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Presentation Progetto LIBRA Linee Guida ASMA BPCO

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Presentation Progetto LIBRA Linee Guida ASMA BPCO Powered By Docstoc
					Grazie per aver scelto di utilizzare a
  scopo didattico questo materiale
     delle Guidelines 2011 libra.
Le ricordiamo che questo materiale è
  di proprietà dell’autore e fornito
  come supporto didattico per uso
             personale.
        Epidemiology of Complex Chronic
             Comorbidities of COPD




David M. Mannino, M.D.
Professor
Department of Preventive Medicine and
Environmental Health
University of Kentucky, College of Public Health
                  COPD Phenotypes (NEW)
Clinical                                                Physiologic
Dyspnea                                                 Airflow limitation
Frequent Exacerbator                                    Rapid decliner
Low BMI                                                 BD-responsiveness
Pulmonary Cachexia                                      Hyperrresponsiveness
ICS-responsive                                          Hypercapneic
Depression and Anxiety                                  Poor exercise tolerance
Non-smokers                                             Hyperinflation
                                                        Low DLCO
                                                        Pulmonary hypertension



                                           Radiologic
                                           Emphysema
                                           Airways disease



Friedlander et al, COPD 2007; 4: 355-384
                  COPD Progression




Fletcher et al, The Natural History of Chronic Bronchitis and Emphysema, 1976
Natural History of Chronic Airflow Obstruction




  Adapted from Fletcher and Peto, Burrows
           Survival by Lung Function Impairment

               1.0


                                                      Normal
                                                      GOLD 1
                .9
                                                      GOLD 0

                                                      Restricted
Survival




                .8                                    GOLD 2




                .7



                                                      GOLD 3 or 4
                .6
                     0   2       4     6     8   10     12


                                     Years



 Mannino et al, Resp Med, 2006
    What do COPD Patients Die From?
      (rate per 1,000 person-years)
   Normal

Restricted

 GOLD 0

 GOLD 1

 GOLD 2

GOLD 3/4

              0              10            20          30         40     50

                    COPD           ASCVD        Lung Cancer    Other


    Mannino et al, Resp Med, Jan 2006                         Slide 3b
            What is Progression of COPD?

                                        Health

                                                           Incident Disease
              0             I             II           III            IV
           At Risk         Mild        Moderate      Severe      Very Severe


                                  Progressive Disease
                            Prevalent Disease
                                                                         ???
         “Restriction”
                                                      Death
*GOLD   Guidelines. Am J Respir Crit Care Med. 2004;163:1256-1276.
COPD – Consequences and Comorbidities




COPD 2008 ; 5: 235-256
COPD – Consequences and Comorbidities




COPD 2008 ; 5: 235-256
Sevenoaks and Stockley, Resp Res 2006
 Clinical Overlap Between COPD
 and Asthma
                       COPD                           Asthma
                                                     Early and/or family
               Smoking history
                                                     history
           Progressive dyspnea;                       Intermittent wheezing;
           productive cough                           hay fever; atopy

           Bronchodilator                              Bronchodilator
           response: AC>BA                             response: BA>AC

                   Neutrophilic                        Eosinophilic
                   inflammation                        inflammation

 AC= Anticholinergic
 BA= 2-agonist.
                                Airflow Limitation
Adapted by Christopher B. Cooper, MD.
Barnes. Chest. 2000;117:10S-14S; Balmes et al, for the American Thoracic Society. Am J
Respir Crit Care Med. 2003;167:787-796.
Diagnosed Lung Disease and Lung Function
Impairment in the US Adult Population




   Asthma                     5.5%
   Chronic bronchitis         3.2%
   Emphysema                  1.5%
   Airflow obstruction int.   1.6%
   Airflow obstruction ext.   3.1%
                                                          NHANES III

NHANES III Current Diseases as a Proportional Venn Diagram.
Soriano et al. Chest. 2003;124:474-481.
       Life time Asthma and GOLD 2+ COPD
       Findings from NHANES 3
Percent with COPD
       Predictors of Airway Obstruction by Diagnosis and Smoking Status
          100




           10




            1




                 Current Smokers         Former Smokers     Never Smokers

From NHANES III, 1988-1994 (In Review, Resp. Med.)
                              Mortality by Disease Status




                                                                                None

                                                                           Asthma only

                                                                                COPD only


                                                                          Asthma and COPD




From NHANES III, 1988-1994 and Follow-up through 2006 (In Review, Resp. Med.)
COPD and Comorbid Disease




From Holguin and Mannino (Chest, 2005), NHDS data
     Does COPD Cause Lung Cancer?
    Adjusted* Kaplan-Meier Curves for Incident Lung Cancer




                                                                                       Moderate COPD


                                                                                       Restrictive Disease
                                                                                       Mild COPD

                                                                                       No Lung Disease



Mannino et al, Archives Int Med, 2003 ; 163: 1475-1480
*adjusted for age, race sex, education, smoking status, pack years, and years since regular smoking
  Interaction of Pack Years and Lung
 Function and Lung Cancer Incidence
Incident cases per 1000 person years

   25
   20
   15
   10




                                                                                60
                                                                                    +
                                                                            40
    5




                                                                              -5
                                                                                9
                                                                  20
                                                                     -3
                                                                        9
                                                                        >0
    0




                                                                          -1
                                                                            9
                                                              0
                   2



                            1




                                                  0



                                                         al
          4




                                        d
        3/




                                       cte
               LD



                        LD




                                              LD



                                                        m
                                                                   Pack-years
                                                         r
    LD




