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Asthma COPD overlap: a case study

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Asthma COPD overlap:

a case study
Emma Ray and Carol Kelly

Abstract

Asthma and chronic obstructive pulmonary disease (COPD) are common COPD is an umbrella term for common disease
respiratory diseases that account for a significant number of primary care presentations such as chronic bronchitis and
consultations. The classical clinical features of asthma and COPD can be emphysema (Vanfleteren et al, 2016). In contrast
clearly differentiated. However, many patients have contemporaneous features to asthma, COPD is a progressive disease with
of asthma and COPD, and it is estimated that a significant proportion of these significant impact on mortality and morbidity
patients have asthma-COPD overlap (ACO). This article provides an overview of (Kaplan and Thomas, 2017). It is largely
the diagnostic process and clinical management, both pharmacological preventable, and most commonly caused by
and non‑pharmacological, of a 58-year-old male presenting at his GP practice smoking, although other causes may be attributed
with ACO. (Parker and Eaton, 2012). Patients with COPD
typically experience persistent symptoms including
Key words: asthma | chronic obstructive pulmonary disease | asthma-COPD overlap breathlessness, reduced exercise tolerance, and
| case study | breathlessness increased production of mucus in the airways.
This leads to chronic cough and susceptibility
to infection, which may result in frequent

A
exacerbations (Viniol and Vogelmeier, 2018).
sthma and chronic obstructive pulmonary One of the key differentiating features between
disease (COPD) are the most common asthma and COPD is the presentation of symptoms.
respiratory diseases routinely seen in The variable nature of symptoms throughout
primary care. In the UK, there are an the day, season or lifespan, in conjunction with
estimated 8 million people with asthma, compared a family history of allergy and asthma as well as
to approximately 1.2 million people with COPD clear respiratory triggers, such as pollen, can often
(British Lung Foundation, 2016). There are several signpost to a diagnosis of asthma (Bousquet et al,
clinical features that clearly distinguish them 2000). In contrast, COPD should be suspected
from one another (Table 1) (Heffler et al, 2018). in patients aged over 35 years with a significant
Asthma is characterised by chronic inflammation smoking history (although it can affect younger
and hyper-responsiveness of the airways, leading to people) and with concurrent symptoms of dyspnoea
variable airflow limitation (Bousquet et al, 2000). It and/or productive cough, with little day-to-day
is usually, but not always, diagnosed in childhood variation (Vanfleteren et al, 2016).
and patients typically experience intermittent Differences in lung function may also be marked
wheeze, shortness of breath, chest tightness and in asthma compared to COPD. In stable asthma,
cough, which improves either spontaneously or with lung function tends to be normal, although it may
treatment (Martinez and Vercelli, 2013). vary due to the hyper-responsive nature of the
disease and it should also be possible to improve
airway limitation by optimising treatment (Martinez
and Vercelli, 2013). However, persistent chronic
Emma Ray
inflammation of the airways can lead to irreversible
Respiratory Nurse and Research Fellow, damage and treatments becoming less effective, and
University Hospital Southampton NHS Foundation Trust a reduction of lung function (Martinez and Vercelli,
© 2019 MA Healthcare Ltd

[email protected] 2013). Where airway limitation does not improve

following treatment with bronchodilation, COPD
Carol Kelly
Reader in Respiratory Care,
should be considered if the patient has accompanying
Edge Hill University clinical features, but asthma cannot be excluded
[email protected] in the presence of an associated history (Global

