Asthma control in elderly asthmatics. An Italian observational study

Assessment of functional diversities in patients with Asthma, COPD, Asthma-COPD overlap, and Cystic Fibrosis (CF)

The objectives of the present study were to evaluate the discriminating power of spirometric and plethysmographic lung function parameters to differenciate the diagnosis of asthma, ACO, COPD, and to define functional characteristics for more precise classification of obstructive lung diseases. From the databases of 4 centers, a total of 756 lung function tests (194 healthy subjects, 175 with asthma, 71 with ACO, 78 with COPD and 238 with CF) were collected, and gradients among combinations of target parameters from spirometry (forced expiratory volume one second: FEV1; FEV1/forced vital capacity: FEV1/FVC; forced expiratory flow between 25-75% FVC: FEF25-75), and plethysmography (effective, resistive airway resistance: sReff; aerodynamic work of breathing at rest: sWOB), separately for in- and expiration (sReffIN, sReffEX, sWOBin, sWOBex) as well as static lung volumes (total lung capacity: TLC; functional residual capacity: FRCpleth; residual volume: RV), the control of breathing (mouth occlusion pressure: P0.1; mean inspiratory flow: VT/TI; the inspiratory to total time ratio: TI/Ttot) and the inspiratory impedance (Zinpleth = P0.1/VT/TI) were explored. Linear discriminant analyses (LDA) were applied to identify discriminant functions and classification rules using recursive partitioning decision trees. LDA showed a high classification accuracy (sensitivity and specificity > 90%) for healthy subjects, COPD and CF. The accuracy dropped for asthma (~70%) and even more for ACO (~60%). The decision tree revealed that P0.1, sRtot, and VT/TI differentiate most between healthy and asthma (68.9%), COPD (82.1%), and CF (60.6%). Moreover, using sWOBex and Zinpleth ACO can be discriminated from asthma and COPD (60%). Thus, the functional complexity of obstructive lung diseases can be understood, if specific spirometric and plethysmographic parameters are used. Moreover, the newly described parameters of airway dynamics and the central control of breathing including Zinpleth may well serve as promising functional marker in the field of precision medicine.

Symptom Burden, Health Status, and Productivity in Patients with Uncontrolled and Controlled Severe Asthma in NOVELTY

Background

Few studies have quantified symptom burden, health status, and productivity in patients with uncontrolled and controlled severe asthma. Up-to-date, real-world, global evidence is needed.

Objective

To quantify symptom burden, health status, and productivity in patients with uncontrolled and controlled severe asthma using baseline data from the NOVEL observational longiTudinal studY (NOVELTY; NCT02760329).

Methods

NOVELTY included patients aged ≥18 years (or ≥12 years in some countries) from primary care and specialist centres in 19 countries, with a physician-assigned diagnosis of asthma, asthma+chronic obstructive pulmonary disease (COPD), or COPD. Disease severity was physician-assessed. Uncontrolled severe asthma was defined by an Asthma Control Test (ACT) score <20 and/or severe physician-reported exacerbations in the previous year; controlled severe asthma required an ACT score ≥20 and no severe exacerbations. Assessment of symptom burden included Respiratory Symptoms Questionnaire (RSQ) and ACT score. Assessment of health status included St George's Respiratory Questionnaire (SGRQ), EuroQoL 5 Dimensions 5 Levels Health Questionnaire (EQ-5D-5L) index value, and EQ-5D-5L Visual Analog Score (EQ-VAS). Assessment of productivity loss included absenteeism, presenteeism, overall work impairment, and activity impairment.

Results

Of 1652 patients with severe asthma, asthma was uncontrolled in 1078 (65.3%; mean age 52.6 years, 65.8% female) and controlled in 315 (19.1%; mean age 55.2 years, 56.5% female). With uncontrolled versus controlled severe asthma, symptom burden was higher (mean RSQ score 7.7 vs 2.5), health status more impaired (mean SGRQ total score 47.5 vs 22.4; mean EQ-5D-5L index value 0.68 vs 0.90; mean EQ-VAS score 64.1 vs 78.1), and productivity lower (presenteeism 29.3% vs 10.5%).

Conclusion

Our findings highlight the symptom burden of uncontrolled severe asthma compared with controlled severe asthma and its impact on patient health status and productivity, and support the need for interventions to improve control of severe asthma.

[Risk factors for adverse outcomes in elderly patients with asthma and severe COVID-19 at the hospital and early post-hospital stages]

BACKGROUND

Mortality and COVID-19 related factors are thoroughly analyzed. Given the large number of hospitalized patients, the potential short- and long-term COVID-19 related complications, further research is needed on the possible consequences of hospitalization, especially in higher-risk patients, after prolonged hospitalization and intensive care admission.

AIM

To study the clinical course and outcomes of severe COVID-19 in elderly patients with asthma at the hospital and early post-hospital stages.

MATERIALS AND METHODS

The study included 131 elderly patients (WHO, 2020) >60 years old, n=131 with asthma, hospitalized for severe COVID-19. Of these, 86 (65.6%) patients survived, 30 (22.9%) died in the hospital, and 15 (14.9%) patients died after discharge from the hospital (in the 90-day post-hospital period). COVID-19 was confirmed by laboratory tests (SARS-CoV-2 PCR RNA test) and/or clinically and radiologically. All patients had a documented history of asthma. Patients were followed up during the hospital stay and for 90 days after discharge.

RESULTS

Comparison of outcomes showed that in the groups of patients with a fatal outcome (regardless of the stage), the Charlson comorbidity index, respiratory rate, extent of lung damage assessed by computed tomography, the absolute leukocyte and neutrophil number and the ratio of neutrophils to lymphocytes were statistically significantly higher. The absolute number of eosinophils was lower in these groups. In the group of patients who died during hospitalization, severe (IV-V) asthma (p=0.03), steroid use during the previous year (p=0.02), chronic heart failure with a reduced ejection fraction (p=0.009) were more common, and atopic asthma phenotype was less common (p=0.02). In those who died after discharge, more common were non-invasive ventilation and diabetes mellitus (p<0.001). The multivariate regression analysis model revealed the most significant predictors of mortality at the hospital and early post-hospital stages.

CONCLUSION

Adverse outcomes of severe COVID-19 in elderly patients with asthma include hospital and post-hospital mortality. The most significant predictors of mortality are the comorbidity index and low eosinophil count. Hospital mortality is associated with a higher ratio of neutrophils to lymphocytes and lower total protein levels; early (90-day) post-hospital mortality is associated with extensive lung damage shown by computed tomography and diabetes mellitus.

Functional Predictors Discriminating Asthma-COPD Overlap (ACO) from Chronic Obstructive Pulmonary Disease (COPD)

Background

A significant proportion of patients with obstructive lung disease have clinical and functional features of both asthma and chronic obstructive pulmonary disease (COPD), referred to as the asthma–COPD overlap (ACO). The distinction of these phenotypes, however, is not yet well-established due to the lack of defining clinical and/or functional criteria. The aim of our investigations was to assess the discriminating power of various lung function parameters on the assessment of ACO.

Methods

From databases of 4 pulmonary centers, a total of 540 patients (231 males, 309 females), including 372 patients with asthma, 77 patients with ACO and 91 patients with COPD, were retrospectively collected, and gradients among combinations of explanatory variables of spirometric (FEV₁, FEV₁/FVC, FEF_25-75), plethysmographic (sR_eff, sG_eff, the aerodynamic work of breathing at rest; sWOB), static lung volumes, including trapped gases and measurements of the carbon monoxide transfer (DL_CO, K_CO) were explored using multiple factor analysis (MFA). The discriminating power of lung function parameters with respect to ACO was assessed using linear discriminant analysis (LDA).

Results

LDA revealed that parameters of airway dynamics (sWOB, sR_eff, sG_eff) combined with parameters of static lung volumes such as functional residual capacity (FRC_pleth) and trapped gas at FRC (V_TG^FRC) are valuable and potentially important tools discriminating between asthma, ACO and COPD. Moreover, sWOB significantly contributes to the diagnosis of obstructive airway diseases, independent from the state of pulmonary hyperinflation, whilst the diffusion capacity for carbon monoxide (DL_CO) significantly differentiates between the 3 diagnostic classes.

