Definition and terminology

A flare-up or exacerbation is an acute or sub-acute worsening

of symptoms and lung function compared with the patients
usual status
Terminology
Flare-up is the preferred term for discussion with patients
Exacerbation is a difficult term for patients
Attack has highly variable meanings for patients and
clinicians
Episode does not convey clinical urgency
Consider management of worsening asthma as a continuum
Self-management with a written asthma action plan
Management in primary care
Management in the emergency department and hospital
Follow-up after any exacerbation
 Identify patients at risk of asthma-related death
Patients at increased risk of asthma-related death should be
identified
Any history of near-fatal asthma requiring intubation and
ventilation
Hospitalization or emergency care for asthma in last 12
months
Not currently using ICS, or poor adherence with ICS
Currently using or recently stopped using OCS
(indicating the severity of recent events)
Over-use of SABAs, especially if more than 1 canister/month
Lack of a written asthma action plan
History of psychiatric disease or psychosocial problems
Confirmed food allergy in a patient with asthma
Flag these patients for more frequent review
 Written asthma action plans
All patients should have a written asthma action plan
The aim is to show the patient how to recognize and
respond to worsening asthma
It should be individualized for the patients medications,
level of asthma control and health literacy
Based on symptoms and/or PEF (children: only symptoms)
The action plan should include:
The patients usual asthma medications
When/how to increase reliever and controller or start OCS
How to access medical care if symptoms fail to respond
Why?
When combined with self-monitoring and regular medical
review, action plans are highly effective in reducing asthma
mortality and morbidity
 Written asthma action plans
Effective asthma self-management education requires:

Self-monitoring of symptoms and/or lung function If PEF or FEV1

<60% best, or not
Written asthma action plan improving after
Regular medical review 48 hours
Continue reliever

All patients Continue controller

Increase reliever Add prednisolone

4050 mg/day
Early increase in
controller as below Contact doctor

Review response
EARLY OR MILD LATE OR SEVERE
 Written asthma action plans medication options
Increase inhaled reliever
Increase frequency as needed
Adding spacer for pMDI may be helpful
Early and rapid increase in inhaled controller
Up to maximum ICS of 2000mcg BDP/day or equivalent
Options depend on usual controller medication and type of
LABA
See GINA 2015 report Box 4-2 for details
Add oral corticosteroids if needed
Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7
days
Children: 1-2mg/kg/day up to 40mg, usually 3-5 days
Morning dosing preferred to reduce side-effects
Tapering not needed if taken for less than 2 weeks
 Rationale for change in recommendation about controller
therapy in asthma action plans
For the last 10 years, most guidelines recommended treating
worsening asthma with SABA alone until OCS were needed, but ...
Most exacerbations are characterised by increased inflammation
Most evidence for self-management involved doubling ICS dose
Outcomes were consistently better if the action plan prescribed both increased
ICS, and OCS
Generalisability of placebo-controlled RCTs of doubling ICS
Participants were required to be highly adherent
Study inhalers were not started, on average, until symptoms and airflow
limitation had been worsening for 4-5 days.
Severe exacerbations are reduced by short-term treatment with
Quadrupled dose of ICS
Quadrupled dose of budesonide/formoterol
Early small increase in ICS/formoterol (maintenance & reliever regimen)
Adherence by community patients is poor
Patients commonly take only 25-35% of prescribed controller dose
Patients often delay seeking care for fear of being given OCS
 Managing exacerbations in primary care
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE

Talks in phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
PEF >50% predicted or best
LIFE-THREATENING
Talks in words, sits hunched
forwards, agitated Drowsy, confused
Respiratory rate >30/min or silent chest
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF 50% predicted or best URGENT

START TREATMENT
SABA410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone:adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg While waiting: give inhaled SABA
and ipratropium bromide, O2,
Controlled oxygen(if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed

WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

Symptoms improved, not needing SABA Reliever:continue as needed
PEF improving, and >60-80% of personal Controller:start, or step up. Check inhaler
best or predicted technique, adherence
Oxygen saturation >94% room air Prednisolone:continue, usually for 57 days
(3-5 days for children)
Resources at homeadequate
Follow up: within 27 days

FOLLOW UP
Reliever: reduce to as-needed
Controller:continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan:Is it understood? Was it used appropriately? Does it need modification?

