Funding for this newsletter series was provided by
Pulmonary Practice Pearls for Primary Care Physicians
10-part eNewsletter series
Vol 1, Issue 10
Primary care physicians routinely see patients with chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD). Although treatment guidelines are available, we still need practical information that translates guidelines and other evidence so that we can better diagnose and manage these diseases. Each issue in the Pulmonary Practice Pearls for Primary Care Physicians eNewsletter series focuses on a key topic in the management of COPD or asthma within the context of current national guidelines and clinical practice. Topics are brought to life through the presentation of hypothetical clinical cases, and an emphasis is placed on applying key learnings to clinical practice. Practice tools and links to additional information are featured in each issue.
Series Author
Barbara P. Yawn, MD, MSc, FAAFP
Director of Research
Olmsted Medical Center
Rochester, Minnesota

Dr. Yawn disclosed that she serves on advisory boards for Boehringer Ingelheim GmbH and Novartis Pharmaceuticals Corporation and has received grant support from AstraZeneca; Boehringer Ingelheim GmbH; Merck & Co., Inc.; and Novartis Pharmaceuticals Corporation.




Differentiating Asthma and COPD

Key Points
  • Asthma and COPD are obstructive respiratory disorders characterized by airflow limitation and inflammation, although their pathogenesis, natural history, treatment, and prognosis differ.
  • Overlapping clinical signs and symptoms can contribute to a challenging diagnosis.
  • Prognosis differs for patients with asthma versus COPD; patients with well-controlled asthma should have normal activity levels and life expectancy, whereas COPD is usually a progressive disease, even with the best available care, limiting patients' longevity and activity.
  • Guidance is provided for accurate diagnosis, which is vital for development of appropriate disease management strategies and treatment approaches.



Introduction

The respiratory diseases asthma and COPD are commonly encountered in clinical practice and result in substantial health care burdens. Establishing a diagnosis of asthma or COPD may be challenging because of overlapping characteristics and the possibility for both diseases to coexist; however, an accurate diagnosis is necessary because treatment approaches are different for each disease.

Prognosis differs for patients with asthma or COPD.1 Patients with well-controlled asthma should have normal activity levels and life expectancy, whereas COPD is usually progressive, meaning that patients' lung function can be expected to worsen over time, even with the best available care, potentially limiting longevity and activity. Patients with COPD typically have multiple comorbidities that further complicate the diagnosis and prognosis.

This newsletter aims to review the characteristic features of asthma and COPD along with tools that may facilitate their differential diagnosis.


Burden and Prevalence of Asthma and COPD

Primary care physicians (PCPs) treat the majority of patients with asthma and COPD and frequently are the first point of contact for patients with these chronic diseases.2 As the incidence of asthma and COPD grows, the number of asthma and COPD patients seeking care represents an increasing burden for PCPs.3 Most patients (80%) see their physician or other clinician once annually, and most patients with asthma report seeing family medicine physicians or PCPs (54%) for the usual care of their asthma.4 In 2009, the National Asthma Surveillance survey found that there were 10.6 million office visits in the United States for asthma, and there were 43 office visits for every 100 persons with asthma.5

The economic burden of asthma is significant. In 2010, there were an estimated 14.2 million physician office visits and 1.8 million emergency department visits with asthma as the primary diagnosis.6 The asthma burden was higher in children than adults, as children were more likely to receive care for their asthma during ≥1 routine office visits, emergency department visits, or urgent care visits.7 It is likely that many after-hour and urgent office calls could also be prevented by better control of asthma.

