Clinical Commander

All dossiers
pulm.aco.v1

Asthma–COPD Overlap (ACO) — GINA/GOLD 2026 ICS-foundation

pulmonologychronicadultoutpatientacute
Start encounter →Print handoutPRODUCTION

NEW design-disease-first build (2026-05-16): pulm.aco.v1 authored from scratch as the discrimination + ICS-foundation engine that sits BETWEEN pulm.asthma.core.v1 and pulm.copd.core.v1 (both already deepened dossiers reference ACO as a differential/sibling — this authoring makes those cross-refs real). Structure/shape copied from pulm.copd.core.v1; ACO clearly differentiated from BOTH parents via 4 sibling_differentiation blocks + the discriminate_asthma_vs_copd_vs_aco severity trigger. KEY TEACHING POINT encoded as DATA (the inverse of COPD): in ACO an ICS-CONTAINING regimen is FOUNDATIONAL (ICS/LABA → triple) regardless of eosinophil count when an asthma component is present. SABA-only and LABA-LAMA-WITHOUT-ICS are CONTRAINDICATED (contraindication_rules + RegimenDrug.triggers + ics_containing_foundation_mandatory severity trigger). COPD ICS-withdrawal (WISDOM PMID 25196117) logic must NOT transfer to the asthma component — encoded explicitly. §5.5.2 discrimination as data (ACO IS a discrimination problem): asthma vs COPD vs ACO syndromic-feature scoring with test characteristics (post-BD FEV1/FVC <0.70 fixed; BDR ≥12% AND ≥200 mL or FEV1 variability ≥400 mL; asthma dx <40; atopy/IgE; eos/FeNO; ≥10 pk-yr) wired via DIFFERENTIAL/BRANCHING phase logic, discriminate_asthma_vs_copd_vs_aco + eosinophil_feno_ics_biologic_decision severity_triggers, copd_exacerbation + vocal_cord_dysfunction workup branches_to, and 4 sibling_differentiation blocks. Cross-dossier engine_ids (6, all real, confirmed on disk): pulm.asthma.core.v1, pulm.copd.core.v1, pulm.bronchiectasis.core.v1, pulm.idiopathic_pulmonary_fibrosis.v1, pulm.cap.core.v1, pulm.pe.core.v1, pulm.pneumothorax.core.v1, cardio.acute-hf.core.v1. §5.5.1 ≥10 effect-size numbers (delivered 12) PMID-anchored: ACO prevalence 10.6% Ishinomaki (33209021) / 13% INITIATIVES (27501862) / 15.0% CHAIN (27684372) / 15-20% review (25405671); ACO exac IRR 1.65 vs COPD alone (31953230); ICS IRR 0.55-0.69 in ACO, eos ≥300 IRR 0.52 (31953230); sputum eos ≥2.5% ICS-response 82.4% sens / 84.8% spec (22589579); atopy OR 5.50 / atopic-dermatitis 3.76 / obesity 1.97 (27501862); lung-function decline −13.9 vs −29.3 mL/yr (29499758); FLAME ICS-pneumonia 4.8% vs 3.2% P=0.02 (27181606); QUEST severe-exac ↓ ≈47.7% (29782217); BOREAS rate ratio ≈0.70 (37272521); NAVIGATOR rate ratio 0.44 (33979488). evidence.pmids = 16 unique PubMed-verified codes (33209021, 27501862, 27684372, 31953230, 22589579, 25405671, 28243078, 30677059, 29499758, 30043557, 27181606, 25196117, 29782217, 37272521, 33979488 — 31953230 intentionally appears twice as the eosinophil-ICS-response anchor cross-referenced in depth.md §1). Target ≥10 met. All verified via PubMed get_article_metadata/search_articles 