CLINICS 2012;67(11):1335-1343 DOI:10.

6061/clinics/2012(11)19

REVIEW
Airway disease: similarities and differences between
asthma, COPD and bronchiectasis
Rodrigo Athanazio
Hospital das Clı́nicas da Faculdade de Medicina da Universidade de São Paulo, Heart Institute (InCor), Pulmonary Division, São Paulo/SP, Brazil.

Airway diseases are highly prevalent worldwide; however, the prevalence of these diseases is underestimated.
Although these diseases present several common characteristics, they have different clinical outcomes. The
differentiation between asthma, chronic obstructive pulmonary disease and bronchiectasis in the early stage of
disease is extremely important for the adoption of appropriate therapeutic measures. However, because of the high
prevalence of these diseases and the common pathophysiological pathways, some patients with different diseases
may present with similar symptoms. The objective of this review is to highlight the similarities and differences
between these diseases in terms of the risk factors, pathophysiology, symptoms, diagnosis and treatment.

KEYWORDS: Asthma; Chronic Obstructive Pulmonary Disease; Bronchiectasis.

Athanazio R. Airway disease: similarities and differences between asthma, COPD and bronchiectasis. Clinics. 2012;67(11):1335-1343.
Received for publication on September 27, 2012; Accepted for publication on September 27, 2012
E-mail: [email protected]
Tel.: 55 11 2661-5695

INTRODUCTION in smokers, 7% in former smokers and 3% in individuals

who never smoked (3). Surveys on the prevalence of asthma
The prevalence of airway diseases has increased in recent suggest a prevalence of approximately 9% in the British
decades despite therapeutic advances. Furthermore, the population. In Brazil, an epidemiological study of the
prevalence of these diseases is underestimated according to population in São Paulo revealed a COPD prevalence of
epidemiological surveys, which further increases the com- 15.8% (4), whereas the prevalence of asthma was estimated
plexity of managing these diseases. In Brazil, acute asthma to be approximately 10% of the general population (1).
exacerbations and chronic obstructive pulmonary disease Several studies have suggested a similar prevalence of
(COPD) are major causes of hospitalization (1,2). Despite the asthma among children and adult populations; however,
presentation of similar symptoms, such as dyspnea, cough- extensive variability has been found depending on multiple
ing, wheezing and expectoration, airway diseases have factors that include geographic differences and socioeco-
different underlying pathophysiological processes and must nomic status (5).
be distinguished to enable the administration of appropriate Because of a lack of well-conducted epidemiological
treatment. With an appropriate clinical history and objective studies, an accurate prevalence of bronchiectasis is more
diagnostic testing, the distinction between these diseases difficult to estimate than that of asthma and COPD. There
can be performed efficiently in most cases. However, many has been a decrease in the incidence of this disease, which
patients who are evaluated for respiratory symptoms are has been attributed to the increased use of antibiotics for
misdiagnosed due to an atypical case presentation, an infection control and immunization strategies in children.
insufficient etiological investigation or an overlapping of the Tsang and Tipo (6) reported a hospital admission rate of
diseases. 16.4 per 100,000 people and a mortality rate of 1 out of
This review aims to present the similarities and differ- 100,000 people in Hong Kong.
ences between airway diseases and suggest a practical The overlap in the terminology that is used to define
approach for the differentiation of the most common asthma, chronic bronchitis, emphysema, COPD and bronch-
respiratory illnesses, i.e., asthma, COPD and bronchiectasis. iectasis is the greatest cause of confusion in distinguishing
these diseases and in accurately determining the prevalence
Epidemiology of airway diseases. The prevalence of obstructive diseases in
Because of the variability in the definition of COPD in adults can vary by more than 200% in the general
epidemiological studies, an accurate prevalence of this disease population and depends on the definition that is used (a
is difficult to determine. The prevalence is approximately 14% self-reported diagnosis versus a diagnosis based on spiro-
metry findings) (7). Furthermore, the actual prevalence of
obstructive diseases is underestimated. When a spirometric
This is an Open Access article distributed under the terms of the Creative Commons evaluation was performed in the general population,
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) approximately 58% of the patients with an obstructive
which permits unrestricted non-commercial use, distribution, and reproduction in any
disorder did not report a prior lung disease diagnosis (8).
medium, provided the original work is properly cited.
Individual patients may have different combinations of
No potential conflict of interest was reported. airway diseases. Studies in an American population

