CORSI DI AGGIORNAMENTO PER MMG Modena 12 aprile 2002 Criteri decisionali fra Global Initiatives on...

CORSI DI AGGIORNAMENTO PER MMGCORSI DI AGGIORNAMENTO PER MMGModena 12 aprile 2002Modena 12 aprile 2002

Criteri decisionali fra Criteri decisionali fra Global Initiatives on Asthma (GINA) e Global Initiatives on Asthma (GINA) e

Obstructive Lung Disease (GOLD)Obstructive Lung Disease (GOLD)

Prof. Leonardo M. FabbriProf. Leonardo M. FabbriClinica di Malattie dell’Apparato RespiratorioClinica di Malattie dell’Apparato Respiratorio

GGloballobalININitiative foritiative forAAsthmasthma

www.ginasthma.comwww.ginasthma.com

G G lobal Initiative for Chroniclobal Initiative for Chronic

O O bstructivebstructive

L L ungung

D D iseaseisease

www.goldcopd.comwww.goldcopd.com

Global Initiative on Obstructive Global Initiative on Obstructive Lung DiseaseLung Disease

EXECUTIVE COMMITTEEEXECUTIVE COMMITTEEChair: Romain PauwelsChair: Romain Pauwels

S. Buist, USS. Buist, USP. Calverley, UKP. Calverley, UKB. Celli, USB. Celli, USL. Fabbri, ItalyL. Fabbri, ItalyY. Fukuchi, JapanY. Fukuchi, JapanS. Hurd, USS. Hurd, USL. Grouse, USL. Grouse, US

C. Jenkins, AustraliaC. Jenkins, Australia

N. Khaltaev, CHN. Khaltaev, CH

C. Lenfant, USC. Lenfant, US

J. Luna, GuatemalaJ. Luna, Guatemala

W. McNee, UKW. McNee, UK

R. Rodriguez Roisin, ER. Rodriguez Roisin, E

N.Zhong, ChinaN.Zhong, China

Global Initiative on Obstructive Lung DiseaseGlobal Initiative on Obstructive Lung Disease

SCIENTIFIC COMMITTEESCIENTIFIC COMMITTEEChair: Leonardo M. FabbriChair: Leonardo M. Fabbri

P. Barnes, UKP. Barnes, UKS. Buist, USS. Buist, US

P. Calverley, UKP. Calverley, UKY. Fukuchi, GiapponeY. Fukuchi, Giappone

W. McNee, UKW. McNee, UKR. Pauwels, BelgiumR. Pauwels, Belgium

K. Rabe, GermanyK. Rabe, GermanyRoberto Rodrigues Roisin, SpainRoberto Rodrigues Roisin, Spain

N. Zielinski, PolandN. Zielinski, Poland

Third Quarter, 2000: Publication Date from 2000/07/01 to 2000/09/30

Search COPD NOT ASTHMA: All Fields.

Limits: All Adult: 19+ years, only items with abstracts, English, Clinical Trial, Human

Sort by: Authors (20 citations)

No star = Clinical Trial, One * = Randomized Clinical Trials (15 citations)

Two ** = Randomized Clinical Trials and Core Clinical Journals (7 citations)

ASSIGNMENTS, REVIEWER, PUBLICATION NUMBER

Peter Barnes, 8

Sonia Buist, 16, 17

Leo Fabbri, 14, 20, 10, 19

Yoshi Fukuchi, 5, 7, 10, 12, 19, 20

Bill MacNee, 1, 5, 8, 15

Romain Pauwels, 16, 17

Klaus Rabe, 2, 3, 4, 11, 14

Roberto Rodriguez-Roisin, 2, 3, 4, 11, 13, 18

Jan Zielinski, 1, 7, 10, 15, 19

GOLD REPORT – Section 4Page 32, left column, end of para 2,

ORIGINAL TEXT…. tract inflammation57-61. It is likely that

indoor air pollution derived from the burning of biomass fuels will prove to

have similar effects.

