Unmet needs in COPD: COPD Guidelines 2011

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My presentation “Unmet needs in COPD” dedicated to modern COPD guidelines.
Visit our site: http://respiratorydecade.blogspot.com/

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  • It¨s a good presentation.
    Could you please send me this ppt? thank you so much.
    My email: antoniocochachi07@yahoo.es
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  • Great PPT! Please consider sending so that I might share with Nurse practitioner students learning to care for respiratory disease states. Thanks dkfitzpatrick@comcast.net
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  • Very excellent ppt,please would you send me this ppt to me for teaching medicine student in Taiwan NCKUH. My email : joshcclin@gmail.com Thanks a lot
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  • Very good ppt,please would you send me this ppt.
    My email : eli.janeva@yahoo.com Thanks a lot
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  • I would appreciate a copy of this ppt presentation if you are open to sharing it. Please email to me at lbrauer@comcast.net
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  • In majoritatea ţărilor prevalenţa BPOC-ul este subestimată, nefiind diagnosticat de regulă decât când este aparent clinic şi de severitate moderată Prevalenţa BPOC variază între 0,23%-18,3%, cele mai multe tari 4-10%(R. J. Halbert si col, Chest 2003); şi creşte cu vârsta şi cu statutul de fumător Studii efectuate – BOLD, PLATINO Variaţiile de prevalenţă între diverse ţări se datorează diferenţelor în metodele de diagnostic, anul studiului, vârsta populaţiei implicată în studiu şi prevalenţa factorilor de risc majori cum ar fi fumatul
  • Between September 2009 and September 2010, there were a very large number of publications concerning COPD. It is a difficult task to provide an overview of so many publications I have therefore been forced to make difficult choices and I would like to apologise to the audience and the authors if I have omitted certain excellent papers on COPD COPD is a complex disease characterized by considerable heterogeneity in the intensity and extent of lung and airway damage and in clinical presentation, leading to important differences in disease progression and patient outcome The complexity and diversity of disease phenotypes results from the effects of many factors, and these effects are not fully understood. I have chosen a large number of papers that I believe have constituted major steps forward in our understanding of the factors influencing COPD phenotype I will successively review papers that have greatly improved our knowledge of the factors affecting COPD phenotype. I will also review new findings in the following domains: Mechanisms of inflammation in the pathogenesis of tissue destruction and inflammation in the lung parenchyma and airways The influence of genetics The role of comorbidities New insight into the phenotypes of the disease I will end this presentation by giving an oveview on new data concerning the treatment of COPD
  • Attempts to identify phenotypes began as early as 1955, when Dornhorst proposed the distinction between pink puffers and blue bloaters
  • The pathophysiology of COPD is complex: it cannot be attributed to any single cause and hence it can be described as a multi-component disease To have clinical efficacy in COPD it is necessary to treat more than one component BPCO se consideră boală sistemică cu manifestări sistemice (pierderea masei corporale, slăbiciune musculară , etc ), care nu pot fi apreciate numai după funcţia pulmonară
  • Non-proportional Venn diagram showing the number of overlapping conditions in patients with asthma, emphysema and chronic bronchitis (reproduced with permission from the American Journal of Respiratory and Critical Care Medicine). COPD, chronic obstructive pulmonary disease. Nonproportional Venn diagram of COPD showing subsets of patients with chronic bronchitis, emphysema, and asthma. The subsets comprising COPD are shaded. Subset areas are not proportional to the actual relative subset sizes. Asthma is by definition associated with reversible airflow obstruction, although in variant asthma special maneuvers may be necessary to make the obstruction evident. Patients with asthma whose airflow obstruction is completely reversible (ie, subset 9) are not considered to have COPD. Because in many cases it is virtually impossible to differentiate patients with asthma whose airflow obstruction does not remit completely from persons with chronic bronchitis and emphysema who have partially reversible airflow obstruction with airway hyperreactivity, patients with unremitting asthma are classified as having COPD (ie, subsets 6, 7, and 8). Chronic bronchitis and emphysema with airflow obstruction usually occur together (subset 5), and some patients may have asthma associated with these two disorders (ie, subset 8). Individuals with asthma who have been exposed to chronic irritation, as from cigarette smoke, may develop chronic productive cough, which is a feature of chronic bronchitis (ie, subset 6). Such patients often are referred to in the United States as having asthmatic bronchitis or the asthmatic form of COPD. Persons with chronic bronchitis and/or emphysema without airflow obstruction (ie, subsets 1, 2, and 11) are not classified as having COPD. Patients with airway obstruction due to diseases with known etiology or specific pathology, such as cystic fibrosis or obliterative bronchiolitis (subset 10), are not included in this definition. Reprinted with permission from the American Thoracic Society.6
  • Percentage of adults (by gender) with airflow obstruction who have an overlap syndrome with increasing age. Males are shown in the black bars and females in the white bars. Data from Soriano et al.4
  • Evidenţierea unei hiperreactivităţi bronşice definită prin PC 20 , adică concentraţia de metacolină / histamină care determină o scădere cu 20% a VEMS faţă de valoarea iniţială.
