1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. GOLD refined ABCD Symptoms & History fit?
FEV1/Vcmax (post BD) < 0.7
FEV1 % predicted:
Gold 1 ≥80%
Gold
Gold
Gold 4 < 30%
9th July 2019
WECCG

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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)

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

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