Asthma COPD Overlap (ACO)

Asthma and COPD
-- differentiation and
update
Dr Md Main Uddin
MBBS, FCPS
Assistant Professor (Medicine)
Cox’s Bazar Medical College
8-Sep-18 Cox's Bazar Medical College 1

Contents
• Asthma
• COPD
• Asthma-COPD
overlap
• Key changes in
GINA 2017update
• Key changes in
GOLD 2017 update
BTS, SIGN

Asthma
• Asthma is a chronic inflammatory
disorder of the airways, associated
with airway hyper-responsiveness
that leads to recurrent episodes of
wheezing, breathlessness, chest
tightness and coughing, particularly
at night and in the early morning.

Epidemiology
• Current estimates suggest that
asthma affects 300 million people
worldwide, with a predicted
additional 100 million people
affected by 2025.

Pathophysiology
• Airway hyper-reactivity (AHR)
• Atopy (the propensity to produce
IgE)
• Common allergens include house
dust mites, pets such as cats and
dogs, pests such as cockroaches, and
fungi

Clinical features
• Typical symptoms include recurrent
episodes of wheezing, chest
tightness, breathlessness and cough.
• Wheeze apart, there is often very
little to find on examination.

Diagnosis
• The diagnosis of asthma is
predominantly clinical and based on
a characteristic history.
• Supportive evidence is provided by
the demonstration of variable airflow
obstruction, preferably by using
spirometry

© Global Initiative for Asthma
GINA assessment of
symptom control
A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
GINA 2017, Box 2-2A
Level of asthma symptom control
*Excludes reliever taken before exercise, because many people take this routinely

GINA assessment of asthma control
A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
• Assess risk factors at diagnosis and periodically
• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
• Exacerbations
• Fixed airflow limitation
• Medication side-effects
GINA 2017 Box 2-2B (1/4)
Level of asthma symptom control

The control-based asthma
management cycle
GINA 2017, Box 3-2
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Stepwise approach to control asthma
symptoms and reduce risk
GINA 2017, Box 3-5 (1/8)
Symptoms
Exacerbations
Side-effects
Lung function
Other
controller
options
RELIEVER
REMEMBER
TO...
• Provide guided self-management education (self-monitoring + written action plan + regular review)
• Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
• Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of
sensitizers where appropriate
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler
technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite
ICS treatment, provided FEV1 is >70% predicted
• Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol#
Low dose
ICS/LABA**
Med/high
ICS/LABA
Diagnosis
Patient preference
Asthma medications
PREFERRED
CONTROLLER
CHOICE
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low dose
OCS
Refer for add-
on treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
UPDATED
2017

8-Sep-18 16Cox's Bazar Medical College
Iprasol
Bexitrol-F
Monocast
Contine

Stepwise management - pharmacotherapy
GINA 2017, Box 3-5 (2/8) (upper part)
Diagnosis
Patient preference
Asthma medications
Symptoms
Exacerbations
Side-effects
Lung function
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Considerlow
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol
Low dose
ICS/LABA**
Med/high
ICS/LABA
PREFERRED
CONTROLLER
CHOICE
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low
dose OCS
Refer for
add-on
treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
UPDATED
2017

Low, medium and high dose inhaled
corticosteroids
– This is not a table of equivalence, but of estimated clinical comparability
– Most of the clinical benefit from ICS is seen at low doses
– High doses are arbitrary, but for most ICS are those that, with prolonged use, are
associated with increased risk of systemic side-effects
Inhaled corticosteroid Total daily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000
Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
GINA 2015, Box 3-6 (1/2)

Stepwise management – additional components
GINA 2017, Box 3-5 (3/8) (lower part)
REMEMBER
TO...
SLIT: sublingual immunotherapy
• Provide guided self-management education
• Treat modifiable risk factors and comorbidities
• Advise about non-pharmacological therapies and strategies
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks,
but check diagnosis, inhaler technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who
have exacerbations despite ICS treatment.
• Consider stepping down if … symptoms controlled for 3 months
+ low risk for exacerbations. Ceasing ICS is not advised.
UPDATED
2017

