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Description : This medical presentation titled ""COPD - Differential Diagnosis"" describe constellation of symptoms and evaluation leading to consideration of chronic obstructive pulmonary disease (COPD) as diagnosis, delineates modifiable and non-modifiable risk factors for chronic obstructive pulmonary disease, explains diagnostic criteria for COPD, and describes other diseases that need to be considered in the workup of a patient with dyspnea, chronic cough, and sputum production.

Tags : COPD, Differential Diagnosis, symptoms, evaluation, chronic obstructive pulmonary disease, diagnosis, modifiable, non-modifiable, risk factors, diagnostic criteria for COPD, diseases, dyspnea, chronic cough, sputum production, asthma, allergy

Published on : Apr 24, 2021 | Views : 3112 | Downloads : 14

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Slide 1-

COPD: Differential Diagnosis Grant Hoekzema, MD Program Director, Mercy Family Medicine Residency, St. Louis, MO Elissa J. Palmer, MD, FAAFP Professor and Chair, Department of Family & Community Medicine, University of Nevada School of Medicine, Las Vegas, NV
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Educational Objectives At the end of this presentation, the learner should be able to … Describe constellation of symptoms and evaluation leading to consideration of chronic obstructive pulmonary disease (COPD) as diagnosis. Delineate modifiable and non-modifiable risk factors for chronic obstructive pulmonary disease. Understand diagnostic criteria for COPD. Describe other diseases that need to be considered in the workup of a patient with dyspnea, chronic cough, and sputum production.
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Differential Diagnosis Evaluation Risk Factors Diagnostic Criteria Other Conditions to Consider
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Evaluation Assessment of symptoms Severity of breathlessness, cough, sputum production, wheezing, chest tightness, weight loss or anorexia Change in alertness or mental status, fatigue, confusion, anxiety, dizziness, pallor or cyanosis COPD should be considered in any patient with a chronic cough, dyspnea or sputum production Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Evaluation Medical History Allergies Sinus problems Other respiratory disease Risk factors Exposures (occupational and environmental) Family history Co-morbidities that may affect activity Medications Prior hospitalizations or evaluation to date Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Evaluations Vital Signs Respiratory rate, pattern, effort Pulse oximetry Extremities Inspection for cyanosis Chest Inspection to assess AP diameter (barrel chest) Palpation and percussion of chest Lungs Auscultation for wheezing, crackles, and/or decreased breath sounds Stephens, 2008
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The differential diagnosis of COPD should be considered in patients who present with which of the following symptoms? Chronic cough Any sputum production Dyspnea Increased sputum production All of the above Question
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Differential Diagnoses Dewar, 2006 Non-pulmonary Congestive Heart Failure Hyperventilation syndrome/panic attacks Vocal cord dysfunction Obstructive sleep apnea – undiagnosed Aspergillosis Chronic Fatigue Syndrome Pulmonary Asthma Bronchogenic carcinoma Bronchiectasis Tuberculosis Cystic fibrosis Interstitial lung disease Bronchiolitis obliterans Alpha-1 antitrypsin deficiency Pleural effusion Pulmonary edema Recurrent aspiration Tracheobronchomalacia Recurrent pulmonary emboli Foreign body
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Question Which of the following is the most appropriate to use to confirm the diagnosis of COPD? Chest X-ray Arterial blood gas Spirometry High resolution CT scan of chest Clinical examination
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Evaluation Studies that may help in diagnosis: Chest X-ray (SOR: C) Spirometry (SOR: C) Arterial blood gas (SOR: C) Alpha-1 antitrypsin levels (SOR: C) High resolution CAT scan of chest (SOR: C) SOR: Strength of Recommendation Stephens, 2008
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Evaluation Spirometry Gold standard for diagnosis Standard to establish severity and stage Perform both pre- and post-bronchodilator Irreversible airflow limitation is the hallmark of COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Risk Factors Smoking Major risk factor (duh!) Risk increases with number of pack years smoked Secondhand smoke in large amounts presents risk Environmental pollution Smog and exhaust from vehicles Smoke from burning wood or other biomass fuels Particulates in occupational dust
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Risk Factors Occupational Irritants
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Risk Factors Nonmodifiable Risk Factors Gender (Risk about equal in men and women) Attributed to smoking habits of both genders Age Develops slowly Most people ≥ 40 years old when symptoms start Alpha-1 antitrypsin deficiency Mostly Northern European heritage Rare cause (2% of COPD population) Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Risk Factors Additional risk factors Severe lung infections as a child Previous tuberculosis Gastroesophageal reflux disease Possible cause as recurrent irritant May worsen COPD Lower socioeconomic status Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Diagnostic Criteria Global Initiative for Chronic Obstructive Lung Disease (GOLD) Criteria Program to provide guidelines for management of COPD; started 1998; international effort. Consider COPD in any patient with following: Dyspnea Chronic cough or sputum production and/or Exposure to risk factors Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Diagnostic Criteria GOLD Criteria (continued) Symptoms and risk factors are not diagnostic in themselves but should prompt spirometry in patients >40 yrs of age Diagnosis should be confirmed by pre- and post-bronchodilator spirometry Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Diagnostic Criteria Key Indicators Dyspnea Progressive, usually worse with exercise, persistent, described as increased effort to breathe Chronic cough May be intermittent, may be nonproductive Chronic sputum production Any pattern History of exposure to risk factors Tobacco smoke, occupational dust, chemicals, fumes or smoke from cooking or heating fuels Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Spirometry Classification for COPD Adapted from GOLD, 2009
