Acos
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Asthma or COPD? More features favor COPD: - Age >40 years - Smoking history - Chronic symptoms not fully relieved by SABA - Previous LRTI requiring hospitalization Diagnosis: COPD
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Acos
- 1. DEFINITIONS Asthma *A heterogeneous disease, usually 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 *A common preventable and treatable disease. *Characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases.
- 2. *Exacerbations and comorbidities contribute to the overall severity in individual patients. ACOS *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
- 3. Step-wise approach to diagnosis of pt with resp. symptoms
- 4. Step 1 DIAGNOSE CHRONIC AIRWAY DISEASE Do symptoms suggest chronic airways disease? NoYes Consider other diseases first Step 2 SYNDROMIC DIAGNOSIS OF AIRWAYS DISEASE 1- Assemble the features for asthma and for COPD that best describe the pt. 2- Compare the number of features in favor of each diagnosis and select diagnosis . Step 3 SPIROMETRY ASTHMA : Marked reversible airflow limitation (pre – post BD) ACOS & COPD : FEV1/FVC <0.7 post BD
- 5. Step 4 INITIAL TREATMENT Asthma drugs but No LABA monotherapy ( possible or Asthma ) ICS and LABA +/or LAMA ( ACOS) COPD drugs but No ICS monotherapy (Possible or COPD) Step 5 SPECIALIZED INVESTIGATIO NS OR REFER IF: *Persistent symptoms and / or exacerbation despite treatment. * Diagnostic uncertainty eg suspected PAH , CVD , and other causes of respiratory symptoms. *Suspected Asthma or COPD with atypical or additional s&s eg haem0ptysis, w. loss , n. sweats , fever, signs of bronchiectasis other structural lung disease. * Fews features of either asthma or COPD . * Co morbidities present.
- 6. Step 1: Does the patient have chronic airways disease? Clinical history *History of chronic or recurrent cough, sputum production, dyspnea, or wheezing; or repeated acute LRTI. *Report of a previous doctor diagnosis of asthma or COPD. *History of prior treatment with inhaled medications . *History of smoking tobacco and/or other substances. *Exposure to air pollution e.g. occupational or domestic.
- 7. Step 1: Does the patient have chronic airways disease? (cont) Physical examination *May be normal . *hyperinflation and other features of chronic lung disease or R.failure . *Abnormal auscultation (wheeze and/or crackles). Radiology (CXR or CT) *May be normal, particularly in early stages . *May be abnormal (hyperinflation, airway wall thickening, air trapping, hyperlucency, bullae or other features of emphysema). Or *Alternative diagnosis, including bronchiectasis ,lung infections such as tuberculosis, ILD or CHF.
- 8. STEP 2: Syndromic diagnosis of airways disease ? (cont) *Brief review of Usual features of asthma , COPD and ACOS. *From the following boxes:- 1- Count the number of check boxes in each column. 2- If three or more boxes are checked for either asthma or COPD, that diagnosis is suggested. 3- If there are similar numbers of checked boxes in each column, the diagnosis of ACOS should be considered. *If the syndromic assessment suggests asthma or ACOS, or there is significant uncertainty about the diagnosis of COPD, it is prudent to start treatment as for asthma until further investigation has been performed to confirm or refute this initial position.
- 9. 1- Usual features of asthma , COPD and ACOS Feature Asthma COPD ACOS Age of onset Usually childhood onset but can commence at any age. Usually > 40 years of age Usually age ≥40 years, but may have had symptoms in childhood or early adulthood Pattern of respiratory symptoms Symptoms may vary over time (day to day, or over longer periods), often limiting activity. Often triggered by exercise, emotions including laughter, dust or exposure to allergens Chronic usually continuous symptoms, particularly during exercise, with ‘better’ and ‘worse’ days Respiratory symptoms including exertional dyspnea are persistent but variability may be prominent
- 10. 2- Usual features of asthma , COPD and ACOS Feature Asthma COPD ACOS Lung function Current and/or historical variable airflow limitation, e.g. BD reversibility, AHR FEV1 may be improved by therapy, but post- BD FEV1/FVC < 0.7 persists Airflow limitation not fully reversible, but often with current or historical variability Lung function between symptoms May be normal between symptoms Persistent airflow limitation Persistent airflow limitation Past history or family history Many patients have allergies and a personal history of asthma in childhood, and/or family history of asthma History of exposure to noxious particles and gases (mainly tobacco smoking and biomass fuels) Frequently a history of doctor- diagnosed asthma (current or previous), allergies and a family history of asthma, and/or a history of noxious exposures
- 11. 3- Usual features of asthma , COPD and ACOS Feature Asthma COPD ACOS Time course Often improves spontaneously or with treatment, but may result in fixed airflow limitation Generally, slowly progressive over years despite treatment Symptoms are partly but significantly reduced by treatment. Progression is usual and treatment needs are high Chest X-ray Usually normal Severe hyperinflation & other changes of COPD Similar to COPD
- 12. 4- Usual features of asthma , COPD and ACOS Feature Asthma COPD ACOS Exacerbation Exacerbations occur, but the risk of exacerbations can be considerably reduced by treatment Exacerbations can be reduced by treatment. If present, comorbidities contribute to impairment Exacerbations may be more common than in COPD but are reduced by treatment. Comorbidities can contribute to impairment Typical airway inflammation Eosinophils and/or neutrophils Neutrophils in sputum, lymphocytes in airways, may have systemic inflammation Eosinophils and/or neutrophils in sputum.