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 CLINICAL FOCUS

Initiative for Asthma (GINA), 2018; Global Initiative Table 1. Clinical features differentiating asthma and chronic obstructive
for Chronic Obstructive Lung Disease (GOLD), pulmonary disease
2019). A specialist referral is advised if there is any
COPD Asthma
diagnostic uncertainty.
At their extremes, asthma and COPD can be Smoker/ex-smoker Nearly all Possibly
straightforward to recognise. However, when patients
Symptoms under aged 35 Rare Often
present with clinical features of both diseases,
diagnostic uncertainty can occur. This is because Family history Uncommon Common
asthma and COPD are heterogeneous diseases with Chronic productive sputum Common Uncommon
a range of clinical phenotypes that are not yet fully
understood (Baarnes et al, 2017). Breathlessness Persistent and Variable
progressive
Asthma-COPD overlap (ACO) describes a subset
of patients with airways disease who have features Night time wakening with Uncommon Common
of both asthma and COPD. These patients remain breathlessness and/or wheeze
challenging to manage because of the complexity Significant diurnal or day-to-day Uncommon Common
of their disease, and their long-term prognosis is variability of symptoms
poor (Baarnes et al, 2017). There is no consensus
COPD: chronic obstructive pulmonary disease
on the pathogenesis of ACO, and arguments persist
as to whether it is (a) a discrete disease, (b) as a
result of airway remodelling due to exposure to
noxious fumes in asthma, or (c) caused by continued and evening (National Institute for Health and Care
airway inflammation, usually eosinophilic, in COPD Excellence (NICE), 2017). The patient had not
(Novkovic et al, 2017; Boulet et al, 2018). Because of attended his annual asthma review for some time,
this, ACO has been problematic to define, although and came to the practice because he noticed that over
prevalence does increase with age, particularly in the recent years he had become increasingly short of
presence of persistent airflow limitation with either breath on exertion. His peak flow at the consultation
a history of asthma or significant bronchodilator was 420 L/min (72% of predicted) and his expected
reversibility (Boulet et al, 2018). GINA and GOLD was 594 L/min. He also had a regular cough and
have attempted to clarify their position on ACO and expectorated a small amount (approximately a
provide a broad description, recently omitting the teaspoon) of sputum every day, which he described as
word ‘syndrome’ to avoid confusion (GINA, 2018; thick in texture and creamy in colour. He experienced
GOLD, 2019). some wheeziness in the morning, and had been using
his short acting β2 agonist (SABA) inhaler most days
‘ACO is characterised by persistent airflow to relieve his symptoms.
limitation with several features usually associated The patient was being managed on inhaled
with asthma, and several features usually associated corticosteroids (ICSs), beclometasone 100
with COPD. ACO is therefore identified in clinical microgram, two puffs twice daily (total daily dose of
practice by the features it shares with both asthma 400 microgram). A review of his electronic records
and COPD.’ (GINA, 2018; 92) revealed that he ordered two prescriptions of the ICS,
and seven prescriptions of his salbutamol (SABA)
ACO affects approximately 10–20% of patients inhaler (100 microgram, two puffs as required) in the
with established asthma or COPD, but many of past 12 months. When questioned about why he was
these patients remain undiagnosed due to a lack of not using his preventer inhaler, he explained that he
understanding and poor recognition of the condition felt that the brown inhaler did not seem to relieve his
among health care staff (Novkovic et al, 2017). symptoms, and he preferred taking his blue reliever
inhaler, as the effect was immediate.
Case study He was a smoker with a pack year history of 55,
This case study focuses on a 58-year-old male and while he had cut down, he was still smoking at
attending his GP surgery for his annual asthma least five roll-ups per day. In the past, the patient had
review with a practice nurse. tried stopping smoking through will power alone, but
had never succeeded in staying smoke-free. During
Patient history his working life, he worked in the Merchant Navy,
The patient had a history of asthma since childhood, and was regularly exposed to diesel fumes.
© 2019 MA Healthcare Ltd

and there was a history of asthma in his immediate The patient had a past medical history of
family. He had a past positive test for peak flow depression and hypertension, for which he was
variability documented in his records. This means taking citalopram 20 mg and ramipril 10 mg once
he achieved >20% diurnal variation after completing daily. On examination, his blood pressure, heart rate,
at least 2–4 weeks of peak flow tests in the morning respiratory rate and oxygen saturations were within

