Download COPD and asthma

Considering chronic obstructive pulmonary disease as an alternative or
concomitant diagnosis in an adult with known or suspected asthma, and
managing asthma in a person with coexisting COPD
This PDF is a print-friendly reproduction of the content included in the Clinical issues – COPD section of the
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CFC
chlorofluorocarbon
COPD chronic obstructive pulmonary disease
COX
cyclo-oxygenase
ED
emergency department
EIB
exercise-induced bronchoconstriction
FEV1
forced expiratory volume over one second
FVC
forced vital capacity
FSANZ Food Standards Australia and New Zealand
GORD gastro-oesophageal reflux disease
HFA
formulated with hydrofluroalkane propellant
ICS
inhaled corticosteroid
ICU
intensive care unit
IgE
Immunoglobulin E
IV
intravenous
LABA
long-acting beta2-adrenergic receptor agonist
ABN 61 058 044 634
Suite 104, Level 1, 153-161 Park Street South
Melbourne, VIC 3205, Australia
LAMA
LTRA
MBS
NIPPV
NSAIDs
OCS
OSA
PaCO
PaO
PBS
PEF
pMDI
SABA
LAMA
TGA
long-acting muscarinic antagonist
leukotriene receptor antagonist
Medical Benefits Scheme
non-invasive positive pressure ventilation
nonsteroidal anti-inflammatory drugs
oral corticosteroids
obstructive sleep apnoea
carbon dioxide partial pressure on blood gas analysis
oxygen partial pressure on blood gas analysis
Pharmaceutical Benefits Scheme
peak expiratory flow
pressurised metered-dose inhaler or 'puffer'
short-acting beta2 -adrenergic receptor agonist
long-acting muscarinic antagonist
Therapeutic Goods Administration
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practitioners, pharmacists, asthma educators, nurses and other
health professionals and healthcare students. The information
and treatment protocols contained in the Australian Asthma
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HOME > CLINICAL ISSUES > COPD
Chronic obstructive pulmonary disease (COPD) and asthma
Overview
Asthma and COPD are quite distinctive and readily distinguishable from each other when they occur in their most
characteristic forms. However, many adult patients show features of both these conditions.
The possibility of COPD as an alternative diagnosis and the possibility of asthma-COPD overlap should be considered during
diagnostic investigation of respiratory symptoms in adults, particularly in smokers, ex-smokers and older adults.
Current asthma guidelines and COPD guidelines make contrasting recommendations for pharmacotherapy, based on
differing safety findings in each population. Asthma guidelines generally recommend inhaled corticosteroids for most adults
and recommend against long-acting beta2 agonist without concomitant or combination inhaled corticosteroid therapy,
whereas COPD guidelines recommend a long-acting beta2 agonist as initial treatment and inhaled corticosteroids only for
patients with more severe disease. Special considerations are therefore needed when a patient has features of both
diagnoses.
In this section
Diagnostic considerations
Diagnostic considerations when
COPD is a possibility
https://www.asthmahandbook.org.au/clinical-issues/copd/diagnostic-considerations
Managing asthma-COPD overlap
Management considerations for patients with asthmaCOPD overlap
https://www.asthmahandbook.org.au/clinical-issues/copd/managing-asthma-copd-overlap
1
HOME > CLINICAL ISSUES > COPD > DIAGNOSTIC CONSIDERATIONS
Diagnostic considerations when COPD is a possibility
Go to: The COPD-X Concise Guide for Primary Care
Recommendations
Consider the possibility of COPD as an alternative diagnosis or asthma-COPD overlap in patients with respiratory
symptoms and any of the following risk factors:
•
•
•
•
current smoking or history of smoking and age 35 years and over
exposure to environmental tobacco smoke or other smoke
age 55 years and over
longstanding asthma.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Gibson et al. 20101
• Guerra, 20092
• Abramson et al. 20123
If spirometry before and after bronchodilator demonstrates airflow limitation that is not completely reversible in an
adult with risk factors for COPD, consider the possibility of COPD, even if the person has never smoked.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Abramson et al. 20123
If an adult has risk factors for COPD, spirometry before and after bronchodilator demonstrates airflow limitation that is
not completely reversible, and other diagnostic tests do not confirm asthma, start a treatment trial with an inhaled
corticosteroid and repeat spirometry 6–8 weeks later.