- 13. 1- Asthma or COPD Feature Favors asthma Favors COPD Age of onset Before age 20 years After age 40 years Pattern of respiratory symptoms Variation in symptoms over minutes, hours or days Symptoms worse during the night or early morning Symptoms triggered by exercise, emotions including laughter, dust or exposure to allergens Persistence of symptoms despite treatment Good and bad days but always daily symptoms and exertional dyspnea Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers
- 14. 2- Asthma or COPD Feature Favors asthma Favors COPD Lung function Variable airflow limitation (spirometry, peak flow) Persistent airflow limitation (post-bronchodilator FEV1/FVC < 0.7 ) 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 a risk factor: tobacco smoke, biomass fuels
- 15. 3- Asthma or COPD Feature Favors asthma Favors COPD Time course No worsening of symptoms over time. Symptoms vary either seasonally, or from year to year. May improve spontaneously or have an immediate response to BD 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 BA Some features OF BA Features OF both Some features OF COPD COPD CONFIDENCE IN DIAGNOSIS BA Possible BA ACOS Possible COPD COPD NOTE: *These features best distinguish between athma and COPD. * postive features (3 or more) for either asthma or COPD sugest that diagnosis. *If there are a similar number for both asthma and COPD consider ACOS.
- 16. STEP 3: Spirometry *Spirometry is essential for the assessment of patients with suspected chronic disease of the airways. *It must be performed at either the initial or a subsequent visit, if possible before and after a trial of treatment. *Early confirmation or exclusion of the diagnosis may avoid needless trials of therapy, or delays in initiating other investigations. *Spirometry confirms chronic airflow limitation but is of more limited value in distinguishing between asthma with fixed airflow obstruction, COPD and ACOS . *PEF, although not an alternative to spirometry, if performed repeatedly on the same meter over a period of 1–2 weeks may help to confirm the diagnosis of asthma by demonstrating excessive variability, but a normal PEF does not rule out either asthma or COPD.
- 17. STEP 3: Spirometry (cont) *A high level of variability in lung function may also be found in ACOS. *Spirometry at a single visit is not always confirmatory of a diagnosis. *Further tests might therefore be necessary either to confirm the diagnosis or to assess the response to initial and subsequent ttt. *Spirometric measures in asthma, COPD and ACOS
- 18. Spirometric measures in asthma, COPD and ACOS Spiro metric variable Asthma COPD ACOS normal FEV1/FVC pre- or post BD Compatible with diagnosis Not compatible with diagnosis Not compatible unless other evidence of chronic airflow limitation Post-BD FEV1/FVC <0.7 Indicates airflow limitation but may improvespontaneously or on treatment Required for diagnosis Usually present
- 19. Spirometric measures in asthma, COPD and ACOS Spiro metric variable Asthma COPD ACOS FEV1 ≥80% predicted Compatible with diagnosis (good asthma control or interval between symptoms) Compatible with GOLD classification of mild airflow limitation(categories A or B) if post- BD FEV1/FVC <0.7 Compatible with diagnosis of mild ACOS FEV1 <80% predicted Compatible with diagnosis. Risk factor for asthma exacerbations An indicator of severity of airflow limitation and risk of future events (e.g. mortality and COPD exacerbations) An indicator of severity of airflow limitation and risk of future events (e.g. mortality and exacerbations)
- 20. Spirometric measures in asthma, COPD and ACOS Spirometric variable Asthma COPD ACOS Post-BD increase in FEV1>12% and 200 ml from baseline (reversible airflow limitation) Usual at some time in course of asthma, but may not be present when well-controlled or on controllers Common and more likely when FEV1 is low, but ACOS should also be considered Common and more likely when FEV1 is low, but COPD should also be considered Post-BD increase in FEV1>12% and 400ml from baseline (marked reversibility) High probability of asthma Unusual in COPD. Consider ACOS Compatible with diagnosis of ACOS
- 21. STEP 4: Commence initial therapy *ACOS start treatment with ICS because of the pivotal role of ICS in preventing morbidity and even death in pt with uncontrolled asthma symptoms, for whom even seemingly ‘mild’ symptoms (compared to those of moderate or severe COPD) might indicate significant risk of a life-threatening attack. *If the syndromic assessment suggests asthma or ACOS, or there is significant uncertainty about the diagnosis of COPD, it is prudent to start treatment as for asthma until further investigation has been performed to confirm or refute this initial position. ( Treatments will include an ICS and LABA should also be continued -if already prescribed-, or added. * No LABA mono therapy if there are features of asthma.
