EPOC:PERSPECTIVAS DE FUTURO
(Y UNA MIRADA AL PASADO)

1
“Nunca hago predicciones y nunca las
haré”
Paul Gascoigne

2
ÍNDICE
1. ¡Que es la demografía!
2. Tabaquismo: malas perspectivas
3. Las “noncommunicable”
4. Peligro: camino equivocado
...
¡Que es la demografía!

2011

Manila (Filipinas) 31 octubre 2011
Nace Danica May Manila Camacho
Es la ciudadana número 7mi...
¡Que es la demografía!

Sarajevo(Bosnia) 13 octubre, 1999
Nace Adnan Nevic, el ciudadano número 6 millones

5
¡Que es la demografía!

El mundo en 2050.Todas las tendencias que canviaran el planeta
(The Economist).ed Franklin D. y An...
Tabaquismo: malas perspectivas

Eriksen M. Judith Mackay Hana Ross EL ATLAS
DEL TABACO cuarta edición.
http://www.tobaccoa...
Tabaquismo: malas perspectivas

8
N Engl J Med. 2013 Jan 24;368(4):341-50
Tabaquismo: malas perspectivas

9
N Engl J Med. 2013 Jan 24;368(4):351-64
Tabaquismo: malas perspectivas

…More women die of lung cancer than of breast cancer. But
there is no “race for the cure” ...
Las “noncommunicable”

Noncommunicable Diseases David J. Hunter, M.B., B.S., M.P.H., Sc.D., and K. Srinath Reddy, M.D., D....
Las “noncommunicable”

PLoS Med. 2006 Nov;3(11):e442.
Projections of global mortality and burden of disease from 2002 to 2...
Las “noncommunicable”

PLoS Med. 2006 Nov;3(11):e442.
Projections of global mortality and burden of disease from 2002 to 2...
Las “noncommunicable”

14
Las “noncommunicable”

- Stockley RA. Am J Respir Crit Care Med. 2013 Apr 15;187(8):786-8
- Mathers CD, Loncar D. PLoS Med...
Las “noncommunicable”

16
Peligro: camino equivocado

Thorax. 2011 Aug;66(8):643-5

17
Peligro: camino equivocado






Even more effective tobacco legislation, including prevention of passive smoking
expo...
Peligro: camino equivocado

19
Peligro: camino equivocado

Am J Respir Crit Care Med. 2012 Nov 15;186(10):975-81

20
Peligro: camino equivocado
• Host Factors
–
–
–

Genes
Airway Hyperresponsiveness
Lung Growth

• Exposures

1)

2)

–
Toba...
Peligro: camino equivocado

…The adjusted differences in FEV1 between individuals who did not consume cured meats and thos...
Peligro: camino equivocado

Biochem. Soc. Trans. (2009) 37, 814–818;

Am J Respir Crit Care Med Vol 176. pp 1281–1288, 200...
Peligro: camino equivocado
Necesidad de criterio único

24
Peligro: camino equivocado

…This is clearly apparent if one keeps in mind that
two patients with FEV1 of 20 and 100% pred...
Peligro: camino equivocado

26
Thorax. 2009 Oct;64(10):894-900
Peligro: camino equivocado

Chest. 2006 Aug;130(2):318-25

27
Peligro: camino equivocado
4

ENFERMEDAD
S
Í
N
D
R
O
M
E

3
2

1

Causa - Etiología
Desorden Funcional
Característico
Lesi...
Peligro: camino equivocado

1. Miravitlles M, Morera J. It's time for an aetiology-based definition of
chronic obstructive...
Peligro: camino equivocado

30
Fenotipos o formas clínicas
P.G. Gibson, J.L. Simpson.Thorax 2009;64:728-735
The overlap syndrome of asthma and COPD: what...
Fenotipos o formas clínicas
Miguel-Angel Martínez-García, et al.Prognostic Value of Bronchiectasis in
Patients with Modera...
Fenotipos o formas clínicas
Jose M. Marin, et al. "Outcomes in Patients with Chronic Obstructive Pulmonary
Disease and Obs...
Fenotipos o formas clínicas
John R. Hurst, Evaluation of COPD Longitudinally to Identify Predictive Surrogate
Endpoints (E...
Fenotipos o formas clínicas
Camp PG, et al.
COPD phenotypes in biomass smoke- versus tobacco smoke-exposed Mexican
females...
Fenotipos o formas clínicas

¿Paciente sano? o ¿Paciente no sano?
36
Fenotipos o formas clínicas

37
Fenotipos o formas clínicas

38
Fenotipos o formas clínicas

39
Fenotipos o formas clínicas

40
Fenotipos o formas clínicas

Almagro P, et al.
Comorbidities in patients hospitalized due to chronic obstructive
pulmonary...
Fenotipos o formas clínicas

42
Am J Respir Crit Care Med. 2012 Jan 1;185(1):44-52
Fenotipos o formas clínicas
Guerra S, et al.Combined effects of parental and active smoking on early lung
function deficit...
Fenotipos o formas clínicas

Han MK, et al.
Chronic Obstructive Pulmonary Disease Exacerbations in the COPDGene Study:
Ass...
Fenotipos o formas clínicas

45
Fenotipos o formas clínicas

“Blue Bloater / Blow-up”
46

Inspirado en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7...
1, 2, 3, 4…?