Step 5
• Preferred option is referral for specialist
investigation and consideration of add-on treatment
– Add-on tiotropium for patients ≥12 years with history of
exacerbations
– Add-on anti-IgE (omalizumab) for patients with severe
allergic asthma
– Add-on anti-IL5 (mepolizumab (SC) or reslizumab (IV)) for
severe eosinophilic asthma (≥12 yrs)
• Other add-on treatment options at Step 5 include:
– Add-on low dose oral corticosteroids (≤7.5mg/day
prednisone equivalent)
GINA 2017
UPDATED
2017

Reviewing response and adjusting
treatment
• How often should asthma be reviewed?
–1-3 months after treatment started, then
every 3-12 months
–During pregnancy, every 4-6 weeks
–After an exacerbation, within 1 week
• Stepping up asthma treatment
–Sustained step-up, for at least 2-3 months if
asthma poorly controlled
GINA 2017

–Short-term step-up, for 1-2 weeks, e.g. with
viral infection or allergen
• May be initiated by patient with written
asthma action plan
• Stepping down asthma treatment
–Consider step-down after good control
maintained for 3 months
–Find each patient’s minimum effective dose,
that controls both symptoms and
exacerbations

• Prepare for step-down
– Record the level of symptom control and consider
risk factors
– Make sure the patient has a written asthma action
plan
• Step down through available formulations
– Stepping down ICS doses by 25–50% at 3 month
intervals is feasible and safe for most patients
• Stopping ICS is not recommended in adults with
asthma because of risk of exacerbations

Key changes in GINA 2017
• The word ‘syndrome’ has been removed from
the previous term ‘asthma-COPD overlap
syndrome (ACOS)’
• Clarification about ‘periodical’ assessment of
lung function
– Most adults: lung function should be recorded at
least every 1-2 yrs
– More frequently in higher risk patients
What’s new in GINA 2017?

Fraction of Exhaled Nitric Oxide –
FENO
• Diagnosis of asthma
– Additional factors that increase or decrease FENO are
listed
– FENO is not helpful in ruling in or ruling out asthma as
defined by GINA
• Assessment of future risk
– Elevated FENO in allergic patients has been added to the
list of independent predictors of exacerbations
• Single measurements
– Results of FENO measurement at a single point in time
should be interpreted with caution

Key changes in GINA 2017 – other
treatment
• Step 5 treatment for severe asthma
– Anti-IL5: reslizumab (IV) added to mepolizumab (SC)
• Vitamin D
– To date, no good quality evidence that Vitamin D
supplementation leads to improved asthma control or
fewer exacerbations
• Chronic sinonasal disease
– Treatment with nasal corticosteroids improves sinonasal
symptoms but not asthma outcomes

Key changes in GINA 2017 – role of SLIT
GINA 2017, Box 3-5 (3/8) (lower part)
REMEMBER
TO...
• Provide guided self-management education
• Treat modifiable risk factors and comorbidities
• Advise about non-pharmacological therapies and strategies
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks,
but check diagnosis, inhaler technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who
have exacerbations despite ICS treatment, provided FEV1 is 70% predicted
• Consider stepping down if … symptoms controlled for 3 months
+ low risk for exacerbations. Ceasing ICS is not advised.
SLIT: sublingual immunotherapy
Pollen or HDM containing tablet given S/L to make allergic response with
view to desensitize against common allergen.

8-Sep-18Cox's Bazar Medical College
28

GOLD 2017 Report: Chapters
1. Definition and Overview
2. Diagnosis and Initial Assessment
3. Evidence Supporting Prevention
& Maintenance Therapy
4. Management of Stable COPD
5. Management of Exacerbations
6. COPD and Comorbidities

Prevalence
Prevalence of COPD
► Estimated 384 million COPD cases in 2010.
► Estimated global prevalence of 11.7% (95% CI 8.4%–
15.0%).
► Three million deaths annually.
► With increasing prevalence of smoking in developing
countries, and aging populations in high-income
countries, the prevalence of COPD is expected to
rise over the next 30 years.
► By 2030 predicted 4.5 million COPD related deaths
annually.

