Asthma and COPD

1. Asthma and COPD 李世偉 署立桃園醫院胸腔內科

2. GINA 2006 GOLD 2006

3. Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program Implementation of Asthma Guidelines in Health Systems Definition, Classification Burden of COPD Risk Factors Pathogenesis, Pathology, Pathophysiology Management Practical Considerations GINA 2006 GOLD 2006

4. Asthma 與 COPD 之定義

5. Definition of Asthma • A chronic inflammatory disorder of the airways • Many cells and cellular elements play a role • Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing • Widespread, variable, and often reversible airflow limitation

6. Definition of COPD • COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. • Its pulmonary component is characterized by airflow limitation that is not fully reversible. • The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

7. Asthma Prevalence and Mortality Source: Masoli M et al. Allergy 2004

8. 台北市學童氣喘病及氣喘症狀盛行率 (%) 1974年 1985年 1991年 1994年 2001年

9. COPD Prevalence Study in Latin America The prevalence of post-bronchodilator FEV1/FVC < 0.70 increases steeply with age in 5 Latin American Cities Source: Menezes AM et al. Lancet 2005

10. Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 1.0 0.5 –59% –64% –35% +163% –7% 0 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 Source: NHLBI/NIH/DHHS

11. Risk Factors for Asthma • Host factors: predispose individuals to, or protect them from, developing asthma • Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

12. Factors that Exacerbate Asthma • Allergens • Respiratory infections • Exercise and hyperventilation • Weather changes • Sulfur dioxide • Food, additives, drugs

13. Mechanisms Underlying the Definition of Asthma Risk Factors (for development of asthma) INFLAMMATION Airway Hyperresponsiveness Airflow Obstruction Symptoms Risk Factors (for exacerbations)

14. Risk Factors for COPD • Genes • Exposure to particles • Tobacco smoke • Occupational dusts, organic and inorganic • Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings • Outdoor air pollution Lung growth and development Oxidative stress Gender Age Respiratory infections Socioeconomic status Nutrition Comorbidities

15. Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations

16. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD

17. Source: Peter J. Barnes, MD Mechanisms: Asthma Inflammation

18. Cellular Mechanisms of COPD

20. Asthma Sensitizing agent COPD Noxious agent Asthmatic airway inflammation CD4+ T-lymphocytes Eosinophils COPD airway inflammation CD8+ T-lymphocytes Macrophages Neutrophils Small airway disease Airway inflammation Airway remodeling Parenchymal destruction Loss of alveolar attachments Decrease of elastic recoil Airflow limitation Completely reversible Completely irreversible

21. Inflammation and remodeling in asthmatic airway • Inflammation (I) • Mucus Plugging (MP) • Subepithelial Fibrosis (SF) • Myocyte Hypertrophy And Hyperplasia (MH) • Neovascularization (N)

25. Asthma COPD Epithelial loss Thickened RBM Epithelial metaplasiaNormal RBM

26. Asthma 與 COPD 之診斷

27. Asthma Diagnosis • History and patterns of symptoms • Measurements of lung function - Spirometry - Peak expiratory flow • Measurement of airway responsiveness • Measurements of allergic status to identify risk factors • Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly

28. FEV1 PEFR

29. Typical Spirometric (FEV1) Tracings Volume FEV1 Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) 1 2 3 4 5 Time (sec) Note: Each FEV1 curve represents the highest of three repeat measurements

30. Daily Variability of PEFR PEFR at night – PEFR at morning --------------------------------------------------------- x 100% ½ (PEFR at night + PEFR at morning)

31. Measuring Variability of Peak Expiratory Flow

32. Monitoring of asthma treatment

33. Measuring Airway Responsiveness

34. Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation shortness of breath indoor/outdoor pollution è è è SPIROMETRY

35. Spirometry: Normal and Patients with COPD

36. Differential Diagnosis: COPD and Asthma COPD ASTHMA • Onset early in life (often childhood) • Symptoms vary from day to day • Symptoms at night/early morning • Allergy, rhinitis, and/or eczema also present • Family history of asthma • Largely reversible airflow limitation • Onset in mid-life • Symptoms slowly progressive • Long smoking history • Dyspnea during exercise • Largely irreversible airflow • limitation

37. Asthma 與 COPD 之治療

38. 1997 NAEPP Guidelines Classification of Asthma Severity 4 Severe Persistent 3 Moderate Persistent 2 Mild Persistent 1 Mild Intermittent

39. 氣喘病的嚴重度分級標準 治療前之臨床症狀 日間症狀 夜間症狀 尖峰呼氣流速 日常活動受限 低於預測值的 60% 變異度大於 30% 經常性 4. 嚴重持續性 3. 中度持續性 每天都有,每天都用乙二型交感興奮吸入劑 介預測值的 60-80%, 變異度大於 30% 大於每週一次 每週都有，但少於每天一次 大於預測值的 80%, 變異度介於 20-30% 大於每月二次 2. 輕度持續性 大於預測值的 80%, 變異度小於 20% 少於每週一次 , 氣喘發作之間無症狀 1. 輕度間歇性 每月二次或二次以下 只要符合症狀或尖峰呼氣流速值標準之一即可列入嚴重度分類，不必同時符合。 GINA 2002

40. Levels of Asthma Control

41. Component 4: Asthma Management and Prevention Program Controller Medications • Inhaled glucocorticosteroids • Leukotriene modifiers • Long-acting inhaled β2-agonists • Systemic glucocorticosteroids • Theophylline • Cromones • Long-acting oral β2-agonists • Anti-IgE • Systemic glucocorticosteroids

42. Component 4: Asthma Management and Prevention Program Reliever Medications • Rapid-acting inhaled β2-agonists • Systemic glucocorticosteroids • Anticholinergics • Theophylline • Short-acting oral β2-agonists

43. LEVEL OF CONTROL TREATMENT OF ACTION REDUCE maintain and find lowest controlling step controlled consider stepping up to gain control partly controlled uncontrolled step up until controlled INCREASE exacerbation treat as exacerbation REDUCE INCREASE TREATMENT STEPS STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

46. Treating to Achieve Asthma Control • Step 1 – As-needed reliever medication • Patients with occasional daytime symptoms of short duration • A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A) • When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)

48. Treating to Achieve Asthma Control • Step 2 – Reliever medication plus a single controller • A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A) • Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids

50. Treating to Achieve Asthma Control • Step 3 – Reliever medication plus one or two controllers • For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A) • Inhaled long-acting β2-agonist must not be used as monotherapy • For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)