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Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease. Diagnosis Treatment Causes Surveillance. S C Stenton, Newcastle upon Tyne. Change in Age-Adjusted Death Rates, U.S., 1965-1998. IHD Stroke. 1965 1970 1975 1980 1985 1990 1995 2 000.

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Chronic obstructive pulmonary disease

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  1. Chronic obstructive pulmonary disease • Diagnosis • Treatment • Causes • Surveillance S C Stenton, Newcastle upon Tyne

  2. Change in Age-Adjusted Death Rates, U.S., 1965-1998 IHD Stroke 1965 1970 1975 1980 1985 1990 1995 2 000

  3. Change in Age-Adjusted Death Rates, U.S., 1965-1998 COPD IHD Stroke 1965 1970 1975 1980 1985 1990 1995 2 000

  4. Who gets heart disease

  5. Who gets COPD

  6. Investment in COPD Devon Donkey Sanctuary British Lung Foundation Annual income £22,000,000 (2009) Annual income £6,000,000 (2012)

  7. COPD now a disease of women CHRONIC OBSTRUCTIVE PULMONARY DISEASE SURVEILLANCE—UNITED STATES, 1972-2000.

  8. Chronic obstructive pulmonary disease (COPD) 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.

  9. COPD diagnosis • Diagnosis based on FEV/FVC • FEV/FVC <70% • Severity based on FEV % predicted • Stage 1 : FEV >80% (mild) • Stage 2 : FEV 50-79% (moderate) • Stage 3 : FEV 30-49% (severe) • Stage 4 : FEV <30% (very severe)

  10. Changes in FEV/FVC with age Melville ERJ 2010 : 850 subjects age 45-70

  11. Changes in FEV/FVC with age Melville ERJ 2010 : 850 subjects age 45-70

  12. Changes in FEV/FVC with age Melville ERJ 2010: 850 subjects age 45-70

  13. 70% vs LLN (lower limit of normal)for COPD diagnosis FEV/FVC 70% LLN

  14. 80% vs LLN (lower limit of normal)for COPD sseverity 80% LLN

  15. Other issues in COPD diagnosis • Distinguishing asthma • Not all airflow obstruction is due to COPD • Emphysema without airflow obstruction • But markedly impaired gas transfer • Combination of COPD and fibrosis • Normal spirometry but impaired gas transfer • Low FEV1/FVC with normal FEV and FVC • can be a normal variant bodybuilders, divers, rowers, firemen

  16. Asthma v COPD • Asthma phenotype • Family history • Childhood symptoms • Allergy history • Variable symptoms • Good response to treatment • COPD phenotype • Rare before 40s • Smoking history • Fixed symptoms • Poor response to treatment

  17. Other issues in COPD diagnosis • Distinguishing asthma • Not all airflow obstruction is due to COPD • Emphysema without airflow obstruction • But markedly impaired gas transfer • Combination of COPD and fibrosis • Normal spirometry but impaired gas transfer • Low FEV1/FVC with normal FEV and FVC • can be a normal variant • bodybuilders, divers, rowers, firemen

  18. Treatment of COPD to prevent exacerbations Placebo LAMA (Tiotropium) Placebo LABA + ICS (Symbicort) Tashkin NEJM 2008 Calverley ERJ 2003

  19. Pharmacological treatment of COPD • Long acting B agonist (LABA)/ Inhaled corticosteroid (ICS) • Seretide (Salmeterol + Fluticasone proprionate) • Symbicort (Formoterol + Budesonide) • Fostair (Formoterol + Beclomethasone0 • Relvair (Vilanterol+ Fluticasone Fumarate) • Flutiform (Formoterol + Fluticasone Fumarate) • Duoresp (Formoterol + Budesonide) • Long acting antimuscarinic (LAMA) • Spiriva (Tiotropium) • Seebri (Glycopyrrinium) • Eklira (Aclidinium) • Long acting B agonist (LABA) + antimuscarinic (LAMA) • Anaro (Vilanterol+ Umeclidinium) • Ultibro (Indacaterol +glycopyrronium)  • PF-4348235, PF-3429281, GSK961081 • Phosphodiesterase inhibitors • Rofumilast • Triple therapy (LABA, LABA, ICS) • tiotropium , formoterol, ciclesonide

  20. Pharmacological treatment of COPD • Long acting B agonist (LABA)/ Inhaled corticosteroid (ICS) • Seretide (Salmeterol + Fluticasone proprionate) • Symbicort (Formoterol + Budesonide) • Fostair (Formoterol + Beclomethasone0 • Relvair (Vilanterol+ Fluticasone Fumarate) • Flutiform (Formoterol + Fluticasone Fumarate) • Duoresp (Formoterol + Budesonide) • Long acting antimuscarinic (LAMA) • Spiriva (Tiotropium) • Seebri (Glycopyrrinium) • Eklira (Aclidinium) • Long acting B agonist (LABA) + antimuscarinic (LAMA) • Anaro (Vilanterol+ Umeclidinium) • Ultibro (Indacaterol +glycopyrronium)  • PF-4348235, PF-3429281, GSK961081 • Phosphodiesterase inhibitors • Rofumilast • Triple therapy (LABA, LABA, ICS) • tiotropium , formoterol, ciclesonide