COPD has been the third leading cause of death in the United States since 2011, with approximately 6.8 million adults living with diagnosed COPD in 2012, and as many as 12 million may have undiagnosed COPD according to the National Heart, Lung, and Blood Institute.8-10 In a survey, 784 practicing PCPs estimated that 12% of their patients had COPD.11


Features and Clinical Presentation of Asthma and COPD

Despite the shared characteristics of airflow obstruction and chronic persistent airway inflammation, asthma and COPD have distinct pathophysiological features and immunological mechanisms mediated by different cell types and factors.12

Within these obstructive diseases, there are multiple phenotypes associated with different expressions of these pathophysiological features. This accounts for the clinical differences in how patients present at office visits and their variable responses to triggers and some types of therapy.13,14

A patient's age may help distinguish between diseases, as asthma onset often occurs in childhood, whereas COPD predominately occurs in adults aged ≥40 years.2 Commonly observed clinical characteristics that differentiate asthma and COPD are summarized in Table 1.3,13,15

Asthma is a heterogeneous disease, associated with recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. The frequency and duration of symptoms are variable, and patients can experience periods with few or no symptoms. Patients with asthma are often able to identify triggers or events that prompt their episodic symptoms, and up to 90% of patients with asthma find that exercising can trigger symptoms.12,16 Allergies are present in more than 50% of patients with asthma and are associated with many of the triggers of exacerbations.12 Vocal cord dysfunction and other respiratory diseases may mimic asthma in adult patients. For example, episodic wheezing can be seen in congestive heart failure and obesity. In children, other respiratory diseases that can have symptoms similar to those for asthma should be considered during evaluation (Table 2).14,17,18

COPD is typically associated with progressive shortness of breath and a morning cough that may or may not produce sputum; patients less commonly have periods without symptoms. Patients with COPD do not typically display atopy.12 Because COPD symptoms are progressive, patients with COPD may not recognize them and may slowly adjust their lifestyle. Patients may report recurrent episodes of "bad colds" or "bronchitis," not recognizing these as COPD exacerbations and identifying triggers or events that set off their symptoms.12 Although cigarette smoking is the most commonly encountered risk factor for COPD, exposure to other lung irritants at work or home should also be considered when compiling a patient history. A number of comorbidities may also complicate the diagnosis of COPD (Table 3).3,13,19-21

Case Study 1

Jane is a 50-year-old woman who presents for a "bad cold" and asks for antibiotics and an inhaler. She has problems with bad colds most years, but this one is worse. She works at a nursing home, so she had a "flu shot" that "should have prevented this." She reports that most days are fine, and she has no shortness of breath, coughing, or wheezing. She is only troubled by these episodes when she has a cold.

Examination reveals that Jane is afebrile with few scattered wheezes that clear with some coughing. Otherwise, there are no unusual findings.

Patient history shows that Jane had asthma as a child. She continued to have problems until her third pregnancy at age 35 years, when the asthma seemed to improve. She has used no daily asthma medications since then. She has a brother and a son who both have asthma and her granddaughter was recently diagnosed with asthma at age 5 years. Jane has a 15 pack-year smoking history. She stopped smoking with her third pregnancy (15 years ago).
Case Study 2

Tom comes in for a yearly executive physical examination. As it is his first "executive physical," you have little previous information. He is aged 54 years and a former smoker including some recreational marijuana use. He has hypertension treated with combination therapy, hyperlipidemia treated with a moderate dose of statins, and erectile dysfunction treated with as-needed medication. He has just been promoted to Vice President of Marketing for a large corporation – hence his "executive physical." He reports no major problems.

Review of systems is negative, except he mentions a little problem with dyspnea when golfing that has gotten progressively worse over the past 3 years; he has begun golfing with an older group of players so that he can use a cart. In focused discussion, he says he thinks he had some asthma problems a few years ago and was given some inhalers, but he is unable to remember what they were and did not like using them before golf because they "made him look weak."
Note: This is a hypothetical case description for teaching purposes.



Differential Diagnosis of Asthma and COPD

Medical History
A medical history should be taken that includes questioning about differentiating factors (see Table 4).14,22-24

Questionnaires
Symptom-based questionnaires may be useful tools in the initial evaluation and differentiation of asthma and COPD. A 4-item questionnaire was found to correctly classify COPD in 87.4% of cases (Table 5).25

Physical Examination
Physical examination primarily helps rule out possible alternative diagnoses.13,17 Physical findings may be normal in either condition because of the variability of the disease in patients with asthma and the lack of overt physical signs in patients with early COPD. Among patients with COPD, symptoms of airflow limitation such as dyspnea on exertion or progressive declining functional status are not usually detected until patients have lost 50% or more of their lung function.13

