ARTICLE OPEN
P e alence o as hma–COPD o e lap synd ome among
p ima y ca e as hma ics wi h a smoking his o y:
a c oss-sec ional s udy
Toni Kiljande
1
, Timo Helin
2
, Ka i Venho
3
, An e o Jaakkola
4
and Lau i Leh imäki
5
BACKGROUND: The o e lap be ween as hma and ch onic obs uc i e pulmona y disease (COPD) is an impo an clinical
phenomenon. Howe e , he p e alence o as hma–COPD o e lap synd ome (ACOS) is no known.
AIMS: To in es iga e he p e alence o ACOS among as hma ic pa ien s wi h a smoking his o y, and e alua e he ac o s p edic ing
ACOS in his pa ien g oup.
METHODS: We in es iga ed 190 p ima y ca e as hma pa ien s wi h no p e ious diagnosis o COPD, bu who we e ei he cu en o
ex-smoke s, wi h a smoking his o y o a leas 10 pack-yea s. Spi ome y was pe o med on all he pa ien s while hey we e aking
hei no mal as hma medica ion. Pa ien s we e conside ed o ha e ACOS i hei pos b onchodila o o ced expi a o y olume in
1 s/ o ced i al capaci y was o0.70.
RESULTS: Fi y- wo (27.4%) o he pa ien s we e ound o ha e ACOS. Age ⩾60 yea s and smoking o ⩾20 pack-yea s we e he
bes p edic o s o ACOS. I bo h o hese c i e ia we e me , he odds a io (95% confidence in e al) o ACOS was 6.08 (2.11–17.49),
compa ed wi h he si ua ion whe e nei he o hese c i e ia we e ulfilled.
CONCLUSIONS: The e is a high p e alence o ACOS among p ima y heal h ca e as hma ics wi h a posi i e smoking his o y bu no
p e ious diagnosis o COPD. In his popula ion, age o e 60 yea s and a smoking his o y o mo e han 20 pack-yea s we e he bes
p edic o s o ACOS.
npj P ima y Ca e Respi a o y Medicine (2015) 25, 15047; doi:10.1038/npjpc m.2015.47; published online 16 July 2015
INTRODUCTION
As hma and ch onic obs uc i e pulmona y disease (COPD) a e
he wo mos common obs uc i e pulmona y diseases. Al hough
as hma and COPD mos o en ep esen wo dis inc diseases,
he e is also significan o e lap be ween hese wo diseases.
1,2
The defini ion o as hma–COPD o e lap synd ome (ACOS) is
unde e mined. Mos commonly, i is defined as ei he he
diagnosis o COPD in a pa ien wi h p e iously diagnosed as hma,
o as incomple ely e e sible ai way obs uc ion accompanied by
symp oms o signals o inc eased e e sibili y o he obs uc ion.
3
A ecen upda e o he GINA epo ecommended a s epwise
app oach o he diagnosis o ACOS, and defined i as a synd ome
cha ac e ized by pe sis en ai flow limi a ion wi h se e al ea u es
usually associa ed wi h as hma and se e al ea u es usually
associa ed wi h COPD.
1
Compa ed wi h as hma o COPD alone, ACOS is associa ed
wi h wo se heal h- ela ed quali y o li e,
4,5
mo e equen
exace ba ions,
5,6
inc eased hospi alisa ion
6,7
and highe heal h
ca e cos s.
8
Al hough ACOS appea s o be clinically highly
significan , li le is known abou he ea men o hese pa ien s,
as hey a e ypically excluded om he apy ials o as hma
o COPD.
9
The e is only some da a on he p e alence o ACOS. Ha din
e al.
5
ound ha 13% o he COPD pa ien s in he COPDGene
s udy epo ed a his o y o doc o -diagnosed as hma. Simila ly,
Mi a i lles e al.
10
epo ed ha 17.4% o COPD pa ien s in he
EPI-SCAN s udy epo ed ha hey had been p e iously diagnosed
wi h as hma. The p e alence o o e lap synd ome has been
shown o inc ease wi h age,
11
which may eflec he ac ha , o e
he yea s, as hma ics may de elop fixed ai way obs uc ion,
especially i hey do no use an i-inflamma o y medica ion
12
o i
hey smoke.
