Webinar recorded on Tuesday, May 31, 2022

There are similarities and differences between asthma and COPD.  What are the connections?  What are the best treatment options?  Join us for a discussion with Dr. Vickram Tejwani on this important topic.


  • Dr. Vickram Tejwani


Transcript: This transcript is automatically generated. While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.


Today we’re going to answer a question that has been on the minds of many. Are asthma and COPD two separate diseases, or spectrum of a single health concern? My name is Sally Schoessler and I’m director of Education for Allergy & Asthma Network.. We’d like to welcome all of our listeners today, including the networks asthma and COPD Community expert volunteers. We’re really glad you chose to spend some time with us today. On the next slide, you can see the mission of Allergy & Asthma Network. We’re a grassroots organization that began over 35 years ago by a mom who knew that other mothers needed resources and support just like she did.


Our mission has been the same for 35 years, and that is to end the needless death and suffering due to allergies, asthma and related conditions through outreach, education, advocacy and research. Today, it is my pleasure to introduce our speaker, Dr. Viickram Tejwani. Dr. Tejwani is a physician in the asthma and COPD centers at Cleveland Clinic, where he joined after completion of a pulmonary and Critical Care Fellowship at Johns Hopkins University. Doctor Tejwani is an active scientific investigator in both asthma and COPD and an assistant professor at the Cleveland Clinic Lerner Center College of Medicine. He is passionate about patient education and ranslating nuanced evidence and data into actionable recommendations, he has enjoyed partnering with Allergy & Asthma Network on numerous patient centered and academic endeavors. Doctor Tejwani, thank you so much for being with us today and for sharing your unique perspective to this important question.

Thank you, Sally. Thank you for the kind introduction and kind invitation and to you and the Allergy & Asthma Network for organizing this. I was grateful to be invited and also really enthused when we were discussing the topic as i think this is something certainly very dear to my heart both in terms of research and clinical practice and I think very relevant given the morbidity and prevalence just very high prevalence of both these diseases and so thanks again to you and all the attendees.


So as Sally mentioned, I’m really hoping today to kind of outline Asthma and COPD, the overlap and what that all translates into in terms of how to care for patients that may share features of both diseases. I always like to start approaching this with a little bit of just a brief historical perspective and kind of an understanding about how we’ve arrived where we are now in 2022 and then make the case that there is relevance to the individuals that have features of both from a clinical and mechanism perspective and then just a little bit about. After we go over the data and a little bit of detail just what that all means and what we can all kind of expect moving forward. So just to start this back actually in 1961 which is fascinating that there was a group of physicians from the Netherlands as the name suggests that we’re realizing in a number of their patients that they had childhood allergies, had childhood asthma, maybe had some second hand smoke exposure, maybe not that much smoking.


And then they would go on to develop COPD while maintaining some of those allergic traits that they had as a  child or in their adolescence. So they didn’t describe it as this at the time, but they essentially described it as a chronic nonspecific lung disease. But this was really kind of the 1st at least known or recent description of the fact that these diseases might share some, have some overlap and be caused by multiple shared causes in terms of pollution, smoke exposure, allergies that lead to the same disease traits and then I think. On the right, I just want to share that this has been mirrored, this kind of discovery and more recently in particular by a really active scientific interest in this among the scientific community.


So this is a result just of publications per year by PUBMed and this gets us two up about 200 per year in 2018 So I think more so than the actual number. I think what is remarkable as you’re seeing not a lot of interest in or I shouldn’t say a lot of interest but not a lot of awareness for publication around this topic and then really. Over the last 10 to 15 years, a really exponential rise in investigators, clinicians trying to understand what this means and what the implications are.


So in terms of interpreting the implications, one of the major challenges with this area actually is just agreeing, reaching consensus about what we’re all talking about. So this table is very busy and not necessarily intended to be reviewed in the context of this talk. It’s taken from this article by Leong and Donson published in Chester this year, if you would like to look at in more detail. But really what I want to highlight here is you’re looking at multiple. Society guidelines? Check Finish the dancing group is from Canada. And really. Unlike COPD which has fixed obstruction or asthma, which has some kind of agreed upon consensus in terms of what it is.


