Measure twice, diagnose once (updated)

I have a patient who has fairly extensive COPD, by PFTs, imaging, and symptoms, however, she has never smoked.  She has some secondhand smoke exposure, but none at all in the last 15 years.  She was not doing well on her current management.

When things aren’t adding up, reconsider the diagnosis. Everytime someone hands you a diagnosis, reconsider the diagnosis. When you are randomly thinking about a patient on your drive home, reconsider the diagnosis.

What else could my patient have, if COPD is not the answer?  Here’s a quick differential diagnosis of COPD. There are other things to consider, but these can mimic COPD often enough that they should come to your mind in particular situations. As usual, a good history and physcial can help you sort these out.

COPD
Smoking history
Older than 35
Productive cough
Persistent/progressive breathlessness
PFTs with irreversible airflow obstruction
Asthma
Younger than 35
Nighttime waking with breathlessness
Variation in symptoms day to day
Improvement
Triggers: smells, seasonal, pets, secondhand smoke
Associated atopic conditions
Reversible airflow obstruction
Heart failure
Exam: fine crackles, edema
CXR, TTE
PFTs with restrictive pattern
Bronchiectasis
lots of sputum, frequent respiratory infections
Exam with course crackles, clubbing
CT with bronchial dilation, bronchial wall thickening
Obliterative bronchiolititis
Younger age
Non smokers
Associated RA
CT: hypodense areas
Diffuse panbronchiolititis 
Men, East Asians
Non smokers (2/3)
Associated with chronic sinusitis
HRCT small centrilobular nodular opacity, hyperinflation
TB
High prevalence in the community
CXR with upper lung zone scar or granuloma
+PPD or Quantiferon Gold
Malignancy- bronchial tumor of compression
Hemoptysis, pain, B symptoms
If central, may have stridor
CXR may be normal
HRCT vs Bronchoscopy to dx
Alpha1 antitrypsin Deficiency
Younger age
Non smokers
Associated liver, skin manifestations
Check out this new post on Asthma vs COPD for more…