  • This provides a summary of the recommended treatment at each stage of COPD.
  • The pathophysiology of COPD is complex: it cannot be attributed to any single cause and hence it can be described as a multi-component disease To have clinical efficacy in COPD it is necessary to treat more than one component BPCO se consideră boală sistemică cu manifestări sistemice (pierderea masei corporale, slăbiciune musculară , etc ), care nu pot fi apreciate numai după funcţia pulmonară
  • Celli, Cote şi colegii au elaborat în 2004 indicele BODE (Body mass index, airflow Obstruction, Dyspnoea şi Exercise capacity), care a inclus: IMC, VEMS, gradul dispneei şi testul de mers 6 minute. Aceste variabile au fost folosite pentru elaborarea unui scor compozit – predictor mai bun al riscului de deces comparativ cu VEMS. BODE variază pe o scala de la 0-10. Valorile mari (8-10) indică un risc de deces de 80% în următoarele 28 luni, valorile mici (0-3) indică un prognostic mai bun al bolii.
  • A fost dovedit că indicele BODE are capacităţi bune predictive, este o modalitate simplă de calculare şi nu necesită echipament special.
  • Exist ă două aspecte clinico-evolutive care imprimă acestei patologii pulmonare un caracter tipic, particular, distinct printre alte afecţiuni cu evoluţie cronică: exacerbările recurente (acutizări care apar pe parcursul evoluţiei bolii cronice), complicaţiile extrapulmonare şi comorbidităţile frecvente (complicaţiile fac ca BPOC să fie mai mult decât o boală pulmonară iar comorbidităţile asociate sunt foarte diverse: cardiovasculare, DZ, osteoporoză, cancer pulmonar – acestea se află într-o relaţie de intercondiţionare cu BPOC din punct de vedere patogenic şi clinic, evolutiv) Atât exacerbările cât şi comorbidităţile contribuie la scăderea QoL, accelerarea progresiei bolii, creşterea frecvenţei spitalizărilor şi a costurilor aferente îngrijirilor medicale precum şi creşterea mortalităţii. Din aceste motive, în cadrul managementului BPOC, alături de măsurile pentru controlul clinic curent al bolii (reducerea simptomelor şi creşterea toleranţei la efort), se regăsesc măsuri importante din punct de vedere al controlului evoluţiei bolii pe termen lung prin prevenirea şi tratamentul comorbidităţilor precum şi limitarea frecvenţei şi severităţii exacerbărilor.
  • This provides a summary of the recommended treatment at each stage of COPD.
  • ESC heart failure guidelines. Clearly state that most patients with HF and COPD can safely tolerate beta-blocker therapy. Run through.
