COPD: Differential Diagnosis

COPD: Differential Diagnosis
Grant Hoekzema, MD Program Director, Mercy Family Medicine Residency, St. Louis, MO Elissa J. Palmer, MD, FAAFP Professor and Chair, Department of Family & Community Medicine, University of Nevada School of Medicine, Las Vegas, NV

Educational Objectives
At the end of this presentation, the learner should be able to … Describe constellation of symptoms and evaluation leading to consideration of chronic obstructive pulmonary disease (COPD) as diagnosis. Delineate modifiable and non-modifiable risk factors for chronic obstructive pulmonary disease. Understand diagnostic criteria for COPD. Describe other diseases that need to be considered in the workup of a patient with dyspnea, chronic cough, and sputum production. The educational objectives for the differential diagnosis module for chronic obstructive pulmonary disease are: 1. Describe the constellation of symptoms and the evaluation leading to consideration of chronic obstructive pulmonary disease as a diagnosis 2. Understand modifiable and non-modifiable risk factors for chronic obstructive pulmonary disease 3. Understand the diagnostic criteria for chronic obstructive pulmonary disease 4. Describe other diseases that need to be considered in the workup of a patient with dyspnea, chronic cough, and sputum production

Differential Diagnosis
Evaluation Risk Factors Diagnostic Criteria Other Conditions to Consider This module has 4 sections: Section 1. Evaluation Section 2. Risk Factors Section 3. Diagnostic Criteria Section 4. Conditions to Consider

Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
Evaluation Assessment of symptoms Severity of breathlessness, cough, sputum production, wheezing, chest tightness, weight loss or anorexia Change in alertness or mental status, fatigue, confusion, anxiety, dizziness, pallor or cyanosis COPD should be considered in any patient with a chronic cough, dyspnea or sputum production Assessment of symptoms: Severity of breathlessness, cough, sputum production, wheezing, chest tightness, weight loss/anorexia Change in alertness or mental status, fatigue, confusion, anxiety, dizziness, pallor or cyanosis COPD should be considered in any patient with a chronic cough, dyspnea or sputum production Part of diagnosing COPD is to distinguish it from other causes. The patient’s history of symptoms will help in considering if COPD is the etiology. Pulmonary symptoms are the hallmark of the disease but systemic symptoms will often occur due to hypoxia. Reference: GOLD 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Evaluation Medical History Allergies Sinus problems Other respiratory disease Risk factors Exposures (occupational and environmental) Family history Co-morbidities that may affect activity Medications Prior hospitalizations or evaluation to date Medical History that should be obtained in any patient who presents with symptoms suggestive of COPD: Allergies Sinus problems Other respiratory disease Risk factors Exposures (occupational and environmental) Family history Co-morbidities that may affect activity Medications Prior hospitalizations or evaluation to date In considering the likelihood of COPD versus other causes, one must take into account medical history for conditions that may mimic COPD like sinus problems or other respiratory diseases, risk factors such as smoking or occupational exposures that can cause lung damage, prior episodes or workup that may have ruled out other factors. Reference: GOLD 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Evaluations Vital Signs Extremities Chest Lungs
Respiratory rate, pattern, effort Pulse oximetry Extremities Inspection for cyanosis Chest Inspection to assess AP diameter (barrel chest) Palpation and percussion of chest Lungs Auscultation for wheezing, crackles, and/or decreased breath sounds Note effort of breathing; signs below suggest increased effort Use of accessory muscles - sternocleidomastoid, pectoralis minor Arms braced on knees or table Difficulty speaking in full sentences Pursing of lips Nasal flaring Paradoxical abdominal breathing Sweating Assess for cyanosis Central - look at lips, oral mucosa and tongue Peripheral - nails, hands and feet Chest wall deformities or asymmetries of shape or movement Increased Anterior-Posterior (AP) diameter (barrel chest) Intercostal, subcostal and supraclavicular indrawing Tracheal position and presence of a downward tug Decreased inspiratory range with hyperinflated lungs of COPD Tactile fremitus - decreased in COPD Percuss anterior and posterior, comparing left to right – hyper-resonance with COPD Listen to each of the five lung lobes and compare findings between sides Air entry - decreased in COPD Adventitious sounds Wheezes, crackles, other Generalized versus localized Volume - Loud versus soft References: GOLD, 2009 Stephens, 2008 Stephens, 2008

