**13. When should we suspect that COPD is not secondary to tobacco?**

An example, a female patient over 70 who had lived much of her life in a rural area, who had never smoked, presents with cough, expectoration and airway obstruction would be a candidate that her disease was secondary to exposure biomass. We cannot be in accordance with a diagnosis of COPD in individuals who had smoked fewer than 10 packs / year,

**Digestive** 

 Others **Endocrine**  Diabetes Hypogonadism

 Others **Systemic**  Cachexia Myopathia Anemia Osteoporosis Polycythemia Facial wrinkles

 Others **Others**  Rhinitis Cataracts Inguinal hernia Nephrotic syndrome Periodontal disease, etc

delay the practice of spirometry. Recently, Remy-Jardin et al have made an interesting proposal to TC (dual-energy) for the simultaneous evaluation of pulmonary and vascular

An example, a female patient over 70 who had lived much of her life in a rural area, who had never smoked, presents with cough, expectoration and airway obstruction would be a candidate that her disease was secondary to exposure biomass. We cannot be in accordance with a diagnosis of COPD in individuals who had smoked fewer than 10 packs / year,

**13. When should we suspect that COPD is not secondary to tobacco?** 

Gastroesophageal reflux

*Helicobacter pylori* infection

Hypercoagulable state

Malabsorption

Systemic features of cigarette smoking

Table 3. Mechanisms underlying the comorbidity of COPD

Extrapulmonary feature of COPD

 Bronchopulmonary carcinoma Pulmonary arterial hypertension

Aneurysm of thoracoabdominal aorta

 *Pneumocystis* pneumonia Obstructive sleep apnea Invasive aspergillosis

Systemic features of COPD Comorbidity of COPD

**Respiratory** 

 Others **Cardiovascular**  Coronary disease Auricular fibrillation Cardiac failure Carotid stenosis

Arritmia

Ictus

Others

damage smoking.

 *Cor pulmonale*  Others **Neuropsychic** 

 Lacunar infart Anxiety disorders Orthostatic hypotension Intracranial hypertension Cognitive impairment

Depressive disorder

Table 4. Comorbidity of COPD

 Bronchiectasis Pneumonia

unless they had simultaneous deficiency of alpha-1-antitrypsin disease. In obvious cases of airway obstruction in people younger than 40 years, it is unusual that this was secondary to smoking. If the annual decline of FEV1 was greater than 75 ml, an additional cause should be suspected. A familial aggregation might suggest cystic fibrosis in adults. The coexistence of joint, skin or ophthalmic symptoms, mucosal dryness and thyroid disease should alert us about other causes of COPD. Bronchiectasis, mostly in women, with *Micobacterium avium complex* is associated with low body mass index. Finally, laboral and hobbies history should be complete in the first interview in pneumologic specialty. Table 5 shows signs and symptoms to help to exclude COPD.


Table 5. Signs and symptoms to help to exclude COPD
