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ChronicObstructivePulmonaryDisease
andAsthmaUpdate
JohnL.Faul,MDFCCPAssistantProfessor,DivisionofPulmonary/CriticalCareMedicineStanfordUniversityChronicObstructivePulmonaryChronicObstructivePulmonaryCOPD:OutlineEpidemiologyDefinitionsMedicalmanagementHypoxiaInfectionsVaccination
COPD:OutlineEpidemiologyCOPD:OutlineEpidemiologyCOPD:UniversalProblem
UniversalProblem
UniversalProblem
UniversalPCOPD:epidemiology14millionintheUSwithCOPD12.5millionwithchronicbronchitis1.65millionwithemphysema4thleadingcauseofdeathinUS3rdmostfrequentdiagnosisofpatientsreceivinghomecareCOPD:epidemiology14millioniCOPD:epidemiology14millioniPrevalenceofCOPDintheUS*Age-adjustedto2000USpopulation.?Representsastatisticallysignificantdifferencefromrateamongmales.Manninoetal.MMWR.2002;51(SS-6):1-16.Rate/1,000Population*020304050607080901980198219841986YearMaleFemaleTotal101988199019921994199619982000Since1987,theprevalenceofCOPDamongwomenhasbeensignificantlyhigherthanthatamongmen???????????????PrevalenceofCOPDintheUS*APrevalenceofCOPDintheUS*ACOPD:
TheUsualSuspectsCOPD:
TheUsualSuspectsCOPD:
TheUsualSuspectsCOPD:
COPD:riskfactorstobaccosmokingaccountsfor80-90%oftheriskofdevelopingCOPDageofstarting,totalpack-yearsandcurrentsmokingstatusarepredictiveofmortalityonly15%ofsmokersdevelopclinicallysignificantCOPDalpha1-antitrypsindeficiency(accountsforlessthan1%ofallCOPDcases)occupationalexposurestodustsandfumesCOPD:riskfactorstobaccosmokCOPD:riskfactorstobaccosmokLungfunctiondeclineswithageLungfunctiondeclineswithagLungfunctiondeclineswithagElastictissueislostinemphysemaElastictissueislostinemphElastictissueislostinemphCOPD:definitionsChronicbronchitis---aclinicaldefinition:“thepresenceofchronicproductivecoughfor3monthsineachof2successiveyearsinapatientinwhomothercausesofchroniccoughhavebeenexcluded”Emphysema---apathologicdefinition:“abnormalpermanentenlargementoftheairspacesdistaltotheterminalbronchiolesaccompaniedbydestructionoftheirwalls”COPD:definitionsChronicbroncCOPD:definitionsChronicbronc
Pinkpuffers
&
Bluebloaters
Pinkpuffers
&
Blue
Pinkpuffers
&
BlueCOPD:HyperinflationIncreasedretrosternalairspaceFlatdiaphragmsIncreasedAPdiameterCOPD:HyperinflationIncreasedCOPD:HyperinflationIncreasedCOPDCOPDCOPDCOPDCOPD:OxygentherapyOxygentherapyinCOPD:extendslifeinhypoxemicpatientsNOTTtrial,AnnIntMed1980;93:391-398MRCtrial,Lancet1981;1:681-685strengthenscardiacfunction,improvesexerciseperformanceandADLswhenFEV1<1.0L(or<50%predicted)an ABGshouldbedoneHomeO2costsintheUS/yr:$2,400,000,000COPD:OxygentherapyOxygentheCOPD:OxygentherapyOxygentheOxygenDissociationCurve1008060BelowPaO2=60mmHg,Hemoglobinrapidlylosesoxygencarryingcapacity (West:TextbookofPhysiology)