There’s really not agreement actually about what Asthma-COPD overlap is. So there is, as you might imagine, some traits of both meaning fixed obstruction for with COPD, some bronchodilator reversibility, some elevated Eosinophils, some elevated IG E varying cut offs for smoking history. But I think just what I really want to convey with this is that even among groups within the country and then this is talking about it. Cost different nations. There really is not consensus on what this disease is and as I alluded to this actually holds true.


These are all American organizations like GINA (global initiative for asthma) well I should say not American but American centric and the global initiative for obstructive lung disease. And in 2015 there was kind of a push that this is a distinct entity. So they published an update on what at the time was known as asthma COPD Overlap syndrome and. Highlighting the syndrome intentionally because the idea there was that this is its own disease.


So just like you have Bronchiectasis, you have asthma, you have COPD and then you have asthma, COPD overlap syndrome and it’s almost a third entity. But then due to like continued data around it and again some of those challenges we talked about with consensus issues, essentially they in 2017 updated it to just as most COPD overlap and that’s really what has held true, which is just a. And it doesn’t, it’s not really implied to be a distinct entity, it’s just a way of characterizing an individual that has both features of asthma and COPD and this again Harkins back to the last slide where that’s a little vague and a little bit up to an individual to determine.


So, which is, I think, very reasonable for seeing an individual patient that’s in front of you, but it does make defining the, how prevalent the disease is, the impact of the disease and importantly once we get to specific treatments a little bit more challenging. So what those traits are things that I think we all might imagine they would be if we were asked this question. So intermittent episodic symptoms. So again that is not typical for COPD. Some of these are a little focused with COPD but have traits of asthma because COPD you can actually make the diagnosis with breathing tests whereas with asthma somebody if you don’t catch them during a flare may not have any breathing test abnormalities.


So if you’re going to excuse me, an individual with COPD based on breathing tests and then they have. Intermittent or episodic symptoms. It started at a young age. Those are things that might make you think about asthma. And the other one and as you might recognize this figure is kind of the complete figure which I used to describe the Dutch hypothesis and what it was. What’s interesting about this is in 1961 just based on the technology and data that was available at that time, they were just kind of simply making clinical observations that they saw these individuals with this overlap and now we know with time the upstream cause of that is that there are a lot of shared factors between the two as far as things that both cause disease and then worsened disease if present. So this is where things are right now in terms of the definition of the disease. It’s, I think, the most practical way to think about it is somebody with COPD on breathing tests, but that has some features of asthma or shared risk factors for both diseases. The other possibility is that you have somebody with asthma that doesn’t quite get to a normal lung function state when they receive albuterol or bronchodilator reversibility testing. And again, I think a theme here is that given this varying definition both across different populations and then even evolving overtime, we really don’t have a great, a very concrete measure of how much or how present this disease is. So depending on the definition used, the ranges of the general population range from 1 to 11 %, which is a very wide range. We’re talking about one in 100 versus one in 10. And then the same thing for asthma and COPD. So in individuals that have asthma it could be from one in ten to six in ten and then in patients with COPD from 4 and 100 to 6 in 10.


And so this I think a lot of this and this will be a recurrent theme certainly we talk about future directions is just. Reaching agreement on what exactly we’re all talking about to allow to allow us to study this in a more systematic fashion. But even with these varied definitions, there have been some consistent themes throughout and that I think you know, it certainly exemplifies a very real relevance to identifying the presence of these traits given both clinical and treatable features of the overlap.


So one thing that’s different are three things that are different. One is that the demographics of people with overlap disease compared to COPD, or just asthma, a little bit different. Particularly when you compare them to COPD, the individuals tend to be younger. They’re more likely to be women. And then they’re more likely to have a higher BMI. So that those are things that just might, if that is present, might clue you in on starting to think about that.


The other thing that there are two things which are both really unfortunate and very important to recognize from a treating perspective is that there are a number of comorbidities that track along with both COPD and asthma. And what we see is that individuals with overlap actually have higher amounts of both of them. And I suppose intuitively this does make some sense. Because they’re not necessarily just having one disease. Technically they have two diseases depending on how you look at it or a spectrum of 1, which I suppose is the question we’re aiming to answer here with this talk.


