Asthma Management Handbook
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Table. Differential diagnosis of severe asthma in adults

Clinical feature

Alternative diagnoses or comorbidity*

Dyspnoea prominent

Obesity and inactivity with deconditioning

COPD

Alpha-1 antitrypsin deficiency

Heart disease

Pulmonary hypertension

Central airway stenosis

Tracheobronchomalacia

Interstitial lung disease

Bronchiolitis obliterans

Lung cancer

Tracheal stricture

Pulmonary embolism

Cough prominent

Upper airway dysfunction

Upper airway cough syndrome

Adverse drug reaction (e.g. angiotensin-converting enzyme inhibitors, beta-adrenergic blockers)

Bronchiolitis obliterans

Lung cancer

Herpetic tracheobronchitis

Tracheal stricture
Chronic sputum production

COPD

Bronchiectasis

Allergic bronchopulmonary aspergillosis

Cystic fibrosis
History of exposure to tobacco smoke/biomass fuels

COPD

Lung cancer
Dizziness or lightheadedness

Dysfunctional breathing/hyperventilation syndrome

Tachyarrhythmias
Sudden-onset symptoms

Vocal cord dysfunction (paradoxical vocal cord movement)

Panic attacks with hyperventilation

Pulmonary embolism
Irritative triggers, tightness in upper chest/neck, dysphonia Vocal cord dysfunction (paradoxical vocal cord movement)
Symptoms triggered by food or posture Symptomatic gastro-oesophageal reflux disease
Night waking

Obstructive sleep apnoea

Symptomatic gastro-oesophageal reflux disease

Heart failure
Chest crackles

Bronchiectasis

Heart failure

Interstitial lung disease

Hypersensitivity pneumonitis
Respiratory symptoms with sinusitis and/or nasal polyposis#

Eosinophilic granulomatosis with polyangiitis (Churg–Strauss syndrome)

Aspirin-exacerbated respiratory disease
Respiratory symptoms with gastrointestinal symptoms

Cystic fibrosis

Hypereosinophilic syndrome
Onset related to menstrual cycle Premenstrual (catamenial) asthma
Eosinophilia

Chronic eosinophilic pneumonia

Eosinophilic granulomatosis with polyangiitis (Churg–Strauss syndrome)

Hypereosinophilic syndrome

Hypersensitivity pneumonia

Parasitic infection

*Most of the differential diagnoses listed can also occur with asthma.

#especially if evidence of other organ involvement (skin, mononeuritis multiplex, cardiac)

Sources: Israel and Reddel (2017), Chung et al (2014), Maltby et al (2016), Papi et al (2018), FitzGerald et al (2017)

Last reviewed version 2.0

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