ECI- COPD Course Lecture 1


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ECI COPD Educator Course.

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ECI- COPD Course Lecture 1

  1. 1. COPDDefinitionEpidemiologyPrevalencePathophysiology
  2. 2. GOLD Definition COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. GOLD 2013
  3. 3. ATS/ ERS Definition Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease involving the airways or pulmonary parenchyma (or both) that results in airflow obstruction. Manifestations of COPD range from dyspnea, poor exercise tolerance, chronic cough with or without sputum production, and wheezing to respiratory failure or cor-pulmonale. Exacerbations of symptoms and concomitant chronic diseases may contribute to the severity of COPD in individual patients.Ann Intern Med. 2011;155:179-191.
  4. 4. Definition : Airflow Limitation  The chronic airflow limitation characteristic of COPD is caused by a mixture of small airway disease (obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to personGlobal initiative for chronic obstructive pulmonary disease updated 2013
  5. 5. DefinitionsEmphysema pathological term which is destruction of the gas exchanging surfaces of the lung (alveoli). Chronic bronchitis is the presence of cough and sputum production for at least 3 months in each of two consecutive years.GOLD 2013
  6. 6. EpidemiologyCOPD is a leading cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing.COPD is the result of cumulative exposures over decadesGOLD 2013
  7. 7. Epidemiology Studies to improve the global understanding of COPD prevalence and prognosis include: ▫ Burden of Obstructive Lung Disease (BOLD) Initiative 1 (now complete in China, Turkey, Austria, South Africa, Iceland, Poland, Germany, Norway, Canada, Philippines, USA and Australia) 2 ▫ Latin-American Project for the Investigation of Pulmonary Obstruction (PLATINO) (in Brazil, Chile, Mexico and Uruguay) 31-Buist et al COPD 2005; 2-BOLD 2007; 3-Menezes et al LANCET 2005
  8. 8. EpidemiologyThe BOLD Study: a population-based prevalencestudy 9425 Participants from 12 sites , aged 40 years and older.The prevalence of stage II or higher COPD was 10・1% (SE 4・8) overall, 11・8% (7・9) for men, and 8・5% (5 ・8) for women.Generally, the prevalence of COPD that is GOLD stage II or higher increased steadily with age for men and women in every site.The prevalence increased with increasing pack-years.Lancet 2007; 370: 741–50
  9. 9. EpidemiologyThe Global Burden of Disease Study projected that COPD, which ranked sixth as the cause of death in 1990, will become the third leading cause of death worldwide by 2020; a newer projection estimated COPD will be the fourth leading cause of death in 2030And the seventh leading cause of DALYs lost worldwide in 2030. GOLD 2013
  10. 10. Epidemiology COPD prevalence by gender and age groups 60 50 40Prevalence % 30 Male Female 20 10 0 40-49 50-59 60-69 70+ Prevalence of COPD According to GOLD Stage I and Higher COPD Chest 2007;131;29-36
  11. 11. EpidemiologyFactors Influence disease development and progression Genes Age and Gender Lung Growth and Development Exposure to particles ▫ Tobacco smoke ▫ Occupational dusts, organic and inorganic ▫ Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings ▫ Outdoor air pollution Socioeconomic status Respiratory InfectionsChronic BronchitisAsthma / Bronchial Hyperreactivity GOLD 2013
  12. 12. Epidemiology Factors Influence disease development and progression Cigarette smoking is the most commonly encountered risk factor for COPD 100 Never smoked or not susceptible to smoke FEV1 (% of value at age 25) 80 Smoked regularly 60 and susceptible to its effects Stopped at 45 40 Disability 20 Death Stopped at 65 0 25 50 75Adapted from Fletcher C, et al. Br Med J 1977 Age (years)
  13. 13. Epidemiology Genes The genetic risk factor that is best documented is a severe hereditary deficiency of alpha-1 antitrypsin, a major circulating inhibitor of serine proteases. Genetic factors with environmental factors could influence susceptibility to develop airflow limitation Gender In the past most studies showed that COPD were greater among men But now studies shows prevalence is almost equal which reflects changing patterns of tobacco smoking
  14. 14. Prevalence of COPDOther Risk FactorsComorbid conditionsUnder-diagnosisComplex disease
  15. 15. COPD has the third highest overall lifetime risk after diabetes and asthmaGershon AS et al. Lancet 2011; 378: 991–96
  16. 16. COPD: Prevalence RatesCountry/region Extrapolated Population estimated Prevalence useEgypt 3,777,886 76,117,421Gaza strip 65,762 1,324,991Jordan 278,497 5,611,202Kuwait 112,047 2,257,549Lebanon 187,472 3,777,218Saudi Arabia 1,280,313 25,795,938United Arab Emirates 125,267 2,523,915West Bank 114,710 2,311,204Yemen 993,881 20,024,867 last accessed 20/3/2013
  17. 17. 17 COPD in Egypt Statistical analysis of COPD prevalence in Egypt showed that 3 millions from the egyptian population have COPD.1 In different studies prevalence were from 3.3% up to 10%. 1,2 Prevalence rate in men was ~6.7 % while it was ~1.5% in woman11-BREATHE Study, Prevalence of COPD in middle east and north Africa. E-poster, ERS Sep 20112- E-poster Burden of COPD in some African and Asian countries V.Kiri et al, Sep 2007