COPD Definition
► Chronic Obstructive Pulmonary Disease (COPD) is a
common, preventable and treatable disease that is
characterized by persistent respiratory symptoms and
airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure
to noxious particles or gases.

Risk factors
 Cigarette smoking
represents the most
significant risk factor
for COPD and
relates to both the
amount and the
duration of smoking.
8-Sep-18
34
Cox's Bazar Medical College
It is unusual to develop COPD with less than 10 pack years
(1 pack year = 20 cigarettes/day/year) and not all smokers
develop the condition, suggesting that individual susceptibility
factors are important.

Factors that influence disease progression
► Genetic factors
► Age and gender
► Lung growth and development
► Exposure to particles
► Socioeconomic status
► Asthma & airway hyper-reactivity
► Chronic bronchitis
► Infections

Pathology, pathogenesis & pathophysiology
► Pathology
 Chronic inflammation
 Structural changes
► Pathogenesis
 Oxidative stress
 Protease-antiprotease imbalance
 Inflammatory cells
 Inflammatory mediators
 Peribronchiolar and interstitial fibrosis
► Pathophysiology
 Airflow limitation and gas trapping
 Gas exchange abnormalities
 Mucus hypersecretion
 Pulmonary hypertension

Diagnosis and Initial Assessment

Spirometry

Classification of severity of airflow
limitation

Choice of thresholds
► COPD Assessment Test (CAT TM )
► Chronic Respiratory Questionnaire (CCQ® )
► St George’s Respiratory Questionnaire (SGRQ)
► Chronic Respiratory Questionnaire (CRQ)
► Modified Medical Research Council (mMRC) questionnaire

Modified MRC (mMRC)Questionnaire
PLEASE TICK IN THE BOX THAT APPLIES TO YOU
(ONE BOX ONLY)
mMRC Grade 0. I only get breathless with strenuous exercise.
mMRC Grade 1. I get short of breath when hurrying on the level
or walking up a slight hill.
mMRC Grade 2. I walk slower than people of the same age on the
level because of breathlessness, or I have to stop for breath when
walking on my own pace on the level.
mMRC Grade 3. I stop for breath after walking about 100 meters or
after a few minutes on the level.
mMRC Grade 4. I am too breathless to leave the house or I am
breathless when dressing or undressing.

ABCD Assessment Tool

Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
8-Sep-18Cox's Bazar Medical College
45 Risk
(GOLDClassificationofAirflowLimitation))
Risk
(Exacerbationhistory)
≥ 2
or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0
Symptoms
(C) (D)
(A) (B)
CAT < 10
4
3
2
1
CAT > 10
Breathlessness
mMRC 0–1 mMRC > 2

Example
► Consider two patients:
 Both patients with FEV1 < 30% of predicted
 Both with CAT scores of 18
 But, one with 0 exacerbations in the past year and the
other with 3 exacerbations in the past year.
► Both would have been labelled GOLD D in the prior
classification scheme.
► With the new proposed scheme, the subject with 3
exacerbations in the past year would be labelled GOLD grade
4, group D.
► The other patient, who has had no exacerbations, would be
classified as GOLD grade 4, group B.

Differential Diagnosis

Management of Stable COPD
► Once COPD has been diagnosed, effective management
should be based on an individualized assessment to reduce
both current symptoms and future risks of exacerbations.

Management of Stable COPD
Identify and reduce exposure to risk factors
►Identification and reduction of exposure to risk
factors is important in the treatment and
prevention of COPD.
►Cigarette smoking is the most commonly
encountered and easily identifiable risk factor for
COPD, and smoking cessation should be
continually encouraged for all individuals who
smoke.
►Reduction of total personal exposure to
occupational dusts, fumes, and gases, and to
indoor and outdoor air pollutants, should also be
addressed.

