OBSTRUCTIVE PULMONARY DISEASES:

BRONCHIAL ASTHMA CHRONIC OBSTRUCTIVE PULMONARY DISEASE

IDA BAGUS NGURAH RAI

Trends in Prevalence of Asthma By Age, U.S., 1985-1996

80 70 60 50 40 30 20 85 86 87 88 89 90 91 Year 92 93 94 95 96 Rate/1,000 Persons

Age (years)
<18 18-44

45-64
65+ Total (All Ages)

Hospitalization Rates for Asthma

by Age, U.S., 1974 - 2000
Rate/100,000 Persons 40 35 <15 15-44 45-64 65+

30
25 20

15
10 5 0 74 76 78 80 82 84 86 Year 88 90 92 94 96 98 00

Death Rates for Asthma

By Race, Sex, U.S., 1980-2000
Rate/100,000 Persons 5 Black Female 4 3 White Female 2 1 0 1980 White Male Black Male

1985

1990 Year

1995

2000

Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998

Proportion of 1965 Rate
3.0 3.0 2.5 2.5

Coronary Heart Disease

Stroke

Other CVD

COPD

All Other Causes

2.0 2.0 1.5 1.5 1.0 1.0

0.5 0.5 0.0 0

59% 1965 - 1998

64% 1965 - 1998

35% 1965 - 1998

+163% 1965 - 1998

7% 1965 - 1998

Age-Adjusted Death Rates for COPD, U.S., 1960-1998

Deaths per 100,000 60 60 50 50
40 40 Black Male 30 30 White Female 20 20 Black Female 10 10 00 1960 1960 White Male

1965

1965

1970

1970

1975

1975

1980

1980

1985

1985

1990

1990

1995

1995

2000

2000

CASE HISTORY
A 24-year-old female was admitted with breathlessness for 6 h. She has had cold for 2 days. Past history revealed her being chesty as a child. It was noticed that she could not complete sentences easily. Heart rate was 126/min and respiratory rate was 30/min. There was expiratory wheeze over the lung field

Definition of Asthma

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role
Chronic inflammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment

Mechanisms Underlying the Definition of Asthma

Risk Factors (for development of asthma)

INFLAMMATION
Airway Hyperresponsiveness Airflow Obstruction

Risk Factors (for exacerbations)

Symptoms

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

Risk Factors that Lead to Asthma Development

Host Factors
Genetic predisposition Atopy Airway hyperresponsiveness Gender Race/Ethnicity

Environmental Factors
Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Parasitic infections Socioeconomic factors Family size Diet and drugs Obesity

Factors that Exacerbate Asthma

Allergens Air Pollutants Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

Is it Asthma?

Recurrent episodes of wheezing

Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants

Colds go to the chest or take more than 10 days to clear

Asthma Diagnosis

History and patterns of symptoms

Physical examination

Measurements of lung function

Measurements of allergic status to identify risk factors

Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms STEP 4 Severe Persistent STEP 3 Continuous Limited physical activity Daily Attacks affect activity Nocturnal Symptoms FEV1 or PEF 60% predicted

Frequent

Variability > 30% 60 - 80% predicted

> 1 time week

Moderate Persistent STEP 2

Mild Persistent STEP 1 Intermittent

Variability > 30%

80% predicted

> 1 time a week but < 1 time a day < 1 time a week Asymptomatic and normal PEF between attacks

> 2 times a month

Variability 20 - 30%

2 times a month

80% predicted

Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.

Six-Part Asthma Management Program

1. Educate Patients

2. Assess and Monitor Severity

3. Avoid Exposure to Risk Factors 4. Establish Medication Plans for Chronic Management: Adults and Children 5. Establish Plans for Managing Exacerbations

6. Provide Regular Follow-up Care

Six-part Asthma Management Program

Goals of Long-term Management

Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal levels as possible Maintain normal activity levels, including exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow limitation Prevent asthma mortality

Six-part Asthma Management Program

Control of Asthma
Minimal (ideally no) chronic symptoms

Minimal (infrequent) exacerbations

No emergency visits Minimal (ideally no) need for as needed use of 2-agonist No limitations on activities, including exercise PEF circadian variation of less than 20 percent (Near) normal PEF Minimal (or no) adverse effects from medicine