HemoglobinSaturation%406080__________40__200iiiAt80mmHg,95%satAt60mmHg,90%satAt40mmHg,70%satPaO2(mmHg)OxygenDissociationCurve10080OxygenDissociationCurve10080HypoxicPulmonaryVasoconstrictionThelungregulatesbloodflowaccordingtoitsoxygencontentAlowvenousoxygencontent(lowoxygencontentinthepulmonaryartery)preventsbloodflowtothelungBloodFlow%Airsack(Alveolar)OxygenWest:TextbookofPhysiologyOxygen-sensitivechemoreceptorslocatedinthepulmonaryarteriolearethedominantcontrollersofpulmonaryvasculartone FishmanAP:Hypoxiaonthepulmonarycirculation.Howandwhereitacts. CircRes1976;38:221–231HypoxicPulmonaryVasoconstricHypoxicPulmonaryVasoconstricCOPD:acaseinpointCC:Mrs.H.isa67y.ofemalewith worseningdyspneaxseveralyearswhopresentsfor2ndopinionregardingdiagnoses,andmanagement,ofher“breathingproblem”herpastdiagnoseshaveincludedasthma,bronchitis,andemphysemashewantstoknowexactlywhatshehas...COPD:acaseinpointCC:MrsCOPD:acaseinpointCC:MrsCOPD:acaseinpointHerdyspneaismuchworseinthelastyear,tothepointthatshecannolongerbatheorcookwithouthelp...Shehasanoccasionalcough,productiveofscantsputum...Shesmoked2ppdx40yearsbutquit6yearsago...COPD:acaseinpointHerdyspnCOPD:acaseinpointHerdyspnCOPD:acaseinpointShetakesthefollowingmedications:albuterolMDI2-4puffsQIDandprnthisisher“favorite”medicineatroventMDI2puffsQIDshe’snotsurethisonehelps,butmaybetheophylline200mgBIDsomedoctorgaveherthis“yearsago”prednisone10mgQDcontinuouslyfor3yearswithoccasionalincreasesshe’snevertakenanyestrogenreplacementCOPD:acaseinpointShetakesCOPD:acaseinpointShetakesCOPD:acaseinpointShe’stakesantibiotics6-7times/yearwhenherbreathing“getsreallybad”She’sbeenon
oxygen
butdoesn’tlikeitShe’stooshortofbreathtodoanyexerciseShehasbeeninthehospital4timesinthelastyearandwasintubatedonce,6monthsagoHPI:COPD:acaseinpointShe’stakCOPD:acaseinpointShe’stakExacerbationofCOPD
Anthonisenetal,AnnIntMed1987;106:196Saintetal,JAMA1995;273(12):957If2of3followingcriteriaaremet:increasingdyspneaincreasedsputumvolumeincreasedsputumpurulenceExacerbationofCOPD
If2of3ExacerbationofCOPD
If2of3ExacerbationofCOPD
NoninfectiousandinfectiousInfectionsincludeviralControversialifallsputumculturesarecausativeForpatientswith2orespecially3cardinalfeatures,antibioticsareusefulShortcoursesofantibioticsareuseful AmsdenGWetal.,Chest2003:123:772-777ExacerbationofCOPD
NoninfecExacerbationofCOPD
NoninfecAntimicrobialTherapyOralagentsusedearlierintherapyMonotherapyusedwheneverpossiblePatientcompliance(once-dailydosing)ComprehensivediseasemanagementAntimicrobialTherapyOralagenAntimicrobialTherapyOralagenVaccinationsandCOPD
Annualinfluenzavaccine:Reductionsinexacerbationratesparticularlywithin3weeks.Noevidenceofaneffectofintranasalliveattenuatedviruswhenthiswasaddedtoinactivatedintramuscularvaccination.
Pneumococcalvaccineevery5yearsNoevidencethatpneumococcalvaccinereducestheseverityofCOPDPoolePJ.CochraneDatabaseSystRev.2000;(4):CD002733.LeechJA.CMAJ.1987:136(4):361-5.
VaccinationsandCOPD
AnnualiVaccinationsandCOPD
AnnualiCOPD:oralsteroidsforERdischargesAaronSD.NEnglJMed.2003;348(26):2618-25.
