Diagnostic Considerations

COPD

For diagnosis of COPD, the Global initiative for Obstructive Lung Disease (GOLD) endorses the spirometry criterion of post-BD forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < 0.70. This fixed cut-off is susceptible to the risk of overdiagnosing a substantial number of older symptomatic individuals as having COPD, which might contribute to the relative underdiagnosis of asthma in the elderly, particularly females. An alternative approach has been proposed to overcome this problem, whereby the cut-off is based on the lower limit of predicted normal. This cut-off assumes the “usual progressive” lung function decline of COPD is greater than the physiological age-related decline of the FEV1/FVC ratio.

Asthma-COPD Overlap

Older patients frequently present with chronic respiratory symptoms with features of both asthma and COPD and are found to have chronic airflow limitation that is not completely reversible with bronchodilation. The Global Initiative for Asthma (GINA) and the Global Initiative for Obstructive Lung Disease (GOLD) guidelines offer the following clinical descriptions to help distinguish asthma, COPD and asthma-COPD overlap^[15]:

Asthma - characterized by chronic airway inflammation defined by a history of respiratory symptoms including wheezing, shortness of breath, chest tightness and cough that vary in intensity and over time. Variable expiratory airflow limitation is also present.

COPD - characterized by persistent respiratory symptoms and airflow limitations due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

Asthma-COPD overlap - characterized by persistent respiratory symptoms and airflow limitations with multiple features associated with asthma and multiple features associated with COPD.

