1. Best care management in COPD and asthma
Diagnosis and treatment in Asthma COPD overlap
Professor Hilary Pinnock
Asthma UK Centre for Applied Research,
The University of Edinburgh
General Practitioner
Whitstable Medical Practice, Kent
November 2018

2. Declaration of interests
Teva
Declaration of interests
Airsonett,
ALK-Abello,
Allergy Therapeutics,
AstraZeneca
Bausch and LoMe,
Boerhinger Ingelheim
Chiesi,
Cipla
GSK,
Johnson and Johnson,
Mead Johnson Nutrition,
Meda,
Mylan
Napp Pharmaceuticals,
Novartis
ThermoFisher,
Napp,
Nutrica.
Pfizer
Teva
Vitalograph

3. Asthma Airway inflammation Eosinophilic infiltration
Mast cells activation
Asthma
GINA guidelines:
Reversible airway narrowing
Bronchoconstriction
Mucosal oedema
Excess mucus secretion
Hyperresponsiveness
+/- Airway remodelling
Thickened basement membrane
Muscle hypertrophy
Increased goblet cells

4. COPD Cigarette smoking or other irritant Recurrent infections
GOLD guidelines:
Recurrent infections
Mucus hypersecretion
Gas Exchange Abnormalities
Small airway inflammation
Neutrophils and macrophages
Repair and airway fibrosis
Airway collapse
Loss of alveolar structure
Decrease elastic recoil
Air trapping

5. Reversible Airflow limitation Irreversible
It ought to be easy to distinguish asthma from COPD…
Asthma
COPD
Mast cells
Eosinophils
Triggers
Smoking
Macrophages
Neutrophils
Reversible
Hyper-responsiveness
Bronchoconstriction
Alveolar destruction
Small airway fibrosis
Airflow limitation
Irreversible

6. Asthma highly probable
Suspected asthma:
Watchful waiting (if asymptomatic)
or Commence treatment,
Assess response objectively
Adjust maintenance dose
Provide self-management
Arrange on-going review
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness
Structured clinical assessment (from history and examination of previous medical records)
Look for: Recurrent episodes of symptoms; Recorded observation of wheeze;
Symptom variability; Personal history of atopy; Absence of symptoms of alternative diagnosis
Record of peak flow variability or obstructive spirometry/reversibility
Code as:
Suspected asthma
Asthma highly probable
Commence treatment
(lung function/validated symptom score)
Good response
Asthma
Low probability of asthma
Investigate/treat for other more likely diagnosis
Other diagnosis
confirmed
Intermediate probability of asthma
Test for airway obstruction
Spirometry
Poor response
Test for variability:
Reversibility
PEF charting
Challenge tests
Test for eosinophilic inflammation or atopy:
FeNO
Blood eosinophils,
SPT, IgE
Other diagnosis unlikely
Options for investigations are:

7. Three of my patients Low Intermediate High
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness
Three of my patients
Low
Intermediate
High

8. Structured clinical assessment✓
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness
Recurrent episodes (attacks) of symptoms
Recorded observation of wheeze heard by a professional
Symptoms of wheeze, cough, breathlessness and dyspnoea that vary over time
Personal/family history of other atopic conditions
No symptoms/signs to suggest alternative diagnoses.
Low
Intermediate
High

9. Structured clinical assessment✓
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness
Wheezing after URTI and in pollen season
Asymptomatic between episodes
Recent acute attack. PF 250l/min Wheeze heard by GP
PF after steroids l/min Chest clear
Non-smoker
Low
Intermediate
High

10. Q Structured clinical assessment ✓
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness ✓
Structured clinical assessment
Wheezing after URTI and in pollen season
Asymptomatic between episodes
Recent acute attack. PF 250l/min Wheeze heard by GP
PF after steroids l/min Chest clear
Non-smoker Q
Asthma is highly probable: I am happy to start treatment
Asthma is highly probable, but I want to confirm with spirometry
She has probably got COPD
It might be asthma and COPD, I need some investigations
Low
Intermediate
High

11. Structured clinical assessment
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness ✓
Structured clinical assessment
Wheezing after URTI and in pollen season
Asymptomatic between episodes
Recent acute attack. PF 250l/min Wheeze heard by GP
PF after steroids l/min Chest clear
Non-smoker
Spirometry is likely to be normal…
Low
Intermediate
High