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Athanazio R

demonstrated that more than 15% of the patients with an several risk factors have been found, including smoking,
obstructive disease received more than one diagnosis, and occupational exposure, advanced age, an unfavorable socio-
this rate reached 50% in a population older than 50 years of economic condition and housing in an urban center (18).
age (8). In Australia (9), this proportion was approximately Asthma can be induced by either animal or plant proteins
25% in individuals who were between 45 and 69 years of and by organic and inorganic chemical agents (19,20). In
age. In Italy (10), approximately 20% of the asthmatic addition, the development of asthma is correlated with the
population had symptoms that included a productive Western lifestyle, which is characterized by a high hygiene
cough, which is compatible with a diagnosis of chronic rate. Increased hygiene reduces exposure to allergens and
bronchitis. Patients who exhibit the coexistence of two or decreases natural desensitization (21). The exposure to
more obstructive diseases tend to be older and have external agents can result in the development of COPD,
spirometric data that indicate lower values of forced which is mainly associated with occupational activities,
expiratory volume in the first second (FEV1) (8). such as coal and gold mining (22), cadmium mining (23)
Furthermore, the coexistence of asthma and COPD was and exposure to smoke from burning wood (24,25).
associated with a higher mortality rate (11). Regarding bronchiectasis, exposure to fungi is a cause of
The high prevalence and morbidity of these diseases exacerbated allergic responses, such as in allergic bronch-
translates into a substantial cost to the healthcare system. opulmonary aspergillosis (15).
Drug costs are the main expenses that are associated with Smoking is the main etiological factor for the develop-
the treatment of asthma, whereas COPD and bronchiectasis ment of COPD. While it is known that quitting smoking is
have a greater economic impact due to high hospitalization the only factor that can slow the progression of this disease,
rates (12). The main findings from these epidemiological there is no evidence that there exists a reversion for
studies are as follows: (1) the prevalence of chronic the pulmonary impairment that has already began.
obstructive pulmonary disease, which is closely correlated Approximately 90% of COPD cases are related to smoking,
with the definition that is used, is an important social and whereas other less common risk factors include occupa-
economic problem; (2) the overlap between asthma, COPD tional exposure and biomass burning (26,27,28). The
and bronchiectasis is associated with an increase in clinical historical finding of a lower prevalence of COPD in the
severity and mortality; and (3) approximately half of female population is associated with a lower proportion of
patients with obstructive findings on spirometry are not smokers in this group. However, an increase in the number
properly diagnosed; therefore, screening programs that of women who smoke in recent decades has increased the
include a pulmonary function evaluation (with an assess- prevalence of COPD in the female population and the
ment of both spirometry and peak flow) should be adopted mortality that is associated with this pathology (29-31).
to decrease the proportion of patients without adequate In Brazil, data indicate a decline in the smoking
monitoring (13,14). prevalence (32); however, several factors are extremely
relevant. There are an insufficient number of effective public
Risk factors policies that discourage smoking among young people who
Patients with asthma and COPD can usually be distin- are usually influenced by alcohol consumption, media
guished according to the classic risk factors that are advertising and paternal smoking (33). In addition, a large
associated with each disease. However, certain risk factors portion of pneumologists in Brazil need to be trained
may be common in both diseases. Regarding the illnesses because these physicians cannot effectively treat smoking
that are associated with bronchiectasis, the identification of (34). These steps are crucial in reducing the prevalence of
the risk factors is crucial and is complex because of the wide COPD.
variety of conditions that predispose a patient to a Regarding genetic factors, several conditions are classi-
permanent dilation of the airways (15) (Table 1). cally associated with the development of COPD. A
In atopic individuals, the main risk factor for developing deficiency of alpha-1 antitrypsin decreases the defense of
asthma is exposure to allergens. Consequently, many the lungs against inhaled noxious agents, thus increasing
patients with asthma have high serum levels of IgE and the development of emphysema. Patients with this defi-
eosinophils (16,17). For individuals with non-atopic asthma, ciency account for approximately 1-2% of COPD cases

Table 1 - Risk factors for asthma, COPD and bronchiectasis.