Treatment of Stable COPD
Pharmacologic treatment algorithms
►A proposed model for the initiation, and then subsequent
escalation and/or de-escalation of pharmacologic
management of COPD according to the individualized
assessment of symptoms and exacerbation risk is shown.
►We suggest escalation (and de-escalation) strategies.
►The recommendations made are based on available
efficacy as well as safety data.
►It should be noted that there is a lack of direct evidence
supporting the therapeutic recommendations for patients
in groups C and D. These recommendations will be re-
evaluated as additional data become available.

Treatment of Stable COPD

Group A
►All Group A patients
should be offered
bronchodilator treatment
based on its effect on
breathlessness. This can
be either a short- or a
long-acting
bronchodilator.
►This should be continued
if symptomatic benefit is
documented.

Group B
►Initial therapy should consist
of a long acting
bronchodilator.
►There is no evidence to
recommend one class of
long-acting bronchodilators
over another.
►For patients with persistent
breathlessness on
monotherapy the use of two
bronchodilators is
recommended.

Group B (continued)
►For patients with severe
breathlessness initial therapy with
two bronchodilators may be
considered.
►If the addition of a second
bronchodilator does not improve
symptoms, we suggest the treatment
could be stepped down again to a
single bronchodilator.
►Group B patients are likely to have
comorbidities that may add to their
symptomatology and impact their
prognosis, and these possibilities
should be investigated.

Group C
►Initial therapy should consist of a single long acting
bronchodilator. In two head-to head
comparisons the tested LAMA was
superior to the LABA regarding
exacerbation prevention, therefore we
recommend starting therapy with a
LAMA in this group.
►Patients with persistent exacerbations
may benefit from adding a second long acting
bronchodilator (LABA/LAMA) or using a combination
of a long acting beta2-agonist and an inhaled
corticosteroid.

Group D
►We recommend starting
therapy with a LABA/LAMA
combination because:
 A LABA/LAMA combination was
superior to a LABA/ICS
combination in preventing
exacerbations and other patient
reported outcomes in Group D
patients. Group D patients are at higher risk of developing
pneumonia when receiving treatment with ICS.

Group D (continued)
► In some patients initial therapy with
LABA/ICS may be the first choice.
These patients may have a history
and/or findings suggestive of
asthma-COPD overlap. High blood
eosinophil counts may also be
considered as a parameter to
support the use of ICS, although
this is still under debate (for details see Chapter 2 and
Appendix).
►In patients who develop further exacerbations on
LABA/LAMA therapy we suggest two alternative pathways:
Escalation to LABA/LAMA/ICS or switch to LABA/ICS.

Group D (continued)
If patients treated with LABA/LAMA/ICS still have
exacerbations the following options may be
considered:
►Add roflumilast
►Add a macrolide. The best available evidence exists
for the use of azithromycin.
►Stopping ICS. A reported lack of efficacy, an
elevated risk of adverse effects (including
pneumonia) and evidence showing no significant
harm from withdrawal supports this
recommendation.

Non-Pharmacologic Treatment
►Education and self-management
►Physical activity
►Pulmonary rehabilitation programs
►Exercise training
►Self-management education
►End of life and palliative care
►Nutritional support
►Vaccination
►Oxygen therapy

Oxygen therapy
Long-term oxygen therapy is indicated for stable
patients who have:
►PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at
or below 88%, with or without hypercapnia
confirmed twice over a three week period; or
►PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa
(60 mmHg), or SaO2 of 88%, if there is evidence
of pulmonary hypertension, peripheral edema
suggesting congestive cardiac failure, or
polycythemia (hematocrit > 55%).

