Practical Guide to the Identification and Diagnosis of Asthma-COPD Overlap (ACO)

Figures & data

Table 1. The different criteria proposed for the diagnosis of ACO in different consensus and guidelines.

Consensus	Diagnostic criteria of ACO
Finnish guidelines (13)	ACO is confirmed by presenting two main criteria or one main criteria and two additional criteria: Main criteria: Very positive BDT FEV1 >15 % and >400 ml Sputum eosinophilia or elevated FENO (>50 ppb) Previous asthma symptoms (starting age at < 40 y) Additional criteria Elevated total IgE Atopy Repeated significant positive BDT (FEV1 >12 % and >200 ml) Peak expiratory flow follow-up typical of asthma
Czech guidelines (14)	ACO is confirmed by the presence of two major criteria or one major plus two minor criteria: Definitive diagnosis of COPD Major criteria: Very positive BDT FEV1 >15% and >400 mL FENO ≥45–50 ppb and/or sputum eosinophils ≥3% history of asthma Minor criteria: Positive BDT (FEV1 >12% and >200 mL) elevated total IgE, history of atopy
Sin et al. (16)	ACO is confirmed by the presence of three major and at least one minor criteria Major criteria Post BDT FEV1/FVC <0.70 in individuals>40 years of age At least 10 pack-years of tobacco smoking Documented history of asthma before 40 years of age. BDT of >400 mL in FEV1 Minor criteria Documented history of atopy or allergic rhinitis BDR of FEV1 ≥200 mL and 12% from baseline values on 2 or more visits Peripheral blood eosinophil count of ≥300 cells/uL
GesEPOC-GEMA algorithm (17)	Age ≥35 years old Tobacco exposure ≥10 pack-years Post BDT FEV1/FVC < 0.70 Diagnosis of asthma In absence of asthma diagnosis: very positive BDT(≥400 mL and 15% ) and/or blood eosinophilia ≥300 cells/µL

BDT: bronchodilator test; FENO: fractioned exhaled nitric oxide; ppb: parts per billion; FEV₁: forced expiratory volume in the first second; FVC: forced vital capacity.

Table 2. Different diagnostic criteria of ACO used in clinical observational studies.

Study	Diagnostic criteria of ACO	N (total)	ACO N (%)
Hardin et al.(7) COPDGene	Age: 45–80 years old Smoking history ≥10 pack-years Post BDT FEV1/FVC <0.70 History of asthma (defined as diagnosis reported by a physician before 40 years of age)	915	119 (13%)
Miravitlles et al. (8) EPI-SCAN	Age: 40–80 years old Post BDT FEV1/FVC <0.70 Previous diagnosis of asthma	385	67 (17.4%)
Menezes et al. (9) PLATINO	COPD diagnosis (post BDT FEV1/FVC <0.70) Concomitant diagnosis of asthma: wheezing in the last 12 months + post BDT increase in FEV1 or FVC of 200 ml and 12% or previous diagnosis of asthma	767	89 (11.6%)
Barrecheguren et al. (23) FyCEPOC	Age ≥40 years old Smoking history ≥10 pack-years Post BDT FEV1/FVC<0.70 ACOS 1: ACOS diagnostic criteria of the Spanish consensus 2012 (12): 1) Major criteria: very positive bronchodilator test (improvement in FEV1 400 mL and 15%); sputum eosinophilia or a previous diagnosis of asthma before the age of 40 years. 2) Minor criteria: increased total serum immunoglobulin (Ig)E; and previous history of atopy or a positive bronchodilator test (200 mL and 12% in FEV1) on at least two occasions. ACOS 2: Previous diagnosis of asthma before the age of 40 years	3125	158 (5.1%) 338 (10.8%)
Wurst et al. (24) ECLIPSE	COPD diagnosis (FEV1/FVC <0.70) Self-reported previous diagnosis of asthma	1483	493 (25%)
Pérez de Llano et al. (40) CHACOS	GESEPOC- GEMA algorithm (17): Age ≥35 years old Tobacco exposure ≥10 pack-years Post BDT FEV1/FVC <0.70 History of asthma and/or other features of asthma (atopy and/or respiratory symptoms: wheezing, cough, chest oppression) In absence of asthma diagnosis: very positive BDT (≥400 mL and 15%) and/or Blood eosinophilia ≥300 eosinophils/µL	292	87 (29.8%)

BDT: bronchodilator test; FEV₁: forced expiratory volume in the first second; FVC: forced vital capacity.

Figure 1. Nonproportional Venn diagram showing the interrelationship of ACO criteria in a population of 292 patients with chronic obstructive airways disease. Asthma means “current diagnosis” of the disease; ++ means “very positive” bronchodilator test. Reproduced with permission from Sociedad Española de Neumología y Cirugía Torácica (SEPAR) from Pérez de Llano et al. (40)

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