Asthma COPD Bronchiectasis

Environmental factors Allergen exposure Smoking Respiratory infections

Occupational sensitizers Occupational exposure Bronchial obstructions
Respiratory infections Pollution Transplantation
Alcoholism
Low socio-economic condition
Host factors Atopy Alpha-1 antitrypsin deficiency Alpha-1 antitrypsin deficiency
Gender Low birth weight Cystic fibrosis
Low birth weight Family history Immunodeficiency
Genetic predisposition Autoimmune disease
Mucociliary dysfunction
Yellow nail syndrome
Congenital diseases (Mounier-Kuhn syndrome,
Williams-Campbell syndrome)

COPD: Chronic obstructive pulmonary disease.

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(35,36). Other genetic influences on the development of membrane thickening. These alterations are positively
COPD include a polymorphism in the promoter region of correlated with the frequency of asthma attacks and
inflammatory mediators, such as tumor necrosis factor- bronchial hyperresponsiveness (55,56).
alpha (TNF-alpha) (37), and polymorphic variants in the COPD patients exhibit a reduced airway caliber, which is
hydrolase-encoding genes (38). associated with cell damage that is induced by external toxic
Several genetic diseases are associated with the develop- agents, especially cigarette smoke, via reactive oxygen
ment of bronchiectasis. Cystic fibrosis is characterized by a species (57,58). The presence of goblet cells (mucous
mutation in the cystic fibrosis transmembrane conductance metaplasia) in the small airways and mucous hypersecre-
regulator (CFTR) gene and is the leading cause of genetic tions results from the process of airway narrowing (59,60).
disease-related death among Caucasians, which is typically Despite the prevalence of inflammation in COPD, which
due to respiratory failure. In addition, immotile cilia occurs due to the presence of neutrophils and macrophages,
syndrome (primary ciliary dyskinesia) and genetic anoma- several studies have demonstrated the presence of eosino-
lies that are associated with a humoral or cellular philic inflammation both in stable patients and in patients
immunodeficiency are common causes of bronchiectasis with acute exacerbations of the disease (61). This finding
(39). confirms the potential anti-inflammatory effect of inhaled
Several studies have analyzed the development of asthma corticosteroids in the treatment of COPD. Another interest-
and specific genetic alterations but have not found an ing finding for this disease is the correlation between
association. Because of the multifactorial presentation of this inflammation intensity and COPD severity. In the final
disease, the existence of a single genetic site associated with stages of the disease, an intense inflammatory process
the development of this disease is questionable. However, occurs, which suggests that, even in these scenarios,
evidence suggests that chromosomal regions may modulate treatment with anti-inflammatory drugs, such as inhaled
the degree of disease severity, such as the relationship corticosteroids, may be effective (62).
between chromosome 2q and the levels of IgE and bronchial Bronchiectasis develops with recurrent damage to the
hyperresponsiveness (40). airways, which generally occurs in individuals with
The influence of gender on the development of asthma mucociliary clearance that is altered by genetic suscept-
varies with age. Childhood asthma is more common among ibility, thus leading to inflammation and destruction of the
boys, whereas women are more commonly diagnosed with muscular and elastic components of the bronchial walls (63).
asthma in adulthood (41,42). COPD is more common among Respiratory infections are the leading causes of bronchiec-
men than women, which is related to the gender difference tasis; however, other pro-inflammatory attacks can trigger