After the trial of inhaled corticosteroid treatment, the diagnosis of asthma is supported if pre-bronchodilator
spirometry shows that airflow limitation has resolved, or if spirometry before and after bronchodilator demonstrates
airflow limitation that is fully reversible.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
Identify patients with characteristics strongly favouring either asthma or COPD. If the diagnosis is unclear, consider
referral to a specialist respiratory physician.
2
Note: It is clinically important to identify asthma features because, in patients with features of both asthma and COPD, treatment
should include an inhaled corticosteroid to reduce risk of flare-ups, and the use of long-acting beta2 agonist or long-acting muscarinic
antagonist without concomitant inhaled corticosteroid should be avoided to reduce risk of adverse effects. s
How this recommendation was developed
Adapted from existing guidance
Based on reliable clinical practice guideline(s) or position statement(s):
• Abramson et al. 20123
More information
Risk factors for COPD
Smoking is the most important risk factor for COPD.3 Current national COPD guidelines recommend that COPD should
be considered in all smokers and ex-smokers over 35 years, and in all patients with other smoking-related diseases.3
The other main risk factors for COPD include:3, 2, 1
•
•
•
•
•
exposure to environmental tobacco smoke
occupational exposure to dusts and fumes
exposure to biological dust, diesel exhaust
exposure to smoke from biomass fuels
genetic predisposition (alpha1 antitrypsin deficiency) interacting with environment (e.g. smoking)
Other risk factors for fixed (irreversible or incompletely reversible) airflow limitation include:1
• inadequate maximal lung function achieved in early life (e.g. due to untreated asthma or severe asthma in early
childhood, premature birth, or bronchopulmonary dysplasia)
• ageing
• longstanding asthma.
Diagnosis of COPD
The main symptoms of COPD are breathlessness, cough and sputum production. Patients often attribute breathlessness
to ageing or poor cardiopulmonary fitness. A persistent cough, typically worse in the mornings with mucoid sputum, is
common in smokers. Other symptoms, such as chest tightness, wheezing, fatigue and airway irritability are common.3
The clinical diagnosis of COPD is usually based on clinical presentation (e.g. breathlessness, productive cough), together
with both the following:3, 4
• a history of smoking or exposure to other noxious agents
• post-bronchodilator FEV1/FVC < 0.7 (or < lower limit of normal) together with FEV1 < 80% of the predicted value.
Coexisting asthma and COPD
There is a subgroup of patients with longstanding asthma who do not demonstrate reversible airflow limitation.5, 6 Asthma
that begins later in life often shows a component of irreversible or incompletely reversible airflow limitation (also called
‘fixed airway obstruction’), due to airway remodelling and stiffening of the chest wall.7 The same may be seen in patients
with a history of severe asthma in childhood.
Correspondingly, there is a subgroup of patients with COPD who demonstrate significant (though incomplete)
bronchodilator response and meet the diagnostic criteria for variable airflow limitation in asthma.5, 6 Most patients with
COPD show some reversibility of airflow limitation with bronchodilators,3 and the degree of reversibility can vary from
visit to visit.8
Overlap of asthma and COPD is fairly common among older patients attending primary care:
• In a Dutch analysis of GP patient lists, approximately 10% of patients using an inhaled medication had both COPD and
asthma as assessed by an independent pulmonologist.9
3
• In a Belgian survey of 26 GPs, 30% of patients with asthma and 38% with COPD had their diagnosis changed to the
combination of asthma and COPD following re-examination.9
• In a New Zealand population study, over 50% of people older than 50 years with airflow limitation showed some
degree of overlap of asthma and COPD.10
COPD is an important comorbidity and can lead to under-diagnosis of asthma in older people.1
In older people, COPD and asthma can be difficult to distinguish because both disorders have similar manifestations
despite potentially different causes and underlying abnormalities.1
Current Australian guidelines for the diagnosis and management of COPD recommend referral to a specialist respiratory
outpatient service for patients with a clinical diagnosis of COPD in whom asthma cannot be excluded.3
Risk factors for coexisting asthma and COPD include ageing, longstanding asthma, and smoking. The coexistence of
incompletely reversible airflow limitation (characteristic of COPD) and increased airflow variability (characteristic of
asthma) is common among people with respiratory symptoms aged 65 years and over, and even among those over 50
years.1, 5
The coexistence of asthma and COPD in older patients is not always due to cigarette smoking.7 In some people, persistent
airflow limitation may develop as a complication of long-term asthma.1, 9
Is it asthma, COPD or both?