47
N Engl J Med. 2007 Feb 22;356(8):775-89
1, 2, 3, 4…?

48
1, 2, 3, 4…?

49
N Engl J Med. 2011 Aug 25;365(8):689-98
1, 2, 3, 4…?

50
Am J Respir Crit Care Med. 2012 Jan 15;185(2):152-9
1, 2, 3, 4…?

51
N Engl J Med. 2010 Sep 23;363(13):1233-44
1, 2, 3, 4…?

Thorax. 2010 Apr;65(4):298-302

52
1, 2, 3, 4…?

53
1, 2, 3, 4…?

The Lancet Respiratory Medicine, Early Online Publication, 6 December 2012

54
1, 2, 3, 4…?

55
Chest. 2012 Nov;142(5):1300-7.
Nuevas tecnologías
Estépar RS, et al. Computed tomographic measures of pulmonary vascular
morphology in smokers and their ...
Nuevas tecnologías
Carlos H Martinez,et al. Relationship between quantitative CT metrics and health
status nd BODE in chro...
Nuevas tecnologías

58
Conclusiones

1. Debemos maximizar nuestros esfuerzos en la batalla del tabaquismo
y el diagnóstico precoz.
2. En un futur...
MUCHAS GRACIAS
60
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EPOC: perspectivas de futuro (y una mirada al pasado).

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EPOC: perspectivas de futuro (y una mirada al pasado).

