When Difficulty Breathing Is Asthma or Something Else

If you are experiencing difficulty breathing, it could very well be asthma, especially if the symptoms occur in episodes and flare up suddenly. With asthma, symptoms typically include wheezing, chest pain or tightness, shortness of breath, and coughing.

However, a number of other conditions can cause difficulty breathing, some of which may be more serious. As distressing as asthma can be, it rarely causes progressive lung damage. Some common lung diseases can and, if left undiagnosed, can allow the injury to progress unimpeded. In other cases, difficulty breathing may be the sign of a related disorder affecting the heart or other organ systems.

Diagnosing asthma is not as straightforward as it may seem. In the end, only a doctor can definitively diagnose asthma and differentiate it from other possible diseases and disorders.

Conditions That Mimic Asthma

There are a number of conditions that can cause shortness of breath, wheezing, coughing, and chest tightness. While most are related to the lungs and respiratory system, others are associated with other organ systems, like the heart and respiratory tract. When investigating asthma, the doctor will consider all possible causes of your breathing difficulty (referred to as the differential diagnosis).

Congestive Heart Failure

Congestive heart failure (CHF) is a condition in which your heart does not pump strongly enough to supply the rest of the body with blood and oxygen. In addition to asthma-like symptoms, CHF may cause the build-up of fluid in the lungs (pleural effusion), swelling in the lower extremities (edema) and shortness of breath (dyspnea) when lying flat.

Pulmonary Embolism

Pulmonary embolism (PE) is a condition in which a blood clot develops in an artery in the lungs. PE is associated with obesity, smoking, certain medications (including birth control pills), and prolonged immobility in a car or airplane. Compared to asthma, wheezing is less common, while chest pains tend to be sharp and worsen when you cough or inhaling. It is not uncommon to cough up pinkish bloody foam if you have PE.

COPD

Chronic obstructive pulmonary disease (COPD) is a progressive lung disorder most commonly associated with smoking. In the early stages of the disease, the symptoms can appear asthma-like and may even flare if the lungs are exposed to allergens, fumes, or cold weather. Among some of the differentiating early clues are fluid retention, trouble sleeping, an increasing nagging cough, and the coughing of up clear, whitish, or yellowing phlegm.

GERD

Gastroesophageal Reflux Disease (GERD) is a chronic condition in which acid from the stomach escapes into the esophagus. Although GERD is characterized by its gastrointestinal symptoms, the frequent regurgitation of acid can lead to lead to pneumonitis (inflammation of the air sacs of the lungs).

In addition to asthma-like symptoms, pneumonitis can be recognized by crackling sound in the lungs (rales) along with unexplained weight loss, persistent fatigue, and clubbing of the fingers or toes. Lung scarring (fibrosis) is a long-term consequence of GERD-induced pneumonitis (also referred to as reflux-aspiration syndrome).

Hypersensitivity Pneumonitis

Hypersensitivity pneumonitis (HP) is an uncommon condition in which exposure to certain substances, such as moldy hay and bird droppings, can lead to an allergic reaction in the lungs. Because HP has many of the same allergenic triggers as asthma, it can easily be mistaken for asthma.

Flu-like symptoms, rales, weight loss, fatigue, and clubbing of the fingers and toes are clues that HP is involved, but only allergy testing can confirm the diagnosis. Chronic HP cases may require a or a lung biopsy if allergy tests are inconclusive.

Pulmonary Sarcoidosis

Pulmonary sarcoidosis is a disease characterized by the formation of granular lumps (granulomas) in the lungs. The cause of the disease is unknown but typically manifests with asthma-like symptoms. However, with pulmonary sarcoidosis, the symptoms will be persistent rather than episodic and may be accompanied by night sweats, swollen lymph glands, fatigue, fever, joint or muscle pain, skin rashes, blurred vision, and light sensitivity.

Vocal Cord Dysfunction

Vocal cord dysfunction means that your vocal cords are not acting normally. Instead of the vocal cords opening when you inhale or exhale, they remain closed, making it harder to get air in or out of the lungs. Vocal cord dysfunction typically causes hoarseness along with wheezing and a feeling of tightness and strangulation in the throat.

Tracheal Tumors

Tracheal tumors affecting the windpipe (trachea) can often start with asthma-like symptoms. Because they are so rare, tracheal tumors are frequently diagnosed as asthma. Coughing up blood (hemoptysis) is often the first clue that something else more serious than asthma is involved. Tracheal tumors can either be benign (non-cancerous) or malignant (cancerous) and typically require a biopsy to confirm the diagnosis.