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CLINICAL FOCUS

Smoking cessation
Table 2. Patient characteristics and spirometry results
Smoking cessation is a key treatment in the
ID: 001 management of lung disease, as it will reduce the
Sex: Male speed of further lung function decline and may
Age: 58 years improve the effectiveness of inhaled treatments
Factor 100 (Caucasian) (Parker and Eaton, 2012). In this instance, the
Height: 1.75 m nurse used the ‘very brief advice’ intervention to
Weight: 78 kg discuss quitting smoking with the patient (NICE,
BMI: 25.4 kg/m2 2018a). First, she asked him how he felt about his
smoking, he explained that he had recently been
Base thinking about stopping due to concerns about his
(Pre BD) % Predicted Post BD % Predicted % Change
breathing. The nurse advised him that the best way
FEV1 2.05 57 2.10 58 1 to stop smoking is with medication and specialist
FVC 3.84 96 3.85 97 1
support provided by the smoking cessation services
available on the NHS (NICE, 2018a). The nurse
FEV1/FVC 53 55 offered him a referral to the local smoking cessation
services, which he accepted. As the patient was
FEV1: forced expiratory volume; FVC: forced vital capacity; BD: bronchodilator
a light smoker (<10 roll ups per day) it is likely
that the smoking cessation service will offer him
nicotine replacement therapy (NRT) in the form of
Table 3. Gradation of airflow obstruction a 24 hour transdermal patch, typically 14 mg for
Post BD FEV1/FVC ratio % predicted FEV1 Stage 6–8 weeks, then 7 mg for 2–4 weeks. Additionally,
dual NRT, either a mouth spray (1 mg nicotine/
<0.7 ≥80% Mild
spray dose), gum (4 mg and 2 mg), lozenge (2 mg
<0.7 50-79% Moderate and 1 mg) or an inhalator (15 mg cartridge)
<0.7 30-49% Severe
should improve his chances of quitting (NICE,
2018a). Public Health England (PHE) also endorse
<0.7 <30% Very severe e-cigarettes as a means of stopping smoking, as
current evidence demonstrates that vaping is safer
FEV1: forced expiratory volume; FVC: forced vital capacity; BD: bronchodilator
From: Global Initiative for Chronic Obstructive Lung Disease (2019) than smoking tobacco (PHE, 2018). The local
smoking cessation service now offer an e-cigarette
voucher scheme with behavioural support, which
may be a successful means to stopping smoking for
normal limits. His pulse was regular on palpation, this patient.
but an expiratory wheeze was noted
on auscultation. Medication review
As the patient was non-adherent to his medication,
Investigations and initial treatment plan he was also advised to start taking his ICS inhaler
In this case study, the patient already had regularly as prescribed; 2 puffs twice daily. The
an established diagnosis of asthma, but was patient demonstrated his inhaler technique and it
non‑adherent to his medication regimen, as noted was observed that he had poor coordination and
in his electronic records. This may be the possible breathed the medication in too quickly, which was
cause of the worsening of his symptoms; however, likely to be impacting on the medication delivery
he also had features characteristic of COPD. This to the airways (Haughney et al, 2010). He was
included the gradual onset of breathlessness, retrained on the correct method of actuation
regular sputum production, a significant pack year and inspiratory technique, and was prescribed a
history (>10) and he was over 40 years of age. spacer device to help improve medication delivery.
The patient was signposted to the Asthma UK
Investigations training videos should he need reminding about the
Presented with an established history of asthma inhaler technique.
and signs and symptoms that are suspicious
of COPD, a possible diagnosis of ACO Spirometry results
should be investigated. This should include In normal airways, air is able to pass in and
© 2019 MA Healthcare Ltd

post‑bronchodilator (BD) spirometry testing (6–8 out of the lungs easily. Where there is collapse,
weeks post-adherence to ICS treatment), a chest consolidation and inflammation, such as in
x-ray and a full blood count (FBC). A differential asthma and COPD, the airways become blocked
diagnosis for respiratory symptoms may be or narrowed causing ‘airway obstruction’
considered if these tests are inconclusive. (Eschenbacher, 2016). Spirometry can help detect

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 CLINICAL FOCUS

Table 4. Approach to differentiating between asthma, COPD and ACO

Step 1. DIAGNOSE CHRONIC AIRWAY DISEASE

Do symptoms suggest chronic airways disease?