GINA 2015, Box 4-3 (1/7)

 START TREATMENT
SABA 410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone:adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 12 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen(if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENTwith SABA as needed

WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

Symptoms improved, not needing SABA Reliever:continue as needed
PEF improving, and >60-80% of personal Controller:start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone:continue, usually for 57 days
(3-5 days for children)
Resources at homeadequate
Follow up: within 27 days

FOLLOW UP
Reliever: reduce to as-needed
Controller:continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan:Is it understood? Was it used appropriately? Does it need modification?

GINA 2015, Box 4-3 (7/7) Global Initiative for Asthma

 Managing exacerbations in acute care settings

INITIAL ASSESSMENT Are any of the following present?

A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE

Talks in phrases Talks in words

Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

Short-acting beta2-agonists Short-acting beta2-agonists

Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as

severe and re-aassess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently

GINA 2015, Box 4-4 (1/4)

 INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE

Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

GINA 2015, Box 4-4 (2/4) Global Initiative for Asthma

 MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
PEF >50% predicted or best
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Oral corticosteroids
GINA 2015, Box 4-4 (3/4)
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF 50% predicted or best
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
 Short-acting beta2-agonists Short-acting beta2-agonists
Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as

severe and re-assess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF <60% of predicted or

FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

GINA 2015, Box -4 (4/4) Global Initiative for Asthma

 Follow-up after an exacerbation
Follow up all patients regularly after an exacerbation,
until symptoms and lung function return to normal
Patients are at increased risk during recovery from an
exacerbation
The opportunity
Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patients asthma
management
At follow-up visit(s), check:
The patients understanding of the cause of the flare-up
Modifiable risk factors, e.g. smoking
Adherence with medications, and understanding of their
purpose
Inhaler technique skills
Written asthma action plan
 Background
For patients with respiratory symptoms, infectious diseases
and non-pulmonary conditions need to be distinguished from
chronic airways disease
In patients with chronic airways disease, the differential
diagnosis differs by age
Children and young adults: most likely to be asthma
Adults >40 years: COPD becomes more common, and
distinguishing asthma from COPD becomes more difficult
Many patients with symptoms of chronic airways disease have
features of both asthma and COPD
This has been called the Asthma-COPD Overlap Syndrome
(ACOS)
ACOS is not a single disease
It is likely that a range of different underlying mechanisms and
origins will be identified
 Background
Patients with features of both asthma and COPD have worse
outcomes than those with asthma or COPD alone
Frequent exacerbations
Poor quality of life
More rapid decline in lung function
Higher mortality
Greater health care utilization
Reported prevalence of ACOS varies by definitions used
Concurrent doctor-diagnosed asthma and COPD are found
in
1520% of patients with chronic airways disease
Reported rates of ACOS are between1555% of patients
with chronic airways disease, depending on the definitions
used for asthma and COPD, and the population studied
Prevalence varies by age and gender
 Objectives of the ACOS chapter
To assist clinicians (especially in primary care and non-
pulmonary specialties):
To identify patients with a disease of chronic airflow
limitation
To distinguish asthma from COPD and the asthma-
COPD overlap syndrome (ACOS)
To decide on initial treatment and/or need for referral
To stimulate research into ACOS, by promoting:
Study of characteristics and outcomes in broad
populations of patients with chronic airflow limitation
Research into underlying mechanisms that might allow
development of specific interventions for prevention and
management of ACOS
 Definitions

Asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway
inflammation. It is defined by the 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. [GINA 2015]
COPD
COPD is a 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 2015]
Asthma-COPD overlap syndrome (ACOS) [a description]
Asthma-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 is therefore identified by the features that it
shares with both asthma and COPD.
A specific definition for ACOS cannot be developed until more evidence is available
about its clinical phenotypes and underlying mechanisms.
GINA 2015, Box 5-1 (3/3) Global Initiative for Asthma
 Stepwise approach to diagnosis and
initial treatment
DIAGNOSE CHRONIC AIRWAYS DISEASE
STEP 1
Do symptoms suggest chronic airways disease?