COPD and Comorbidities
Some common comorbidities occurring in patients with COPD with
stable disease include:
► Cardiovascular disease (CVD)
► Heart failure
► Ischaemic heart disease (IHD)
► Arrhythmias
► Peripheral vascular disease
► Hypertension
► Osteoporosis
► Anxiety and depression
► COPD and lung cancer
► Metabolic syndrome and diabetes
► Gastroesophageal reflux (GERD)
► Bronchiectasis
► Obstructive sleep apnea

© Global Initiative for Asthma3.
GINA Global Strategy for Asthma Management
and Prevention
GOLD Global Strategy for Diagnosis,
Management and Prevention of COPD
Diagnosis and initial treatment of
asthma, COPD and asthma-COPD
overlap (ACO)
A joint project of GINA and GOLD
GINA 2017
UPDATED
2017

Asthma-COPD overlap – change in
terminology
• Distinguishing asthma from COPD can be problematic
– Particularly in smokers and older adults
• Most clinical trials and guidelines are about asthma or
COPD alone
• The descriptive term asthma-COPD overlap (ACO) is useful
– It maintains awareness by clinicians, researchers and regulators
of the needs of these patients
• “Asthma-COPD overlap” is not a single disease entity
– As for asthma and COPD, it includes patients with several
different forms of airways disease (phenotypes)...
• To avoid the impression that this is a single disease, the
previous term Asthma COPD Overlap Syndrome (ACOS) is
no longer advised.
UPDATED
2017

Stepwise approach to diagnosis and
initial treatment
For an adult who presents with
respiratory symptoms:
1. Does the patient have chronic
airways disease?
2. Syndromic diagnosis of asthma,
COPD and overlap
3. Spirometry
4. Commence initial therapy
5. Referral for specialized
investigations (if necessary)
GINA 2017, Box 5-4
DIAGNOSE CHRONIC AIRWAYS DISEASE
Do symptoms suggest chronic airways disease?
STEP 1
Yes No Consider other diseases first
SYNDROMIC DIAGNOSIS IN ADULTS
(i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest ASTHMA COPD
Age of onset Before age 20 years After age 40 years
Pattern of symptoms Variation over minutes, hours or days
Worse during the night or early
morning. Triggered by exercise,
emotions including laughter, dust or
exposure to allergens
Persistent despite treatment
Good and bad days but always daily
symptoms and exertional dyspnea
Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Lung function
Record of variable airflow limitation
(spirometry or peak flow)
Record of persistent airflow limitation
(FEV1/FVC < 0.7 post-BD)
Lung function between
symptoms Normal Abnormal
Previous doctor diagnosis of asthma
Familyhistory of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
Heavy exposure to risk factor: tobacco
smoke, biomass fuels
Time course No worsening of symptoms over
time. Variation in symptoms either
seasonally, or from year to year
May improve spontaneously or have
an immediate response to
bronchodilators or to ICS over weeks
Symptoms slowly worsening over
time (progressive course over years)
Rapid-acting bronchodilator treatment
provides only limited relief
Chest X-ray Normal Severe hyperinflation
DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Some features
of asthma
Asthma
Features of
both
Could be
ACO
Some features
of COPD
Possibly
COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or
COPD suggest that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACO
Marked
reversible airflow limitation
(pre-post bronchodilator) or other
proof of variable airflow limitation
STEP 3
PERFORM
SPIROMETRY
FEV1/FVC < 0.7
post-BD
Asthma
drugs
No LABA
monotherapy
STEP 4
INITIAL
TREATMENT*
COPD
drugs
Asthma drugs
No LABA
monotherapy
ICS, and
usually
LABA
+/or LAMA
COPD
drugs
*Consult GINA and GOLD documents for recommended treatments.
STEP 5
SPECIALISED
INVESTIGATIONS
or REFER IF:
• Persistent symptoms and/or exacerbations despite treatment.
• Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases
and other causes of respiratory symptoms).
• Suspected asthma or COPD with atypical or additional symptoms or signs (e.g.
haemoptysis, weight loss, night sweats, fever, signs of bronchiectasis or other structural lung
disease).
• Few features of either asthma or COPD.
• Comorbidities present.
• Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.
Past history or family
history
UPDATED
2017

