History: The three most common symptoms in COPD are 1) cough, 2) sputum production and 3) exertional dyspnea. Many patients will have the above named symptoms for months or years. They will seek medical attention only when there will be an episode of acute exacerbation. However, a careful history usually reveals the presence of symptoms prior to the acute exacerbation. Exertional dyspnea is often described as 1) increased effort to breathe, 2) heaviness, 3) air hunger or 4) gasping. The dyspnea is more when the patient does activities involving significant arm work, particularly at or above shoulder level. Conversely, activities that allow the patient to brace the arms and use accessory muscles of respiration are better tolerated.e.g. pushing a shopping cart, walking on a treadmill or pushing a wheelchair. As COPD advances, the principal feature is worsening dyspnea on exertion with increasing intrusion on the ability to perform vocational or avocational activities. In