GPAtlas🧭 When to suspect
Asthma–COPD overlap (ACO) describes a patient with persistent airflow obstruction who has clinical features of both asthma and COPD. It is best understood as a descriptive label, not a single disease – GINA now prefers the term “asthma + COPD” precisely because “overlap” was so often wrongly assumed to represent one discrete condition. These patients carry a greater burden of symptoms and exacerbations, faster lung-function decline and higher mortality than either asthma or COPD alone.
Suspect it in a patient, typically over 40 with a smoking or exposure history, presenting in one of two patterns: an adult with a personal or family history of asthma or atopy who develops persistent, progressive breathlessness, or someone carried as COPD who shows marked day-to-day variability, a large bronchodilator response, raised eosinophils or nocturnal symptoms.
The key primary-care skill is twofold: recognise the asthma component (because it changes treatment and safety entirely), and never miss an alternative diagnosis such as lung cancer, bronchiectasis or heart failure.
| Features pointing to the asthma component | Features pointing to the COPD component |
|---|---|
|
• Symptoms under age 35, or a secure previous asthma diagnosis |
• Current or ex-smoker (or significant dust/fume/biomass exposure) |
|
• Variable symptoms – day-to-day, seasonal, or with triggers (allergen, exercise, cold air) |
• Persistent, progressive breathlessness rather than variable |
|
• Nocturnal waking with cough or wheeze; atopy (eczema, rhinitis) |
• Chronic productive cough, especially in the mornings |
|
• Large reversibility, raised eosinophils or raised FeNO (steroid-responsive markers) |
• Fixed obstruction with little day-to-day variability |
Source: NICE NG115 · NICE NG245 · GINA 2025
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