  • Because physicans and patients, have different views of the same disease. It’s obvious: one is the expert of the disease, and one has a personal experience of the disease But qol provides an objective assessment of subjective aspects. So we can traslate patient’s perscetive into numbers, scores, indicators
  • Unmet needs in COPD: COPD Guidelines 2011

    1. 1. Unmet needs in COPD: COPD Guidelines 2011 Alexandru CORLATEANU, MD, PhD National Delegate of ERS for Moldova CLINICA MEDICALĂ NR. 2, USMF „N.TESTEMIŢANU”
    2. 2. World’s Top Ten Killers: WHO
    3. 3. 4 horsemen of the Apocalypse Vasnetov ,1887 CHD CVD COPD 2009 Lung cancer
    4. 4. <ul><li>COPD is a multifaceted disease </li></ul><ul><li>Multilateral evaluation COPD </li></ul><ul><li>Priorities in COPD management </li></ul>Summary
    5. 5. <ul><li>COPD is a multifaceted disease </li></ul><ul><li>Multilateral evaluation COPD </li></ul><ul><li>Priorities in COPD management </li></ul>
    6. 6. G lobal Initiative for Chronic O bstructive L ung D isease 2011 in press 2011
    7. 7. What is COPD? <ul><li>Chronic Obstructive Pulmonary Disease is a preventable and treatable disease with some significant extra-pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airway obstruction that is not fully reversible . The airway obstruction is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases </li></ul>GOLD 20 11 , UPDATE
    8. 8. COPD: 4 key moments <ul><li>airway obstruction </li></ul><ul><li>not fully reversible </li></ul><ul><li>progressive </li></ul><ul><li>abnormal inflammatory response </li></ul>GOLD 2011, UPDATE
    9. 9. Fletcher C & Peto R. BMJ 1977;1:1645-8 FEV 1 (% predicted at age 25 years) Age (years) 25 50 75 0 25 50 75 100 Disability Death COPD : Natural history Never smoked or not susceptible to smoke Susceptible smoker predicted decline if patient stops smoking
    10. 10. COPD : Natural history Age (years) 25 50 75 0 25 50 75 100 FEV 1 (% predicted at age 25 years) D yspnea Intoleran ce at physical effort Exacerbations Hospitalizations Systemic effects Respiratory failure Pulmonary hypertension
    11. 11. Factors which can influence natural hisory of COPD Ph enot ype Progres sion Answer to treatment Clinical presentation Genot ype Risk Factor s Comorbidit ies LUNG
    12. 12. Pink Puffer Blue Bloater COPD Phenotypes Dornhorst AC, Lancet 1955
    13. 13. BPCO as a systemic disease Cardiovascular comorbidities Muscle weakness malnutri tion Weight loss osteoporo sis Mucocyliar dysfunction Structural changes Inflam a tion Limitation of air flow J COPD 2005;2:253-62 Percep tion Pulmonary hyperinflation Systemic effects
    14. 14. Systemic Effects of COPD Diabetes Peptic ulceration Depression Depression Diabetes Metabolic syndrome Depression Peptic ulceration Fab b ri, ERJ, 2008 Lung Infections Lung Cancer Weight loss Muscle weakness Osteoporosis Angina Acute coronary syndromes Systemic Inflammation Oxidatitive Stress Depression
    15. 15. Overlap syndrom in pulmonary obstructive diseases
    16. 16. Asthma COPD “ Dutch hypothesis” [COLD] Asthma COPD “ British hypothesis” Common cause? Common mechanisms Different mechanisms Different causes Allergy “ irritants” Professor Dick Orie Groningen NL Prof Charles Fletcher London UK
    17. 17. Non-proportional Venn diagram showing the number of overlapping conditions in patients with asthma, emphysema and chronic bronchitis (reproduced with permission from the American Journal of Respiratory and Critical Care Medicine). Gibson P G , Simpson J L Thorax 2009;64:728-735 ©2009 by BMJ Publishing Group Ltd and British Thoracic Society
    18. 18. Percentage of adults (by gender) with airflow obstruction who have an overlap syndrome with increasing age. Gibson P G , Simpson J L Thorax 2009;64:728-735
    19. 19. Clinical and physiological characteristics of obstructive airway syndromes Asthma Overlap syndrome COPD Healthy Symptoms + + + − FEV 1 /FVC ≥ 70% <70% <70% ≥ 70% FEV 1  % predicted* >80% <80% <80% >80% AHR, PD 15 † <12 ml <12 ml >12 ml >12 ml
    20. 20. From E. Bel Auffray et al . Genome Med 2009;1:2 Patient reported Clinical Functional Cellular Molecular Future of phenotyping: ‘Systems Medicine’
    21. 21. <ul><li>COPD is a multifaceted disease </li></ul><ul><li>Multilateral evaluation COPD </li></ul><ul><li>Priorities in COPD management </li></ul>
    22. 22. COPD: 4 key moments key moments evaluarea <ul><li>airway obstruction </li></ul><ul><li>not fully reversible </li></ul><ul><li>progressive </li></ul><ul><li>abnormal inflammatory response </li></ul><ul><li>spirometr y </li></ul><ul><li>B ronhodilat ator test </li></ul><ul><li>monitoriz ation </li></ul><ul><li>b iomarker s </li></ul>GOLD 2011, UPDATE
