“Asthma-COPD Overlap Syndrome (ACOS),” Footnotes & a Commentary from a Patient (5th Edition)


“Asthma-COPD Overlap Syndrome (ACOS): A diagnostic challenge,” was a Top 100 WebxMD article for 2015. http://onlinelibrary.wiley.com/doi/10.1111/resp.12653/full It caught my attention because I’ve had this condition for ten years; however, I never heard the two described as a unit in this manner! Three symptoms stood out on my first reading: increased sputum, more dyspnea (breathlessness), but better response to inhaled corticosteroids. At once, I told all my local health connections about ACOS. This article was written by three doctors in the Far East: Vietnam, Korea, and Japan. “Tho, N. V., Park, H. Y. and Nakano, Y. (2015), Asthma–COPD overlap syndrome (ACOS): A diagnostic challenge. Respirology. doi: 10.1111/resp.12653.”

Furthermore, a Google search for ACOS yielded nothing unless I entered the complete term. So the breakthroughs didn’t happen around here—adding to this disabled Developmental English/Writing—ESOL teacher’s sense of urgency!

Definition of Terms

I printed this article and started highlighting and making notes. Fortunately for me, many of these technical terms corresponded to familiar brand names for my many ACOS drugs. Symbicort is a Long-Acting Beta2-Agonist (LABA) and an Inhaled Corticosteroid (ICS). A LABA is a long-term brochodilator while an ICS decreases inflammation. Rinse your mouth with water after each use, and don’t swallow the water; spit it out. Recently, I was switched from Advair (another LABA +ICS drug) to Symbicort. It’s used for asthma. A Muscarinic Antagonist is also a bronchodilator, such as tiotropium (Spiriva) and aclidinium. Spiriva is used for COPD, including emphysema and chronic bronchitis. There is only one PDE4 inhibitor—Daliresp (roflumilast), and it works against excess bronchitis and phlegm. Daliresp decreases the number of exacerbations in severe COPD, and it’s not a bronchodilator. Daliresp decreases lung inflammation and prevents COPD flare-ups. Don’t use Symbicort, Spiriva, or Daliresp for an acute attack.

For an acute attack, use your “inhaler,” such as ProAir and Proventil; they’re examples of Short-Acting Beta2-Agonists (SABA); both are albuterol. Proair will open the airways and prevent a bronchospasm. You could go for your nebulizer for an acute attack, especially a bad attack. Our albuterol vials for the nebulizer could be called an”extra-strength” SABA. Iprat-Albut (Albuterol & Ipratropium) are two bronchodilators for the COPD patients’ nebulizer. For two decades, I was on pure Albuterol for my nebulizer.

Atopic is an allergic reaction, often hereditary. Atopy is a feature of ACOS and associated with a higher prevalence of chronic cough and sputum production, according to Tho, Park, and Nakano. Eosinophilic airway inflammation means there’s a higher than average number of white blood cells. It can be detected in mucus if it’s tissue eosinophilia. Tho, Park, and Nakano note that ACOS patients have higher sputum eosinophil counts than those with COPD alone, but sputum count profiles may change over time. Blood eosinophilia is over 500 in a microliter of blood. I found these definitions at Medicine Net and the Mayo Clinic websites too.  Much of the drug definitions came from the pharmacy’s medicine sheets themselves.

Economic Burden & Disability

Tho, Park, & Nakano note that the percentage of ACOS patients visiting the ER or admitted to hospitals is significantly higher than COPD alone in South Korea. A United States Medicaid population reports that ACOS patients have a higher rate of utilizing any service versus asthma or COPD alone. Moreover, the average annual medical cost for an ACOS patient in the US is $14, 914–much higher than asthma, $2307 or COPD,  $4879. ACOS is common in the elderly. It features more dyspnea (breathlessness), wheezing, and more frequent exacerbations. The respiratory quality of life and amount of physical activity for those with COPD alone.

Addendum to Tho, Park, & Nakano

Using my peak flow meter to check my forced exhale volume (FEV) always has been one of my strong points in managing my ACOS. I check my peak flow meter before I go for a walk, and if I’m under my usual low moderate level of impairment, I head for the albuterol nebulizer. Check my article https://www.newscastic.com/news/forced-exhale-volume-fev-lung-disease-your-peak-flow-meter-1155949/ The “whole story” includes a link to an About.com article on Pulmonary Function tests, by Deborah Leader, RN, COPD Expert.

Returning to the Tho, Park, and Nakano article, we see that a staggering 49% of smokers develop chronic bronchitis and 24% get emphysema or COPD. “Smoker’s cough” is worst upon arising. Dyspnea increases as the disease worsens. Quit smoking or else!

Guaifenesin (Mucinex) has been one of my favorite OTC medicines for years because it’s an expectorant. You can find a cheaper generic version in the dollar store too. Warn the doctor if you smoke, or have asthma or emphysema. It thins the mucus, so it’s less sticky and easier to cough up, according to www.drugs.com/mucinex.html  Take guaifenesin when you have a cold, bronchitis, flu, or allergies–whatever got your chest full of phlegm. Still drink plenty of fluids. www.webmd.com/drugs/2/drug-63818/mucinex-oral/details I’ve been told by my doctor to take a larger than average dose of guaifenesin during an ACOS attack.

Beware of drinks with carbon dioxide (CO2) also, such as beer and soda. http://respiratorytherapycave.blogspot.com/2008/06/asthmacopders-should-avoid-pop-beer.html The ability to exhale carbon dioxide is vastly impaired for the bad lung crowd. “The normal human body breathes to eliminate CO2, producing 200 cc./minute. However, one can of soda has up to 1000 cc. of dissolved CO2. Most is absorbed by into the blood stream by the intestines.” This can lead to more dyspnea (breathlessness) in those with lung disease. Furthermore, beer can cause dehydration too–another cause of dyspnea. Maybe gas pills help; time will tell.

On the other hand, if you like alcoholic drinks and wish to be more careful, then try red wine. First of all, you won’t have to worry about bubbles. Red wine increases antioxidant status and decreases oxidative stress in circulation, mainly because of glutathione (GSH). The “French Paradox” is explained by their love of red wine lessening coronary heart disease despite a fatty diet. https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-6-27

In closing, there’s a rich amount of literature on asthma, bronchitis, and COPD. Learn to manage your illness before you continue to deteriorate, and get a pulmonologist if you don’t have one already.