13
So iano e al.
11
ound ha as many as hal o he
pa ien s wi h obs uc i e pulmona y disease, aged 50 yea s o
mo e, had simul aneously mo e han one obs uc i e condi ion.
The aim o he p esen s udy was o in es iga e he p e alence
o undiagnosed ACOS among p ima y heal h ca e as hma pa ien s
who a e cu en o ex-smoke s, and he ac o s p edic ing ACOS in
his pa ien g oup.
MATERIALS AND METHODS
This was a c oss-sec ional s udy. Pa ien s we e ec ui ed mos ly om he
appoin men s o p ima y ca e physicians and h ough newspape
ad e isemen s. In addi ion, a ew pa ien s we e also ec ui ed by p i a e
pulmonologis s ea ing p ima y ca e-like as hma pa ien s.
The s udy was app o ed by he E hics Commi ee o Pi kanmaa Heal h
Ca e Dis ic , and e e y pa ien ga e w i en in o med consen be o e any
s udy- ela ed p ocedu es we e pe o med.
Pa ien s
The inclusion c i e ia we e as ollows: age 18–70 yea s, cu en o
ex-smoke wi h 10 o mo e pack-yea s, doc o -diagnosed as hma wi h
special eimbu semen o as hma medica ion g an ed by he Na ional
Heal h Insu ance. To quali y o his eimbu semen , pa ien s mus ha e
ulfilled a leas one o he ollowing c i e ia: (1) ⩾12% (and 200 ml)
1
Depa men o Respi a o y Diseases, Te eys alo Hospi al, Tu ku, Finland;
2
Depa men o Alle gology, Helsinki Uni e si y Cen al Hospi al, Helsinki, Finland;
3
Depa men o
Respi a o y Medicine, Cen al Hospi al o Cen al Finland, Jy äskylä, Finland;
4
Boeh inge Ingelheim Finland, Helsinki, Finland and
5
Depa men o Respi a o y Medicine,
Uni e si y o Tampe e, Tampe e, Finland.
Co espondence: D T Kiljande ( oni.kiljande @fimne .fi)
Recei ed 13 Ap il 2015; accep ed 1 June 2015
www.na u e.com/npjpc m
All igh s ese ed 2055-1010/15
© 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed
e e sibili y in o ced expi a o y olume in 1 s (FEV
1
) o o ced i al capaci y
(FVC) in a b onchodila ion es , (2) du ing a 2-week peak expi a o y flow
moni o ing a leas h ee imes ei he a b onchodila o esponse o ⩾15%
(and 60 l/min) o a diu nal a ia ion o ⩾20%, (3) mode a e- o-se e e
b onchial hype esponsi eness in his amine o me hacholine inhala ion
challenge o (4) FEV
1
had imp o ed mo e han 15% du ing a co icos e oid
ea men es .
The exclusion c i e ia we e as ollows: any se e e illness, any known
pulmona y disease o he han as hma, use o inhaled an icholine gic o
indaca e ol o o al oflumilas .
Me hods
A e in o med consen was ecei ed, he in es iga o and he pa ien
comple ed a ques ionnai e including ques ions abou he inclusion and
exclusion c i e ia, and he pa ien ’s as hma medica ion, symp oms and
exace ba ions. The in es iga o s o ed he da a in a da abase. Body mass
index and cu en smoking s a us we e eco ded as a s anda d p ocedu e
when spi ome y was pe o med.
Spi ome ies (Medik o Kuopio, Finland) we e pe o med acco ding o
he guidelines
14
be o e and a e adminis a ion o 400 μg o inhaled
salbu amol while he pa ien s we e aking hei usual as hma medica ion.
The pa ien s we e conside ed o ha e ACOS i hei pos b onchodila o
FEV
1
/FVC was less han 0.70. Pa ien s wi h ACOS we e di ided in o GOLD
g ades o ai way obs uc ion acco ding o he GOLD epo .
2
Pa ien s we e conside ed o ha e had an exace ba ion du ing he
p e ious yea i hey had been hospi alised, o had used a cou se o o al
co icos e oids, o hei as hma du ing he p e ious yea .
