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Conflict of interest

Conflict of interest. Bilimsel Danışma Kurulu, Kongre/toplantı sponsorluğu, konuşmacı veya bilimsel araştırma desteği sağlanan kuruluşlar (Harf sırasına göre sıralanmışlardır) AstraZeneca Boehringer - Ingelheim Chiesi GSK Novartis Nycomed TÜBİTAK.

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Conflict of interest

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  1. Conflict of interest Bilimsel Danışma Kurulu, Kongre/toplantı sponsorluğu, konuşmacı veya bilimsel araştırma desteği sağlanan kuruluşlar(Harf sırasına göre sıralanmışlardır)AstraZenecaBoehringer-IngelheimChiesiGSKNovartisNycomedTÜBİTAK

  2. Nonsmokingrisk factors in COPDEnvironmentalandoccupationalexposureDr. Mehmet Polatlı

  3. Smoking is themostimportant risk factor in COPD. But not theonlyone. • COPD duetosmoking “Populationattributablefraction,PAF” is usually < % 80 • COPD prevalance in neversmokers % 3-15 (BOLD, PLATINO) • PAF is lower in youngadults, womenandlowerdevelopedeconomics  OTHER RISK FACTORS?

  4. RISK FACTORS EXCEPT SMOKING • Genetics • Chronicasthma • Airpollutionandpassivesmoking • Occupationalexposure • Biomass • Diet

  5. Factorseffectinglungfunctionand COPD development Speizer and Tager

  6. Cellularinflammation in COPD

  7. Lungandambientair •  400 L oxygen/day • 10.000 L airinhalation/day • İndoorandoutdoorairpollution • Primarypollutants: SO2, NO2, CO, CO2, UOB, PM, NH3, Pb, etc • Secondarypollutants: Ozon (O3) ve NO2 • Particulatematter (PM) suspendedparticles in theair (dieselexhaust, energysources) • < 10 µm  PM10 2.5-10 µm course PM; • <2.5 µm  PM2.5 fine PM; < 100nm ultrafine PM

  8. Proposedlevels of pollutantsforcleanair 400 100 300 150 300 240 Türkiye Hava Kalitesinin korunması yönetmeliği 1986

  9. Ambientairpollutionfactors • Increasedpopulation • Urbanization • Industrilization • Variousconsumption • Consumptionfossilfuel • Vehicletraffic • Topographiccharacteristics of theland • Geograficalreasons

  10. Acuteeffects of airpolllution • Increase in symptoms • Decrease in lungfunction • Increase in seekingmedicaladvice • Increase in emergencyconsult • Hastaneye admission • Mortality • Sunyer J, EurRespir J 2001, Reviewconclusion

  11. Theeffects of ambientairpollution on inflammation • Increase in ROS andinflammation • Directtoxiceffects of theparticulates • İnflux of inflammatorycells in theairways • Macrophagesstimulation • Intertitialstimulation • Decrease in mucociliaryclearance • Increase in epitelialpermeability • Pulmonaryvasculature • MacNee, Donaldson, Review in EurRespir J, 2002 • Ling SH el al. International Journal of COPD 2009:4

  12. Is therechroniceffects of airpollution? • When do theeffects of thepolutantsbegin? • How do thesymptomsandpulmonaryfunctionchange? • Does it effect on PFT aftergoingawayfromthepollutionarea ? • Doesthemortalityincrease?

  13. Thefactorseffectinglungfunctionanddevelopment Speizer and Tager

  14. Airpollutionand COPDSunyer J. ERJ 2001

  15. Airpollutionand COPD Sunyer J. ERJ 2001 …conclusion • CB andemphysemaincrease in NHANES and AHSMOG studies • Dyspneaandmucushypersecretion in SAPALDIA • Lower PFT values in cross-sectionalstudies airpollution is relatedto an increasedprevalance in COPD.

