Exacerbated chronic obstructive pulmonary disease: a frequently unrecognized condition

Objectives. To assess to which extent exacerbated chronic obstructive pulmonary disease (COPD) remains unrecognized in the emergency department, which factors account for misdiagnosis and which are the effects of misdiagnosis on patient's management. Design. Retrospective study and stratified random sampling method as selection criterion. Setting. University Hospital. Subjects. Eighty patients representative of those discharged from the wards of medicine with a diagnosis of exacerbated COPD and 72 having a discharge diagnosis of coronary artery disease (CAD) were studied. Main outcome measures. Degree of concordance between admission and discharge diagnosis; presenting symptoms and signs of patients correctly or incorrectly classified on admission; impact of diagnostic procedures carried out by the physician on call on patient's management. Results. The correct diagnosis was missed on admission in 13/80 COPD and 3/72 CAD patients (chi(2) : 5.87, P =0.015). The prevalence of the following presenting features distinguished the 67 COPD patients who were correctly classified on admission from the remaining 13: severe weakness (21 vs. 10, chi(2) : 9.53, P =0.002), dyspnea (60 vs. 3, chi(2) : 28.75, P < 0.001), and limb oedema (14 vs. 6, chi(2) : 3.70, P =0.054). Critical hypoxemia was diagnosed and treated only after admission in 19 COPD patients. Conclusions Exacerbated COPD frequently escapes recognition in the emergency room, mainly if severe weakness and limb oedema are its presenting features. Arterial blood gas analysis is not systematically performed in the emergency room and, consequently, oxygen therapy is either not administered or given to selected COPD patients on an empirical basis.