28/04/2015. Dr. Brandie Walker March 30, Disclosures

Transcription

1 Dr. Brandie Walker March 30, 2015 Disclosures 1

2 Objectives 1. To Define the Asthma COPD Overlap Syndrome 2. Understand why it is important to distinguish ACOS from both Asthma and COPD 3. How will ACOS affect practice for CREs/ Family Physicians? 1. Management? 2. Referral Outline 1. Review of Definitions 1. Asthma 2. COPD 3. ACOS 2. Case Presentation 3. Approach to diagnosis of chronic airways disease 4. Treatment approach 2

3 ASTHMA Heterogenous disease, usually characterized by chronic airway inflammation. Defined by history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. (from GINA 2014) ASTHMA 3

4 2013 Canadian Thoracic Society 4

5 COPD Common, preventable and treatable disease, characterized by PERSISTENT airflow limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. (GOLD 2014) COPD 5

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7 What do we do with a mixture? Asthma COPD Overlap Syndrome Characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. It is identified by the features it shares with both COPD and asthma. ACOS Asthma COPD 7

8 Why is ACOS important? Patients with features of both asthma and COPD have frequent exacerbations, poor quality of life, more rapid decline of lung function, higher mortality and use more healthcare resources than patients with either COPD or asthma alone Prevalence is likely between 15 and 55% of COPD patients that fit potential criteria for ACOS. (Bujarski et al Curr Allergy Asthma Rep 2015) Treatment approach is different than for either COPD or asthma. Approach to Diagnosis of Patients with Respiratory Symptoms Step One: Does the patient have chronic airways disease? 1. Clinical History 1. History of chronic/recurrent cough, sputum, dyspnea or wheeze, or repeat LRTI? 2. Previous doctor diagnosis of asthma or COPD 3. History of prior inhaler use 4. History of smoking 5. Exposures (occupational/ domestic) 8

9 Approach to Diagnosis of Patients with Respiratory Symptoms Step One: Does the patient have chronic airways disease? 2. Physical Examination 1. Might be normal 2. Evidence of hyperinflation and other features of chronic lung disease 3. Abnormal auscultation (wheeze and or crackles?) Approach to Diagnosis of Patients with Respiratory Symptoms Step One: Does the patient have chronic airways disease? 3. Radiology 1. Could be normal (especially early) 2. Abnormal chest xray or CT scan eg. Hyperinflation, airway wall thickening, air trapping, hyperlucency, bullae etc. 3. Might show other diagnosis (bronchiectasis, lung infections, interstitial lung disease, malignancy, heart failure) 9

10 Step 2: The syndromic diagnosis of asthma, COPD and ACOS A. Assemble the features that favor a diagnosis of asthma or of COPD 10

11 Compare the features that favor a diagnosis of asthma or COPD Having three or more features that support either asthma or COPD, in the absence of features that supports the alternate diagnosis, makes the likelihood of the correct diagnosis strong Absence of features has less predictive value, and does not rule out either disease (ie history of allergies supports diagnosis of asthma, but absence of allergies does not rule it out as non allergic asthma is well recognized phenotype of asthma) If similar number of features of both diseases, consider diagnosis of ACOS ACOS Clinically, ACOS usually is either: COPD patient with increased reversibility Asthmatic patient with history of smoking that develop non fully reversible airway obstruction at an older age (Barrencheguren et al Curr Opin Pulm Med Jan 2015) 11

12 Case: Mr R.J. 45 year old man, ex smoker, 22 pack years Comes to his family doctor with complaints of daily cough with sputum, short of breath on exertion for 3 years, but getting worse Diagnosis of asthma, but not on puffers since teenage years Hay fever in spring, allergic to cats Brother and daughter have asthma Mr R.J. Physical exam is normal Spirometry shows a reduced post FEV1/FVC ratio of 0.65 Pre FEV1 is 68% predicted, and improves by 12% with bronchodilation Chest xray is normal 12

13 What is the diagnosis? Asthma? COPD? ACOS? How can we decide? Always do the Spirometry! Essential for patient assessment in asthma, COPD and ACOS Normal FEV1/FVC pre or post bronchodilator is not compatible with COPD or ACOS* Post BD increase in FEV1 >12% and 200ml from baseline can be seen in all 3 conditions (if 400ml, more likely asthma or ACOS) Bronchial hyperresponsiveness is present in up to 2/3 of COPD patients 13

14 Features that favor Asthma Features that favor COPD Age of Onset Onset before age 20 Onset after age 40 Pattern of Respiratory Symptoms Variation in symptoms over minutes, hours or days Persistence of symptoms despite treatment Symptoms worse during night or early morning Good and bad days, but always daily symptoms and exertional Symptoms triggered by exercise, dyspnea emotions including laughter, dust or exposure to allergens Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers Lung Function Record of variable airflow limitation (spirometry, peak flow) Record of persistent airflow limitation Lung Function between symptoms Past history or family history Lung function normal between symptoms Previous doctor diagnosis of asthma Family history of asthma, and other allergic conditions Lung function abnormal Previous doctor diagnosis of COPD, chronic bronchitis, or emphysema Heavy exposure to a risk factor: tobacco smoke or biomass fuels Time Course No worsening of symptoms over time. Symptoms vary either seasonally, or from year to year May improve spontaneously or have an immediate response to BD or to ICS over weeks Symptoms slowly worsening over time (progressive course over years) Rapid acting BD treatment provides only limited relief Chest xray Usually normal hyperinflation Age of Onset Features that favor Asthma Onset before age 20 Pattern of Respiratory Symptoms Variation in symptoms over minutes, hours or days Symptoms worse during night or early morning Symptoms triggered by exercise, emotions including laughter, dust or exposure to allergens Features that favor COPD Onset after age 40 Persistence of symptoms despite treatment Good and bad days, but always daily symptoms and exertional dyspnea Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers Lung Function Record of variable airflow limitation (spirometry, peak flow) Record of persistent airflow limitation Lung Function between symptoms Past history or family history Lung function normal between symptoms Previous doctor diagnosis of asthma Family history of asthma, and other allergic conditions Lung function abnormal Previous doctor diagnosis of COPD, chronic bronchitis, or emphysema Heavy exposure to a risk factor: tobacco smoke or biomass fuels Time Course No worsening of symptoms over time. Symptoms vary either Symptoms slowly worsening over time (progressive course over 14

