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CORSI DI AGGIORNAMENTO PER MMG Modena 12 aprile 2002

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 dell’Apparato Respiratorio. G lobal IN itiative for A sthma. www.ginasthma.com.

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CORSI DI AGGIORNAMENTO PER MMG Modena 12 aprile 2002

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  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 dell’Apparato Respiratorio

  2. Global INitiative for Asthma www.ginasthma.com

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

  4. 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 Global Initiative on Obstructive Lung DiseaseEXECUTIVE COMMITTEEChair: Romain Pauwels

  5. 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 Global Initiative on Obstructive Lung DiseaseSCIENTIFIC COMMITTEEChair: Leonardo M. Fabbri

  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. 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 GOLD REPORT – Section 4Page 32, left column, end of para 2, 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

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

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

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

  12. Stage Characteristics 0 : At risk Normal spirometry. Chronic symptoms (cough, sputum), I : Mild FEV1/FVC < 70%, FEV1 > 80% predicted with or without symptoms (cough, sputum) II : Moderate FEV1/FVC < 70%, 30% < FEV1 < 80% predicted with or without chronic symptoms (cough, sputum, dyspnea) (IIA: 50% < FEV1 < 80; IIB: 30 < FEV1 < 50) IV : Severe FEV1/FVC < 70%, FEV1 < 30% predicted or presence of respiratory failure or clinical signs of right heart failure Classification by severity GOLD guidelines 2001

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

  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 dell’Apparato Respiratorio

  15. Differences and similarities betweenasthma and COPD ASTHMA Sensitizing agent COPD Noxious agent Asthmatic airway inflammation CD4+ T-lymphocytes Eosinophils COPD airway inflammation CD8+ T-lymphocytes Marcrophages Neutrophils Airflow limitation Completely reversible Completely irreversible Airflow limitation

  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

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

  19. Fixed airflow limitation in Asthma and COPD FEV1 changes after oral corticosteroids History of Asthma No history of Asthma History of Asthma No history of Asthma 400 14 ** ** 12 300 10 % predicted ml 8 200 6 4 100 2 0 0

  20. Fixed airflow limitation in Asthma and COPD Airway Responsiveness to methacholine History of Asthma No history of Asthma 10 Methacholine PC20FEV1 (mg/ml) 1 0,1

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

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

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

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

  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 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 dell’Apparato Respiratorio

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