Conclusion

The complexity of COPD with its components of interaction and their heterogeneity, especially in discrimination from ACO, may well be differentiated if patients are explored by a whole set of target parameters evaluating, interactionally, flow limitation, airway dynamics, pulmonary hyperinflation, small airways dysfunction and gas exchange disturbances assessing specific functional deficits.

Epidemiology of Asthma-Chronic Obstructive Pulmonary Disease Overlap

Asthma COPD Overlap has consistently reported to be associated with an increase burden of disease but the impact on lung function decline and mortality varies by study. The prevalence increases with age but the relationship with gender also varies with the study population. The variability in the prevalence and clinical characteristics of ACO is linked to differences in how chronic obstructive pulmonary disease (COPD) and asthma are defined, including diagnostic criteria (spirometry-based vs. clinical or symptom-based diagnoses vs. claims data), the population studied, the geographic region and environment and a consensus approach to the diagnosis of ACO is needed to allow meaningful and consistent epidemiologic information to be generated about this condition.

Current Knowledge of Asthma-COPD Overlap (ACO) Genetic Risk Factors, Characteristics, and Prognosis

Asthma-COPD overlap (ACO) is a newly identified phenotype of chronic obstructive airway diseases with shared asthma and COPD features. Patients with ACO are poorly defined, and some evidence suggests that they have worse health outcomes and greater disease burden than patients with COPD or asthma. Generally, there is no evidence-based and universal definition for ACO; several consensus documents have provided various descriptions of the phenotype. In addition, the mechanisms underlying the development of ACO are not fully understood. Whether ACO is a distinct clinical entity with its particular discrete genetic determinant different from asthma and COPD alone or an intermediate phenotype with overlapping genetic markers within asthma and COPD spectrum of obstructive airway disease remains unproven. This review summarizes the current knowledge of the genetic risk factors, characteristics, and prognosis of ACO.

Patterns of medical care utilization according to environmental factors in asthma and chronic obstructive pulmonary disease patients

BACKGROUND/AIMS

Weather and air pollution are associated with the exacerbation of respiratory diseases. We investigated patterns of medical care use according to meteorological factors and air pollution in patients with asthma or chronic obstructive pulmonary disease (COPD).

METHODS

We analyzed the medical care utilization patterns of patients with asthma or COPD registered in the Korea Health Insurance Review and Assessment database for the period 2007 to 2013. The patterns were divided into hospitalization and emergency department (ED) use.

RESULTS

The medical care use of patients with asthma or COPD increased when the mean temperature and relative humidity were lower, and the temperature difference and atmospheric pressure were greater. Medical care use increased with the concentrations of particulate matter and ozone. Among age groups, sensitivity to pollutants was greatest in patients aged ≥ 65 years. The effect of being elderly was greater for asthma than for COPD, with a higher hospitalization rate. ED utilization affected by environmental factors was significantly greater for females and hospitalization was significantly more common for males.

CONCLUSION

Meteorological factors and air pollutants were shown to contribute to increased medical care utilization by patients with asthma and COPD, particularly elderly patients. The overall effect was greater for COPD, but the effect in elderly patients was greater for asthma. In addition, the patterns of change in medical care use due to environmental factors differed according to sex.

Update on Asthma-COPD Overlap (ACO): A Narrative Review

Although chronic obstructive pulmonary disease (COPD) and asthma are well-characterized diseases, they can coexist in a given patient. The term asthma-COPD overlap (ACO) was introduced to describe patients that have clinical features of both diseases and may represent around 25% of COPD patients and around 20% of asthma patients. Despite the increasing interest in ACO, there are still substantial controversies regarding its definition and its position within clinical guidelines for patients with obstructive lung disease. In general, most definitions indicate that ACO patients must present with non-reversible airflow limitation, significant exposure to smoking or other noxious particles or gases, together with features of asthma. In patients with a primary diagnosis of COPD, the identification of ACO has therapeutic implication because the asthmatic component should be treated with inhaled corticosteroids and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. This manuscript aims to summarize the current state-of-the-art of ACO. The definitions, prevalence, and clinical manifestations will be reviewed and some innovative aspects, such as genetics, epigenetics, and biomarkers will be addressed. Lastly, the management and prognosis will be outlined as well as the position of ACO in the COPD and asthma guidelines.

Concurrent asthma and chronic obstructive pulmonary disease in adult ED patients: A national perspective

OBJECTIVES

Emergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone.

METHODS

We conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005-2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables.

RESULTS

From 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p < 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20-109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p < 0.001) and COPD Only (p < 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056-0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31-0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12-0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091-0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31-0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23-0.93).

CONCLUSIONS

ACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.

Small Airway Dysfunction Links Asthma Severity with Physical Activity and Symptom Control

BACKGROUND

Little is known about the role of small airway dysfunction (SAD) and its complex relation with asthma control and physical activity (PA).

OBJECTIVE

To investigate the interrelations among SAD, risk factors for asthma severity, symptom control, and PA.

METHODS

We assessed SAD by impulse oscillometry and other sophisticated lung function measures including inert gas washout in adults with asthma (mild to moderate, n = 140; severe, n = 128) and 69 healthy controls from the All Age Asthma Cohort. We evaluated SAD prevalence and its interrelation with risk factors for asthma severity (older age, obesity, and smoking), type 2 inflammation (sputum and blood eosinophils, fractional exhaled nitric oxide), systemic inflammation (high-sensitivity C-reactive protein), asthma control (AC), and PA (accelerometer for 1 week). We applied a clinical model based on structural equation modeling that integrated causal pathways among these clinical variables.

RESULTS

The prevalence of SAD ranged from 75% to 90% in patients with severe asthma and from 53% to 64% in mild to moderate asthma. Severe SAD was associated with poor AC and low PA. Structural equation modeling indicated that age, obesity, obesity-related systemic inflammation, T2 inflammation, and smoking are independent predictors of SAD. Small airway dysfunction was the main determinant factor of AC, which in turn affected PA. Obesity affected AC directly and through its contribution to SAD and low PA. In addition, PA had bidirectional associations with obesity, SAD, and AC. Structural equation modeling also indicated interrelations among distal airflow limitation, air trapping, and ventilation heterogeneity.

CONCLUSIONS

Small airway dysfunction is a highly prevalent key feature of asthma that interrelates a spectrum of distal lung function abnormalities with risk factors for asthma severity, asthma control, and physical activity.

Clinical, laboratory, and functional characteristics of asthma-COPD overlap in patients with a primary diagnosis of COPD

OBJECTIVE

To evaluate the frequency of asthma-COPD overlap (ACO) in patients with COPD and to compare, from a clinical, laboratory, and functional point of view, patients with and without ACO, according to different diagnostic criteria.

METHODS

The participants underwent evaluation by a pulmonologist, together with spirometry and blood tests. All of the patients were instructed to record their PEF twice a day. The diagnosis of ACO was based on the Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar (PLATINO, Latin American Project for the Investigation of Obstructive Lung Disease) criteria, the American Thoracic Society (ATS) Roundtable criteria, and the Spanish criteria. We investigated patient histories of exacerbations and hospitalizations, after which we applied the COPD Assessment Test and the modified Medical Research Council scale, to classify risk and symptoms in accordance with the GOLD criteria.

RESULTS

Of the 51 COPD patients, 14 (27.5%), 8 (12.2%), and 18 (40.0) were diagnosed with ACO on the basis of the PLATINO, ATS Roundtable, and Spanish criteria, respectively. The values for pre-bronchodilator FVC, post-bronchodilator FVC, and pre-bronchodilator FEV1 were significantly lower among the patients with ACO than among those with COPD only (1.9 ± 0.4 L vs. 2.4 ± 0.7 L, 2.1 ± 0.5 L vs. 2.5 ± 0.8 L, and 1.0 ± 0.3 L vs. 1.3 ± 0.5 L, respectively). When the Spanish criteria were applied, IgE levels were significantly higher among the patients with ACO than among those with COPD only (363.7 ± 525.9 kU/L vs. 58.2 ± 81.6 kU/L). A history of asthma was more common among the patients with ACO (p < 0.001 for all criteria).

CONCLUSIONS

In our sample, patients with ACO were more likely to report previous episodes of asthma and had worse lung function than did those with COPD only. The ATS Roundtable criteria appear to be the most judicious, although concordance was greatest between the PLATINO and the Spanish criteria.

