eMedicine Specialties > Emergency Medicine > Pulmonary

Chronic Obstructive Pulmonary Disease and Emphysema: Differential Diagnoses & Workup

Author: Paul Kleinschmidt, MD, Consulting Staff, Department of Emergency Medicine, Womack Army Medical Center
Contributor Information and Disclosures

Updated: Mar 13, 2008

Differential Diagnoses

Acute Respiratory Distress Syndrome
Pneumonia, Empyema and Abscess
Congestive Heart Failure and Pulmonary Edema
Pneumonia, Immunocompromised
Myocardial Infarction
Pneumonia, Mycoplasma
Panic Disorders
Pneumonia, Viral
Pleural Effusion
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Pneumonia, Aspiration
Pulmonary Embolism
Pneumonia, Bacterial

Workup

Laboratory Studies

  • Arterial blood gas  
    • Arterial blood gas (ABG) analysis provides the best clues as to acuteness and severity.
    • In general, renal compensation occurs even in chronic CO2 retainers (ie, bronchitics); thus, pH usually is near normal.
    • Generally, consider any pH below 7.3 a sign of acute respiratory compromise.
  • Serum chemistry  
    • These patients tend to retain sodium.
    • Diuretics, beta-adrenergic agonists, and theophylline act to lower potassium levels; thus, serum potassium should be monitored carefully.
    • Beta-adrenergic agonists also increase renal excretion of serum calcium and magnesium, which may be important in the presence of hypokalemia.
  • CBC - Polycythemia
  • BNP
    • Human BNP binds to particulate guanylate cyclase receptors of vascular smooth muscle and endothelial cells. Binding to the receptors causes an increase in cyclic guanosine monophosphate (GMP), which serves as a secondary messenger to dilate veins and arteries. 
    • By measuring the BNP level, it was thought that the ability to differentiate between CHF and COPD exacerbations in blue bloaters would have become much easier. However, clinical observation and research demonstrated that, in the cases of mild CHF exacerbations, the ability to differentiate between CHF and COPD is still not straightforward. A mild elevation of a BNP level still must be taken in context with the overall clinical picture.

Imaging Studies

  • Chest radiography 
    • Chronic bronchitis is associated with increased bronchovascular markings and cardiomegaly.
    • Emphysema is associated with a small heart, hyperinflation, flat hemidiaphragms, and possible bullous changes.

Other Tests

  • Pulse oximetry  
    • Pulse oximetry does not offer as much information as ABG analysis.
    • When combined with clinical observation, this test can be a powerful tool for instant feedback on the patient's status.
  • Electrocardiography
    •  The presence of underlying cardiac disease is highly likely.
    • Establish that hypoxia is not resulting in ischemia.
    • Establish that the underlying cause of respiratory difficulty is not cardiac in nature.
  • Pulmonary function tests  
    • Decreased forced expiratory volume in 1 second (FEV1) with concomitant reduction in FEV1/forced vital capacity (FVC) ratio
    • Poor/absent reversibility with bronchodilators
    • FVC normal or reduced
    • Normal or increased total lung capacity (TLC)
    • Increased residual volume (RV)
    • Normal or reduced diffusing capacity

More on Chronic Obstructive Pulmonary Disease and Emphysema

Overview: Chronic Obstructive Pulmonary Disease and Emphysema
Differential Diagnoses & Workup: Chronic Obstructive Pulmonary Disease and Emphysema
Treatment & Medication: Chronic Obstructive Pulmonary Disease and Emphysema
Follow-up: Chronic Obstructive Pulmonary Disease and Emphysema
References
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Further Reading

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Keywords

COPD, chronic bronchitis, cough, dyspnea, pulmonary infections, cardiac failure, respiratory failure, edema, weight gain, obesity, mucopurulent relapses, cachexia, blue bloater, pink puffer, asthma, wheeze, wheezing, emphysema, tobacco abuse, cystic fibrosis, alpha-1 antitrypsin deficiency, bronchiectasis, bullous lung disease, excessive mucus production, hyperplasia of mucus-producing glands, hypoxemia, polycythemia, hypercapnia, respiratory acidosis, cor pulmonale, hypoxemia, right heart failure, progressive exercise intolerance, recurrent pulmonary infections, progressive cardiac failure, progressive respiratory failure, progressive dyspnea, coarse rhonchi, wheezing, cyanosis, barrel chest, air pollution

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Contributor Information and Disclosures

Author

Paul Kleinschmidt, MD, Consulting Staff, Department of Emergency Medicine, Womack Army Medical Center
Paul Kleinschmidt, MD is a member of the following medical societies: American Academy of Emergency Medicine and Special Operations Medical Association
Disclosure: Nothing to disclose.

Medical Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Program Director, Department of Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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