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1. EXPERIMENTAL
ANDTOXICOLOGIC
P A T H O L O G Y
Experimental and Toxicologic Pathology 57 (2006) S2, 35–40
Asthma and COPD
Tobias Weltea
, David A. Groneberga,b,
a
Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
b
Allergy-Centre-Charité, Charité School of Medicine, Free University and Humboldt University,
Augustenburger Platz 1/OR-1, 13353 Berlin, Germany
Received 21 October 2005; accepted 16 February 2006
Abstract
The two obstructive airway diseases bronchial asthma and chronic obstructive pulmonary disease (COPD) represent
major global causes of disability and death, and COPD is estimated to become the third most common cause of death
by 2020. The structural and pathophysiologic findings in both diseases appear to be easily differentiated in the
extremes of clinical presentation. However, a significant overlap may exist in individual patients regarding features
such as airway wall thickening on computer tomography or reversibility and airway hyperresponsiveness in lung
function tests. Airway inflammation differs between the two diseases. In bronchial asthma, airway inflammation is
characterized in most cases by an increased number of activated T-lymphocytes, particularly CD4+ Th2 cells, and
sometimes eosinophils and mast cells. The most notable difference of chronic severe asthma compared with mild to
moderate asthma is an increased number of neutrophils. In stable COPD, airway inflammation is characterized by an
increased number of T-lymphocytes, particularly CD8+ T cells, macrophages and neutrophils. With the progression
of the disease severity, macrophage and neutrophil numbers increase. Although there may be a partial overlap between
asthma and COPD in some patients, the differences in functional, structural and pharmacological features clearly
demonstrate the consensus that asthma and COPD are different diseases along all their stages of severity.
r 2006 Elsevier GmbH. All rights reserved.
Keywords: Airways; Asthma; COPD; Drug; Inflammation; Lung; Therapy
Introduction
The two airway diseases bronchial asthma and
chronic obstructive pulmonary disease (COPD) are
chronic conditions that exact an enormous toll on
patients, healthcare providers and the society (Chung
et al., 2002). There has been a substantial increase in the
prevalence of both diseases in the last decades that has
led to sizable concerns being expressed from national
and international healthcare authorities. The underlying
characteristics of both conditions involve inflammatory
changes in the respiratory tract, while the specific nature
and the reversibility of these processes largely differ in
each entity and disease stage (Table 1). In the context of
disease management, acute exacerbations are important
clinical events in both illnesses that largely contribute to
an increase in mortality and morbidity (Skrepnek and
Skrepnek, 2004).
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doi:10.1016/j.etp.2006.02.004
Corresponding author. Zentrum Innere Medizin, Abteilung
Pneumologie, Medizinische Hochschule Hannover, Carl-Neuberg-
Straße 1, 30625 Hannover, Germany. Tel.: +49 511 532 3530;
fax: +49 511 532 3353.
E-mail address: groneberg.david@mh-hannover.de
(D.A. Groneberg).

2. COPD
The clinical diagnosis of COPD relies on abnormal
lung function tests and the patient’s history. COPD is
characterized by a largely variable pathology and the
molecular mechanisms are not completely understood
so far. Therefore, it has been difficult to define a simple
disease definition. First approaches based on the
epidemiological features of chronic cough and sputum
production such as duration of symptoms for 3 months
over a period of at least 2 years (chronic bronchitis) or
on pathological features such as the identification of
emphysema in COPD airway tissue. However, these
approaches did not prove to be efficient in the clinical
management of the disease. Therefore, important
approaches towards a rational disease definition were
first reports that related death and disability in COPD to
a progressive decrease in the forced expiratory volume in
1 s (FEV1) (Fletcher and Peto, 1977; Peto et al., 1983).
Today there is a consensus that the diagnosis of
COPD relies on the presence of airflow obstruction
defined as decreased FEV1 to FVC (forced vital
capacity) or vital capacity ratio. Extending these basic
functional features, the GOLD guidelines introduced
persistent inflammation and the potential presence of
noxious stimuli to the disease definition (Pauwels et al.,
2001). Also, a classification of COPD disease severity
was defined with five stages from risk group to very
severe disease (Table 2). With regard to inhalant
noxious stimuli, tobacco smoke is regarded as a major
cause, but toxic gases or indoor air pollution may also
be regarded as major factors leading to COPD (Pandey,
1984; Perez-Padilla et al., 1996).
Bronchial asthma
Bronchial asthma is defined as chronic inflammatory
disorder of the airways (Caramori et al., 2005). The
chronically inflamed airways of patients with bronchial
asthma are hyperresponsive and become obstructed
due to bronchoconstriction and mucus hypersecretion
(Caramori et al., 2005). Clinically, asthma is character-
ized by wheezing, breathlessness, chest tightness and
coughing particularly at night or in the early morning.