Question The differential diagnosis of COPD should be
considered in patients who present with which of the following symptoms? Chronic cough Any sputum production Dyspnea Increased sputum production All of the above Answer E. Patients with COPD most commonly present with dyspnea, chronic cough or sputum production. Although none of these symptoms alone is diagnostic of COPD it should be included in the differential in any patient with these symptoms. Those patients who smoke, are over 40 yrs of age and have more than one of these clinical indicators of chronic lung disease are more likely to have COPD. By suspecting COPD in patients with undifferentiated symptoms the diagnosis may be made at an earlier stage in the disease when interventions are more likely to help. Reference: GOLD 2009

Differential Diagnoses
Pulmonary Asthma Bronchogenic carcinoma Bronchiectasis Tuberculosis Cystic fibrosis Interstitial lung disease Bronchiolitis obliterans Alpha-1 antitrypsin deficiency Pleural effusion Pulmonary edema Recurrent aspiration Tracheobronchomalacia Recurrent pulmonary emboli Foreign body Non-pulmonary Congestive Heart Failure Hyperventilation syndrome/panic attacks Vocal cord dysfunction Obstructive sleep apnea – undiagnosed Aspergillosis Chronic Fatigue Syndrome Asthma is the most common alternative diagnosis that mimics COPD is asthma. Others can mimic COPD due to the overlap in symptoms and physical findings. By taking into account the clinical characteristics and epidemiological factors the differential may be narrowed down. Differential diagnosis is derived from symptom complex in history and physical examination. Further evaluation with specific studies like chest x-ray and spirometry will help confirm a diagnosis. References: Dewar, 2006 GOLD 2009 Dewar, 2006

Question Which of the following is the most appropriate to
use to confirm the diagnosis of COPD? Chest X-ray Arterial blood gas Spirometry High resolution CT scan of chest Clinical examination Answer C. Spirometry is the gold standard for diagnosis of COPD. It is the standard to establish severity/stage based on FEV1 and FEV1/FVC. Spirometry should be performed both pre- and post-bronchodilator since airflow limitation that is not fully reversible is a hallmark of the disease. All major international practice guidelines use spirometry in the diagnostic criteria for COPD. Chest x-rays can help in ruling out other causes of chronic lung disease and blood gases may help to establish if supplemental oxygen is needed. High resolution CT scans may help in severe cases or to exclude malignancy. The clinical examination may suggest COPD but no set of clinical findings is diagnostic. References: Celli, 2004 GOLD 2009. National Collaborating Centre for Chronic Conditions. 2004 Qaseem, 2007

Evaluation Studies that may help in diagnosis: Chest X-ray (SOR: C)
Spirometry (SOR: C) Arterial blood gas (SOR: C) Alpha-1 antitrypsin levels (SOR: C) High resolution CAT scan of chest (SOR: C) SOR: Strength of Recommendation Studies that will help narrow the diagnostic possibilities are all recommended by expert panels Chest X-ray (SOR: C) Helpful in excluding alternative diagnoses Seldom diagnostic but may have hyperinflation, bullous changes, decreased vascularity Normal result with chronic cough can occur with COPD, asthma, post nasal drip Spirometry (SOR: C) – need to confirm diagnosis Arterial blood gas (SOR: C) – helpful if pO2 is less than 60. Can help determine is supplemental oxygen is needed. Alpha-1 antitrypsin levels (SOR: C) - Patients with severe alpha-1 antitrypsin deficiency usually are of European descent and develop clinical evidence of COPD approximately 10 years earlier than patients who are not alpha-1 antitrypsin deficient High resolution CAT scan of chest (SOR: C) in severe cases or if diagnosis is unclear, may help detect emphysematous changes or exclude malignancy Reference: Stephens, 2008. Stephens, 2008