Six-Part Asthma Management Program

The most effective management is to prevent airway inflammation by eliminating the causal factors Asthma can be effectively controlled in most patients, although it can not be cured

The major factors contributing to asthma morbidity and mortality are under-diagnosis and inappropriate treatment

Six-Part Asthma Management Program

Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms

Typical Spirometric (FEV1) Tracings

Volume FEV1

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

3 4 Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements

A Simple Index of PEF Variation

800 700 600 500 400 300

Highest PEF (670)

PEF (L/min)

Lowest morning PEF (570)

Morning PEF Evening PEF

14

Days

Minimum morning PEF ( % recent best): 570/670 = 85%

(From Reddel, H.K. et al. 1995)

Six-part Asthma Management Program

Part 4: Establish Medication Plans for Long-Term Asthma Management

A stepwise approach to pharmacological therapy is recommended The aim is to accomplish the goals of therapy with the least possible medication Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma Therapy

The choice of treatment should be guided by:
Severity of the patients asthma
Patients current treatment Pharmacological properties and availability of the various forms of asthma treatment Economic considerations

Cultural preferences and differing health care systems need to be considered

Part 4: Long-term Asthma Management

Pharmacologic Therapy
Controller Medications:
Inhaled glucocorticosteroids Systemic glucocorticosteroids Cromones Methylxanthines Long-acting inhaled 2-agonists Long-acting oral 2-agonists Leukotriene modifiers Anti-IgE

Part 4: Long-term Asthma Management

Pharmacologic Therapy
Reliever Medications:
Rapid-acting inhaled 2-agonists Systemic glucocorticosteroids

Anticholinergics
Methylxanthines Short-acting oral 2-agonists

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma Therapy Adults/Children Older Than 5 yrs

Outcome: Asthma Control
Outcome: Best Possible Results

Controller:

Controller: Controller:
None

Controller:

Low-dose inhaled corticosteroid

Low to medium- dose inhaled corticosteroid plus long-acting inhaled -Theophylline-SR 2-agonist -Leukotriene

High-dose inhaled corticosteroid plus long acting inhaled 2-agonist plus (if needed)

When asthma is controlled, reduce therapy Monitor

-Long-acting inhaled 2- agonist -Oral corticosteroid

Reliever:
STEP 1: Intermittent

Rapid-acting inhaled 2-agonist prn

STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down

Alternative controller and reliever medications may be considered (see text).

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug
Beclomethasone-CFC Beclomethasone-HFA Budesonide-DPI Budesonide-Neb Inhalation Suspension Flunisolide Fluticasone Mometasone furoate Triamcinolone acetonide Low Daily Dose (g) > 5 y Age < 5 y 200-500 100-250 200-600 500-1000 500-1000 100-250 200-400 400-1000 400-800 Medium Daily Dose (g) > 5 y Age < 5 y 500-1000 250-500 600-1000 1000-2000 1000-2000 250-500 400-800 1000-2000 800-1200 High Daily Dose (g) > 5 y Age < 5 y >1000 >500 >1000 >2000 >2000 >500 >800 >2000 >1200 >500 >400 >600 >1000 >1250 >400

100-250 50-200 100-200 250-500 500-750 100-200

250-500 200-400 200-600 500-1000 750-1250 200-400

Six-part Asthma Management Program

Part 5: Establish Plans for Managing Exacerbations Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the particular patient Availability of medications Emergency facilities

Six-part Asthma Management Program

Part 5: Establish Plans for Managing Exacerbations Primary therapies for exacerbations: Repetitive administration of rapid-acting inhaled 2-agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

Emergency Department Management

Acute Asthma
Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators; O2 if needed Good Response Observe for at least 1 hour Incomplete/Poor Response Add Systemic Glucocorticosteroids Good Response If Stable, Discharge to Home Poor Response Respiratory Failure

Discharge

Admit to Hospital

Admit to ICU

GINA,2004
Parameter Breathless

Severity Of Asthma Exacerbations

Mild
Walking Can lie down

Moderate
Talking Infantsofter shorter cry; difficulty feeding Prefers sitting Sentences Usually agitated Increased Usually