Differential Diagnoses

Workup

Desai M, Oppenheimer J, Lang DM. Immunomodulators and biologics: beyond stepped-care therapy. Clin Chest Med. 2019 Mar. 40(1):179-92. [QxMD MEDLINE Link].
Drazen JM, Harrington D. New biologics for asthma. N Engl J Med. 2018 Jun 28. 378(26):2533-4. [QxMD MEDLINE Link].
Rank MA, Oppenheimer JJ. Asthma biologics: underuse, overuse, and best use?. Ann Allergy Asthma Immunol. 2019 Apr. 122(4):358-9. [QxMD MEDLINE Link].
Castro M, Corren J, Pavord ID, et al. Dupilumab efficacy and safety in moderate-to-severe uncontrolled asthma. N Engl J Med. 2018 Jun 28. 378(26):2486-96. [QxMD MEDLINE Link]. [Full Text].
Smith AM, Villareal M, Bernstein DI, Swikert DJ. Asthma in the elderly: risk factors and impact on physical function. Ann Allergy Asthma Immunol. 2012 May. 108(5):305-10. [QxMD MEDLINE Link].
Bauer BA, Reed CE, Yunginger JW, Wollan PC, Silverstein MD. Incidence and outcomes of asthma in the elderly. A population-based study in Rochester, Minnesota. Chest. 1997 Feb. 111(2):303-10. [QxMD MEDLINE Link].
Huss K, Naumann PL, Mason PJ, et al. Asthma severity, atopic status, allergen exposure and quality of life in elderly persons. Ann Allergy Asthma Immunol. 2001 May. 86(5):524-30. [QxMD MEDLINE Link].
Enright PL, McClelland RL, Newman AB, Gottlieb DJ, Lebowitz MD. Underdiagnosis and undertreatment of asthma in the elderly. Cardiovascular Health Study Research Group. Chest. 1999 Sep. 116(3):603-13. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention (CDC). Asthma mortality and hospitalization among children and young adults--United States, 1980-1993. MMWR Morb Mortal Wkly Rep. 1996 May 3. 45(17):350-3. [QxMD MEDLINE Link]. [Full Text].
de Groot JC, Ten Brinke A, Bel EH. Management of the patient with eosinophilic asthma: a new era begins. ERJ Open Res. 2015 May. 1(1):[QxMD MEDLINE Link]. [Full Text].
Centers for Disease Control and Prevention. Asthma prevalence. Reviewed: October 17, 2019. Available at https://www.cdc.gov/asthma/data-visualizations/prevalence.htm. Accessed: December 10, 2019.
Centers for Disease Control and Prevention. Mortality data. Reviewed: September 23, 2019. Available at https://www.cdc.gov/asthma/data-visualizations/mortality-data.htm. Accessed: December 10, 2019.
de Marco R, Pesce G, Marcon A, et al. The coexistence of asthma and chronic obstructive pulmonary disease (COPD): prevalence and risk factors in young, middle-aged and elderly people from the general population. PLoS One. 2013. 8(5):e62985. [QxMD MEDLINE Link]. [Full Text].
Ortiz G, Sanders DH. Adult asthma. J Asthma Allergy Educ. 2012 June. 3(3):129-31.
[Guideline] Global Initiative for Asthma. Global strategy for asthma management and prevention, 2019. Available at http://ginasthma.org/gina-reports/. Accessed: December 10, 2019.
Crapo RO, Hankinson JL, Irvin C, et al, for the American Thoracic Society. Standardization of spirometry, 1994 update. Am J Respir Crit Care Med. 1995 Sep. 152(3):1107-36. [QxMD MEDLINE Link].
Tepper RS, Wise RS, Covar R, et al. Asthma outcomes: pulmonary physiology. J Allergy Clin Immunol. 2012 Mar. 129(3 Suppl):S65-87. [QxMD MEDLINE Link]. [Full Text].
Carr TF, Peters AT. Chapter 12: Asthma: principles of treatment. Allergy Asthma Proc. 2012 May-Jun. 33 Suppl 1:39-43. [QxMD MEDLINE Link].
Ortega HG, Liu MC, Pavord ID, et al, for the MENSA Investigators. Mepolizumab treatment in patients with severe eosinophilic asthma. N Engl J Med. 2014 Sep 25. 371(13):1198-207. [QxMD MEDLINE Link]. [Full Text].
Poulakos MN, Cargill SM, Waineo MF, Wolford AL Jr. Mepolizumab for the treatment of severe eosinophilic asthma. Am J Health Syst Pharm. 2017 Jul 1. 74(13):963-9. [QxMD MEDLINE Link].
Pelaia C, Vatrella A, Gallelli L, et al. Dupilumab for the treatment of asthma. Expert Opin Biol Ther. 2017 Dec. 17(12):1565-72. [QxMD MEDLINE Link].
Nair P, Wenzel S, Rabe KF, et al, for the ZONDA Trial Investigators. Oral glucocorticoid-sparing effect of benralizumab in severe asthma. N Engl J Med. 2017 Jun 22. 376(25):2448-58. [QxMD MEDLINE Link]. [Full Text].
FitzGerald JM, Bleecker ER, Menzies-Gow A, et al. Predictors of enhanced response with benralizumab for patients with severe asthma: pooled analysis of the SIROCCO and CALIMA studies. Lancet Respir Med. 2018 Jan. 6(1):51-64. [QxMD MEDLINE Link].
Castro M, Zangrilli J, Wechsler ME, et al. Reslizumab for inadequately controlled asthma with elevated blood eosinophil counts: results from two multicentre, parallel, double-blind, randomised, placebo-controlled, phase 3 trials. Lancet Respir Med. 2015 May. 3(5):355-66. [QxMD MEDLINE Link].
[Guideline] Reddell, H, Vogelmeier C, Decker R et al. 2017 Asthma, COPD, and Asthma-COPD overlap: A joint project of GINA and GOLD. April 2017. Global Initiative for Asthma. Available at http://ginasthma.org/gina-reports/. Accessed: December 10, 2017.
Centers for Disease Control and Prevention. Asthma Facts: CDC’s National Asthma Control Program Grantees. July 2013. Available at https://www.cdc.gov/asthma/pdfs/asthma_facts_program_grantees.pdf. Accessed: December 10, 2017.
Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011 Jan. 127(1 Suppl):S1-55. [QxMD MEDLINE Link].
Delea TE, Hagiwara M, Stempel DA, Stanford RH. Adding salmeterol to fluticasone propionate or increasing the dose of fluticasone propionate in patients with asthma. Allergy Asthma Proc. 2010 May-Jun. 31(3):211-8. [QxMD MEDLINE Link].
Fanta CH. Asthma. N Engl J Med. 2009 Mar 5. 360(10):1002-14. [QxMD MEDLINE Link].
Fuhlbrigge AL, Lemanske RF Jr, Rasouliyan L, Sorkness CA, Fish JE. Practice patterns for oral corticosteroid burst therapy in the outpatient management of acute asthma exacerbations. Allergy Asthma Proc. 2012 Jan-Feb. 33(1):82-9. [QxMD MEDLINE Link].
Georgy MS, Saltoun CA. Chapter 3: Allergen immunotherapy: definition, indication, and reactions. Allergy Asthma Proc. 2012 May-Jun. 33(Suppl 1):9-11. [QxMD MEDLINE Link].
Greenberger PA. Asthma. Grammer LC, Greenberger PA, eds. In: Patterson’s Allergic Diseases. 7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2009. 333-8.
Bleecker ER, FitzGerald JM, Chanez P, et al, for the SIROCCO study investigators. Efficacy and safety of benralizumab for patients with severe asthma uncontrolled with high-dosage inhaled corticosteroids and long-acting β₂-agonists (SIROCCO): a randomised, multicentre, placebo-controlled phase 3 trial. Lancet. 2016 Oct 29. 388(10056):2115-27. [QxMD MEDLINE Link].

Media Gallery

Asthma in older adults. Lung tissue normal versus constricted.
Asthma in older adults. Airway histology and pathology.
Asthma in older adults. Allergic and nonallergic triggers.
Asthma in older adults. Spirometric data plot. Pre-bronchodilator forced expiratory volume-one second (FEV1) = 1.77 L, post-bronchodilator FEV1 = 3.11 L, approximating a 75% change or airway reversibility.
There has been an upward trend in the prevalence of asthma across all age groups since 2001. Courtesy of the CDC (https://www.cdc.gov/asthma/data-visualizations/prevalence.htm).
Asthma prevalence by age, 2017. Courtesy of the CDC (https://www.cdc.gov/asthma/data-visualizations/prevalence.htm).