Difficulty Breathing: Is It Asthma or Something Else?

Difficulty breathing—be it wheezing, chest pain or tightness, shortness of breath, and coughing—is characteristic of asthma, but it can also occur with gastrointestinal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), heart failure, and other concerns (including viral infections).

As distressing as asthma can be, the disease rarely causes progressive lung damage. But other lung diseases that cause breathing difficulty can and, if left undiagnosed, can progress unimpeded. Still, other possible diagnoses affecting the cardiovascular or other organ systems can be serious and require early treatment for the best outcomes.

That's why seeking a proper diagnosis is essential. You may very well have asthma if you have trouble breathing, particularly if your symptoms occur in episodes and flare up suddenly. But in the end, only a doctor can definitively 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 potential asthma, your doctor will consider all possible causes of your breathing difficulty (a process called differential diagnosis).

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).

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.

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.

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.

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 it.

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 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 it 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.

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 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.

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 inhale. It is not uncommon to cough up pinkish bloody foam if you have PE.

Diagnosis

As you can see, 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 but may include others as well.

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 monitored 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 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 lung biopsy.

In the end, three criteria must 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 formal asthma diagnosis can be made.

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
Feeling of strangulation
Endoscopy of the trachea
Tracheal tumors Barking cough
Coughing up blood
Chest X-ray
Tumor biopsy

Treatment

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

In the event that asthma is not the cause of your breathing difficulties, other treatments will be considered based on your diagnosis. These can range from chronic medications to manage symptoms of GERD, COPD, or CHF to more invasive procedures or surgeries to treat acute heart failure or tracheal tumors.

Short-Acting Beta-Agonists

Short-acting beta-agonist (SABAs), also known as rescue inhalers, are commonly used to treat acute asthma symptoms as well as respiratory impairment and acute exacerbations in people with COPD.

They are used for quick relief whenever you experience severe episodes of dyspnea and wheezing. SABAs are also commonly inhaled before physical activity to prevent a COPD exacerbation.

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.

Inhaled or oral corticosteroids are often included in the treatment of COPD and pulmonary sarcoidosis. Oral steroids may be used in emergency situations to treat severe asthma attacks.

Options include:

Long-Acting Beta-Agonists

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

LABAs are also used in tandem with inhaled corticosteroids for the daily management of COPD.

Options include:

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

There are also four combination inhalers approved by the U.S. Food and Drug Administration that combine an inhaled LABA with an inhaled corticosteroid:

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 for disease management.

Anticholinergics used for bronchodilators include:

There is also a combination inhaler called Combivent that contains albuterol, a SABA, and the anticholinergic drug ipratropium.

As with inhaled SABAs, LABAs, and corticosteroids, anticholinergics are also sometimes used to the treatment COPD. With that said, tiotropium and ipratropium may increase the risk of a cardiovascular event, including heart failure, in people with COPD who have an underlying heart condition.

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:

Although some asthma medications are useful in treating other respiratory conditions, never use a drug prescribed for asthma for any other purpose without first speaking with your doctor.

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, any alleviation of symptoms does not mean that asthma was 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.

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