Differential Diagnosis of Asthma
Condition	Differentiating Symptoms	Differentiating Tests
Congestive heart failure	History of coronary artery disease (CAD) Swelling of legs Rales Shortness of breath when lying down	Chest X-ray showing pleural effusion Echocardiogram
Pulmonary embolism	Sharp chest pain when coughing or inhaling Pink, foamy sputum	CT scan of airways with contrast dye
COPD	History of smoking Productive (wet) cough Shortness of breath can occur on its own	PFT values different from asthma Chest X-ray showing lung hyperinflation
GERD-induced pneumontitis	Rales Clubbing of fingers or toes Reflux symptoms	Endoscopy to check for esophageal injury Chest X-ray showing lung scarring
Hypersensitivity pneumonitis	Weight loss Fever Rales Clubbing of fingers or toes	Chest X-ray showing lung scarring Allergy antibody testing Lung biopsy
Pulmonary sarcoidosis	Weight loss Night sweats Skin rash Visual problems Swollen lymph glands	Chest X-ray showing areas of cloudiness
Vocal cord dysfunction	Wheezing when inhaling and exhaling Throat tightness A feeling of strangulation	Endoscopy of the trachea
Tracheal tumors	A "barking" cough Coughing up blood	Chest X-ray Tumor biopsy

Diagnosis

If you experience asthma-like symptoms, your doctor may order a number of diagnostic tests to identify the cause of your breathing difficulty. These include pulmonary function tests (PFTs) to evaluate how well the lungs work and imaging studies to check for abnormalities in the lungs and airways.

Among the tests most commonly used:

Peak expiratory flow rate (PEFR) measures how much air you can quickly exhale from the lung.
Spirometry is a more comprehensive test that measures the capacity of the lungs and the strength by which air is exhaled.
Bronchoprovocation challenge testing involves exposure to substances meant to trigger respiratory symptoms.
Bronchodilator response involves the use of an inhaled bronchodilator to see if your lung function improves.
Exhaled nitric oxide is a test that measures how much nitric oxide is exhaled from the lungs (a common indicator of lung inflammation).
Chest X-ray uses ionizing radiation to create detailed images to see if there are clots, effusion, or tumors in the lungs.
Computed tomography (CT) scans take multiple X-ray images which are then converted by the computer into three-dimensional "slices" of the lungs and respiratory tract.

Based on the finding of these investigations, other tests may be performed, including endoscopy, allergy tests, and biopsy.

How Asthma Is Diagnosed

Three criteria should be met to definitively diagnose asthma:

The history or presence of asthma symptoms
Evidence of airway obstruction using PFTs and other tests
Improvement of lung function of 12% or more when provided a bronchodilator

All other causes of airway obstruction, most especially COPD, need to be excluded before a definitive diagnosis can be made.

Treatment

If asthma is diagnosed, your doctor may prescribe a number of treatments to improve breathing in an emergency and prevent the recurrence of acute flares.

Short-Acting Beta-Agonists

Short-acting beta-agonist (SABAs), also known as rescue inhalers, are used for quick relief whenever you experience severe episodes of dyspnea and wheezing. SABAs are commonly used to treat acute asthma symptoms as well as respiratory impairment in people with COPD. Options include:

Albuterol (known by the names Proventil, Ventolin, ProAir, and others)
Combivent (albuterol plus ipratropium)
Xopenex (levalbuterol)

Inhaled Steroids

Inhaled corticosteroids, also referred to as inhaled steroids, are used to alleviate lung inflammation and reduce airway hypersensitivity. Inhaled steroids are the most effective medications available for the long-term control of asthma. Options include:

Aerobid (flunisolide)
Alvesco (ciclesonide)
Asmanex (mometasone furoate)
Azmacort (triamcinolone acetonide)
Flovent (fluticasone propionate)
Pulmicort (budesonide powder)
Qvar (beclometasone dipropionate)

Long-Acting Beta-Agonists

Long-acting beta-agonists (LABAs) are used to support inhaled steroids when asthma symptoms are not controlled with LABAs alone. If you experience difficulty breathing at night, a LABA can help you get more rest. Options include:

Arcapta (indacaterol)
Brovana (arformoterol)
Perforomist (formoterol)
Serevent (salmeterol)
Stiverdi (olodaterol)

Leukotriene Modifiers

Leukotriene modifiers are a class of drugs that may be considered if your doctor thinks your asthma attacks are related to allergies. Although less effective than inhaled steroids, the drugs may be used on their own if breathing problems are mild and persistent Three leukotriene modifiers are currently approved for use in the United States:

Accolate (zafirlukast)
Singulair (montelukast)
Zyflo (zileuton)

Anticholinergics

Anticholinergics are often used in combination with SABAs in the treatment of respiratory emergencies. They are used for severe allergy attacks rather than on an ongoing basis. Anticholinergics used for bronchodilators include:

Atrovent (ipratropium)
Spiriva Respimat (tiotropium)

There are products like Combivent than combine the SABA albuterol with the anticholinergic ipratropium.

Some of these medications can be used to treat other obstructive lung disorders. But, do not use a drug prescribed for asthma to treat other respiratory conditions unless your doctor tells you to.

A Word From Verywell

What may seem like asthma is not always asthma. The only way to know for sure is to see a lung specialist, called a pulmonologist, who can order tests to confirm that asthma is indeed the cause.

If you decide to skip the doctor and treat your condition with an over-the-counter asthma product like Primatene Mist, the alleviation of symptoms does not mean that asthma is the cause. All you may be doing is masking the real cause of your breathing problems and placing yourself at risk of long-term harm.