Common risk factors of the disease include the exposure
to seasonal or perennial allergens including pollens,
molds, animal allergens or domestic dust mites. Other
risk factors can be tobacco smoke, air pollution,
respiratory infections, exercise, occupational irritants,
physical and chemical irritants and drugs including
aspirin or beta blockers. There is also good evidence of a
genetic component in asthma since the disease often
occurs in families. The severity of the disease can be
intermittent, persistently mild, moderate or severe.
Inflammation
Important features of both diseases are ongoing
chronic inflammatory processes in the airways as
indicated by the current GINA and GOLD guidelines
(Pauwels et al., 2001). There are great differences
between COPD and bronchial asthma (Groneberg and
Chung, 2004): while mast cells and eosinophils represent
prominent cell types in allergic diseases such as asthma
or atopic dermatitis (Groneberg et al., 2005), the major
inflammatory cell types in COPD are different (Table 2)
(Saetta et al., 1998). Neutrophils play a crucial role in
the pathophysiology of COPD. They release multiple
mediators and tissue-degrading enzymes such as elas-
tases that orchestrate tissue destruction and chronic
inflammation (Chung, 2001; Stockley, 2002). Neutrophil
and macrophage numbers are also increased in bronch-
oalveolar lavage fluids from cigarette smokers (Hunnin-
ghake and Crystal, 1983). COPD patients with a high
degree of airflow limitation have a higher level of
induced sputum neutrophilia than COPD patients with
a milder airflow limitation. In this respect, increased
sputum neutrophilia is related to an accelerated decrease
in the FEV1 and more prevalent in subjects with the
symptoms of chronic cough and sputum production
(Stanescu et al., 1996).
ARTICLE IN PRESS
Table 1. Phenotype differences between COPD and bronchial asthma
Feature COPD Asthma
Limitation of airflow Largely irreversible Largely reversible
Bronchial hyperresponsiveness Variable (small) Significant
Parenchymal integrity Destruction Intact
Steroid response Varying Present
Table 2. Inflammatory cell population differences between
COPD and bronchial asthma
COPD Asthma
Neutrophils Eosinophils
Macrophages Mast cells
CD8-T-lymphocytes CD4-T-lymphocytes
Eosinophils (exacerbations) Macrophages, neutrophils
Ranked in relative order of importance.
T. Welte, D.A. Groneberg / Experimental and Toxicologic Pathology 57 (2006) S2, 35–40
36

3. The second major cell type that plays a crucial role in
COPD are macrophages (Shapiro, 1999). Similar to
neutrophils, they release tissue-degrading enzymes such
as matrix metalloproteinases (MMPs). Neutrophils and
macrophages communicate with other cells such as
airway smooth muscle cells, endothelial cells or sensory
neurons, and release inflammatory mediators that
propagate the events of bronchoconstriction (O’Byrne
and Inman, 2003), airway remodeling (Vignola et al.,
2002), and mucus hypersecretion involving the induction
of mucin genes (Groneberg et al., 2002b, c, 2003b,
2004c).
As in bronchial asthma, lymphocytes are also
involved in cellular mechanisms underlying COPD
(Majo et al., 2001). However, the T-cell-associated
inflammatory processes largely differ from those in
allergic asthma, which is characterized by increased
numbers of CD4-positive T-lymphocytes (Fabbri et al.,
2003; Sutherland and Martin, 2003) (Table 2). In
COPD, there are increased numbers of CD8-positive
T-lymphocytes present in the airways (Saetta et al.,
1999). The degree of airflow obstruction is correlated
with the numbers of CD8-positive T-lymphocytes
(O’Shaughnessy et al., 1997).
In contrast to asthma, eosinophils may only play a
major role in acute exacerbations of COPD (Saetta
et al., 1994). However, their presence in stable COPD
has been shown to be an indicator of steroid respon-
siveness (Pizzichini et al., 1998; Fujimoto et al., 1999).
Features such as mucus hypersecretion, basing on mucin
gene induction (Groneberg et al., 2002b, c, 2003b, 2004c;
Chung et al., 2004) or chronic cough basing on an
increased expression of transient receptor potential
vanilloid-1 (VR1 or TRPV1) (Groneberg et al., 2004b),
may be found both in bronchial asthma and COPD as
well as in other respiratory diseases.
Bronchodilator reversibility
One of the main features used to distinguish bronchial
asthma from COPD is the acute bronchodilator
reversibility of the FEV1. Historically, asthma has been
defined as an obstructive disease with bronchodilator
reversibility in most patients while definitions of COPD
emphasized little or no bronchodilator reversibility.
However, there has been increasing evidence in the past
few years that COPD patients have a large variability of
reversibility that may vary day-to-day (Nisar et al.,
1990, p. 457). It can be assumed that acute bronchodi-
lator reversibility may be present in a significant
proportion of COPD patients depending on definitions
and nature and dosing of drugs (Kerstjens et al., 1993).