  21. Pharmacological treatment of COPD • Long acting B agonist (LABA)/ Inhaled corticosteroid (ICS) • Seretide (Salmeterol + Fluticasone proprionate) • Symbicort (Formoterol + Budesonide) • Fostair (Formoterol + Beclomethasone0 • Relvair (Vilanterol+ Fluticasone Fumarate) • Flutiform (Formoterol + Fluticasone Fumarate) • Duoresp (Formoterol + Budesonide) • Long acting antimuscarinic (LAMA) • Spiriva (Tiotropium) • Seebri (Glycopyrrinium) • Eklira (Aclidinium) • Long acting B agonist (LABA) + antimuscarinic (LAMA) • Anaro (Vilanterol+ Umeclidinium) • Ultibro (Indacaterol +glycopyrronium)  • PF-4348235, PF-3429281, GSK961081 • Phosphodiesterase inhibitors • Rofumilast • Triple therapy (LABA, LABA, ICS) • tiotropium , formoterol, ciclesonide

  22. Treating COPD to prevent exacerbations Number needed to treat to prevent an exacerbation = 4 Number needed to prevent an admission =20

  23. Pneumonia and inhaled corticosteroids in COPD Placebo Salmeterol # Flutacisone Seretide Crim ERJ 2009

  24. Non-pharmacological management of COPD • Smoking cessation • Weight control • Pulmonary rehabilitation • Anxiety management

  25. Non-pharmacological management of COPD Anxiety • 60% prevalence • Catastrophic thoughts & impending danger. • Mistaken for worsening COPD. • Predictor of hospital admissions • Smoking cessation • Weight control • Pulmonary rehabilitation • Anxiety management

  26. Non-pharmacological management of COPD Depression • 40% prevalence • Loss of interest & enjoyment in ordinary things & experiences & low mood • Attention shifts to physical health problem & depression may be overlooked • Smoking cessation • Weight control • Pulmonary rehabilitation • Anxiety management

  27. Causes of COPD • Smoking • Asthma • Other genetic factors (atopy) • Biomass cooking • Environmental factors • Occupational exposures

  28. Causes of COPD Smoking Asthma Other genetic factors (atopy) Biomass cooking Environmental factors Occupational exposures

  29. Causes of COPD Childhood asthma persisting to adult life = smoking 40 cigarettes/day Smoking Asthma Other genetic factors (atopy) Biomass cooking Environmental factors Occupational exposures

  30. Causes of COPD • Smoking • Asthma • Other genetic factors (atopy) • Biomass cooking • Environmental factors • Occupational exposures

  31. Causes of COPD Smoking Asthma Other genetic factors (atopy) Biomass cooking Environmental factors Occupational exposures

  32. Effects of coal, smoking and age on lung function Average 221 98 1600 Mean effects (ml) on FEV1 of 40 years exposure

  33. Coal miners and emphysema

  34. Occupational COPD FEV1 normal Smokers Or occupational exposures Susceptible individuals age

  35. Occ Env Med 2005

  36. Agents reported to cause chronic airflow obstruction • Inorganic dusts Coal • Silica/ hard rock mining • Asbestos • Wollastoninte • Carbon Black • Iron dust/ steelworkers • Ceramic fibres • Organic dusts Cotton • Grain • Wood • Gases/ fume/chemicals Ammonia • Welding fume • Sulphur dioxide/ paper mills • Firefighting • Isocyanates

  37. Biases in occupational epidemiology • Healthy worker effect • Survivor effect • Smoking • Uncertainty about exposures • Recall biases

  38. Biases in occupational epidemiology • Healthy worker effect • Survivor effect • Smoking • Uncertainty about exposures • Recall biases

  39. General population : predictors of respiratory symptoms • 12,000 Newcastle residents, 40-75 yr • Questionnaire • Respiratory symptoms • Occupations, social status, diagnosis, treatment • 850 laboratory studies • Lung function tests • Detailed questionnaire Melville ERJ 2010

  40. Accuracy of diagnosis of COPD 139 49 36 85 had COPD by lung function criteria 188 reported diagnosis of COPD (bronchitis, emphysema etc)

  41. General population : predictors of respiratory symptoms odds ratio wheeze, SOB, cough Melville ERJ 2010

  42. General population : predictors of respiratory symptoms Melville ERJ 2010

  43. Occupational exposures account for 15% of COPD

  44. Exposures to vapours gases dusts and fumes and COPD development low high low high mild COPD severe COPD Metha Am J Respir Crit Care Med 2014

  45. Relevance of current occupational COPD for current exposure standards exposure limits

  46. Occupational exposure limits • Silica 0.1 mg/m3 • Coal (US) 1.5 mg/m3 • Coal (UK) 2.0 mg/m3 • Dust 4.0 mg/m3

  47. Surveillance for COPD FEV1 normal Susceptible individual age

  48. Surveillance for COPD FEV1 normal Susceptible individual age

  49. Surveillance for COPD FEV1 normal Susceptible individual age

  50. Surveillance for COPD FEV1 normal 30 ml/yr Susceptible Individual 60 -90ml/yr age

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