SUGGESTED REVISION…. tract inflammation57-61. It is likely that indoor

air pollution derived from the burning of biomass fuels will prove to have similar effects. Also bacterial colonization

contributes to the airway inflammation in patients with stable COPD. The

degree of inflammation also relating to the bacterial load and to the bacterial

species (Hill at et al, 2000). Consequences of such colonization

and enhanced inflammation on morbidity and lung function is not clear

Hill AT, Campbell EJ, Hill SL, Bayley DL, Stockley RA. Association between airway bacterial load and markers of airway inflammation in patients with stable chronic

bronchitis. Am J Med 2000 Sep;109(4):288-95

Levels of evidenceLevels of evidenceLevelLevel SourceSource

AA Randomized clinical trials Randomized clinical trials (RCT). Several, consistent(RCT). Several, consistent

BB Randomized clinical trials Randomized clinical trials (RCT). Few, inconsistent(RCT). Few, inconsistent

CC Non-randomized clinical Non-randomized clinical trials. Small and/or trials. Small and/or observational studiesobservational studies

DD Opinion of expertsOpinion of experts

Severity of Severity of symptomssymptoms

Threshold forThreshold forIncreasingIncreasing

control control medicationmedication

Poor controlPoor controlPoor compliancePoor compliance

Good controlGood control

Good complianceGood compliance

No of puffs ofNo of puffs ofalbuterolalbuterol

TimeTime

ExacerbatioExacerbationsns

Classification of Asthma SeverityClassification of Asthma Severity

CLASSIFY SEVERITYClinical Features Before Treatment

Symptoms

STEP 4Severe

Persistent

ContinuousLimited physicalactivity

Frequent≤60% predictedVariability >30%

Nighttime Symptoms PEF

STEP 3ModeratePersistent

Daily

Use 2-agonist dailyAttacks limit activity

>1 time week 60-80% predictedVariability >30%

STEP 2Mild

Persistent≥1 time a weekbut <1 time a day >2times a months

≥80% predictedVariability 20-30%

STEP 1Intermittent

<1 time a week

Asymptomatic andnormal PEF betweenattacks

≤2 times a month≥80% predictedVariability <20%

One of the features of severity is sufficient to place a patient in that category

Intensity of treatment

Treatment

MANAGEMENT OF ASTHMAMANAGEMENT OF ASTHMA

Long-acting bronchodilators and/or LTRALong-acting bronchodilators and/or LTRA

Inhaled steroidsInhaled steroids

Short-acting Short-acting 2 agonists prn2 agonists prn

PREVENTIONPREVENTION

Severity of asthmaSeverity of asthma

Oral steroidsOral steroids

Classification by severityStageStage CharacteristicsCharacteristics

0 : At risk0 : At risk Normal spirometry. Chronic symptoms (cough, sputum),Normal spirometry. Chronic symptoms (cough, sputum),

I : MildI : Mild FEV1/FVC < 70%, FEV1 > 80% predicted with or without FEV1/FVC < 70%, FEV1 > 80% predicted with or without symptoms (cough, sputum) symptoms (cough, sputum)

II : ModerateII : Moderate FEV1/FVC < 70%, 30% < FEV1 < 80% predicted with or FEV1/FVC < 70%, 30% < FEV1 < 80% predicted with or without chronic symptoms (cough, sputum, dyspnea) without chronic symptoms (cough, sputum, dyspnea)

(IIA: 50% < FEV1 < 80; (IIA: 50% < FEV1 < 80; IIB: 30 < IIB: 30 < FEV1 < 50)FEV1 < 50)

IV : SevereIV : Severe FEV1/FVC < 70%, FEV1 < 30% predicted or presence of FEV1/FVC < 70%, FEV1 < 30% predicted or presence of respiratory failure or clinical signs of right heart failurerespiratory failure or clinical signs of right heart failure

GOLD guidelines 2001GOLD guidelines 2001

MANAGEMENT OF COPDMANAGEMENT OF COPD

Inhaled SteroidsInhaled Steroids

Anti-cholinergics Anti-cholinergics long-acting long-acting 2 Agonists2 Agonists

Short-acting Short-acting 2 agonists prn2 agonists prn

PREVENTIONPREVENTION

Severity of COPDSeverity of COPD

TheophyllineTheophyllineOral steroidsOral steroids





Differences and similarities betweenDifferences and similarities betweenasthma and COPD asthma and COPD

ASTHMAASTHMASensitizing agentSensitizing agent

COPDCOPDNoxious agentNoxious agent

Asthmatic airwayAsthmatic airwayinflammationinflammation

CD4+ T-lymphocytesCD4+ T-lymphocytes

EosinophilsEosinophils

COPD airway inflammationCOPD airway inflammationCD8+ T-lymphocytesCD8+ T-lymphocytes