The main symptoms of chronic obstructive pulmonary disease (COPD) are breathlessness, cough and sputum production.
Chest tightness, wheezing and airway irritability are also common. Patients often attribute breathlessness to ageing or
poor cardiopulmonary fitness.3
The definitions of asthma and COPD overlap, and asthma and COPD frequently coexist in people aged 65 years and
over.1 Comorbid COPD is often misdiagnosed as asthma in older people,1 and vice versa.
See: Chronic obstructive pulmonary disease (COPD) and asthma
See: Asthma in older adults
For information on diagnosis and management of COPD, refer to the COPD-X Concise Guide for Primary Care.11
The Global Initiative for Asthma (GINA) and Global Initiative Obstructive Lung Disease (GOLD) recommend the following
stepwise approach for adults presenting with respiratory symptoms:12
1. Identify whether the patient has clinical features of, or is at risk of, chronic airway disease. This may be suggested
by the clinical history and physical examination.
2. Identify features that favour a diagnosis of typical asthma or typical COPD. If several features of both are present,
asthma-COPD overlap is likely.
3. Perform spirometry to confirm airflow limitation.
4. Start treatment, selected according to whether the assessment favoured the single diagnosis of asthma, the single
diagnosis of COPD, or asthma-COPD overlap.
5. Refer for specialist assessment and other investigations, if necessary.
Definition of variable expiratory airflow limitation
Most of the tests for variable expiratory airflow limitation are based on showing variability in FEV1. While reduced FEV1
may be seen with many other lung diseases (or due to poor spirometric technique), a reduced ratio of FEV1 to FVC
indicates airflow limitation.13 Normal FEV1/FVC values derived from population studies vary,14, 15 but are usually greater
than:14
•
•
•
•
0.85 in people aged up to 19 years
0.80 in people aged 20–39 years
0.75 in people aged 40–59 years
0.70 in people aged 60–80 years.
In children, it is less useful to define expiratory airflow limitation according to a specific cut-off for FEV1/FVC ratio,
because normal values in children change considerably with age.15
4
Some spirometers provide predicted normal values specific to age group. If these are available, a FEV1/FVC ratio less than
the lower limit of normal (i.e. less than the 5th percentile of normal population) indicates airflow limitation.
Variable expiratory airflow limitation (beyond the range seen in healthy populations) can be documented if any of the
following are recorded:
• a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least
12% from baseline for children) 10–15 minutes after administration of bronchodilator
• clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g.
spirometry on separate visits)
• a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on
spirometry, or decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise
challenge testing uses different criteria for exercise-induced bronchoconstriction)
• a clinically important increase in lung function (at least 200 mL and 12% from baseline) after a trial of 4 or more weeks
of treatment with an inhaled corticosteroid
• clinically important variation in peak expiratory flow (diurnal variability of more than 10%)
• a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway
hyperresponsiveness (exercise challenge test or bronchial provocation test) measured by a respiratory function
laboratory.
Notes
Patients referred to a respiratory function laboratory may be asked not to take certain medicines within a few hours to days before a
spirometry visit.
A clinically important increase or decrease in lung function is defined as a change in FEV1 of at least 200 mL and 12% from baseline for
16, 13
A
adults, or at least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.
clinically important increase in FVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less
reliable measure in primary care because FVC may vary due to factors such as variation in inspiratory volume or expiratory time.
The finding of ‘normal’ lung function during symptoms reduces the probability that a patient has asthma, but a clinically important
improvement in response to bronchodilator or inhaled corticosteroid can occur in patients whose baseline value is within the predicted
normal range.
The greater the variation in lung function, the more certain is the diagnosis of asthma. However, people with longstanding asthma may
develop fixed airflow limitation.
Reversibility in airflow limitation may not be detected if the person is already taking a long-acting beta2 agonist or inhaled
corticosteroid.
