Asthma-COPD Overlap Syndrome (ACOS)

Is it a common entity?
What do we know about asthma and
COPD?
What do we know about asthma and COPD?

Asthma COPD

• Younger patients
• Elder patients
• Symptoms vary – daily,
• Symptoms slowly
worse at night/early
progressive
morning
• History of tobacco
• Family history of
exposure/smoke
asthma
• Neutrophils
• Eosinophils
• Airflow limitation
• Airflow limitation fully
partly reversible
reversible
What do we know about asthma and COPD?

Asthma COPD

Different expressions of a single disease

 Let’s take an clinical example:
• Old patient
• History of seasonal allergy and asthma
• Current/past history of smoking
• Progressive symptoms
• Acute and chronic dyspnea
• Partial reversibility with spirometry
• Elevated IgE

What's the diagnosis?

 What's the diagnosis?

• Mixed asthma with COPD

• Mixed COPD with asthma
• Asthma with fixed airflow limitation
• COPD with asthma component
• Asthma-COPD phenotype …… Asthma COPD
overlap syndrome?
What is Asthma COPD Overlap Syndrome (ACOS)?

Asthma COPD

ACOS

• Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow

limitation with several features usually associated with asthma and several features
usually associated with COPD.
• ACOS is therefore identified by the features that it shares with both asthma and
COPD.

Global Initiative for Asthma (GINA) 2014

 Is ACOS common in general population?

Overlap ~ half of asthma

and ~one-third of COPD

“Other” represents a combination of bronchitis, bronchiectasis, bronchiolitis, and/or cystic fibrosis cases

J Allergy (Cairo). 2011;2011:861926. doi: 10.1155/2011/861926. Epub 2011 Oct 30

The prevalence rates of overlap documented by GINA
are 15-55% with variation by gender and age.

Global Initiative for Asthma (GINA) 2014

How is ACOS different from asthma and COPD?

Symptoms
Exacerbations
Hospitalizations
Healthcare utilization

QoL
Dyspnea and wheezing more common in patients with overlap

Respir Med 2013; 107: 1053-1060

Clinical and physiological characteristics of obstructive airway
syndromes

Thorax 2009;64:728–735. doi:10.1136/thx.2008.108027

 Patients with overlap have higher BODE index

BODE score

3.1

2.9

COPD COPD and asthma P = 0.02

BODE: Body mass index, Airflow obstruction, Dyspnea and Exercise capacity

Eur Respir J 2014; 44: 341–350 | DOI: 10.1183/09031936.00216013

Exacerbations in patients with ACOS are more
frequent and severe

Respiratory Research 2011; 12:127

Clinical features of patients with overlap

Eur Respir J 2014; 44: 341–350 | DOI: 10.1183/09031936.00216013

 Patients with overlap have low quality of life
compared to patients with COPD
SGRQ score

47.4

39.7

COPD COPD and asthma P < 0.001

SGRQ: St. George’s Respiratory Questionnaire

Eur Respir J 2014; 44: 341–350 | DOI: 10.1183/09031936.00216013

Health care utilization is high!

COPD. 2014 Apr;11(2):163-70. doi: 10.3109/15412555.2013.831061. Epub 2013 Oct 10

Is treating ACOS important?

Or should it be same as
Asthma/COPD
 Overlap features become more prevalent with increasing age

• Common in elderly
• COPD patients have more co-morbid conditions
• Other changes in the lungs with age

Thorax 2009;64:728–735. doi:10.1136/thx.2008.108027

Current evidence of ACOS treatment is
limited!

Elder patients, patients with no clear asthma/COPD

diagnosis are often excluded from the trials
A new chapter introduced in GINA 2014
 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 ACOS
3. Spirometry
4. Commence initial therapy
5. Referral for specialized
investigations (if necessary)

Global Initiative for Asthma (GINA) 2014

Step 1: Does the patient have chronic airways
disease?

• Clinical history

• Physical examination

• Radiology

Global Initiative for Asthma (GINA) 2014

Step 2: The syndromic diagnosis of asthma, COPD and
ACOS in an adult patient

a. Assemble the features that favour a diagnosis of asthma

and of COPD
b. Compare the number of features in favour of a diagnosis of
asthma or a diagnosis of COPD
c. Consider the level of certainty around the diagnosis of
asthma or COPD, or whether there are features of both
suggesting asthma-COPD overlap syndrome

Global Initiative for Asthma (GINA) 2014

Usual features of
asthma, COPD and
ACOS

Not all, but only those that most easily

distinguish between asthma and COPD are
listed

Global Initiative for Asthma (GINA) 2014

 Features that favour asthma
or COPD

Having several (3 or more) of the features listed either asthma

or COPD, in the absence of those for alternative diagnosis,
provides a strong likelihood of a correct diagnosis
However, the absence of any of these features has less
predictive value, and does not rule out the diagnosis of either
disease
Global Initiative for Asthma (GINA) 2014
 Step 3: Spirometry

• Essential for the assessment of patients

suspected with chronic airways disease
• Must be performed at either initial or a
subsequent visit, if possible before and after a
trial of treatment.
• Limited value in distinguishing between asthma
with fixed airflow obstruction, COPD and ACOS

PEF if performed repeatedly over 1-2 weeks may help to confirm diagnosis, but a normal
PEF does not rule out either asthma or COPD.