Role of pulmonary function and FeNO detection in early screening of patients with ACO

Measurement of fractional exhaled nitric oxide (FeNO) is a quantitative and non-invasive approach to examine airway inflammation, which is a powerful aid in diagnosing chronic disorders of airways like asthma. Diagnostic value of FeNO and relevant indices on pulmonary function in the patients with asthma and chronic obstructive pulmonary disease (COPD) was evaluated. A total of 164 patients [58 asthma, 49 COPD and 57 asthma-COPD overlap (ACO)] were randomly recruited. FeNO, pulmonary ventilation function, and bronchial diastolic function were performed. Eight indicators including FeNO, vital capacity percentage (VC%), forced vital capacity percentage (FVC%), forced expiratory volume in one second percentage (FEV1%), forced expiratory volume in one second to forced vital capacity percentage (FEV1/FVC%), maximum independent ventilation volume percentage (MVV%), the increased percentage of FEV1 after bronchial diastolic test, the increased absolute value of FEV1 after bronchial diastolic test were examined. Significant difference in VC%, FVC%, FEV1%, FEV1/FVC%, MVV%, the increased absolute value of FEV1 after bronchial diastolic test and FeNO were significantly different between patients with asthma and patients with COPD (P<0.05). There were significant differences of VC%, FVC%, FEV1%, FEV1/FVC%, MVV% and the increased percentage of FEV1 after bronchial diastolic test in cases of patients with asthma compared to ACO patients (P<0.05). There was no statistical significance on VC%, FVC%, FEV1%, FEV1/FVC%, MVV% between COPD patients and ACO patients (P>0.05). However, more importantly, the increased percentage of FEV1 after bronchial diastolic test, the increased absolute value of FEV1 after bronchial diastolic test and the alterations on FeNO were found significantly different in ACO group compared with COPD alone (P<0.05). We compared the results from pulmonary ventilation function, bronchial diastolic function examination as well as FeNO detection among 3 groups of asthma, COPD and ACO. The examination of pulmonary ventilation function and bronchial diastolic function combined with FeNO detection is helpful in the early screening of ACO.

Identification and definition of asthma-COPD overlap: The CanCOLD study

BACKGROUND AND OBJECTIVE

Lack of consensus on diagnosis of ACO limits our understanding of the impact, management and outcomes of ACO. The present observational study aims to describe the prevalence, clinical characteristics and course of individuals with ACO based on various definitions used in clinical practice.

METHODS

We included individuals with COPD from the prospective, multisite CanCOLD study and defined subjects with ACO using seven definitions commonly used in the literature.

RESULTS

Data including questionnaires, lung function and CT scans were analysed from 522 individuals with COPD who were randomly recruited from the population. Among them, 264 fulfilled at least one of the seven definitions of ACO. Prevalence of ACO varied from 3.8% to 31%. Regardless of the definition, individuals with ACO had worse outcomes (lung function and higher percentage of fast decliners, symptoms and exacerbations, health-related quality of life and comorbidities) than the remaining patients with COPD. Conversely, patients with non-ACO had higher emphysema and bronchiolitis scores. The three definitions that included atopy and/or physician diagnosis of asthma identified subjects who differed significantly from patients with COPD. The two ACO definitions with post-bronchodilator reversibility were concordant with COPD and were the least stable, with less than 50% of the patients from each group maintaining reversibility over visits.

CONCLUSION

Atopy and physician-diagnosed asthma are more distinguishing characteristics to identify ACO. This finding needs to be validated using measures of airway inflammation and other specific biomarkers.

Risk Factors for Acute Exacerbations in Elderly Asthma: What Makes Asthma in Older Adults Distinctive?

Purpose

Asthma in the elderly (EA; ≥ 65 years of age) is increasing, adding a heavy socioeconomic burden to the healthcare system. However, little is known about risk factors associated with acute exacerbations in EA patients. The objective of this study was to investigate risk factors for acute exacerbation in EA compared to non-elderly asthma (NEA).

Methods

We combined data from 3 adult asthma cohorts under a unified protocol and database. Asthmatic patients with regular follow-up during a 1-year period were selected from the cohorts to identify the risk factors predicting acute exacerbations in EA compared to NEA.

Results

We selected a total of 1,086 patients from the merged cohort. During the observation period, 503 and 583 patients were assigned to the EA and NEA groups, respectively. The exacerbation rate was 31.0% in the EA and 33.2% in the NEA group. Multivariate logistic regression analysis revealed fixed airway obstruction, chronic rhinosinusitis (CRS), and male sex as independent risk factors for exacerbation in the EA group. In the NEA group, exacerbation increased along with an increase in eosinophil count. Bayesian analysis of the interactions among clinical factors revealed that forced expiratory volume in 1 second/forced vital capacity was directly related to exacerbation in the EA group, and eosinophil count was related to exacerbation in the NEA group.

Conclusions

We suggest that fixed airway obstruction and CRS as the important clinical factors predicting acute exacerbations in EA, whereas in NEA, eosinophil count was the strong predictor of exacerbation.

Asthma-COPD Overlap and Chronic Airflow Obstruction: Definitions, Management, and Unanswered Questions

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a common clinical presentation of chronic airways disease in which patients show some features usually associated with asthma, and some usually associated with COPD. There is ongoing debate over whether ACO is a discrete clinical entity, or if it is part of a continuum of airways disease. Furthermore, there is considerable variation among current definitions of ACO, which makes diagnosis potentially challenging for clinicians. Treating ACO may be equally challenging because ACO is an understudied population, and the evidence base for its management comes largely from asthma and COPD studies, the relevance of which deserves careful consideration. In this review, we synthesize the various approaches to ACO diagnosis and evaluate the role of currently available diagnostic tests. We describe the potential benefits of existing asthma and COPD therapies in treating patients with ACO, and the value of a "treatable traits" approach to ACO management. Throughout the review, we highlight some of the pressing, unanswered questions surrounding ACO that are relevant to the clinical community. Ultimately, addressing these questions is necessary if we are to improve clinical outcomes for this complex and heterogeneous patient population.

Identification of Asthma-COPD Overlap, Asthma, and Chronic Obstructive Pulmonary Disease Phenotypes in Patients with Airway Obstruction: Influence on Treatment Approach

BACKGROUND

Many studies have described asthma-COPD overlap (ACO) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD), but less so in broad populations of patients with chronic airway obstruction.

OBJECTIVE

This study aimed to (i) examine the prevalence of ACO, asthma, and COPD phenotypes among subjects referred for pulmonary function testing (PFT), who had airway obstruction in spirometry (forced expiratory volume in 1 s [FEV1]/forced vital capacity [FVC] <0.7); and (ii) delineate the therapeutic approach of each group.

METHODS

Cross-sectional study of patients who were referred for PFT at the Rokach Institute, in Jerusalem. Working definitions were as follows: (a) COPD: post-bronchodilator (BD) FEV1/FVC <0.70; (b) asthma: physician-diagnosed asthma before age 40 and/or minimum post-BD increase in FEV1 or FVC of 12% and 200 mL; and (c) ACO: the combination of the 2. Demographics, smoking habits, episodes of exacerbation, health-related quality of life (HRQL), and respiratory medication utilization were analyzed.

RESULTS

Of 3,669 referrals from January 1 to April 30, 2017, 1,220 had airway obstruction of which 215 were included. Of these, 82 (38.1%) had ACO, 49 (22.8%) asthma, and 84 (39.1%) COPD. ACO subjects tended to (a) be predominantly female; (b) be older than asthmatics, (c) be smokers; (d) have worse HRQL in the activity domain; and (d) have more exacerbations. Treatment of ACO and COPD patients differed from that of asthmatics, but not from each other, in the proportion of subjects on maintenance treatment, use of LABA, LAMA, and ICS, alone or in combination, and in the number of inhaler devices used by patients.

CONCLUSION

ACO represented >1/3 of patients referred for PFT. Despite a clearly identifiable phenotype, ACO patients received treatment similar to COPD patients, suggesting poor ACO identification. Our data emphasize the need to raise the awareness of ACO among clinicians, in order to guide better recognition and appropriate treatment in individual patients.