Evaluation Spirometry Gold standard for diagnosis Standard to establish severity and stage Perform both pre- and post-bronchodilator Irreversible airflow limitation is the hallmark of COPD Spirometry Gold standard for diagnosis Standard to establish severity and stage Perform both pre- and post-bronchodilator Airflow limitation that is not fully reversible is a hallmark of the disease In severe persistent asthma airflow limitation may not be fully reversible as well but most other diagnoses have characteristic spirometry features that distinguish them from COPD. All patients should be evaluated with spirometry to establish the diagnosis per international guidelines. Without spirometry it is very difficult to distinguish older adults with asthma from those with COPD. Home lung function tests are marketed on the internet but are not established to make the diagnosis of COPD, but rather are useful for monitoring asthma condition. References: Celli, 2006 GOLD, 2009 National Collaborating Centre for Chronic Conditions. 2004 Qaseem, 2007 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Risk Factors Smoking Environmental pollution Major risk factor (duh!)
Risk increases with number of pack years smoked Secondhand smoke in large amounts presents risk Environmental pollution Smog and exhaust from vehicles Smoke from burning wood or other biomass fuels Particulates in occupational dust The most significant risk factor for COPD is long-term cigarette smoking. The more years you smoke and the more packs you smoke, the greater your risk. Smokers who are susceptible to lung injury experience an increase in the rate of age-related loss in FEV1 compared with nonsmokers. After lung function declines to threshold levels, clinical symptoms develop. When a smoker stops smoking, the rate of FEV1 loss again approximates to that of a nonsmoker. Symptoms of COPD usually appear about 10 years after smoking starts. Pipe smokers, cigar smokers and people exposed to large amounts of secondhand smoke also are at risk. Environmental pollution such as smog, dust, wood smoke, particulates in occupational dust and others can cause damage to lung tissue similar to smoking. References Cosio, 2009 GOLD, 2009

Risk Factors Occupational Irritants Occupation Irritant
Agricultural worker Endotoxin Coal miner Coal dust Concrete worker Mineral dust Construction worker Dust Gold miner Silica Hard rock miner Rubber worker Industrial chemicals Occupational Irritants Several occupational irritants, usually in the form of dusts, be risk factors for COPD. Knowing what occupations are associated with these irritants will help the clinician recognize the potential risk for lung injury. It can be difficult sometimes to distinguish occupational lung disease (e.g. coal miner’s lung or silicosis) from COPD, and the conditions may overlap. Reference: Dewar, 2006