S a is ical analysis
The p ima y ou come was he p e alence o ACOS, as defined abo e,
among as hma ics wi h a smoking his o y o a leas 10 pack-yea s. The
sample size calcula ion was based on he assump ion ha he p e alence
o ACOS in as hma ics is app oxima ely 45%.
11
Using he la ge sample
no mal app oxima ion, 265, 195, 149, 118 o 96 pa ien s would be equi ed
o es ima e he p e alence o be 95% confiden ha he es ima e will no
di e om he ue p e alence by mo e han 6, 7, 8, 9 o 10 pe cen ,
espec i ely. The final sample size o 219 ec ui ed pa ien s was assessed o
be la ge enough o ob ain a su ficien p ecision. The 95% confidence
in e al o p e alence was calcula ed using he la ge sample no mal
app oxima ion. The dis ibu ion o he a iables was checked using he
Kolmogo o –Smi no es and g aphical plo s. The dis ibu ions o
demog aphic con inuous da a we e skewed and a e exp essed as medians
(in e qua ile ange). The nonpa ame ic Mann–Whi ney U- es was used o
compa e he g oups wi h and wi hou ACOS wi h espec o con inuous
a iables. The Chi-squa e es and he exac Fishe 's es , when app op ia e,
we e used o ca ego ical a iables. Spea man’s ank co ela ion (Rho) was
used o s udy he associa ions be ween pos b onchodila o FEV
1
/FVC
e sus age and pack-yea s. The ecei e ope a ing cu e analysis (ROC)
was used o de e mine he bes cu -o alues o age and pack-yea s
o di e en ia e be ween as hma pa ien s wi h and wi hou o e lap
synd ome. Sensi i i y and specifici y we e assessed o be equally impo an
when he bes cu -o alues we e chosen. In addi ion, posi i e p edic i e
alues and nega i e p edic i e alues we e calcula ed. The po en ial
p ognos ic ac o s o o e lap we e sex, age, body mass index, cu en
smoking s a us and pack-yea s o smoking. Uni a iable logis ic eg ession
analyses we e pe o med o s udy he associa ions. The esul s a e gi en as
odds a ios wi h 95% confidence in e als. P alues less han 0.05 we e
conside ed s a is ically significan . The analyses we e pe o med using IBM
SPSS S a is ics o Windows ( e sion 22.0, A monk, NY, USA, IBM Co p.).
RESULTS
Two hund ed and nine een pa ien s we e ec ui ed and 190 o
hem we e included in he analysis (Figu e 1). Thei median age
( ange) was 58 (23–70) yea s, hey had smoked o 20 (10–60)
pack-yea s, and hei body mass index was 27.5 (16.1–50.3) kg/m
2
.
Eigh y- h ee (44.1%) o he pa ien s we e cu en smoke s and 112
(58.9%) we e emale.
Fi y- wo (27.4%, 95% confidence in e al 21–34%) pa ien s
we e ound o ha e pos b onchodila o FEV
1
/FVC o0.70 and
we e hus conside ed o ha e ACOS. Twel e (23.1%), 38 (73.1%)
As hma pa ien s,
n=219
Spi ome y measu emen s
we e no a ailable,
n=26
Spi ome y measu emen s
we e a ailable,
n=193
Spi ome y was no alid,
n=3
Pa ien s included
in analysis,
n=190
Pos b onchodila o
FEV1/FVC < 0.70,
n= 52 (27.4%)
Pos b onchodila o
FEV1/FVC > 0.70,
n= 138 (72.6%)
Figu e 1. Flow o pa icipan s. FEV
1
, o ced expi a o y olume in 1 s;
FVC, o ced i al capaci y.