Step 1 – Does the patient have chronic
airways disease?
GINA 2017
DIAGNOSE CHRONIC AIRWAYS DISEASE
Do symptoms suggest chronic airways disease?
STEP 1
Yes No Consider other diseases first

airways disease?
• Clinical history: consider chronic airways disease
if
– Chronic or recurrent cough, sputum, dyspnea or
wheezing, or repeated acute lower respiratory tract
infections
– Previous doctor diagnosis of asthma and/or COPD
– Previous treatment with inhaled medications
– History of smoking tobacco and/or other substances
– Exposure to environmental hazards, e.g. airborne
pollutants
GINA 2017

airways disease?
• Radiology (CXR or CT scan performed for other reasons)
– May be normal, especially in early stages
– Hyperinflation, airway wall thickening,
hyperlucency, bullae
– May identify or suggest an alternative or
additional diagnosis, e.g. bronchiectasis,
tuberculosis, interstitial lung disease, cardiac
failure
GINA 2017

Step 2 – Syndromic diagnosis of asthma,
COPD and asthma-COPD overlap
• Assemble the features that, when present, most
favor a diagnosis of typical asthma or typical COPD
• Compare the number of features on each side
– If the patient has ≥3 features of either asthma or
COPD, there is a strong likelihood that this is the
correct diagnosis
• Consider the level of certainty around the diagnosis
– When a patient has a similar number of features
of both asthma and COPD, consider the diagnosis
of asthma-COPD overlap
GINA 2017
UPDATED
2017

© Global Initiative for AsthmaGINA 2014 © Global Initiative for AsthmaGINA 2017, Box 5-4
SYNDROMIC DIAGNOSIS IN ADULTS
(i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest - ASTHMA COPD
Age of onset  Before age 20 years  After age 40 years
Pattern of symptoms  Variation over minutes, hours or days
 Worse during the night or early morning
 Triggered by exercise, emotions
including laughter, dust or exposure
to allergens
 Persistent despite treatment
 Good and bad days but always daily
symptoms and exertional dyspnea
 Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Lung function  Record of variable airflow limitation
(spirometry or peak flow)
 Record of persistent airflow limitation
(FEV1/FVC < 0.7 post-BD)
Lung function between
symptoms
 Normal  Abnormal
Past history or family history  Previous doctor diagnosis of asthma
 Family history of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
 Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
 Heavy exposure to risk factor: tobacco
smoke, biomass fuels
Time course  No worsening of symptoms over time.
Variation in symptoms either
seasonally, or from year to year
 May improve spontaneously or have
an immediate response to
bronchodilators or to ICS over weeks
 Symptoms slowly worsening over time
(progressive course over years)
 Rapid-acting bronchodilator treatment
provides only limited relief
Chest X-ray  Normal  Severe hyperinflation
DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Some features
of asthma
Asthma
Features of
both
Could be ACO
Some features
of COPD
Possibly COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACO
UPDATED
2017

© Global Initiative for AsthmaGINA 2017
Marked
reversible airflow limitation
(pre-post bronchodilator) or other
proof of variable airflow limitation
STEP 3
PERFORM
SPIROMETRY
FEV1/FVC < 0.7
post-BD

Step 3 - Spirometry
Spirometric variable Asthma COPD Overlap
Normal FEV1/FVC
pre- or post-BD
Compatible with asthma Not compatible with
diagnosis (GOLD)
Not compatible unless
other evidence of chronic
airflow limitation
FEV1 ≥80% predicted Compatible with asthma
(good control, or interval
between symptoms)
Compatible with GOLD
category A or B if post-
BD FEV1/FVC <0.7
Compatible with mild
ACO
Post-BD increase in
FEV1 >12% and 400mL
from baseline
- High probability of
asthma
Unusual in COPD.
Consider ACO
Compatible with
diagnosis of ACO
Post-BD FEV1/FVC <0.7- Indicates airflow
limitation; may improve
Required for diagnosis
by GOLD criteria
Usual in asthma-COPD
overlap (ACO)
Post-BD increase in
FEV1 >12% and 200mL
from baseline (reversible
airflow limitation)
- Usual at some time in
course of asthma; not
always present
Common in COPD and
more likely when FEV1
is low
Common in ACO, and
more likely when FEV1 is
low
FEV1<80% predicted Compatible with asthma.
A risk factor for
exacerbations
Indicates severity of
airflow limitation and risk
of exacerbations and
mortality
Indicates severity of
airflow limitation and risk
of exacerbations and
mortality
GINA 2017, Box 5-3
UPDATED
2017