Risk Factors Nonmodifiable Risk Factors Gender (Risk about equal in men and women) Attributed to smoking habits of both genders Age Develops slowly Most people ≥ 40 years old when symptoms start Alpha-1 antitrypsin deficiency Mostly Northern European heritage Rare cause (2% of COPD population) Nonmodifiable risks are those related to gender, age and genetics: Risk of developing COPD about equal in men and women May be accounted for by smoking habits of both genders Age Develops slowly Most people ≥ 40 years old when symptoms start Alpha-1 antitrypsin deficiency Mostly Northern European heritage Rare cause (2% of COPD population) References: Am J Respir Crit Care Med 2003;168.:818–900. GOLD, 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Risk Factors Additional risk factors Severe lung infections as a child Previous tuberculosis Gastroesophageal reflux disease Possible cause as recurrent irritant May worsen COPD Lower socioeconomic status Socioeconomic status (SES) addresses all risk factors including childhood exposures and smoking incidence, which are higher in lower SES groups. However, given the higher incidence of asthma in lower SES populations, the risks of COPD and asthma may overlap in this population. Additional risk factors Severe lung infections as a child Previous tuberculosis Gastroesophageal reflux disease Possible cause as recurrent irritant May worsen COPD References: GOLD, 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Diagnostic Criteria Global Initiative for Chronic Obstructive Lung Disease (GOLD) Criteria Program to provide guidelines for management of COPD; started 1998; international effort. Consider COPD in any patient with following: Dyspnea Chronic cough or sputum production and/or Exposure to risk factors COPD GOLD report – this report is an international effort to address COPD and it’s risk factors. It is a comprehensive resource, accessible online at goldcopd.org, updated annually. Diagnostic criteria for COPD call for consideration of the diagnosis in any patient with chronic dyspnea, cough, sputum production or exposure to risk factors. References: GOLD, 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Diagnostic Criteria GOLD Criteria (continued) Symptoms and risk factors are not diagnostic in themselves but should prompt spirometry in patients >40 yrs of age Diagnosis should be confirmed by pre- and post-bronchodilator spirometry GOLD Criteria – diagnosis of COPD is based on symptoms and spirometry: Symptoms and exposure to risk factors are not diagnostic in themselves but should prompt spirometry in pts >40 yrs of age Diagnosis should be confirmed by pre- and post-bronchodilator spirometry Key factors in the report are age and the need for spirometry, younger patients should be considered for other diagnoses that occur more often in their age groups – but they are not necessarily excluded from having COPD References: GOLD, 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Diagnostic Criteria Key Indicators Dyspnea Progressive, usually worse with exercise, persistent, described as increased effort to breathe Chronic cough May be intermittent, may be nonproductive Chronic sputum production Any pattern History of exposure to risk factors Tobacco smoke, occupational dust, chemicals, fumes or smoke from cooking or heating fuels Key indicators for considering the diagnosis of COPD – these may be symptoms, clinical findings or historical risk factors: Dyspnea Progressive (worsens over time) Usually worse with exercise Persistent (present everyday) Described by the patient as an “increased effort to breathe,” heaviness,” “air hunger,” or “gasping.” Chronic cough May be intermittent and may be unproductive Chronic sputum production Any pattern of chronic sputum production may indicate COPD History of exposure to risk factors Tobacco smoke Occupational dusts and chemicals Smoke from home cooking and heating fuels References: GOLD, 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

Spirometry Classification for COPD
Stage FEV1:FVC FEV1 1: Mild <0.70 ≥80% of predicted value 2: Moderate 50% to 79% of predicted value 3: Severe 30% to 49% of predicted value 4: Very severe <30% of predicted value OR <50% of predicted value with chronic respiratory failure Spirometry is essential for the diagnosis of COPD and helps classify its severity. Random population studies have shown post-bronchodilator FEV1/FVC exceeds 0.70 for all healthy people, except perhaps the very elderly. References: GOLD, 2009 Adapted from GOLD, 2009 20

Differential Diagnoses
Pulmonary Asthma Bronchogenic carcinoma Bronchiectasis Tuberculosis Cystic fibrosis Interstitial lung disease Bronchiolitis obliterans Alpha-1 antitrypsin deficiency Pleural effusion Pulmonary edema Recurrent aspiration Tracheobronchomalacia Recurrent pulmonary emboli Foreign body Non-pulmonary Congestive heart failure Hyperventilation syndrome/panic attacks Vocal cord dysfunction Obstructive sleep apnea (undiagnosed) Aspergillosis Chronic fatigue syndrome BOLDED diseases are commonly confused with COPD and will be discussed in more detail in later slides. The most common diagnostic dilemma will be differentiating COPD from asthma. However, many other illnesses share symptoms and/or physical findings with COPD. Most can be excluded without an extensive workup. Some may require the judicious utilization of select tests. The differential diagnosis is derived from the symptom complex obtained from the history, findings of the physical examination, and the results of specific testing, such as spirometry. References: Dewar, 2006 GOLD, 2009 Qaseem, 2007 Stephens, 2008 Stephens, 2008

Diagnostic Criteria Asthma
Episodic symptoms of airflow obstruction or airway hyper-responsiveness Airflow obstruction partially reversible by spirometry Characterized by reversibility and variability in symptoms and airflow Alternative diagnosis excluded by history and exam Asthma is the primary diagnosis that must be distinguished from COPD. The following slides will emphasize the diagnostic criteria for asthma, based on accepted national and international guidelines, and how they differ from COPD. Episodic symptoms of airflow obstruction or airway hyper-responsiveness. Airflow obstruction is at least partially reversible as demonstrated by spirometry. Characterized by reversibility and variability in symptoms and airflow. Alternative diagnosis are excluded by history and exam. References: GOLD, 2009 Guidelines for the Diagnosis and Management of Asthma, 2007. Global Initiative for Asthma ( Global Initiative for Asthma (GINA) Report, 2009