  1. 1. EPOC:PERSPECTIVAS DE FUTURO (Y UNA MIRADA AL PASADO) 1
  2. 2. “Nunca hago predicciones y nunca las haré” Paul Gascoigne 2
  3. 3. ÍNDICE 1. ¡Que es la demografía! 2. Tabaquismo: malas perspectivas 3. Las “noncommunicable” 4. Peligro: camino equivocado 5. Fenotipos o formas clínicas 6. 1,2,3,4......? 7. Nuevas tecnologías 8. Conclusiones 3
  4. 4. ¡Que es la demografía! 2011 Manila (Filipinas) 31 octubre 2011 Nace Danica May Manila Camacho Es la ciudadana número 7mil millones del planeta 4
  5. 5. ¡Que es la demografía! Sarajevo(Bosnia) 13 octubre, 1999 Nace Adnan Nevic, el ciudadano número 6 millones 5
  6. 6. ¡Que es la demografía! El mundo en 2050.Todas las tendencias que canviaran el planeta (The Economist).ed Franklin D. y Andrews J. 2012 6
  7. 7. Tabaquismo: malas perspectivas Eriksen M. Judith Mackay Hana Ross EL ATLAS DEL TABACO cuarta edición. http://www.tobaccoatlas.org/uploads/Images/PDFs/ TA4Spanish.pdf 7
  8. 8. Tabaquismo: malas perspectivas 8 N Engl J Med. 2013 Jan 24;368(4):341-50
  9. 9. Tabaquismo: malas perspectivas 9 N Engl J Med. 2013 Jan 24;368(4):351-64
  10. 10. Tabaquismo: malas perspectivas …More women die of lung cancer than of breast cancer. But there is no “race for the cure” for lung cancer, no brown ribbon, and no group analogous to the Susan G. Komen Breast Cancer Foundation… Thorax. 2011 Aug;66(8):645-6 10
  11. 11. Las “noncommunicable” Noncommunicable Diseases David J. Hunter, M.B., B.S., M.P.H., Sc.D., and K. Srinath Reddy, M.D., D.M.N New Engl J Med 2013; 369:1336-1343 October 3, 2013 11
  12. 12. Las “noncommunicable” PLoS Med. 2006 Nov;3(11):e442. Projections of global mortality and burden of disease from 2002 to 2030. Mathers CD, Loncar D. 12
  13. 13. Las “noncommunicable” PLoS Med. 2006 Nov;3(11):e442. Projections of global mortality and burden of disease from 2002 to 2030 Mathers CD, Loncar D. 13
  14. 14. Las “noncommunicable” 14
  15. 15. Las “noncommunicable” - Stockley RA. Am J Respir Crit Care Med. 2013 Apr 15;187(8):786-8 - Mathers CD, Loncar D. PLoS Med. 2006 Nov;3(11):e442. Projections of global mortality and burden of disease from 2002 to 2030 15
  16. 16. Las “noncommunicable” 16
  17. 17. Peligro: camino equivocado Thorax. 2011 Aug;66(8):643-5 17
  18. 18. Peligro: camino equivocado     Even more effective tobacco legislation, including prevention of passive smoking exposure for children in cars and at home. Legislation works17dor, if it does not, let us prorogue parliament at once! Recognition that airborne pollution is a human rights issuedif you live in a Western city you cannot avoid air pollution. The roots of much disease are in povertydand yet it is not only low and middle income countries that are affected. All major Western countries still have substantial poverty affecting children. Finally, invest in research to understand early lung development, and devise interventions to operate before the lungs are shot to pieces. Thorax. 2011 Aug;66(8):645-6 18
  19. 19. Peligro: camino equivocado 19
  20. 20. Peligro: camino equivocado Am J Respir Crit Care Med. 2012 Nov 15;186(10):975-81 20
  21. 21. Peligro: camino equivocado • Host Factors – – – Genes Airway Hyperresponsiveness Lung Growth • Exposures 1) 2) – Tobacco Smoke – Occupational Dust and Chemicals – Outdoor and Indoor Air Pollution – Infections – Socioeconomic Status No menciona que el efecto del tabaco es dosis/efecto. !!!!! No menciona la palabra “Smoke” hasta después de 688 palabras y 2 tablas, y 688 palabras hasta repetirla. !!!!! Am J Respir Crit Care Med Vol 163. pp 1256–1276, 2001 21
  22. 22. Peligro: camino equivocado …The adjusted differences in FEV1 between individuals who did not consume cured meats and those who consumed cured meats 1 to 2,3 to 4, 5 to 13, and 14 or more times per month were 37.6, 11.5, 42.0, and 110 ml, respectively (p for trend 0.001).Corresponding differences for FEV1/FVC were 0.91,0.54, 1.13, and 2.13% (p for trend 0.001). These associations were not modified by smoking status. The multivariate odds ratio for COPD (FEV1/FVC 0.7 and FEV1 80% predicted) was 1.78 (95% confidence interval, 1.29–2.47) comparing the highest with the lowest category of cured meat consumption. The corresponding odds ratios for mild, moderate, and severe COPD were 1.11, 1.46, and 2.41, respectively…. …High dietary nitrite intake warrants further evaluation in prospective, longitudinal studies as a novel risk factor for COPD. Am J Respir Crit Care Med. 2007 Apr 15;175(8):798-804 22
  23. 23. Peligro: camino equivocado Biochem. Soc. Trans. (2009) 37, 814–818; Am J Respir Crit Care Med Vol 176. pp 1281–1288, 2007 23
  24. 24. Peligro: camino equivocado Necesidad de criterio único 24
  25. 25. Peligro: camino equivocado …This is clearly apparent if one keeps in mind that two patients with FEV1 of 20 and 100% pred may have the same FEV1/FVC ,0.70 or even, LLN, depending on the associated reduction of FVC… 25 Eur Respir J. 2008 Mar;31(3):681-2
  26. 26. Peligro: camino equivocado 26 Thorax. 2009 Oct;64(10):894-900
