**3. Alpha-1-antitrypsin deficiency**

There are excellent reviews about alpha 1 antitrypsin deficiency (AATD). AATD is associated with impaired pulmonary antiproteasas defenses leading to unopposed protease activity. ATTD is the best model of COPD and emphysema. The clinical course is accelerated mainly by the smoking, but also by air pollution, and phenotype well-known. Some cases are diagnosed as asthma or bronchiectasis for clinical manifestations. Others may be diagnosed by hepatologists if the first manifestation is liver findings. In recent years, the characteristics in

COPD: Differential Diagnosis 109

Fig. 1. A 55-year old woman, nonsmoker, was seen as outpatient in a check-up, a spirometry revealed the presence of obstructive patterns. A diagnosis of Pulmonary Tuberculosis had been made 25 year ago and antituberculosis treatment was completed. Diagnosis: sequelae

problem of differential diagnosis. The comorbidity of COPD and heart failure caused by smoking, metabolic syndrome, the syndrome of obstructive sleep apnea and aging, could hinder the diagnosis of COPD exacerbation vs heart failure. However, measurement of the natriuretic peptide can help in the differential diagnosis. Once patients have been discharged from hospital, they should be required to filial the impact of both processes. Studio ergometer

To date, Birringer et al have perhaps been the only ones who have been systematically studied COPD in nonsmokers. Four hundred consecutive patients who visited for 2 years, Birringer found that 25% of them were smokers. Once discarded asthmatics, patients with bronchiectasis and a small subgroup with sputum eosinophilia, they were probably nonreversible asthma, a small percentage of 4% had common characteristics: they were preferably female, with age over 50 years, often with a history of Hashimoto's thyroiditis and / or antithyroid antibodies and / or antitissular antibodies or other features of autoimmune disease. Therefore, the measurement of antithyroid antibodies should be

should be made in outpatients in stable phase, although this is done in rare occasions.

**8. No smoking COPD and antitissular antibody** 

included in patients with features similar.

of tuberculosis.

subjects over 60 years of age have been described. It is important the determination of the DLCO for evaluation of its prognosis and outcome, not only spirometry.

Heterozygous individuals have a higher susceptibility to develop COPD in the presence of smoking or cigarrete exposure, and should be detected for a better affiliation of the syndrome. Therefore, measurement of alpha-1-antitrypsin should be practiced at least once in all patients with chronic airflow obstruction.
