“Asthma-COPD Overlap Syndrome (ACOS),” Footnotes & a Commentary from a Patient (6th Edition), by J.D. Meyer


“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. I was switched back to Advair (another LABA +ICS drug), which has bee my usual inhaled corticosteroid. Both drugs are used for asthma &COPD. A Muscarinic Antagonist is also a bronchodilator, such as tiotropium (Spiriva) and aclidinium.

Spiriva, an inhaled capsule, is used for COPD, including emphysema and chronic bronchitis. Later, I was switched to Montelukast, the pill version of Singulair.

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. Now my inhaler is Combivent–a stronger ipratropium-albuterol inhaler.

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.

I also take an over-the-counter allergy pill, for I’m allergic to Bermuda and Johnson grass. My choice is non-drowsy Loratadine Tablets, an antihistamine that’s another find at Family Dollar. Loratadine is a generic form of Claritin.

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.

MY MEDICAID ADVENTURE by Joffre (“J.D.”) Meyer

I have had COPD since December 2005 and asthma since 1987. I got on SSDI in March 2010, Medicare in November 2011, and Medicaid in July 2012. Not everyone goes through the same sequence. I checked into a neighborhood nursing home once I got on Medicare, so I could get two long overdue surgeries: hernia since December 2007 and a bad big right toe (either broke or a bunion) since spring 2010. Can you imagine what it was like to hold one’s groin when a COPD sufferer with little medicine coughed for four years?
I made sure that I was affiliated with East Texas Council for Independent Living (ETCIL) when I committed myself. I got a wonderful social worker/relocation specialist, Suzan Chapman, who I still see at downtown art events because her hobby is jewelry, and she’s a fan of the arts and Downtown Tyler too.
Getting out of the nursing home was dependent on getting on Medicaid. Unlike many, I got on SSDI and Medicare on my first try. My last job was a nightmare, so I got lung and mental status testing to be safe, and not end up under a bridge; thus I call my SSDI monthly check, “a bad lung/crazy check.”
While in the nursing home, I went to Pulmonary Rehabilitation at Trinity Mother Francis. This led to attending monthly Better Breather luncheons on second Tuesdays at TMF. It’s a group for those with lung and/or heart diseases. There’s always a guest speaker at our free luncheons.
Turned down for Medicaid the first time, I caught a bus to the records building of East Texas Medical Center’s (ETMC) records department. I provided the records of astronomical E.R. bills from 2008-12 to the nursing home social workers and got out quickly.
I relocated within walking distance from the hospitals in the east-central part of my hometown, Tyler. It’s known as Midtown or the Hospital District. Before checking out, I made sure I was part of Neighborhood Services, so I could get a 2/3 discount on my efficiency. It was great to reunite with a favorite prominent alumnus, Andy Davis, of the HBCU, Texas College, where I’d taught from 2001-06.
Now that I was on the outside, I could have a G.P. and a pulmonologist. I’d always managed to keep my albuterol flowing through my nebulizer since ’97. Having a rescue inhaler is an obvious necessity, but probably tougher now for the strugglers after the end of Primatene, the over-the-counter inhaler that cratered and rising pulmonary illness medicine costs. I started on Advair, the purple disk, while still teaching for the HBCU, but its expense meant sporadic help through service organizations.
My new lung medicines were a tiny pill called Daliresp, and Spiriva, the medicine advertised on TV with an elephant on the actor’s chest. My first pulmonologist prescribed oxygen canula for sleeping. Then the new pulmonologist, Dr. Luis Destarac, noticed my condition was more severe and sent for sleep studies.
Sure enough, I have severe sleep apnea and got a C-PAP machine. The C-PAP helps the apnea condition of waking up off and on unknowingly in my sleep because I quit breathing repeatedly! I bet the C-PAP is also good for the inelasticity of my lungs due to emphysema. Dr. Destarac is also an allergist, so I get allergy shots for bermuda and Johnson Grass primarily twice a month from his also very likable nurses, Esmeralda and Emily.
The G.P., Dr. Paula Bessonette, discovered that I have high cholesterol and require a Lipitor-type drug, as well as Vitamin D. Dr. Bessonette is so cool that she leaves some time open her day without appointments,so she can treat conditions like a COPD exacerbation to keep folks like me from automatically going to the expensive E.R. A recent eye exam caught the onset of macular degeneration, and combination vitamin/mineral capsule is arresting that condition.
My health hasn’t been this good in years–no E.R. visits since early January 2015! I used to go to the E.R. on a monthly basis. I’ve been a volunteer with the East Texas Human Needs Network (ETHNN), starting in the education and health committees before changing to the new transportation committee because I’m an avid bus rider. Then I was invited to the Community Health Worker (CHW) coalition.
Now I’m going through a disability rights group to see if I can have a trial work period, so I can start publishing my Developmental English/Writing textbook–already copyrighted and illustrated. Thus my adventure with Medicaid is about to have a new chapter!