b'Differential Diagnosis Asthma vs. COPDAsthma COPDOnset Before age 20 After age 40Smoker or former smoker orSometimes Almost alwaysexposure to other irritantsSymptoms Variable by day, season, Persistent despite treatment,year-to-year worsen over timeChronic productive cough Uncommon CommonBreathlessness Variable Persistent and progressiveNighttime waking with Common Uncommonbreathlessness or wheezingFamily history of asthma Frequent Uncommonor allergiesSymptoms improve spontane-ously or respond quickly to bron- Yes Limited reliefchodilator treatment or inhaled corticosteroids Chest X-ray Normal Hyperinflation or other changesSources: American Academy of Family Physicians. COPD and Asthma: Differential Diagnosis. 1 April 2017; Ray E and Kelly C. The overlap between asthma and COPD:a case study. Independent Nurse. 16 Oct 2019;2019(10). Asforpharmacotherapies,inhal- use of a rescue inhaler is insufficient.Pressair for aclidinium and Ellipta for ers are the first step for patients withInhaled corticosteroids reduce inflam- umeclidinium.LABAs(indacaterol, asthma, COPD or ACOS.mationbybindingtoglucocorticoidarformoterol,formoterol,salmeterol Thealgorithmpresentedbythereceptors. Drugs in this class includeandolodaterol)areadministeredvia authorsrecommendsstartingpatientsbeclomethasone,budesonide,fluti- metered dose inhaler, nebulizer, or the withACOSonashort-actingbeta casoneandmometasone.TheymayDiscus, Ellipta or Respimat inhalers. 2 receptoragonistorashort-actingbe delivered by metered dose inhaler/ Treatmentcanbecustomizedfor muscarinic receptor antagonist. Thesehydrofluoroalkane inhaler, dry powdereachpatient,because[ACOS]isnot short-actingbronchodilatorsareusedinhaler or nebulizer. one disease, Albertson said.as rescue medications. ThosewithothertypesofACOSIf those drugs do not provide sufficient SABAsincludealbuterolandleval- may move to a long-acting muscarinicsymptom relief and control of exacerba-buterol,whichmaybeadministeredreceptororlong-actingbeta receptortions, combining an ICS with a LAMA 2 by metered dose inhaler or nebulizer.agonist.LABAsstimulatebronchodi- or LABA is the next step, followed by Ipratropiumisthemostcommonlation by acting on the betareceptors,tripletherapywithICS,LABAand 2SAMAandcomesinbothnebulizerwhile LAMAs address the cholinergicLAMA. Combinations of LAMA/LABA and inhaler forms. Some bronchodila- pathway.delivered in single inhalers include ume-tors combine a SABA and SAMA, alb- LAMAsincludeaclidinium,gly- clidinium/vilanterol,olodaterol/tiotro-uterol and ipratropium. copyrrolate,tiotropiumandumecli- pium,indacaterol/glycopyrrolate,and PatientswithACOSwithType2dinium. The drugs are delivered usingglycopyrrolate/formoterol. inflammatoryactivationthenproceedspecializedinhalers,theRespimatUsing the three types of medicationto inhaled corticosteroids, if occasionalfortiotropiumandglycopyrrolate,ICS,LABA,andLAMAtogether 2020 COMPENDIUM OF FEDERAL MEDICINE 9'