But one thing that to take away is that they have really the comorbidities of both of both asthma and COPD, such as asthma, such as the comorbid comorbid ATP, some of the psycho psychological and psychiatric illness that comes along with asthma, and then a lot of the. Comorbid COPD issues as well with coronary vascular disease and infections and in keeping with this and keeping with the concept that they have two diseases or a worse form of at least a single disease. There’s much more symptoms both in quality of life questionnaires and symptom burning questionnaires and much more exacerbations, flares and ultimately much more healthcare utilization, be it an urgent care or emergency department or even hospitalization.


There’s conflicting data on the mortality rate and again, I think that Harkins back to the. To the definition issues, but certainly more severe disease. This is a little bit of an oversimplification, but I think. And brief, there does seem to be a little bit just like there’s a spectrum of symptoms, a spectrum of disease severity. There does seem to be a spectrum of immune underlying immune pathophysiology. Although this again is a very simplified version of a topic that’s not clearly not quite as linear as this graph would or this image would depict.


But generally speaking, if you have a person with COPD and they maybe have a high SNFL count or if you’re measuring that kind for some other reason and they happen to have high TH2 which would be like interleukin 4, interleukin 5 cytokines. You might start thinking about a quote unquote asthma trait and. Asthma, and allergic asthma at least, is generally more T2 or eosinophilic. I think this one again is a little bit of an oversimplification because there is just purely neutrophilic asthma. But if you have an individual that you’re seeing with asthma and they don’t have any eosinophilic at all, you might at least start thinking about some concomitant COPD.


And so I think what ultimately the purpose of all of this is to lead to is there something unique or distinct that we can provide for these individuals? And I think the simplest way to think about it in most practical way to think about it is if they’re. COPD, or if they’re asthma predominant, asthma only, you’re really using inhaled steroids. There is some role for bronchodilators, but inhaled steroids are really the mainstay for asthma treatment. But if there are asthma with a flavor of COPD, you might be a little bit more aggressive with your long acting muscarinic and beta agonist your bronchodilators, and that basically is inverted for COPD, which is that for COPD, really the mainstay of treatment is bronchodilators like Spiriva or tiotropium.


And so matter all and inhaled steroids are used for some patients and I think the patients that they should definitely be used for and the guidelines support this is patients that have COPD with flavors of asthma. So you can kind of think about this just in line as we did with the last graph, so as on the left, superior on the right.


So if they’re predominantly asthma, you’re really focused more on inhaled steroids. If they’re really just COPD, you’re focused much on the bronchodilators. But for the individuals in between, they really should be on both to cover both aspects of the disease. And I think the really the hope with this unfortunately hasn’t borne out yet, but asthma? Has really experienced a burst of new therapies in the past few years in the form of biologic therapies that are targeting eosinophils and that arm of our immune system. So not surprisingly there was the idea to see can this can this work in COPD as well.


So the first of these studies was mepolizumab, and they looked at exacerbations in individualist COPD. This Eosinophilic phenotype was a eosinophil cut off of one fifty. And you could see that there technically was a difference. So the P value on this for those that are interested was 04 But in the overall population there was not and important to note is they actually excluded people with a documented history of asthma. But that was actually the only exclusion criteria. Meaning if let’s say you had childhood asthma but it wasn’t treated, therefore you never knew you had it and so when you were and then developed COPD.


As an adult, you would have made it into this study because there wasn’t any asthma specific testing. It was simply do you have asthma right now? Do you have a history of asthma? And if the answer to both those questions were no, you were eligible for this study. And in the same study they looked at, they actually did two trials together and this was another arm of that same study and they cut off here for those that are interested as a P of 1-4 which technically is not significant. So on the basis of this, they did submit for FDA approval for this medication, but I’ve basically given there was one arm that was positive, one arm that was kind of border basically negative and then the possibility that there were also individuals with undiagnosed.


Asthma in this study, this was not approved for specifically eosinophilic COPD, but I do think it might have a role which will come back to a little bit later in asthma COPD overlap. The other biologic which is again been fantastic for individuals with pure asthma is benralizumab. And on this top row, we’re looking at, again it’s similar to the last one with two trials and we’re looking at how good it was at reducing moderate or severe exacerbations. And you’re seeing here that I kind of did. I won’t delve too deeply into the statistical interpretation of these, but i’ll just say that general interpretation is that maybe it does, maybe it doesn’t, but there’s certainly not a clear signal that it does.


