leonardo m. fabbri clinica di malattie dellapparato respiratorio università degli studi di modena e...
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Leonardo M. Fabbri
Clinica di Malattie dell’Apparato RespiratorioUniversità degli Studi di Modena e Reggio EmiliaAzienda Ospedaliero-Universitaria - Policlinico di Modena
Ridefinizione della Ridefinizione della BPCO e delle BPCO e delle
riacutizzazioniriacutizzazionidei sintomi in pazienti dei sintomi in pazienti
con BPCOcon BPCO
Modena 6-7/8-9 Settembre 2011
Corso di Aggiornamento su MALATTIE RESPIRATORIE
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COPD and chronic comorbidities
Exacerbations in COPD
Current and future treatment
Treatment of co-morbidities of COPD
Futuristic treatments
TREATMENT TARGETS IN COPD:
CURRENT AND EVOLVING MANAGEMENT OPTIONS
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20%-24%20%-24%(1 year)(1 year)
2.5%-10%2.5%-10%(5 days)(5 days)
22%-32%22%-32%(14 days)(14 days)
13%-33%13%-33%(14 days)(14 days)
Hospital mortalityHospital mortality
Hospital mortalityHospital mortality
Relapse (repeat ER visit)Relapse (repeat ER visit)
Treatment failure rateTreatment failure rate
OUTCOME OF COPD EXACERBATIONS
Seneff et al. JAMA. 1995; 274:1852-1857; Murata et al. Ann Emerg Med. 1991;20:125-129; Adams et al. Chest. 2000; 117:1345-1352; Patil et al. Arch Int Med. 2003; 163:1180-1186.
In hospitalized In hospitalized patientspatients
In ER patientsIn ER patients
In ICU patientsIn ICU patients
In outpatientsIn outpatients
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Goal of COPD Management
Overall COPD Control
Current Control Future Risk
Symptoms
Activity
Reliever use
Lung function
Exacerbations
Progressionof the disease
Mortality
Medication adverse effects
achieving reducing
defined by defined by
????? GOLD 2011 www.goldcopd.org
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COPD
Chronic disease
Tashkin D. N Engl J Med 2010; 363: 1184
Hurst et al, N Engl J Med 2010; 363: 1128-38
progressive nature
• lung function
• symptoms
• comorbidities
Exacerbations
• typically 1 - 3 per year
• frequency proportionalto COPD severity
• the frequent exacerbator
• chronic decline resulting
in poorer prognosis
HRQL
hospitalizations
mortality
COPD exacerbations
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ASSOCIATION OF DISEASE SEVERITY WITH THE FREQUENCY AND SEVERITY OF EXACERBATIONS DURING THE FIRST YEAR
OF FOLLOW-UP IN PATIENTS WITH COPD
Hurst J.R. et al., N Engl J Med 2010; 363: 1128-38
7
22
18
33 33
47
0
10
20
30
40
50
GOLD 2 GOLD 3 GOLD 4
Hospitalized for exacerbation in yr 1
Frequent exacerbations
(N=945)
% o
f p
ati
en
ts
(N=900) (N=293)
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0 20 40 60 80 100Percent
0 20 40 60 80 100Percent
0 20 40 60 80 100Percent
0 20 40 60 80 100Percent
0 20 40 60 80 100
0 20 40 60 80 100
0 20 40 60 80 100
0 20 40 60 80 100
0 20 40 60 80 100
0 20 40 60 80 100
0 20 40 60 80 100
0 20 40 60 80 100
0 20 40 60 80 100Percent
Year 1 Year 2 Year 323%
6%2%6%3%2%
2%2%1%
5%3%1%
3%2%2%
2%2%3%
2%1%1%
2%2%3%1%4%12%
Patients with no
exacerbation
Patients with 1
exacerbation
Patients with ≥ 2
exacerbations
STABILITY OF THE FREQUENT-EXACERBATION PHENOTYPE IN THE 1679 PATIENTS WITH CHRONIC OBSTRUCTIVE
PULMONARY DISEASE WHO COMPLETED THE STUDY
Hurst J.R. et al., N Engl J Med 2010; 363: 1128-38
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Breast Cancer Diseases - 2015
All Breast Cancers
ER+65-75%
HER2+15-20%
Triple negative
15%
HER3+
IGFR1+
p95+ 4%
P53mut
30-40 %FGFR1Ampl 8%
PTENloss
30-50%
PI3Kmut
10%
BRCAMut
8%
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12-02
BAC EGFR mut+: Response to TKI
12-00
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INTACT 1: Lack of benefit in combination with chemotherapy
Population: intention to treat
0.0
0.2
0.4
0.6
0.8
1.0
Survival time (months)0 4 8 12 16 20 24
Proportioneventfree
641 463 152 118981093At risk
Median survival, months1-year survival rate, %Log rank vs placebo
9.9243
0.7759(p=0.4377)
9.8641
1.0290(p=0.3034)
11.0745
Gefitinib 500 mg/dayGefitinib 250 mg/dayPlacebo
WE DIDN’T KNOW ABOUT EGFR MUTATION
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K Kobayashi et al, P ASCO 2009K Kobayashi et al, P ASCO 2009
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PNEUMONIA
THROMBOEMBOLISM
ACUTE HEART FAILURE
METABOLIC ACIDOSIS
ANEMIA
CAUSES OF EXACERBATION OF
RESPIRATORY SYMPTOMS IN CHRONIC PATIENTS
