How can a 62-year-old man control his asthma–COPD?

Question

Hi doctor,

A 62-year-old man with a long-standing history of asthma–COPD overlap syndrome presents with worsening breathlessness over the past two weeks, especially at night and with mild activity. He reports frequent wheezing, chest tightness, and a persistent productive cough with thick sputum. His oxygen saturation has recently dropped to 89 percent on room air, and he has needed his rescue inhaler more than six times a day.

Recent spirometry shows an FEV₁ of 42 percent predicted with marked reversibility, and his eosinophil count is elevated at 560 cells/µL. He has also experienced two severe exacerbations in the last six months that required oral steroids. A chest X-ray shows hyperinflation and mild peribronchial thickening, while his CRP is elevated at 14 mg/L. He has a 20-pack-year smoking history but quit five years ago.

Despite using high-dose ICS/LABA, LAMA, and Montelukast, his symptoms remain uncontrolled. He is concerned about increasing fatigue, disturbed sleep, and difficulty performing daily activities. He wants to know whether his current treatment needs escalation, whether biologics may help, how he can prevent further flare-ups, and what lifestyle changes could improve his breathing and overall quality of life.

Please help.

Answer 1

Hi,

Welcome to icliniq.com.

I understand your concern.

From what you have described, your asthma–COPD (chronic obstructive pulmonary disease) overlap is not under good control right now, and this is not something to simply “wait and watch.”

The first thing to focus on is your inhaler use. Even very strong inhalers will not work properly if the technique is even slightly incorrect or if doses are missed. Please watch a reliable inhaler technique video online for your exact device, practice it at home, and at your next visit, use the inhaler in front of your pulmonologist so they can correct any small mistakes.

Before discussing stronger injections, it is important to get a clearer picture of the allergic or eosinophilic component of your disease. I would advise blood tests for total IgE (immunoglobulin E) and eosinophil count, and, if available, a FeNO (fractional exhaled nitric oxide) test, which helps show how active the airway inflammation is. These results, along with your history and spirometry, will help determine which biologic, if any, is suitable for you.

Given your FEV₁ (forced expiratory volume in 1 second) with clear reversibility, frequent flare-ups, and elevated eosinophil count despite high-dose ICS or LABA (inhaled corticosteroid or long-acting beta₂-agonist), LAMA (long-acting muscarinic antagonist), and Montelukast, you fall into the group in whom biologic treatment is strongly considered. These injections are added on top of your inhalers to calm the eosinophilic inflammation and reduce the number of attacks and steroid courses. Once your test results are available, we can decide which option best fits your pattern and how it should be given and monitored.

At the same time, we need to work on preventing further flare-ups. This means absolutely no smoking or exposure to secondhand smoke, avoiding strong fumes and dust, keeping vaccinations for flu, pneumonia, and COVID (coronavirus) up to date, and treating any sinus or reflux problems that might trigger your symptoms. A structured pulmonary rehabilitation program can also help improve your stamina, sleep, and confidence with daily activities.

With correct inhaler technique, the appropriate add-on treatment, and these preventive steps, there is a good chance we can bring your breathing and day-to-day life to a much better level than they are right now.

I hope this has helped you.

Please feel free to reach out to me again for further queries.

Thank you.