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CORSI DI AGGIORNAMENTO PER MMG Modena 12 aprile
2002
Criteri decisionali fra Global Initiatives on
Asthma (GINA) e Obstructive Lung Disease (GOLD)
Prof. Leonardo M. Fabbri Clinica di Malattie
dellApparato Respiratorio
2
Global INitiative for Asthma
www.ginasthma.com
3

• G lobal Initiative for Chronic
• O bstructive
• L ung
• D isease

www.goldcopd.com
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Global Initiative on Obstructive Lung
DiseaseEXECUTIVE COMMITTEEChair Romain
Pauwels

• C. Jenkins, Australia
• N. Khaltaev, CH
• C. Lenfant, US
• J. Luna, Guatemala
• W. McNee, UK
• R. Rodriguez Roisin, E
• N.Zhong, China

• S. Buist, US
• P. Calverley, UK
• B. Celli, US
• L. Fabbri, Italy
• Y. Fukuchi, Japan
• S. Hurd, US
• L. Grouse, US

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Global Initiative on Obstructive Lung
DiseaseSCIENTIFIC COMMITTEEChair Leonardo M.
Fabbri

• P. Barnes, UK
• S. Buist, US
• P. Calverley, UK
• Y. Fukuchi, Giappone
• W. McNee, UK
• R. Pauwels, Belgium
• K. Rabe, Germany
• Roberto Rodrigues Roisin, Spain
• N. Zielinski, Poland

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• 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

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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 Sep109(4)288-95
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Levels of evidence
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Severity of symptoms
No of puffs of albuterol
Poor control Poor compliance
Threshold for Increasing control medication
Good control Good compliance
Time
Exacerbations
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Classification of Asthma Severity
Treatment
Intensity of treatment
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MANAGEMENT OF ASTHMA
Oral steroids
Long-acting bronchodilators and/or LTRA
Inhaled steroids
Short-acting ?2 agonists prn
Severity of asthma
PREVENTION
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Classification by severity

• Stage Characteristics
• 0 At risk Normal spirometry. Chronic symptoms
  (cough, sputum),
• I Mild FEV1/FVC lt 70, FEV1 gt 80 predicted
  with or without symptoms (cough, sputum)
• II Moderate FEV1/FVC lt 70, 30 lt FEV1 lt 80
  predicted with or without chronic symptoms
  (cough, sputum, dyspnea)
• (IIA 50 lt FEV1 lt 80 IIB 30 lt FEV1 lt 50)
• IV Severe FEV1/FVC lt 70, FEV1 lt 30 predicted
  or presence of respiratory failure or clinical
  signs of right heart failure

GOLD guidelines 2001
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MANAGEMENT OF COPD
Theophylline Oral steroids
Inhaled Steroids
Anti-cholinergics ? long-acting ?2 Agonists
Short-acting ?2 agonists prn
Severity of COPD
PREVENTION
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CORSI DI AGGIORNAMENTO PER MMG Modena 5 aprile
2002
Criteri decisionali fra Global Initiatives on
Asthma (GINA) e Obstructive Lung Disease (GOLD)
Prof. Leonardo M. Fabbri Clinica di Malattie
dellApparato Respiratorio
15
Differences and similarities betweenasthma and
COPD
ASTHMA Sensitizing agent
COPD Noxious agent
Asthmatic airway inflammation CD4
T-lymphocytes Eosinophils
COPD airway inflammation CD8 T-lymphocytes Marcro
phages Neutrophils
Airflow limitation
Completely reversible
Completely irreversible
Airflow limitation
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Bronchial biopsies from 2 asthmatics of similar
age and with similar degree of fixed airflow
limitation
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Characteristics of patients with fixed airflow
limitation
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Fixed airflow limitation in Asthma and COPD
FEV1 changes after bronchodilator
L/s

300
History of Asthma
No history of Asthma
History of Asthma
No history of Asthma
16
14
250


12
10
200
8
6
150
4
2
100
0
19
Fixed airflow limitation in Asthma and COPD
FEV1 changes after oral corticosteroids
History of Asthma
No history of Asthma
History of Asthma
No history of Asthma
400
14


12
300
10
predicted
ml
8
200
6
4
100
2
0
0
20
Fixed airflow limitation in Asthma and COPD
Airway Responsiveness to methacholine
History of Asthma
No history of Asthma
10
Methacholine PC20FEV1 (mg/ml)
1
0,1
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Fixed airflow limitation in Asthma and COPD
Residual Volume
History of Asthma
No history of Asthma
pred
L
History of Asthma
No history of Asthma
150


3,0
125
2,5
2,0
100
1,5
22
Fixed airflow limitation in Asthma and COPD
Carbon monoxide diffusion capacity (Kco)
predicted


mmol min-1 l-1
120
History of Athma
No history of Asthma
History of Asthma
No history of Asthma
110
100
1,5
90

80

70
1,0
60
50
40
0,5
30
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Fixed airflow limitation in Asthma and COPD
SPUTUM
120


cells
110
100
90
History of Asthma
80
No history of asthma
70
60
50
40
30
20
10
0
Macrophages
Eosinophils
Lymphocytes
Neutrophils
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Fixed airflow limitation in Asthma and COPD
Exhaled Nitric Oxide

History of Asthma
No history of Asthma
60
50
40
Exhaled NO
(ppb)
30
20
10
0
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HIGH RESOLUTION COMPUTED TOMOGRAPHY (HRCT) IS
DIFFERENT IN PATIENTS WITH FIXED AIRFLOW
LIMITATION DUE TO SMOKING OR TO ASTHMA
Patients with fixed airflow limitation due to
smoking maintain distinct radiological and
functional characteristics from patients with a
history of asthma, even when they develop fixed
airflow limitation, suggesting that fixed
airflow limitation does not define a unique
disease entity.
Romagnoli M et al, American Thoracic Society
2002, Atlanta, submitted
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CORSI DI AGGIORNAMENTO PER MMG Modena 12 aprile
2002
Criteri decisionali fra Global Initiatives on
Asthma (GINA) e Obstructive Lung Disease (GOLD)
Prof. Leonardo M. Fabbri Clinica di Malattie
dellApparato Respiratorio