12. Asthma highly probable
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness ✓
Structured clinical assessment
Adjust maintenance dose
Provide self-management
Arrange on-going review
Code as:
Suspected asthma
Asthma highly probable
Commence treatment
Assess response objectively
(lung function/validated symptom score)
Good response
Asthma
Initiating treatment
Code as ‘suspected asthma’
Initiate treatment (typically ICS)
Assess response (validated questionnaire, FEV1,serial PFs) ✓
No response, discontinue medication, reconsider
Good response,
code ‘asthma’, record basis of diagnosis
Provide self-management education (PAAP) before arranging repeat prescribing
Adjust treatment
Low
Intermediate
High

13. Q Structured clinical assessment ✓ Smoker
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness ✓
Structured clinical assessment
Smoker
Insidious development of dyspnoea over last 20 years
Productive cough
Inexorable deterioration
Little variability Q
Asthma is highly probable: I am happy to start asthma treatment
COPD is highly probable, but I want to confirm with spirometry
It might be asthma and COPD, I need some investigations
I don’t know what the problem is…
Low
Intermediate
High

14. Structured clinical assessment
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness ✓
Structured clinical assessment
Smoker
Insidious development of dyspnoea over last 20 years
Productive cough
Inexorable deterioration
Little variability
FEV1 = 28% predicted: FEV1/FVC = 51%
Bronchodilator reversibility 18% (210mls)
Low
Intermediate
High

15. Low probability of asthma
Presentation with respiratory symptoms: wheeze, cough, dyspnoea, chest tightness ✓
Structured clinical assessment
Low probability of asthma
Investigate/treat for other more likely diagnosis
Other diagnosis
confirmed
Low
Intermediate
High

16. ? Brian: 61yr old garage owner Wheezy after an URTI Smoker
Tendency to chestiness as a child
Has been given blue inhalers in the past
Pre-bronchodilator peak flow: 200
Post-bronchodilator peak flow: 240 ?

17. ? Brian: 61yr old garage owner Wheezy after an URTI Smoker
Tendency to chestiness as a child
Has been given blue inhalers in the past ?
Pre-bronchodilator peak flow: 200
Post-bronchodilator peak flow: 240

18. ? Brian: 61yr old garage owner FEV1 = 66% predicted: FEV1% = 62% ?
Wheezy after an URTI
Smoker
Tendency to chestiness as a child
Has been given blue inhalers in the past
FEV1 = 66% predicted: FEV1% = 62%
Bronchodilator reversibility 10% (190mls) ? ?
Restrictive

19. Asthma-COPD overlap A help or a hindrance? Diagnosis Management
Multimorbidity
A help or a hindrance?

20. A help or a hindrance?

21. Terminology and definitions are (part of) the problem
A help if:
It focuses attention on the additional complexity of co-morbidity
A hindrance if:
It creates another condition (‘syndrome’)
It confuses patients and professionals
Terminology and definitions are (part of) the problem

22. Terminology and definitions are (part of) the problem
COPD is a slowly progressive disorder characterised by airflow obstruction that does not change markedly over several months. [BTS 1997]
Asthma
COPD
Bronchitis
Emphysema
Terminology and definitions are (part of) the problem

23. COPD is… characterised 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 [GOLD 2018]
Asthma is a heterogeneous disease, usually characterised by chronic (eosinophilic) airway inflammation. It is defined by a history of respiratory symptoms … that vary over time and in intensity together with variable airflow limitation. [GINA 2018]
Different definitions
Different pathophysiology
Different cause/risk factors
Different demography
Different epidemiology
Different clinical course
Different response to treatment
Asthma
COPD
Asthma
COPD
Bronchitis
Emphysema

24. COPD is… characterised 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 [GOLD 2015]
Different definitions
Different pathophysiology
Different cause/risk factors
Different demography
Different epidemiology
Different clinical course
Different response to treatment
Asthma
COPD
Bronchitis
COPD
Asthma
Emphysema
Asthma is a heterogeneous disease, usually characterised by chronic (eosinophilic) airway inflammation. It is defined by a history of respiratory symptoms … that vary over time and in intensity together with variable airflow limitation. [GINA 2015]

25. COPD and asthma Some patients with COPD have some reversibility
Some patients with asthma have a progressive course
Barnes et al. Am J Respir Crit Care Med 2006;174:240–244
This might be evidence of a continuum from asthma to COPD and these atypical patients falling somewhere in between.
However, it is more likely that both of these very common diseases may occur concurrently in some patients.