  16. Theeffects of airpollutionbeginsantenatalperiod Latzin P et al. Air pollution during pregnancy and lungfunction in newborns: a birth cohort study. ERJ 2009

  17. Theeffects of airpollutionbeginsantenatalperiod • > 200 chemicalandpollutants’ presence in umblicalcordsuggeststhatplacenta is not have a role in barrieragaşnstthesesubstances • Lowbirthweight,, pretermsandincreasedperinatalmortality • Suddenbabydeathsyndromecommon Latzin P et al. ERJ 2009

  18. Neonatalandchildhoodperiod • Neonatalperiod significantassociationbetweenO3, CO, SO2, NO2 andrespiratoryproblems • Themostsignificantassociation is between NO2 and O3

  19. Lung Function Growth in Children with Long-Term Exposure to Air Pollutants in Mexico City. AJRCCM 2007 • 3170 children, 3 yearsfollow, 7 PFT measurement • Deficits in FVC and FEV1 growth over the 3-year follow-upperiod were significantly associated with exposure to O3, PM10and NO2 • increase in mean O3 concentration was associated with anannual deficit in FEV1 of 12 ml in girls and 4 ml in boys

  20. Chronicbronchitissymptomsareassociatedwith COPD risk • 11 yearsfollowup • Aged: 18-60 years • COPD OR 1.23 afteradjustedforage, sex, education, smoking, asthma, wheezing • Probst-Hensch N et al. Swiss SAPALDIA Study, Thorax 2010;65:150-156

  21. Asthma, CB andemphysema in theparentsincreasetheeffects of airpollution • 20 yearsfollowup in nonsmokers. PM, Sulfates, SO2 and O3 effects on PFT. • 1391 nonsmokers. • Incase of asthma, bronchitisandempysemahistory in family • PM10>100g/m3 increase (54 days/year) FEV1 decreaseassociatewith % 7.2 • Mean 8 hours O3 23 ppbincrease FEV1 decrease % 6.3 • Males SO4 density 1.6g/m3 increase FEV1 decrease % 1.5 • AM J RESPIR CRIT CARE MED 1998;158:289–298.

  22. Improvements in PM10 Exposure and Reduced Rates of Respiratory Symptoms in a Cohort of Swiss Adults (SAPALDIA) • SAPALDIA 1991, 9651 adults • SAPALDIA 2002, 7019/8047 adults • PM10 decreaseeffect on symptoms. • PM10 meandecreaselevel 6.2 µg/m3 • Improvements in PM10 Exposure Reduced Rates of Respiratory Symptoms in a Cohort of Swiss Adults • Schindler et al. 179 (7): 579. (2009)

  23. RespiratoryResearch 2005, 6:152

  24. SeventhDayAdventistStudyAbbey DE et al. EnvironmentalHealthPerspectives • 6102 adultsfollowup; obstructiveairwaydiseaseanddoctordiagnosed COPD • obstructiveairwaydiseaseandchronicbronchitis total particulates >200 µg/m3 andexposureduration>1000 hours/year risk 1.36 ve 1.33.

  25. European Prospective Study into Cancer and Nutrition (EPIC)Study • EPIC, 3904 adults in Atina • 168 healthycontrol (mean FEV1/FVC:% 102) • 168 COPD symptomatology(+) PFT andexamination 84 CB, empysemaor COPD KOAH • NO2 andblacksmokeindex in thelast 5 years • Eposure ¼ increase, disease risk increase % 37  • When most of the subjects exposed are considered vs. all others, there is a twofold increase in disease risk • Karakatsani et al. J Epidemiol 2003;18(1):45-53

  26. Naess et al . Relation between Concentration of Air Pollution and Cause-Specific Mortality: Four-Year Exposures to Nitrogen Dioxide and Particulate Matter Pollutants in 470 Neighborhoods in Oslo, Norway. Am J Epi 2007 • 143.842 aduts; 51-70 ve 70-90 years • NO, PM10, PM2.5 effects • Airpollutionassociatedwithmortality • NO2 > 40g/m3 significant • chronic obstructive pulmonary disease and the elderly seemto be susceptible to air pollution at lower levels than the general population

  27. persons discharged alive with chronic obstructive pulmonary disease • PM10’da 10µg/m3 increase mortality % 22  EnvironmentalHealth 2008, 7:48

  28. Strongevidence of associationoutdoorpollutionanddecreasedlunggrowth in adolescenceandchildhood • Fewstudywithspirometry but suggestiveevidencewithairpollutionand COPD • Thelikelihood of the role of airpollutionwith COPD is highbecause of PFT results

  29. PM ve FEV1, COPD Sean H Ling, Stephan F vanEeden. International J COPD 2009.

  30. PM ve COPD • PM inhaled from cigarettesmokeorambientairpollutionparticlesfromothersourcesboth have been associated with the development and progressionof COPD • With the rapid urbanization of thepopulation,a better understanding of the importance is necessaryfor educational and preventative measures Sean H Ling, Stephan F vanEeden. International J COPD 2009.