Severe
At rest Infantstops feeding Hunched forward

Respiratory arrest imminen

Talks in Alertness Respiratory rate Accessory muscles and suprasternal retractions Wheeze

Phrases May be agitated Increased Usually not

Words Usually agitated Often >30/min Usually Paradoxical thoracoabdominal movement Absence of wheeze Drowsy or confused

Moderate, often only end expiratory <100 Absent <10 mm Hg

Loud

Usually loud

Pulse/min Pulsus paradoxus

100-120 May be present 10-25 mm Hg Approximately 60-80%

>120 Often present >25 mm Hg (adult) 20-40 mm Hg (child) <60% predicted or personal best (<100 L/min adults) or response lasts <2 hours <60 mm Hg Possible cyanosis >45 mm Hg: Possible respiratory failure <90%

Bradycardia Absence suggests respiratory muscle fatigue

PEF after initial bronchodilator % predicted or % personal best PaO2 (on air) and/or

Over 80%

Normal Test not usually necessary <45 mm Hg >95%

>60 mm Hg

PaCO2 SaO2% (on air)

<45 mm Hg 91-95%

http://www.ginasthma.org

CASE HISTORY
A 63-year-old male ex-smokers has had chronic productive cough for 20 years. For 10 years he has had gradually increasing exertional dyspnoea. His usual exercise tolerance is 200 yards on the flat. One week previously he become breathless on walking between rooms and his sputum became purulent. His normal medication is salbutamol and beclomethasone inhalers

Definition of COPD
Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

Pathogenesis of COPD
NOXIOUS AGENT
(tobacco smoke, pollutants, occupational agent)
Genetic factors Respiratory infection Other

COPD

Noxious particles and gases

Host factors

Lung inflammation
Anti-oxidants

Anti-proteinases

Oxidative stress

Proteinases
Repair mechanisms

COPD pathology

GOLD Workshop Report

Four Components of COPD Management

1. Assess and monitor disease 2. Reduce risk factors

3. Manage stable COPD

Education Pharmacologic Non-pharmacologic

4. Manage exacerbations

Diagnosis of COPD
SYMPTOMS cough sputum dyspnea
EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution

SPIROMETRY

Classification by Severity
Stage
0: At risk

Characteristics
Normal spirometry Chronic symptoms (cough, sputum) FEV1/FVC < 70%; FEV1 80% predicted With or without chronic symptoms (cough, sputum) FEV1/FVC < 70%; 50% FEV1 < 80% predicted With or without chronic symptoms (cough, sputum, dyspnea) FEV1/FVC < 70%; 30% FEV1 < 50% predicted With or without chronic symptoms (cough, sputum, dyspnea)

I: Mild

II: Moderate

III: Severe

IV: Very Severe FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

Therapy at Each Stage of COPD

Old (2001)
New (2003)
Characteristics

0: At Risk
0: At Risk
Chronic Symptoms Exposure to risk factors Normal spirometry

I: Mild
I: Mild
FEV1/FVC < 70% FEV1 80% With or without symptoms

II: Moderate IIA IIB

II: Moderate
FEV1/FVC < 70% 50% < FEV1 < 80% With or without symptoms

III: Severe
IV: Very Severe
FEV1/FVC < 70% FEV1 < 30% or FEV1 < 50% predicted plus chronic respiratory failure

III: Severe
FEV1/FVC < 70% 30% < FEV1 < 50% With or without symptoms

Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more longacting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations

Add long-term oxygen if chronic respiratory failure Consider surgical treatments

Manage Exacerbations Key Points

Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD. The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about one-third of severe exacerbations cannot be identified (Evidence B).

Manage Exacerbations Key Points

Inhaled bronchodilators (beta2-agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocorticosteroids are effective for the treatment of COPD exacerbations (Evidence A).

Manage Exacerbations Key Points

Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, and/or fever) may benefit from antibiotic treatment (Evidence B).

Manage Exacerbations Key Points

Noninvasive intermittent positive pressure ventilation (NIPPV) in exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A).

GOLD Website Address

http://www.goldcopd.com