Asthma, or COPD, or ACOS (Asthma + COPD crossover Syndrome, or something else? And WHY does it matter which label? WECCG – time to Learn -- Respiratory 9th July 2019

Some Treatment is the same Asthma, COPD, ACOS, ILD etc: ALL MUST have Smoking cessation support Agreed self management of exacerbations Accurate diagnosis Patient empowerment 9th July 2019 WECCG

Some Treatment is different Asthma – MUST have ICS There is NO step 1 = SABA only Mild COPD can be treated with LAMA/LABA – this can be fatal if patient has Asthma Other Dx have different management 9th July 2019 WECCG

Consider COPD if patient has: any of: Dyspnoea Chronic cough or sputum Recurrent lower respiratory tract infections Hx of exposure to risk (Smoke, weed, flour dust) 9th July 2019 WECCG – GOLD Dx COPD 2019

COPD Must have: Post bronchodilator Spirometry with FEV1/FVC < 0.70 i.e. obstructive pattern, or Mixed obstructive & restrictive 9th July 2019 WECCG – GOLD Dx COPD 2019

Spirometry: age, height, M/F Volume In Litres FVC= forced vital capacity (3-24 seconds) Normal only if both FEV1 & FVC are ≥ Minimum PREDICTED based On Height, Age & Gender FEV1= forced expiratory volume in 1 second FEV1/FVC ≥ 80% is normal or restrictive TIME in seconds

Spirometry: NOT obstructive = NOT COPD Volume In Litres FVC= forced vital capacity (3-24 seconds)LONGER Predicted Obstructive: FEV1= Lower & FVC = Normal compared to PREDICTED based On Height, Age & Gender FEV1/FVC ≤ 70% is obstructive FEV1= forced expiratory volume in 1 second Reduced, but FVC is preserved! TIME in seconds

Spirometry: Restrictive = NOT COPD Volume In Litres FVC= forced vital capacity (3-24 seconds)LONGER Restrictive: FEV1 &FVC are BOTH Lower compared to PREDICTED based On Height, Age & Gender Predicted FEV1/FVC more than 70% in RESTRICTIVE FEV1= forced expiratory volume in 1 second Reduced, AND FVC reduced in proportion! TIME in seconds

Spirometry: MIXED = Restrictive + Obstructive Volume In Litres FVC= forced vital capacity (3-24 seconds)LONGER Restrictive: FVC is reduced, AND Obstructive because FEV1 is even MORE Reduced, compared to PREDICTED based On Height, Age & Gender Predicted FEV1/FVC ≤ 70% is obstructive FEV1= forced expiratory volume in 1 second Reduced, AND FVC is LESS reduced! TIME in seconds

Beware false restrictive Moderate or severe COPD With cough: Cough, interrupts expiration Terminates the blow at 1-2 seconds. FEV1/FEV1.5 sec False low FVC = false restrictive 9th July 2019 WECCG

Spirometry in COPD: MUST be Obstructive NOT Obstructive = NOT COPD Symptoms can be quite variable BUT Spirometry varies ≤ 15% Use POST bronchodilator Spirometry If varies > 15% - consider Asthma Asthma & COPD can co-exist

GOLD – COPD classification all must have FEV1/Vcmax < 0.7 FEV1 compared to predicted for height, age, gender: GOLD 1- Mild – FEV1 ≥ 80% predict GOLD 2–Moderate 50%≤FEV1<80% GOLD 3-Severe 30%≤FEV1<50% GOLD 4- Very Severe FEV1 < 30% predicted 9th July 2019 WECCG

MRC Dyspnoea scale 0-1 Grade 0: Only breathless with strenuous exercise. Grade 1: SOB when hurry on level or walk up slight hill 9th July 2019 WECCG

MRC Dyspnoea scale 2, 3, 4 Grade 2: Walk slower than others on level due SOB or have to stop for breath on my own on level. Grade 3: Stop after walk 100m or after few minutes on level Grade 4: too breathless to leave house, or when dress/undressing 9th July 2019 WECCG

CAT score – 8 items 0-5 Never cough – cough all the time No plegm on chest – chest full mucus Chest not tight at all – chest feels very tight Walk up hill or 1 flight=NOT SoB – VERY breathless hill or 1 flight 9th July 2019 WECCG

