I have asthma and COPD. Do I need oxygen therapy?

Question

Hello doctor,

I am 63 years old and have both severe asthma and COPD, which makes breathing extremely difficult daily. I smoked for 30 years but quit five years ago when I was diagnosed.

My pulmonologist has me on Advair, Spiriva, and Montelukast daily, along with an albuterol rescue inhaler, which I use about six to eight times a day. My peak flow is around 180 on good days, and my FEV1 is 48 % of predicted.

I have been hospitalized four times in the past year due to exacerbations, and during my most recent admission, I required ICU care and BiPAP support.

I am currently on Prednisone 10 mg daily just to be able to function, but it has led to significant side effects, including weight gain, diabetes, and osteoporosis. My asthma symptoms tend to worsen around my period, even though I am perimenopausal, which seems unusual to me.

I am unable to walk more than 50 feet without becoming short of breath, and my oxygen saturation drops to around 88 %.

My pulmonologist mentioned biologic therapy for severe asthma, but my insurance denied coverage, stating that I do not have enough exacerbations, despite my severe breathing difficulties. I would like to know:

Is there any way to improve lung function with COPD and asthma together?
Should I be on oxygen therapy?

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

What you are describing is a sign of high-risk asthma–COPD (chronic obstructive pulmonary disease) overlap (ACO) with severe daily limitation and steroid dependence. Your current pattern suggests that the baseline regimen is not strong enough.

Repeated use of oral steroids causes significant harm, as you are already experiencing, so the priority is to replace long-term oral steroids with safer and more effective controller strategies.

I suggest switching to a single-inhaler triple therapy, which can improve adherence and reduce exacerbations compared to using multiple devices. Given the strong asthma component, a maintenance-and-reliever strategy with a Budesonide–Formoterol inhaler should also be discussed with your doctor.

This allows the same anti-inflammatory inhaler to be used for both maintenance and relief instead of relying solely on albuterol, which often significantly reduces exacerbations and rescue inhaler use. Using a spacer and rinsing your mouth after inhalation can help prevent hoarseness and thrush.

Considering your steroid dependence, frequent hospitalizations, and ICU (intensive care unit) admission, you likely meet criteria for biologic therapy.

I suggest asking your pulmonologist to submit an appeal with clear documentation of at least two severe exacerbations per year or any ICU stay, daily oral steroid dependence, FEV1 (forced expiratory volume in one second) of 48 %, and poor control despite high-dose inhaled therapy.

Laboratory markers such as blood eosinophils, total IgE (immunoglobulin E), and possibly FeNO (fractional exhaled nitric oxide) can help match you to the most appropriate biologic. These treatments can reduce flare-ups by about 50 % or more and often allow tapering or discontinuation of oral steroids.

You can enrol for pulmonary rehabilitation, which combines supervised exercise and breathing retraining and is one of the highest-value interventions for COPD and ACO. Airway clearance techniques, such as a PEP device and controlled huff-coughing, along with a daily mucolytic if sputum is an issue, may also help.

In selected patients, long-term Azithromycin taken three times weekly can reduce exacerbations. It is also important to screen for and manage comorbidities that worsen respiratory control and to stay current with influenza, pneumococcal, COVID-19, and Tdap (Tetanus, Diphtheria, and acellular Pertussis) vaccinations.

Regarding oxygen therapy, oxygen saturation dropping to 88 % with walking warrants formal evaluation. An arterial blood gas (ABG) and exertional oxygen testing are recommended.

If desaturation occurs mainly with activity, ambulatory oxygen can improve walking tolerance and symptoms, with a target oxygen saturation of at least 90 % during exertion and sleep. Your care team can arrange a portable oxygen system tailored to your needs.

Worsening symptoms around your cycle are consistent with perimenstrual asthma, which can occur even in perimenopause due to hormonal fluctuations. A gynecology consultation to discuss hormonal management can also be considered.

Given your age and smoking history, you should also discuss annual low-dose CT (computed tomography) lung cancer screening with your physician.

I hope this helps you.

Thank you.