Yes No Consider other diseases first

Step 2. DIAGNOSIS IN ADULTS

1. Assemble the features for asthma and for COPD that best describe the patient

Feature Asthma COPD

Age of onset  Before age 20 years  After age 40 years

Pattern of symptoms  Variation over minutes, hours or days  Persistent despite treatment
 Worse during the night or  Good and bad days but always daily
early morning symptoms and exertional dyspnoea
 Triggers (eg exercise, emotions  Chronic cough and sputum
including laughter, dust or exposure preceded onset of dyspnoea, unrelated
to allergens) to triggers

Lung function  Record of variable airflow limitation  Record of persistent airflow

(spirometry or peak flow) limitation (FEV1/FVC <0.7 post-BD)

Lung function between symptoms  Normal  Abnormal

Past history or family history  Previous doctor diagnosis of asthma  Previous diagnosis of COPD,
 Family history of asthma and other chronic bronchitis or emphysema
allergic conditions (eg allergic rhinitis  Heavy exposure to risk factor:
or eczema) tobacco smoke, biomass fuels

Time course  Variation in symptoms either  Symptoms slowly worsening over

seasonally, or from year to year time (progressive course over years)
 May improve spontaneously or  Rapid-acting bronchodilator
have an immediate response to treatment provides only limited relief
bronchodilators or to ICS over weeks

Chest x-ray (If ≥ 3 weeks history  Normal  Severe hyperinflation

of cough and/or increasing
breathlessness)

Total number of features

COPD: chronic obstructive pulmonary disease; ACO: asthma-COPD overlap; BD: bronchodilator; FEV1: forced expiratory volume;
FVC: forced vital capacity

the presence of airway obstruction and is a key Chest x-ray results

measure in the diagnosis and severity classification A chest x-ray was requested for the patient as he had
of COPD (GOLD, 2019). Airway obstruction is a significant smoking history and current respiratory
determined by a post-bronchodilator (BD) FEV1/ symptoms, which may indicate possible lung cancer
FVC (frequency of expired volume over 1 second/ (NICE, 2011). It is also good practice to order a
forced vital capacity) ratio of <0.70. Combined with chest x-ray if obstruction is noted in a spirometry
the characteristic signs and symptoms of COPD, this report, to identify the cause. A normal chest x-ray,
would indicate a positive diagnosis of COPD (NICE, however, does not exclude the presence of disease,
© 2019 MA Healthcare Ltd

2018b). In this case, the post-bronchodilator FEV1/ as early changes may only be visible in higher
FVC ratio was <0.70 (0.55), and his FEV1 reduced resolution imaging.
to 59% (2.10 L) (Table 2). This indicates that the In this case, the x-ray results showed that
patient had moderate obstruction, as the FEV1 falls hyperinflation was visible in the lung bases,
between 50–79% (Table 3). and emphysema was suggested as a diagnosis.