in smoking intensities (43). However, women develop more or accelerate the process, such as a toxin inhalation,
severe airflow obstruction than men after an adjustment for environmental exposure, smoking, aspiration of gastric
the tobacco intake intensity (44,45). contents or changes in immune responses (6).
Additionally, other factors influence obstructive respira- Abnormally dilated airways are susceptible to bacterial
tory diseases. The presence of gastroesophageal reflux is colonization, which leads to a constant presence of
correlated with increased inflammation in the airways of inflammation that is mainly mediated by neutrophils (64).
patients with bronchiectasis and is associated with There is progressive impairment of ciliary function with a
increased asthma severity. However, because of a lack of worsening of airway mucociliary clearance, which further
well-conducted longitudinal studies, the relationship facilitates the presence of bacterial colonization and the
between gastroesophageal reflux disease and bronchial accumulation of thick mucus (65,66). In addition, the
hyperresponsiveness may not be causal and may not be perpetuation of inflammation leads to further damage to
associated with severity (46). In addition, a low birth weight the mucosal integrity of the airways, thus promoting
may predispose individuals to the development of asthma continuous bacterial invasion and permanence in the
(47) or COPD (48). The proposed mechanism for this mucosa. This infectious and inflammatory cyclic process
association is based on the normal respiratory functional causes progressive damage to the bronchial wall with
decline with age that occurs from a lower peak in these associated clinical deterioration. Increased arterial bronchial
individuals. Additionally, a history of viral or bacterial proliferation and arteriovenous malformations can occur as
infections in childhood is correlated with the development a result of the inflammatory process and bronchial wall
of asthma, and these infections are well-established causes alterations. This vicious cycle can produce significant
of bronchiectasis in adulthood (49,50). Passive smoking and bacterial proliferation and inflammation with increased
a deficiency of certain dietary elements, such as polyunsa- suppuration and clinical worsening.
turated fatty acids, are associated with the development of However, understanding the inflammatory patterns of
chronic airway inflammation in adulthood (51). each disease is important for distinguishing between airway
diseases. In a study of 27 COPD patients and 19 asthma
Physiopathology patients with similar degrees of pulmonary obstruction,
Asthma, COPD and bronchiectasis are diseases that cause several parameters were evaluated. Several functional
chronic inflammation of the airways but have distinct (residual volume and diffusion capacity) and tomographical
characteristics. In asthma, eosinophils, mast cells and CD4 (emphysema score) parameters could differentiate between
T lymphocytes represent the predominant cell types in the the individuals with COPD and those with asthma.
inflammatory process. In contrast, COPD and bronchiectasis However, the inflammatory and pathological features of
demonstrate a greater number of neutrophils, macrophages basal membrane thickening, eosinophilia and the CD4/CD8
and CD8 T lymphocytes (52-54). relationship in the bronchoalveolar lavages were the best
Asthmatic patients have airway obstructions that are predictors of a history of asthma (67).
predominantly characterized by bronchoconstriction Immunological differentiation may have an impor-
through the activation of the smooth muscle and basal tant prognostic role in patients. Sputum eosinophilia is