Yes No Consider other diseases first

SYNDROMIC DIAGNOSIS IN ADULTS

STEP 2 (i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis For an adult who presents with
Features: if present suggest ASTHMA

Age of onset Before age 20 years
Pattern of symptoms Variation over minutes, hours or days
Worse during the night or early
morning. Triggered by exercise,
emotions including laughter, dust or
exposure to allergens
Record of variable airflow limitation
Lung function
respiratory symptoms:
COPD
After age 40 years
Persistent despite treatment
Good and bad days but always daily
symptoms and exertional dyspnea
Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
1. Does the patient have chronic
Record of persistent airflow limitation

Lung function between

symptoms
(spirometry or peak flow)

Normal
(FEV1/FVC < 0.7 post-BD)
Abnormal
airways disease?
Previous doctor diagnosis of asthma Previous doctor diagnosis of COPD,
Past history or family
history Family history of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
chronic bronchitis or emphysema
Heavy exposure to risk factor: tobacco
smoke, biomass fuels
2. Syndromic diagnosis of asthma,
Time course No worsening of symptoms over
time. Variation in symptoms either
seasonally, or from year to year
May improve spontaneously or have
Symptoms slowly worsening over
time (progressive course over years)
Rapid-acting bronchodilator treatment
COPD and ACOS
an immediate response to provides only limited relief

Chest X-ray
bronchodilators or to ICS over weeks
Normal Severe hyperinflation
NOTE: These features best distinguish between asthma and COPD. Several positive features (3 or more) for either asthma or
3. Spirometry
COPD suggest that diagnosis. If there are a similar number for both asthma and COPD, consider diagnosis of ACOS

DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma

Asthma
Some features
of asthma
Asthma
Features of
both
Could be
ACOS
Some features
of COPD
Possibly
COPD
COPD

COPD
4. Commence initial therapy
STEP 3
PERFORM
Marked
reversible airflow limitation FEV1/FVC < 0.7
5. Referral for specialized
(pre-post bronchodilator) or other post-BD
SPIROMETRY proof of variable airflow limitation
investigations (if necessary)
STEP 4 Asthma Asthma drugs ICS, and
INITIAL drugs No LABA usually COPD COPD
No LABA monotherapy LABA drugs drugs
TREATMENT*
monotherapy +/or LAMA
*Consult GINA and GOLD documents for recommended treatments.

Persistent symptoms and/or exacerbations despite treatment.

Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases
STEP 5 and other causes of respiratory symptoms).
SPECIALISED Suspected asthma or COPD with atypical or additional symptoms or signs (e.g.
INVESTIGATIONS haemoptysis, weight loss, night sweats, fever, signs of bronchiectasis or other structural lung
or REFER IF: disease).
Few features of either asthma or COPD.
Comorbidities present.
Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.

GINA 2015, Box 5-4 Global Initiative for Asthma

 Step 1 Does the patient have chronic
airways disease?

STEP 1 DIAGNOSE CHRONIC AIRWAYS DISEASE

Do symptoms suggest chronic airways disease?

Yes No Consider other diseases first

GINA 2015 Global Initiative for Asthma

 Step 1 Does the patient have chronic airways disease?

Clinical history: consider chronic airways disease if

Chronic or recurrent cough, sputum, dyspnea or wheezing, or
repeated acute lower respiratory tract infections
Previous doctor diagnosis of asthma and/or COPD
Previous treatment with inhaled medications
History of smoking tobacco and/or other substances
Exposure to environmental hazards, e.g. airborne pollutants
Physical examination
May be normal
Evidence of hyperinflation or respiratory insufficiency
Wheeze and/or crackles
 Step 1 Does the patient have chronic airways disease?