© Global Initiative for AsthmaGINA 2017
Asthma drugs
No LABA
monotherapy
STEP 4
INITIAL
TREATMENT*
COPD drugs
Asthma drugs
No LABA
monotherapy
ICS and
consider LABA
+/or LAMA
COPD drugs
*Consult GINA and GOLD documents for recommended treatments.

Step 4 – Commence initial
therapy
• If syndromic assessment suggests asthma as single
diagnosis
– Start with low-dose ICS
– Add LABA and/or LAMA if needed for poor control
despite good adherence and correct technique
– Do not give LABA alone without ICS
• If syndromic assessment suggests COPD as single
diagnosis
– Start with bronchodilators or combination therapy
– Do not give ICS alone without LABA and/or LAMA
GINA 2017
UPDATED
2017

Step 4
• If differential diagnosis is equally balanced
between asthma and COPD, i.e. asthma-COPD
overlap
–Start treatment as for asthma, pending
further investigations
–Start with ICS at low or moderate dose
–Usually also add LABA and/or LAMA, or
continue if already prescribed

Step 4 – Commence initial therapy
• For all patients with chronic airflow limitation:
– Treat modifiable risk factors including advice
about smoking cessation
– Treat comorbidities
– Advise about non-pharmacological strategies
including physical activity, and, for COPD or
asthma-COPD overlap, pulmonary rehabilitation
and vaccinations
– Provide appropriate self-management strategies
– Arrange regular follow-up
GINA 2017
UPDATED
2017

STEP 3
PERFORM
SPIROMETRY
STEP 5
SPECIALISED
INVESTIGATIONS
or REFER IF:
• Persistent symptoms and/or exacerbations despite treatment.
• Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases and
other causes of respiratory symptoms).
• Suspected asthma or COPD with atypical or additional symptoms or signs (e.g. haemoptysis,
• weight loss, night sweats, fever, signs of bronchiectasis or other structural lung disease).
• Few features of either asthma or COPD.
• Comorbidities present.
• Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.
GINA 2017

Step 5 – Refer for specialized
investigations if needed
• Refer for expert advice and extra investigations if
patient has:
– Persistent symptoms and/or exacerbations despite
treatment
– Diagnostic uncertainty, especially if alternative
diagnosis (e.g. TB, cardiovascular disease) needs to be
excluded
– Suspected airways disease with atypical or additional
symptoms or signs (e.g. hemoptysis, weight loss, night
sweats, fever, chronic purulent sputum).
GINA 2017

Step 5
–Suspected chronic airways disease but few
features of asthma, COPD or asthma-COPD
overlap
–Comorbidities that may interfere with their
management
–Issues arising during on-going management
of asthma, COPD or asthma-COPD overlap

Summary
• Distinguishing asthma from COPD can be
problematic.
• History – age, symptoms, atopy, smoking, F/H
• Examination – SOB, physic, edema,
smell/staining
-- Hyperinflation of chest, RVH,
hyperresnance, breath sound and added
sound
• Investigation

Summary
• The word ‘syndrome’ has been removed from
ACOS
• Elevated FENO has been added to the list of
independent predictors of exacerbations.
• Consider adding SLIT in adult HDM-sensitive patients.
• Early ICS treatment and early referral

Summary

By 2020 it is forecast to represent the third
most important cause of death world-wide.

THANK YOU….

• GINA reports are available at
http://www.ginasthma.org
• GOLD reports are available at
http://www.goldcopd.org

Asthma COPD Overlap (ACO)

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