  31. Environmentaltobaccosmoke • Ventilationdecreasesthecigarettesmokeindoors but doesn’tdecreasehealthrisks TC Sağlık Bakanlığı. Türkiye Kronik Hava Yolu Hastalıklarını Önleme ve Kontrol Programı.Kasım 2010

  32. Environmentaltobaccosmokeand CB (SAPALDIA) • ETS (+) and (-) • 4.197 nonsmoker (18-60 yaş) • Cross-sectionalanalysis • CB OR 1.65 (1.26-2.14) • Dispnea OR 1.43 (1.18-1.74) • Leuenberger et al. AJRCCM 1994

  33. Environmentaltobaccosmokeand COPD • 2.113 adults , 55-75 aged; telephoned • ETS historyPrenatal, homeandworkplace • Doctordiagnosed CB, Empysema, COPD • OR 1.55 (CI 1.09-2.21) • PAF home ETS % 11, work % 7 public policies aimed at preventing public smoking may reduce the burden of COPD-related death and disability, both by reducing direct smoking and ETS exposure. Eisner MD et al. Environmental Health: A Global Access Science Source 2005, 4:7

  34. Passive smoking exposure and risk of COPD among adults inChina Yin et al. Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study.Lancet 2007; 370: 751–57.

  35. ETS and COPD risk • Exposurelevel • ETS in homeandwork • Outcomes • Chronicrespiratorysymptoms • COPD (FEV1/FVC < % 70) Exposuredensity Smokers in home Smokers in work Exposureduration Hours/week Exposureduration (yıl) Exposureburden Low<2 yıl;40 s/hf Mod 2-5 yıl; 40 s/hf High>5 yıl; 40 s/hf Yin et al. Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study.Lancet 2007; 370: 751–57.

  36. ETS and COPD Yin et al. Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study.Lancet 2007; 370: 751–57.

  37. ETS andSymptoms Lancet 2007; 370: 751–57

  38. ATS statementETS and COPD AmericanThoracicSocietyDocuments: An Official American Thoracic Society PublicPolicy Statement: Novel Risk Factors and theGlobal Burden of Chronic ObstructivePulmonaryDisease. Am J RespirCrit Care Med Vol 182. pp 693–718, 2010

  39. ETS and COPD in Sivas • 74 COPD femalesand 74 healthycontroles • Biomass > 30 years OR 6.61 (%95 CI 2.17-20.18) • ETS> 30 years OR 4.96 (% 95 CI 1.65-14.86)

  40. ETS in South East Turkey • > 40 years of agemales, 63/348 COPD • (% 18.1) • Cafeforregularly OR 5.37 • Cafevisit/week OR 2.72 • Cafevisit/month OR 2.33 Turk J MedSci 2010; 40 (3): 349-355

  41. PAR %11 PAR % 7

  42. Environmental Tobacco ExposureAre Enhanced by Bronchial Hyperreactivity(SAPALDIA 1991-2002) Am J RespirCrit Care Med Vol 174. pp 1125–1131, 2006

  43. Occupationaldustandchemicals • Organicandinorganicdustsandchemicals, gases • Someagents in experimentalstudies • CBendotoxin, mineral dust, SO2, vanadium) • emphysema Kadmium, coal, endotoxin, silica • An Official American Thoracic Society PublicPolicy Statement: Novel Risk Factors and theGlobal Burden of Chronic ObstructivePulmonaryDisease 2010

  44. Difficulties in theassessmentoccupationaland COPD association • Multifactorial (host, others) • Differantiation is difficultfromthediseasecausedbyotheragents • Mostworkersaresmokersand/orirritants in work • Healthyworkerseffect • Followupdifficultiesafterleavingwork • There is no subgrouplikeoccupationalasthma. • Chronic, slowprogression • Irreversiblafterleavingwork

  45. Kuempel ED et al. Contributions of Dust Exposure and Cigarette Smokingto Emphysema Severity in Coal Miners in the United States. AJRCCM 2009 Sigara içmeyen grup Sigara içen grup

  46. Kauffmann, F. J Epidemiol 1979

  47. Additifeffects • Onlyoccupationalexposure OR 1.4 • Onlysmoking OR 2.8 • Smokingandoccupationalexposure OR 6.2 • Trupin et al. ERJ 2003

  48. median PAR % 19

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