corsi di aggiornamento per mmg modena 12 aprile 2002 criteri decisionali fra global initiatives on...
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CORSI DI AGGIORNAMENTO PER MMGCORSI DI AGGIORNAMENTO PER MMGModena 12 aprile 2002Modena 12 aprile 2002
Criteri decisionali fra Criteri decisionali fra Global Initiatives on Asthma (GINA) e Global Initiatives on Asthma (GINA) e
Obstructive Lung Disease (GOLD)Obstructive Lung Disease (GOLD)
Prof. Leonardo M. FabbriProf. Leonardo M. FabbriClinica di Malattie dell’Apparato RespiratorioClinica di Malattie dell’Apparato Respiratorio
GGloballobalININitiative foritiative forAAsthmasthma
www.ginasthma.comwww.ginasthma.com
G G lobal Initiative for Chroniclobal Initiative for Chronic
O O bstructivebstructive
L L ungung
D D iseaseisease
www.goldcopd.comwww.goldcopd.com
Global Initiative on Obstructive Global Initiative on Obstructive Lung DiseaseLung Disease
EXECUTIVE COMMITTEEEXECUTIVE COMMITTEEChair: Romain PauwelsChair: Romain Pauwels
S. Buist, USS. Buist, USP. Calverley, UKP. Calverley, UKB. Celli, USB. Celli, USL. Fabbri, ItalyL. Fabbri, ItalyY. Fukuchi, JapanY. Fukuchi, JapanS. Hurd, USS. Hurd, USL. Grouse, USL. Grouse, US
C. Jenkins, AustraliaC. Jenkins, Australia
N. Khaltaev, CHN. Khaltaev, CH
C. Lenfant, USC. Lenfant, US
J. Luna, GuatemalaJ. Luna, Guatemala
W. McNee, UKW. McNee, UK
R. Rodriguez Roisin, ER. Rodriguez Roisin, E
N.Zhong, ChinaN.Zhong, China
Global Initiative on Obstructive Lung DiseaseGlobal Initiative on Obstructive Lung Disease
SCIENTIFIC COMMITTEESCIENTIFIC COMMITTEEChair: Leonardo M. FabbriChair: Leonardo M. Fabbri
P. Barnes, UKP. Barnes, UKS. Buist, USS. Buist, US
P. Calverley, UKP. Calverley, UKY. Fukuchi, GiapponeY. Fukuchi, Giappone
W. McNee, UKW. McNee, UKR. Pauwels, BelgiumR. Pauwels, Belgium
K. Rabe, GermanyK. Rabe, GermanyRoberto Rodrigues Roisin, SpainRoberto Rodrigues Roisin, Spain
N. Zielinski, PolandN. Zielinski, Poland
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
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 Sep;109(4):288-95
Levels of evidenceLevels of evidenceLevelLevel SourceSource
AA Randomized clinical trials Randomized clinical trials (RCT). Several, consistent(RCT). Several, consistent
BB Randomized clinical trials Randomized clinical trials (RCT). Few, inconsistent(RCT). Few, inconsistent
CC Non-randomized clinical Non-randomized clinical trials. Small and/or trials. Small and/or observational studiesobservational studies
DD Opinion of expertsOpinion of experts
Severity of Severity of symptomssymptoms
Threshold forThreshold forIncreasingIncreasing
control control medicationmedication
Poor controlPoor controlPoor compliancePoor compliance
Good controlGood control
Good complianceGood compliance
No of puffs ofNo of puffs ofalbuterolalbuterol
TimeTime
ExacerbatioExacerbationsns
Classification of Asthma SeverityClassification of Asthma Severity
CLASSIFY SEVERITYClinical Features Before Treatment
Symptoms
STEP 4Severe
Persistent
ContinuousLimited physicalactivity
Frequent≤60% predictedVariability >30%
Nighttime Symptoms PEF
STEP 3ModeratePersistent
Daily
Use 2-agonist dailyAttacks limit activity
>1 time week 60-80% predictedVariability >30%
STEP 2Mild
Persistent≥1 time a weekbut <1 time a day >2times a months
≥80% predictedVariability 20-30%
STEP 1Intermittent
<1 time a week
Asymptomatic andnormal PEF betweenattacks
≤2 times a month≥80% predictedVariability <20%