Radiology
Imaging studies are usually normal in early-stage disease, with few characteristic signs of obstructive disease present on chest radiography. It is not yet clear how useful low-dose computed tomographic scanning, performed for lung cancer screening in those with significant (>30 pack-year) smoking history, may be for identifying features such as emphysema and the distribution of emphysema throughout the lung.26

Spirometry
Asthma and COPD are associated with airflow limitation, and spirometry is important in determining the presence and severity of disease; however, spirometry alone cannot always distinguish between these diseases since some patients with asthma may develop fixed airflow obstruction secondary to airway remodeling.14 For children, adolescents, and adults aged <40 years, a typical clinical history of asthma may be sufficient to make a diagnosis.14 Spirometry testing may be normal or not demonstrate the "obstructive" ratio of forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) observed in COPD in these individuals with asthma during periods when they are minimally symptomatic. For adults aged ≥40 years, especially long-term smokers and new-onset "asthma" in a smoker, spirometry is recommended to differentiate between suspected chronic airway diseases.13,14 A clinical diagnosis consistent with symptoms and history of risk factors for COPD can be confirmed with spirometry.13

Reversibility has been suggested as a test to separate asthma and COPD. The Global Initiative for Asthma (GINA) Guidelines consider reversibility to be an increase in FEV1 of >200 mL after administration of a short-acting β-agonist (SABA) bronchodilator and >12% above prebronchodilator levels to be highly suggestive of asthma.14 However, asthma patients may not demonstrate reversibility at all visits, such as during exacerbations or if they have not stopped all medications. Even patients with initially "normal" FEV1 values may show further improvement meeting the reversibility criteria. Patients with severe asthma may not demonstrate reversibility.14

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines characterize COPD by airflow limitation that is not fully reversible following administration of a SABA. GOLD defines nonreversible spirometry results for COPD as an FEV1/FVC ratio <0.70 with FEV1 and FVC not improving by 12% or 200 mL.13

However, many patients with COPD demonstrate some reversibility of airflow obstruction and a few demonstrate marked reversibility.27 Meeting the reversibility criteria does not rule out COPD in a person with a typical clinical history. Furthermore, limited reversibility to a SABA is not predictive of limited or no response to the use of maintenance long-acting β-agonist bronchodilator (LABA) therapy.19 Patients with poor reversibility often respond well to daily use of a LABA.19 A large percentage of COPD patients can demonstrate reversibility to higher doses of SABAs which may be more predictive of response to daily use of LABAs.19,28 Individual patients may also show varying degree of reversibility over time, complicating the presence or absence of reversibility in an individual.19

Case Study 1 (continued)

Your differential diagnosis for Jane is that she has an upper respiratory infection, resulting in an asthma exacerbation. Her history of asthma, strong family history of asthma, and report that she does not have respiratory-related symptoms or problems most days strongly support a diagnosis of asthma. Even with a 15 pack-year smoking history, COPD seems unlikely.

You prescribe a SABA and oral corticosteroids for 5 days because you believe she probably has asthma but would like to check lung function to confirm your clinical diagnosis.

You plan to have her spirometry testing completed when she has recovered from her exacerbation in about 4 weeks.

Six weeks later, Jane's spirometry measures show that her FEV1 is 85% of predicted, her FVC is 90% of predicted, and her FEV1/FVC is 0.84 L. She has >12% (actually ~15% increase) and 200 mL (actually 235-mL increase) of her FEV1 after 2 puffs of a SABA, which is consistent with full reversibility. You consider that your initial diagnosis was correct. You now place Jane on daily moderate-dose ICS therapy for her asthma. You observe Jane using the inhalers that she will receive for both her inhaled corticosteroid (ICS) and her SABA to assure good inhaler technique. You also continue to work on identifying asthma triggers and trigger avoidance strategies.