Association between asthma/chronic obstructive pulmonary disease overlap syndrome and healthcare utilization among the US adult population

Objectives: Asthma/chronic obstructive pulmonary disease (COPD) overlap (ACO) is a recently described phenomenon defined as the coexistence of both asthma and COPD. Both asthma and COPD are known to result in increased emergency department (ED) visits and hospitalizations, but it is unclear how the ACO population utilizes these same healthcare resources. The objective of this study was to compare healthcare utilization in the ACO population versus the general population, the asthma population and the COPD population. Methods: We conducted a pooled cross-sectional statistical analysis using the 2012-2015 National Health Interview Survey (NHIS) data. We focused on adults 18 years of age and older and excluded pregnant women. We employed an adjusted logit regression model, where the primary outcomes were dichotomous indicators on healthcare utilizations including ED visits and hospital stays. A key covariate was a four-category variable: 1) no asthma or COPD; 2) asthma only; 3) COPD only; and 4) ACO. Other covariates included age, sex, race, education level, marital status, household income level, medical insurance status, smoking status, body mass index (BMI) category, region, year and comorbidities (cancer, diabetes, hypertension, coronary heart disease and ulcer). Results: Adults with ACO were 134%, 53% and 21% more likely to have ED visits than the general population, asthma group and COPD group, respectively. For hospital stay, the ACO group was 120% and 86% more likely to be hospitalized than the general population and the asthma group respectively. In addition, adults with ACO were 61% and 130% more likely to have asthma exacerbations and asthma-related ED visits than the asthma group. Conclusions: ACO is a considerable risk factor for healthcare utilization versus the general population, the asthma population and the COPD population. Future focus should be placed on the ACO population to identify ways to reduce their healthcare utilization.

Effects of a structured educational intervention in moderate-to-severe elderly asthmatic subjects

Background

Adherence to inhaled drugs is linked to patients’ satisfaction with their device, and an incorrect use can negatively affect the outcomes of asthma treatment. We speculated that this is particularly true in elderly asthmatic subjects.

Aim

We performed a national pre-post interventional multicentre study, enrolling moderate-to-severe asthmatic subjects aged ≥65 ​years treated with fixed inhaled combination drugs by dry powder inhaler (DPI) or pressurized metered dose inhaler (pMDI). Adherence and critical errors were evaluated by means of validated questionnaires at first visit (V1) and after 3–6 months (V2). At V1, subjects underwent intensive training on the correct use of their device by physical demonstration.

Results

A total of 411 asthmatics (F/M: 238/173, mean age±SD: 72 ​± ​5 ​years) participated to the study. At V1, 50% of the study subjects showed an Asthma Control Test (ACT) score ≤19 despite GINA step 3 and 4 treatment, and 40% had experienced at least one severe asthma exacerbation in the previous year. Poor adherence to treatment was recorded in 43% of subjects, and at least one error in using the device was registered in 56% of subjects. At V2, available for 318 patients, both the percentage of individuals with poor adherence and with at least one critical error significantly decreased (from 46% to 25%, and from 49% to 25%, respectively; p ​< ​0.001 for both comparisons) with a significant increase of the ACT score (from 19 ​± ​4.9 to 20 ​± ​4.0, p ​< ​0.001).

Conclusions

Asthma in the elderly is characterized by low levels of symptom control. Educational interventions are strongly advocated in this age group in order to increase adherence to treatment and inhaler techniques.

Asthma-COPD Overlap-A Discordance Between Patient Populations Defined by Different Diagnostic Criteria

BACKGROUND

The concordance between asthma-chronic obstructive pulmonary disease overlap (ACO) defined according to Global Inititative for Asthma (GINA)/Global Initiative for Chronic Obstructive Lung Disease (GOLD) and other diagnostic criteria is unknown.

OBJECTIVE

To assess the concordance between different ACO definitions and to estimate the definition-based ACO prevalence and characteristics.

METHODS

A prospective, real-life study based on a 32-item data set was performed in a mixed population of patients with asthma and chronic obstructive pulmonary disease (COPD). Five different definitions of ACO, including the GINA/GOLD criteria, were analyzed.

RESULTS

A total of 1609 patients were included in the final analysis. Application of Venn diagram for ACO populations resulted in 31 ACO subpopulations, which were further reduced to 6 separate populations by introducing a rank order for the analyzed definitions to classify patients from intersecting groups. Overall, the level of agreement between different ACO definitions was poor. Cohen kappa coefficient for the agreement between ACO GINA/GOLD definition and other ACO definitions varied from 0.06 to 0.21. Only 2 patients (0.12%) met all the ACO definitions. Definition-based ACO prevalence ranged between 3.8% (Spanish criteria) and 18.4% (clinician's diagnosis). A total of 573 (33.4%) patients met the criteria from at least 1 ACO definition. Patients who could not be classified as suffering from "pure" asthma, "pure" COPD, or ACO accounted for as much as 27.5% of the whole investigated group. The most severe symptoms were observed in patients with ACO defined as COPD and asthma diagnosed at age less than 40 years.

CONCLUSIONS

The current ACO definitions identify distinct populations that share only a small number of common features and present with different disease phenotypes. ACO prevalence is highly variable, depending on the definition applied.

Epidemiology and risk factors of asthma-chronic obstructive pulmonary disease overlap in low- and middle-income countries

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents the confluence of bronchial airway hyperreactivity and chronic airflow limitation and has been described as leading to worse lung function and quality of life than found with either singular disease process.

OBJECTIVE

We aimed to describe the prevalence and risk factors for ACO among adults across 6 low- and middle-income countries (LMICs).

METHODS

We compiled cross-sectional data for 11,923 participants aged 35 to 92 years from 4 population-based studies in 12 settings. We defined COPD as postbronchodilator FEV₁/forced vital capacity ratio below the lower limit of normal, asthma as wheeze or medication use in 12 months or self-reported physician diagnosis, and ACO as having both.

RESULTS

The prevalence of ACO was 3.8% (0% in rural Puno, Peru, to 7.8% in Matlab, Bangladesh). The odds of having ACO were higher with household exposure to biomass fuel smoke (odds ratio [OR], 1.48; 95% CI, 0.98-2.23), smoking tobacco (OR, 1.28 per 10 pack-years; 95% CI, 1.22-1.34), and having primary or less education (OR, 1.35; 95% CI, 1.07-1.70) as compared to nonobstructed nonasthma individuals. ACO was associated with severe obstruction (FEV₁ %, <50; 31.6% of ACO vs 10.9% of COPD alone) and severe spirometric deficits compared with participants with asthma (-1.61 z scores FEV₁; 95% CI, -1.48 to -1.75) or COPD alone (-0.94 z scores; 95% CI, -0.78 to -1.10).

CONCLUSIONS

ACO may be as prevalent and more severe in LMICs than has been reported in high-income settings. Exposure to biomass fuel smoke may be an overlooked risk factor, and we favor diagnostic criteria for ACO that include environmental exposures common to LMICs.

Mortality in Asthma-Chronic Obstructive Pulmonary Disease Overlap in the United States

OBJECTIVES

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is recognized increasingly as a distinct clinical entity and is associated with higher comorbidities compared with patients with asthma and COPD alone. Little is known about the leading causes of death related to ACO in the US general population, however. Our aim was to define the causes of mortality among patients with ACO compared with asthma and COPD in the US population.

METHODS

We examined questions using the National Health and Nutrition Examination Survey III database linked to the National Death Index. The data from 4434 participants were stratified into 4 groups, those with asthma, COPD, ACO, and those without any obstructive lung disease. We examined baseline demographics and used multivariate logistic regression to model the impact of demographics, smoking, and self-reported, physician-diagnosed lung disease on mortality generating odds ratios (ORs) and confidence intervals (CIs).

RESULTS

Among 4434 participants, 120 (2.7%), 340 (7.6%), and 126 (2.8%) participants self-reported diagnoses of asthma, COPD, and ACO syndrome, respectively. Patients with COPD were older (69.7 ± 10.9 years) than other groups. Cardiovascular disease, malignancy, and chronic lower respiratory disease were frequent causes of death. The mortality rates for cardiovascular disease and malignancy were not significantly different among respiratory disease categories. Deaths resulting from chronic respiratory disease were higher in the ACO group (OR 4.9, 95% CI 2.5-9.4) and the COPD group (OR 2.9, 95% CI 1.5-5.4) when compared with those without obstructive lung disease (P < 0.0001).

CONCLUSIONS

Although cardiovascular- and malignancy-related deaths are common, a higher proportion of mortality in ACO and COPD is attributed to chronic lung disease.