15 Features that favor Asthma Features that favor COPD Age of Onset Onset before age 20 Onset after age 40 Pattern of Respiratory Symptoms Variation in symptoms over minutes, hours or days Symptoms worse during night or early morning Symptoms triggered by exercise, emotions including laughter, dust or exposure to allergens Lung Function Record of variable airflow limitation (spirometry, peak flow) Lung Function between symptoms Past history or family history Lung function normal between symptoms Previous doctor diagnosis of asthma Family history of asthma, and other allergic conditions Persistence of symptoms despite treatment Good and bad days, but always daily symptoms and exertional dyspnea Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers Record of persistent airflow limitation Lung function abnormal Previous doctor diagnosis of COPD, chronic bronchitis, or emphysema Heavy exposure to a risk factor: tobacco smoke or biomass fuels Time Course No worsening of symptoms over Symptoms slowly worsening over Features that favor Asthma Features that favor COPD Age of Onset Onset before age 20 Onset after age 40 Pattern of Respiratory Symptoms Variation in symptoms over minutes, hours or days Persistence of symptoms despite treatment Symptoms worse during night or early morning Good and bad days, but always daily symptoms and exertional Symptoms triggered by exercise, dyspnea emotions including laughter, dust or exposure to allergens Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers Lung Function Lung Function between symptoms Past history or family history Record of variable airflow limitation (spirometry, peak flow) Lung function normal between symptoms Previous doctor diagnosis of asthma Family history of asthma, and other allergic conditions Record of persistent airflow limitation Lung function abnormal Previous doctor diagnosis of COPD, chronic bronchitis, or emphysema Heavy exposure to a risk factor: tobacco smoke or biomass fuels Time Course No worsening of symptoms over time. Symptoms vary either seasonally, or from year to year May improve spontaneously or h d Symptoms slowly worsening over time (progressive course over years) Rapid acting BD treatment d l l d l f 15

16 y p g g early morning Symptoms triggered by exercise, emotions including laughter, dust or exposure to allergens y, y daily symptoms and exertional dyspnea Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers Lung Function Record of variable airflow limitation (spirometry, peak flow) Lung Function between symptoms Past history or family history Lung function normal between symptoms Previous doctor diagnosis of asthma Family history of asthma, and other allergic conditions Time Course No worsening of symptoms over time. Symptoms vary either seasonally, or from year to year May improve spontaneously or Record of persistent airflow limitation Lung function abnormal Previous doctor diagnosis of COPD, chronic bronchitis, or emphysema Heavy exposure to a risk factor: tobacco smoke or biomass fuels Symptoms slowly worsening over time (progressive course over years) Rapid acting BD treatment y y other allergic conditions y p tobacco smoke or biomass fuels Time Course No worsening of symptoms over time. Symptoms vary either seasonally, or from year to year May improve spontaneously or have an immediate response to BD or to ICS over weeks Symptoms slowly worsening over time (progressive course over years) Rapid acting BD treatment provides only limited relief Chest xray Usually normal hyperinflation 16

17 So what do you think Mr R.J. has? ACOS Mr. R.J. has a similar number of checked boxes for each diagnosis, so would consider a diagnosis of Why does this matter? ACOS 17

18 ACOS Mr. R.J. has a similar number of checked boxes for each diagnosis, so would consider a diagnosis of Why does this matter? ACOS Asthma or ACOS treatment should include ICS LABA should be continued or added, but should NOT treat with LABA monotherapy ACOS Mr. R.J. has a similar number of checked boxes for each diagnosis, so would consider a diagnosis of ACOS Why does this matter? Treatment is different! Asthma or ACOS treatment should include ICS LABA should be continued or added, but should NOT treat with LABA monotherapy No large trials conducted including ACOS patients 18

19 Chronic Airways Disease COPD Initial treatment: LABA &/or LAMA *Add ICS as triple therapy (for those with moderate to severe disease and history of exacerbations) Asthma or ACOS Initial treatment: ICS is first line treatment Add in LABA (and evidence For addition of LAMA, +/ LTRA) Think about referral if patients have persistent symptoms and/or exacerbations despite treatment There is diagnostic uncertainty (especially if alternate diagnosis needs exclusion, such as bronchiectasis, IPF, PHTN, cardiac disease etc) There are atypical features of disease (ie hemoptysis, significant weight loss, night sweats, fever, etc) Patient with comorbidities that make treatment more difficult 19

20 Take Home Points 1. First step is confirmation of diagnosis 1. Must include spirometry 2. Careful history and physical not always straightforward! 2. Features of both Asthma and COPD? Consider ACOS 3. Treatment is different 4. If features that make patient more complicated, consider referral References Diagnosis of Diseases of Chronic Airflow Limitation: Asthma, COPD and Asthma COPD Overlap Syndrome (ACOS) GINA 2014 The clinical and genetic features of COPD asthma overlap syndrome Hardin et al. ERJ 2014 The asthma chronic obstructive pulmonary disease overlap syndrome (ACOS): opportunities and challenges Barrencheguren et al Curr Opin Pulm Med

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