Your follow-up visit in 3 to 6 months will review her asthma control status, history of any exacerbations, ICS adherence, inhaler technique, and triggers.
Case Study 2 (continued)

You suggest to Tom that he may have some respiratory problems. He agrees that he probably has asthma and is willing to try some asthma medications, such as ICSs, like his hunting buddy uses. You complete Tom's assessment including spirometry, which shows an FEV1 of 65% of predicted, an FVC of 80% of predicted, and an FEV1/FVC of 0.68 L. He has limited reversibility of <8% and 100 mL on his FEV1 and no change in his FVC.

You believe that Tom has COPD because of his long history of smoking, no history of childhood asthma, his report of a progressive loss of ability to walk on the golf course, and the fact that his symptoms are chronic, not episodic.

Your next steps are helping Tom to accept the diagnosis of COPD and to negotiate with him use of what you think is appropriate COPD therapy.

Today, you begin Tom on a combination inhaler of a LABA and ICS, because it appears that Tom has COPD with at least 3 exacerbations during the past 2 years. The ICS is added for COPD exacerbation prevention. You observe his inhaler technique with both his rescue medication and the combination of LABA and ICS.

You invite Tom back in a month because you are concerned about his repeated COPD exacerbations and his reluctance to accept ongoing therapy. You plan to suggest pulmonary rehabilitation and develop a COPD action plan at the next visit. Your parting diagnosis to Tom is "breathing problems with exacerbations" with some features of smoking-related lung disease, because he refuses to hear the words chronic obstructive pulmonary disease.
Note: This is a hypothetical case description for teaching purposes.



Treatment Overview

Once a diagnosis has been made, the severity of disease should be established and the disease managed according to current evidence-based guidelines.13,14,17 In general, asthma that has persistent symptoms should be treated with ICSs to address the underlying inflammation, with LABAs used as an adjunct to provide long-term control of symptoms if the patient's disease is not fully controlled on ICSs alone.17 Over time you also try to identify triggers—both allergic and nonallergic—and develop trigger avoidance or treatment strategies.

Long-acting inhaled formulations of β-agonists and anticholinergics are the basis of COPD therapy.13 Identification and reduction of risk factors and triggers—particularly smoking—are crucial steps in the management of COPD.13 ICS-LABA combination therapy is suggested as treatment for COPD patients who are at increased risk for exacerbations and/or are more symptomatic (GOLD class C and D), as ICSs are not recommended as monotherapy.13 Recent evidence suggests that dual bronchodilator therapy is also effective in preventing exacerbations.29-32 Therefore, options are available when selecting therapy to prevent COPD exacerbations and should be based on weighing the risks and benefits of each therapy.


Conclusions

Although asthma and COPD are defined by the presence of airflow obstruction and airway inflammation, each disease exhibits characteristic clinical and pathophysiological features. Different therapeutic strategies for asthma and COPD underpin the need to accurately differentiate the diseases. Differential diagnosis can be aided through a detailed evaluation of patient history using questions from validated questionnaires, but spirometry is often the most useful assessment. Longitudinal monitoring can further separate the progressive nature of COPD from most people with asthma. Diagnoses should be linked to the appropriate treatment according to evidence-based guidelines. Asthma and COPD can co-occur and are now labeled as asthma-COPD overlap syndrome (ACOS), which will be the discussion of a future newsletter.33

Acknowledgments

I thank Scientific Connexions (Lyndhurst, NJ, USA) for medical writing support funded by AstraZeneca LP (Wilmington, DE, USA).


