Diagnosis of asthma, COPD and

asthma-COPD overlap syndrome

(ACOS)
A joint project of GINA and GOLD

GINA Global Strategy for Asthma Management

and Prevention
GOLD Global Strategy for Diagnosis,
Management and Prevention of COPD

GINA 2014 © Global Initiative for Asthma3.

Diagnosis of diseases of chronic airflow
limitation

© Global Initiative for Asthma

 Background

 For patients with respiratory symptoms, infectious diseases and

non-pulmonary conditions need to be distinguished from chronic
airways disease
 In patients with chronic airways disease, the differential
diagnosis differs by age
 Children and young adults: most likely to be asthma
 Adults >40 years: COPD becomes more common, and
distinguishing asthma from COPD becomes more difficult
 Many patients with symptoms of chronic airways disease have
features of both asthma and COPD

GINA 2014 © Global Initiative for Asthma

 Background

 Patients with features of both asthma and COPD have worse

outcomes than those with asthma or COPD alone
 Frequent exacerbations
 Poor quality of life
 More rapid decline in lung function
 Higher mortality
 Greater health care utilization
 Prevalence of the ‘overlap’ syndrome varies by definition
 Reported rates are between15–55% of patients with chronic
airways disease
 Concurrent doctor-diagnosed asthma and COPD are found in
15–20% of patients with chronic airways disease
 Prevalence varies by age and gender

GINA 2014 © Global Initiative for Asthma

 Objective

 This document was developed by the Science Committees of

GINA and GOLD, to assist clinicians to:
 Identify patients with a disease of chronic airflow limitation
 Distinguish asthma from COPD and the asthma-COPD overlap
syndrome (ACOS)
 Decide on initial treatment and/or need for referral

GINA 2014 © Global Initiative for Asthma

 Definitions

Asthma
Asthma is 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. [GINA 2014]

COPD
COPD is 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.
Exacerbations and comorbidities contribute to the overall severity in individual
patients. [GOLD 2014]

Asthma-COPD overlap syndrome (ACOS) [a description]

Asthma-COPD overlap syndrome (ACOS) is 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.

GINA 2014, Box 5-1 © Global Initiative for Asthma

 Stepwise approach to diagnosis and
initial treatment

For an adult who presents with

respiratory symptoms:
1. Does the patient have chronic
airways disease?
2. Syndromic diagnosis of
asthma, COPD and ACOS
3. Spirometry
4. Commence initial therapy
5. Referral for specialized
investigations (if necessary)

GINA 2014, Box 5-4 © Global Initiative for Asthma

 Step 1 – Does the patient have chronic
airways disease?

GINA 2014 © Global Initiative for Asthma

 Step 1 – Does the patient have chronic
airways disease?
 Clinical history: consider chronic airways disease if
 Chronic or recurrent cough, sputum, dyspnea or wheezing, or
repeated acute lower respiratory tract infections
 Previous doctor diagnosis of asthma and/or COPD
 Previous treatment with inhaled medications
 History of smoking tobacco and/or other substances
 Exposure to environmental hazards, e.g. airborne pollutants
 Physical examination
 May be normal
 Evidence of hyperinflation or respiratory insufficiency
 Wheeze and/or crackles

GINA 2014 © Global Initiative for Asthma

 Step 1 – Does the patient have chronic
airways disease?
 Radiology (CXR or CT scan performed for other reasons)
 May be normal, especially in early stages
 Hyperinflation, airway wall thickening, hyperlucency, bullae
 May identify or suggest an alternative or additional diagnosis, e.g.
bronchiectasis, tuberculosis, interstitial lung disease, cardiac failure
 Screening questionnaires
 Designed to assist in identification of patients at risk of chronic
airways disease
 May not be generalizable to all countries, practice settings or
patients
 See GINA and GOLD reports for examples

GINA 2014 © Global Initiative for Asthma

 Step 2 – Syndromic diagnosis of asthma,
COPD and ACOS
 Assemble the features that, when present, most favor a
diagnosis of asthma or COPD
 Compare the number of features on each side
 If the patient has ≥3 features of either asthma or COPD, there is a
strong likelihood that this is the correct diagnosis
 Consider the level of certainty around the diagnosis
 Diagnoses are made on the weight of evidence
 The absence of any of these typical features does not rule out
either diagnosis, e.g. absence of atopy does not rule out asthma
 When a patient has a similar number of features of both asthma
and COPD, consider the diagnosis of ACOS

GINA 2014 © Global Initiative for Asthma

 GINA
GINA 2014, Box 5-4
2014 © Global Initiative for©Asthma
Global Initiative for Asthma
GINA 2014 © Global Initiative for Asthma
 Step 3 - Spirometry