Asthma COPD overlap: Impact of associated comorbidities

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic pulmonary conditions worldwide which often coexist. Patients with asthma COPD overlap (ACO) may have worse outcomes than those with either disease alone, for example, more respiratory symptoms and frequent exacerbations, and worse lung function. Additionally, there is a growing interest in factors that affect the disease including comorbid conditions. Indeed, recent studies have demonstrated higher rates of comorbid conditions in the ACO population, but the mechanisms behind these observations remain unclear. The objective of this review is to describe current knowledge and clinical implications of the overlapping features of asthma and COPD, and discuss the prevalence and impact of comorbidities, such as osteoporosis, cardiovascular disease, gastroesophageal reflux disease, and depression, in this subgroup of patients.

Differences in airway structural changes assessed by 3-dimensional computed tomography in asthma and asthma-chronic obstructive pulmonary disease overlap

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a clinical phenotype sharing features of asthma and COPD. Multidetector row computed tomography (MDCT) can be used to evaluate the airway structure; however, differences between asthma and ACO seen on MDCT are poorly understood.

OBJECTIVE

To investigate the difference in airway structural between asthma and ACO, using MDCT in patients with clinical asthma.

METHODS

Sixty-four patients with asthma were allocated to an asthma group (never smokers and ex-smokers with a smoking history of < 10 pack-years) or an ACO group (patients with a ≥10-pack-year smoking history and forced expiratory volume in 1 second [FEV₁]/forced vital capacity [FVC] < 0.7). The asthma group was further divided into patients with airflow limitation (AL; FEV₁/FVC < 0.7) and those without AL. Wall thickness (WT) and airway inner luminal area in the third-generation to fifth-generation bronchi were evaluated using MDCT in both study groups and in 29 healthy controls.

RESULTS

Forty-three patients were included in the asthma group (20 with AL, 23 without AL) and 16 in the ACO group. Patients with asthma and ACO had significantly greater WT than the healthy controls. WT in the third-generation bronchi was significantly greater in the ACO group than in the asthma group. The ACO group and the asthma with AL group were matched for age, disease duration, and FEV₁/FVC. The WT in the third-generation bronchi was still greater in the ACO group than in the asthma with AL group.

CONCLUSION

Patients with ACO have a thicker airway wall than those with asthma, suggesting that airway remodeling is more prominent in ACO than in asthma. UMIN Clinical Trials Registry (UMIN-CTR) system (http://www.umin.ac.jp/ctr/UMIN000028913).

Prevalence, characteristics and management of frequently exacerbating asthma patients: an observational study in Sweden (PACEHR)

The aim of the study was to investigate the prevalence, management and characteristics of asthma patients with frequent exacerbations.Data from asthma patients (aged ≥18 years) identified in primary care medical records were linked to Swedish national health registries. Exacerbations were defined as hospitalisations, emergency visits and/or collection of oral steroids. Frequent exacerbations were defined as two or more exacerbations per year during the 3-year observation period.Of 18 724 asthma patients, 81.49% had no exacerbations and 6.3% had frequent exacerbations in the year prior to the index date. Frequent exacerbations were observed yearly for 1.8% of the patients. Frequent exacerbators were older, more often females, and had increased eosinophil and neutrophil counts, lower lung function, and more comorbidities than patients without exacerbations. There was a slight increase in asthma medication claims and a slight decrease in physician visits compared with baseline, both in the group with and the group without frequent exacerbations.Patients with frequent exacerbations were characterised by greater age, female predominance, high eosinophil and neutrophil counts, and high prevalence of comorbidities. This study indicates that the Swedish healthcare system lacks efficiency to adjust treatment and management for this patient group. With new treatment options targeting severe asthma available, identification of these patients should be in focus to ensure reduction of exacerbations.

Clinical characteristics and comorbidities of elderly asthmatics who attend allergy clinics

Background

To date, few studies have focused on the clinical and allergic characteristics of asthma in the elderly, defined as asthma in people aged 60 or over. Thus, we propose to identify and study the clinical and allergic characteristics and comorbidities of patients with asthma among the elderly.

Methods

A retrospective, observational, descriptive study was developed in five clinics and hospitals in Argentina. Allergy Physicians analyzed their patients' medical records in 2014 and included those adults over the age of 60, who had been diagnosed with asthma according to the GINA guidelines. Clinical and allergic characteristics were analyzed.

Results

A total of 152 patients diagnosed with asthma, of whom 73% were women and 11% ex-smokers, were included in this study, with a mean age of 66 years. Only 10.5% of the participants had onset asthma past the age of 60. Regarding asthma severity, 74.3% were diagnosed with moderate persistent asthma, and 7.2% with severe persistent asthma. Eighty-four percent of the patients were treated with an inhaled corticosteroid (ICS) along with a long-acting β 2-adrenergic agent (LABA). More than half of the patients had two or more comorbidities simultaneously. Allergic comorbidities were the most frequent comorbidities, followed by arterial hypertension. Among allergic comorbidities, most patients presented allergies at the nasal level. There were no significant differences between the subpopulations of patients with late-onset asthma (LOA) and asthma with onset before the age of 60, i.e. early onset asthma (EOA) in most of their clinical characteristics. However, it was observed that EOA accounted for a higher percentage of patients with nasal allergies as compared to LOA (71% vs 46%, p <  0.05).It is worth mentioning that almost half of the patients with LOA had allergies at the nasal level.

Conclusion

These results may provide a better understanding of the clinical characteristics of asthma in the elderly in Argentina, thus, enabling the development of future therapeutic strategies and a better quality of life for our elderly asthma patients.

Chronic airway obstruction in a population-based adult asthma cohort: Prevalence, incidence and prognostic factors

BACKGROUND

Asthma and COPD may overlap (ACO) but information about incidence and risk factors are lacking. This study aimed to estimate prevalence, incidence and risk factors of chronic airway obstruction (CAO) in a population-based adult asthma cohort.

METHODS

During 1986-2001 a large population-based asthma cohort was identified (n = 2055, 19-72y). Subsamples have participated in clinical follow-ups during the subsequent years. The entire cohort was invited to a clinical follow-up including interview, spirometry, and blood sampling in 2012-2014 when n = 983 subjects performed adequate spirometry. CAO was defined as post-bronchodilator FEV₁/FVC<0.7.

RESULTS

At study entry, asthmatics with prevalent CAO (11.4%) reported more respiratory symptoms, asthma medication use, and ischemic heart disease than asthmatics without CAO (asthma only). Subjects who developed CAO during follow-up (17.6%; incidence rate of 16/1000/year) had a more rapid FEV₁ decline and higher levels of neutrophils than asthma only. Smoking, older age and male sex were independently associated with increased risk for both prevalent and incident CAO, while obesity had a protective effect.

CONCLUSIONS

In this prospective adult asthma cohort, the majority did not develop CAO. Smoking, older age and male sex were risk factors for prevalent and incident CAO, similar to risk factors described for COPD in the general population.

The impact of aging on outpatients with asthma in a real-world setting

BACKGROUND

Asthma is characterized by airway inflammation and bronchial hyperreactivity. It is conceived that aging may affect asthma characteristics, but this issue is still not completely clarified in clinical practice.

OBJECTIVE

The present study investigated whether aging may affect some clinical and functional factors in outpatients with asthma visited in a real-world setting, such as clinical practice.

METHODS

Globally, 391 outpatients (163 males, median age 47 years) with asthma were consecutively evaluated. The following parameters were assessed: history, including, smoking, comorbidity, and inhaled corticosteroids (ICS) use, physical examination, body mass index (BMI), lung function, level of asthma control, asthma control test (ACT), and fractional exhaled NO (FeNO).

RESULTS

The elderly with asthma had: more frequently not controlled asthma, higher BMI, higher ICS dosages, more impaired lung function, including plethysmographic parameters, than adult asthmatics (p < 0.001 for all, but p = 0.002 for RV and p = 0.008 for FRC). Elderly asthmatics were also less frequently allergic (p < 0.001) and had less rhinitis comorbidity (p < 0.001) and less nasal symptoms (p < 0.05) than younger asthmatics.

CONCLUSIONS

The present study conducted in a real-world setting shows that aging significantly affects asthma, mainly concerning asthma control, lung function, and steroid-sensitivity.