And the SNFL. Inclusion criteria for people in this study was two twenty and the actual eosinophil count for those enrolled in this study was four or 500 So these are patients with very high using uphill counts and very similar to the last study they did exclude people that were endorsed a positive history of asthma. Again, just by history, there was no specific testing conducted. So i think what to take away is at least neither of them have been approved and the way that I’ve approached them and we’ll talk about it later. But if you have an individual with COPD that has some of these traits that has asthma or eosinophil count and particularly if you’re running out of options which can sometimes be the case with very severe COPD.


You should be able to qualify an individual for this medication based on the asthma history as opposed to the COPD. So that brings us to our last section, which is. What do we do with all this? So we have kind of some muddy definitions, some clear signals and how do we translate that all into the way that we care for our patients. So I think the first thing is really just to recognize it. So once you recognize that there’s the overlap syndrome based on some of those overlap traits, you now know you’re treating a patient that is going to have.


Higher risk for comorbidities that are going to have a higher symptom burden, higher emergency department visitation, higher need for Prednisone, higher need for flares or higher occurrence of flares of their disease. So I think the first step is just recognizing the presence of overlap and then recognizing that there is an associated increased risk. The next is what to treat them with. And I think the fundamental part of that is the inhalers. And generally speaking when you’re ultimately at the overlap syndrome you really using, you are using all three of our major inhalers inhaled corticosteroids, LABA and LAMA.


And that’s because as we discussed the LABA and LAMA component is really critical for the COPD side of the disease. And the asthma is or the ICS is very critical for the asthma side of the disease and in fact even in the justice COPD guidelines excluding any overlap syndrome. If a patient with COPD has an S NFL count of over 300 in ICS is strongly essentially recommended to be prescribed. And then at least right now there is no FDA approved biologic for purely eosinophilic COPD. But if they have COPD with other traits of overlap syndrome, this would include bronchodilator reversibility.


Episodic symptoms. So it just a minor anecdote as I saw a patient two weeks ago, very severe COPD is FEV1 was in the 20-25% range and however, so we always had this these baseline symptoms, but every time you went to pulmonary rehab, the cleaning chemicals there would just completely set them off to the point where he was actually avoiding pulmonary rehab just because he couldn’t tolerate the cleaning chemicals there.


And he also had a 27 % bronchodilator reversibility. So that’s someone that he very clearly has COPD, but also has the superimposed component of asthma. And we went ahead and I went ahead and started on a biologic agent and you’ll be able to get that through coverage, not because you’re treating eosinophilic COPD, but because you’re treating. Really the asthma arm of his symptoms. So where is this all  going forward? I think the 1st. Step is the most fundamental, which is defining what we’re talking about and sharing the same language. So i think the short answer to the question in the title, which is this 2 diseases or spectrum of one is maybe to disappoint someone the audiences we don’t know is the short answer i think there are.


Patients that definitely have a spectrum of one there are certainly patients that kind of have a flavor of both of them and they’re which is arguably what the AC O term is trying to capture is that there are these individuals and it’s a little bit of once you start measuring you know IgE eosinophilic count bronchodilator reversibility and everybody then you start to get it. And that is why as a as a practice even in my COPD patients will measure bronchodilator reversibility just to see if there is that superimposed.


Plasma component, but I think just defining what we’re all talking about as a first step is most critical so we can appropriately treat and study this moving forward. And then I think really the future of airway disease and hopefully medicine more globally is a little bit more of a precision medicine therapy. And I think that really applies to asthma and COPD is that for many years, many decades, I think we’ve taken heterogeneous diseases and lump them into a. Very singular title and I think this is just another example of that. And I think the hope is that if given, there’s clearly, clinically seems to be something different about these individuals with overlap disease, the ideas that would translate into different mechanisms of disease and ultimately different or unique therapies of disease.


So with that again I’d like to thank you all for attending and I’d be glad to take any questions. Thank you so much. Doctor Tejwani, we do have questions.We want one patient that’s tuned in says I have the overlap of asthma and COPD had asthma my whole life, COPD the last five and I can tell the difference between the exacerbations, but is it possible to tell the difference between the exacerbations? Yeah, that’s a great question. I think if you feel like there is a difference there then you probably are and i think particularly with asthma just because the objective testing is not always perfect because you’re catching people in between flares.


