Transcript Increased Risk of Exacerbation and Hospitalization in Subjects With

Increased Risk of Exacerbation and
Hospitalization in Subjects With an
Overlap Phenotype
(COPD-Asthma)
Ana Maria B. Menezes , MD ; Maria Montes de Oca , MD ; Rogelio
Pérez-Padilla , MD ;
Gilbert Nadeau, BSc; Fernando César Wehrmeister , PhD; Maria
Victorina Lopez-Varela, MD;
Adriana Muiño , MD ; José Roberto B. Jardim , MD ; Gonzalo Valdivia ,
MD ;
and Carlos Tálamo , MD, FCCP ; for the PLATINO Team*
CHEST 2014; 145(2):297-304
R1.이성곤/prof. 박명재
Abstract of COPD & Asthma
• Most prevalent obstructive airway dz. worldwide.
(vary global prevalence)
• Latin American Project for the Investigation of
Obstructive Lung Disease (PLATINO)
-> 14.3% --stages I to IV, >40 yrs 5 Latin American cities
(by GOLD: Global Initiative for Chronic Obstructive Lung Disease)
• Several COPD phenotypes exist
: Overlap COPD-asthma(most recognized)
• Hardin et al : COPD Gene Study
->13% subjects COPD reported physician-diagnosed asthma.
Materials and Methods I
• PLATINO: Multi-center, population-based survey
1) American Thoracic Society (ATS) criteria
: baseline vs 15 min after 200 mg salbutamol(bronchodilator:BD)
[Portable spirometer (EasyOne spirometer)]
*Definition of asthma [post-BD]
① FEV1 15%↑
② peak flow variability(PEFR) 20%↑(during 1 week)
③ Physician Dx. of asthma + current symptoms
Materials and Methods II
2) Outcomes
:self-reported exacerbations in the last year
① Deterioration of breathing Sx. (yes/no)
[affected usual daily activities or caused missed work]
② Number of hospitalizations d/t the exacerbations
(yes/no),
③ Limitations d/t physical health, & pts’ perception of
their GHS
[excellent/very good/good/fair/poor by the Short Form-12 questionnaire (SF-12)]
Materials and Methods III
• Definition
(1) COPD—based on the ratio of the post-BD FEV 1/FVC
< 0.70
+lower limit of normal(LLN) (lower 15th percentile)
: as another criterion for COPD
(2) Asthma
①Wheezing in the last 12 mo.
+ post-BD -> FEV 1(200 mL) or FVC(12%) ↑
②“Medical Dx. of asthma”: also
(3) Overlap—the combination of the 2 previous dz.
Aim of the study
(1) Prevalence of three subgroups:
asthma, COPD, and COPD-asthma overlap
(PLATINO population)
(2) Explore the main characteristics: the 3 subgroups
(3) Determine the association btw.
-> COPD-asthma overlap: Outcomes
① Exacerbation ② Hospitalization
③ Limitation due do physical health
④ Perception of general health status (GHS).
Results I
• Prevalence - 5,044 subjects -> 767
: COPD group 594 (11.7%) + asthmatic group 84 (1.7%) + overlap group 89 (1.8%)
Results II-1
Results II-2
Results III
Results IV
Discussion I
**Principal finding
1) COPD 12%, Asthma 1.7% Overlap 1.8%
2) Overlap : more respiratory Sx., hospitalization, medication
worse Lung function, GHS
3) Adjusting : overlap a/w exacerbation, hospitalization compared with COPD
<Different definition of Asthma>
-> prevalence is vary -> Lack of consensus
ev)The European Community Respiratory Health Survey
: geographical difference
:English speaking countries vs Mediterranean & Eastern Europe
[eg.Manfreda et al, Arif et al 4.5~16.4%]
:Latin America[Brazil, highest prevalence wheezing (24.3%)
6th-highest medical diagnosis of asthma (12%) among 70 countries]
Discussion II
Asthma and COPD are different dz. But share
characteristics
: co-exist is recognized but not clearly defined
*PLATINO (mainly mild COPD)
VS COPDGene(more severe COPD-GOLD stages II-IV)
*[In this study] – Denominator N=5,044
1.8% -> 11.6%(N=767)
cf) Gene Environment Interactions in Respiratory Diseases study,
de Marco et al (total sample size as the denominator)
:1.6%(95% CI, 1.3%-2.0%) 20~44-yr-old age group
4.5% (95% CI, 3.2%-5.9%) 60~84-yr-old age group.
Discussion III
1) Pul. function?
*Overlap syndrome: Lung function↓ & more respiratory Sx. than either dz
alone.
cf) COPDGene study: did not show difference in lung function btw
*This study: worse pulmonary function & more respiratory Sx. in the overlap
group.
2) QOL?
① COPDGene cohorts: worse disease-related QOL, severe COPD
exacerbation,
& experience frequent exacerbations (as also Kauppi et al.)
② Our results : a/w worse GHS, more hospitalization &
exacerbations(compared with COPD)
Higher risk ~ all the outcomes in the overlap phenotype
(<- Definition: medically diagnosed asthma & a post-BD FEV 1
/FVC , <0.70).
Discussion IV
* The mechanisms are difficult to explain
*Some limitations:
: ① Asthma: official definition VS GINA (Global Initiative for Asthma)
e.g) *Wheezing in the last year?
: more sensitive & less specific than physician-diagnosed asthma.
*Adding BD response : Specificity↑ vs “medical diagnosis”
② COPD - overdiagnose dz. (in older individuals) cf) LLN
③ Exacerbation: Retrospective report of breathing symptoms->recall bias?
④ Crosssectional study -> underestimate the true rate of COPD
exacerbations.