Is it Asthma? Is it COPD? Dr Peter Hawkins Consultant Chest Physician

Outline • Definitions and diagnostic criteria Asthma COPD • Case Histories • Summary • Questions

Definition of Asthma 

A chronic inflammatory disorder of the airways



Many cells and cellular elements play a role



Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing



Widespread, variable, and often reversible airflow limitation

2008 Guidelines • 2.4 DIAGNOSIS IN ADULTS (1) - based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them

- the key is to take a careful clinical history - if asthma is a likely diagnosis, the history should explore possible causes, particularly occupational - even in relatively clear-cut cases, to try to obtain objective support for the diagnosis

Measuring Airway Responsiveness

Measuring Variability of Peak Expiratory Flow

Typical Spirometric (FEV1) Tracings Volume FEV1 Normal Subject

Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator)

1

2 3 4 Time (sec)

5

Note: Each FEV1 curve represents the highest of three repeat measurements

Definition of COPD COPD is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible1

The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking1 Although COPD affects the lungs, it also produces significant systemic consequences1

ATS/ERS Guidelines 2004 1. ATS/ERS 2004

Diagnosis of COPD EXPOSURE TO RISK FACTORS

SYMPTOMS cough sputum shortness of breath

tobacco occupation indoor/outdoor pollution

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SPIROMETRY

Partial Reversibility is Common in COPD N=813

* Increase in FEV1 of 12% or 200 mL Donohue JF, et al. Am J Resp Crit Care Med. 1997;155:A227.

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Reversibility with Ipratropium Plus Albuterol in the UPLIFT Clinical Trial

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_

_

1

1

Tashkin DP, et al. Eur Respir J. 2008;31:742-750.

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Differential Diagnosis: COPD and Asthma COPD  Chronic  Onset

cough

in mid-life

 Symptoms  Long

slowly progressive

smoking history

 Dyspnoea

during exercise

 Largely

irreversible airflow limitation

ASTHMA  Onset

early in life (often childhood)

 Symptoms

vary from day to day

 Symptoms

at night/early morning

 Allergy,  Family

rhinitis, and/or eczema also present

history of asthma

 Largely

reversible airflow limitation

From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for 13 Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.

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COPD Misdiagnosis Is Common in Women Hypothetical Male Patient With COPD Symptoms 65%

Diagnosed as COPD by 65% of physicians

49% Hypothetical Female Patient With COPD Symptoms Diagnosed as COPD by 49% of physicians

COPD symptoms in women were most commonly misdiagnosed as asthma

Chapman KR, et al. Chest. 2001;119:1691-1695.

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COPD

ASTHMA

Cigarette smoke

Allergens

Ep cells

Mast cell

CD4+ cell (Th2)

Eosinophil

Bronchoconstriction AHR

Reversible

Alv macrophage Ep cells

CD8+ cell (Tc1)

Neutrophil

Small airway narrowing Alveolar destruction

Airflow Limitation

Irreversible Source: Peter J. Barnes, MD

Case 1 • 53 year old man • Ticklish, dry cough • Nasal congestion • Previous nasal polypectomy • Slightly altered voice

• Initially referred to ENT

• Cough present for 6 months

• Nuisance during the day, not at night

• Triggered by cool evening air

• Longstanding post nasal drip

• Very little to find at nasendoscopy

• “probably cough variant asthma”

• Suggested trial of nasal steroid for 4 weeks and CXR

• “Hyperinflated lung fields. There is no way that a CXR can diagnose asthma. What is the FEV1”!

• Referred by GP

• Peak flow diary “very little evidence of consistent morning dipping”

• Trial of omeprazole

• Cough dry and worse over last 8 months

• Worse in evenings and with exercise

• Occasionally wheezy in the mornings

• No reflux

• Non smoker

• “The negative trial of omeprazole does not exclude reflux associated cough”

• “There is a family history of lung cancer but both of those affected were smokers and I note that he has had a recent normal CXR which is reassuring”

• “His peak flow diary is fairly flat around 500 L/min”

• Slightly obstructed right nostril

• FEV1 2.69 (79%)

• FVC 4.46

• Ratio 60%

A)Full lung function and reversibility

B)Trial of ICS for 6 weeks

C)Trial of Prednisolone for 2 weeks

D)Trial of inhaled salbutamol p.r.n.

E)Other

A)Full lung function and reversibility

B)Trial of ICS for 6 weeks

C)Trial of Prednisolone for 2 weeks

D)Trial of inhaled salbutamol p.r.n.

E)Other

• Peak flow improved from 480 to 570

• FEV1 improved from 2.69 to 2.89

• Much better

•Asthma ?

• 2 weeks later coughing, dysphonia and severe headache

• Not improved by switching to Fluticasone

• No neurology

• ? due to salmeterol

• Restarted prednisolone

• Cough improved but not headache

• CT brain - multiple metastases

• CT chest - central tumour (confirmed at bronchoscopy)

• Small cell lung cancer

• and probably asthma.