26. Two common diseases….
… will occur concurrently in some patients

27. ACOS Asthma-COPD overlap ‘syndrome’...
ACOS is characterised by persistent airflow limitation
with several features usually associated with asthma
and several features usually associated with COPD.

28. ACOS Asthma-COPD overlap ‘syndrome’...
There is a phenotype of COPD that is difficult to separate from asthma:
eosinophilia in sputum,
positive bronchodilator test
history prior to the age of 40,
including allergic rhinitis
high total IgE
personal history of atopy
J.J. Soler-Catalun a et al. Arch Bronconeumol. 2012;48:331–337
ACOS

29. ACOS Asthma-COPD overlap ‘syndrome’...
There is a phenotype of asthma that is:
Non-eosinophilic
Tendency to be obese
More likely to be female
Less atopic
High symptom scores
Haldar et al. Am J Respir Crit Care Med 2008; 178:
Moore et al. Am J Respir Crit Care Med 2010; 181:
ACOS
ACOS?

30. Asthma-COPD co-morbidity
Barnes et al. Am J Respir Crit Care Med 2006;174:240–244
However, it is more likely that both of these very common diseases may occur concurrently in some patients.

31. Asthma-COPD co-morbidity
Nissen et al. Br J Gen Pract 2018;68:e775-e782
351 patients with asthma
52 (14.8%) also had COPD
400 patients with COPD
58 (14.6%) also had asthma

32. Diagnosis

33. Does the patient have chronic airflow limitation?
Take a good history…
Symptoms of cough, sputum, wheeze, breathlessness
Age of onset
Risk factors
Variability

34. Balance the probabilities

35. Balance the probabilities3+ =

36. 3+ = 3+ Spirometry Substantial variability
Obstructive spirometry =
Reversibility but not to normal 3+

37. Managing asthma + COPD?

38. Management Inhaled steroids No monotherapy with LABA
Advise smoking cessation
Management
Inhaled steroids
No monotherapy with LABA
Start with treatment for asthma
Support self-management
Promote exercise
Pulmonary rehabilitation
Bronchodilators
No monotherapy with ICS

39. Referral Refer for expert advice and evaluation Diagnostic uncertainty
Failure to respond to treatment
Complex co-morbidities
‘Red flags’

40. Multimorbidity

41. Asthma-COPD co-morbidity
3,885 adults in Spain
Screened for COPD
385 (10.1%) were diagnosed with COPD,
67 (17.4%) had a previous diagnosis of asthma
Patients with COPD and asthma had:
More dyspneoa and wheezing
More co-morbidities
More frequent exacerbations
Worse quality of life
despite similar age & lung function, and less likely to be smokers
Miravitles et al. Respir Med 2013; 107:

42. It focuses attention on the additional complexity of co-morbidity
Hospital episodes
Anderson et al. Clin Respir J 2013; 7: 342–346
105,122 adults in Finland
It focuses attention on the additional complexity of co-morbidity

43. Multimorbidity in COPD
50yrs
65yrs
1 condition
2 conditions
3 conditions
4 conditions
5 conditions
6 conditions
7 conditions
8 conditions
“Multimorbidity is becoming the norm rather than the exception…”
Barnett et al. Lancet 2012; 380: 37–43

44. Multimorbidity in COPD?
Barnett et al. Lancet 2012; 380: 37–43

45. Take home messages 10-20% of people with COPD also have asthma
Despite descriptions of the overlap as a ‘syndrome’ this is likely to be co-morbidity in most cases.
The co-morbidity is important because of the increased morbidity
Diagnosis depends on a good history, looking for features of both asthma and COPD
Manage the asthma first
Remember the impact of multimorbidity
Take home messages

46. Best care management in COPD and asthma
Diagnosis and treatment in Asthma COPD overlap
Professor Hilary Pinnock
Asthma UK Centre for Applied Research,
The University of Edinburgh
General Practitioner
Whitstable Medical Practice, Kent