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Update Of Common Pulmonary Conditions

Update Of Common Pulmonary Conditions. Moises R Cossio DO. FCCP., FACP. Carilion Clinic - Pulmonary Critical Care Division September 24 , 2011. Objectives. Review the definition of COPD, asthma, Idiopathic pulmonary fibrosis (IPF), and pulmonary arterial hypertension (PAH).

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Update Of Common Pulmonary Conditions

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  1. Update Of Common Pulmonary Conditions Moises R Cossio DO. FCCP., FACP. Carilion Clinic - Pulmonary Critical Care Division September 24 , 2011

  2. Objectives • Review the definition of COPD, asthma, Idiopathic pulmonary fibrosis (IPF), and pulmonary arterial hypertension (PAH). • Explore the impact of COPD, Asthma, IPF, PAH, including rates of morbidity and mortality • Review the risk factors for COPD, asthma, IPF, PAH • Explore the natural history of COPD, Asthma, IPF, PAH from its earlier asymptomatic stages to the late stages associated with morbidity and mortality • Explore the current understanding of the pathophysiology of these diseases : the pathologic consequences of airway inflammation and parenchymal lung destruction. • Explore the systemic consequences of the disease and the comorbidities associated with these diseases • Review the current state of pharmacologic and no pharmacologic therapy for these diseases, including preventive measures

  3. Cumulative Exposure to Noxious Particles isthe Key Risk Factor for COPD

  4. Impact of COPD in the U.S. • Affected an estimated 23.6 million (13.9% of the adult population) Americans in 20011,2 • 10.5 million diagnosed1, • 48% increase in the number of patients with COPD between 1980 and 20001 • 39% not currently treated with prescription medicine3 • Estimated annual cost in 2004: $37.2 billion4 • $20.9 billion in direct healthcare costs • $16.3 billion in indirect healthcare costs 1. Maninno. MMWR 2002;51(SS-6):1-16. 2. published analysis of NHANES (National Health and Nutrition Examination) III data Survey GSK, June 2001. 3. Confronting COPD in America Survey. Available at URL: www.copdinamerica.com. Accessed January 21, 2004. 4. NIH/NHLBI. Morbidity and Mortality: 2004 Chart Book on Cardiovascular, Lung, and Blood Diseases. May 2004:17.

  5. Prevalence of COPD in the US 90 † † † † 80 † • Since 1987, the prevalence of COPD among women has been significantly higher than that among men † † † † † † † † 70 † † 60 50 Rate/1,000 Population* 40 Male Female Total 30 20 10 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 Year *Age-adjusted to 2000 US population. †Represents a statistically significant difference from rate among males. Mannino et al. MMWR. 2002;51(SS-6):1-16.

  6. Impact of COPD in the U.S. COPD was responsible for an estimated: • 13.8 million physician office visits* • 673,000 hospitalizations† • 118,000 deaths* *2001 data †2002 data NIH/NHLBI. Morbidity and Mortality: 2004 Chart Book on Cardiovascular, Lung, and Blood Diseases. May 2004:58-59.

  7. Leading Causes of Deaths: U.S. 2002 Cause of Death Number • Heart Disease 695,794 • Cancer 558,847 • Cerebrovascular disease (stroke) 163,010 • COPD and allied conditions* 125,550 • Accidents 102,303 • Diabetes 73,119 • Influenza and pneumonia 65,984 • Alzheimer’s disease 58,785 • Nephritis 41,018 • Septicemia 33,881 • All other causes of death 529,661 *Chronic lower respiratory diseases NIH/NHLBI. Morbidity and Mortality: 2004 Chart Book on Cardiovascular, Lung, and Blood Diseases. May 2004:10.

  8. Increase in COPD Mortality: 1990-2000 Percent Change in Age-Adjusted Death Rates in the US Over 10 Years (1990-2000) 25.5% –6.9% –6.9% –19.9% –48.0% Mannino et al. MMWR. 2002;51(SS-6):1-16. Pastor et al. Chartbook on Trends in the Health of Americans. Health, United States, 2002. Hyattsville, Md: National Center for Health Statistics. 2002. DHHS publication 1232-1.

  9. Facts About COPD Worldwide • In 2000, there were an estimated 2.5 million deaths worldwide from COPD1 • In 1990, COPD was ranked 12th as a burden of disease; by 2020 it is projected to rank 5th2 • It is estimated that by 2020 COPD will be the third leading cause of death in the world3 1. WHO, Number of Registered Deaths, WHO Mortality Database, 25 Feb 2003. 2. NIH/NHLBI. Global Initiative for Chronic Obstructive Lung Disease (“GOLD”). April 2001. NIH Publication Number 2701. Updated 2004, available at URL: www.goldcopd.com. 3. Murray, et al. Lancet 1997;349:1498-1504.

