4. The Asthma COPD overlap syndrome (ACOS) is a
newly recognized entity, one that has long been
neglected in part because clinical trials for
decades have excluded patients with
overlapping asthma and COPD, using
strict inclusion & exclusion criteria.
These criteria routinely excluded asthma
patients from COPD studies, and COPD patients
from asthma studies .
4
5. The concept of the asthma COPD overlap
syndrome is an attempt to develop
diagnostic criteria for patients with
features of both asthma and COPD.
The pitfall is to presume that both
conditions can not possisbly exist in the
same patient.
5
6. Recently, much attention has been focused on
patients with overlapping features of both asthma
and COPD, those with asthma COPD overlap
syndrome (ACOS).
A consensus ACOS description for clinical use has
recently been published by both :The Global
Initiative for Asthma (GINA) and the Global Initiative
for Chronic Obstructive Lung Disease (GOLD) in
2014.
6
19. The GINA/GOLD document emphasized that
ACO is not a definition of a new disease but
a ‘description for clinical use.
When a patient has similar numbers of
features of both asthma and COPD, the
diagnosis of ACO should be considered.
19
20. The GINA/GOLD document defined the ACOS
phenotype as persistent airflow limitation
with characteristics of both asthma and
COPD but did not clearly specify how many
shared clinical features of asthma & COPD
should be met to establish a diagnosis of
ACOS.
20
21. Because the GINA/GOLD document on ACOS is a series
of checklist of characteristics of ACOS without
thresholding, it is not particularly useful
as a diagnostic tool for the clinician.
Other expert societies have offered more practical
case definitions of ACOS (endorsed case definitions
based on major and minor criteria).
21
23. In 2016 a global expert panel of specialists &
generalists from North America, Western Europe
and Asia proposed a set of diagnostic criteria
consisting of 3 major & 3 minor criteria.
Patients who meet all 3 major criteria and at
least 1 minor criterion should be considered
as having ACOS
23
27. More recently, the new consensus between GesEPOC
& the Spanish Guidelines for the Management of
Asthma (GEMA) 2017,defined overlapping of asthma
and COPD (ACO) as :
The presence of chronic persistent airflow
limitation, in a smoker or former smoker [tobacco
exposure≥10 pack-years] with a concomitant
diagnosis of asthma or with characteristics of
asthma such as very positive BDR (≥15% and
≥400ml) and/or blood eosinophilia (≥300
eosinpophils/µL).
27
30. Always do the spirometry
Essential for patient assessment in asthma ,COPD and ACO
Normal FEV1/FVC pre or post bronchodilator is not
compatible with COPD or ACO
Post BD increase in FEV1 >12% and 200 ml from baseline
can be seen in all 3 conditions (if 400 ml ,more likely asthma
or ACO)
30
31. The ACO phenotype includes not only smoker
asthma patients who develop persistent airflow
obstruction but also COPD with characteristics of
asthma.
To fulfill this definition:
1. Airflow limitation must be persistent over
time
2.Current or past smoking should be the main risk
factor
3.The patient must present the clinical ,biological or
functional characteristics of asthma
31
32. The presence of significant exposure to tobacco smoke is
one of the features favouring COPD.
However, smoking (or exposure to biomass fuels)
should be a necessary factor for the diagnosis of
ACO; a never-smoking asthmatic with persistent
airflow obstruction cannot be diagnosed with ACO.
No overlap with COPD can be postulated if there is
no significant exposure to inhaled risk factors.
32
33. Clinical expression of the asthma-COPD
overlap (ACO)
1)The ACOS usually corresponds to a smoker
asthmatic patient that develops non fully
reversible airway obstruction and/or
2)a COPD individual (with or without a known
history of asthma) with a Th2 signature
(increased blood and lung eosinophilia,
increased airway hyper-responsiveness, and
better response to ICS).
33
34. ACOS accounts for approximately
15–25% of the obstructive airway
diseases and patients experience
worse outcomes compared with
asthma or COPD alone .
34
40. Asthma management guidelines and COPD
management guidelines make opposing safety
recommendations.
In asthma, long-acting bronchodilators should
never be used without ICS, while in COPD,
treatment should start with long-acting
bronchodilators without ICS.
40
42. 42
The importance of diagnosing ACO is
to identify patients with COPD who
require treatment with ICS
plus LABA from early phases of the
disease.
43. Experts have suggested inhaled
corticosteroids/long acting beta2 agonist
combination (ICS/LABA) as the first line
therapy for ACOS, followed by the addition
of a long acting anticholinergic if the
patient remains persistently symptomatic
with ICS/LABA combination
43
44. The presence of ACO has been associated with a
higher degree of bronchial eosinophilic
inflammation,
This would account for its greater clinical and
spirometric response to inhaled corticosteroids
(ICS), and justifies the use of these combined
with a LABA as a first option to improve lung
function and respiratory symptoms & reduce
44
45. 45
Follow-up is needed in these cases to evaluate
response and, as with asthma, to select the
minimum ICS dose necessary for long-term
treatment
Triple ICS/LABA/LAMA treatment may be required
in more severe cases.
53. 53
Use combination inhaler , ICS plus LABA (in a
single inhaler,if possible) to prevent patients
taking long acting bronchodilators without ICS
LABAs and LAMAs should not be used by
people with asthma or asthma–COPD overlap
unless they are also taking an ICS
(either in combination or separately).
54. 54
The combination of ICS , LABA and LAMA (with
at least two of the agents in a single inhaler)
If possible, minimise the number of different
types of inhaler devices to avoid confusion
about inhaler technique.