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BIOCHEMICAL MARKERS OF CARDIAC DYSFUNCTION PREDICT MORTALITY IN
ACUTE EXACERBATIONS OF COPD
Elevated levels of NT-proBNP and troponin T are strong predictors of early mortality among patients
admitted to hospital with acute exacerbations of COPD independently of other known prognostic
indicators
The pathophysiological basis for this is unknown, but indicates that cardiac involvement in
exacerbations of COPD may be an important determinant of prognosis
Chang CL et al, Thorax in pressChang CL et al, Thorax in press
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UNRECOGNIZED VENTRICULAR DYSFUNCTION IN CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
CHF and COPD frequently coexist
Ventricular dysfunction worsens survival in patients with COPD
Considering the high prevalence and the prognostic implications of ventricular dysfunction, routine assessment with either BNP or echocardiogram
should be considered in COPD patients
Macchia A et al, ERJ Express - June 23, 2011
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THE PROGNOSTIC IMPORTANCE OF THE PROGNOSTIC IMPORTANCE OF LUNG FUNCTION IN PATIENTS LUNG FUNCTION IN PATIENTS
ADMITTED WITH HEART FAILUREADMITTED WITH HEART FAILURE
Prognostic importance for all-cause mortality Prognostic importance for all-cause mortality of lung function variables obtained by of lung function variables obtained by
spirometry in an unselected group of patients spirometry in an unselected group of patients admitted with heart failure (HF)admitted with heart failure (HF)
Iversen KK et al, Iversen KK et al, Eur J Heart Fail. 2010 Jul;12(7):685-Eur J Heart Fail. 2010 Jul;12(7):685-91. 91.
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TARGETING THE LUNG TARGETING THE LUNG ATTACKSATTACKS
Current management strategiesfor acute asthma and AECOPD within and
subsequent to discharge from hospital are suboptimal
We suggest that the term ‘lung attack’ may resonate more with patients and the
broader communityFitzGerald JM, FitzGerald JM, Thorax May 2011 Vol 66 No 5
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Aggiornamento concetti generali sulla componente respiratoria della BPCO
Leonardo M. Fabbri
Aggiornamento concetti generali sulla componente respiratoria della BPCO
Leonardo M. Fabbri
DEFINIZIONE
Chronic Obstructive Pulmonary Disease (COPD) is a common preventable and treatable disease.
It is characterized by chronic respiratory symptoms, particularly dyspnea and persistent airflow limitation that is usually progressive and associated with an enhanced
chronic inflammatory response of the airways and the lung to cigarette smoke and/or other noxious particles or gases.
Exacerbations and significant concomitant disorders contribute to the overall severity in individual patients.
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5-yrs mortality5-yrs mortality
The present study analysed data from 20,296 subjects aged >45 yrs at baseline in the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular Health Study (CHS).
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COPD and chronic comorbidities
Exacerbations in COPD
Current and future treatment
Treatment of co-morbidities of COPD
Futuristic treatments
CORSO DI AGGIORNAMENTO SU MALATTIE RESPIRATORIECORSO DI AGGIORNAMENTO SU MALATTIE RESPIRATORIEModena 20-21 Luglio 2011Modena 20-21 Luglio 2011
INTRODUZIONE E LINEE GUIDA PER LA BPCO INTRODUZIONE E LINEE GUIDA PER LA BPCO Leonardo M. FabbriLeonardo M. Fabbri
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Barnes PJ et al., Eur Respir J 2009;33:1165–1185Barnes PJ et al., Eur Respir J 2009;33:1165–1185
SYSTEMIC EFFECTS AND COMORBIDITIES OF SYSTEMIC EFFECTS AND COMORBIDITIES OF CHRONIC OBSTRUCTIVE PULMONARY DISEASECHRONIC OBSTRUCTIVE PULMONARY DISEASE
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Severity of airflow limitationFrequency and severity of exacerbations
Comorbidities
Severity of airflow limitationFrequency and severity of exacerbations
Comorbidities
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Leonardo M. Fabbri
Clinica di Malattie dell’Apparato RespiratorioUniversità degli Studi di Modena e Reggio EmiliaAzienda Ospedaliero-Universitaria - Policlinico di Modena
Ridefinizione della Ridefinizione della BPCO e delle BPCO e delle
riacutizzazioniriacutizzazionidei sintomi in pazienti dei sintomi in pazienti
con BPCOcon BPCO
Modena 20-21 Luglio 2011
Corso di Aggiornamento su MALATTIE RESPIRATORIE