Adapted from NHLBI/NIH NAEP Guidelines, 2007
Diagnostic Criteria Asthma – Key indicators Cough, worse particularly at night Recurrent wheezing, chest tightness or difficulty breathing Wheezing on physical examination Symptoms that occur or worsen in presence of known triggers Symptoms that occur/worsen at night Asthma – Key indicators which will help distinguish it from COPD on clinical grounds: History of cough, worse particularly at night History of recurrent wheezing, chest tightness or difficulty breathing Wheezing on physical examination Symptoms that occur or worsen in the presence of known triggers (e.g. smoke, exercise, pollen, viral infections) Symptoms that occur/worsen at night Reference: Guidelines for the Diagnosis and Management of Asthma, Box 3-1, page 42; 2007. Adapted from NHLBI/NIH NAEP Guidelines, 2007

NHLBI/NIH NAEP Guidelines, 2007
Diagnostic Criteria Asthma – Spirometry Establishes diagnosis of asthma Perform when key indicators present Demonstrates obstruction and assesses for reversibility Reversibility defined as >12% increase in FEV1 from baseline Spirometry is necessary for diagnosing both COPD and asthma. Here are the spirometric criteria for diagnosing asthma. The key element is reversibility, which is not usually found in patients with COPD. Spirometry in asthma patients is: Needed to establish diagnosis of asthma. Should be performed when key indicators are present (see previous slide). Demonstrates obstruction and assesses for reversibility. Reversibility is defined as >12% increase in FEV1 from baseline Reference: Guidelines for the Diagnosis and Management of Asthma, page 40; 2007. NHLBI/NIH NAEP Guidelines, 2007

Diagnostic Criteria Asthma – Similarities with COPD
Major epidemiologic causes of chronic obstructive airway disease Involve underlying airway inflammation Can cause similar chronic respiratory symptoms and fixed airflow limitation Can co-exist with the other making diagnosis more difficult Asthma – Similarities with COPD here are emphasized. Note that the two can coexist thus the need to carefully consider the differences and finer points of diagnosis since distinguishing the two can have major implications in terms of management and life expectancy. COPD & Asthma both are major epidemiologic causes of chronic obstructive airway disease. Both involve underlying airway inflammation. Both can cause similar chronic respiratory symptoms and fixed airflow limitation. Both can co-exist with the other making diagnosis more difficult. References: GOLD, 2009 GINA, 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009 Global Initiative for Asthma (GINA) Report, 2009

Diagnostic Criteria Asthma – Differences from COPD Underlying immune mechanism of chronic inflammation different Age of onset Earlier in life with asthma Usually > age 40 in COPD Symptoms in asthma vary; COPD slowly progressive Smoking associated with COPD Asthma with reversible airflow limitation; irreversible airflow limitation in COPD Asthma – Differences with COPD are emphasized on this slide. Underlying immune mechanism of chronic inflammation is different. Age of onset in often earlier in life with asthma, usually > age 40 in COPD. Symptoms in COPD slowly progressive, in asthma may vary from day to day. Smoking key risk factor for COPD. Largely irreversible airflow limitation in COPD, largely reversible in asthma. The immune mechanisms are complex and can only be seen on lung/bronchial biopsies. However, they are crucial to the understanding of the two conditions and play a significant role in the clinical picture and response to therapy so they must be emphasized along with the other less specific historical/clinical findings. References: GOLD, 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