A problem lies within the lack of clarity concerning
the term ‘irreversibility’. This is due to the inappropriate
restriction of the bronchodilator reversibility to the
FEV1 since the COPD definition also requires an
obstructive forced expiratory ratio that is the ratio of
the FEV1 to the FVC. A FEV1/FVC ratio of o0.7 is
essential for the diagnosis of airway obstruction and
it remains o0.7 after bronchodilator use in COPD
patients. It is therefore particularly the FEV1/FVC ratio
in COPD that is ‘irreversible’ after bronchodilator use
(McKenzie et al., 2003). The definition of COPD,
diagnosis and severity grading according to spirometric
parameters are critical issues that even affect COPD
prevalence, burden of disease and the effects of
interventions. Recently, a 200% variation in COPD
prevalence was reported that resulted from applying
different definitions of airway obstruction from widely
used guidelines (Celli et al., 2003).
Patients with COPD who presented reversibility are
often classified as having an ‘asthmatic’ component in
contrast to the ‘pure’ or ‘true’ COPD. A serious
consequence is that certain therapeutic options may
not be taken into consideration for the ‘true COPD’
group. In this respect, small-scaled clinical trials
assessing inhaled steroids in COPD and the use of
FEV1 as main end-point suggested the commonly held
view that inhaled steroids should not be prescribed for
patients with COPD with no acute response to inhaled
bronchodilators or oral corticosteroids (van Schayck,
2000). In this respect, it is not logic to solely define the
disease by its lack of reversibility to bronchodilators
while therapeutic studies are then conducted using
spirometry as the primary outcome. However, larger
studies with multiple end-points including quality of life,
exercise capacity and exacerbations demonstrated that
neither bronchodilator nor oral steroid response tests
can be used to predict the benefit of inhaled steroids
(Weir and Burge, 1993; Burge et al., 2000; Calverley
et al., 2003).
It is now also clear that there is a large variability and
that an acute bronchodilator reversibility may be
present on one occasion and not another, within a short
period of time. Also, several definitions used to calculate
acute bronchodilator reversibility of the FEV1 can result
in different proportions of patients being classified as
having reversibility, and studies have shown that the
reversibility is affected by many factors (O’Donnell,
2000).
Therefore, the currently accepted disease definitions
do not state that COPD is a disease characterized by a
completely irreversible airflow limitation but state that
the obstruction cannot be fully reversed, referring in
particular to the persistence of an abnormal FEV1/FVC
ratio (o0.7) after bronchodilator use. Also, the recogni-
tion that clinical improvements in symptoms, exercise
capacity and quality of life can occur in the presence of
minimal changes in FEV1 is a crucial feature with regard
to therapeutic options (Hay et al., 1992; Paggiaro et al.,
1998). However, the FEV1 remains a very important test
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4. despite its limitations when used as isolated diagnostic
tool and the risk of death from COPD is closely related
to the degree of impairment of the FEV1 (Thomason
and Strachan, 2000). It can be stated that the
bronchodilator reversibility should not be used as an
isolated parameter to define two completely separate
classes of COPD patients since this is an artificial and
misleading representation.
It is now generally accepted that patients with COPD
may benefit from a broad range of treatments including
long-acting bronchodilators, pulmonary rehabilitation
or inhaled steroids. While some of these benefits may be
measured by spirometric parameters, real-life outcomes
such as quality of life or walking distance may also be
important indexes to quantify the benefit (O’Donnell
et al., 1999).
Conclusion
Bronchial asthma and chronic obstructive pulmonary
disease (COPD) represent major global causes of
disability and death. While there may be a significant
overlap in individual patients, the structural and
pathophysiologic findings in both diseases can be easily
differentiated. Regarding pharmacotherapy, COPD
should no longer be viewed as a disease for which
nothing can be done. In view of the wide range of
bronchodilator reversibility in COPD patients and the
limitations of FEV1 reversibility as a sole marker of
benefit, new treatment options (Groneberg et al., 2003d,
2004a) may be evaluated on the basis of more real-life or
combined outcome parameters (Celli et al., 2004).
Concerning novel treatment options, future studies
addressing the molecular, biochemical and pathophy-
siological characteristics of asthma and COPD need to
be performed applying modern techniques of morphol-
ogy (Groneberg et al., 2002a, 2002d, 2003a; Heppt et al.,
2004; Springer et al., 2005), molecular biology (Grone-
berg et al., 2003c; Springer et al., 2004b, 2004c) and
physiology (Quarcoo et al., 2004; Springer et al., 2004a).
Acknowledgements
This study was supported by the German Academic
Exchange Service (DAAD, D/00/10559), and the
Deutsche Forschungsgemeinschaft (DFG, GR 2014/2-1).
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