Global Initiative for Asthma (GINA) 2014

 Spirometric variable Asthma COPD ACOS

Normal FEV 1 /FVC Compatible with asthma Not compatible with Not compatible unless
pre- or post-BD diagnosis (GOLD) other evidence of chronic Spirometry
airflow limitation
measures in
Post -BD FEV 1 /FVC <0.7 Indicates airflow Required for diagnosis Usual in ACOS asthma, COPD and
limitation; may improve by GOLD criteria ACOS
FEV 1
≥80% predicted Compatible with asthma C ompatible with GOLD Compatible with mild
(good control, or interval category A or B if post - ACOS
between symptoms) BD FEV 1 /FVC <0.7

FEV 1
<80% predicted Compatible with asthma. Indicates severity of Indicates severity of
A risk factor for airflow limitation and risk airflow limitation and risk
exacerbations of exacerbations and of exacerbations and
mortality mortality
Post - BD increase in Usual at some time in Common in COPD and Common in ACOS, and
Spirometry at single
FEV 1 >12% and 200mL course of asthma; not more likely when FEV 1 is more likely when FEV 1 is visit is not always
from baseline (reversible always present low, but consider ACOS low confirmatory of
airflow limitation) diagnosis & results
must be considered in
Post - BD increase in High probability of Unusual in COPD. Compatible with
asthma context of the clinical
FEV 1 >12% and 400mL Consider ACOS diagnosis of ACOS
presentation & whether
from baseline
treatment has been
commenced

Global Initiative for Asthma (GINA) 2014

 Its time to diagnose a case!

• Female, age 46
• History of childhood wheezing
• Feels breathless mostly during early morning
• Spirometry showed 72% predicted FEV1, post
bronchodilator change from baseline in FEV1 > 20%,
FEV1/FVC = 0.79
• X-Ray Normal

What’s your diagnosis?

 Its time to diagnose a case!

• Male, age 62
• Smoked 1 to 2 packs/ day, since age 22
• After counselling, quit after 10 years
• History of childhood asthma
• Complains of chronic cough, breathlessness increases when starts
playing with his grand children
• Spirometry showed 86 % predicted FEV1, post bronchodilator
change from baseline in FEV1 > 17% and 146ml, FEV1/FVC = 0.67
• X- Ray shows hyperinflation

What’s your diagnosis?

 Its time to diagnose a case!

• Male, age 54
• Smoked at least 1 pack/ day, since age 16
• Currently smokes 1-2 cigarettes/ week
• Family history of asthma
• Spirometry showed 72% predicted FEV1, post bronchodilator
change from baseline in FEV1 > 20%, FEV1/FVC = 0.64
• X- Ray shows hyperinflation

What’s your diagnosis?

 Step 4: Commence initial therapy
• Differential diagnosis equally balanced between asthma and COPD
(i.e. ACOS) - Start treatment for asthma

• Syndromic assessment suggests asthma or ACOS, or there is

significant uncertainty about the diagnosis of COPD - Start treatment
as for asthma until further investigation

• Syndromic assessment suggests COPD

Symptomatic treatment with bronchodilators or combination therapy. Patients should
not be prescribed ICS as monotherapy

Global Initiative for Asthma (GINA) 2014

 Step 4: Commence initial therapy (treatment options)

Asthma ACOS COPD

●
LABA
●
LABA
●
ICS + LABA ●
ICS + LAMA
●
ICS ●
ICS + LAMA ●
ICS + LABA
●
ICS + LABA ●
ICS + LABA + ●
ICS + LABA +
LAMA
LAMA
●
LABA + LAMA
Global Initiative for Asthma (GINA) 2014
 Refer for specialized investigations if needed
Investigation Asthma COPD
DLCO Normal or slightly elevated Often reduced
Arterial blood gases Normal between exacerbations In severe COPD, may be abnormal
between exacerbations

Airway Not useful on its own in distinguishing asthma and COPD.

hyperresponsiveness High levels favor asthma

High resolution CT scan Usually normal; may show air Air trapping or emphysema; may show
trapping and increased airway wall bronchial wall thickening and features of
thickness pulmonary hypertension

Tests for atopy (sIgE Not essential for diagnosis; Conforms to background prevalence; does
and/or skin prick tests) increases probability of asthma not rule out COPD

FENO If high (>50ppb) supports Usually normal. Low in current smokers

eosinophilic inflammation

Blood eosinophilia Supports asthma diagnosis May be found during exacerbations

Sputum inflammatory cell Role in differential diagnosis not established in large populations
analysis

Global Initiative for Asthma (GINA) 2014

 5 step
approach for
managing
ACOS
 5 step
approach for
managing
ACOS