Airflow limitation can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during a severe
acute infection of the respiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have a respiratory
tract infection. Reduction in lung function during a respiratory tract infection with improvement in lung function after its resolution,
commonly occurs in people with asthma, but can also be seen in patients with COPD or in healthy people without either asthma or
COPD.17,18
Go to: National Asthma Council Australia’s Spirometry Resources
Go to: National Asthma Council Australia and Woolcock Institute Peak Flow Chart
References
1. Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010; 376: 803-813. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20816547
2. Guerra S. Asthma and chronic obstructive pulmonary disease. Curr Opin Allergy Clin Immunol. 2009; 9: 409-16.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2832909/
3. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the
management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic
Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
4. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management and
prevention of COPD. GOLD, 2013. Available from: http://www.goldcopd.org/guidelines-global-strategy-for-diagnosismanagement.html
5. Gibson PG, Simpson JS. The overlap syndrome of asthma and COPD: what are its features and how important is it?.
Thorax. 2009; 64: 728-735. Available from: http://thorax.bmj.com/content/64/8/728.full
6. McDonald VM, Higgins I, Gibson PG. Managing older patients with coexistent asthma and chronic obstructive
pulmonary disease. Drugs Aging. 2013; 30: 1-17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23229768
7. Reed CE. Asthma in the elderly: diagnosis and management. J Allergy Clin Immunol. 2010; 126: 681-7; quiz 688-9.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/20673985
5
8. Albert P, Agusti A, Edwards L, et al. Bronchodilator responsiveness as a phenotypic characteristic of established
chronic obstructive pulmonary disease. Thorax. 2012; 67: 701-8. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22696176
9. van der Molen T. Co-morbidities of COPD in primary care: frequency, relation to COPD, and treatment
consequences. Prim Care Resp J. 2010; 19: 326-334. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20842323
10. Weatherall M, Travers J, Shirtcliffe PM, et al. Distinct clinical phenotypes of airways disease defined by cluster
analysis. Eur Respir J. 2009; 34: 812-818. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19357143
11. Abramson M, Frith P, Yang I, et al. COPD-X Concise Guide for Primary Care. Lung Foundation Australia, Brisbane, 2016.
Available from: http://lungfoundation.com.au/health-professionals/guidelines/copd/copd-x-concise-guide-forprimary-care/
12. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2016. Available
from: http://ginasthma.org/
13. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948968. Available from: http://erj.ersjournals.com/content/26/5/948
14. National Heart Lung and Blood Institute (NHLBI) National Asthma Education and Prevention Program. Expert Panel
Report 3: guidelines for the diagnosis and management of asthma. Full report 2007. US Department of Health and Human
Services National Institutes of Health, Bethesda, 2007. Available from: http://www.nhlbi.nih.gov/healthpro/guidelines/current/asthma-guidelines/full-report
15. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the
global lung function 2012 equations. Eur Respir J. 2012; 40: 1324-43. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22743675
16. Levy ML, Quanjer PH, Booker R, et al. Diagnostic Spirometry in Primary Care: Proposed standards for general
practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care
Respir J. 2009; 18: 130-147. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19684995
17. Collier AM, Pimmel RL, Hasselblad V, et al. Spirometric changes in normal children with upper respiratory infections.
Am Rev Respir Dis. 1978; 117: 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/619724
18. Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994;
7: 1239-1245. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7925901
6
HOME > CLINICAL ISSUES > COPD > MANAGING ASTHMA-COPD OVERLAP
Management considerations for patients with asthma-COPD
overlap
Recommendations
For patients with asthma-COPD overlap, prescribe long-term inhaled corticosteroids (at a low dose, if possible, or at the
lowest effective dose) to reduce the risk of asthma flare-ups.
• Monitor closely for lower respiratory tract infections, and advise patients to get medical advice immediately if they
develop symptoms of a lower respiratory tract infection.
s
How this recommendation was developed
Adapted from existing guidance
Based on reliable clinical practice guideline(s) or position statement(s):
• Abramson et al. 20121
For patients with asthma-COPD overlap, consider treatment with both an inhaled corticosteroid and a long-acting
bronchodilator, as (either of):
• combination inhaled corticosteroid/long-acting beta2 agonist in a single inhaler (or separate inhalers if the preferred
combination is not available in a single inhaler)
• concomitant treatment with an inhaled corticosteroid and a long-acting muscarinic
antagonist (anticholinergic) agent such as tiotropium.
Note: The use of separate inhalers for concomitant treatment with an inhaled corticosteroid and a long-acting bronchodilator (longacting beta2-agonist or long-acting muscarinic antagonist) in patients with asthma should be avoided if possible, even if the person
also has COPD. If no combination product is available for the desired combination, carefully explain to the patient that it is very
important that they continue taking the inhaled corticosteroid. s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Abramson et al. 20121
In addition to prescribing inhaled corticosteroids in combination with long-acting bronchodilators, manage coexisting
asthma and COPD according to the individual’s clinical features, comorbidities and response to treatment.