%relapsefreeDayn=147,Pred40/dayfor10days***COPD:oralsteroidsforERdisCOPD:oralsteroidsforERdisVladtheInhalerVladtheInhalerVladtheInhalerVladtheInhalCOPD:inhaledsteroidsandLABACalverleyP.Lancet.2003Feb8;361(9356):449-56ChangeInFEV1(ml)
n=1465******COPD:inhaledsteroidsandLABCOPD:inhaledsteroidsandLABPeakFlowRates
Tiotropium
versus
Salmeterol
DonohueJFChest2002.122:47-55.
PeakFlowRates
Tiotropium
vPeakFlowRates
Tiotropium
vCOPD:smokingcessationTobaccosmokingisthemostimportantfactorinCOPD,andstoppingsmokingistheonlyinterventionknowntomodifythenaturalhistoryofairwaysobstruction.COPD:smokingcessationTobaccoCOPD:smokingcessationTobaccoCOPD:smokingcessation%abstinence**TonstadS.EurHeartJ.2003May;24(10):946-55.COPD:smokingcessation%abstiCOPD:smokingcessation%absti
COPD:advancedtherapiesBullectomyLungvolumereductionsurgery(LVRS)TransplantationSurgeryforemphysema:
COPD:advancedtherapiesBulle
COPD:advancedtherapiesBulleGOLD’03ClassificationofCOPD*respiratoryfailure:PaO2<60mmHgwithorw/oPaCO2>50mmHgGOLD’03ClassificationofCOGOLD’03ClassificationofCOTherapyatEachStageofCOPDGoldUpdate2003*FEV1/FVC<70%TherapyatEachStageofCOPDGTherapyatEachStageofCOPDG
COPD:managementStopsmokingLong-termoxygenInhaledsteroidsandlong-actingbetaagonistsDietandexerciseTreatacuteexacerbationsMonitorlungfunctionVaccinate
COPD:managementStopsmoking
COPD:managementStopsmoking
AsthmaFactsintheUnitedStatesAnnualnumberofhospitalizations:478,000Annualnumberofdeathsfromasthma:4,657Annualnumberofworkdayslost:14.5millionAnnualnumberofschooldayslost:14millionEstimateddirectandindirectmedicalcosts:$16billion(needsvalidation)MorbMortalWklyRep.2002March29;51:1-13.AsthmaFactsintheUnitedStaAsthmaFactsintheUnitedStaSmoothMuscleDysfunctionAirway
InflammationInflammatoryCellActivationMucosalEdemaProliferationEpithelialDamageB.MembraneThickeningBronchoconstrictionBronchialHyperreactivityHypertrophyHyperplasiaSymptoms/ExacerbationsAsthmaPathophysiologySmoothMuscleAirway
InflammatSmoothMuscleAirway
InflammatFlow(l/s)Vol(l)-20-41324521345-6Pre-albuterolPost-albuterolPredictedSpirometryFlow(l/s)Vol(l)-20-413245213Flow(l/s)Vol(l)-20-413245213EosinophilsinHumanBronchiEosinophilsinHumanBronchiEosinophilsinHumanBronchiEoChangesinEG2duringFPtherapy
FaulJL,Thorax1998.53,753-61ChangesinEG2duringFPtheraChangesinEG2duringFPtheraChangeinMeanPeakFlowwiththerapyHaahtelaT.NEnglJMed1994,331:700ChangeinMeanPeakFlowwithChangeinMeanPeakFlowwithChangeinMeanPeakFlowwiththerapyGreeningAP.Lancet1994,344:219-24ChangeinMeanPeakFlowwithChangeinMeanPeakFlowwithStudyDayProbability
ofRemainingintheStudy1.00.80.60.40.2Sal/FP100/50
FP100
Salmeterol50
Placebo*3%0 7 14 21 28 35 42 49 56 63 70 77 11%35%49%ComparisonofAsthmaTherapiesKavuruMetal.JAllergyClinImmunol.2000;105:1108-1116.StudyDayProbability
ofRemaiStudyDayProbability
ofRemaiTimetoFirstExacerbation*10095908580750 2 4 6 8 10 12 14 16 18 20 22 24TimetoFirstExacerbation(weeks)Exacerbation-Free
Patients(%)FP88mcgb.i.d.+Salmeterol
FP220mcgb.i.d.MatzJetal.JAllergyClinImmunol.2000;105:162S.TimetoFirstExacerbation*100TimetoFirstExacerbation*100Kavuruetal.JAllergyClinImmunol.2000;105:1108-1116.
