Elsevier

Mayo Clinic Proceedings

Volume 85, Issue 12, December 2010, Pages 1122-1129
Mayo Clinic Proceedings

REVIEW
Improving the Differential Diagnosis of Chronic Obstructive Pulmonary Disease in Primary Care

https://doi.org/10.4065/mcp.2010.0389Get rights and content

Chronic obstructive pulmonary disease (COPD) and asthma represent a substantial portion of primary care practice. In adults, differentiating asthma from COPD can be difficult but is important because of the marked differences in treatment, disease progression, and outcomes between the 2 conditions. Currently, clinical COPD is often misdiagnosed or undiagnosed until late in the disease. Earlier diagnosis could markedly reduce morbidity and improve quality of life. Establishing a diagnosis of COPD requires spirometry testing, interpreted in the context of the patient's symptoms, smoking status, age, and comorbidities. Additional tests and tools may be helpful in the differential diagnosis, including questionnaires specifically developed to discriminate between COPD and asthma and, in special cases, imaging studies. Follow-up and monitoring of asthma and COPD are always necessary and provide additional benefit in patients in whom only continued care and reassessment can confirm the final diagnosis, such as younger individuals with fixed airway obstruction, smokers with asthma, and patients with both disorders. Key areas for improvement include enhanced case identification, improved quality and interpretation of findings on spirometry, and increased use of tools such as differential diagnosis questionnaires and algorithms to guide the diagnostic and monitoring process. To achieve optimal outcomes, the primary care team should make every effort to establish a firm diagnosis. For this review, we conducted a PubMed search with no time limits using the Medical Subject Headings chronic obstructive pulmonary disease or COPD and asthma, in association with the following search terms: diagnosis, differential diagnosis, mixed or comorbid disease, diagnostic techniques, spirometry, questionnaires, and primary care.

Section snippets

METHODS

We conducted a literature search with no date limitations for all relevant articles using PubMed, a bibliographic database providing access to citations for biomedical articles from MEDLINE (1950s to present) and life science journals. We used the Medical Subject Headings chronic obstructive pulmonary disease or COPD and asthma, in association with the following search terms: diagnosis, differential diagnosis, mixed or comorbid disease, diagnostic techniques, spirometry, questionnaires, and

IMPORTANCE OF DIFFERENTIAL DIAGNOSIS

Differentiation between asthma and COPD is extremely important because treatment strategies differ for the 2 conditions, although smoking cessation is vital irrespective of disease.10, 19 Treatment of asthma includes the use of inhaled corticosteroids (ICSs) in patients with persistent disease9, 20 to suppress eosinophilia-based airway inflammation, leading to symptom control and restoration of pulmonary function.9, 21 However, responsiveness to ICSs is reduced in smokers with asthma, who may

Initial Diagnosis

A typical patient with COPD is likely to be 35 years or older and have a history of risk factors such as smoking or extended occupational exposures to toxins.10, 26 It is usually unrecognized until patients are in their sixties. Although COPD was once considered a disease of men, a higher prevalence of chronic bronchitis and emphysema has been reported in US women than US men in 2010.27 Furthermore, women's smaller lung size and differing lung geometry appear to increase their susceptibility to

CONCLUSION

For many years, COPD was deemed to be a disease of fixed airflow obstruction for which no beneficial treatment was available. This led to a largely nihilistic view of COPD among health care professionals, with little incentive to diagnose COPD accurately. However, early detection of airflow limitation and intervention for smoking abstinence can delay lung function decline, reduce the burden of COPD symptoms, and improve patients' quality of life.19, 84 Accurate differential diagnosis of asthma

Acknowledgments

We thank Mary Sayers of ACUMED, who provided medical writing services. This support was funded by Novartis Pharma AG.

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    eAppendix

    1

    Dr Price has consultant arrangements with Boehringer Ingelheim, GlaxoSmithKline, Merck, Novartis, and Teva. He or his research team have received grants and support for research in respiratory disease from the following organizations in the past 5 years: UK National Health Service, Aerocrine, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Merck, Novartis, Nycomed, Pfizer, and Teva. He has spoken for Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Merck, Pfizer, and Teva. He has shares in AKL International, which produces phytopharmaceuticals. He is the sole owner of Research in Real-Life. Dr Yawn has received investigator-initiated research grants from Novartis, Boehringer Ingelheim, and GlaxoSmithKline related to studies of screening for chronic obstructive pulmonary disease (COPD). She has been paid to take part in advisory boards related to COPD for Boehringer Ingelheim, GlaxoSmithKline, and Novartis and for asthma by GlaxoSmithKline, Merck, and AstraZeneca. Dr Jones has been paid to take part in advisory boards related to COPD for Boehringer Ingelheim, GlaxoSmithKline, Novartis, Nutricia, Pfizer, and Teva in the past 3 years. He has spoken at scientific/educational meetings financed by Altana, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Merck Sharp & Dohme, Pfizer, Teijin, and Trinity-Chiesi in the past 3 years. He is a consultant for the global emPOWER educational program supported by Pfizer and Boehringer Ingelheim.

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