- 22. STEP 4: Commence initial therapy (cont) *COPD, appropriate symptomatic treatment with bronchodilators or combination therapy should be commenced, but not ICS mono therapy. *Treatment of ACOS should also include advice about other therapeutic strategies including:- 1- Smoking cessation. 2- Pulmonary rehabilitation. 3- Vaccinations. 4-Treatment of co morbidities . *In a majority of patients, the initial management of asthma and COPD can be satisfactorily carried out at primary care level.
- 23. Drugs for Asthma & COPD & ACOS Inhaler Short Acting BD SABA as Salbutamol, Terbutaline & SAMA as Ipratropium Long Acting BD LABA as Salmeterol, Formoterol & LAMA as Tioptropium ICS As Fluticasone, Budesonide, beclomethasone Combination SABA + SAMA as Salbutamol + Ipratropium LABA + ICS as Salmeterol + Fluticasone and Formoterol + Budesonide Non inhaler LTRAs montelukast Anti- IgE Ab Omalizumab SCS Prednisolone , methylprednisolone , hydrocortisone
- 24. Specialized investigations sometimes used in distinguishing asthma and COPD Asthma COPD DLCO Normal (or slightly elevated). Often reduced ABG Normal between exacerbations May be chronically abnormal between exacerbations in more severe forms of COPD AHR Not useful on its own in distinguishing asthma from COPD, but high levels of AHR favor asthma High resolution CT Scan Usually normal but air trapping and increased bronchial wall thickness may be observed. Low attenuation areas denoting either air trapping or emphysematous change can be quantitated ; bronchial wall thickening and features of pulmonary hypertension may be seen.
- 25. Inflammatory biomarkers Asthma COPD Test for atopy (specific IgE and/or skin prick tests) Modestly increases probability of asthma; not essential for diagnosis Conforms to background prevalence; does not rule out COPD FENO A high level (>50 ppb) in nonsmokers supports a diagnosis of eosinophilic airway inflammation Usually normal. Low in current smokers Blood eosinophilia Supports asthma diagnosis May be present during exacerbations Sputum inflammatory cell analysis Role in differential diagnosis is not established in large populations
- 26. Examples
- 27. CASE 1 * 19 year old female student. * C/O: 3 days cough, wheezing, SOB. - Precipitated by exercise . - Relieved by salbutamol nebulization (past 3 nights) - Self medicated with prednisone 10mg 1 dose * (+ve) history of asthma attacks during childhood * (+ve) family Hx of asthma (mother). * (+ve) Hx of atopy. * EX: talks in sentences & wheeze. Diagnosis Athma
- 28. Case 2 * 72 year old housewife * C/O: on and off cough, wheezing, shortness of breath - Relieved by SABA nebulization - lately is more bothersome after hosting a birthday party - with grayish sputum, difficulty sleeping - Has consulted several doctors; has 4 inhaler devices * Smoker * Previously hospitalized due to LRTI 3 months ago * EX: talks in phrases & wheezing both lung fields Diagnosis COPD
- 29. Case 3 * 55 year old, male, teacher * C/O: cough, wheezing, shortness of breath 7 days - Precipitated by exposure to dust. - Sneezing, itchy throat - Unable to sleep due to SOB, partially relieved by SABA neb * (+ve) history of childhood asthma * (+ve) 20 pack year (current) smoker * (+ve) history of antibiotic (Co-amox) intake 4 weeks ago after diagnosed with pneumonia as outpatient. *EX: talks in sentences & wheezing both lung fields Diagnosis ACOS
- 30. What is the single most effective intervention to slow the progression of COPD? 1 Home Oxygen 2 Pulmonary Rehab. 3 Smoking Cessation 4 Flu Vaccination Smoking Cessation Evidence A
- 31. Remember
- 32. 1- Distinguishing asthma from COPD can be problematic, particularly in smokers and older adults. 2- ACOS is identified by the features that it shares with both asthma and COPD. 3- A stepwise approach to diagnosis is advised, comprising recognition of the presence of a chronic airways disease, syndromic categorization as asthma, COPD or ACOS, confirmation by spirometry and, if necessary, referral for specialized investigations. 4- Although initial recognition and treatment of ACOS may be made in primary care, referral for confirmatory investigations is encouraged. 5- Outcomes for ACOS are often worse than for asthma or COPD alone.
- 33. 6- The single most effective intervention to slow the progression of COPD is Smoking Cessation. 7- Initial treatment of Pt with features of asthma is adequate controller therapy including ICS, but not LABA mono therapy. 8- Patients with COPD receive appropriate symptomatic treatment with bronchodilators or combination therapy , but not ICS mono therapy. 9- ACOS need further study of the character and treatments for this common clinical problem.
- 34. 10- Inhaler use is a skill - must be learned and maintained *Up to 70–80% are unable to use their inhaler correctly. *Unfortunately, many health care providers are unable to correctly demonstrate how to use the inhalers they prescribe. *Most people with incorrect technique are unaware that they have a problem. *There is no ‘perfect’ inhaler - patients can have problems using any inhaler device.