Impact of periodontal treatment on hospitalization for adverse respiratory events in asthmatic adults: A propensity-matched cohort study

BACKGROUND

Periodontal disease is prevalent in asthmatics, but it is unclear whether periodontal treatment plays a role in adverse respiratory events in these patients. We evaluated risk of hospitalization for adverse respiratory events (acute exacerbation, pneumonia, and acute respiratory failure) and mortality in asthmatic adults with and without periodontal treatment.

METHODS

We used National Health Insurance (NHI) claims data of Taiwan to identify 4771 asthmatic adults with periodontal disease who underwent periodontal treatment during 2000-2006. The control group consisted of asthmatic adults without periodontal disease at a 1:1 ratio matched by the propensity score. Both groups were followed up for 5years to estimate the risk of hospitalization for adverse respiratory events and mortality.

RESULTS

Compared with controls, the periodontal treatment group had lower overall incidence of hospitalization for adverse respiratory events [5.41 vs. 6.07 per 100 person-years, 95% confidence interval (CI)=0.78-0.92] and intensive care unit admissions (1.14 vs. 1.25 per 100 person-years, 95% CI=0.79-0.99). In addition, the all-cause mortality rate was significantly lower in the periodontal treatment group than in the control group during the follow-up period (1.86 vs. 2.79 per 100 person-years, 95% CI=0.59-0.71).

CONCLUSION

Asthmatic adults who underwent periodontal treatment were at lower risk of hospitalization for adverse respiratory events and mortality than those without periodontal disease. Asthmatic adults should adopt more precautionary oral hygiene and ensure that they undergo regular periodontal health checkups.

Leukotriene Receptor Antagonists for the Treatment of Asthma in Elderly Patients

Elderly asthma (EA) is regarded as a distinct phenotype of asthma and is associated with age-related changes in airway structure and alterations in lung function and immune responses. EA is difficult to diagnose because of aging and co-morbidities, and overlaps with fixed airway obstructive disease. Novel modalities to differentiate between EA and chronic obstructive pulmonary disease (COPD) are necessary. A multifaceted approach, including clinical history, smoking habits, atopy, and measurement of lung function, is mandatory to differentiate asthma from COPD. There are a variety of co-morbidities with EA, of which COPD, upper airway diseases, depression, obesity, and hypertension are the most common, and these co-morbidities can affect the control status of EA. However, leukotriene receptor antagonists (LTRAs) can facilitate the management of EA, and thus addition of an LTRA to inhaled corticosteroid (ICS) monotherapy or ICS plus long-acting β₂-agonist therapy improves symptoms in EA patients. LTRA treatment is safe and beneficial in patients who are unable to use inhalation devices properly or who have co-morbid diseases. Therefore, clinical studies targeting a specific population of EA patients are warranted to help achieve a better therapeutic strategy in EA patients.

Pharmacological Management of Elderly Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome: Room for Speculation?

Asthma and chronic obstructive pulmonary disease (COPD) are two distinct diseases that share a condition of chronic inflammation of the airways and bronchial obstruction. In clinical settings, it is not rare to come across patients who present with clinical and functional features of both diseases, posing a diagnostic dilemma. The overlap condition has been termed asthma-COPD overlap syndrome (ACOS), and mainly occurs in individuals with long-standing asthma, especially if they are also current or former smokers. Patients with ACOS have poorer health-related quality of life and a higher exacerbation rate than subjects with asthma or COPD alone. Whether ACOS is a distinct nosological entity with genetic variants or rather a condition of concomitant diseases that overlap is still a matter of debate. However, there is no doubt that extended life expectancy has increased the prevalence of asthma and COPD in older ages, and thus the probability that overlap conditions occur in clinical settings. In addition, age-associated changes of the lung create the basis for the two entities to converge on the same subject. ACOS patients may benefit from a stepwise treatment similar to that of asthma and COPD; however, the proposed therapeutic algorithms are only speculative and extrapolated from studies that are not representative of the ACOS population. Inhaled corticosteroids are the mainstay of therapy, and always in conjunction with long-acting bronchodilators. The potential heterogeneity of the overlap syndrome in terms of inflammatory features (T helper-1 vs. T helper-2 pathways) may be responsible for the different responses to treatments. The interaction between respiratory drugs and concomitant diseases should be carefully evaluated. Similarly, the effect of non-respiratory drugs, such as aspirin, statins, and β-blockers, on lung function needs to be properly assessed.

Predictors of asthma control in elderly patients

PURPOSE OF REVIEW

We are in the era of rapid aging of the global population. Elderly asthmatic patients have an increased frequency of hospitalization and a high mortality rate. In this review, we focus on comorbidities and treatment issues in terms of the predictors of asthma control in the elderly.

RECENT FINDINGS

Some frequent comorbidities, such as chronic obstructive pulmonary disease, chronic sinusitis, obesity, and depression, are associated with uncontrolled asthma in elderly asthmatic patients. Smoking status in elderly asthmatic patients was associated with more frequent exacerbations. Management of comorbidities should be taken into account when we treat elderly asthmatic patients. Low treatment adherence, which is common in elderly asthmatic patients, predicts poor asthma control status. A poor knowledge about asthma, cognitive function impairment, and inappropriate inhaler technique result in low treatment adherence. Polypharmacy is associated with low treatment adherence, adverse drug reactions, and drug-drug interactions, and it is supposed to be a predictor of asthma control.

SUMMARY

Multifactorial assessments, including comorbidities, treatment adherence, and polypharmacy, are important for better asthma control in elderly asthmatic patients. Further studies on the strategy for the management of elderly asthmatic patients in a real-world setting are warranted.

Addressing unmet needs in understanding asthma mechanisms: From the European Asthma Research and Innovation Partnership (EARIP) Work Package (WP)2 collaborators

Asthma is a heterogeneous, complex disease with clinical phenotypes that incorporate persistent symptoms and acute exacerbations. It affects many millions of Europeans throughout their education and working lives and puts a heavy cost on European productivity. There is a wide spectrum of disease severity and control. Therapeutic advances have been slow despite greater understanding of basic mechanisms and the lack of satisfactory preventative and disease modifying management for asthma constitutes a significant unmet clinical need. Preventing, treating and ultimately curing asthma requires co-ordinated research and innovation across Europe. The European Asthma Research and Innovation Partnership (EARIP) is an FP7-funded programme which has taken a co-ordinated and integrated approach to analysing the future of asthma research and development. This report aims to identify the mechanistic areas in which investment is required to bring about significant improvements in asthma outcomes.

Differences between asthma-COPD overlap syndrome and adult-onset asthma

Differences between asthma-COPD overlap syndrome (ACOS) and adult-onset asthma are poorly understood. This study aimed to evaluate these differences in a clinical cohort of patients with adult-onset asthma, as a part of the Seinäjoki Adult Asthma Study (SAAS).188 patients were diagnosed with adult-onset asthma and re-evaluated 12 years after diagnosis. They were divided into three groups based on smoking history and post bronchodilator spirometry values: 1) never- and ex-smokers with <10 smoked pack-years; 2) non-obstructive (forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) ≥0.7) patients with ≥10 pack-years; and 3) ACOS patients with ≥10 pack-years and FEV₁/FVC <0.7.ACOS patients had lower diffusing capacity (D_LCO/V_A 86% predicted versus 98 or 96% predicted; p<0.001), higher blood neutrophil levels (4.50 versus 3.60 or 3.85×10⁹ L^-1; p=0.008), and higher IL-6 levels (2.88 versus 1.52 or 2.10 pg·mL^-1, p<0.001) as compared to never- and ex-smokers with <10 pack-years, or non-obstructive patients with ≥10 pack-years smoking history, respectively. ACOS patients also showed reduced lung function, higher remaining bronchial reversibility and a higher number of comorbidities.This study shows distinct differences in diffusing capacity, blood neutrophil and IL-6 levels, bronchial reversibility, lung function and comorbidities between ACOS and adult-onset asthma. The present findings should be considered in the comprehensive assessment of adult asthma patients.