Table 1. Cha ac e is ics o 190 as hma ics wi h and wi hou o e lap synd ome
Pa ien s wi h o e lap synd ome
(N= 52)
Pa ien s wi h as hma only
(N= 138)
P alue
a
Age (yea s) 63.0 (52.5–66.5) 57.0 (49.0–64.0) 0.008
Pack-yea s 24.5 (20.0–37.0) 20.0 (13.0–28.0) 0.003
BMI (kg/m
2
) 26.2 (23.2–29.9) 27.8 (24.6–31.6) 0.09
Cu en smoke s 28 (54.9%) 55 (40.1%) 0.07
Females 31 (59.6%) 81 (58.7%) 0.91
Inhaled co icos e oid (ICS) 50 (96.2%) 129 (93.5%) 0.48
Inhaled co icos e oid+inhaled long-ac ing β
2
-agonis (ICS+LABA) 36 (69.2%) 86 (62.3%) 0.38
Sho -ac ing β-agonis (SABA) mo e o en han wice a week 19 (36.5%) 37 (26.8%) 0.19
Exace ba ion du ing p e ious yea 16 (30.8%) 35 (25.4%) 0.45
Significan e e sibili y 8 (15.4%) 9 (6.5%) 0.08
b
All pa ien s we e cu en o ex-smoke s. Resul s a e gi en as median (in e qua ile ange) o numbe (%).
Abb e ia ion: BMI, body mass index.
a
Mann–Whi ney U- es was used o con inuous a iables and Chi-squa ed es o ca ego ical a iables.
b
Fishe 's exac es .
P e alence o as hma–COPD o e lap synd ome
T Kiljande e al
2
npj P ima y Ca e Respi a o y Medicine (2015) 15047 © 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed
and 2 (3.8%) belonged o GOLD s ages 1, 2 and 3, espec i ely.
None o he pa ien s belonged o GOLD s age 4.
A compa ison o he pa ien s wi h ACOS and hose wi h as hma
alone is shown in Table 1. Pa ien s wi h o e lap synd ome we e
olde and had smoked mo e han pa ien s wi h as hma alone.
O e lap pa ien s ended o be mo e o en cu en smoke s and o
ha e mo e o en significan e e sibili y, bu hese di e ences
we e no s a is ically significan .
A nega i e co ela ion be ween pos b onchodila o FEV
1
/FVC
and age (Spea man Rho = −0.28, Po0.001) and pack-yea s
(Rho = −0.25, Po0.001) was ound (Figu e 2).
ROC analysis o age and pack-yea s e ealed ha age ⩾60
yea s and smoking o ⩾20 pack-yea s we e he bes p edic o s o
ACOS in he s udy popula ion (Figu e 3). The a ea unde he ROC
cu e was 0.625 and 0.639 o age and pack-yea s, espec i ely.
The cu -o poin o 60 yea s o age yielded 63.5% sensi i i y and
59.4% specifici y, and he cu -o poin o 20 pack-yea s 80.8%
sensi i i y and 42.8% specifici y, o de ec o e lap synd ome
(Table 2). Howe e , he combina ion o bo h age ⩾60 yea s and
smoking o ⩾20 pack-yea s yielded he bes a ea unde he ROC
cu e: 0.670, and 53.8% sensi i i y and 74.6% specifici y.
The esul s o he logis ic eg ession analysis a e shown in
Table 3. Using he cu -o poin s gi en by he ROC analysis, age
and pack-yea s we e he only significan ac o s p edic ing o e lap
synd ome. I he pa ien was a leas 60 yea s old and had
simul aneously smoked o a leas 20 pack-yea s, he odds a io
(95% confidence in e al) o o e lap synd ome was 6.08
(2.11–17.49), P= 0.001, compa ed wi h he si ua ion whe e nei he
o hese c i e ia we e ulfilled. In pa ien s wi h one c i e ion
ulfilled (age ⩾60 o smoking o ⩾20 pack-yea s), he isk o
ACOS was abou wice as high as o pa ien s who we e younge
han 60 yea s and had smoked less han 20 pack-yea s. In
o he wo ds, i nei he o he c i e ia (age ⩾60 yea s and
smoking ⩾20 pack-yea s) we e ulfilled, he p e alence o o e lap
synd ome was 11.6% (5/43 pa ien s). I one o he c i e ia was me ,
hen o e lap synd ome was ound in 22.6% (19/84) o he pa ien s.
I bo h c i e ia we e me he p e alence o o e lap synd ome was
ound o be 44.4% (28/63 pa ien s).
DISCUSSION
Main findings
We ound he p e alence o as hma–COPD o e lap synd ome o
be 27.4% among p ima y heal h ca e as hma ics wi h no p e ious
diagnosis o COPD, bu who we e ei he cu en o ex-smoke s
wi h a smoking his o y o a leas 10 pack-yea s. The pa ien s
wi h ACOS we e olde and had smoked mo e han pa ien s wi h
as hma alone.