One of the features of severity is sufficient to place a patient in that category
Intensity of treatment
Treatment
MANAGEMENT OF ASTHMAMANAGEMENT OF ASTHMA
Long-acting bronchodilators and/or LTRALong-acting bronchodilators and/or LTRA
Inhaled steroidsInhaled steroids
Short-acting Short-acting 2 agonists prn2 agonists prn
PREVENTIONPREVENTION
Severity of asthmaSeverity of asthma
Oral steroidsOral steroids
Classification by severityStageStage CharacteristicsCharacteristics
0 : At risk0 : At risk Normal spirometry. Chronic symptoms (cough, sputum),Normal spirometry. Chronic symptoms (cough, sputum),
I : MildI : Mild FEV1/FVC < 70%, FEV1 > 80% predicted with or without FEV1/FVC < 70%, FEV1 > 80% predicted with or without symptoms (cough, sputum) symptoms (cough, sputum)
II : ModerateII : Moderate FEV1/FVC < 70%, 30% < FEV1 < 80% predicted with or FEV1/FVC < 70%, 30% < FEV1 < 80% predicted with or without chronic symptoms (cough, sputum, dyspnea) without chronic symptoms (cough, sputum, dyspnea)
(IIA: 50% < FEV1 < 80; (IIA: 50% < FEV1 < 80; IIB: 30 < IIB: 30 < FEV1 < 50)FEV1 < 50)
IV : SevereIV : Severe FEV1/FVC < 70%, FEV1 < 30% predicted or presence of FEV1/FVC < 70%, FEV1 < 30% predicted or presence of respiratory failure or clinical signs of right heart failurerespiratory failure or clinical signs of right heart failure
GOLD guidelines 2001GOLD guidelines 2001
MANAGEMENT OF COPDMANAGEMENT OF COPD
Inhaled SteroidsInhaled Steroids
Anti-cholinergics Anti-cholinergics long-acting long-acting 2 Agonists2 Agonists
Short-acting Short-acting 2 agonists prn2 agonists prn
PREVENTIONPREVENTION
Severity of COPDSeverity of COPD
TheophyllineTheophyllineOral steroidsOral steroids
CORSI DI AGGIORNAMENTO PER MMGCORSI DI AGGIORNAMENTO PER MMGModena 5 aprile 2002Modena 5 aprile 2002
Criteri decisionali fra Criteri decisionali fra Global Initiatives on Asthma (GINA) e Global Initiatives on Asthma (GINA) e
Obstructive Lung Disease (GOLD)Obstructive Lung Disease (GOLD)
Prof. Leonardo M. FabbriProf. Leonardo M. FabbriClinica di Malattie dell’Apparato RespiratorioClinica di Malattie dell’Apparato Respiratorio
Differences and similarities betweenDifferences and similarities betweenasthma and COPD asthma and COPD
ASTHMAASTHMASensitizing agentSensitizing agent
COPDCOPDNoxious agentNoxious agent
Asthmatic airwayAsthmatic airwayinflammationinflammation
CD4+ T-lymphocytesCD4+ T-lymphocytes
EosinophilsEosinophils
COPD airway inflammationCOPD airway inflammationCD8+ T-lymphocytesCD8+ T-lymphocytes
MarcrophagesMarcrophages
NeutrophilsNeutrophils
Airflow limitationAirflow limitationCompletelyCompletelyreversiblereversible
CompletelyCompletelyirreversibleirreversible
Airflow limitationAirflow limitation
Bronchial biopsies from 2 asthmatics of similar Bronchial biopsies from 2 asthmatics of similar age and with similar degree of fixed airflow age and with similar degree of fixed airflow
limitationlimitation
Characteristics of patients with fixed Characteristics of patients with fixed airflow limitationairflow limitation
COPDCOPD ASTHMAASTHMA
NumberNumber
AgeAge
Males/FemalesMales/Females
NS/ExS/SNS/ExS/S
AtopyAtopy
2929
67 + 1.767 + 1.7
19/1019/10
2/23/42/23/4
3/293/29
1919
64 + 1.964 + 1.9
12/712/7
14/5/014/5/0
16/1916/19
FEVFEV11 56 + 356 + 3 56 + 256 + 2
ReversibilityReversibility 4.7 + 0.94.7 + 0.9 8.7 + 2.4*8.7 + 2.4*
Fixed airflow limitation in Asthma and COPDFixed airflow limitation in Asthma and COPD
L/sL/s
100100
150150
200200
250250
