ACO (Asthma–COPD Overlap) Is Independent from COPD: The Case Against
Abstract
:1. Introduction
2. Defining ACO
3. A Pathology of ACO?
4. The Clinical Significance of ACO
5. The Physiology of ACO
6. Therapeutic Implications of ACO
7. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Major Criteria | Minor Criteria |
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|
|
Study | Definition of ACO | Main Findings |
---|---|---|
Reddel et al. [52] | Physician diagnosis of asthma, COPD or both | 12.4% asthma and COPD (ACO) More likely to smoke, higher blood neutrophil count, more breathless and poorer health status compared with asthma Earlier diagnosis, more upper airway disease compared with COPD Bronchodilator responsiveness and FeNO similar across groups |
Morgan et al. [53] | Features of both: COPD—post-bd FEV1/FVC below LLN and Asthma—self report physician asthma diagnosis, use of asthma medication last year or wheezing last year | Prevalence of ACO 3.8% in LMIC residents People with ACO had more biomass fuel exposure, higher smoking and lower educational attainment Worse AFO than asthma or COPD groups |
Toledo-Pons et al. [54] | Three groups: Diagnosed with asthma and COPD (smoking asthmatic) COPD and bronchial hyperresponsiveness (FEV1 increase >400 mL and 15%) (COPD high bronchial response) COPD and eosinophilia (eosinophils >300cells/µL) (COPD eosinophilia) | 27.4% fulfilled one or more criteria for ACO 13.8% smoking asthmatic, 12.1% COPD with eosinophilia and 1.5% COPD with high bronchodilator response Smoking asthmatics were younger, more likely female and more atopic |
Singh A et al. [55] | COPD—post-bronchodilator FEV1/FVC <0.7 Asthma—>200 mL and >12% improvement in FEV1 with bronchodilator ACO—both present | Prevalence of ACO 4.6% in firefighters Eosinophil count >300 cells/µL more common in ACO More likely to have accelerated decline in FEV1 |
Cosentino et al. [56] | ACO; either: history of asthma or hay fever, FEV1/FVC <0.7, >200 mL and >12% improvement in FEV1 with bronchodilator and less than 15% emphysema on CT, or FEV1/FVC <0.7, >400 mL and >15% improvement in FEV1 with bronchodilator and less than 15% emphysema on CT and less than 15% emphysema on CT regardless of history of asthma or hay fever | Compared to subjects with COPD and emphysema ACO subjects were younger, more likely African-American, higher BMI and more likely to still smoke |
Krishnan et al. [57] | ACO defined as >40 years old, current or former smoker, FEV1/FVC <0.7 and >200 mL and >12% improvement in FEV1 with bronchodilator | Prevalence of ACO of 18.2% More common in people diagnosed with both asthma and COPD Younger and higher BMI compared with COPD cohort More likely to smoke and less rhinitis than asthma cohort |
Izbicki et al. [58] | COPD was defined as FEV1 <80% predicted and FEV1/FVC <0.7. ACO was defined as this plus >200 mL and >12% improvement in FEV1 with bronchodilator | No differences seen compared with the COPD cohort except lower pre-bronchodilator lung function in ACO |
Barrecheguren et al. [59] | ACO defined as COPD patients reporting a previous diagnosis of asthma Classified as ACO2 if had 2 major or 1 major & 2 minor criteria: Major criteria were improvement in FEV1 >400 mL and >15% with bronchodilator, sputum eosinophilia or a previous diagnosis of asthma before the age of 40 years Minor criteria were increased total serum immunoglobulin E, previous history of atopy or FEV1 >200 mL and >12% on two or more occasions | Prevalence of ACO of 15.9% Two thirds did not fulfil ACO2 criteria ACO subjects were more likely to be female, had more exacerbations, had better lung function and higher blood eosinophilia |
Llanos et al. [60] | 40 years old or greater with at least 1 asthma and 1 COPD characteristic: Asthma characteristic—even given a physician diagnosis of asthma or had an ‘asthma attack’ in the previous year COPD characteristic—post-bd FEV1/FVC <0.7 and ever told they had emphysema or chronic bronchitis by a physician | ACO subjects had poorer lung function than those with asthma or COPD, higher eosinophil counts than those with asthma or COPD and had more ‘asthma attacks’ than the asthma group |
Baarnes et al. [61] | At least 1 previous hospitalisation for asthma and 1 for COPD | Subjects with ACO were older, more likely to smoke, had lower educational attainment and took less regular exercise |
Pitfall with Reversibility Testing | Reason for the Problem |
---|---|
The bronchodilator drug used | Additional bronchodilation with the combination of short-acting beta-agonists and short-acting anti-muscarinics compared to one bronchodilator |
The timing of reversibility testing | Short-acting anti-muscarinics achieve maximum bronchodilation longer than 15 min after administration, the timing typically used for beta-agonist reversibility |
The dose of bronchodilator drug | Higher doses of salbutamol (>400 mcg) will result in further small increases in FEV1 compared with lower doses |
The reproducibility of result | The magnitude of reversibility, and classification of reversibility (positive or negative), varies significantly between tests |
The impact of pre-test FEV1 | Individuals with a lower pre-test FEV1 are less likely to shown significant reversibility |
The clinical implications of reversibility | Reversibility does not predict clinical symptoms, exacerbations and subsequent decline in lung function |
Phenotype of ACO | Clinical and Biological Features |
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Smokers with airflow obstruction and eosinophilic inflammation | Exacerbations driven by eosinophilic inflammation Better lung function, less emphysema, less disease progression Better response to oral and inhaled corticosteroids Higher level of atopy |
Resistant asthmatic | Asthmatics less responsive to corticosteroids Higher level of irreversible airflow obstruction Neutrophil dominated airway inflammation and exacerbations are more common |
Elderly asthmatic with irreversible airflow obstruction | Long-standing asthma and irreversible airflow obstruction Neutrophil dominated airway inflammation Loss of lung elastic recoil and more hyperinflation |
Childhood asthmatic who smokes and has developed COPD | Asthma as child or young adult but long-term smoking Higher number of pack years (more likely to have >20 pack years) High symptom burden and healthcare utilisation |
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Calverley, P.M.A.; Walker, P.P. ACO (Asthma–COPD Overlap) Is Independent from COPD: The Case Against. Diagnostics 2021, 11, 1189. https://doi.org/10.3390/diagnostics11071189
Calverley PMA, Walker PP. ACO (Asthma–COPD Overlap) Is Independent from COPD: The Case Against. Diagnostics. 2021; 11(7):1189. https://doi.org/10.3390/diagnostics11071189
Chicago/Turabian StyleCalverley, Peter M. A., and Paul Phillip Walker. 2021. "ACO (Asthma–COPD Overlap) Is Independent from COPD: The Case Against" Diagnostics 11, no. 7: 1189. https://doi.org/10.3390/diagnostics11071189