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Differential Diagnoses Stephens, 2008 Pulmonary Asthma Bronchogenic carcinoma Bronchiectasis Tuberculosis Cystic fibrosis Interstitial lung disease Bronchiolitis obliterans Alpha-1 antitrypsin deficiency Pleural effusion Pulmonary edema Recurrent aspiration Tracheobronchomalacia Recurrent pulmonary emboli Foreign body Non-pulmonary Congestive heart failure Hyperventilation syndrome/panic attacks Vocal cord dysfunction Obstructive sleep apnea (undiagnosed) Aspergillosis Chronic fatigue syndrome
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Diagnostic Criteria Asthma Episodic symptoms of airflow obstruction or airway hyper-responsiveness Airflow obstruction partially reversible by spirometry Characterized by reversibility and variability in symptoms and airflow Alternative diagnosis excluded by history and exam Global Initiative for Asthma (GINA) Report, 2009
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Diagnostic Criteria Asthma – Key indicators Cough, worse particularly at night Recurrent wheezing, chest tightness or difficulty breathing Wheezing on physical examination Symptoms that occur or worsen in presence of known triggers Symptoms that occur/worsen at night Adapted from NHLBI/NIH NAEP Guidelines, 2007
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Diagnostic Criteria Asthma – Spirometry Establishes diagnosis of asthma Perform when key indicators present Demonstrates obstruction and assesses for reversibility Reversibility defined as >12% increase in FEV1 from baseline NHLBI/NIH NAEP Guidelines, 2007
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Diagnostic Criteria Asthma – Similarities with COPD Major epidemiologic causes of chronic obstructive airway disease Involve underlying airway inflammation Can cause similar chronic respiratory symptoms and fixed airflow limitation Can co-exist with the other making diagnosis more difficult Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009 Global Initiative for Asthma (GINA) Report, 2009
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Diagnostic Criteria Asthma – Differences from COPD Underlying immune mechanism of chronic inflammation different Age of onset Earlier in life with asthma Usually > age 40 in COPD Symptoms in asthma vary; COPD slowly progressive Smoking associated with COPD Asthma with reversible airflow limitation; irreversible airflow limitation in COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
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Diagnostic Criteria Asthma – Using spirometry to differentiate from COPD Post-bronchodilator FEV1 <80% predicted together with FEV1/FVC <0.70 confirms airflow limitation that is not fully reversible Asthma may show similar changes in chronic and more severe cases; PFT’s may be needed to distinguish it from COPD NHLBI/NIH Asthma Guidelines , 2007
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Clinical Features in Differentiating COPD from Asthma Adapted with permission from Stephens, 2008
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Clinical Features in Differentiating COPD from Asthma (continued) Adapted with permission from Stephens, 2008
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Diagnostic Criteria Adapted with permission from DeWar, 2006 Continued on next slide
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Key Points COPD is associated with several chronic respiratory symptoms that suggests its diagnosis Symptoms overlap with other conditions -- asthma in particular History, risk factors and progression of disease assist with diagnosis Spirometry, with and without bronchodilator, usually necessary to make diagnosis
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American Thoracic Society/European Respiratory Society Statement: Standards for the Diagnosis and Management of Individuals with Alpha-1 Antitrypsin Deficiency. Am J Respir Crit Care Med 2003;168;818–900. Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932. Cosio MG, Saetta M, Agust A. Immunologic Aspects of Chronic Obstructive Pulmonary Disease. N Engl J Med 2009;360:2445-54. Dewar M, Curry RW. Chronic Obstructive Pulmonary Disease: Diagnostic Considerations. Am Fam Physician 2006;73(4):669-676. Global Initiative for Asthma (GINA) Report, 2009: Diagnosis and Classification, pg 16-24. Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Report, 2009. http://www.goldcopd.org. Muller NL, Coxson H. Chronic obstructive pulmonary disease. 4: imaging the lungs in patients with chronic obstructive pulmonary disease. Thorax. 2002;57:982–5. References
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References (continued) Murgu, SD and Colt, HG. Symptoms often mimic those of asthma and COPD -- Recognizing tracheobronchomalacia.(chronic obstructive pulmonary disease); J Respir Dis. 2006;27(8):327-335 Niewoehner DE. Outpatient Management of Severe COPD. N Engl J Med 2010;362:1407-16 NHLBI/NIH National Asthma Education and Prevention Program: Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007. Qaseem A, Snow V, Shekelle P, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007;147:633-8. Price DB, et al. Symptom-based questionnaire for identifying COPD in smokers. Respiration 2006; 73(3):285-95. Stephens MB, Yew KS. Diagnosis of Chronic Obstructive Pulmonary Disease. Am Fam Physician 2008;78(1):87-92. Sutherland ER, Cherniack, RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004;350:2689-97. Tinkelman DG, et al. Symptom-based questionnaire for differentiating COPD and asthma. Respiration 2006; 73(3):296-305.