How to manage COPD and asthma in elderly?

Question

Hi doctor,

My father is 65 and has been diagnosed with both COPD and asthma. His recent spirometry showed FEV1 54%, and his eosinophil count was 720. He uses triple inhaler therapy and a nebuliser twice daily, but still gets breathless after short walks.

Would adding biologic injections like Mepolizumab help in such mixed asthma-COPD cases?
Also, how can we differentiate between an asthma flare and a COPD attack at home?
He often skips inhaler doses due to hand tremor. Should we switch to a simpler device type?
Are there breathing exercises that can really help improve lung capacity?

Please advise.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com

I am deeply concerned about your worries.

Asthma–chronic obstructive pulmonary disease (COPD) overlap (ACO) diagnosis with a forced expiratory volume (FEV₁) of 54 percent (moderate obstruction), and an eosinophil count of 720/µL, indicates it is markedly elevated. All these points suggest that he may indeed be a good candidate for biologic therapy, especially anti–interleukin (IL-5) agents like Mepolizumab or Benralizumab.

Mepolizumab has shown benefit in patients with COPD who have eosinophilic inflammation (≥300/µL), reducing exacerbation frequency. It is officially approved for severe eosinophilic asthma, but in ACO cases with persistent symptoms and frequent exacerbations despite maximal inhaler therapy, specialists sometimes consider an off-label trial under close supervision. Benefit is typically seen in patients with:

High eosinophil counts (more than 300 to 500).
Recurrent exacerbations despite optimal inhalers.
Strong asthma features (for example, variability in symptoms, allergic history).

I would suggest the following treatment plan for your father:

Discuss with his pulmonologist about adding Mepolizumab (100 mg subcutaneously every four weeks) or a similar biologic. Insurance or local guidelines may restrict use, but his eosinophil level makes him a strong candidate.

It is important to differentiate an asthma flare and a. COPD exacerbation at home. Both can look similar, but there are some useful clues:

Asthma attacks often start suddenly, within a few hours, and are triggered by allergies, cold air, or missed inhaler doses.
The cough is often dry, and wheezing sounds are loud and musical. Breathing improves quickly after using a bronchodilator, usually.
In COPD, flare-ups develop more slowly over a few days due to infection or weather changes.
The cough in COPD is more likely to produce thick or colored mucus, and wheezing may be softer and lower-pitched. People with COPD respond slowly to inhalers.

I hope this helps answer your query. Feel free to ask if you have any questions.

Thank you.