Radiology (CXR or CT scan performed for other reasons)

May be normal, especially in early stages
Hyperinflation, airway wall thickening, hyperlucency, bullae
May identify or suggest an alternative or additional diagnosis,
e.g. bronchiectasis, tuberculosis, interstitial lung disease,
cardiac failure
Screening questionnaires
Designed to assist in identification of patients at risk of
chronic airways disease
May not be generalizable to all countries, practice settings or
patients
See GINA and GOLD reports for examples
Step 2 Syndromic diagnosis of asthma, COPD and ACOS

Assemble the features that, when present, most favor a

diagnosis of typical asthma or typical COPD
Compare the number of features on each side
If the patient has 3 features of either asthma or
COPD, there is a strong likelihood that this is the
correct diagnosis
Consider the level of certainty around the diagnosis
Diagnoses are made on the weight of evidence
The absence of any of these features does not rule out
either diagnosis, e.g. absence of atopy does not rule
out asthma
When a patient has a similar number of features of
both asthma and COPD, consider the diagnosis of
ACOS
 SYNDROMIC DIAGNOSIS IN ADULTS
STEP 2 (i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis

Features: if present suggest - ASTHMA COPD

Age of onset Before age 20 years After age 40 years
Pattern of symptoms Variation over minutes, hours or days Persistent despite treatment
Worse during the night or early morning Good and bad days but always daily
symptoms and exertional dyspnea
Triggered by exercise, emotions
including laughter, dust or exposure Chronic cough & sputum preceded
to allergens onset of dyspnea, unrelated to triggers

Lung function Record of variable airflow limitation Record of persistent airflow limitation
(spirometry or peak flow) (FEV1/FVC < 0.7 post-BD)
Lung function between Normal Abnormal
symptoms
Past history or family history Previous doctor diagnosis of asthma Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
Family history of asthma, and other
allergic conditions (allergic rhinitis or Heavy exposure to risk factor: tobacco
eczema) smoke, biomass fuels

Time course No worsening of symptoms over time. Symptoms slowly worsening over time
Variation in symptoms either (progressive course over years)
seasonally, or from year to year
Rapid-acting bronchodilator treatment
May improve spontaneously or have provides only limited relief
an immediate response to
bronchodilators or to ICS over weeks

Chest X-ray Normal Severe hyperinflation

NOTE: These features best distinguish between asthma and COPD. Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. If there are a similar number for both asthma and COPD, consider diagnosis of ACOS

Asthma Some features Features of Some features

DIAGNOSIS COPD
of asthma both of COPD
CONFIDENCE IN Asthma Asthma Could be ACOS Possibly COPD COPD
DIAGNOSIS

GINA 2014 Global Initiative for Asthma

STEP 3 Marked
PERFORM reversible airflow limitation FEV1/FVC < 0.7
SPIROMETRY (pre-post bronchodilator) or other post-BD
proof of variable airflow limitation

Global Initiative for Asthma

 Step 3 - Spirometry
Essential if chronic airways disease is suspected
Confirms chronic airflow limitation
More limited value in distinguishing between asthma with
fixed airflow limitation, COPD and ACOS
Measure at the initial visit or subsequent visit
If possible measure before and after a trial of treatment
Medications taken before testing may influence results
Peak expiratory flow (PEF)
Not a substitute for spirometry
Normal PEF does not rule out asthma or COPD
Repeated measurement may confirm excessive variability,
found in asthma or in some patients with ACOS
 Step 3 - Spirometry

Spirometric variable Asthma COPD ACOS

Normal FEV1/FVC Compatible with asthma Not compatible with Not compatible unless
pre- or post-BD diagnosis (GOLD) other evidence of chronic
airflow limitation
Post-BD
- FEV1/FVC <0.7 Indicates airflow Required for diagnosis Usual in ACOS
limitation; may improve by GOLD criteria
FEV1 80% predicted Compatible with asthma Compatible with GOLD Compatible with mild
(good control, or interval category A or B if post- ACOS
between symptoms) BD FEV1/FVC <0.7
FEV1<80% predicted Compatible with asthma. Indicates severity of Indicates severity of
A risk factor for airflow limitation and risk airflow limitation and risk
exacerbations of exacerbations and of exacerbations and
mortality mortality
Post-BD
- increase in Usual at some time in Common in COPD and Common in ACOS, and
FEV1>12% and 200mL course of asthma; not more likely when FEV1 more likely when FEV1 is
from baseline (reversible always present is low low
airflow limitation)
Post-BD
- increase in High probability of Unusual in COPD. Compatible with
FEV1>12% and 400mL asthma Consider ACOS diagnosis of ACOS
from baseline
GINA 2015, Box 5-3 Global Initiative for Asthma
 Asthma Asthma
drugs drugs ICS and
STEP 4 consider
No LABA No LABA COPD
INITIAL LABA COPD
monother monother drugs
TREATMENT* +/or drugs
apy apy LAMA

