Beth is 52-years-old and comes to your office with worsening respiratory complaints. Beth currently smokes approximately 2 packs per day. She started smoking at age 16, and gradually increased the number of cigarettes she smoked, so that by the time she turned 21, she was already at 1.5 packs per day. She has had progressive dyspnea over the past year and has difficulty playing tennis now with her friends.
She reports a strong allergic history, and notes seasonal allergies: she can’t visit her friend at her home because of her cat. Her symptoms of breathlessness, wheezing, and cough seem to be worse in the cold air and often wake her up at night. She describes a chronic cough of white phlegm, although she often develops “bronchitis,” particularly during the winter months, with green phlegm, and worsening dyspnea and cough, which needs treatment with an antibiotic and sometimes a short course of steroids. This has happened twice over the past year.
She remembers that she had mild asthma as a child and took allergy shots, but seemed to “outgrow” those symptoms as a teenager. Her daughter has asthma, and she has been using her daughter's short acting beta agonist reliever medication almost every day, and once a week at night for relief.
What is the leading differential diagnosis? Asthma? COPD? Something else? There is considerable diagnostic uncertainty at this point. The patient has a long smoking history, consistent with COPD. She has progressive, chronic respiratory symptoms, including a productive cough, both uncommon in asthma, and common in COPD. She has infectious exacerbations, also common in COPD and uncommon in asthma. However, she seems to have variable symptoms which get worse at night, with cold air, and with exercise, common in asthma, uncommon in COPD. She has a strong history of allergic rhinitis, and a possible history of childhood asthma, both favoring a diagnosis of asthma, not COPD.
T: 98.6 P: 70 R: 14 BP: 120/80
Lungs: Decreased breath sounds, prolonged expiratory phase, mild wheezing bilaterally
Assessment: Possible COPD, possible asthma, ?mixed
You then administer two standardized tests: the COPD Assessment Test (CAT) for COPD1 (Figure 1, above) and the Asthma Control Test (Act) for asthma,2 (Figure 2, above). Her CAT score is 15, indicating symptomatic COPD; (higher than 10 is usually considered the cutoff). Her ACT score is 16, suggesting poor control of asthma; (19 or less is usually considered the cutoff).
Spirometry is then performed before and after bronchodilator administration. Results are seen in the table in Figure 3, above.
1. COPD Assessment Test.Accessed March 1, 2018.
2. Asthma Contorl Test. Accessed March 1, 2018.
3. Gold 2017 Global Strategy for the Diagnosis, Management, and Prevention of COPD. Accessed March 1, 2018.
4. Global Initiative for Asthma. Accessed March 1, 2018.