Dataonfile,GlaxoWellcomeInc.WeekMeanChange
fromBaseline
inFEV1(%)3025201510500 2 4 6 8 10 12 Endpoint15%
[0.28L]5%
[0.11L]2%
[0.01L]Sal/FP100/50FP100Salmeterol50Placebo25%
[0.51L]**P0.008vsFP100,salmeterol50,andplaceboatendpoint.Dosesinmcgb.i.d.PatientsTreatedWithADVAIR?Diskus?100/50hadaSignificantlyGreaterImprovementinFEV1Kavuruetal.JAllergyClinIKavuruetal.JAllergyClinINoonanetal.AmJRespirCritCareMed.1999;159(3):640.Reissetal.ArchInternMed.1998;158:1213-1220.FEV1(%
ChangefromBaseline;Mean
±SE)StudyWeeks(Postrandomization)302520151050-5036912151923313947526068768492100108116124132140CumulativeExtensionPlaceboMontelukastBeclomethasonePrimaryStudyPatients(15Years)NotControlledonPRNBeta-Agonists
ImprovedFEV1(Study1andExtension)Noonanetal.AmJRespirCritNoonanetal.AmJRespirCritProportion
ofPatients
WithoutAsthmaAttackDaysSinceRandomizationBeclomethasone(n=248)Montelukast(n=379)Placebo(n=253)P=0.006MontelukastvsplaceboP=0.001BeclomethasonevsplaceboP=0.129Montelukastvsbeclomethasone10.950.900.850.800.750.700102030405060708090Patients(15Years)NotControlledonPRNBeta-Agonists
Malmstrometal.AnnInternMed.1999;130:487-495.Inthisstudy,allpatientsbenefitedfrommandatoryuseofspacers,enforcedcompliance,andrigorousmonitoringofpatientsProportion
ofPatients
WithoutProportion
ofPatients
WithoutAnti-IgEAsthmaTherapiesruhMAbE-25****NS*MilgromH.NEnglJMed.199923;341(26):1966-73.SxAnti-IgEAsthmaTherapiesruhMAnti-IgEAsthmaTherapiesruhMASTHMA:acaseinpointCC:Ms.B.isa22
y.ofemalewith episodicdyspneax2yearswhopresentsfor2ndopinionregardingdiagnoses,andmanagement,ofher“breathingproblem”herpastdiagnoseshaveincludedasthma,bronchitis,andallergiesshewantstoknowexactlywhatshehas...ASTHMA:acaseinpointCC:MASTHMA:acaseinpointCC:MASTHMA:acaseinpointHerdyspneaismuchworseinthelastyear,tothepointthatsheoccasionallyhastoskipclassandonceshehashadtogototheED...Shehasanoccasionalcough,productiveofgreensputum...Sheneversmokedsheisallergictopollenandcats...She’saStanfordstudentwhoeatsa“healthydietandtakeslotsofvitamins”ASTHMA:acaseinpointHerdysASTHMA:acaseinpointHerdysAcaseinpointShetakesthefollowingmedications:albuterolMDI2-4puffsQIDandprnthisisher“favorite”medicineprednisone10mgQDsheisjustfinishingasteroidtaperthatwasprescribedafterhermostrecentEmergencyRoomvisitshe’snevertakenanysteroidinhaler,becausetheydon’tworkandshe’sfearfuloftheiradverseeffectsAcaseinpointShetakesthefAcaseinpointShetakesthefCOPD:acaseinpointShe’stakesantibiotics5times/yearwhenherbreathing“getsreallybad”ShesometimeswheezesafterexerciseShehasbeenintheED4timesinherlifetime,wasadmittedonce,buthasnotbeenintubatedHPI:COPD:acaseinpointShe’stakCOPD:acaseinpointShe’stakConsiderationsinAsthmaTherapyEfficacyConvenienceControlAdverseeffectsConsiderationsinAsthmaTheraConsiderationsinAsthmaTheraAdverseeffectsofAsthmaTherapyBetaagonists:tremor,tachycardiaInhaledsteroids:Voice,Bones,?MetabolicLKRAs:HeadachePrednisone:Cushing’ssyndromeAdverseeffectsofAsthmaTherAdverseeffectsofAsthmaTher012340130135140145140145150012346.56.05.55.04.50.0Time(yrs)Time(yrs)StandingHeight(cm)Standing-heightVelocity(cm/yr)NEnglJMed2000;343:1054-63.BudesonideNedocromilPlaceboBudesonideNedocromilPlaceboLong-TermEffectsofBudesonideorNedocromilinChildrenwithAsthma012340130135140145140145150012012340130135140145140145150012TheRuleofTwos
(WhoNeedsControllerTherapy)Twobeta-agonistcanisters/yearTwodosesofbeta-agonist/weekTwonocturnalawakenings/monthTwounscheduledvisits/yearTwoprednisonebursts/yearTheRuleofTwos
(WhoNeedsCoTheRuleofTwos
(WhoNeedsCo2002NAEPPGUIDLINESSTEP1:MildIntermittentAsthma
SymptomsPresent<2days/weekBriefExacerbationsNighttimeSymptoms<2nights/monthAsymptommaticwithnormallungfunctionbetweenexacerbationsFEV1andPEF>80%predictedPEFvariability<20%NodailymedicationSevereexacerbationsmayoccur–acourseoforalcorticosteroids2002NAEPPGUIDLINESSTEP1:Mi2002NAEPPGUIDLINESSTEP1:Mi2002NAEPPGUIDELINESStep2:MildPersistentAsthma
Symptomspresent>2x/weekbut<1x/dayExacerbationsmayaffectactivityNighttimesymptoms>2x/monthFEV1andPEF80%predictedPEFvariability20-30%Dailylow-doseinhaledcorticosteroidsORLeukotrienemodifier,theophylline2002NAEPPGUIDELINESStep2:M2002NAEPPGUIDELINESStep2:M2002NAEPPGUIDELINESStep3:ModeratePersistentAsthma
SymptomsdailyExacerbationsaffectactivityNighttimesymptoms>1x/weekFEV1andPEF60-80%predictedPEFvariability>30%Low-mediumdoseinhaledcorticosteroidswithlong-actingBetaagonistORLeukotrienemodifier,theophylline2002NAEPPGUIDELINESStep3:M2002NAEPPGUIDELINESStep3:M2002NAEPPGUIDELINESStep4:SeverePersistentAsthma
ContinualSymptomsExacerbationsaffectactivityNighttimesymptomsfrequentFEV1andPEF<60%predictedPEFvariability>30%High-doseinhaledcorticosteroidsAndLong-actingbetaagonistANDoralcorticosteroids(2mg/kg/day)2002NAEPPGUIDELINESStep4:S2002NAEPPGUIDELINESStep4:SChronicObstructivePulmonaryDisease
andAsthmaUpdate
JohnL.Faul,MDFCCPAssistantProfessor,DivisionofPulmonary/CriticalCareMedicineStanfordUniversityChronicObstructivePulmonaryChronicObstructivePulmonaryCOPD:OutlineEpidemiologyDefinitionsMedicalmanagementHypoxiaInfectionsVaccination
COPD:OutlineEpidemiologyCOPD:OutlineEpidemiologyCOPD:UniversalProblem
UniversalProblem
UniversalProblem