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Athanazio R

associated with difficult-to-control asthma (68), and the change in dyspnea, cough and/or basal expectoration of the
normalization of this condition after treatment was corre- patient who goes beyond the normal daily variation, and
lated with a decrease in the number of exacerbations and that can cause a change in regular medication of the
hospitalizations. Neutrophilic inflammation in asthma is patient’’ (78).
less sensitive to corticosteroid treatment and is associated
with rapid functional loss (69). Lung function
Despite the distinct pathophysiological mechanisms of In asthma, the typical finding of airflow obstruction that
airway diseases, these diseases share several common is characterized by a decrease of VEF1/FVC (forced vital
features. Specific therapies, especially anti-inflammatory capacity) with a disorder reversal after the administration of
medications and bronchodilators, may be the most bene- a bronchodilator is the mainstay in the diagnostic confirma-
ficial treatments for these diseases because these drugs tion of the disease (79). However, many patients may
control symptoms and improve the quality of life of the present with a reversal after the use of a bronchodilator
patients. without exhibiting normalization in pulmonary function
tests, thus indicating signs of bronchial remodeling. In
Diagnosis addition, clinically stable patients may present with normal
Characterizing the physiological and phenotypic differ- spirometry but a positive bronchial provocation test (1).
ences between patients with obstructive diseases is impor- Other functional variables can be used for the diagnosis of
tant for obtaining a greater understanding of the evolution obstructive lung disease, such as the forced expiratory flow
of these diseases and the therapeutic implications. Most at 50% of the FVC FEF50%/0.5FVC (80) ratio. However, the
patients can be distinguished by a detailed clinical history use of the FEV1/FVC ratio remains the most widely
and simple functional and imaging tests; however, many accepted parameter for diagnostic confirmation.
patients have atypical clinical profiles due to the hetero- In COPD, a post-bronchodilator FEV1,80% that is
geneity of the airway diseases, which can lead to a associated with a FEV1/FVC ratio ,70% confirms the
misdiagnosis. This factor is particularly important for the obstructive disorder, which is characterized by a lack of
elderly population in which the coexistence of asthma, complete reversibility of airflow. However, a significant
COPD and bronchiectasis is common. response to the bronchodilator does not exclude a COPD
diagnosis (78).
Symptoms More accurate functional tests can differentiate between
Asthmatic patients who exhibit bronchoconstriction are these two diseases through measures that assess lung
characterized by wheezing, breathlessness, chest tightness hyperinflation and the diffusion capacity of the lungs for
and coughing. The characteristic of the reversible inflam- carbon monoxide (DLCO). Hyperinflation, which is con-
matory process in asthma and a good response to firmed by plethysmography, is more commonly found in
therapeutic measures characterize the evolution of the COPD that is characterized by a greater residual volume
disease, which is marked by intermittent exacerbations than is found in asthma. Another characteristic of COPD is a
(70-72). However, the lack of these symptoms can define a decrease in the DLCO (70).
subgroup of patients who are considered hypoperceivers Early in the course of the disease, patients with
and who evolve with a worse prognosis for disease control bronchiectasis usually present with lung function tests that
(73). are characteristic of an obstructive disorder, thus confirming
The main clinical manifestation of patients with bronch- the inflammatory nature of this disease and the initial
iectasis is a chronic cough with sputum production, involvement of the small airways. However, with the
although patients may only have a dry cough. Patients progression of the disease, a mixed functional disorder or
often have dyspnea on exertion (75%), wheezing (75%) and a restrictive disorder can be found due to the progressive
pleuritic chest pain (50%). Additionally, patients may have destruction of the pulmonary parenchyma, which is
systemic symptoms, such as fatigue or weight loss, and characterized by recurrent infectious exacerbations and
rhinosinusitis. A physical examination may identify crackles massive destruction of the small airways (81).
(70%), snoring (44%) and wheezing (34%). Clubbing
appears in approximately 3% of the cases. The clinical Imaging tests
evolution consists of a progressive functional loss and is Chest radiography is not sufficiently sensitive for the
marked by recurrent infectious exacerbations with the need diagnosis of airway diseases, and this test is recommended
for frequent antibiotics (15). for the differential diagnosis of a patient with respiratory
Patients with COPD have a cough that is frequently symptoms. In more severe cases of patients with bronch-
associated with chronic sputum production (74). Cha- iectasis, the dilation of large airways can be visualized as a
racteristically, these individuals present with dyspnea and thickening of the peribronchovascular interstitium using
effort limitations due to the fixed airflow obstruction (75- this method. A universal radiographic finding in obstructive
77). More advanced stages of the disease result in a worse diseases is lung hyperinflation, which is characterized as
quality of life for these patients. Respiratory exacerbations follows: (1) an increase in the lung volume, (2) an increase in
are associated with an increased underlying inflammatory the intercostal spaces, (3) a rectification of the diaphragmatic
process that requires appropriate therapy with antibiotics domes, (4) an accentuation of the retrosternal space and (5)
and systemic corticosteroids. These exacerbations are the presence of air below the inferior border of the heart
characterized by a worsening of the basal symptoms of (82).
the patient, such as cough, expectoration and dyspnea. A thoracic CT scan is a more sensitive test than chest
According to the Global Initiative for Chronic Obstructive radiography and is useful in the management of airway
Lung Disease (GOLD), an exacerbation is defined as ‘‘an diseases. This test is considered the gold standard in the
event in the natural course of the disease characterized by a diagnosis of bronchiectasis. Common findings in obstructive

