FEATURE | Posted Nov. 13, 2014

Lung health champions

UC Davis specialists blur the lines between COPD and asthma

Patient William Cullifer © UC Regents
Karina Berge, pulmonary rehabilitation program coordinator, supports Bill Cullifer in exercise aimed at increasing endurance.

Controlling the symptoms of asthma or chronic obstructive pulmonary disease (COPD) is tough, but twice as challenging for those who have both diseases.

“Most people take breathing for granted,” said William Cullifer, a Folsom, Calif., resident who has battled severe asthma daily for 15 years and COPD for about half that time. “In addition to fighting to breathe all the time, there are frightening times each day when it’s like being stuck in a small space and sucking air through a tight straw.”

Cullifer is describing his experiences with a condition that UC Davis pulmonary specialists Samuel Louie and Amir Zeki have named asthma-COPD overlap syndrome, or ACOS.

The physicians recognized the high incidence of the condition — defined by the higher number and intensity of symptoms — after evaluating UC Davis patients with obstructive lung diseases and finding that ACOS was present in about a quarter of patients with severe asthma. They also observed that, on average, 1 in 5 patients with obstructive lung diseases have ACOS.

“It’s standard in our field to diagnose COPD or asthma but not both,” said Louie, professor of internal medicine. “That can lead to treatment plans that don’t fully address the breathing problems of a large group of patients and that put them at risk of losing rather than preserving their lung health.”

People with ACOS

  • Tend to be in their 40s or 50s (asthma patients tend to be younger, while COPD patients tend to be older)
  • Experience more acute exacerbations with greater intensity
  • Use more health-care resources than those with other obstructive airway diseases
  • May experience higher mortality rates than those with asthma or COPD alone

In articles published in the Journal of Allergy, Expert Review of Clinical Pharmacology and Consultant 360, Louie and Zeki presented a diagnosis and treatment approach for patients with  asthma, COPD or ACOS. In May of this year, their approach was incorporated in part by the Global Initiative for Asthma (GINA) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

“We don’t have complete consensus yet on the definition of ACOS, given the limited number of studies so far,” said Louie. “But this was a very important start.”

Different mechanisms, similar outcomes

Sam Louie © UC Regents
Sam Louie

Louie explained that asthma is the result of environmental triggers, including allergens and air pollution, which cause chronic inflammation and airflow obstruction.

Adults with COPD have lung damage in the form of emphysema, typically due to smoking or environmental exposures, causing chronic and progressive shortness of breath. A majority of COPD patients also have chronic bronchitis, causing airway swelling, mucus and coughing.

Both diseases lead to acute exacerbations — episodes when breathing rapidly deteriorates, potentially leading to emergency department visits, hospitalizations and death. ACOS patients experience these episodes more frequently and with greater severity than those with asthma or COPD alone.

Cullifer's treatment plan was developed in collaboration with pulmonologists, nurse practitioners and respiratory therapists of a UC Davis clinic focused on difficult-to-control asthma. His program includes pulmonary rehabilitation, which involves exercise therapy, medication management, nutrition and sleep education, and psychological support for those with obstructive lung diseases. While more confident about handling his frequent exacerbations, he is currently disabled.

“It’s not a matter of ‘what will I do today’ but ‘how will I manage my condition so I can live long enough to see my grandchildren,’” Cullifer said.

Healing through advocacy

Despite his condition and daily struggles, Cullifer helped establish the World Asthma Foundation and keeps patients and clinicians informed about asthma and COPD news and clinical trials through the organization's website. He also encourages early and aggressive treatment, including pulmonary rehabilitation, for asthma symptoms and advocates for greater attention and research funding for ACOS.

Amir Zeki & #169; UC Regents
Amir Zeki

Funders are starting to pay attention. Zeki recently received a Gordon Wong Research Endowment Grant from the UC Davis Department of Pulmonary, Critical Care and Sleep Medicine for a pilot study of the biological features of ACOS through longitudinal specimen analysis. He hopes the results provide the foundation for a much larger, randomized clinical trial that brings greater specificity to the disease and its treatments, along with ways to improve patient safety.

“ACOS is a unique syndrome that may occur through disease mechanisms that are distinct from asthma or COPD,” said Zeki, an assistant professor of internal medicine. “Understanding these distinctions is key to providing the right treatments and improving consistency of care among doctors.”

Until that happens, Zeki and Louie recommend that everyone with persistent asthma and significant tobacco exposure be evaluated for the overlap condition and specific treatment options.

“I call it ‘a clinical trial of one,’ since it involves one patient at a time.” said Louie. “There are many medications today approved for treating asthma and COPD. It’s a matter of working together with patients and their families to find the right combination that works to improve breathing, limit side effects and reduce exacerbations over the longest periods of time.”