NHLBI/NIH Asthma Guidelines , 2007
Diagnostic Criteria Asthma – Using spirometry to differentiate from COPD Post-bronchodilator FEV1 <80% predicted together with FEV1/FVC <0.70 confirms airflow limitation that is not fully reversible Asthma may show similar changes in chronic and more severe cases; PFT’s may be needed to distinguish it from COPD Asthma – using spirometry to differentiate from COPD. This is most reliable clinical criteria for distinguishing COPD from Asthma and yet as the second bullet point indicates it is not foolproof in severe cases. Post-bronchodilator FEV1<80% predicted, together with FEV1/FVC<0.70 confirms airflow limitation that is not fully reversible. Asthma may show similar changes in chronic and more severe cases and therefore full PFT’s may be needed to distinguish it from COPD. References: GOLD, 2009 Guidelines for the Diagnosis and Management of Asthma NHLBI/NIH Asthma Guidelines , 2007

Clinical Features in Differentiating COPD from Asthma
Age Older than 35 years Any age Cough Persistent, productive Intermittent, usually nonproductive Smoking Typical Variable Dyspnea Progressive, persistent Nocturnal symptoms Breathlessness, late in disease Coughing, wheezing Table (continued on next slide) provides a summary of the differing clinical features of COPD and asthma. Some of these clinical features have significant overlap between the two diagnoses. The most notable differences are the progressive, persistent course of COPD with its irreversible airway limitation. Older patients, particularly those who smoke are also more characteristics of COPD. Nocturnal symptoms in a younger patient should suggest asthma. References: Stephens, 2008 Adapted with permission from Stephens, 2008

Clinical Features in Differentiating COPD from Asthma (continued)
Family history Less common More common Atopy Diurnal symptoms Spirometry Irreversible airway limitation Reversible airway limitation Table provides a summary of the differing clinical features of COPD and asthma. Some of these clinical features have significant overlap between the two diagnoses. The most notable differences are the progressive, persistent course of COPD with its irreversible airway limitation. Older patients, particularly those who smoke are also more characteristics of COPD. Nocturnal symptoms in a younger patient should suggest asthma. References: Stephens, 2008 Adapted with permission from Stephens, 2008 29

Diagnostic Criteria Heart Failure (HF) Characteristics
Midlife to late-life onset; associated with risk factors such as hypertension and coronary artery disease Clinical presentation Fatigue, exertional and paroxysmal nocturnal dyspnea, and peripheral edema, crackles on auscultation Pulmonary function test Decreased DLCO, predominantly used to exclude other diagnoses HEART FAILURE (HF) – the following slides will enumerate several criteria to help clinicians distinguish COPD from other diagnoses; the first two concern Heart Failure: Characteristics: Midlife to late-life onset; associated with risk factors such as hypertension and coronary artery disease Clinical presentation: Fatigue, exertional and paroxysmal nocturnal dyspnea, and peripheral edema, crackles on auscultation Pulmonary function test findings: Decreased DLCO, show restriction not obstruction, predominantly used to exclude other diagnoses BNP = brain natriuretic peptide References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide

Diagnostic Criteria Heart Failure (HF, continued) Chest radiography
Increased heart size, pulmonary vascular congestion, pleural effusions Other recommended testing Echocardiography, BNP measurement, electrocardiography; cardiac catheterization in selected patients HEART FAILURE Chest radiography findings: Increased heart size, pulmonary vascular congestion, pleural effusions Other recommended testing: Echocardiography, BNP measurement, electrocardiography; cardiac catheterization in selected patients References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide 31

Diagnostic Criteria Bronchiectasis Characteristics
Usually midlife onset; progressive with exacerbations Clinical presentation Productive cough with large volumes of thick, purulent sputum; dypsnea; and wheezing associated with bacterial infections, crackles, and clubbing on exam Pulmonary function test Obstructive airflow limitation, both fixed and reversible BRONCHIECTASIS Characteristics: Usually midlife onset; progressive with exacerbations. Clinical presentation: Productive cough with large volumes of thick, purulent sputum; dypsnea; and wheezing associated with bacterial infections, crackles and clubbing on exam. Pulmonary function test findings: Obstructive airflow limitation, both fixed and reversible. References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide

Diagnostic Criteria Bronchiectasis (continued)
Chest radiography Focal pneumonia, atelectasis; dilated bronchial tree, thickened airways (ring shadow) Other recommended testing Bacterial, microbacterial, and fungal sputum culture, chest CT. BRONCHIECTASIS Pulmonary function test findings: Obstructive airflow limitation, both fixed and reversible. Chest radiography findings: Focal pneumonia, atelectasis; dilated bronchial tree, thickened airways (ring shadow). Other recommended testing: Bacterial, microbacterial, and fungal sputum culture, chest CT. References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide 33

Diagnostic Criteria Tuberculosis Characteristics
Onset at any age; associated with history of exposure, local prevalence may suggest diagnosis Clinical presentation Productive cough, hemoptysis, fever, and weight loss Pulmonary function test Not used for diagnosis TUBERCULOSIS Characteristics: Onset at any age; associated with history of exposure, local prevalence may suggest diagnosis. Clinical presentation: Productive cough, hemoptysis, fever, and weight loss Pulmonary function test findings: Not used for diagnosis References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide

Diagnostic Criteria Tuberculosis (continued)
Chest radiography Infiltrate, nodular lesions, hilar adenopathy, cavitary lesions or granulomas Other recommended testing Sputum AFB culture, PPD, sputum cultures confirm diagnosis TUBERCULOSIS Chest radiography findings: Infiltrate, nodular lesions, hilar adenopathy, cavitary lesions or granulomas. Other recommended testing: Sputum acid-fast bacillus (AFB) culture, purified protein derivative (PPD), sputum cultures confirm diagnosis References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide 35

Diagnostic Criteria Bronchiolitis obliterans Characteristics
Onset at any age but often younger; may be associated with history of flu-like illness, collagen vascular disease, or toxic fume exposure, non-smokers Clinical presentation Often subacute presentation with dyspnea, cough, and fever Pulmonary function test Decreased vital capacity, decreased DLCO, usually no obstructive component BRONCHIOLITIS OBLITERAN Characteristics: Onset at any age but often younger; may be associated with history of flu-like illness, collagen vascular disease, or toxic fume exposure, non-smokers Clinical presentation: Often subacute presentation with dyspnea, cough, and fever. Pulmonary function test findings: Decreased vital capacity, decreased carbon monoxide diffusion in the lung (DLCO), usually no obstructive component. References: Dewar, 2006 GOLD, 2009. Adapted with permission from DeWar, 2006 Continued on next slide

Diagnostic Criteria Bronchiolitis obliterans (continued)
Chest radiography Multifocal, bilateral alveolar infiltrates Other recommended testing ESR, high-resolution CT shows hypodense areas, lung biopsy BRONCHIOLITIS OBLITERAN Chest radiography findings: Multifocal, bilateral alveolar infiltrates Other recommended testing: Erythrocyte sedimentation rate (ESR), high-resolution CT shows hypodense areas, lung biopsy. References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide 37

Diagnostic Criteria Tracheobronchomalacia Characteristics
Onset usually more middle age; idiopathic or acquired during the course of other illnesses Clinical presentation Cough, difficulty in clearing secretions, wheezing, recurrent bronchitis, pneumonia Pulmonary function test Obstructive ventilatory impairment not responsive to conventional treatment with bronchodilators or inhaled corticosteroids TRACHEOBRONCHOMALACIA – Characteristics: Onset usually more middle age; idiopathic or acquired during the course of other illnesses Clinical presentation: cough, difficulty in clearing secretions, wheezing, recurrent bronchitis, pneumonia Pulmonary function test findings: obstructive ventilatory impairment who do not respond to conventional treatment with bronchodilators or inhaled corticosteroids Reference: Murgu, 2006 Adapted with permission from DeWar, 2006 Continued on next slide

