Approach to airways disease and smoke related disease

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Approach to airways disease and smoke related
disease

• ??. ??. ????? ?????????? M.D., Ph.D.
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Obstructive airway disease
Pressure
FLOW
Resistance
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Irreversible FEV1 ? lt15
????
Reversible FEV1 ?gt15
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Spirometry FEV1/ FVC lt70
?????????????????? (spirometry)
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Spirometry FEV1/ FVC lt70
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Peak Flow meter (????????????????????????)
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Bronchodilator Test

• ??????????????? ???? Peak Flow ???????????????????
  ??????? 15 ????
• FEV1 ???????????????? 15 ????????????????
• PEFR ???????????????? 20 ????????????????

• Salbutamol inhaler 2 puff
• ?????? 15 ????

PEFR 300 L/min
PEFR 390 L/min
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asthma

• Cough
• Wheeze
• Dyspnea

Reversible airway obstruction
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Reversible airway obstruction
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Airway Hyperresponsiveness
Stimuli
Reversible airway obstruction
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Methacholine dose response curve
PD20
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Pathology of asthma

• Smooth muscle hypertrophy
• Mucosal disruption
• Mucus plug
• Cells infiltration

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Bronchospasm
?????????????????????? Before 1980
Airway hyperresponsive
Smooth muscle hypertrophy
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Normal
Asthma
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Allergen inhalation challenge
Early asthmatic response
Late asthmatic response
Increase AHR
Increase inflammatory cells
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Bronchospasm
?????????????????????? 1980-1990
Inflammation
Airway hyperresponsive
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Change in FEV1 in asthmatic
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Early intervention with inhaled steroid
2. Agertoft and Pedersen, Respir Med 1994
1. Selroos et al, Chest 1995
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Haahtela T et al. N Engl J Med 1994331700-5.
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Airway remodelling
Epithelium damage

• Sub-basement membrane thickening
• Smooth muscle hypertrophy and hyperplasia
• Mucus metaplasia
• Increase vascularity

Normal
Asthma
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Airway remodelling
1. Persistent airway obstruction
2. Persistent airway hyperresponsiveness
Normal
Asthma
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Bronchospasm
?????????????????????? 1990-2000
Inflammation
Remodelling
Airway hyperresponsive
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Changing concept in asthma treatment
short-acting b2-agonists
Inh corticosteroid
Combination
Bronchospasm
Inflammation
Airway Hyperresponsiveness
Remodelling
1980
1985
1990
1995
2000
1975
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Is it Asthma?

• Recurrent episodes of wheezing
• Troublesome cough at night
• Cough or wheeze after exercise
• Cough, wheeze or chest tightness after exposure
  to airborne allergens or pollutants
• Colds go to the chest or take more than 10 days
  to clear

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Definition of asthma

• Airway inflammation
• Airway hyperresponsiveness
• Reversible airway obstruction
• Symptoms (cough, wheeze, dyspnea)

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Asthma Diagnosis

• History and patterns of symptoms
• Physical examination
• Measurements of lung function

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Pharmacological therapy

• Controllers
• Inhaled corticosteroids
• Inhaled long-acting b2-agonists
• Oral anti-leukotrienes
• Oral theophyllines

• Relievers
• Inhaled fast-acting b2-agonists

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Inhaled corticosteroids
Beclomethasone
Budesonide
Fluticasone
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Classification of asthma severity GINA 1995
Severe Persistent
Moderate persistent
Mild persistent
Intermittent
lt1/wk
gt1/wk
daily
Day symptoms
daily
lt2/mo
gt2/mo
gt1/wk
frequent
Night symptoms
gt80
gt80
60-80
lt60
PEFR
lt20
20-30
gt30
gt30
PF variability
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GINA1995
GINA 2002
High dose ICS other controller
ICSLABA other controller
Level 4
high dose ICS
ICSLABA
Level 3
ICS
Level 2
B2 agonist prn
Level 1
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Definition of COPD

• COPD is a disease state characterized by airflow
  limitation that is not fully reversible.
• The airflow limitation is usually both
  progressive and associated with an abnormal
  inflammatory response of the lungs to noxious
  particles or gases.

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Diagnosis of COPD
GOLD Global Initiative in Obstructive Lung
Disease 2001
Exposure to risk factors Tobacco occupation pol
lution

• Symptoms
• Cough
• Sputum
• dyspnea

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Spirometry post bronchodilator FEV1/ FVC lt70
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GOLD classification of COPD
At-Risk Stage (Stage 0) No spirometric changes Chronic symptoms (cough, sputum)
Mild (Stage I ) FEV1/FVC lt 70 FEV1 gt 80 predicted
Moderate (Stage II ) FEV1/FVC lt 70 50 lt FEV1 lt80 predicted
Severe (Stage III ) Very Severe (Stage IV) 30 lt FEV1 lt50 predicted FEV1 lt30 predicted or presence of respiratory insufficiency or right hart failure
GOLD Global Initiative in Obstructive Lung
Disease 2003
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Pathophysiology
COPD
Airflow obstruction
V/Q Mismatching
Work of breathing
VD/VT
PaO2
Ventilatory capacity
Ventialatory requirement
Exercise limitation (Dyspnea)
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Treatment