I do find, and I’ll just harken back to the example that I share is that the shortness of breath and flares that he was talking about versus those on exertion which is kind of the COPD versus these really clear. Episodic flares with the trigger were very distinct, so I think. Certainly the symptoms can be recognized as different and I would say that the exacerbations as well can be recognized as different. Not always, but i think if you’re having wheezing chest tightness, you’re not increasing your sputum production or your sputum is not changing and consistency, all of that would favor asthma predominantly.


Whereas if you’re coughing up more, your symptom is looking a little different than it does, that might favor a COPD flair. And the importance there is that if it’s just a true asthma flare, you’re really only needing to use Prednisone, whereas if it’s a COPD and asthma flare or excuse me, a COPD flare, predominantly you’re using Prednisone and an antibiotic such as zithromax or doxycycline. Ok. Well, thank you so much.


We have another question from a patient and they’re questioning, is there a difference between adults and children with asthma symptoms? Yeah, that’s a good question. I should carry out this by predominantly will not probably only treat clinically adult patients. I’ve done research in pediatric populations but clinically only see adult children from speaking to my pediatric colleagues. I believe the answer is yes. I would hesitate to comment on that further just because I don’t,, I’m not as familiar with the pediatric presentation side of it.


Ok, thank you. Is weight gain or obesity a side effect of the medications used for asthma? So waking obesity is unfortunate can play a kind of cyclical role in both diseases, which is that it worsens the disease and then as the disease gets worse, you may need more Prednisone. And Prednisone can lead to weight gain and obesity the inhaled steroids. As long as they’re taken appropriately, 99 9 % of it stays in the lung. So the amount that gets into the bloodstream and then causes weight could cause weight gain is very limited.


So I think if there’s a concern around that, my first, you know, curiosity would be how much Prednisone have you received and i think if the answer is you’ve been receiving a lot of Prednisone, the next question becomes how can we avoid receiving all that Prednisone because certainly that is associated with weight gain. Thank you. Next question is can kids have COPD kids, a true child that meaning a pediatric, a child under 18 should not have COPD. So COPD can develop very early in life predominantly when there’s a genetic cause which is alpha one antitrypsin deficiency but even individuals with alpha one antitrypsin deficiency, even if they smoke and I mean not just a little bit of hyperbole, they smoke, they work in a coal mine, they.


Step out of the coal mine and walk into polluted air. Whatever exposure you can think of, it really still should not happen before they’re thirties. So in kind of the most accelerated form of COPD, which is genetic, multiple risk factors, you’re still looking at your thirties and even forties in that case. So no COP is fortunately not a disease of childhood. Ok. Next question is how do you know when to observe at home, schedule an appointment or go to urgent care or the emergency room for asthma or COPD? Yeah, that’s a great question and it’s a challenging one I think really.


So first if you’re certain I would encourage you to speak to your healthcare provider and come up with an asthma or COPD action plan which kind of goes over some of those. There’s like a particular on the asthma side of red, yellow, green nomenclature. But I think if you if one, if it’s helpful to have a pulse ox at home or a pulse oximeter particularly for COPD because if your oxygen is low, then that’s a clear indication to seek care sooner than maybe waiting for your provider or physician to call back or whatever it may be. The other one with asthma is if you’re wheezing, that’s.a relatively good thing. But really when the Airways get really tight, air stops moving all together. So if you find yourself wheezing and then the wheezing stops, but you’re still feeling bad, that is a medical emergency as well, because it might mean that your Airways have gotten so tight that no air is moving at all. Beyond that, it’s just a little bit Gray a part of so I would say if you’re, despite using your rescue inhalers – like nebulizers and albuterol rescue inhalers, you’re not getting any relief,  that would be a reason to go to an emergency department because that means even if you’re using it every two three hours until you can get some Prednisone you’re not going to, it’s not going to make it.


So I think low oxygen, wheezing not going away altogether. And then if you’re rescue, inhalers are not giving you any relief at all. Well, thank you so much for that. Your next question I’ll answer, it’s is the handout printable and what we do is we do provide you with a PDF version of the slides that you saw today. So within 48 hours the webinar will be posted on our website and in the same area you’ll find the PDF for the slides.


