1. Leonardo M. Fabbri leonardo.fabbri@unimore.it First World Conference of COPD patients a global mandate for COPD care Holiday Inn Hotel Rome 14 June 2009 Impact of co-morbid conditions on care of COPD patients http//pneumologia.unimo.it

3. Pathogenesis of COPD Modified from Barnes, 2003 Cigarette smoke or air pollutant Alveolar macrophage Neutrophil Proteases ? CD8+ T-cell Alveolar wall destruction EMPHYSEMA Mucus hypersecretion CHRONIC BRONCHITIS Inflammatory cytokines (IL-8, LTB 4 ) CXCL-10 CXCR3

4. Leading Causes of Death in U.S. 1. Myocardial Infarction 2. Cancer 3. Cerebrovascular Diseases 4. COPD Cigarette Related Diseases Leading Causes of Death Worldwide 2010

5. Inhaled particles: pulmonary and heart co-morbidity

6. Complex Chronic Comorbidities of COPD Fabbri et al Eur Respir J 2008;31:204-212

7. Prevalence of heart failure in stable ‘COPD’ (aged 65 years or over) Rutten FH et al, Eur Heart J 2005;26:1887-94 Rutten FH et al, Eur Heart J 2005;26:1887-94

8. Prevalence of COPD and COPD severity in patients with Chronic Heart Failure 29 % 71 % GOLD: Global Obstructive Lung disease All but two of the patients were unaware of COPD % of patients Boschetto, Ceconi, Ferrari et al Eur Heart J, in preparation

9. Add inhaled glucocorticosteroids if repeated exacerbations IV: Very Severe III: Severe II: Moderate I: Mild Therapy at Each Stage of COPD  FEV 1 /FVC < 70%  FEV 1 > 80% predicted  FEV 1 /FVC < 70%  50% < FEV 1 < 80% predicted  FEV 1 /FVC < 70%  30% < FEV 1 < 50% predicted  FEV 1 /FVC < 70%  FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add long term oxygen if chronic respiratory failure. Consider surgical treatments

10. 5-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).

11. Add inhaled glucocorticosteroids if repeated exacerbations IV: Very Severe III: Severe II: Moderate I: Mild Therapy at Each Stage of COPD  FEV 1 /FVC < 70%  FEV 1 > 80% predicted  FEV 1 /FVC < 70%  50% < FEV 1 < 80% predicted  FEV 1 /FVC < 70%  30% < FEV 1 < 50% predicted  FEV 1 /FVC < 70%  FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add long term oxygen if chronic respiratory failure. Consider surgical treatments

12. What systemic aspects of COPD can be affected by therapy Weakness Weight loss Cardiac risk Arrythmias Coagulability Depression Osteoporosis Fluid retention

13. Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions Professional societies and charities should be encouraged and supported to develop clinical guidelines in compliance with NHMRC requirements Future guidelines should place more emphasis on the management of older people with multiple comorbid conditions Vitri AL et al., MJA 2008; 189: 360–365

14. Levin A. et al, CMAJ 2008; 179 (11):1154-1162 GUIDELINES FOR THE MANAGEMENT OF CHRONIC KIDNEY DISEASE

15. BOX 1: Guidelines for the treatment of hypertension in patients with chronic kidney disease BOX 2: Guidelines for the treatment of diabetes in patients with chronic kidney disease BOX 3: Guidelines for the treatment of dyslipidemia in patients with chronic kidney disease BOX 4: Guidelines for lifestyle management for patients with chronic kidney disease BOX 5: Guidelines for the measurement and treatment of proteinuria in patients with chronic kidney diseaseBOX 5: Guidelines for the measurement and treatment of proteinuria in patients with chronic kidney disease Levin A. et al, CMAJ 2008; 179 (11):1154-1162 GUIDELINES FOR THE MANAGEMENT OF CHRONIC KIDNEY DISEASE

16. BOX 6: Guidelines for the treatment of anemia in patients with stage 3-5 chronic kidney disease BOX 7: Guidelines for the assessment and treatment of mineral metabolism abnormalities in patients with chronic kidney disease BOX 8: Guidelines for preparation for initiation of renal replacement therapy for patients with chronic kidney disease BOX 9: Guidelines for comprehensive conservative management for patients with chronic kidney disease Levin A. et al, CMAJ 2008; 179 (11):1154-1162 GUIDELINES FOR THE MANAGEMENT OF CHRONIC KIDNEY DISEASE

17. Chronic Systemic Inflammatory Syndrome (CSIS) Age > 50 years Smoking > 10 pack/years Abnormal lung function Ventricular dysfunction and/or ↑ BNP Metabolic syndrome ↑ CRP Fabbri and Rabe, The Lancet 1 September 2007

18. I'm a 41 years old italian "Lammie", diagnosed with Lam in 2007, a rare and chronic desease which destroys the lungs progressively. Many young women die prematurely because of it. Unfortunately about Lam much is still unknown. Since my diagnosis I'm trying to do all I can to talk to as much as possible to people, researchers, doctors about it and stimulate their interest and to find more people in the world which can dedicate their studies to the research of a cure and to get to know Lam. The scientific community believes that the number of lam patients could be more than 30% compared to the known cases as Lam is often confused with Emphysema or COPD or not diagnosed at all. I thought that the Rome meeting could be a chance for us patients to spread also the knowledge about Lam globally and an occasion promote the Lam sight, which is which aims to create a global lam patient data. I'm sending the copy of this message also to Doctor Amy Farber, who has made so much for the global Lam community during the last years, founding the Lam Treatment Alliance in Harvard. www.lamtreatmentalliance.org, www.thelamfoundation.org www.lamsight.org www.lamtreatmentalliance.orgwww.thelamfoundation.org www.lamsight.org www.lamtreatmentalliance.orgwww.thelamfoundation.org www.lamsight.orgLYMPHANGIOLEIOMYOMATOSIS

19. LYMPHANGIOLEIOMIOMATOSIS Rare (1 per million) and progressive interstitial lung disease of unknown etiology, which can occur sporadically or in association with tuberous sclerosis. LAM almost exclusively affects females, generally developing before menopause. There are a few case reports describing LAM in males and children with tuberous sclerosis.

20. Dipartimento di Oncologia Ematologia e Pneumologia Sezione di Malattie dell’Apparato Respiratorio Direttore: Prof. Luca Richeldi Dott. Fabrizio Luppi Dott. Pietro Roversi Dott. Paolo Spagnolo Dott.ssa Giulia Cervi Dott. Giacomo Sgalla Dott.ssa Silvia Marani

21. Leonardo M. Fabbri leonardo.fabbri@unimore.it First World Conference of COPD patients a global mandate for COPD care Holiday Inn Hotel Rome 14 June 2009 Impact of co-morbid conditions on care of COPD patients http//pneumologia.unimo.it