                                  tri




                                                      No
              GO



                       GO




                                             GO
                                   s
   GO




                                Re




              Lung Function
Barr et al, AJM 2009: 348- 355
Barr et al, AJM 2009: 348- 355
Barr et al, AJM 2009: 348- 355
    Hypertension at Baseline
   Percent
   60

   50

   40

   30

   20

   10

    0
         GOLD 3/4   GOLD 2   GOLD 1   Restricted   GOLD 0   Normal

Mannino et al, ERJ 2008
 Diabetes Mellitus at Baseline


   Percent
   25

   20

   15

   10

    5

    0
         GOLD 3/4    GOLD 2   GOLD 1   Restricted   GOLD 0   Normal

Mannino et al, ERJ 2008
 Cardiovascular Disease at Baseline


   Percent
   30

   25

   20

   15

   10

    5

    0
         GOLD 3/4    GOLD 2   GOLD 1   Restricted   GOLD 0   Normal

Mannino et al, ERJ 2008
      Risk of Death within 5 Years from Baseline
                                                             With 3 Comorbid Diseases
                                                             With 2 Comorbid Diseases
                                                             With 1 Comorbid Disease
100                                                          With No Comorbid Disease




 10




  1
        GOLD 3/4      GOLD 2       GOLD 1      Restricted    GOLD 0          Normal


 Models adjusted for age, sex, race, smoking status, education level, and body mass index

Mannino et al, ERJ 2008
          Risk of Hospitalization
                                                              With 3 Comorbid Diseases
                                                             With 2 Comorbid Diseases
                                                             With 1 Comorbid Disease
100                                                          With No Comorbid Disease




 10




  1
         GOLD 3/4      GOLD 2       GOLD 1      Restricted    GOLD 0            Normal

 Models adjusted for age, sex, race, smoking status, education level, and body mass index
Mannino et al, ERJ 2008
        Multivariate Risk of Recurrent CVD by GOLD Stage
                   .8                                                GOLD 3 or 4

                                                                     Restricted
                                                                      GOLD 2
                   .6
                                                                     GOLD 1/ GOLD 0

                                                                     Normal

                   .4




                   .2




                  0.0
                        0     2   4    6      8      10    12   14         16


                                      Years of Follow-up



Johnston et al, Thorax 2008
        Multivariate Risk of Incident CVD by GOLD Stage
                 .8


                 .7


                 .6


                 .5


                 .4                                              GOLD 3 or 4

                 .3
                                                                     Restricted
                 .2                                                   GOLD 2
                                                                      GOLD 1/ GOLD 0
                 .1                                                   Normal

                0.0
                      0       2   4    6      8      10    12   14        16


                                      Years of Follow-up



Johnston et al, Thorax 2008
    Figure 1


                              GOLD 3 or 4

                              Restricted
                              GOLD 2




                              GOLD 0
                              GOLD 1


                              Normal




Johnston et al, Thorax 2008
    Figure 2

                              GOLD 3 or 4



                              GOLD 2
                              Restricted
                              GOLD 0
                              GOLD 1
                              Normal




Johnston et al, Thorax 2008
       GOLD Classification and Comorbidity
        0                   I                    II                  III                 IV
     At Risk               Mild               Moderate             Severe           Very Severe

 Normal               FEV1/FVC            FEV1 /FVC          FEV1 /FVC <      FEV1 /FVC <70%
Spirometry              <70%                 <70%                70%
                                                                                  FEV1 < 30%
 Respiratory          FEV1 ≥ 80%          50% ≥ FEV1         30% ≥ FEV1        or presence
Symptoms                                     < 80%               < 50%             of chronic
(Cough, Sputum)                                                                    respiratory
                                                                                   failure or right
                                                                                   heart failure


Avoidance of risk factor(s); influenza vaccination

                         Add short-acting bronchodilators* when needed

                                             Add regular Rx with 1 long-acting bronchodilator.*
                                             Add rehabilitation

                                                                Add ICS if repeated exacerbations†

                                                                               Consider O2 and
                                                                               surgery
 *GOLD    Guidelines. Am J Respir Crit Care Med. 2004;163:1256-1276.
                              0


Mancini et al. J Am Coll Card 2006;47:2554
         Beta-Blockers in COPD Exacerbations




Dransfield et al, Thorax 2008
            Lung Function Decline and Comorbid Disease




Fletcher et al, The Natural History of Chronic Bronchitis and Emphysema, 1976
    What do COPD Patients Die From?
      (rate per 1,000 person-years)
   Normal

Restricted

 GOLD 0

 GOLD 1

 GOLD 2

GOLD 3/4

              0              10            20          30        40   50

                    COPD           ASCVD        Lung Cancer   Other


    Mannino et al, Resp Med, Jan 2006
Interventions for Chronic Disease

   Tobacco Control
   Diet
   Activity
   Obesity Prevention
HealthCanada
       End-of-Life – Disease C




Lorenz et al, Ann Intern Med 2008:148:147-159
 End-of-Life – Disease A




Lorenz et al, Ann Intern Med 2008:148:147-159
                     Mannino 2/21/2008 Slide # 41
Conclusions
   COPD is part of a complex mix of polymorbid
    diseases related to ageing, lifestyle choices,
    genetics, and environmental exposures
   The future of COPD management will include
    better phenotypic characterization and integration
    of the polymorbidity associated with COPD as
    part of the treatment plan
 Chronic Obstructive Pulmonary Disease


    COPD is a PREVENTABLE and
     TREATABLE disease




ATS/ERS Guidelines for the Treatment of COPD, 2004

				
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