S eng hs and limi a ions o his s udy
The cu en s udy has i s weaknesses. Fi s , he numbe o
pa icipan s was ela i ely small o in es iga e he di e ences
be ween pa ien s wi h ACOS and as hma alone. Howe e , we
we e able o find ha olde age and hea ie smoking his o y
p edic ACOS, which a e he mos common a iables ound in
o he s udies oo. Mo eo e , wi h 190 pa icipan s, we we e able
o e alua e he p e alence o ACOS among as hma ics wi h a
posi i e smoking his o y, which was he p ima y objec i e o he
s udy. Second, as we did no in es iga e consecu i e pa ien s,
he e migh ha e been selec ion bias. On he o he hand, as we
excluded pa ien s wi h known COPD, and e en hose using he
Age (yea s)
FEV1(l)/FVC(l)
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Pack-yea s
FEV1(l)/FVC(l)
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Rho= – 0.25
P< 0.001
Rho= –0.28
P< 0.001
6010 20 30 40 50
60 7020 30 40 50
Figu e 2. Sca e plo s and eg ession lines showing he associa ion
be ween age and pack-yea s e sus pos b onchodila o FEV
1
/FVC in
190 as hma pa ien s wi h a posi i e smoking his o y. FEV
1
, o ced
expi a o y olume in 1 s; FVC, o ced i al capaci y.
1-Speci ici y
0.5
Sensi i i y
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Age
Pack-yea s
Age.60
Pack-yea s.20
1.00 0.1 0.2 0.3 0.4 0.9
0.80.7
0.6
Figu e 3. Recei e ope a ing cu e (ROC) analysis o age and
pack-yea s in 190 as hma ic pa ien s. The cu -o poin s o 60 yea s
o age yielded 63.5% sensi i i y and 59.4% specifici y and he cu -o
poin o 20 pack-yea s yielded 80.8% sensi i i y and 42.8% specifici y
o de ec o e lap synd ome.
Table 2. The bes cu -o alues o age and pack-yea s and hei
combina ion o de ec as hma–COPD o e lap synd ome among 190
as hma ics wi h posi i e smoking his o y
Sensi i i y
(%)
Specifici y
(%)
PPV
(%)
NPV
(%)
Age ⩾60 yea s 63.5 59.4 37.1 81.2
Pack-yea s ⩾20 80.8 42.8 34.7 85.5
Age ⩾60 yea s o pack-yea s ⩾20 90.4 27.5 32.0 88.4
Age ⩾60 yea s and pack-yea s ⩾20 53.8 74.6 44.4 81.1
Abb e ia ions: COPD, ch onic obs uc i e pulmona y disease; NPV,
nega i e p edic i e alue; PPV, posi i e p edic i e alue.
P e alence o as hma–COPD o e lap synd ome
T Kiljande e al
3
© 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed npj P ima y Ca e Respi a o y Medicine (2015) 15047
d ugs mos commonly p esc ibed o COPD, one could specula e
ha he esul migh a he be biased he o he way. Thi d, as a
ew pa ien s we e ec ui ed by p i a e pulmonologis s, one could
a gue ha we did no in es iga e exclusi ely p ima y ca e
pa ien s. Howe e , in Finland, ea men o he mos se e e
as hma ics is concen a ed in cen al and uni e si y hospi als, and
he ec ui ing p i a e pulmonologis s we e emphasised o ec ui
only pa ien s who could also be ea ed by gene al p ac i ione s.
Mo eo e , as ACOS pa ien s’COPD was mos ly mild, wi h 96%
being classed as GOLD s ages 1 and 2, we s ongly belie e ha we
in es iga ed p ima y heal h ca e ou pa ien s as was in ended.
The s udy also has i s s eng hs. Fi s , as he c i e ia o special
eimbu semen o as hma medica ion a e s ic , we a e posi i e
ha all he pa ien s in es iga ed eally had as hma. Second, as a
as we know his is he fi s s udy o in es iga e he p e alence o
ACOS among p ima y heal h ca e as hma ics wi h a posi i e
smoking his o y bu wi hou a p e ious diagnosis o COPD. In
mos ea lie s udies, he p e alence o ACOS has been e alua ed
among COPD pa ien s by asking hem i hey ha e doc o -
diagnosed as hma.
