Chronic COPD- ACO Background and Therapy

Question 1

ACO definition

Answer 1

persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Identified by the features that it shares with both asthma and COPD

Question 2

Is ACO a single disease entity?

Answer 2

No

Question 3

ACO features

Answer 3

≥40 years old

May have had symptoms in early childhood

Persistent airflow limitation, not fully reversible, and with variability

Often has history of childhood asthma, allergies, exposure to smoke or other irritants, FH of asthma

Treatment partly decreases symptoms

Chest x-ray similar to COPD

Exacerbations more common than in COPD alone

Eosinophils and/or neutrophils in sputum

Comorbidities may lead to further impairment

Question 4

4 steps into figuring out ACO diagnosis and treatment

Answer 4

1. Find out if the patient has chronic airway disease
2. Syndromic diagnosis of asthma, COPD, and overlap
3. Spirometry
4. Start therapy

Question 5

Step 2: Syndromic diagnosis of asthma, COPD, and overlap

Answer 5

Assemble the features that, when present, must favor a diagnosis of typical asthma or COPD

Think about that checklist- if there’s ≥3 boxes on either side, you probably only have one or the other. If you check a similar number of boxes on each side, you probably have ACO

Question 6

Step 3: spirometry results

Answer 6

FEV1/FVC <0.7 post-bronchodilator indicates COPD

Reversibility post-bronchodilator vs. pre-bronchodilator indicated asthma

If it falls in between, it’s ACO

Question 7

Step 4: Commence initial therapy- which med can you not use as monotherapy in asthma?

Answer 7

LABA, because it won’t address the underlying inflammation

Question 8

Step 4: Commence initial therapy- which med can you not use as monotherapy in COPD?

Answer 8

ICS

Question 9

Step 4: Commence initial therapy- if ACO is suspected, what do you start?

Answer 9

Initial treatment with ICS (low or moderate dose), can add on LABA and/or LAMA or continue if already prescribed

Question 10

Step 4: if asthma is suspected, what do you start?

Answer 10

Low-dose ICS, add LABA and/or LAMA if needed for poor control despite good adherence and inhaler technique

Question 11

Step 4: if COPD is suspected, what do you start?

Answer 11

Bronchodilators or combo therapy; don’t give ICS alone without LABA and/or LAMA

Question 12

What should we do in all patients with chronic airflow limitation?

Answer 12

Treat modifiable risk factors including advice about smoking cessation

Treat comorbidities

Advise about nonpharm strategies such as physical activity, and for COPD or ACO, pulmonary rehab and vaccinations

Provide appropriate self-management strategies

Arrange regular follow-up