References

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  2. Levy ML, Fletcher M, Price DB, Hausen T, Halbert RJ, Yawn BP. International primary care respiratory group (IPCRG) guidelines: diagnosis of respiratory diseases in primary care. Prim Care Respir J. 2006;15(1):20-34.
  3. Price DB, Yawn BP, Jones RC. Improving the differential diagnosis of chronic obstructive pulmonary disease in primary care. Mayo Clin Proc. 2010;85(12):1122-1129.
  4. Murphy KR. Meltzer E, Blaiss MS, Nathan RA, Stoloff SW, Doherty DE. Asthma management and control in the United States: results of the 2009 Asthma Insight and Management survey. Allergy Asthma Proc. 2012;33(1):54-64.
  5. Moorman JE, Akinbami LJ, Bailey CM, et al. National Surveillance of Asthma: United States, 2001–2010. Vital Health Stat. 2012;(35):1-67.
  6. Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. CDC website. http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed November 5, 2014.
  7. Centers for Disease Control and Prevention. Asthma Facts—CDC's National Asthma Control Program Grantees. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2013.
  8. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: national health interview survey, 2012. Vital Health Stat. 2014;(260).1-161.
  9. Centers for Disease Control and Prevention. What is COPD? CDC website. http://www.cdc.gov/copd/index.htm. Updated November 13, 2013. Accessed April 21, 2014.
  10. National Heart, Lung, and Blood Institute. COPD Learn more breathe better. NIH Publication No. 07-5840. NHLBI website. //www.nhlbi.nih.gov/files/docs/public/lung/copd-atrisk.pdf. Originally printed September 2006; Reprinted September 2013. Accessed November 5, 2014.
  11. Foster JA, Yawn B, Maziar A, Jenkins T, Rennard SI, Casebeer L. Enhancing COPD management in primary care settings. MedGenMed. 2007;9(3):24.
  12. Doherty DE. The pathophysiology of airway dysfunction. Am J Med. 2004;117(suppl 12A):11S-23S.
  13. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease website. http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Updated 2014. Accessed March 7, 2014.
  14. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. http://www.ginasthma.org/local/uploads/files/GINA_Report_March13.pdf. Published March 2013. Accessed July 1, 2014
  15. Postma DS, Reddel HK, ten Hacken NH, van den Berge M. Asthma and chronic obstructive pulmonary disease: similarities and differences. Clin Chest Med. 2014;35(1):143-156.
  16. Eichenberger PA, Diener SN, Kofmehl R, Spengler CM. Effects of exercise training on airway hyperreactivity in asthma: a systematic review and meta-analysis. Sports Med. 2013;43(11):1157-1170.
  17. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. Full Report 2007. NHLBI website. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Published August 28, 2007. Accessed August 8, 2014.
  18. Tilles SA. Differential diagnosis of adult asthma. Med Clin North Am. 2006;90(1):61-76.
  19. Hanania NA, Celli BR, Donohue JF, Martin U. Bronchodilator reversibility in COPD. CHEST. 2011;140(4):1055-1063.
  20. Yawn BP. Recognizing and managing COPD in patients with multiple morbidities. J Fam Pract website. http://newsletter.qhc.com/jfp/copd_121610.html. Published 2010.
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  22. Yawn BP. Differential assessment and management of asthma vs chronic obstructive pulmonary disease. Medscape J Med. 2009;11(1):20.
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  24. Hureaux J, Drouet M, Urban T. A case report of subacute bronchial toxicity induced by an electronic cigarette. Thorax. 2014;69(6):596-597.
  25. Beeh KM, Kornmann O, Beier J, Ksoll M, Buhl R. Clinical application of a simple questionnaire for the differentiation of asthma and chronic obstructive pulmonary disease. Respir Med. 2004;98(7):591-597.
  26. Moyer VA; U.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338.
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  28. Celli BR, Tashkin DP, Rennard SI, McElhattan J, Martin UJ. Bronchodilator responsiveness and onset of effect with budesonide/formoterol pMDI in COPD. Respir Med. 2011;105(8):1176-1188.
  29. Price D, Yawn B, Brusselle G, Rossi A. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Respir J. 2013;22(1):92-100.
  30. Yawn BP, Li Y, Tian H, Zhang J, Arcona S, Kahler KH. Inhaled corticosteroid use in patients with chronic obstructive pulmonary disease and the risk of pneumonia: a retrospective claims data analysis. Int J Chron Obstruct Pulmon Dis. 2013;8:295-304.
  31. Yawn BP, Yawn RA. Immunosuppressive and anti-inflammatory consequences of ICS therapy in COPD: the epidemiology perspective. Resp Drug Deliv. 2014;1:25-38.
  32. Magnussen H, Disse B, Rodriguez-Roisin R, et al; the WISDOM Investigators. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-1294.
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  Table 1. Clinical Characteristics: Factors Differentiating Asthma and COPD3,13,15
Clinical History Asthma COPD
Childhood problems Common Not strongly suggestive
Atopic features Common Not associated
Smoking Often not present Very common and the predominant risk factor
Night symptoms Common Less common
Cough and sputum Cough may be present, but less often productive of sputum Chronic cough with sputum production is very common
Age of onset Any Age ≥40 y
Pattern of respiratory symptoms Variable Persistent
Lung function between symptoms Typically normal, but may develop persistent airflow obstruction over time Abnormal with evidence of airflow obstruction
Abbreviation: COPD, chronic obstructive pulmonary disease.