300300
FEV1 changes after bronchodilatorFEV1 changes after bronchodilator
%%
00
22
44
66
88
1010
1212
1414
1616 HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
****
Fixed airflow limitation in Asthma and Fixed airflow limitation in Asthma and COPDCOPD
% p
red
icte
d%
pre
dic
ted
00
100100
200200
300300
400400
ml
ml
00
22
44
66
88
1010
1212
1414
********
FEVFEV11 changes after oral corticosteroids changes after oral corticosteroids
HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
Airway Responsiveness to methacholineAirway Responsiveness to methacholineM
eth
acho
line
PC
Met
hac
holi
ne P
C2020
FE
V1
FE
V1
(mg/
ml)
(mg/
ml)
Fixed airflow limitation in Asthma and COPDFixed airflow limitation in Asthma and COPD
0,10,1
11
1010
LL
1,51,5
2,02,0
2,52,5
3,03,0
Residual VolumeResidual Volume
% pred% pred
100100
125125
150150 HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
****
Fixed airflow limitation in Asthma and COPDFixed airflow limitation in Asthma and COPD
Fixed airflow limitation in Asthma and COPDFixed airflow limitation in Asthma and COPD
0,50,5
1,01,0
1,51,5
Carbon monoxide diffusion capacity (Kco)Carbon monoxide diffusion capacity (Kco) % predicted% predicted
3030
4040
5050
6060
7070
8080
9090
100100
110110
120120
HistoryHistoryof Athmaof Athma
No historyNo historyof Asthmaof Asthma
HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
************ mmol minmmol min-1-1 l- l-11
SPUTUMSPUTUM % cells% cells
00
1010
2020
3030
4040
5050
6060
7070
8080
9090
100100
110110
120120
MacrophagesMacrophages EosinophilsEosinophils LymphocytesLymphocytesNeutrophilsNeutrophils
********
Fixed airflow limitation in Asthma and COPDFixed airflow limitation in Asthma and COPD
History ofHistory ofAsthmaAsthma
No history No history of asthmaof asthma
Exh
aled
NO
Exh
aled
NO
(ppb
)(p
pb)
00
1010
2020
3030
4040
5050
6060
HistoryHistoryof Asthmaof Asthma
No historyNo historyof Asthmaof Asthma
Exhaled Nitric OxideExhaled Nitric Oxide
******
Fixed airflow limitation in Asthma and COPDFixed airflow limitation in Asthma and COPD
HIGH RESOLUTION COMPUTED TOMOGRAPHYHIGH RESOLUTION COMPUTED TOMOGRAPHY
(HRCT) IS DIFFERENT IN PATIENTS WITH FIXED (HRCT) IS DIFFERENT IN PATIENTS WITH FIXED
AIRFLOW LIMITATION DUE TO SMOKING OR TO ASTHMAAIRFLOW LIMITATION DUE TO SMOKING OR TO ASTHMA
Patients with fixed airflow limitation due to smoking Patients with fixed airflow limitation due to smoking
maintain distinct radiological and functional maintain distinct radiological and functional
characteristics from patients with a history of asthma, characteristics from patients with a history of asthma,
even when they develop fixed airflow limitation, even when they develop fixed airflow limitation,
suggesting that fixed airflow limitation suggesting that fixed airflow limitation
does not define a unique disease entity.does not define a unique disease entity.
Romagnoli M et al, American Thoracic Society 2002, Atlanta, submittedRomagnoli M et al, American Thoracic Society 2002, Atlanta, submitted
CORSI DI AGGIORNAMENTO PER MMGCORSI DI AGGIORNAMENTO PER MMGModena 12 aprile 2002Modena 12 aprile 2002
Criteri decisionali fra Criteri decisionali fra Global Initiatives on Asthma (GINA) e Global Initiatives on Asthma (GINA) e
Obstructive Lung Disease (GOLD)Obstructive Lung Disease (GOLD)
Prof. Leonardo M. FabbriProf. Leonardo M. FabbriClinica di Malattie dell’Apparato RespiratorioClinica di Malattie dell’Apparato Respiratorio