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Athanazio R

diseases include bronchial wall thickening, centrilobular are not consistent with the initial clinical hypothesis
nodules and mosaic attenuation by air trapping (82). (Table 2).
The following tomographic criteria are used for the
diagnosis of CT bronchiectasis: (1) a bronchial internal Treatment
diameter that is larger than 1.5 times the diameter of the Asthma treatment guidelines aim for the appropriate
adjacent pulmonary artery (signet ring sign), (2) an absence control of symptoms through a strategy of phased measures
of a gradual decrease in the bronchial diameter from the that focus on the severity of the disease and the daily
central regions to the periphery and (3) bronchial visualiza- complaints of the patient. Once this goal has been achieved,
tion in the periphery 1-2 cm from the parietal pleura (6). the treatment should be maintained at the lowest possible
According to CT scan findings, we can classify bronchiec- dosage to reduce side effects and the associated costs (1,5).
tasis as cylindrical (bronchial dilation), varicose (with focal In addition, the guidelines for the treatment of COPD use a
constrictions along the airways) or cystic (saccular dilations phased strategy according to the severity of the disease.
at the end of a bronchus). In addition, we can classify the However, the guidelines emphasize the prevention of
bronchiectasis as localized (i.e., confined to one lobe) or disease progression. Moreover, once the treatment goal
generalized (83). has been achieved, a reduction in the medication dosage is
In asthma patients, bronchial wall thickening and air uncommon (2,78,89). Regarding bronchiectasis, there is a
trapping are commonly found; however, patients with mild lack of literature on the guidelines for the treatment of this
asthma may have completely normal thoracic tomography pathology. British guidelines were recently published (90);
findings. However, current analyses with quantitative however, there are few data on the therapeutic recommen-
techniques and high-resolution scans can distinguish dations for bronchiectasis due to a lack of well-conducted
between normal and mildly controlled asthmatic individuals randomized clinical trials. Many measures are still being
based on the degree of air trapping and bronchial thickening. extrapolated from studies of cystic fibrosis, but physicians
Moreover, severe asthma is associated with a greater degree must be aware of the differences between the various
of bronchial thickening in these individuals. Another inter- diseases that may be similar to bronchiectasis (91).
esting finding of these studies is that a greater degree of air Much of the therapeutic arsenal is common between
trapping was associated with an increased risk of exacerba- obstructive diseases, especially bronchodilators (beta2-ago-
tion. Because CT scan is noninvasive, this technique may be nists and anticholinergics) and inhaled corticosteroids.
used to monitor patients with severe asthma, especially for However, the treatment goal for each disease may vary.
the evaluation of bronchial remodeling (84,85). COPD therapy is directed primarily to the relief of
In patients with COPD, the most important tomographic symptoms and the prevention of disease progression. In
finding is the presence of centrilobular emphysema in the bronchiectasis, the primary goal of treatment is to prevent
superior lung fields (smoking-related) or diffuse panlobular disease progression and improve the quality of life and
emphysema (alpha-1 antitrypsin deficiency). The intensity symptoms. In asthma, the primary goal of treatment is to
of emphysema, which is characterized by the amount of control the underlying inflammatory process with the
area with low attenuation, and bronchial thickening consequent control of symptoms.
correlate with the degree of airflow obstruction that is
measured in functional tests (86-88). Beta2-agonists
Therefore, thoracic tomography is an important tool that Bronchodilators with a direct action on beta-adrenergic
can be used in the differential diagnosis of airway diseases receptors can be classified as short- or long-term depending
(Figure 1). However, many of these CT findings are on the half-life.
common among several obstructive diseases, and more Short-acting beta2-agonists (SABAs) are the first-line
advanced stages of asthma and COPD may lead to the treatment for COPD; however, the use of SABAs as a rescue
development of bronchiectasis. medication in asthma is appropriate. In patients with
The diagnosis of an airway disease in patients should bronchiectasis, SABAs are generally used for symptom
begin with a detailed anamnesis, and complementary exams relief despite the lack of evidence for the use of these drugs.
should be performed as appropriate. No single test can In contrast, long-acting beta2-agonists (LABAs) are used
completely differentiate between these diseases. The coex- in combination with anti-inflammatory medications in
istence of more than one disease in the same patient should asthma. LABAs may be used alone in patients with
always be considered when a patient presents with an COPD. The isolated use of a beta2-agonist in asthma is
unfavorable clinical evolution or when their laboratory tests contraindicated and is associated with a poor prognosis (92).

Figure 1 - Tomographic cross-sections. A) Asthmatic patient with diffuse bronchial wall thickening. B) COPD patient with extensive
areas of centrilobular emphysema predominantly in the superior lung fields. C) Patient with cystic and varicose bronchiectasis
characterized by dilation and thickening of airways.

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Table 2 - Important clinical characteristics in the differentiation of patients with asthma, COPD and bronchiectasis.
Clinical characteristic Asthma COPD Bronchiectasis Potential overlap

Risk factors Family history Allergies Smoking Repeated infections Asthmatics Smokers have an
Immunodeficiency increased risk of developing COPD
Age Children and young people Advanced age Variable Asthma and bronchiectasis are
misdiagnosed in the elderly and
are commonly mistaken for COPD
Symptoms Wheezing Outbreaks of Chronic dyspnea Productive cough Patients with bronchiectasis are
dyspnea Productive cough diagnosed late because they are
first treated for COPD due to
productive cough symptoms
Spirometry Reversibility Absence of reversibility Absence of reversibility Asthmatic patients may lose
May present restrictive pattern reversibility over time
Computerized tomography Bronchial thickening Central lobular Bronchial dilations Bronchial thickening can occur in
emphysema patients with COPD and
bronchiectasis, and bronchiectasis
may appear in asthmatics and
individuals with COPD

COPD: Chronic obstructive pulmonary disease.