  10. Asthma Incidence In The US 2001-2009MMWR

  11. Asthma - Age-Adjusted Death Rates Based on the 1940 and 2000 Standard populations, 1979-2007

  12. Emphysema • Abnormal permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of their walls and without obvious fibrosis* Inelastic collapsible bronchioles Destruction of the alveolar wall damages pulmonary capillaries by tearing, fibrosis, or thrombosis Enlarged air sacs due to destruction of alveolar walls (bullae) Walls of individual sacs torn (repair not possible) *American Thoracic Society. Am J Respir Crit Care Med 1995;152:S77-S121.

  13. Structural Changes* in COPD • Epithelial changes • Ciliary dysfunction • Increase in mucus-secreting cells • Fibrosis of the small airways • Destruction of alveolar walls • Reduction in area for gas exchange • Loss of elastic recoil (emphysema) • Vascular changes may lead to pulmonary hypertension Normal Abnormal * No medication has been shown to reverse the structural changes associated with COPD. Global Initiative for Chronic Obstructive Lung Disease.Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: NHLBI/WHO Workshop Report. Bethesda, Md: NHLBI; NIH;March 2001. NIH publication 2701A.

  14. Gross Appearance of Human Lung Normal Asthma Emphysema

  15. Question 1. Which of the following tests bestdistinguish asthma from COPD? Choose the bestanswer • a) Bronchial inhalation challenge with methacholine • b) An FEV1 response to a short acting beta agonist of > 12% improvement (and > 200 cc increase) • c) Measurements of lung volumes (TLC, FRC, RV) • d) Sputum eosinophil count

  16. 1000 P = 0.01 r = -0.63 800 600 CD8+ (cells/mm2) 400 200 0 50 60 70 80 90 100 110 0 FEV1 (% predicted) Correlation of CD8+ T-Lymphocyte Infiltration and Airflow Limitation in Smokers • Peripheral airways were evaluated from surgical specimens from smokers with normal lung function and from patients with COPD. Saetta et al. Am J Respir Crit Care Med. 1998;157:822-826.

  17. Differentiating COPD and Asthma • Approximately 40% of patients diagnosed with COPD also had an asthma diagnosis, based on an analysis of ICD-9 electronic claims data over a 2-year period1 • Some patients with chronic asthma cannot be distinguished from those with COPD with current diagnostic tests2 • Management of these patients should be similar to that of patients with asthma2 1. Surveillance Data, Inc. (SDI). COPD/Asthma Diagnoses Overview; 2001-2003. March 2004. 2. Celli et al. Eur Respir J. 2004;23:932-946.

  18. Distinguishing Asthma and COPD • Both may lead to fixed airflow obstruction but most show reversibility to short-acting bronchodilators • Differences in lung function tests (diffusing capacity, residual volume, PaO2) statistically significant but there is large overlap • COPD has higher emphysema score on HRCT • Exhaled NO higher in asthmatics but there is overlap • Asthmatics have significantly more eosinophils in the peripheral blood, sputum and BAL

  19. Nearly 2/3 of patients with severe COPD (mean FEV1 39.3% pred)respond to bronchodilators* (15% or 12% & 200 ml increase in FEV1) * Ipratropium and albuterol Tashkin DP, et al. Eur Respir J.2008;31:742-750.

  20. COPD and ASTHMA: Different Diseases

  21. Airway Remodeling Fixed Airway Obstruction In Asthma

  22. Impact Of Smoking severe Fletcher C and Peto R. BMJ. 1977;1:1645-1648.

  23. Facts About Tobacco Use and COPD • Cigarette smoking is the primary cause of COPD1 • In the U.S. in 2000, 46.5 million adults (23.3%) were current smokers -- 25.7% of men and 21.0% of women2 • At least one-third of the global adult population, or 1.1 billion people, use tobacco3 1. NIH/NHLBI. Global Initiative for Chronic Obstructive Lung Disease (“GOLD”). April 2001. NIH Publication Number 2701. Updated 2004, available at URL: www.goldcopd.com. 2.MMWR 2002;51(29):642. 3. WHO Fact Sheet No. 222, April 1999.