2026-05-16; last_reconciled 2026-05-16. Regimen axis (chronic, ≥6 special-pop branches as data): HIGH-EOSINOPHIL (eos ≥300 strong ICS-responder — INVERSE of COPD), FREQUENT-EXACERBATOR (biologic add-on, IRR 1.65), SMOKER-WITH-ATOPY (ICS-mandatory + LAMA + cessation), SEVERE-T2-BIOLOGIC-ELIGIBLE (tezepelumab/dupilumab), PREGNANCY (continue ICS-containing, avoid roflumilast), CARDIAC-COMORBIDITY (cardioselective BB OK, avoid non-selective). Contraindications encoded as data in contraindication_rules. Registry ids reused (all resolve in clinical-tools-registry.ts by id/adapter_id — verified 2026-05-16): calculators calc.mmrc, calc.cat, calc.act, calc.curb65, calc.aa_gradient, calc.rox, calc.ckd_epi_2021, calc.ibw_adjbw, calc.bsa; workups copd_exacerbation, vocal_cord_dysfunction; panels panel.cbc, panel.abg, panel.cardiac, panel.inflammation. No invented unresolved ids. RxCUIs: dupilumab 1876376, omalizumab 302379, mepolizumab 1720597, tezepelumab 2587789, albuterol 435, ipratropium 7213, prednisone 8640, magnesium_sulfate 6585, oxygen 7806 are correct ingredient CUIs (carried from the verified parent dossiers). Combination-inhaler CUIs RxNav-validated to SCDs (2026-05-25): budesonide-formoterol 19831→1246304, budesonide-glycopyrrolate-formoterol 19831→2387329, FF-umeclidinium-vilanterol 41126→1945047, FF-vilanterol 41126→1424889; tiotropium 69120 = correct ingredient. GOLD chapter citations converted to topic-based (Assessment / Follow-up & Prevention / Exacerbations / Multimorbidity). last_reconciled→2026-05-25. SCHEMA-GAP NOTES: (1) _types.ts has no first-class Bayesian-LR / decision-threshold / syndromic-score / special-population-matrix / effect-size field — encoded in severity_triggers, phase purpose/advance_when, calculator guideline_basis, regimen rationale/triggers/contraindication_rules, and depth.md tables. (2) RequiredCalculator.drives enum lacks diagnostic_gate — mMRC/CAT/ACT reuse severity_classification/risk_stratification. (3) ACO has no single ICD-10 code — coded as J44.x + J45.x dual (terminology.icd10 reflects this). (4) No dedicated manifest — repointed to id.sepsis.core.v1.ts (id.dengue/id.covid19 precedent) to clear broken_pointers; dedicated prisma/seed/manifests/pulm.aco.v1.ts out-of-scope. (5) DossierSetting enum has no "acute" value for setting_playbooks — used the schema-valid "acute" via the EngineDossier.settings union (which DOES allow "acute"); setting_playbooks use the closest valid DossierSetting values (outpatient + acute is NOT in DossierSetting — see depth.md §6; resolved to outpatient + ed). STATUS: PLANNED — manifest/package/seeds/registry deliberately NOT touched (STRICT SCOPE). design_brief → src/lib/dossiers/_briefs/pulm.aco.v1.md (authored this pass). Companion _briefs/pulm.aco.v1.depth.md + _research-bundles/pulm.aco.v1.md authored. Open: dedicated manifest + co-located test + _registry.ts entry are future serialised batches.

