1. Masqueraders of Asthma: Differential Diagnosis of Asthma in Adults George Su, MD SFGH/UCSF Division of Pulmonary and Critical Care San Francisco Asthma Task Force Networking Forum November 5, 2010

2. Asthma/COPD “Overlap syndrome” Exhibits features of both conditions Incompletely reversible airflow obstruction +Increased variability of airflow (BD response, increased airways hyperresponsiveness) Dlco deficit Worse prognosis 1, higher utilization of resources These patients are excluded from clinical trials, so results are not generalizable to them 30% asthmatics are smokers 1. Shaya et al., 2008

3. Case 2 43 yo F with long standing history of “asthma” Wheeze and shortness of breath with exercise and stress Treated with maximum dose ICS Has received multiple prednisone courses Presents to you, Cushingoid Inspiratory wheeze

4. Case 2

5. Vocal Cord Dysfunction (VCD)

6. VCD Precipitating factors Exercise Psychological conditions –PTSD, anxiety, depression, GAD Irritants Rhinosinusitis GERD Medications: neuroleptics, e.g. phenothiazines

7. VCD Diagnosis PFTs Extrathoracic upper airway obstruction. Flexible laryngoscopy

8. Asthma VCD Young age of onset Female predominance Intermittent symptoms Inspiratory wheeze Stridor Hyperinflation Response to BDs Response to ICS/steroids Airflow limitation BD Reversibility Decreased DLco Atopy Inspiratory limb decreased flows Exercise-induced X X X X X X XX X X X X X X X X X

9. VCD Treatment Short term –Reassure –Panting, diaphragmatic-, nose-, straw-, pursed-lip breathing –Exhaling with a hissing sound –Heliox trial Long-term –Avoid triggers, smoke, airborne irritants, –Tx anxiety, depression, GERD, rhinosinusitis –Trial of ipratropium –Referral for speech therapy –Long-term tracheostomy may be appropriate in severe, resistant cases

10. Case 3 58 yo M with long standing history of “asthma” Stable on low dose ICS, minimal use of BDs Progressively worsening cough, shortness of breath, exercise limitation over last 3 months 4 courses of prednisone with minimal, if any effect 2+ pitting edema on lower extremities

11. Common diseases with symptoms that can mimic asthma Coronary artery disease Congestive heart failure Pulmonary embolism National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NHLBI, NIH; 2007

12. Respiratory Tract Nasopharynx Oropharynx Tongue Trachea Pleura Lung Diaphragm Pharynx Epiglottis Larynx Bronchi Lung UPPER TREE LOWER

13. Upper Airway Nasopharynx Larynx Cricoid Cartilage Trachea Oropharynx Larynx Vocal Cords Esophagus

14. “Chronic Upper Airway Cough Syndrome (UACS)” (Post-Nasal Drip Syndrome)

15. Drainage of secretions from nose/paranasal sinuses into pharynx Multiple etiologic conditions UACS instead of PNDS because no proven association with “drip” and cough Key to diagnosis is response to therapy

17. Upper Airway Nasopharynx Larynx Cricoid Cartilage Trachea Oropharynx Larynx Vocal Cords Esophagus

18. Tonsillar Hypertrophy B. Ghorayeb, MD

19. Vocal Cord Lesions CystLaryngocele PolypPapilloma Normal Sessile polyp B. Ghorayeb, MD

20. Laryngeal Web

21. Intubation Granuloma B. Ghorayeb, MD

22. Tracheobronchial Tree

23. Tracheal Stenosis Airway Obstruction Endobronchial Mass Chondroma Fibroma Hemangioma Granular cell tumors

24. Foreign Body Aspiration C. Marquette, MD Acute Retained

25. Congenital Vascular Rings

26. Double Aortic Arch Right Aortic Arch Aberrant Left Subclavian Artery Left Ligamentum Arteriosum

27. Tracheomalacia

28. Lower Airways

29. Bronchopulmonary Dysplasia (BPD) Cystic Fibrosis Chronic Lung Disease

30. Bronchiectasis

31. Case 4 37 yo M with long-standing history of wheeze, shortness of breath, and “asthma” Triggered by stress Episodes associated with tingling of fingers, hyperventilation Spirometry with mild curvilnearity, but FEV1/FVC ratio within normal limits

32. “Psychogenic” asthma VCD Generalized anxiety disorder “Panic attacks” –Having asthma linked to a 4.5-fold increase in risk of developing panic disorder Hyperventilation a/w GAD

33. Diagnosis of Asthma Episodic symptoms wheeze, SOB, DOE, cough Atopy? Triggers? Spirometry Response to therapy? RFs?: smoking, CAD, CHF, age, exposures, inhalations Allergy testing (IgE, RAST, skin testing, eNO) DLco, lung volumes, imaging (CXR, CT) Common mimics: COPD, VCD, cardiac, UACS, “psychogenic”) Other? National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NHLBI, NIH; 2007

34. Thank you