  24. Alpha1 –Antitrypsin Deficiency • Patients with emphysema: 1%-2% • Common variants: S and Z - Point mutations in alpha1-antitrypsin gene • S-variant (264GluVal) in 28% of Southern Europeans • Alpha1-antitrypsin levels = 60% • no pulmonary effects • Z-variant (342Glu Lys) is associated with severe deficiency • Levels ≈ 10% of normal • Accumulation of alpha1-antitrypsin in the rough endoplasmic reticulum of the liver • Predisposed to juvenile hepatitis, cirrhosis, and hepatocellular carcinoma Mahadeva R and Lomas DA. Thorax. 1998;53:501-505.

  25. Clinical Features Of COPD • Typical smokers—mean 20 cigarettes/day for 20 years • Usually present in fifth decade of life with productive cough or acute chest illness • Dyspnea with exertion • History of wheezing and dyspnea may lead to an erroneous diagnosis of asthma American Thoracic Society. Am J Respir Crit Care Med 1995;152:S77-S121.

  26. American Thoracic Society Statement: 2004 “Some patients with asthma cannot be distinguished from COPD with the current diagnostic tests. The management of these patients should be similar to that of asthma.” Celli BR, et al. Eur Respir J 2004;23:932-946.

  27. Sleep-disordered breathing and COPD:The overlap syndrome The overlap syndrome

  28. Atopic Asthma (extrinsic) • Genetic susceptibility for developing Immunoglobulin IgE directed to epitopes expressed on common environmental allergens such as dust mites, animal proteins, pollens and fungi. • Ag enters mucosa, exposes to Langerhan’s cells, APC’s, then presented to ThO cells (naïve CD4), differentiated into TH2 cells, different from TH1-associated with delayed hypersensitivity reaction • IL4 enhances synthesis of IgE Ig from plasma cells, IgE then becomes fixed to mast cells, basophils, and dendritic cells , this sets the stage for acute allergic response with the inhalation of more antigen. The reaction is manifested as acute bronchospasm and delayed inflammatory response.

  29. Nonatopic Asthma • Older patients • Generally have negative hypersensitivity reaction to skin prick-tests • More intense inflamatory cell infiltrate with CD3, CD4, leukocytes and macrophages

  30. Natural History of Asthma • Peak prevalence is in childhood and is about 10% of the population • Declines to 5-6% in adolescence, and remissions are quiet high in early adulthood. • The prevalence rises again during late adulthood to 7-9%. • Recent statistics show that early childhood asthma remits by early adulthood in only 30-50%.

  31. Chest X-rays Of A Patient With Advanced Emphysema Enlargedretrosternal air space Flattened diaphragm Flattened diaphragm Posteroanterior Lateral

  32. Centrilobular Emphysema

  33. Emphysema CT-Scan

  34. Classification by Severity Stage Characteristics 0: At risk Normal spirometry Chronic symptoms (cough, sputum)  I: Mild FEV1/FVC < 70%; FEV1> 80% predicted With or without chronic symptoms (cough, sputum) II: Moderate FEV1/FVC < 70%; 50% <FEV1 < 80% predicted With or without chronic symptoms (cough, sputum, dyspnea) III: Severe FEV1/FVC < 70%; 30% < FEV1 < 50% predicted With or without chronic symptoms (cough, sputum, dyspnea) IV: Very Severe FEV1/FVC < 70% FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure NIH/NHLBI. Global Initiative for Chronic Obstructive Lung Disease (“GOLD”). Updated 2004, available at URL: www.goldcopd.com

  35. COPD Exacerbations: Impact Survival Soler-Cataluña JJ et al. Thorax. 2005;64:925-31

  36. Q3. Which of the following therapeutic measures has no improvement in exacerbation rate? • a) Inhaled corticosteroid • b) Oral corticosteroid • c) Long term antibiotic prophylaxis • d) Pneumococcal vaccine

  37. TORCH: Lower Exacerbation Rate WithLABA Plus ICS Calverley PM, et al. N Engl J Med. 2007;356:775-789.

  38. UPLIFT Study – Effects onExacerbations 0.85/yr Tashkin DP, et al. N Engl J Med. 2008;359:1543-1554.

  39. Macrolide Therapy Prevents Exacerbations

  40. Pneumococcal and Influenza VaccinationsReduce COPD Exacerbations Nichol et al. Arch Intern Med. 1999;159:2437-2442

  41. Question 3A 65 year old patient with GOLD Stag III COPD hasjust been entered into a pulmonary rehabilitationprogram. Which of the following is an unlikely outcomeof this program? • a. Reduced hospitalization rate for respiratory illnesses • b. Reduced all cause hospitalization rate • c. Improvement in FVC and FEV1 • d. Improvement in walking time

  42. Pulmonary Rehab: Effect on COPD

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