MarcrophagesMarcrophages

NeutrophilsNeutrophils

Airflow limitationAirflow limitationCompletelyCompletelyreversiblereversible

CompletelyCompletelyirreversibleirreversible

Airflow limitationAirflow limitation

Bronchial biopsies from 2 asthmatics of similar Bronchial biopsies from 2 asthmatics of similar age and with similar degree of fixed airflow age and with similar degree of fixed airflow

limitationlimitation

Characteristics of patients with fixed Characteristics of patients with fixed airflow limitationairflow limitation

COPDCOPD ASTHMAASTHMA

NumberNumber

AgeAge

Males/FemalesMales/Females

NS/ExS/SNS/ExS/S

AtopyAtopy

2929

67 + 1.767 + 1.7

19/1019/10

2/23/42/23/4

3/293/29

1919

64 + 1.964 + 1.9

12/712/7

14/5/014/5/0

16/1916/19

FEVFEV11 56 + 356 + 3 56 + 256 + 2

ReversibilityReversibility 4.7 + 0.94.7 + 0.9 8.7 + 2.4*8.7 + 2.4*

Fixed airflow limitation in Asthma and COPDFixed airflow limitation in Asthma and COPD

L/sL/s

100100

150150

200200

250250

300300

FEV1 changes after bronchodilatorFEV1 changes after bronchodilator

%%

00

22

44

66

88

1010

1212

1414

1616 HistoryHistoryof Asthmaof Asthma

No historyNo historyof Asthmaof Asthma

HistoryHistoryof Asthmaof Asthma


****

Fixed airflow limitation in Asthma and Fixed airflow limitation in Asthma and COPDCOPD

% p

red

icte

d%

pre

dic

ted

00

100100

200200

300300

400400

ml

ml

00

22

44

66

88

1010

1212

1414

********

FEVFEV11 changes after oral corticosteroids changes after oral corticosteroids







Airway Responsiveness to methacholineAirway Responsiveness to methacholineM

eth

acho

line

PC

Met

hac

holi

ne P

C2020

FE

V1

FE

V1

(mg/

ml)

(mg/

ml)


0,10,1

11

1010

LL

1,51,5

2,02,0

2,52,5

3,03,0

Residual VolumeResidual Volume

% pred% pred

100100

125125

150150 HistoryHistoryof Asthmaof Asthma




****



0,50,5

1,01,0

1,51,5

Carbon monoxide diffusion capacity (Kco)Carbon monoxide diffusion capacity (Kco) % predicted% predicted

3030

4040

5050

6060

7070

8080

9090

100100

110110

120120

HistoryHistoryof Athmaof Athma




************ mmol minmmol min-1-1 l- l-11

SPUTUMSPUTUM % cells% cells

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100

110110

120120

MacrophagesMacrophages EosinophilsEosinophils LymphocytesLymphocytesNeutrophilsNeutrophils

********


History ofHistory ofAsthmaAsthma

No history No history of asthmaof asthma

Exh

aled

NO

Exh

aled

NO

(ppb

)(p

pb)

00

1010

2020

3030

4040

5050

6060



Exhaled Nitric OxideExhaled Nitric Oxide

******


HIGH RESOLUTION COMPUTED TOMOGRAPHYHIGH RESOLUTION COMPUTED TOMOGRAPHY

(HRCT) IS DIFFERENT IN PATIENTS WITH FIXED (HRCT) IS DIFFERENT IN PATIENTS WITH FIXED

AIRFLOW LIMITATION DUE TO SMOKING OR TO ASTHMAAIRFLOW LIMITATION DUE TO SMOKING OR TO ASTHMA

Patients with fixed airflow limitation due to smoking Patients with fixed airflow limitation due to smoking

maintain distinct radiological and functional maintain distinct radiological and functional

characteristics from patients with a history of asthma, characteristics from patients with a history of asthma,

even when they develop fixed airflow limitation, even when they develop fixed airflow limitation,

suggesting that fixed airflow limitation suggesting that fixed airflow limitation

does not define a unique disease entity.does not define a unique disease entity.

Romagnoli M et al, American Thoracic Society 2002, Atlanta, submittedRomagnoli M et al, American Thoracic Society 2002, Atlanta, submitted





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