So you will be able to review those again. Ok, when assessing someone with asthma COPD overlap, would we assess them using the asthma control test or the COPD assessment test? Which would be appropriate to use? Asked a question so I do one of three things and so I should start saying there’s no clear answer. I’m just sharing my practice pattern which is if there’s a clear predominant one then I’ll use that one. I have many patients now in my practice where I just use both to document both and it kind of goes back to that exacerbation and symptom question.


It might be that you know there the pollen season is low they’re not, they’re avoiding cleaning chemicals. You know they’re changing their filter and therefore their ACT scores. Nearly 25 but they’re still not getting relief of the shortness of breath on exertion. Still can’t move around so this the cat score is very high so if it’s a true overlap I will and I’ve been doing this quite frequently as I’ll just use both because that you’re really. They’re asking different questions. That’s a great question. I and I think that I don’t know that the answer is a specific questionnaire for overlap, but I do think it does just underpin that once we have consensus on this we can decide how we you know should there be a separate question? I don’t think so.


But that’s at least something, a conversation to have. Thank you. So our next question says I have patients that refuse inhaled steroids because of osteoporosis. Is that a huge concern? Yeah, it goes back to the weight gain question. So I would feel comfortable advising that patient that as long as they’re using it once a day, you know essentially what if it’s something like a twice a day inhaler, once a day inhaler depending on the formulation that the risk of osteoporosis from that is very low and this has been studied and.


It’s not to say that there is no systemic absorption, but as long as they’re not using it more than prescribed it should not be a significant amount. I will say that Gina guidelines have been updated so that people can now take an ICS as needed as a part of their therapy. So I might stay away a little bit from that if they have osteoporosis and just stick to a scheduled ICS then with an as needed short acting inhaler because I if they get up to the point where they’re taking the ICS many times. Ok. Then you do run the risk of a little bit more systemic absorption? Well, I’ll just share a personal story here.


I have asthma and my mother has COPD and I one time I was saying to her, well I’m not really excited about taking too many oral corticosteroids because of all the long term side effects. So one time when her doctor said that he wanted to put her on oral corticosteroids, she said, oh, I don’t think I should take them. And I said Mom, with all the love in my heart, you’re 95 years old, I’m really not so sure you have to worry about long term side effects. But so I think sometimes people really have to weigh the value of what the medication will do for them versus the risk of side effects, would you agree with that? I think that’s a great point.


And I think also that and even if you’re in a flare like you said, if the Prednisone the usual 40 milligrams for five days, whether it’s for COPD or asthma, the. Long term complications of that whether it’s osteoporosis, weight gain, fluid retention, kind of the you know the thing that certainly many of my patients worry about like the Buffalo hump and other fluid and weight changes are really inconsequential. It’s when you get into either multiple courses a year or the disease is so bad that you’re on chronic Prednisone therapy. So I think that’s exactly right tell you that if you can’t breathe and I mean all those things exist, it’s not to minimize that.


And in that situation, the five day course of Prednisone to give you that relief is worth it. It’s just when it becomes a habit, there’s some other issues. Thank you so much. Can hormones and pregnancy or postpartum exacerbate asthma or precipitate the development of COPD? Another really great question. So it should not precipitate the development of COPD. Pregnancy and asthma is also a thing. So we’re starting to look at that more locally. I there’s it definitely seems to be a different disease, it’s one a different disease. Just back to the comment about splitting and you know heterogeneous disease. Asthma seems to be a different disease in men and women to begin with which hasn’t historically, trials have just included both men and women without kind of separating or looking at effects on either one separately.


So and then certainly pregnancy itself with the hormone surge, we see a lot of really bad exacerbations and flares in pregnancy. So and I’m less familiar with the postpartum period, I believe the answer to that is yes also for an asthma flare. So I do think it’s a high risk kind of asthma, period. In terms of flares. But it should not precipitate COPD at all. But it does cause asthma flares. Ok. Oh, we’ve got so many questions for you. Thank you so much for your patience with all these great answers, wonderful questions. So thank you.