UniversalPCOPD:epidemiology14millionintheUSwithCOPD12.5millionwithchronicbronchitis1.65millionwithemphysema4thleadingcauseofdeathinUS3rdmostfrequentdiagnosisofpatientsreceivinghomecareCOPD:epidemiology14millioniCOPD:epidemiology14millioniPrevalenceofCOPDintheUS*Age-adjustedto2000USpopulation.?Representsastatisticallysignificantdifferencefromrateamongmales.Manninoetal.MMWR.2002;51(SS-6):1-16.Rate/1,000Population*020304050607080901980198219841986YearMaleFemaleTotal101988199019921994199619982000Since1987,theprevalenceofCOPDamongwomenhasbeensignificantlyhigherthanthatamongmen???????????????PrevalenceofCOPDintheUS*APrevalenceofCOPDintheUS*ACOPD:
TheUsualSuspectsCOPD:
TheUsualSuspectsCOPD:
TheUsualSuspectsCOPD:
COPD:riskfactorstobaccosmokingaccountsfor80-90%oftheriskofdevelopingCOPDageofstarting,totalpack-yearsandcurrentsmokingstatusarepredictiveofmortalityonly15%ofsmokersdevelopclinicallysignificantCOPDalpha1-antitrypsindeficiency(accountsforlessthan1%ofallCOPDcases)occupationalexposurestodustsandfumesCOPD:riskfactorstobaccosmokCOPD:riskfactorstobaccosmokLungfunctiondeclineswithageLungfunctiondeclineswithagLungfunctiondeclineswithagElastictissueislostinemphysemaElastictissueislostinemphElastictissueislostinemphCOPD:definitionsChronicbronchitis---aclinicaldefinition:“thepresenceofchronicproductivecoughfor3monthsineachof2successiveyearsinapatientinwhomothercausesofchroniccoughhavebeenexcluded”Emphysema---apathologicdefinition:“abnormalpermanentenlargementoftheairspacesdistaltotheterminalbronchiolesaccompaniedbydestructionoftheirwalls”COPD:definitionsChronicbroncCOPD:definitionsChronicbronc
Pinkpuffers
&
Bluebloaters
Pinkpuffers
&
Blue
Pinkpuffers
&
BlueCOPD:HyperinflationIncreasedretrosternalairspaceFlatdiaphragmsIncreasedAPdiameterCOPD:HyperinflationIncreasedCOPD:HyperinflationIncreasedCOPDCOPDCOPDCOPDCOPD:OxygentherapyOxygentherapyinCOPD:extendslifeinhypoxemicpatientsNOTTtrial,AnnIntMed1980;93:391-398MRCtrial,Lancet1981;1:681-685strengthenscardiacfunction,improvesexerciseperformanceandADLswhenFEV1<1.0L(or<50%predicted)an ABGshouldbedoneHomeO2costsintheUS/yr:$2,400,000,000COPD:OxygentherapyOxygentheCOPD:OxygentherapyOxygentheOxygenDissociationCurve1008060BelowPaO2=60mmHg,Hemoglobinrapidlylosesoxygencarryingcapacity (West:TextbookofPhysiology)
HemoglobinSaturation%406080__________40__200iiiAt80mmHg,95%satAt60mmHg,90%satAt40mmHg,70%satPaO2(mmHg)OxygenDissociationCurve10080OxygenDissociationCurve10080HypoxicPulmonaryVasoconstrictionThelungregulatesbloodflowaccordingtoitsoxygencontentAlowvenousoxygencontent(lowoxygencontentinthepulmonaryartery)preventsbloodflowtothelungBloodFlow%Airsack(Alveolar)OxygenWest:TextbookofPhysiologyOxygen-sensitivechemoreceptorslocatedinthepulmonaryarteriolearethedominantcontrollersofpulmonaryvasculartone FishmanAP:Hypoxiaonthepulmonarycirculation.Howandwhereitacts. CircRes1976;38:221–231HypoxicPulmonaryVasoconstricHypoxicPulmonaryVasoconstricCOPD:acaseinpointCC:Mrs.H.isa67y.ofemalewith