  18. 18. Air pollution is a major problem in Asia SO2 : Sulfur Dioxide NO2 : Nitrogen dioxide. PM 10 :particulate matter 10 microns and less TSP :Total suspended particulates Thorax 2007;62:748-749
  19. 19. Biomass smoke exposure and the risk of COPDAm J Respir Crit Care Med Vol 182. pp 693–718, 2010
  20. 20. TORCH : Overall, 27% of the deaths were adjudicated as due to cardiovascular causes, 35% to pulmonary causes, and 21% to cancer Unknown Other 7% Respiratory 10% 35% RespiratoryCancer Cardiac21% Cancer Other Unknown Cardiac 27% N Engl J Med 2007;356:775-89.
  21. 21. COPD Uncovered 75% stated they had ≥1 comorbid condition The most commonly reported conditions were hypertension, asthma, arthritis, anxiety, depression and diabetes.Fletcher et al. BMC Public Health 2011, 11:612
  22. 22. Probability of Cardiovascularevent Thorax 2010;65:719e725
  23. 23. Prevalence of CVD in COPDBCMJ, Vol. 50, No. 5, June 2008, page(s) 246-251
  24. 24. Clinical consequences ofOsteoporosis• Acute and chronic pain • Bulging abdomen, reflux and other Gl symptoms• Kyphosis • Breathing difficulties• Loss of height • Depression• Loss of mobility • Loss of Independence REDUCED QUALITY OF LIFE
  25. 25. Prevalence of osteoporosis in COPDRev Osteoporos Metab Miner 2012 4;2:69-75
  26. 26. GOLD staging and osteoporosisThe prevalence of osteoporosis was greater than 50% regardless of GOLD stageCOPD 2008, 5:291–297
  27. 27. Reported prevalence of chronic obstructive pulmonary disease and relative Underdiagnosis in selected population studiesLancet 2009; 374: 721–32
  28. 28. COPD prevalence and GOLDseverity stages by gender and age M: men W:women; T:totalThorax 2009;64:863-868
  29. 29. Recent trends in COPD prevalence in Spain: a repeated cross-sectional survey 1997-2007Eur Respir J.2010 Oct;36(4):758-65
  30. 30. International COPD network(ICON) study Twelve territories across the Asia-Pacific region, Africa, eastern Europe, and Latin America Total of 600 GPs (50 from each territory) Survey demonstrated that the GPs’ understanding of COPD was variable across the territories, with large numbers of GPs having very limited knowledge of COPD and its management. A consistent finding across all territories was the underutilization of spirometry (median 26%; range 10%–48%) and reliance on X-rays (median 14%; range 5%–22%) for COPD diagnosisInternational Journal of COPD 2012:7 271–282
  31. 31. Perceived prevalence of chronic obstructivepulmonary disease (COPD) in each territoryInternational Journal of COPD 2012:7 271–282
  32. 32. Parameters considered by GPs for ongoing treatment of COPD in different territoriesInternational Journal of COPD 2012:7 271–282
  33. 33. Gender Bias Can ImpedeDiagnosisSurvey of 192 primary care physicians ▫ Provided a case of male patient and female patient with same history and physical exam ▫ Asked about provisional diagnosis Physicians Provisional diagnosis (%) Male Patient Female Patient COPD 65 49 Asthma 32 44
  34. 34. The Changing Face of COPD Younger More women 70% of patients with COPD  In 2004 women are <65 years old, accounting accounted for 63% of for: all self reported COPD ▫ 67% of COPD office visits cases ▫ 43% of hospitalizations
  35. 35. ConclusionsThe Prevalence de COPD is between 10 - 15 %.Most patients have not been diagnosed.Cigarette smoking and biomass are major risk factors for the disease.Co-morbid conditions prevalence are increasing.COPD is a disease of younger patie nts, and increased number of women.Different therapies including smoking cessation, and pharmacotherapy impact the disease.
  36. 36. PathophysiologyInhaled cigarette smoke and other noxious particles such as smoke from biomass fuels cause lung inflammation, a normal response that appears to be modified in patients who develop COPD.This chronic inflammatory response may induce parenchymal tissue destruction (resulting in Emphysema) and disrupt normal repair and defense mechanisms (resulting in small airway fibrosis)
  37. 37. PathophysiologyInflammatory CellsCOPD is characterized by a specific pattern of inflammation involvingNeutrophils ,Macrophages, Cytotoxic LymphocytesOxidative stressA number of studies have indicated that oxidative stress has asignificant role in the pathogenesis of COPD.Biomarkers of oxidative stress are increased in the breath and sputumof COPD patients. Protease-antiprotease imbalanceThis imbalance is at least partly due to the secretion of proteases bymacrophages and neutrophils associated with the chronicinflammatory response
  38. 38. PathophysiologyAlthough both COPD and asthma are associated with chronic inflammation of the respiratory tract, there are differences in the inflammatory cells and mediators involved In the two diseases, which in turn account lor differences in physiological effects, symptoms, and response to therapy.Some patients with COPD have features consistent with asthma and may have mixed inflammatory pattern with increased eosinophils.
  39. 39. Distribution of Direct Costs ofCOPD by Severity100% 90% 80% 70% Equipment aids 60% 50% Oxygen therapy 40% Outpatient care 30% Medicines 20% 10% Hospitalizations 0% <40% 40-59% 60-79% >80% Mean