We have a pulse ox at home and at my parents house. What are the normal numbers for adults and for kids? Yes, I can. I have to unfortunately take a disclaimer on the pediatric population. I apologize, but for adults the normal number with normal lung, normal lung function is generally speaking over 94 %, although you’re safe in the nineties with asthma that holds the same. So asthma if you have asthma your oxygen should be just as normal as anyone else.


In fact if you have asthma and your oxygen is low that is kind of  a 9-1-1 urgent care emergency department type situation. COPD is a little different. So with COPD, there’s permanent lung damage. Unlike asthma where there’s just this spasm COPD, there’s emphysema, natural lung destruction. So it’s. Quote unquote normal to have low oxygen in COPD. Historically we targeted 88 % for individuals with COPD.


I tend to just tell my patients 90 because it’s easier to remember, but the actual number is 88 %. The big change in oxygen for COPD was a study called the lot study a few years ago or actually yeah, now about five to six years ago where it showed that if you move around and you just drop to 85 % for example like. Below the 88 % threshold and you feel OK, it doesn’t really matter.


But if you drop below 88 % and you feel bad or you drop below 80 %. Then you, then it’s a serious situation for COPD. Thank you so much. And always you know, if you’re a patient at home and you’re worried about things, don’t hesitate to call your doctor’s office and ask them what your specific parameters would be to determine when you should consider it an emergency.


Because so many times if Dr. Tejwani can answer our questions but he doesn’t know anybody specific medical records and nor should he comment on that. So don’t hesitate to give your own doctor’s office a call too. Ok. Our next question is post viral infections have inflammation in the large Airways with a classic catch cough with laugh and deep breaths. I have found Flovent very helpful but they are now not available generically and are often not covered for this. Any thoughts? So it’s an unfortunate challenge of all this is switching I myself and my nursing staff more than you know, probably more than 50 % of their time is spent switching inhalers and for me 5 to 10 % just for coverage issues.


So I think the thought for coverage would be it sounds like and as Sally said, I’ll just reiterate, I certainly would encourage you to discuss this with your own healthcare provider that knows your entire personal situation much better than me. But would be that it sounds like you’ve developed a post viral asthma, which is a very common occurrence that cough and everything that’s being described sounds like a post viral asthma.


And within the context of that diagnosis, some form of an inhaled steroid, whether it’s Flovent, Beclovent, Mometasone, whatever you know the formulation is, should be able to be covered. Ok oh, here’s another great question. What does a COPD action plan look like? Is it similar to an asthma action plan? That doesn’t we don’t generally use the same red, yellow, green color, not that there’s anything wrong with that but it kind of goes over what we talked about with the oxygen.


What we talked about was sputum when to call in it addresses that question that was brought up earlier about when to just call and get Prednisone and antibiotics, when to go to an urgent care etcetera and depending on the patient and this is something I would encourage you to discuss with your provider healthcare provider as far as what’s right for you but. I have some patients where they really understand their disease. I mean probably like people on the call because if you’re here you have a interest in understanding this you’re, what’s going on and learning about it. So I will usually just give them Prednisone and if it’s COPD and antibiotic kind of readily available and we’ll discuss what symptoms to have that would then cause them to fill it.


And that way we’re avoiding the delay that might happen to be very transparent. There are other patients that may not appreciate some of the OR understandably they don’t feel good. So don’t mind just want to take Prednisone right away and then they end up, you know, potentially taking a lot of Prednisone. So it really depends on the individual but I think there’s certainly a role to just have a standing prescription or even potentially Prednisone at the house in case you start to experience a flare and then the action plan would go over some other symptoms.


But like we talked about with low oxygen and other changes that would prompt you to Lightheadedness for example, that would prompt you to go to an urgent care in emergency department. Thank you. Our next question is are there benefits to doing nebulization versus inhaler use for albuterol treatment? Yeah, another great question. So scientifically there is not, but medically and clinically there’s there I am very convinced and many of my patients are very convinced, there is I my. Thought is my end, this is speculation, but that when you do the nebulizer you’re really forced to sit and take very deep controlled breaths. And I think a part of that, just it’s both the medication and then the process of actually just sitting, taking these deep breaths particularly in an otherwise stressful situation that results in the increased benefit.