  Table 2. Other Disorders in Children That May Complicate an Asthma Diagnosis14,17,18
Condition Clinical Considerations
Bronchopulmonary dysplasia
  • Usually associated with preterm and respiratory problems at birth
  • Vocal cord dysfunction
  • Inspiratory stridor (recognized as a loud, harsh, high-pitched respiratory sound) is a differentiating hallmark sign of vocal cord dysfunction
  • Loud wheezing and on spirometry the inspiratory loop often reveals an abnormal "uptick" in the midst of inspiration
  • Cystic fibrosis
  • May be noticed by a parent who reports that the child tastes salty when kissed or the presence of recurrent or chronic respiratory symptoms and failure to thrive


  •   Table 3. Other Disorders That May Complicate a COPD Diagnosis3,13,19-21
    Condition Clinical Considerations
    Congestive heart failure
  • Might be incorrectly considered the sole reason for shortness of breath and deny the patient the benefits of COPD medications. May find fine basilar crackles on auscultation
  • Bronchial carcinoma
  • Can include symptoms like dyspnea, hemoptysis, coughing, wheezing, pain in chest or abdomen, cachexia, fatigue, and loss of appetite
  • Arrhythmias, acute myocardial infarction, or hypertension
  • Factors contributing to these comorbidities include systemic inflammatory modulatorsa such as plasma fibrinogen and C-reactive protein, which are associated with atherosclerosis, as well as the common risk factor of smoking
  • Muscle wasting and cachexia, metabolic syndrome, osteoporosis, depression, anxiety, and anemia
  • Indicative of the systemic and interrelated nature of the inflammatory processes in COPD
  • aTo date, evaluation assessing these biomarkers is not recommended for all patients because they are not sufficiently specific to distinguish among conditions, but can be helpful when assessing the existence or importance of specific conditions


      Table 4. Patient Medical History in COPD and Asthma14,22-24
    Aspects of a patient's medical history that may be useful include:
  • Patient occupation, which may highlight occupational noxious exposure
  • Current medication (potential allergies or reactions to specific medications)
  • Presence of atopy or allergies
  • Age of onset
  • Comorbidities such as allergies or coronary artery disease
  • Sleep apnea symptoms such as loud snoring, restless sleep, and daytime sleepiness
  • Recurring respiratory infections
  • Colds that last weeks instead of days
  • Family history of early cardiovascular disease and respiratory diseases
  • History of smoking including use of cigars and "recreational" marijuana (the role of e-cigarettes in COPD is unknown, but they have been shown to be a trigger and pulmonary irritant in those with asthma and COPD)
  • History of chronic or recurrent cough, sputum production, dyspnea, or wheezing
  • Report of a previous doctor diagnosis of asthma or COPD
  • History of prior treatment with inhaled medications
  • Variability of symptoms over time (more characteristic of asthma)


  •   Table 5. Four-Item Questionnaire for Differentiating Asthma and COPD25
    Item Pointsa
    Age of onset, y
    <20 0
    20-40 1
    40-60 2
    >60 3
    Atopy
    yes 0
    no 4
    Smoked, pack-years
    0 0
    >0 to <20 1
    20-40 2
    >40 4
    Cough characteristics
    Dry cough 0
    No cough 2
    Productive cough 4
    Abbreviation: COPD, chronic obstructive pulmonary disease.
    aTotal scores range from 0–15 points. High scores indicate COPD; low scores suggest asthma.