Understanding COPD-overlap syndromes

INTRODUCTION

Chronic obstructive pulmonary disease accounts for a large burden of lung disease. It can 'overlap' with other respiratory diseases including bronchiectasis, fibrosis and obstructive sleep apnea (OSA). While COPD alone confers morbidity and mortality, common features with contrasting clinical outcomes can occur in COPD 'overlap syndromes'. Areas covered: Given the large degree of heterogeneity in COPD, individual variation to treatment is adopted based on its observed phenotype, which in turn overlaps with features of other respiratory disease states such as asthma. This is coined asthma-COPD overlap syndrome ('ACOS'). Other examples of such overlapping clinical states include bronchiectasis-COPD ('BCOS'), fibrosis-COPD ('FCOS') and OSA-COPD ('OCOS'). The objective of this review is to highlight similarities and differences between the COPD-overlap syndromes in terms of risk factors, pathophysiology, diagnosis and potential treatment differences. Expert commentary: As a consequence of COPD overlap syndromes, a transition from the traditional 'one size fits all' treatment approach is necessary. Greater treatment stratification according to clinical phenotype using a precision medicine approach is now required. In this light, it is important to recognize and differentiate COPD overlap syndromes as distinct disease states compared to individual diseases such as asthma, COPD, fibrosis or bronchiectasis.

Asthma and Chronic Obstructive Pulmonary Disease Overlap: The Effect of Definitions on Measures of Burden

Background: Although the overlap between asthma and COPD has been recognized for years this overlap has only recently been given a name, asthma-COPD overlap syndrome (ACOS), and better defined. Different definitions of the component diseases can affect prevalence and outcome measures of ACOS. Methods: We used data from the National Health and Nutrition Examination Survey (NHANES) from 2007-2012 to determine the population estimates of ACOS in U.S. adults using 2 different definitions of ACOS (ACOS1= self-reported COPD and current asthma; ACOS2 = spirometric-confirmed COPD [pre-bronchodilator FEV₁/FVC < 70%] and current asthma) and to describe variation in other factors, such as lung function impairment and health care utilization, by ACOS definitions. Results: Among U.S. adults aged 20 and older, 1.6% had ACOS1, and 1.9% had ACOS2. Both case definitions were similar with regard to symptoms and impairment of lung function. ACOS1 individuals were more likely to have one or more overnight hospital stays relative to those with neither asthma nor COPD, (odds ratio [OR] 3.4, 95% confidence interval [CI] 2.5, 4.6) than ACOS2 (OR 1.6, 95% CI 0.9, 2.9). Conclusions: Different definitions of ACOS in population-based studies affect both estimates of disease prevalence and outcomes related to the disease. These definitions need to be carefully considered in the design of epidemiologic studies and clinical trials.

Asthma-chronic obstructive pulmonary disease overlap syndrome - Literature review and contributions towards a Portuguese consensus

INTRODUCTION

Phenotypic overlap between the two main chronic airway pulmonary diseases, asthma and chronic obstructive pulmonary disease (COPD), has been the subject of debate for decades, and recently the nomenclature of asthma-COPD overlap syndrome (ACOS) was adopted for this condition. The definition of this entity in the literature is, however, very heterogeneous, it is therefore important to define how it applies to Portugal.

METHODS

A literature review of ACOS was made in a first phase resulting in the drawing up of a document that was later submitted for discussion among a panel of chronic lung diseases experts, resulting in reflexions about diagnosis, treatment and clinical guidance for ACOS patients.

RESULTS

There was a consensus among the experts that the diagnosis of ACOS should be considered in the concomitant presence of: clinical manifestations characteristic of both asthma and COPD, persistent airway obstruction (post-bronchodilator FEV₁/FVC<0.7), positive response to bronchodilator test (increase in FEV₁ of ≥200mL and ≥12% from baseline) and current or past history of smoking or biomass exposure. In reaching diagnosis, the presence of peripheral eosinophilia (>300eosinophils/μL or >5% of leukocytes) and previous history of atopy should also be considered. The recommended first line pharmacological treatment in these patients is the ICS/LABA association; if symptomatic control is not achieved or in case of clinical severity, triple therapy with ICS/LABA/LAMA may be used. An effective control of the exposure to risk factors, vaccination, respiratory rehabilitation and treatment of comorbidities is also important.

CONCLUSIONS

The creation of initial guidelines on ACOS, which can be applied in the Portuguese context, has an important role in the generation of a broad nationwide consensus. This will give, in the near future, a far better clinical, functional and epidemiological characterization of ACOS patients, with the ultimate goal of achieving better therapeutic guidance.

Effects of omalizumab in severe asthmatics across ages: A real life Italian experience

BACKGROUND

This retrospective study aimed at evaluating long-term effects of Omalizumab in elderly asthmatics in a real-life setting.

METHODS

105 consecutive severe asthmatics (GINA step 4-5; mean FEV₁% predicted:66 ± 15.7) treated with Omalizumab for at least 1 year (treatment mean duration 35.1 ± 21.7 months) were divided into 3 groups according to their age at Omalizumab treatment onset: 18-39, 40-64 and ≥ 65 years.

RESULTS

Comorbidities, number of overweight/obese subjects and patients with late-onset asthma were more frequent among older people. A similar reduction of inhaled corticosteroids dosage and SABA on-demand therapy was observed in all groups during Omalizumab treatment; a similar FEV₁ increased was also observed. Asthma Control Test (ACT) improved significantly (p < 0.001) in the three groups, increasing from 15 [IQR:12-18] to 24 [IQR:22-25] in younger subjects, from 14 [IQR:10-16] to 21 [IQR:20-23] in the 40-64-year-group and from 15 [IQR:12-16] to 20 [IQR:18-22] in elderly patients where improvement was lower (p = 0.039) compared to younger people. Asthma exacerbations decreased significantly after Omalizumab but the percentage of exacerbation-free patients was higher in younger people (76.9%) compared to middle aged patients (49.2%) and the elderly (29%) (p = 0.049). After Omalizumab treatment, the risk for exacerbations was lower in subjects aged 40-64 (OR = 0.284 [CI95% = 0.098-0.826], p = 0.021) and 18-39 (OR = 0.133 [CI95% = 0.026-0.678], p = 0.015), compared to elderly asthmatics. Also, a significantly reduced ACT improvement (β = -1.070; p = 0.046) passing from each age class was observed.

CONCLUSION

Omalizumab improves all asthma outcomes independently of age, although the magnitude of the effects observed in the elderly seems to be lower than in the other age groups.

Asthma-chronic obstructive pulmonary disease overlap syndrome: A diagnostic puzzle for the clinicians

Although asthma and chronic obstructive pulmonary disease (COPD) are distinct airway diseases characterized by chronic inflammation, in some cases distinguishing between them is puzzling. For example, chronic smoking leads asthmatic inflammation to a differentiated pattern resembling the COPD inflammation, and in some cases to fixed obstruction as in COPD, and on the other hand, few COPD patients may present with airway reversibility. ACOS is the condition sharing features encountered both in asthma and COPD. Asthma-COPD overlap syndrome (ACOS) represents a diagnostic challenge in the clinical practice, since there is lack of specific indicators to distinguish it from asthma or COPD, and moreover, genetic risk factors, underlying pathology and molecular pathways, clinical characteristics, therapeutic interventions, response to treatment and prognosis are poorly described. The management of ACOS is recommended to be individualized and should target on the maximum effectiveness with the least side effects. Combination therapy with ICS/LABA or LAMA, or newly developed specific anti-eosinophil therapies and treatments specifically targeting neutrophils might be of relevance in the management of ACOS, but studies are needed in order to assess the response and prognosis. Based on the current knowledge about ACOS thus far, it would be recommended that we approached chronic obstructive airway disease rather by describing than by classifying the disease; this would allow us to have a picture that better describes the disease and to implement an individualized therapeutic approach, according to the custom phenotype. Nevertheless, more studies are needed in order to clarify several important issues with regard to ACOS, such as the genetic risk factors for developing ACOS, the links between genotype and phenotype, the molecular pathways and underlying mechanisms of ACOS, the identification of possible specific biomarkers for diagnosis and targeted treatment, the optimal therapeutic interventions, and finally, the prognosis of ACOS.

Do we really need asthma-chronic obstructive pulmonary disease overlap syndrome?

The association of asthma and chronic obstructive pulmonary disease (COPD) in the same patient, which is designated as mixed asthma-COPD phenotype or overlap syndrome (ACOS), remains a controversial issue. This is primarily because many conflicting aspects in the definition of ACOS remain, and it is extremely difficult to summarize the distinctive features of this syndrome. Furthermore, we are realizing that asthma, COPD, and ACOS are not single diseases but rather syndromes consisting of several endotypes and phenotypes and, consequently, comprising a spectrum of diseases. The umbrella term ACOS blurs the lines between asthma and COPD and allows an approach that simplifies therapy. However, this approach contradicts the modern concept according to which we must move toward more targeted and personalized therapies to treat patients with these diseases. Therefore we argue that the term ACOS must be abandoned and ultimately replaced when new phenotypes and underlying endotypes are identified and a new taxonomy of airway diseases is generated.