These drugs act by relaxing the bronchial smooth muscle, asthma, inhaled corticosteroids are the mainstay of disease
increasing the mucociliary clearance, decreasing the vascu- treatment and are considered the first-line treatment in
lar permeability and possibly reducing inflammatory patients with persistent asthma. ICs can reduce the number
mediators (5). of exacerbations, improve lung function and quality of life,
In COPD, the use of LABAs is associated with functional control respiratory symptoms and decrease the bronchial
improvement (increased FEV1), symptom control and hyperresponsiveness (102-104). Current guidelines empha-
improved quality of life (93,94). In asthmatic patients, the size the use of an IC in the initial therapy of patients with
combination therapy of a LABA with inhaled corticosteroids asthma symptoms. The combination of an IC with a LABA
(ICs) is more efficient in controlling symptoms than an isolated is recommended as the next step in therapy despite the
increase in the IC dosage (95). For patients with bronchiectasis, potential need to increase the IC dosage (1,5). However, the
the combination of a LABA with a conventional IC improved use of measures that increase patient adherence to treatment
the symptom scores and quality of life (96). and the adequate use of inhalers are fundamental to
achieving good clinical control of symptoms (105-108).
Anticholinergics The use of an IC to treat COPD was effective in reducing
The release of acetylcholine by vagal stimulation triggers airway inflammation, although the IC did not affect the rate
a bronchoconstrictor response and an increased production of functional decline. There are conflicting data on the
of pulmonary secretions. The use of short-acting antic- ability of an IC to improve lung function, whereas there are
holinergic drugs (ipratropium) in patients with COPD concrete data that associate the use of an IC with a
yielded a dose-dependent functional improvement with significant reduction in the exacerbation rate of COPD and
better responses than those that were achieved using a improvements in the quality of life of COPD patients (109).
SABA. For asthma, ipratropium is usually only used for the The discontinuation of treatment results in a poor quality of
management of severe asthma attacks, and there is no life and a faster exacerbation recurrence (110). Current
evidence of benefits in patients with bronchiectasis (97). guidelines recommend the use of an IC in patients with
Long-acting anticholinergics (LAMAs) have a prolonged advanced pulmonary disease that is characterized by a
half-life (36 hours) with an action peak of approximately 1-2 severe obstructive disorder or a large number of exacerba-
hours (98). Tiotropium is the most studied pharmacological tions (78).
agent, and COPD studies have indicated satisfactory results, In patients with bronchiectasis, the use of an IC was
including a reduction in the number of exacerbations, an effective in reducing the inflammatory markers and sputum
improvement in quality of life and an increase in the FEV1 volume. The amount of daily sputum in patients with
(99). There is no evidence that supports the superiority of bronchiectasis is an important severity marker that corre-
LAMAs over LABAs; however, the combination of these lates with the number of lung exacerbations. However,
drugs may be used with an additive effect in patients with studies have not demonstrated a significant impact of ICs on
accentuated lung function or significant functional limita- the lung function and exacerbation rate in individuals with
tions (100). Recently, the use of tiotropium in asthma has bronchiectasis (111).
been studied as an alternative in patients with contra-
indications to the use or in combination with LABAs (101). Other pharmacological agents
Similar to ipratropium, the use of tiotropium for the Xanthines, such as theophylline, have moderate bronch-
treatment of bronchiectasis has not been adequately studied. odilator effects, immunomodulatory properties and anti-
inflammatory effects, which increase sensitivity to corticoids
Corticosteroids in the nucleus of inflammatory cells through the histone
The underlying inflammatory process in obstructive deacetylase pathway. However, the clinical effects of
diseases has always been the focus of therapeutic interven- xanthines, which are associated with a reduced therapeutic
tions that aim to reduce disease progression, improve lung range and an increased risk of severe side effects, have
function and reduce symptoms and exacerbations. In reduced the clinical applicability of these drugs. The use of

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Athanazio R

xanthines is increasingly reserved for severe cases, espe- 2. II Consenso Brasileiro sobre Doença Pulmonar Obstrutiva Crônica –
DPOC. J Bras Pneumol. 2004;30(5):1-52.
cially in patients with COPD (78). 3. Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease
Anti-leukotrienes, such as montelukasts, can reduce and low lung function in adults in the United States: data from the
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