5,10,15
In e p e a ion o findings in ela ion o p e iously published wo k
Ha din e al.
5
ound he p e alence o as hma–COPD o e lap
o be 13% among COPD pa ien s in he COPDGene popula ion.
Mi a i lles e al.
10
ound ha 17.4% o COPD pa ien s in he EPI-
SCAN popula ion epo ed hey had p e iously been diagnosed
wi h as hma, and hus p esen ed wi h as hma–COPD o e lap.
In he PLATINO s udy, 22.8% o pa ien s wi h FEV
1
/FVC o0.7
epo ed a p io diagnosis o as hma and can be conside ed as
o e lap pa ien s.
15
The 27.4% p e alence o as hma–COPD o e lap
synd ome ound in ou s udy is sligh ly highe han in p e ious
s udies. We belie e ha he majo eason o his di e ence may
be he ac ha we in es iga ed a di e en pa ien popula ion.
We s udied as hma ic pa ien s and in es iga ed how o en
hei pos b onchodila o FEV
1
/FVC is o0.7, whe eas o he
s udies
5,10,15
ha e in es iga ed how o en pa ien s wi h pos -
b onchodila o FEV
1
/FVC o0.7 epo ha hey ha e p e iously
been diagnosed wi h as hma. On he o he hand, p e alences o
o e lap e en highe han ou s ha e been sugges ed. Fo example,
So iano e al.
11
ound ha as many as 50% o pa ien s wi h
obs uc i e pulmona y disease, aged 50 yea s o mo e, may su e
simul aneously om mo e han one obs uc i e condi ion.
The high p e alence o ACOS may be explained by he ac ha
as hma and ai way hype esponsi eness a e sugges ed o be isk
ac o s o de eloping COPD.
2
Lange e al.
16
ha e shown ha
decline in pulmona y unc ion is as e in as hma ics han among
hose wi hou as hma, and ha he decline is as es among hose
as hma ics who smoke. In he s udy by Vonk e al.,
12
16% o
pa ien s wi h as hma de eloped i e e sible ai way obs uc ion
du ing a 26-yea ollow-up. I has been shown ha ai way
hype esponsi eness, e en wi hou as hma, is an impo an isk
ac o o de eloping COPD.
17
Smoking is he mos impo an isk ac o o COPD.
2
The e o e,
i is no su p ising ha he ACOS pa ien s in ou s udy had smoked
mo e han hose wi h as hma alone. Also in he s udy by
Lee e al.,
18
g ea e amoun o ciga e e smoking was ela ed o
he de elopmen o fixed ai way obs uc ion among as hma ic
pa ien s.
We ound ACOS pa ien s o be olde han pa ien s wi h as hma
alone. In he s udy by Menezes e al.,
6
pa ien s wi h as hma–COPD
o e lap we e also olde han pa ien s wi h as hma alone. In ha
s udy, and in he COPDGene s udy,
5
pa ien s wi h COPD we e
olde han he o e lap pa ien s. These findings migh sugges a
con inuum om e e sible ai way obs uc ion, ia o e lap, o
i e e sible obs uc ion in some pa ien s. The e is e idence ha
some pa ien s wi h as hma de eloped i e e sible ai way obs uc-
ion du ing long-enough ollow-up,
12
and ha longe du a ion o
as hma may be associa ed wi h i e e sible ai way obs uc ion.
18
Un o una ely, in he cu en s udy, we we e unawa e o how long
he pa ien s had had as hma. Howe e , we belie e ha he age o
he pa ien s indi ec ly eflec s he du a ion o as hma, and
he e o e, ou finding ha age is associa ed wi h low FEV
1
/FVC
is in keeping wi h he esul s o he s udies sugges ing ha longe
du a ion o as hma may be associa ed wi h i e e sible ai way
obs uc ion. On he o he hand, aging pe se causes changes in
lung elas ic ecoil and pulmona y mechanics ha causes FEV
1
/FVC
o dec ease; hence, olde subjec s may be mo e p one o ulfil he
diagnos ic c i e ia o ACOS ega dless o he du a ion o hei
as hma.