• Do not prescribe a long-acting bronchodilator (beta2 agonist or muscarinic antagonist) without an inhaled
corticosteroid in these patients.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• McDonald et al. 20122
7
• McDonald et al. 20113
More information
Coexisting asthma and COPD
There is a subgroup of patients with longstanding asthma who do not demonstrate reversible airflow limitation.4, 2 Asthma
that begins later in life often shows a component of irreversible or incompletely reversible airflow limitation (also called
‘fixed airway obstruction’), due to airway remodelling and stiffening of the chest wall.5 The same may be seen in patients
with a history of severe asthma in childhood.
Correspondingly, there is a subgroup of patients with COPD who demonstrate significant (though incomplete)
bronchodilator response and meet the diagnostic criteria for variable airflow limitation in asthma.4, 2 Most patients with
COPD show some reversibility of airflow limitation with bronchodilators,1 and the degree of reversibility can vary from
visit to visit.6
Overlap of asthma and COPD is fairly common among older patients attending primary care:
• In a Dutch analysis of GP patient lists, approximately 10% of patients using an inhaled medication had both COPD and
asthma as assessed by an independent pulmonologist.7
• In a Belgian survey of 26 GPs, 30% of patients with asthma and 38% with COPD had their diagnosis changed to the
combination of asthma and COPD following re-examination.7
• In a New Zealand population study, over 50% of people older than 50 years with airflow limitation showed some
degree of overlap of asthma and COPD.8
COPD is an important comorbidity and can lead to under-diagnosis of asthma in older people.9
In older people, COPD and asthma can be difficult to distinguish because both disorders have similar manifestations
despite potentially different causes and underlying abnormalities.9
Current Australian guidelines for the diagnosis and management of COPD recommend referral to a specialist respiratory
outpatient service for patients with a clinical diagnosis of COPD in whom asthma cannot be excluded.1
Risk factors for coexisting asthma and COPD include ageing, longstanding asthma, and smoking. The coexistence of
incompletely reversible airflow limitation (characteristic of COPD) and increased airflow variability (characteristic of
asthma) is common among people with respiratory symptoms aged 65 years and over, and even among those over 50
years.9, 4
The coexistence of asthma and COPD in older patients is not always due to cigarette smoking.5 In some people, persistent
airflow limitation may develop as a complication of long-term asthma.9, 7
Is it asthma, COPD or both?
The main symptoms of chronic obstructive pulmonary disease (COPD) are breathlessness, cough and sputum production.
Chest tightness, wheezing and airway irritability are also common. Patients often attribute breathlessness to ageing or
poor cardiopulmonary fitness.1
The definitions of asthma and COPD overlap, and asthma and COPD frequently coexist in people aged 65 years and
over.9 Comorbid COPD is often misdiagnosed as asthma in older people,9 and vice versa.
See: Chronic obstructive pulmonary disease (COPD) and asthma
See: Asthma in older adults
For information on diagnosis and management of COPD, refer to the COPD-X Concise Guide for Primary Care.10
The Global Initiative for Asthma (GINA) and Global Initiative Obstructive Lung Disease (GOLD) recommend the following
stepwise approach for adults presenting with respiratory symptoms:11
1. Identify whether the patient has clinical features of, or is at risk of, chronic airway disease. This may be suggested
by the clinical history and physical examination.
8
2. Identify features that favour a diagnosis of typical asthma or typical COPD. If several features of both are present,
asthma-COPD overlap is likely.
3. Perform spirometry to confirm airflow limitation.
4. Start treatment, selected according to whether the assessment favoured the single diagnosis of asthma, the single
diagnosis of COPD, or asthma-COPD overlap.
5. Refer for specialist assessment and other investigations, if necessary.
Management of coexisting asthma and COPD
• Long-acting beta2 agonists or long-acting muscarinic antagonists should not be prescribed without an inhaled
corticosteroid in patients who have both asthma and COPD, or who have COPD with some features of asthma.
• For patients with both asthma and COPD, treatment should always include inhaled corticosteroids to reduce the risk
of flare-ups.
Coexisting asthma and COPD should be managed according to the individual’s clinical features and response to
treatment, and monitored by comprehensive ongoing assessment.2
Although back-titration of pharmacological treatment is a core principle of asthma management, there is insufficient
evidence about the role of back-titration in patients with coexisting asthma and COPD. However, treatment decisions
should always balance potential benefits with potential risks of treatment.