worseningdyspneaxseveralyearswhopresentsfor2ndopinionregardingdiagnoses,andmanagement,ofher“breathingproblem”herpastdiagnoseshaveincludedasthma,bronchitis,andemphysemashewantstoknowexactlywhatshehas...COPD:acaseinpointCC:MrsCOPD:acaseinpointCC:MrsCOPD:acaseinpointHerdyspneaismuchworseinthelastyear,tothepointthatshecannolongerbatheorcookwithouthelp...Shehasanoccasionalcough,productiveofscantsputum...Shesmoked2ppdx40yearsbutquit6yearsago...COPD:acaseinpointHerdyspnCOPD:acaseinpointHerdyspnCOPD:acaseinpointShetakesthefollowingmedications:albuterolMDI2-4puffsQIDandprnthisisher“favorite”medicineatroventMDI2puffsQIDshe’snotsurethisonehelps,butmaybetheophylline200mgBIDsomedoctorgaveherthis“yearsago”prednisone10mgQDcontinuouslyfor3yearswithoccasionalincreasesshe’snevertakenanyestrogenreplacementCOPD:acaseinpointShetakesCOPD:acaseinpointShetakesCOPD:acaseinpointShe’stakesantibiotics6-7times/yearwhenherbreathing“getsreallybad”She’sbeenon
oxygen
butdoesn’tlikeitShe’stooshortofbreathtodoanyexerciseShehasbeeninthehospital4timesinthelastyearandwasintubatedonce,6monthsagoHPI:COPD:acaseinpointShe’stakCOPD:acaseinpointShe’stakExacerbationofCOPD
Anthonisenetal,AnnIntMed1987;106:196Saintetal,JAMA1995;273(12):957If2of3followingcriteriaaremet:increasingdyspneaincreasedsputumvolumeincreasedsputumpurulenceExacerbationofCOPD
If2of3ExacerbationofCOPD
If2of3ExacerbationofCOPD
NoninfectiousandinfectiousInfectionsincludeviralControversialifallsputumculturesarecausativeForpatientswith2orespecially3cardinalfeatures,antibioticsareusefulShortcoursesofantibioticsareuseful AmsdenGWetal.,Chest2003:123:772-777ExacerbationofCOPD
NoninfecExacerbationofCOPD
NoninfecAntimicrobialTherapyOralagentsusedearlierintherapyMonotherapyusedwheneverpossiblePatientcompliance(once-dailydosing)ComprehensivediseasemanagementAntimicrobialTherapyOralagenAntimicrobialTherapyOralagenVaccinationsandCOPD
Annualinfluenzavaccine:Reductionsinexacerbationratesparticularlywithin3weeks.Noevidenceofaneffectofintranasalliveattenuatedviruswhenthiswasaddedtoinactivatedintramuscularvaccination.
Pneumococcalvaccineevery5yearsNoevidencethatpneumococcalvaccinereducestheseverityofCOPDPoolePJ.CochraneDatabaseSystRev.2000;(4):CD002733.LeechJA.CMAJ.1987:136(4):361-5.
VaccinationsandCOPD
AnnualiVaccinationsandCOPD
AnnualiCOPD:oralsteroidsforERdischargesAaronSD.NEnglJMed.2003;348(26):2618-25.
%relapsefreeDayn=147,Pred40/dayfor10days***COPD:oralsteroidsforERdisCOPD:oralsteroidsforERdisVladtheInhalerVladtheInhalerVladtheInhalerVladtheInhalCOPD:inhaledsteroidsandLABACalverleyP.Lancet.2003Feb8;361(9356):449-56ChangeInFEV1(ml)
n=1465******COPD:inhaledsteroidsandLABCOPD:inhaledsteroidsandLABPeakFlowRates
Tiotropium
versus
Salmeterol
DonohueJFChest2002.122:47-55.