• ‘atypical’ or ‘incomplete’ presentation*

• Not asthma (asthma mimic)

• Errors in diagnostic reasoning (e.g. confirmation bias)

Case 2 • 81 year old man • long standing cough, wheeze and breathlessness • stopped smoking 2003 with 90 pack year history • Mild wheeze • Obstructive spirometry • Diagnosed COPD • Tiotropium

• Gradual deterioration, cough +++, wheeze +++, not sleeping

• Attended A&E - treated for AECOPD, CXR hyperinflated.

• Subsequently started on combination ICS/LABA

• Good response to treatment - no cough/wheeze

• Chest clear, FEV1 1.57L, FVC 3.35L (FEV1 57% predicted)

• Definite COPD

• Probable Asthma

• No childhood/family history of asthma

• Hayfever in 40s

2008 Guidelines • 2.4 DIAGNOSIS IN ADULTS (1) - based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them

- the key is to take a careful clinical history - if asthma is a likely diagnosis, the history should explore possible causes, particularly occupational - even in relatively clear-cut cases, to try to obtain objective support for the diagnosis

Learning point - Adult onset asthma can: • occur at any age • occur in smokers/ex-smokers • co-exist with COPD

Case 3 • 62 year old woman • 1 year history of gradually worsening dyspnoea • Can no longer dance • Cough with sticky clear sputum - feels coming from back of throat/hard to expectorate. • Breathing noisy - ‘wheezy’ • Negligible history of smoking in 20s

Case 2 • No family history of asthma • No atopy • Chest clear on examination (in surgery) • Normal spirometry • CXR normal • Trials of Nasal ICS/Bronchodilators and inhaled ICS no help hence referral.

Could it be asthma?

2008 Guidelines • 2.4 DIAGNOSIS IN ADULTS (4) • Spirometry should be the preferred test where available (training is required to obtain reliable recordings and to interpret the results)

• A normal spirogram (or PEF) obtained when the patient is not symptomatic does not exclude the diagnosis of asthma.

Listen to this doc! • patient demonstrates sound arising from throat during heavy breathing.

Stridor • Harsh inspiratory sound audible without stethoscope. • Usually indicative of upper airway obstruction. • Flow-volume loop

Bronchoscopy • Subglottic stenosis (web) • Referred for laser therapy

2008 Guidelines • 2.4 DIAGNOSIS IN ADULTS (3) • Confirmation hinges on demonstration of airflow obstruction varying over short periods of time • Spirometry is preferable to measurement of peak expiratory flow because it allows clearer identification of airflow obstruction, and the results are less dependent on effort

Learning point • Don’t confuse stridor with wheeze • Flow volume loops provide information regarding inspiration and expiration in addition to that from spirometry. • If symptoms remain unexplained after examination, CXR, spirometry and a suitable trial of treatment, referral is appropriate.

Case 4 • 62 year old man • Progressive breathlessness, worse on exertion. Starting to disturb sleep. • Some cough with sticky mucoid sputum - no haemoptysis. • Going on for several months. Feels as though problem in throat. • Smoker - 20 a day • No past history of asthma/atopy

Case 3 • Investigated over last year for throat symptoms by Gastroenterology and ENT. • OGD/Ba swallow/nasendoscopy NAD - ‘Globus’ sensation • History of anxiety. • Chest - some wheeze, hyperinflated • Spirometry - obstructive FEV1 no reversibility. • Recent normal CXR

Case 3 • Diagnosis mild COPD and anxiety • Stop smoking and prn bronchodilator • ‘No better’ - getting worse despite Tiotropium • Breathing noisy ?functional • Bronchoscopy

Learning point - lung cancer can present with a normal CXR

2008 Guidelines • 2.4 DIAGNOSIS IN ADULTS (2)

- whether or not this should happen before starting treatment depends on the certainty of the initial diagnosis and the severity of presenting symptoms - repeated assessment and measurement may be necessary before confirmatory evidence is acquired.

Case 5 • 65 year old man • cough, wheeze and breathlessness 3/12 • Day and night. Getting worse. • Stopped smoking at onset of symptoms - 45 pack year history. • Chest hyperinflated, some soft wheeze • Moderately obstructive spirometry

Case 4 • CXR clear • Treated as COPD but symptoms persisted • After 2 weeks prednisolone symptoms completely resolved and spirometry normal • Diagnosis - Adult onset asthma

Learning point - smoking • Increases the risk of developing asthma • Has a dose dependent effect on risk of developing asthma

Case 6 • 80 year old lady • 35 pack year history • cough and wheezing episodes • Mild obstruction on spirometry • Treated with LAMA • PMH - hypertension, achalasia, cataract

Case 6 • Not improving despite antibiotics and corticosteroids • Admitted as emergency • Treated as AECOPD • Not improving after 24 hours - respiratory arrest

Is it Asthma? Is it COPD? Dr Peter Hawkins Consultant Chest Physician