Pulmonary rehabilitation is effective for people with symptomatic COPD.1, 12 Pulmonary rehabilitation is also effective for
people with asthma who experience persistent breathlessness, those who are physically inactive, and those with anxiety
or depression.13
Supervised exercise training may help improve asthma symptoms and quality of life in people with coexisting asthma and
COPD, even in older people.14
Comorbid medical conditions are common among people with coexisting asthma and COPD. Comorbidities should be
assessed and managed individually.2, 3
Assessment and management of asthma self-management skills must take into consideration comorbidity associated with
COPD or ageing (e.g. impaired cognition, reduced manual dexterity and impaired vision).2, 3
Pneumonia risk with inhaled corticosteroids in patients with COPD
In people with COPD, the risk of pneumonia is increased by the use of regular inhaled corticosteroids.15, 16, 17, 18 Most of
the available evidence is from patients treated with fluticasone propionate.18, 19, 20, 21, 22, 23 Increased pneumonia rates
have also been observed in studies of patients with COPD using fluticasone furoate/vilanterol.24 The higher dose of
fluticasone furoate/vilanterol (Breo Ellipta 200/25 mcg) is not indicated for patients with COPD.
24, 25
Increased risk of pneumonia with inhaled corticosteroids has not been established in patients with asthma.
However,
the risk of pneumonia in patients with co-existing asthma and COPD is unknown, so caution is advised, particularly if high
doses are being considered.
Definition of variable expiratory airflow limitation
Most of the tests for variable expiratory airflow limitation are based on showing variability in FEV1. While reduced FEV1
may be seen with many other lung diseases (or due to poor spirometric technique), a reduced ratio of FEV1 to FVC
indicates airflow limitation.26 Normal FEV1/FVC values derived from population studies vary,27, 28 but are usually greater
than:
•
•
•
•
27
0.85 in people aged up to 19 years
0.80 in people aged 20–39 years
0.75 in people aged 40–59 years
0.70 in people aged 60–80 years.
In children, it is less useful to define expiratory airflow limitation according to a specific cut-off for FEV1/FVC ratio,
because normal values in children change considerably with age.28
Some spirometers provide predicted normal values specific to age group. If these are available, a FEV1/FVC ratio less than
the lower limit of normal (i.e. less than the 5th percentile of normal population) indicates airflow limitation.
9
Variable expiratory airflow limitation (beyond the range seen in healthy populations) can be documented if any of the
following are recorded:
• a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least
12% from baseline for children) 10–15 minutes after administration of bronchodilator
• clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g.
spirometry on separate visits)
• a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on
spirometry, or decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise
challenge testing uses different criteria for exercise-induced bronchoconstriction)
• a clinically important increase in lung function (at least 200 mL and 12% from baseline) after a trial of 4 or more weeks
of treatment with an inhaled corticosteroid
• clinically important variation in peak expiratory flow (diurnal variability of more than 10%)
• a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway
hyperresponsiveness (exercise challenge test or bronchial provocation test) measured by a respiratory function
laboratory.
Notes
Patients referred to a respiratory function laboratory may be asked not to take certain medicines within a few hours to days before a
spirometry visit.
A clinically important increase or decrease in lung function is defined as a change in FEV1 of at least 200 mL and 12% from baseline for
adults, or at least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.29, 26 A
clinically important increase in FVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less
reliable measure in primary care because FVC may vary due to factors such as variation in inspiratory volume or expiratory time.
The finding of ‘normal’ lung function during symptoms reduces the probability that a patient has asthma, but a clinically important
improvement in response to bronchodilator or inhaled corticosteroid can occur in patients whose baseline value is within the predicted
normal range.
The greater the variation in lung function, the more certain is the diagnosis of asthma. However, people with longstanding asthma may
develop fixed airflow limitation.
Reversibility in airflow limitation may not be detected if the person is already taking a long-acting beta2 agonist or inhaled
corticosteroid.
Airflow limitation can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during a severe
acute infection of the respiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have a respiratory
tract infection. Reduction in lung function during a respiratory tract infection with improvement in lung function after its resolution,
commonly occurs in people with asthma, but can also be seen in patients with COPD or in healthy people without either asthma or
COPD.30,31
Go to: National Asthma Council Australia’s Spirometry Resources
Go to: National Asthma Council Australia and Woolcock Institute Peak Flow Chart
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