19
Implica ions o u u e esea ch, policy and p ac ice
In he cu en s udy, he bes p edic o s o ACOS we e smoking o
⩾20 pack-yea s and age ⩾60 yea s. I bo h o hese c i e ia we e
me , hen ACOS was ound in almos hal o he pa ien s.
Lee e al.
18
ound ha longe du a ion o as hma and g ea e
amoun o ciga e e smoking we e associa ed wi h fixed ai way
obs uc ion, ha is, ACOS, in pa ien s wi h se e e as hma. In
e e yday li e, his could mean ha in he case o an elde ly
as hma ic wi h a clea ly posi i e smoking his o y, whose as hma is
di ficul o ea , a en ion should be gi en no jus o he known
as hma, bu also one should ake he COPD componen o
possible ACOS in o accoun as well.
Table 3. As hma–COPD o e lap synd ome in associa ion o
demog aphic cha ac e is ics in 190 as hma pa ien s wi h posi i e
smoking his o y. Resul s a e gi en by uni a iable bina y logis ic
eg ession analyses
O e lap
synd ome
Unadjus ed P alue
N
a
(%) OR 95% CI
Sex
Female 31/112 (27.7) 1.00
Male 21/78 (26.9) 0.96 0.50–1.84 0.91
Smoking
Ex-smoke 23/105 (21.9) 1.00
Cu en smoke 28/83 (33.7) 1.82 0.95–3.47 0.07
BMI, kg/m
2
o25.0 18/56 (32.1) 1.00
25.0–29.9 21/72 (29.2) 0.87 0.41–1.85 0.72
⩾30.0 12/60 (20.0) 0.53 0.23–1.23 0.14
Age, yea s
20–59 19/101 (18.8) 1.00
60–70 33/89 (37.1) 2.54 1.32–4.91 0.005
Pack-yea s
10–19 10/69 (14.5) 1.00
20–60 42/121 (34.7) 3.14 1.46–6.76 0.004
Age and pack-yea s
Age o60 and
pack-yea s o20
5/43 (11.6) 1.00
Age ⩾60 o pack-yea s
⩾20
19/84 (22.6) 2.22 0.77–6.43 0.14
Age ⩾60 and pack-
yea s ⩾20
28/63 (44.4) 6.08 2.11–17.49 0.001
Abb e ia ions: CI, confidence in e al; COPD, ch onic obs uc i e pulmon-
a y disease; OR, odds a io.
a
Numbe o pa ien s wi h o e lap synd ome/numbe o all pa ien s in
he g oup.
P e alence o as hma–COPD o e lap synd ome
T Kiljande e al
4
npj P ima y Ca e Respi a o y Medicine (2015) 15047 © 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed
Conclusions
The e is a high p e alence o ACOS among as hma ics wi h a
posi i e smoking his o y bu no p e ious diagnosis o COPD. Age
o e 60 yea s and smoking o mo e han 20 pack-yea s we e he
bes p edic o s o ACOS in his popula ion.
ACKNOWLEDGEMENTS
Tuija Poussa is acknowledged o he help wi h he s a is ical analyses.
CONTRIBUTIONS
All he au ho s we e in ol ed in planning o he s udy and w i ing he manusc ip . TK
was esponsible o w i ing he manusc ip .
COMPETING INTERESTS
TK ecei ed pe sonal ees om Boeh inge Ingelheim Finland, GSK, No a is and
Mundipha ma. TH ecei ed pe sonal ees om Boeh inge Ingelheim Finland and
Takeda. KV ecei ed pe sonal ees om Boeh inge Ingelheim Finland, Chiesi, GSK,
No a is, Takeda, Te a, Mundipha ma and Almi all. AJ is an employee o Boeh inge
Ingelheim Finland. LL ecei ed pe sonal ees om Almi all, As a-Zeneca, Boeh inge
Ingelheim Finland, Chiesi, GSK, No a is, O ion Pha ma, Takeda and Mundipha ma.
FUNDING
The s udy was unded by Boeh inge -Ingelheim, Finland.
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P e alence o as hma–COPD o e lap synd ome
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