Robert T. Schreiber, MD, an American Lung Association in New York Expert
A middle-aged woman sits across the desk from me looking somewhat nervous. She’s been sent to my office by her primary care physician for a pulmonary evaluation. As a lung specialist, I’m being asked to determine the cause of her chronic cough and episodes of wheezing. Is it asthma or COPD?
I evaluate and treat patients like this all the time. To give an accurate diagnosis and treatment plan, I take a full history, do a physician examination, and order a few tests.
First I ask about her symptoms and medical history:
- Are the symptoms chronic (meaning long-standing) or did they start recently?
- Was there a sudden change that could have triggered the symptoms, such as an exposure to an allergen or toxic substance, an acute respiratory infection, or a new pet in the home?
- Is there a prior history of childhood asthma or recurrent coughing and wheezing as an adult?
- Is there a history of allergies?
- Does she smoke or has she smoked in the past?
- Do any family members have asthma or COPD?
- What level of physical activity is she able to do? Has her exercise tolerance been declining?
Smoking is the most common cause of COPD. The risk of COPD from smoking is determined by pack years (number of packs per day multiplied by the numbers of years of smoking). COPD is more likely in people who have a history of 20 or more pack years. If the patient’s symptoms have been present for a long time and slowly worsening, it is more likely to be from COPD than asthma.
However, my patient’s symptoms could be a sign of asthma. In people with a history of allergies and childhood asthma, their asthma can reactivate as an adult. People who never had asthma can develop “non-allergic” asthma after an acute respiratory infection.
Both asthma and COPD can produce chronic coughing and wheezing, but the symptoms appear differently: People with COPD tend to have a chronic morning “smokers cough” as a sign of chronic bronchitis; most asthmatics have coughing and wheezing only during flare-ups.
The woman who came in today was a pack-a-day smoker for 25 years, and a casual smoker for five years before that. She quit smoking a few years ago, but has had a morning cough and recently started wheezing in cold weather and when she has a cold. She also gets short of breath easily walking up stairs, particularly if carrying packages.
In the examining room, I check her vital signs and do a head and neck exam, looking for evidence of chronic nasal or sinus swelling or nasal polyps (seen more commonly in asthma and allergies). I listen to her heart and breathing with my stethoscope; I hear mild wheezing in both lungs. Her heart sounds normal. I check the extremities for cyanosis (a blue color that might indicate a low oxygen level) and feet for swelling (which might indicate heart strain).
Next I order a chest x-ray. It looks for signs of cancer, “water on the lungs” and other problems that might cause her symptoms. Luckily, her test doesn’t show any of these.
Pulmonary function tests (PFT’s) are done next; these are breathing tests that measure lung capacity and flow rates. My patient’s PFT’s show that she can’t blow out as much air as she should in one second (her FEV1 is reduced). The next step is to give her a quick-acting bronchodilator and repeat the test. Most asthmatics have normal results after a bronchodilator, but when people have COPD, their tests do not normalize. My patient’s FEV1 is still low and for me, this clinches the diagnosis of COPD.
When I sit down with my patient to review the findings, I tell her she has COPD from years of smoking. Although she quit several years ago, most smoking damage is permanent. It’s common for patients to lose over half of their lung function before they realize it. Some of her loss of lung function is also a part of aging.
I outline a treatment regimen for her which includes taking an inhaled bronchodilator to control her symptoms. I also tell her to:
- Eat a healthy diet to strengthen her immune system.
- Get regular exercise to improve functional capacity.
- Avoid inhaled irritants and, of course, never smoke again.
- Take steps to prevent respiratory infections, such as getting immunizations for influenza and pneumonia, avoiding sick people, and frequent hand cleansing.
Her treatment also requires regular checkups with me to monitor her progress and adjust her medicines. As my new patient leaves, she isn’t happy that she has a chronic condition, but she seems satisfied that she has the right diagnosis and a plan of action.
Dr. Schreiber is board certified in internal medicine and pulmonary diseases by the American Board of Internal Medicine. He is a member of Nassau Chest Physicians, P.C., who are actively involved with the American Lung Association in New York. Schreiber is director of the SICU at St. Francis Hospital, medical director of the Oyster Bay Cove Village Police Department, and a member of the Nassau County Medical Reserve Corps. He is on the professional staffs of St. Francis Hospital, North Shore University Hospital (Manhasset and Plainview), and St. Joseph Hospital.
gotquestions http://www.everydayhealth.com/health-report/chronic-obstructive-pulmonary-disease/copd-blog-copd-or-asthma.aspx
