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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.

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Presentation on theme: "CORSI DI AGGIORNAMENTO PER MMG Modena 12 aprile 2002 Criteri decisionali fra Global Initiatives on Asthma (GINA) e Obstructive Lung Disease (GOLD) Prof."— Presentation transcript:

1 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 G lobal IN itiative for A sthma www.ginasthma.com

3 G lobal Initiative for Chronic O bstructive O bstructive L ung L ung D isease D isease www.goldcopd.com

4 Global Initiative on Obstructive Lung Disease EXECUTIVE COMMITTEE Chair: Romain Pauwels S. Buist, US P. Calverley, UK B. Celli, US L. Fabbri, Italy Y. Fukuchi, Japan S. Hurd, US L. Grouse, US C. Jenkins, Australia N. Khaltaev, CH C. Lenfant, US J. Luna, Guatemala W. McNee, UK R. Rodriguez Roisin, E N.Zhong, China

5 Global Initiative on Obstructive Lung Disease SCIENTIFIC COMMITTEE Chair: 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

6 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

7 GOLD REPORT – Section 4 Page 32, left column, end of para 2, ORIGINAL TEXT …. tract inflammation 57-61. It is likely that indoor air pollution derived from the burning of biomass fuels will prove to have similar effects. SUGGESTED REVISION …. tract inflammation 57-61. 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

8 Levels of evidence LevelSource A Randomized clinical trials (RCT). Several, consistent B Randomized clinical trials (RCT). Few, inconsistent C Non-randomized clinical trials. Small and/or observational studies D Opinion of experts

9 Severity of symptoms Threshold for Increasing control medication Poor control Poor compliance Good control Good compliance No of puffs of albuterol Time Exacerbations

10 Classification of Asthma Severity CLASSIFY SEVERITY Clinical Features Before Treatment Symptoms STEP 4 Severe Persistent Continuous Limited physical activity Frequent 60% predicted Variability >30% Nighttime SymptomsPEF STEP 3 Moderate Persistent Daily Use 2-agonist daily Attacks limit activity >1 time week 60-80% predicted Variability >30% STEP 2 Mild Persistent 1 time a week but <1 time a day >2times a months 80% predicted Variability 20-30% STEP 1 Intermittent <1 time a week Asymptomatic and normal PEF between attacks 2 times a month 80% predicted Variability <20% One of the features of severity is sufficient to place a patient in that category Intensity of treatment Treatment

11 MANAGEMENT OF ASTHMA Long-acting bronchodilators and/or LTRA Inhaled steroids Short-acting 2 agonists prn PREVENTION Severity of asthma Oral steroids

12 Classification by severity StageCharacteristics 0 : At riskNormal spirometry. Chronic symptoms (cough, sputum), I : MildFEV1/FVC 80% predicted with or without symptoms (cough, sputum) I : MildFEV1/FVC 80% predicted with or without symptoms (cough, sputum) II : ModerateFEV1/FVC < 70%, 30% < FEV1 < 80% predicted with or without chronic symptoms (cough, sputum, dyspnea) (IIA: 50% < FEV1 < 80; IIB: 30 < FEV1 < 50) IV : SevereFEV1/FVC < 70%, FEV1 < 30% predicted or presence of respiratory failure or clinical signs of right heart failure GOLD guidelines 2001

13 MANAGEMENT OF COPD Inhaled Steroids Anti-cholinergics long-acting 2 Agonists Short-acting 2 agonists prn PREVENTION Severity of COPD Theophylline Oral steroids

14 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 between asthma and COPD ASTHMA Sensitizing agent COPD Noxious agent Asthmatic airway inflammation CD4+ T-lymphocytes Eosinophils COPD airway inflammation CD8+ T-lymphocytes MarcrophagesNeutrophils Airflow limitation CompletelyreversibleCompletelyirreversible

16 Bronchial biopsies from 2 asthmatics of similar age and with similar degree of fixed airflow limitation

17 Characteristics of patients with fixed airflow limitation COPDASTHMA NumberAgeMales/FemalesNS/ExS/SAtopy29 67 + 1.7 19/102/23/43/2919 64 + 1.9 12/714/5/016/19 FEV 1 56 + 3 56 + 2 Reversibility 4.7 + 0.9 8.7 + 2.4*

18 Fixed airflow limitation in Asthma and COPD L/s 100 150 200 250 300 FEV1 changes after bronchodilator % 0 2 4 6 8 10 12 14 16 History of Asthma No history of Asthma History No history of Asthma * *

19 Fixed airflow limitation in Asthma and COPD % predicted 0 100 200 300 400 ml 0 2 4 6 8 10 12 14 ** ** FEV 1 changes after oral corticosteroids History of Asthma No history of Asthma History No history of Asthma

20 History No history of Asthma Airway Responsiveness to methacholine Methacholine PC 20 FEV1 (mg/ml) Fixed airflow limitation in Asthma and COPD 0,1 1 10

21 L 1,5 2,0 2,5 3,0 Residual Volume % pred % pred 100 125 150 History of Asthma No history of Asthma History No history of Asthma * * Fixed airflow limitation in Asthma and COPD

22 0,5 1,0 1,5 Carbon monoxide diffusion capacity (Kco) % predicted % predicted 30 40 50 60 70 80 90 100 110 120 History of Athma No history of Asthma History No history of Asthma *** *** mmol min -1 l- 1 mmol min -1 l- 1

23 SPUTUM % cells % cells 0 10 20 30 40 50 60 70 80 90 100 110 120 Macrophages EosinophilsLymphocytesNeutrophils **** Fixed airflow limitation in Asthma and COPD History of Asthma No history of asthma

24 Exhaled NO (ppb) 0 10 20 30 40 50 60 History of Asthma No history of Asthma Exhaled Nitric Oxide *** Fixed airflow limitation in Asthma and COPD Fixed airflow limitation in Asthma and COPD

25 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 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

26 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


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