Chronic Obstructive Pulmonary Disease (COPD) Differential Diagnoses

Updated: Jun 03, 2022
  • Author: Zab Mosenifar, MD, FACP, FCCP; Chief Editor: John J Oppenheimer, MD  more...
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Diagnostic Considerations

Congestive heart failure

Congestive heart failure (CHF) may produce wheezing and often may be difficult to differentiate from emphysema. A history of orthopnea and paroxysmal nocturnal dyspnea, fine basal crackles on chest auscultation, and typical findings on chest radiographs can lead to the diagnosis of CHF.

One crude bedside test for distinguishing chronic obstructive pulmonary disease (COPD) from CHF is peak expiratory flow. If patients blow 150-200 mL or less, they are probably having a COPD exacerbation; higher flows indicate a probable CHF exacerbation. Bronchial hyperresponsiveness is increased in CHF. [40]

According to a prospective study in Slovenia by Prosen et al, heart failure–related acute dyspnea could be distinguished from pulmonary-related acute dyspnea in an emergency setting by the presence of a comet-tail sign on bedside lung ultrasonography. The absence of a comet-tail sign correctly ruled out heart failure–related dyspnea even in patients with a history of heart failure. [41]


Patients with bronchiectasis have chronic production of copious purulent sputum, coarse crackles and possibly clubbing upon physical examination, and abnormal findings on chest radiographs and computed tomography (CT) scans.

Bronchiolitis obliterans

Bronchiolitis obliterans is observed in younger persons who do not smoke and in persons with collagen-vascular diseases. A CT scan characteristically shows areas of mosaic attenuation without evidence of generalized emphysema.

Chronic asthma

The delayed onset of severe asthma may be difficult to distinguish from COPD in older patients, but the important distinction is a significant bronchodilator response and normal diffusion (ie, diffusing capacity of lung for carbon monoxide [DLCO]) on pulmonary function tests.

Differential Diagnoses