• Retard the progression of airflow obstruction
• Minimizing airflow obstruction
• Prevent complication
• Optimizing functional capacity

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Prevent disease progression
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Minimizing airflow obstruction

• Bronchodilators
• Anticholinergics
• B2 agonist
• Theophylline

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Corticosteroids

• Oral
• Inhaled

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Number of exacerbations per year stratified by
baseline FEV1
ISOLDE. BMJ20003201297-1303
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Corticosteroids
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GOLD pharmacological treatment
Regular bronchodilator treatment inhaled
corticosteroids Oxygen therapy
FEV1 lt30
Regular bronchodilator treatment Consider inhaled
corticosteroids
FEV1 30-50
Regular bronchodilator treatment
FEV1 50-80
Short acting bronchodilator as needed
FEV1gt80
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GOLD pharmacological treatment
Regular bronchodilator treatment inhaled
corticosteroids Oxygen therapy
LABA ICS Oxygen therapy
FEV1 lt30
Regular bronchodilator treatment Consider inhaled
corticosteroids
LABA ICS
FEV1 30-50
Regular bronchodilator treatment
FEV1 50-80
Short acting bronchodilator as needed
FEV1gt80
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GINA asthma guidelines
LABA ICS prednisolone
Severe persistent
LABA ICS
Moderate persistent
ICS
Mild persistent
Short acting bronchodilator as needed
Intermittent
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??????????????????????(???? 11????????)

• ?? ??????? ??????????? ?????? ??? ????
• 2519 28,685,940 8,629,510 30.1
• 2529 39,245,800 10,377,000 26.4 48.8 4.1
• 2536 45,680,300 10,406,200 22.8 43.2 2.5
• 2542 49,905,600 10,230,600 20.5 38.9 2.4

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Causes of death related to smoking

• Causes of death no.of death mortality ratio
• CA lung 309 31.0
• CA esophagus,larynx,
• mouth, toung,lip 114 7.0
• CA bladder 90 2.17
• CA prostrate 134 1.75
• CA liver,gall bladder 47 4.52

N187783 f/u 44 months
Hammond EC and Horn. JAMA 1958 1661172
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Causes of death related to smoking
Causes of death no.of death mortality
ratio Coronary artery disease 5297 1.7 Cerebrov
ascular disease 1050 1.3 aortic
aneurysm 90 2.72 other vascular
diseases 27 4.5 Pneumonia/influenza 124 3.9
N187783 f/u 44 months
Hammond EC and Horn. JAMA 1958 1661172
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Number of daily cigarettes and risk for lung
cancer
UK doctor n 34440
Doll R BMJ 1976
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Carcinogenic substances in cigarette smoke

• Polyaromatic hydrocarbon
• aromatic amines
• aldehydes
• inorganic compounds
• N-nitrosamines

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COPD mortality in relation to cigarette smoking
standardized mortality ratio
never smoke
former smoke
current smoke
34440 British doctor 1.0 14.7 16.7
Doll. BMJ 21525-15361976
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• Tobacco use results in true drug dependence
• Effective treatment exist
• Treatment are cost-effective

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5As for Promoting Smoking Cessation

• Ask about tobacco use at every visit
• Advice to quit
• Assess readiness to quit
• Assist cessation by providing evidence-based
  aids
• Arrange follow-up.  

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ASSIST
ARRANGE Follow-up
ADVISE
ASSESS
ASK
Never
Commend .
Ex- smoker
Congratulate.
Repeat advise
Not ready
Motivate
Encourage cessation
Current smoker
Prescribe Rxs
Ready to quit
Monitor compliance
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Effective Treatments Are Available

• Counselling / behavioural support
• Pharmacotherapy

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Counselling Works

• Brief supportive advice to quit from doctor is
  effective
• Counselling by other health professionals is
  effective
• Group and individual both effective
• The greater the support, the greater the chances
  of success
• Every smoker should be offered at least brief
  advice

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Pharmacotherapy Works

• First-line pharmacotherapies
• Bupropion SR
• Nicotine replacement therapy
• Second-line pharmacotherapies
• Clonidine
• Nortriptyline

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Treating tobacco dependence Approximate
long-term quit rates

• Cold turkey ?37
• Brief clinical intervention ?10
• More intensive counselling ?15
• Medication (bupropion SR/NRT) ?2030
• Medication counselling ?2535

Source Fiore MC, et al. Treating Tobacco use and
dependence. Clinical Practice Guideline. US DHHS,
2000.
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Who should receive pharmacotherapy?

• All smokers trying to quit except for special
  circumstances
• Special considerations include
• - medical contraindications
• - smoke lt 10 cigarettes/day
• - pregnant/breastfeeding
• - adolescent smokers

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Implementation of treatment is unsatisfactory

• Smoker insufficiently aware
• Treatment is not easily accessible
• Reimbursement is limited

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Conclusions

• More than 10 million smokers in Thailand.
• Smoking is a major health hazard
• Effective treatment for tobacco use is exist but
  under utilized
• we can do better, we must do better!