency and effectiveness
• Maintenance inhalers: LAMA, LABA, inhaled corticosteroid
• Check adherence and inhaler technique
• Recent oral steroids or antibiotics
• Home oxygen: indication, flow rate and hours/day
• CPAP or non-invasive ventilation
• Drug allergies

10. Screen for complications and alternative diagnoses

• Ankle swelling, abdominal swelling, palpitations: cor pulmonale/heart failure
• Sudden pleuritic pain, sudden breathlessness, unilateral calf swelling: PE
• Sudden unilateral chest pain: pneumothorax
• Focal chest pain, fever, purulent sputum: pneumonia
• Weight loss, persistent hemoptysis, hoarseness: malignancy
• Orthopnea/PND: heart failure

11. Social history and functional impact

• Occupation and occupational exposures
• Living arrangements and social support
• Activities of daily living
• Mobility and exercise level
• Ability to work, shop, cook and self-care
• Alcohol and recreational drug use
• Advance care planning or ceiling of care, if severe disease

12. Prevention

• Influenza vaccination
• Pneumococcal vaccination
• COVID-19 vaccination as locally recommended
• Pulmonary rehabilitation attendance
• Smoking-cessation support

Closing summary

“To summarise, you have had progressive breathlessness with [cough/sputum/wheeze] for [duration], with a [smoking/occupational] exposure history. I would like to assess your observations, oxygen saturation and inhaler technique, and review spirometry to confirm and stage COPD. I would also assess exacerbation risk and look for complications or other causes of breathlessness.”