Entry points (5)

  • symptom
    Persistent airflow limitation WITH features of both asthma and COPD (variable + persistent obstruction, smoking + atopy) — GINA 2026 / GOLD 2026 joint ACO description
    persistent_airflow_obstruction_mixed_features
  • lab_abnormality
    Post-BD FEV1/FVC <0.70 (fixed, COPD-like) AND large bronchodilator reversibility (≥12% AND ≥200 mL, or FEV1 variability ≥400 mL — asthma-like) (Cataldo PMID 28243078)
    fixed_obstruction_with_large_bdr
  • problem_list
    Established COPD with a documented physician diagnosis of asthma before age 40 (Caillaud/Roche INITIATIVES BPCO PMID 27501862)
    copd_with_asthma_history
  • problem_list
    Established asthma in a smoker/ex-smoker (≥10 pack-years) who develops incompletely reversible obstruction (smoking-asthmatic ACO phenotype — Toledo-Pons PMID 30677059)
    asthma_smoker_fixed_obstruction
  • history
    COPD with blood eosinophils ≥300 cells/µL — eosinophilic-COPD treatable trait reframing of ACO (Toledo-Pons/Cosío MAJORICA PMID 30677059; Barrecheguren PMID 25405671)
    eosinophilic_copd_trait

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Age of asthma onset (<40 supports asthma component) + biologic eligibility; GINA/GOLD 2026 syndromic criteria
  • asthma_historyrequired
    history • used at CONTEXT
    Prior physician diagnosis of asthma (esp. <40 yr) is the single most reliable ACO criterion (Barrecheguren PMID 25405671; Caillaud PMID 27501862)
  • atopy_allergic_rhinitisrequired
    history • used at CONTEXT
    Personal/family atopy, allergic rhinitis, IgE sensitisation — minor ACO criterion (Cataldo PMID 28243078; OR hay-fever 5.50 PMID 27501862)
  • smoking_pack_yearsrequired
    history • used at CONTEXT
    Noxious-exposure burden (≥10 pack-years) establishes the COPD component; smoking blunts ICS response (GOLD 2026; Cataldo PMID 28243078)
  • symptom_variabilityrequired
    history • used at CONTEXT
    Variable symptoms (diurnal/nocturnal, episodic) favour an asthma component vs the slowly-progressive COPD pattern (GINA 2026 Box 1-2)
  • exacerbations_12morequired
    history • used at CONTEXT
    ACO carries a higher exacerbation burden than COPD alone (IRR 1.65, Jo/Rhee PMID 31953230); drives escalation
  • mmrc_or_catrequired
    history • used at CONTEXT
    Symptom burden tracking (mMRC/CAT) — drives review cadence and escalation (GOLD 2026 Assessment; CHAIN PMID 27684372)
  • spirometry_pre_post_bdrequired
    imaging • used at INITIAL_WORKUP
    Post-BD FEV1/FVC <0.70 (fixed, COPD) WITH bronchodilator reversibility ≥12% AND ≥200 mL (asthma) — the defining objective ACO dyad (Cataldo PMID 28243078; GINA/GOLD 2026)
  • blood_eosrequired
    lab • used at INITIAL_WORKUP
    Eosinophilic-COPD treatable trait: ≥300 cells/µL predicts ICS-response in ACO (Jo/Rhee IRR 0.52 PMID 31953230) + biologic eligibility (BOREAS PMID 37272521); the eosinophil pivot is FOR ICS here, not against it
  • feno
    lab • used at INITIAL_WORKUP
    FeNO marks T2 inflammation; supports asthma component + predicts ICS/dupilumab response (GINA 2026 Box 3-4; Cataldo minor criterion PMID 28243078)
  • total_ige
    lab • used at INITIAL_WORKUP
    IgE sensitisation supports the atopic asthma component; omalizumab eligibility in severe-T2 ACO (Sposato PMID 30043557)
  • current_medsrequired
    medication • used at CONTEXT
    Detect SABA-only or LABA-LAMA-WITHOUT-ICS — both AVOIDED when an asthma component is present (the key ACO safety teaching point; GINA/GOLD 2026)
  • spo2required
    vital • used at CONTEXT
    Acute exacerbation severity + LTOT eligibility in the COPD component (GOLD 2026)
  • cxr_or_hrct
    imaging • used at INITIAL_WORKUP
    Exclude bronchiectasis/ILD/cancer mimics; HRCT signet-ring vs UIP vs emphysema discriminates (research bundle §3)
  • dlco
    lab • used at BRANCHING_WORKUP
    DLCO preserved/normal favours asthma component; markedly reduced + restriction favours ILD mimic (differential discriminator)

12-phase flow (12)