    23. 23. IV: Very Severe III: Severe II: Moderate I: Mild <ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>FEV 1 > 80% predicted </li></ul>GOLD, 20 11 COPD classification <ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>50% < FEV 1 < 80% </li></ul><ul><li>predicted </li></ul><ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>30% < FEV 1 < 50% predicted </li></ul><ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>FEV 1 < 30% predicted </li></ul><ul><li>or FEV 1 < 50% predicted plus chronic respiratory failure </li></ul>
    24. 25. Decramer et al. Resp.Med.2011
    25. 26. Decramer et al. Resp.Med.2011
    26. 27. Decramer et al. Resp.Med.2011 CONCLUSIONS
    27. 28. BPCO as a systemic disease Cardiovascular comorbidities Muscle weakness malnutri tion Weight loss osteoporo sis Mucocyliar dysfunction Structural changes Inflam a tion Limitation of air flow J COPD 2005;2:253-62 Percep tion Pulmonary hyperinflation Systemic effects BODE
    28. 29. BODE Celli BR et al. NEJM 2004;350:1005-12 BMI Obstruction Dyspnea Exercise
    29. 30. Celli BR et al. NEJM 2004;350:1005-12 BODE i n COPD
    30. 31. Celli BR et al. NEJM 2004;350:1005-12 Score 0-2 Score 3-4 Score 5-6 Score 7-10 BODE i n COPD
    31. 32. Design Spirometry , BODE, comorbidit ies 158 COPD Pacien ts
    32. 33. Comorbidities according to GOLD/ATS/ERS classification p > 0.05
    33. 34. Comorbidities according to BODE classification p < 0.05
    34. 35. Correlational analysis between comorbidities and different classifications COPD p < 0.05 Stage COPD gr BODE CHARLSON Stage COPD 1,00 0,69 0,07 gr BODE 0,69 1,00 0,29 CHARLSON 0,07 0,29 1,00
    35. 36. <ul><li>Comorbidity score correlate with BODE, this suggests that BODE is potential able to measure COPD comorbidities. </li></ul><ul><li>Further work is required to evaluate relationship between the BODE and COPD comorbidities. </li></ul>
    36. 37. <ul><li>COPD is a multifaceted disease </li></ul><ul><li>Multilateral evaluation COPD </li></ul><ul><li>Priorities in COPD management </li></ul>
    37. 38. <ul><li>NEW Goal of COPD Management </li></ul>• increasing Quality of Life Achieving Current Control Reducing Future Risk Adapted from Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (updated 2009). http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=2003 Date last accessed: July 2010. 2011 2010 • increasing activity • reduction of symptoms • Reducing medication adverse effects • Reducing Mortality • Preven tion and tr eatment of e xacerbations • Preven tion and tr eatment of complications and systemic effects • Preven tion of progression of the disease
    38. 39. Add inhaled glucocorticosteroids if repeated exacerbations IV: Very Severe III: Severe II: Moderate I: Mild <ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>FEV 1 > 80% predicted </li></ul>Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add long term oxygen if chronic respiratory failure. Consider surgical treatments Ad d ROFLUMILAST GOLD, 201 1 Therapy at Each Stage of COPD <ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>50% < FEV 1 < 80% </li></ul><ul><li>predicted </li></ul><ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>30% < FEV 1 < 50% predicted </li></ul><ul><li>FEV 1 /FVC < 70% </li></ul><ul><li>FEV 1 < 30% predicted </li></ul><ul><li>or FEV 1 < 50% predicted plus chronic respiratory failure </li></ul>Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed)
    39. 41. Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233
    40. 42. Why do doctors not follow guidelines? <ul><li>LACK of: </li></ul><ul><li>Consciousness </li></ul><ul><li>Familiarity </li></ul><ul><li>Agreement </li></ul><ul><li>Auto- effectiveness </li></ul><ul><li>Success expectation </li></ul><ul><li>Motivation and consolidation </li></ul><ul><li>External barriers </li></ul>Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233
    41. 43. Why do patients not follow guidelines? Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233
    42. 44. Physician’s and patient’s viewpoint Physician Patient Limits Emotions Knowledge Satisfaction Fear Sleep School Relationships Diagnosis Drugs Follow-up Guidelines Severity Comorbidity Costs Clinical parameters Functional parameters Education Consideration Disease management
    43. 45. Reality  <ul><li>Under diagnosticat ed </li></ul><ul><li>Underestimated </li></ul><ul><li>Under tr eated </li></ul><ul><li>Hope  </li></ul><ul><li>Better understanding of systemic effects, </li></ul><ul><li>phenotypes , </li></ul><ul><li>comorbidit ies </li></ul><ul><li>Better M anagement  wonderful life </li></ul>

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