This document discusses asthma-COPD overlap (ACO), where patients exhibit features of both asthma and chronic obstructive pulmonary disease (COPD). It defines the conditions and notes that distinguishing them can be difficult, especially in smokers and older adults. Patients with ACO features experience more exacerbations and poorer outcomes than those with asthma or COPD alone. The document provides guidance on diagnosing and initially treating ACO based on GINA and GOLD guidelines, emphasizing inhaled corticosteroids to reduce exacerbation risk in all patients with chronic airflow limitation. Further research is still needed to better classify and treat ACO phenotypes.

1. ASTHMA COPD OVERLAP : A
NEW ENTITY
-Ankit Jaiswal, Resident Medicine
Guided by Dr Nalini Humaney Mam

2. Definition
• Asthma - Asthma is characterized by chronic airway inflammation.
It is defined by the history of respiratory symptoms such as wheeze,
shortness of breath, chest tightness and cough that vary over time and
in intensity, together with variable expiratory airflow limitation.
• COPD - Chronic obstructive pulmonary disease (COPD) is
characterized by persistent respiratory symptoms and airflow
limitation due to airway and/or alveolar abnormalities usually caused
by significant exposure to noxious particles or gases and influenced by
host factors including abnormal lung development.

3. • ‘Asthma-COPD overlap’ and ‘asthma + COPD’ are terms used to
collectively describe patients who have persistent airflow limitation
together with clinical features that are consistent with both asthma
and COPD.

5. Many patients have features of both asthma and COPD
• Distinguishing asthma from COPD can be difficult, particularly in
smokers and older adults
• The terms ‘asthma-COPD overlap’ (ACO) or ‘asthma+COPD’ are simple
descriptors for patients who have features of both asthma and COPD.
• These terms do not refer to a single disease entity. They include
patients with several clinical phenotypes that are likely caused by a
range of different underlying mechanisms.
• More research is needed to better define these phenotypes and
mechanisms, but in the meantime, safety of pharmacologic treatment
is a high priority.

8. Why are the labels ‘asthma’ and ‘COPD’ still important?
• Differences in evidence-based treatment recommendations for
asthma and COPD, with treatment with long-acting bronchodilators
alone (i.e. without inhaled corticosteroids (ICS)) recommended as
initial treatment in COPD but contraindicated in asthma due to the
risk of severe exacerbations and death.
• In both asthma and COPD, patients who, for safety, should not be
treated with long-acting bronchodilators alone due to risk of
exacerbations.
• In COPD, high dose ICS should not be used because of the risk of
pneumonia

9. Prevalence and morbidity of asthma-COPD overlap
• Prevalence rates for asthma-COPD overlap-ranged between 9% and
55% of those who are either COPD or asthma
• Patients with features of both asthma and COPD experience frequent
exacerbations, have poor quality of life, a more rapid decline in lung
function, higher mortality and greater use of healthcare resources
compared with patients with asthma or COPD alone.

10. When to suspect Asthma-COPD Overlap
1. Asthma with current and past history of Smoking.
2. Late Onset Asthma with partially reversible airflow obstruction.
3. COPD with FEV1/FVC <0.7 with any 1 of following features
• Past or current Diagnosis of asthma
• Clinical features of asthma- Episodic , Allergic Triggers ,Elevated IGE
• Variable airflow obstruction
• Eosinophilic airway inflammation(FENO)

11. Approach to initial treatment in patients with asthma and/or COPD
ASTHMA:
History:
• Symptoms vary over time and in intensity
• Triggers may include laughter, exercise, allergens, seasonal
• Onset before 40 years of age
• Symptoms improve spontaneously or with bronchodilators (minutes) or ICS (Days to weeks)
• Current asthma diagnosis, or asthma diagnosis in childhood.
Lung Function:
• Variable expiratory airflow limitation
• Persistent airflow limitation may be present

12. ASTHMA + COPD:
History:
• Symptoms intermittent or episodic.
• May have started before or after age 40
• May have a history or smoking and/or other toxic exposures, or history of low
birth weight or respiratory illness such as tuberculosis.
• Any of asthma features at left (eg. Common triggers; symptoms improve
spontaneously or with bronchodilators or ICS; current asthma diagnosis or
asthma diagnosis in childhood)
Lung Function:
• Persistent expiratory airflow limitation
• With or without bronchodilators reversibility

13. COPD:
History:
• Dyspnea persistent (most days)
• Onset after age 40 years
• Limitation of physical activity
• May have been preceded by cough/ sputum
• Bronchodilator provides only limited relief.
• History of smoking and/or other toxic exposure, or history of low birth weight or
respiratory illness such as tuberculosis.
• No past or current diagnosis of asthma
Lung Function:
• Persistent expiratory airflow limitation
• With or without bronchodilator reversibility

15. investigations

16. Spirometry:
It is essential to confirm
the following:
• The presence of
persistent expiratory
airflow limitation
• Variable expiratory
airflow limitation

17. Initial Pharmacological Treatment Asthma
• Inhaled corticosteroid (ICS) containing treatment is essential to reduce risk of
severe exacerbations and death.
• As needed low dose ICS-formoterol may be used as a reliever.
• DO NOT GIVE Long acting ß𝟐- agonist (LABA) and /or LAMA without ICS
• Avoid maintenance Oral corticosteroid (OCS).
Initial Pharmacological Treatment for ACO
• Treatment is same as asthma as mentioned above.

19. Initial Pharmacological Treatment for COPD
• Initially LAMA and/or LABA (Long acting muscarinic antagonist)
• Add ICS as per GOLD for patients with blood eosinophils ≥300/μl
• Avoid high dose ICS, avoid maintenance OCS.
• Reliever containing ICS is not recommended.

21. All patients with chronic airflow limitation
Global Initiative for Asthma (GINA) and Global Initiative for Obstructive Lung
Diseases (GOLD) reports That:
• Treatment of modifiable risk factors including advice about smoking cessation
• Treatment of comorbidities
• Non-pharmacological strategies including physical activity for COPD or asthma-
COPD overlap, pulmonary rehabilitation and vaccinations
• Regular follow-up

22. FUTURE RESEARCH
• There is an urgent need for more research on this topic, in order to guide better
recognition and safe and effective treatment.
• Patients who do not have ‘classical’ features of asthma or of COPD, or who have
features of both, have generally been excluded from randomized controlled trials
of most therapeutic interventions for airways disease, and from many
mechanistic studies.
• Further research is needed to inform evidence-based definitions and a more
detailed classification of patients who present overlapping features of asthma
and COPD, and to encourage the development of specific interventions for clinical
use.

24. Take Home messages
• Treatment for asthma both ICS & LABA
• Treatment for asthma+COPD –Treat as Asthma
• Treatment for COPD-LAMA OR LABA OR BOTH

25. References
• GINA 2020 guidelines
• GOLD 2020 guidelines
• Harrison 20th edition
• eAPICON conference 2021
• Crofton & Douglas book of respiratory Medicine 5th Edition