So I would basically say if you find that the nebulizer is helping you more to do that. But as when I’m talking and I just, I actually counsel my patients on the exact same thing. I say they’re the same medication. Some people find the nebulizer better. I do think when things get more severe because particularly with asthma, there is a component of anxiety that naturally starts to come in when one can’t breathe, which is very human response to not being able to breathe that sitting and doing the nebulizer treatments and the kind of deep breathing maneuvers of the nebulizer treatment really provides a kind of added unintentional benefit.


Well, that’s a, that’s great to hear. Thank you so much. I’m going to take the next question. It says if someone can’t afford their asthma medications, what would you recommend? Well, Allergy and Asthma Network has been concerned for quite a while about when people can’t afford their medications. On our website under asthma, there is a link that will say what if you can’t afford your medications, you can go to that link and you can look up your medication and it gives you numbers and emails to the company to ask for assistance and many companies will have a patient assistance program. So don’t hesitate to do that. And then the other thing and certainly Doctor Tejwani, I’d like to have you weigh in as well, but I love good RX, the app and that will give you the price of different medications at different pharmacies in your area. Do you have anything else to add to that? Certainly commend you in AAN for everything that all the support.  I think that it’s so and there’s so much to talk about with these diseases. But at the end of the day if we just can’t get the kind of fundamental medications to our patients then everything else is kind of moot.


So I commend you all  for doing that and I do think fortunately many manufacturers have been helpful. It does take some hoops as far as forms and mailing and things like that. So i think that is great. And then yeah there’s I didn’t actually realize good RX provided such a nice comparison. I mean but I think if there’s a way to just find out which one would be the cheapest. And I’ll just say anecdotally, generally speaking the best we’ve we’re kind of getting to outside of when it’s covered by free from manufacturers about 40 to 50$ a month for an inhaler, which still isn’t ideal. It can I mean but that’s the other thing is that there is at the end of the day they tend to, they end up generally speaking not to be free which is unfortunate.


Well, and certainly we want people to have their medication and get it inside of them. And another thing too is if you, especially if you’re dealing with an elderly COPD patient, make sure that they get a good demonstration on how to use the medication. First we want the medication in their hands, but then we certainly want them to get it into their lungs and so often in the doctor’s office, things are going so fast they don’t think they, well, how do I use it? And the pharmacist is another really good source for having them help you understand exactly how to take something, because some of the inhalers are a little different than the others and that’s just a really valuable thing to consider.


I think we’re going to have time for just another question or maybe one or two. And this next question is if a patient has dysphasia, do you still consider overlap or just a bronchitis COPD exacerbation? The so I think if it’s dysphasia, meaning difficulty swallowing, that probably would be outside of the asthma PD realm. With dysphasia from at least a pulmonary perspective my main concern is that they could aspirate which can lead more so to Bronchiectasis if they aspirate recurrently. So generally speaking, my patients that have dysphagia, they’ll aspirate particularly in the right side of their lung just because of anatomy and then develop a Bronchiectasis.


They’re from recurrent aspiration. It’s usually not a I mean certainly a patient with asthma or COPD or overlap could have it, but it’s usually not a part of kind of the constellation of symptoms or disease. Thank you. And we’re going to end with not a question, but a comment from one of our listeners who says this has been very helpful, really helpful. So Dr. Tejwani, thank you so much for sharing everything with today with our listeners. And I know I’ve learned a few things that I hope everybody walks away feeling the same way.


So thank you very much. Thank you. And thank you and I appreciate all the wonderful questions and thank you all for the interest. And I’d also like to thank our asthma and COPD Community expert volunteers. Thank you for being with us today and for being a part of the great work of the network. So thank you again for joining us and please join us for our next webinar on moving allergy and asthma science forward. This is going to be a you’re going to have a chance to listen to doctor DeDe Gardner of Allergy and Asthma Network on Thursday, June 9th at 3 PM Eastern Time.


You can register for this and all of our. Webinars and allergyasthmanetwork.org scroll the way all the way down to the bottom of the home page to find our webinar recordings and links for registration. Thank you again for joining us. Hang on the line for two to three minutes, please, to complete the evaluation survey. This is Sally Schoessler for the staff at Allergy and Asthma Network as we worked understand the disease states of asthma and cOPD we’re all going to be able to breathe Better Together.