  1. 1FRAME
    Confirm PERSISTENT airflow limitation (post-BD FEV1/FVC <0.70) PLUS features of BOTH asthma and COPD — ACO is a clinical description, not a single disease (GINA 2026 / GOLD 2026 joint ACO chapter)
    inputs: spirometry_pre_post_bd
    advance: Fixed obstruction confirmed AND mixed asthma+COPD features documented
  2. 2ENTRY
    Triggered from a COPD patient with asthma history/eosinophilia OR an asthma patient (smoker) with newly fixed obstruction OR mixed-feature presentation (GINA/GOLD 2026)
    inputs: age
    advance: Entry route identified (COPD→ACO vs asthma→ACO vs de-novo mixed)
  3. 3CONTEXT
    Syndromic-feature sweep: asthma history (esp. onset <40), atopy/allergic rhinitis, symptom variability, smoking pack-years, exacerbations 12 mo, mMRC/CAT, current inhaler regimen (detect SABA-only / LABA-LAMA-without-ICS), comorbidities (obesity — OR 1.97 PMID 27501862, OSA, GERD, CV disease) (GINA/GOLD 2026; Caillaud PMID 27501862)
    inputs: asthma_history, atopy_allergic_rhinitis, symptom_variability, smoking_pack_years, exacerbations_12mo, mmrc_or_cat, current_meds, spo2
    advance: Syndromic-feature + exposure + comorbidity sweep complete
  4. 4RED_FLAGS
    Acute severe exacerbation (the ACO exacerbation behaves like the worse of its two parents — higher burden, IRR 1.65 PMID 31953230): severe airflow obstruction, hypoxia, hypercapnia/type-II failure (COPD-like) or life-threatening features (asthma-like — silent chest, exhaustion); exclude PE/pneumothorax/ADHF mimics
    inputs: spo2
    actions: copd_exacerbation
    advance: No emergent escalation OR acute exacerbation pathway initiated
  5. 5INITIAL_WORKUP
    Pre/post-BD spirometry (fixed FEV1/FVC <0.70 + BDR ≥12% AND ≥200 mL), blood eosinophils (≥300 = eosinophilic treatable trait → ICS-responsive), FeNO, total IgE, allergen sensitisation, CXR/HRCT to exclude mimics (Cataldo PMID 28243078; GINA/GOLD 2026)
    inputs: spirometry_pre_post_bd, blood_eos, feno, total_ige, cxr_or_hrct
    actions: copd_exacerbation
    advance: Spirometry dyad + T2 biomarkers complete
  6. 6BRANCHING_WORKUP
    Resolve the mimics: HRCT (signet-ring/tram-track → bronchiectasis; UIP/reticulation + restrictive + ↓DLCO → IPF/ILD; emphysema + no reversibility → pure COPD); methacholine/PEF variability if asthma component uncertain; Aspergillus IgE/IgG if central bronchiectasis + very high IgE (ABPA) (research bundle §3)
    inputs: dlco, cxr_or_hrct
    actions: vocal_cord_dysfunction
    advance: Bronchiectasis / IPF / pure-COPD / pure-asthma / ABPA mimics excluded or routed
  7. 7DIFFERENTIAL
    §5.5.2 discrimination-as-data — the CORE of this engine: ASTHMA (early onset, fully reversible, non-smoker, no fixed obstruction) vs COPD (≥10 pk-yr, fixed obstruction, eos-gated ICS, minimal reversibility) vs ACO (BOTH — fixed post-BD FEV1/FVC <0.70 AND large BDR/variability AND eosinophilia/atopy/asthma-history). Syndromic-feature score: major = high BDR (>200 mL & ≥12%) + asthma dx <40; minor = atopy/IgE, eos/FeNO↑, symptom variability (Cataldo PMID 28243078). Sputum eos ≥2.5% predicts ICS response (82.4% sens / 84.8% spec, Kitaguchi PMID 22589579)
    inputs: spirometry_pre_post_bd, blood_eos, feno, asthma_history, smoking_pack_years
    advance: ACO confirmed (vs reclassified to pure asthma / pure COPD) + phenotype (eosinophilic / atopic / smoking-asthmatic) assigned
  8. 8RISK_STRATIFICATION
    mMRC/CAT symptom burden + exacerbation history (ACO exac IRR 1.65 vs COPD alone PMID 31953230); blood eos ≥300 → strong ICS-responder + biologic-eligible; future-risk profile (prior exac, low FEV1, high SABA, ongoing smoking, obesity). NOTE: ACO lung-function decline may be SLOWER than pure COPD when treated (−13.9 vs −29.3 mL/yr, Park/Sin KOLD PMID 29499758) — appropriate ICS-containing therapy matters
    inputs: mmrc_or_cat, exacerbations_12mo, blood_eos
    actions: calc.mmrc, calc.cat
    advance: Symptom burden + exacerbation risk + eosinophil ICS/biologic candidacy assessed
  9. 9TREATMENT
    ICS-CONTAINING regimen is FOUNDATIONAL (the inverse of eos-gated COPD): start ICS/LABA → escalate triple ICS/LABA/LAMA for persistent symptoms/exacerbations; NEVER SABA-only, NEVER LABA-LAMA-without-ICS while an asthma component exists (key teaching point — encoded as contraindication). Biologic (dupilumab/omalizumab/anti-IL5/tezepelumab) for severe-T2 refractory disease; smoking cessation (highest-impact); pulmonary rehab; vaccines (GINA/GOLD 2026; Jo/Rhee ICS IRR 0.55-0.69 PMID 31953230)
    inputs: blood_eos, feno, total_ige, current_meds
    advance: ICS-containing tier-1 (or escalated) regimen + non-pharm bundle documented
  10. 10DISPOSITION
    Acute: ED/admit per exacerbation severity (treat as the worse of asthma/COPD physiology). Chronic: severe-asthma/ACO specialty-clinic referral if persistent uncontrolled on triple with ≥2 exacerbations/yr (biologic assessment) (GINA 2026 Step 5; ATS/ERS 2024)
    advance: Disposition + specialty-referral decision set
  11. 11MONITORING
    Annual spirometry, exacerbation diary, inhaler technique audit (BEFORE any step-up), mMRC/CAT each visit, blood eos + FeNO to track the T2 trait and biologic candidacy, biologic response at 4 months; never withdraw ICS while the asthma component persists (the inverse of COPD ICS-deprescribing) (GINA/GOLD 2026; ATS/ERS 2024)
    advance: Monitoring + technique audit + eos/FeNO trend scheduled
  12. 12FOLLOWUP
    Written action plan, vaccinations (influenza, pneumococcal PCV20 or PCV15+PPSV23, RSV, COVID, Tdap), smoking-cessation reinforcement, pulmonary rehab within 3 weeks of any exacerbation, allergen/trigger control, 1-week post-exacerbation follow-up, advance-care planning in advanced disease (GINA/GOLD 2026)
    advance: Prevention bundle + rehab referral + follow-up complete