Diagnostic Criteria Tracheobronchomalacia, (continued)
Chest radiography (dynamic CT) Allows volumetric acquisition of data both at end-inspiration and during dynamic expiration; reduction in airway caliber of 50% or more between inspiration and expiration may help in diagnosis Other recommended testing Flexible bronchoscopy; endobronchial ultrasonography TRACHEOBRONCHOMALACIA – Dynamic CT scan: allows volumetric acquisition of data both at end-inspiration and during dynamic expiration; reduction in airway caliber of 50% or more between inspiration and expiration may help in diagnosis Other recommended testing: flexible bronchoscopy; endobronchial ultrasonography Reference: Murgu, 2006 Adapted with permission from DeWar, 2006 Continued on next slide 39

Diagnostic Criteria Cystic fibrosis Characteristics
Usually early-life onset; progressive with exacerbations; associated with pancreatic disease, failure to thrive, intestinal obstruction, cirrhosis, and steatorrhea. Clinical presentation Predictive cough with purulent sputum, dyspnea, and wheezing Pulmonary function test Predominantly fixed airflow obstruction CYSTIC FIBROSIS Characteristics: Usually early-life onset; progressive with exacerbations; associated with pancreatic disease, failure to thrive, intestinal obstruction, cirrhosis, and steatorrhea. Clinical presentation: Predictive cough with purulent sputum, dyspnea, and wheezing. Pulmonary function test findings: Predominantly fixed airflow obstruction. References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide

Diagnostic Criteria Cystic fibrosis (continued) Chest radiography
Bronchiectasis frequent in upper lobes Other recommended testing Sweat chloride test (diagnostic), bacterial sputum culture CYSTIC FIBROSIS Chest radiography findings: Bronchiectasis frequent in upper lobes. Other recommended testing: Sweat chloride test (diagnostic), bacterial sputum culture. References: Dewar, 2006 GOLD, 2009 Adapted with permission from DeWar, 2006 Continued on next slide 41

Key Points COPD is associated with several chronic respiratory symptoms that suggests its diagnosis Symptoms overlap with other conditions -- asthma in particular History, risk factors and progression of disease assist with diagnosis Spirometry, with and without bronchodilator, usually necessary to make diagnosis COPD has several chronic respiratory symptoms that can be suggestive of the diagnosis. Many of these symptoms overlap with other conditions, in particular asthma. The history, risk factors and progression of the disease can help in making the diagnosis. Spirometry, with and without bronchodilator is necessary to make the diagnosis. This final slide summarizes the key points that the audience should come away with from this module. All four points are critical to the understanding of how to diagnose COPD.

References American Thoracic Society/European Respiratory Society Statement: Standards for the Diagnosis and Management of Individuals with Alpha-1 Antitrypsin Deficiency. Am J Respir Crit Care Med 2003;168;818–900. Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932. Cosio MG, Saetta M, Agust A. Immunologic Aspects of Chronic Obstructive Pulmonary Disease. N Engl J Med 2009;360: Dewar M, Curry RW. Chronic Obstructive Pulmonary Disease: Diagnostic Considerations. Am Fam Physician 2006;73(4): Global Initiative for Asthma (GINA) Report, 2009: Diagnosis and Classification, pg Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Report, Muller NL, Coxson H. Chronic obstructive pulmonary disease. 4: imaging the lungs in patients with chronic obstructive pulmonary disease. Thorax. 2002;57:982–5.

References (continued)
Murgu, SD and Colt, HG. Symptoms often mimic those of asthma and COPD -- Recognizing tracheobronchomalacia.(chronic obstructive pulmonary disease); J Respir Dis. 2006;27(8): Niewoehner DE. Outpatient Management of Severe COPD. N Engl J Med 2010;362: NHLBI/NIH National Asthma Education and Prevention Program: Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007. Qaseem A, Snow V, Shekelle P, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007;147:633-8. Price DB, et al. Symptom-based questionnaire for identifying COPD in smokers. Respiration 2006; 73(3): Stephens MB, Yew KS. Diagnosis of Chronic Obstructive Pulmonary Disease. Am Fam Physician 2008;78(1):87-92. Sutherland ER, Cherniack, RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004;350: Tinkelman DG, et al. Symptom-based questionnaire for differentiating COPD and asthma. Respiration 2006; 73(3):

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