PeakFlowRates
Tiotropium
vPeakFlowRates
Tiotropium
vCOPD:smokingcessationTobaccosmokingisthemostimportantfactorinCOPD,andstoppingsmokingistheonlyinterventionknowntomodifythenaturalhistoryofairwaysobstruction.COPD:smokingcessationTobaccoCOPD:smokingcessationTobaccoCOPD:smokingcessation%abstinence**TonstadS.EurHeartJ.2003May;24(10):946-55.COPD:smokingcessation%abstiCOPD:smokingcessation%absti
COPD:advancedtherapiesBullectomyLungvolumereductionsurgery(LVRS)TransplantationSurgeryforemphysema:
COPD:advancedtherapiesBulle
COPD:advancedtherapiesBulleGOLD’03ClassificationofCOPD*respiratoryfailure:PaO2<60mmHgwithorw/oPaCO2>50mmHgGOLD’03ClassificationofCOGOLD’03ClassificationofCOTherapyatEachStageofCOPDGoldUpdate2003*FEV1/FVC<70%TherapyatEachStageofCOPDGTherapyatEachStageofCOPDG
COPD:managementStopsmokingLong-termoxygenInhaledsteroidsandlong-actingbetaagonistsDietandexerciseTreatacuteexacerbationsMonitorlungfunctionVaccinate
COPD:managementStopsmoking
COPD:managementStopsmoking
AsthmaFactsintheUnitedStatesAnnualnumberofhospitalizations:478,000Annualnumberofdeathsfromasthma:4,657Annualnumberofworkdayslost:14.5millionAnnualnumberofschooldayslost:14millionEstimateddirectandindirectmedicalcosts:$16billion(needsvalidation)MorbMortalWklyRep.2002March29;51:1-13.AsthmaFactsintheUnitedStaAsthmaFactsintheUnitedStaSmoothMuscleDysfunctionAirway
InflammationInflammatoryCellActivationMucosalEdemaProliferationEpithelialDamageB.MembraneThickeningBronchoconstrictionBronchialHyperreactivityHypertrophyHyperplasiaSymptoms/ExacerbationsAsthmaPathophysiologySmoothMuscleAirway
InflammatSmoothMuscleAirway
InflammatFlow(l/s)Vol(l)-20-41324521345-6Pre-albuterolPost-albuterolPredictedSpirometryFlow(l/s)Vol(l)-20-413245213Flow(l/s)Vol(l)-20-413245213EosinophilsinHumanBronchiEosinophilsinHumanBronchiEosinophilsinHumanBronchiEoChangesinEG2duringFPtherapy
FaulJL,Thorax1998.53,753-61ChangesinEG2duringFPtheraChangesinEG2duringFPtheraChangeinMeanPeakFlowwiththerapyHaahtelaT.NEnglJMed1994,331:700ChangeinMeanPeakFlowwithChangeinMeanPeakFlowwithChangeinMeanPeakFlowwiththerapyGreeningAP.Lancet1994,344:219-24ChangeinMeanPeakFlowwithChangeinMeanPeakFlowwithStudyDayProbability
ofRemainingintheStudy1.00.80.60.40.2Sal/FP100/50
FP100
Salmeterol50
Placebo*3%0 7 14 21 28 35 42 49 56 63 70 77 11%35%49%ComparisonofAsthmaTherapiesKavuruMetal.JAllergyClinImmunol.2000;105:1108-1116.StudyDayProbability
ofRemaiStudyDayProbability
ofRemaiTimetoFirstExacerbation*10095908580750 2 4 6 8 10 12 14 16 18 20 22 24TimetoFirstExacerbation(weeks)Exacerbation-Free
Patients(%)FP88mcgb.i.d.+Salmeterol
FP220mcgb.i.d.MatzJetal.JAllergyClinImmunol.2000;105:162S.TimetoFirstExacerbation*100TimetoFirstExacerbation*100Kavuruetal.JAllergyClinImmunol.2000;105:1108-1116.
Dataonfile,GlaxoWellcomeInc.WeekMeanChange
fromBaseline
inFEV1(%)3025201510500 2 4 6 8 10 12 Endpoint15%
[0.28L]5%
[0.11L]2%
[0.01L]Sal/FP100/50FP100Salmeterol50Placebo25%
[0.51
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