Characteristics of phenotypes of elderly patients with asthma

BACKGROUND

The characteristics of phenotypes of elderly patients with asthma are unknown. The aim of this study was to classify these phenotypes using lung function tests and images from high-resolution computed tomography (HRCT), and to identify associations between clinical characteristics and phenotypes.

METHODS

A cross-sectional study was conducted in 165 elderly patients (>65 years of age) who underwent a multidimensional assessment of clinical and functional status and comorbidity. The patients were divided into three phenotypes: (1) asthma-predominant, (2) asthma-obstructive airway disease (OAD) overlap without emphysema, and (3) asthma-OAD overlap with emphysema (asthma-emphysema overlap) based on chest HRCT. A receiver operating characteristic (ROC) curve was constructed to evaluate the cutoff for differentiating between the two OAD phenotypes. Multivariate analysis was also used to distinguish between these two phenotypes.

RESULTS

The phenotypes were asthma-predominant in 48 patients (29%), asthma-OAD without emphysema in 36 (22%), and asthma-emphysema in 81 (49%). Patients with asthma-emphysema were more frequent smokers. In multivariate analysis, smoking status (odds ratio 2.92: 95% CI 1.21-7.00, P = 0.03) and % predicted FEV1 ≤70% (odds ratio 3.18: 95% CI 1.13-8.92, P = 0.03) differed significantly between the asthma-emphysema and asthma-OAD without emphysema phenotypes.

CONCLUSIONS

Half of elderly patients with asthma are characterized by asthma-emphysema overlap. Our results showed that elderly patients with asthma who are smokers and have moderate or severe OAD are also likely to have emphysema.

Challenges in the pharmacological treatment of geriatric asthma

Asthma in older populations is characterized by frequent comorbid conditions, which increase the risk of side effects and of detrimental interactions between respiratory and non-respiratory drugs. These observations lead to the need to manage asthma in older populations by applying a multidimensional assessment and a multidisciplinary treatment; therefore, we favor the use of the 'geriatric' term to define asthma in the elderly. Geriatric asthma is a complex disease, which may not necessarily imply that it is also complicated, although the two conditions may often coexist. On this basis, the switch from an organ-driven management to the holistic approach may be the key factor to attain optimal control of the disease in this age range. The current review discusses the age-related factors affecting asthma treatment in the oldest individuals, such as the comorbid conditions, and age-related changes of metabolism and excretion that can impair the efficacy and safety of drugs.

Challenges in the management of severe allergic asthma in the elderly

Little is known about the features of asthma and allergy in the elderly. A significant number of elderly patients with asthma have uncontrolled and severe asthma. This review aims to provide an analysis of the literature on the assessment and phenotype of severe allergic asthma in the elderly. Gaps and pitfalls in diagnostic and therapeutic approaches, as well as management of severe allergic asthma in the elderly, are also discussed.

Asthma and chronic obstructive pulmonary disease overlap syndrome (ACOS): structured literature review and physician insights

OBJECTIVES

To understand the key characteristics of Asthma and Chronic Obstructive Pulmonary Disease Overlap Syndrome (ACOS) and to identify evidence gaps relating to the identification, treatment and management of ACOS patients.

METHODS

A structured literature review and 1-hour telephone interviews with specialist respiratory physicians were conducted (n=10; China, France, Germany, Japan and the USA).

RESULTS

All 10 physicians used the term ACOS in clinical practice. ACOS was not clearly defined in the literature. Prevalence of ACOS among adult patients with COPD or asthma ranged from 12-55%. ACOS patients had severe disease, with increased exacerbations and hospitalisations compared to some asthma and COPD patients. ACOS represented a clinical challenge due to a lack of evidence-based guidelines distinguishing between asthma, COPD and ACOS. Published data quantifying ACOS costs were limited.

CONCLUSIONS

There is a need for consensus evidence-based guidance to facilitate earlier diagnosis and to optimise the management of ACOS patients.

Asthma in the elderly patient

Asthma affects a significant proportion of elderly patients, but unfortunately, it is responsible for a high asthma-related morbidity and mortality in this population. This may be related not only to the development of a more severe asthma phenotype compared to younger patients, with more marked airway obstruction and a more neutrophilic type of airway inflammation, but also to the presence of many co-morbid conditions. Furthermore, in older patients, asthma is often under-diagnosed, undertreated and poorly managed. Unfortunately, elderly patients have usually been excluded of clinical trials on asthma and there is an urgent need to perform more research on the optimal management of asthma in this population.

Phenotyping asthma in the elderly: allergic sensitization profile and upper airways comorbidity in patients older than 65 years

BACKGROUND

Data about allergic rhinitis in elderly patients with asthma are lacking.

OBJECTIVE

To investigate the presence of rhinitis and the role of sensitization of airborne allergens in elderly patients with asthma.

METHODS

This was a multicenter cross-sectional study involving subjects at least 65 years old with asthma. Demographic features, comorbidities, and the presence of allergic respiratory disease were retrieved through interview. Skin prick tests for common allergens were performed. Associations of demographic and clinical features were evaluated in relation to asthma control and forced expiratory volume in the first second less than 80% in the total population and in the subgroup with features resembling chronic obstructive pulmonary disease.

RESULTS

Of 368 elderly subjects with asthma, 101 had features resembling chronic obstructive pulmonary disease. Rhinitis was present in 59.0% of subjects (allergic rhinitis in 47.6%), with an age of onset significantly different from that of asthma (49 ± 18 vs 57 ± 18 years). At least 1 sensitization was observed in 52.4% of subjects, more frequently for house dust mite (HDM; 31.8%). The prevalence of poorly and partially controlled asthma was higher in patients sensitized to airborne allergens (odds ratio 1.64, 95% confidence interval 1.03-2.61), in particular to HDM (odds ratio 1.73, 95% confidence interval 1.05-2.85).

CONCLUSION

Approximately 60% of elderly subjects with asthma had rhinitis, mainly allergic and often untreated, whose onset preceded asthma symptoms by a mean of approximately 10 years. Nonallergic asthma was better controlled than allergic asthma. However, HDM sensitization was greater in subjects with asthma with features resembling chronic obstructive pulmonary disease (39% vs 28%). When restricting analysis to this group, the negative role of HDM in overall asthma control (forced expiratory volume in first second and Asthma Control Test) was significant.

Mechanisms of airway hyper-responsiveness in asthma: the past, present and yet to come

Airway hyper-responsiveness (AHR) has long been considered a cardinal feature of asthma. The development of the measurement of AHR 40 years ago initiated many important contributions to our understanding of asthma and other airway diseases. However, our understanding of AHR in asthma remains complicated by the multitude of potential underlying mechanisms which in reality are likely to have different contributions amongst individual patients. Therefore, the present review will discuss the current state of understanding of the major mechanisms proposed to contribute to AHR and highlight the way in which AHR testing is beginning to highlight distinct abnormalities associated with clinically relevant patient populations. In doing so we aim to provide a foundation by which future research can begin to ascribe certain mechanisms to specific patterns of bronchoconstriction and subsequently match phenotypes of bronchoconstriction with clinical phenotypes. We believe that this approach is not only within our grasp but will lead to improved mechanistic understanding of asthma phenotypes and we hoped to better inform the development of phenotype-targeted therapy.

Asthma-COPD overlap syndrome (ACOS): A diagnostic challenge

Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. ACOS may be a special phenotype of a spectrum of chronic obstructive airway diseases, in which asthma and COPD are at the two opposite ends. The prevalence of ACOS varies considerably due to differing criteria being applied for diagnosis. Patients with ACOS utilize a large proportion of medical resources. They are associated with more frequent adverse outcomes than those with asthma or COPD alone. ACOS is currently a diagnostic challenge for physicians because there are no specific biomarkers to differentiate ACOS from asthma or COPD. The approach to diagnosing ACOS depends on the population from which the patient originated. The management of ACOS should be individualized to ensure the most effective treatment with minimal side effects. In this paper, we review the diagnostic criteria of ACOS used in previous studies, propose practical approaches to diagnosing and managing ACOS and raise some research questions related to ACOS.