  27. 27. Peligro: camino equivocado Chest. 2006 Aug;130(2):318-25 27
  28. 28. Peligro: camino equivocado 4 ENFERMEDAD S Í N D R O M E 3 2 1 Causa - Etiología Desorden Funcional Característico Lesión Anatómica Característica Descripción Clínica Basat en J. G. Scadding. Principles of definition in medicione. Lancet, 1959; 1: 323-325 . Meaning of diagnostic terms in bronchopulmonary disease. BMJ, 1963; 2: 1425-1430. The semantics of medical diagnosis. Niomed. Comput, 1972; 3: 83-90. Helath and disease: what can medicine do for philosophy?. J. Med. Ethics, 1988; 14: 118-124. Definition on asthma. In: Weiss EB, Stein M. Editors. Bronchial asthma, mechanisms and therapeutics, 3erd ed. Boston: Litle Brown; 1993. p.1-13. 28
  29. 29. Peligro: camino equivocado 1. Miravitlles M, Morera J. It's time for an aetiology-based definition of chronic obstructive pulmonary disease. Respirology. 2007 May;12(3):317-9. 2. Morera J, Miravitlles M. [Chronic obstructive pulmonary disease: disease or Zugzwang's syndrome?] Med Clin (Barc). 2008 May 10;130(17):6556. 3. Snider GL. Nosology for our day: its application to chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2003 Mar 1;167(5):67883. 29
  30. 30. Peligro: camino equivocado 30
  31. 31. Fenotipos o formas clínicas P.G. Gibson, J.L. Simpson.Thorax 2009;64:728-735 The overlap syndrome of asthma and COPD: what are its features and how important is it? 31
  32. 32. Fenotipos o formas clínicas Miguel-Angel Martínez-García, et al.Prognostic Value of Bronchiectasis in Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease American Journal of Respiratory and Critical Care Medicine 2013 187: 823-831 32
  33. 33. Fenotipos o formas clínicas Jose M. Marin, et al. "Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea", American Journal of Respiratory and Critical Care Medicine, Vol. 182, No. 3 (2010), pp. 325-331. 33
  34. 34. Fenotipos o formas clínicas John R. Hurst, Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease New engl j med 363;12 september 16, 2010 34
  35. 35. Fenotipos o formas clínicas Camp PG, et al. COPD phenotypes in biomass smoke- versus tobacco smoke-exposed Mexican females. Eur Respir J. 2013 Oct 10. 35
  36. 36. Fenotipos o formas clínicas ¿Paciente sano? o ¿Paciente no sano? 36
  37. 37. Fenotipos o formas clínicas 37
  38. 38. Fenotipos o formas clínicas 38
  39. 39. Fenotipos o formas clínicas 39
  40. 40. Fenotipos o formas clínicas 40
  41. 41. Fenotipos o formas clínicas Almagro P, et al. Comorbidities in patients hospitalized due to chronic obstructive pulmonary disease. A comparative analysis of the ECCO and ESMI. Rev Clin Esp. 2012 Jun;212(6):281-6 Morera Prat J, Martinez –Ortiz ML Chronic obstructive pulmonary disease in the elderly: next phenotype Med Clin (Barc)2012 Apr 28;138(11):478-9. 41
  42. 42. Fenotipos o formas clínicas 42 Am J Respir Crit Care Med. 2012 Jan 1;185(1):44-52
  43. 43. Fenotipos o formas clínicas Guerra S, et al.Combined effects of parental and active smoking on early lung function deficits: a prospective study from birth to age 26 years. Thorax. 2013 Nov;68(11):1021-8. 43
  44. 44. Fenotipos o formas clínicas Han MK, et al. Chronic Obstructive Pulmonary Disease Exacerbations in the COPDGene Study: Associated Phenotypes. Radiology. 2011 Oct;261(1):274-82 44
  45. 45. Fenotipos o formas clínicas 45
  46. 46. Fenotipos o formas clínicas “Blue Bloater / Blow-up” 46 Inspirado en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.
  47. 47. 1, 2, 3, 4…? 47 N Engl J Med. 2007 Feb 22;356(8):775-89
  48. 48. 1, 2, 3, 4…? 48
  49. 49. 1, 2, 3, 4…? 49 N Engl J Med. 2011 Aug 25;365(8):689-98
  50. 50. 1, 2, 3, 4…? 50 Am J Respir Crit Care Med. 2012 Jan 15;185(2):152-9
  51. 51. 1, 2, 3, 4…? 51 N Engl J Med. 2010 Sep 23;363(13):1233-44
  52. 52. 1, 2, 3, 4…? Thorax. 2010 Apr;65(4):298-302 52
  53. 53. 1, 2, 3, 4…? 53
  54. 54. 1, 2, 3, 4…? The Lancet Respiratory Medicine, Early Online Publication, 6 December 2012 54
  55. 55. 1, 2, 3, 4…? 55 Chest. 2012 Nov;142(5):1300-7.
  56. 56. Nuevas tecnologías Estépar RS, et al. Computed tomographic measures of pulmonary vascular morphology in smokers and their clinical implications. Am J Respir Crit Care Med. 2013 Jul 15;188(2):231-9 56
  57. 57. Nuevas tecnologías Carlos H Martinez,et al. Relationship between quantitative CT metrics and health status nd BODE in chronic obstructive pulmonary disease. Thorax,2012,67,399-406 57
  58. 58. Nuevas tecnologías 58
  59. 59. Conclusiones 1. Debemos maximizar nuestros esfuerzos en la batalla del tabaquismo y el diagnóstico precoz. 2. En un futuro, la comunidad científica deberá homogeneizar más los conceptos de la EPOC. 3. Esperanzados con la medicina regenerativa, no sabemos cuando será una realidad. 4. El fenotipo de la EPOC del futuro será el fenotipo de la EPOC del anciano. 5. A nivel clínico es intrigante la comorbilidad con la obesidad. 59
  60. 60. MUCHAS GRACIAS 60

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