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CLINICAL FOCUS

Hyperinflation occurs when air is trapped in the priority, and ICSs should be prescribed alongside
lungs as a result of chronic inflammation and bronchodilators. In this case, stopping the patient’s
collapse of the airways, which is a typical feature of inhaler and changing it to a dual combination
emphysema, which further supports the diagnosis of inhaler, of an ICS plus a long acting β2 agonist
ACO (Gagnon et al, 2014). (LABA) should improve his symptoms, reduce
potential exacerbations and improve lung function
Diagnosis (NICE, 2018b). Combination inhalers are also more
GINA (2018) have updated the guidance on convenient for patients over single medication
treatment and recognition of ACO to aid clinicians inhalers, as they require less time to deliver the dose
where there is diagnostic uncertainty. It has divided and potentially less chance for inhaler device error
the features of asthma and COPD into two distinct (Royal College of Physicians, 2014).
categories (Table 4). A minimum of three boxes As the patient was already taking beclometasone
checked in each column is predictive of asthma or 100 microgram, two puffs twice daily, the
COPD. Where there are a similar amount of boxes combination inhaler with the equivalent ICS dose
checked in each column a diagnosis of ACO should plus bronchodilator would be beclometasone
be considered (GINA, 2018). For this patient, several dipropionate (extrafine) with formoterol (Fostair)
boxes relating to features that are described in both 100/6 microgram. The Fostair inhaler has the benefit
the asthma and the COPD columns can be ticked, of being available as a metered-dose inhaler and also
and therefore we could be confident that this patient as a dry powder inhaler, the dose can be escalated
has ACO. and it can also be used as maintenance and reliever
therapy if warranted. The nurse assessed the patient’s
Treatment and management plan inhaler technique again and allowed him to practise
Following the initial consultation and investigations, with placebo inhalers. The patient preferred the dry
the patient returned to see the nurse and obtain the powder inhaler over the metered-dose inhaler device
test results and treatment and management advice. and his technique was good so this was prescribed to
At the visit he explained that his breathing had him, because it was available on the local formulary
improved slightly since taking his preventer inhaler and the risk to benefit ratio of drug interactions
(ICS) more regularly, although he was still troubled was low. The patient was further advised to return
by symptoms and needed to use his SABA rescue should he experience any new symptoms after
inhaler at least six times a week. He was informed starting the treatment. He did not want to change
that, given his symptoms and history, it is likely that his SABA inhaler to a dry powder inhaler equivalent,
he has COPD as well as asthma (ACO). and although it is better for patients to have devices
that require similar methods of actuation, it is also
Smoking cessation important to consider patient preference (Weinstein,
Since his last visit, the patient met with the local 2013). In an emergency, it may also be better to have
smoking cessation services. At their request, his GP a salbutamol metered-dose inhaler plus spacer device,
practice prescribed NRT, which included a transdermal due to the lower inspiratory effort needed to inhale
patch 7 mg once daily and an inhalator (14 mg as the medication.
required). The patient reported that he had not
smoked since he started the treatment 3 weeks ago. Vaccination
Vaccination against pneumonia and influenza is
Medication review one of the most cost effective treatments in the
The primary treatment for asthma in all cases management of COPD and is associated with
is ICSs, except where there is clear seasonal a decrease in exacerbations and reduction in
variation present (British Thoracic Society/Scottish hospitalisations (Kopsaftis et al, 2018). Therefore, the
Intercollegiate Guidelines Network, 2016). This patient was advised to make a further appointment to
follows evidence from the national review of asthma have these administered.
deaths (NRAD), which highlighted that not treating
underlying inflammation led to the over reliance Pulmonary rehabilitation
of rescue inhalers and delays in seeking urgent Pulmonary rehabilitation is an evidence-based key
medical attention (Royal College of Physicians, treatment in the long-term clinical management
2014). Conversely, bronchodilators are the first‑line of COPD, where the aim is to improve respiratory
treatment in COPD, and ICSs are reserved for strength as well as general muscle strength to
© 2019 MA Healthcare Ltd

patients who frequently exacerbate, due to its increase overall patient fitness, thereby improving
association with increased pneumonia risk (Kew and breathlessness, reducing exacerbation rates and
Seniukovich, 2014). potential hospital admissions (McCarthy et al,
Therefore, in patients who present with ACO, the 2015). The benefits of attending a pulmonary
asthma inflammatory component should always take rehabilitation course were shared with the patient

