Practical approach to ACOSAsthma COPD overlap syndrome ... GINA/GOLD definition of ACOS Asthma COPD...
Transcript of Practical approach to ACOSAsthma COPD overlap syndrome ... GINA/GOLD definition of ACOS Asthma COPD...
Practical approach to ACOS
Yasutaka Nakano, M.D., Ph.D.
Faculty/Presenter Disclosure
Faculty: Yasutaka Nakano
Relationships with commercial interests:
– Speakers Bureau/Honoraria: NBI
– Consulting Fees: Olympus
64-year-old Korean male (1)
3-year history of exertional shortness of
breath (mMRC 3)
current smoker with a 60 pack-year history
medical history of asthma since childhood
cough, sputum, and dyspnea
intermittent episodes of shortness of breath
with wheezing at night
Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,
Respirol Case Rep. 2015 Oct 8;3(4):119-21.
64-year-old Korean male (2)
mild fattening of the diaphragms
Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,
Respirol Case Rep. 2015 Oct 8;3(4):119-21.
64-year-old Korean male (3)
blood eosinophil count: 429/μL (6.6%)
total IgE level: 1089 U/mL
positive skin prick tests:
– Dermatophagoides pteronyssinus
– Cockroach
– Lepidoglyphus destructor
Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,
Respirol Case Rep. 2015 Oct 8;3(4):119-21.
64-year-old Korean male (4)
Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,
Respirol Case Rep. 2015 Oct 8;3(4):119-21.
64-year-old Korean male (5)
Does this patient have
Asthma?
COPD?
Asthma COPD overlap syndrome
Patient with asthma
– who smokes
– may also have COPD
Patient with COPD
– may also have asthma
Asthma COPD
sm
oke
r
asth
ma
Asthma
sm
oke
r
COPDasth
ma
Asthma COPD Overlap Syndrome
sm
oker
AC
OS
When should we consider ACOS in asthma?
Persistent airflow limitation
(FEV1/FVC < 0.7)
Smoking history
When should we consider ACOS in COPD?
Diagnosis of asthma before 40 years of age
BDR of 400 mL or more
History of allergic rhinitis or atopy
Elevated serum IgE
Elevated peripheral eosinophil count
(e.g., >400/μL)
DD Sin. Tuberc Respir Dis 2017; 80: 11-20
GINA/GOLD definition of ACOS
Asthma COPD
Age of onset □Before age 20 years □After age 40 years
Pattern of symptoms □Variation over minutes,
hours or days
□Worse during the night
or early morning
□Triggered by exercise,
emotions including
laughter, dust or exposure
to allergens
□Persistent despite
treatment
□Good and bad days but
always daily symptoms
and exertional dyspnea
□Chronic cough &
sputum preceded onset of
dyspnea, unrelated to
triggers
Lung function □Record of variable
airflow limitation
(spirometry or peakflow)
□Record of persistent
airflow limitation
(FEV1/FVC<0.7 post BD)
Lung function between
symptoms
□Normal □Abnormal
GINA/GOLD definition of ACOS (cont.)
Asthma COPD
Past history or family
history
□Previous doctor
diagnosed asthma
□Family history of
asthma and other allergic
conditions (allergic rhinitis
or eczema)
□Previous doctor
diagnosed COPD, chronic
bronchitis or emphysema
□Heavy exposure to risk
factor: tobacco smoke,
biomass fuels
Time course □No worsening of
symptoms over time.
□Variation of symptoms
either seasonally, or from
year to year
□Symptoms slowly
worsening over time
(progressive course over
years)
□Rapid acting
bronchodilator treatment
provides only limited relief
Chest X-ray □Normal □Severe hyperinflation
GINA/GOLD: Asthma COPD and ACOS, 2015.
SEPAR definition of ACOS (1)
Of patients with persistent airflow limitation
(FEV1/FVC < 0.7)
One major criterion or two minor criteria
Major criteria
– Previous history of asthma
– Bronchodilator response to salbutamol > 15%
and 400mL
Soler-Cataluna JJ, et al. Arch Bronconeumol 2012;48:331-7
SEPAR: Spanish Society of Pulmonology and Thoracic Surgery)
SEPAR definition of ACOS (2)
Of patients with persistent airflow limitation
(FEV1/FVC < 0.7)
One major criterion or two minor criteria
Minor criteria
– IgE > 100 IU or history of atopy
– Bronchodilator response to salbutamol of >
12% and 200 mL at least two separate
occasions or blood eosinophilia > 5%
Soler-Cataluna JJ, et al. Arch Bronconeumol 2012;48:331-7
Diagnosis of ACOS in patients with asthma
Tho, Park, Nakano. Respirology 2016 Apr;21(3):410-8.
Diagnosis of ACOS in patients with asthma
Tho, Park, Nakano. Respirology 2016 Apr;21(3):410-8.
Diagnosis of ACOS in patients with asthma
Tho, Park, Nakano. Respirology 2016 Apr;21(3):410-8.
Definition of ACOS from ATS Roundtable Discussions
Three major + One minor criteria
Major criteria1. Persistent airflow limitation (post-bronchodilator
FEV1/FVC <0.70 or LLN) in individuals 40 years of
age or older; LLN is preferred
2. At least 10 pack-years of tobacco smoking
OR
Equivalent indoor or outdoor air pollution exposure (e.g.
biomass)
3. Documented history of asthma before 40 years of age
OR
BDR of >400 mL in FEV1Sin, Nakano, Park et al. ERJ 2016;48:664-73
Definition of ACOS from ATS Roundtable Discussions
Three major + One minor criteria
Minor criteria
1. Documented history of atopy or allergic rhinitis
2. BDR of FEV1 ≥200 mL and 12% from baseline
values on 2 or more visits
3. Peripheral blood eosinophil count of ≥300
cells/μL
Sin, Nakano, Park et al. ERJ 2016;48:664-73
Japanese ACOS perspective
Major criteria
– Persistent airflow limitation
– At least 10 pack-years of tobacco smoking
– History of asthma
Minor criteria
– History of atopy or allergic rhinitis
– FeNO > 40 ppb
– BDR of FEV1 ≥200 mL and 12% from baseline values
on 2 or more visits
– Peripheral blood eosinophil count of ≥300
cells/μL
Key exclusion criteria of COPD trials
Sin, Nakano, Park et al. ERJ 2016;48:664-73
Key exclusion criteria of asthma trials
Sin, Nakano, Park et al. ERJ 2016;48:664-73
Treatment of ACOS
Smoking cessation
Rehabilitaion
Vactination
Long acting bronchodilator (LAMA, LABA)
Inhaled corticosteroids (ICS)
What we need
Diagnostic criteria
Thank you
감사합니다