CAT score – last 4 items Not limited any home activities – VERY limited doing activities at home Confident leaving home – not confident to leave home due lungs Sleep soundly – do not sleep due L. Lots of energy – no energy at all 9th July 2019 WECCG

GOLD refined ABCD Symptoms & History fit? FEV1/Vcmax (post BD) < 0.7 FEV1 % predicted: Gold 1 ≥80% Gold 2 50-79 Gold 3 30-49 Gold 4 < 30% 9th July 2019 WECCG

Most cases= A, Freq.Flyer=D C= mild Sx + exacerbate D=severe Sx+ exacerbate A =Few exacerbation, mild Symptoms B =Severe symptoms + 0 or 1 exacerbations 9th July 2019 WECCG

Exacerbation History C or D ≥ 2 exacerbations past year Or ≥ 1 leading to admission A or B 0 or 1 exacerbation with hospital admission 9th July 2019 WECCG

COPD Symptom score A or C (left side) mMRC 0-1 CAT < 10 B or D (right column) mMRC ≥ 2 Or CAT ≥ 10 (out of max 40 ) 9th July 2019 WECCG

Consider ASTHMA: Symptoms varied, non-specific Often: wheeze, dyspnea, cough (esp. at night & early am). May trigger by smoke, irritants, exercise, allergy 9th July 2019 WECCG

Spirometry in Asthma May or may not show reversability at any one time Can be any pattern- restrict/obs Variability is key 9th July 2019 WECCG

Action point: Do NOT cancel spirometry when patient arrives symptomatic and / or with recent chest infecrion. This does not save resources (apt already consumed) but robs us of information on reversability. 9th July 2019 WECCG

When is it “Pure COPD?” First onset > 40 years old. ≥ 20 pack years smoking exposure Symptoms vary, but FEV1 & PEF vary less than 10% (do get spiro when symptomatic) MUST have obstructive post BD spirometry 9th July 2019 WECCG

Suspect asthma element?? Onset of symptoms before 40 Hx of atopy, hay fever, marked allergy Eosinophilia, or high IgE Variability Wheezing & cough esp. at night 9th July 2019 WECCG

Spirometry in Asthma If Asthma is the only Diagnosis: Then Must have normal spiro between exacerbations When symptomatic, can be nearly normal, Usually restrictive, can be obstructive Occasionaly mixed (consider Asthma+COPD)

Fixed Restrictive Spirometry Wide differential diagnosis CXR, repeat, then refer to Hospital Differential Diagnosis (DiffDx): CCF (Heart failure) PE Pneumothorax Chest wall disease Lung cancer Lobectomy Scaring, old MTB (Tuberculosis), interstial lung disease, Pneumonia Pleural Disease

Adult Bronchiectasis High mucous production Sometimes so thick cannot get it out Grows unusual/resistant Bugs DO sputum cultures frequently Longer & prompt rescue packs Antibiotics AND steroids Get HRCT 9th July 2019 WECCG

Rescue pack (asthma & COPD) Patient (or wife) detects more sputum or Symptoms 26 hours to provide a sputum sample Start steroids & antibiotics book apt. if better, renew rescue pak. 9th July 2019 WECCG

Reducing inhaled steroids ANY of the asthma elements?? The do NOT stop ICS Can switch to lower/variable dose regiems Fluticasone >> budesonide or beclomethasone 9th July 2019 WECCG

iCS in COPD + no asthma clues Consider reducing ICS to milder ICS Only in Mild COPD with NO asthma-clues >> consider LAMA/LABA 9th July 2019 WECCG

testing Spirometry when symptomatic AS WELL As when at their best CXR is under utilized – what does it cost? Use of rescue pack Trial of Formoterol/beclomethatsone Formoterol/budesonide & Peak FLOW REFER if not responding as planned 9th July 2019 WECCG

9 high impact interventions-1-4 Accurate Diagnosis Co-morbidity (IHD prevention), frailty and end-of-life (if appropriate) Flu Vaccine CAT score, exacerbation & MRC dyspnoea 9th July 2019 WECCG

9 high impact interventions-5-9 Smoking cessation Pulmonary rehab Optimize medication (include IHD prevention) Self management / rescue pack Patient empowerment & care navigation 9th July 2019 WECCG

Your ideas? What will you do differently? 9th July 2019 WECCG