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 CLINICAL FOCUS

in this case, and although he was uncertain that he Key Points

wanted to attend because he is already relatively
active, he accepted a referral. ■■ Identifying asthma-chronic obstructive pulmonary disease (COPD)
overlap (ACO) is complex, and there are many patients who
Self-management remain undiagnosed
Supporting self-management is a key element to ■■ Patients with ACO have worse outcomes than patients with asthma
improving the prognosis for patients with long- and COPD alone
term conditions (Taylor and Pinnock, 2017). This ■■ Diagnosis should involve rigorous investigations that include
can be achieved in a variety of ways, including post-bronchodilator spirometry, chest x-ray and bloods
training patients on correct inhaler technique
■■ ACO should be treated with inhaled cortico-steroids
and providing management plans. In this case, a
and bronchodilators
personalised self-management plan was provided
and completed together with the patient, to ensure ■■ Referral to specialist services may be necessary
that he understood what to do should he experience
worsening of symptoms.
If, in the future, the patient reported regular
exacerbations that necessitated regular primary CPD reflective questions
care consultations, a rescue pack of steroids and
antibiotics should be considered, in order to ■■ How will you change your practice to allow for patients with ACO to
commence therapy in a timely fashion (NICE, 2011). be better identified?
Before prescribing a rescue pack, the clinician will ■■ How would you assess inhaler technique?
need to ensure that high-impact interventions such as ■■ How would you discuss stopping smoking with a patient?
smoking cessation, pulmonary rehabilitation and flu ■■ How would you persuade a patient that attending pulmonary
vaccination have already been offered, as these will rehabilitation would be beneficial to them?
reduce the risk and severity of future exacerbations.
■■ Are you confident that you have access to spirometry that is
An assessment should then be made as to whether
performed and interpreted correctly? If not, how would you
the patient is able and willing to self-manage the
become confident?
rescue pack once informed of the associated risks
and benefits. This should help guard against the ■■ How would you complete an asthma action plan?
unnecessary self-administration of antibiotics,
reducing adverse events and potential antibiotic
resistance (NICE, 2015). Increased breathlessness is
typical in an exacerbation, and a change in sputum that treatment and management strategies are
colour would suggest an infective exacerbation optimised, in order to avoid potential exacerbations
(Viniol and Vogelmeier, 2018). and admissions to hospital. Prescribers need to
The patient was directed to the Asthma UK and be educated on how to recognise and manage
British Lung Foundation websites to explore their the condition, and improvements to GP practice
resources for further support. He was also advised to templates may allow for the easier identification of
make an appointment with the nurse in 6–8 weeks patients with ACO. Diagnosis should be supported
post-treatment for follow-up, but to return earlier by a rigorous selection of investigations, alongside
should his symptoms worsen. tools and national guidelines that are available to
enable clinicians to decide whether their patient has
Mental health ACO. This is a complicated process that may require
Acute breathlessness can be particularly distressing several consultations and onward referral to specialist
for patients with lung disease, and may affect mental services to see improvements to symptoms.  JPrP
health status. Evidence-based treatments that include
pulmonary rehabilitation, breathing retraining
techniques and cognitive behavioural therapy may Conflict of Interest: All authors declare: no support
improve symptoms, quality of life and anxiety and from any organisation for the submitted work;
depression levels alongside traditional drug therapy no financial relationships with any organisations
(Bruton et al, 2018). Patients should be monitored that might have an interest in the submitted work
for anxiety and depression at regular intervals and in the previous 3 years; no other relationships or
offered interventions when warranted. activities that could appear to have influenced the
© 2019 MA Healthcare Ltd

submitted work.
Conclusions ER is supported by the National Institute for
Identifying ACO is a complex process that relies Health Research (NIHR) Collaboration for Applied
on the knowledge and skill of the clinician. It is Health Research and Care (CLAHRC) Wessex. The
clear that early identification is vital to ensure views and opinions expressed are those of the author

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CLINICAL FOCUS

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78 Journal of Prescribing Practice  2019  Vol 1  No 2

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