 Essential if chronic airways disease is suspected

 Confirms chronic airflow limitation
 More limited value in distinguishing between asthma with fixed
airflow limitation, COPD and ACOS
 Measure at the initial visit or subsequent visit
 If possible measure before and after a trial of treatment
 Medications taken before testing may influence results
 Peak expiratory flow (PEF)
 Not a substitute for spirometry
 Normal PEF does not rule out asthma or COPD
 Repeated measurement may confirm excessive variability, found in
asthma or in some patients with ACOS

GINA 2014, Box 5-3 © Global Initiative for Asthma

 Step 3 - Spirometry

Spirometric variable Asthma COPD ACOS

Normal FEV1/FVC Compatible with asthma Not compatible with Not compatible unless
pre- or post-BD diagnosis (GOLD) other evidence of chronic
airflow limitation
Post-BD FEV1/FVC <0.7 Indicates airflow Required for diagnosis Usual in ACOS
limitation; may improve by GOLDcriteria
FEV1 =80% predicted Compatible with asthma Compatible with GOLD Compatible with mild
(good control, or interval category A or B if post- ACOS
between symptoms) BD FEV1/FVC <0.7
FEV1 <80% predicted Compatible with asthma. Indicates severity of Indicates severity of
A risk factor for airflow limitation and risk airflow limitation and risk
exacerbations of exacerbations and of exacerbations and
mortality mortality
Post-BD increase in Usual at some time in Common in COPD and Common in ACOS, and
FEV1 >12% and 200mL course of asthma; not more likely when FEV1 is more likely when FEV1 is
from baseline (reversible always present low, but consider ACOS low
airflow limitation)
Post-BD increase in High probability of Unusual in COPD. Compatible with
FEV1 >12% and 400mL asthma Consider ACOS diagnosis of ACOS
from baseline
GINA 2014, Box 5-3 © Global Initiative for Asthma
GINA 2014 © Global Initiative for Asthma
 Step 4 – Commence initial therapy

 Initial choices based on syndromic assessment and spirometry

 If features are consistent with asthma, treat as asthma
 If features are consistent with COPD, treat as COPD
 If syndromic assessment suggests ACOS, or there is significant
uncertainty about the diagnosis of COPD, start treatment as for
asthma pending further investigation
 Consider both efficacy and safety
 If any features of asthma, do not prescribe LABA without ICS
 If any features of COPD, give symptomatic treatment with
bronchodilators or combination therapy, but not ICS alone
 If ACOS, give ICS and consider LABA and/or LAMA
 Other important strategies for ACOS and COPD
 Non-pharmacological strategies including smoking cessation,
pulmonary rehabilitation, vaccinations, treatment of comorbidities

GINA 2014 © Global Initiative for Asthma

GINA 2014 © Global Initiative for Asthma
 Step 5 – Refer for specialized
investigations if needed
 Refer for expert advice and extra investigations if patient has:
 Persistent symptoms and/or exacerbations despite treatment
 Diagnostic uncertainty, especially if alternative diagnosis
(e.g. TB, cardiovascular disease) needs to be excluded
 Suspected airways disease with atypical or additional symptoms or
signs (e.g. hemoptysis, weight loss, night sweats, fever, chronic
purulent sputum). Do not wait for a treatment trial before referring
 Suspected chronic airways disease but few features of asthma,
COPD or ACOS
 Comorbidities that may interfere with their management
 Issues arising during on-going management of asthma, COPD or
ACOS

GINA 2014 © Global Initiative for Asthma

 Step 5 – Refer for specialized
investigations if needed

Investigation Asthma COPD

DLCO Normal or slightly elevated Often reduced
Arterial blood gases Normal between In severe COPD, may be abnormal
exacerbations between exacerbations
Airway Not useful on its own in distinguishing asthma and COPD.
hyperresponsiveness High levels favor asthma
High resolution CT Usually normal; may show air Air trapping or emphysema; may
scan trapping and increased airway show bronchial wall thickening and
wall thickness features of pulmonary hypertension
Tests for atopy (sIgE Not essential for diagnosis; Conforms to background
and/or skin prick increases probability of prevalence; does not rule out COPD
tests) asthma
FENO If high (>50ppb) supports Usually normal. Low in current
eosinophilic inflammation smokers
Blood eosinophilia Supports asthma diagnosis May be found during exacerbations
Sputum inflammatory Role in differential diagnosis not established in large populations
cell analysis

GINA 2014, Box 5-5 © Global Initiative for Asthma