*Consult GINA and GOLD documents for

recommended treatments.

Global Initiative for Asthma

 Step 4 Commence initial therapy
Initial pharmacotherapy choices are based on both efficacy and safety
If syndromic assessment suggests asthma as single diagnosis
Start with low-dose ICS
Add LABA and/or LAMA if needed for poor control despite good
adherence and correct technique
Do not give LABA alone without ICS
If syndromic assessment suggests COPD as single diagnosis
Start with bronchodilators or combination therapy
Do not give ICS alone without LABA and/or LAMA
If differential diagnosis is equally balanced between asthma and COPD, i.e.
ACOS
Start treatment as for asthma, pending further investigations
Start with ICS at low or moderate dose
Usually also add LABA and/or LAMA, or continue if already prescribed
 Step 4 Commence initial therapy
For all patients with chronic airflow limitation:
Treat modifiable risk factors including advice about
smoking cessation
Treat comorbidities
Advise about non-pharmacological strategies
including physical activity, and, for COPD or ACOS,
pulmonary rehabilitation and vaccinations
Provide appropriate self-management strategies
Arrange regular follow-up
See GINA and GOLD reports for details
 Persistent symptoms and/or exacerbations
despite treatment.
STEP 3 Diagnostic uncertainty (e.g. suspected
PERFORM
SPIROMETRY pulmonary hypertension, cardiovascular
diseases and other causes of respiratory
symptoms).
STEP 5 Suspected asthma or COPD with atypical or
SPECIALISED additional symptoms or signs (e.g. haemoptysis,
INVESTIGATIONS
or REFER IF: weight loss, night sweats, fever, signs of
bronchiectasis or other structural lung disease).
Few features of either asthma or COPD.
Comorbidities present.
Reasons for referral for either diagnosis as
outlined in the GINA and GOLD strategy
reports.

GINA 2015 Global Initiative for Asthma

 Step 5 Refer for specialized investigations if needed
Refer for expert advice and extra investigations if patient has:
Persistent symptoms and/or exacerbations despite treatment
Diagnostic uncertainty, especially if alternative diagnosis
(e.g. TB, cardiovascular disease) needs to be excluded
Suspected airways disease with atypical or additional symptoms or
signs (e.g. hemoptysis, weight loss, night sweats, fever, chronic
purulent sputum). Do not wait for a treatment trial before referring
Suspected chronic airways disease but few features of asthma,
COPD or ACOS
Comorbidities that may interfere with their management
Issues arising during on-going management of asthma, COPD or
ACOS
 Step 5 Refer for specialized
investigations if needed

Investigation Asthma COPD

DLCO Normal or slightly elevated Often reduced
Arterial blood gases Normal between In severe COPD, may be abnormal
exacerbations between exacerbations
Airway Not useful on its own in distinguishing asthma and COPD.
hyperresponsiveness Higher levels favor asthma
High resolution CT Usually normal; may show air Air trapping or emphysema; may
scan trapping and increased airway show bronchial wall thickening and
wall thickness features of pulmonary hypertension
Tests for atopy Not essential for diagnosis; Conforms to background
(sIgE and/or skin increases probability of prevalence; does not rule out COPD
prick tests) asthma
FENO If high (>50ppb) supports Usually normal. Low in current
eosinophilic inflammation smokers
Blood eosinophilia Supports asthma diagnosis May be found during exacerbations
Sputum inflammatory Role in differential diagnosis not established in large populations
cell analysis

GINA 2015, Box 5-5 Global Initiative for Asthma