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Asthma and COPD
李世偉
署立桃園醫院胸腔內科
GINA 2006
GOLD 2006
GINA 2006
• Definition and Overview
• Diagnosis and
Classification
• Asthma Medications
• Asthma Management and
Prevention Program
• Implementation of
Asthma Guidelines in
Health Systems
GOLD 2006
•
•
•
•
Definition, Classification
Burden of COPD
Risk Factors
Pathogenesis,
Pathology,
Pathophysiology
• Management
• Practical Considerations
Asthma 與 COPD 之定義
Definition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent episodes of
wheezing, breathlessness, chest tightness, and coughing

Widespread, variable, and often reversible airflow
limitation
Definition of COPD



COPD is a preventable and treatable disease with some
significant extrapulmonary effects that may contribute to
the severity in individual patients.
Its pulmonary component is characterized by airflow
limitation that is not fully reversible.
The airflow limitation is usually progressive and associated
with an abnormal inflammatory response of the lung to
noxious particles or gases.
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
台北市學童氣喘病及氣喘症狀盛行率
25
(%)
20
15
10
5
0
1974年
1
1985年
2
1991年
3
1994年
4
2001年
5
COPD Prevalence Study in Latin America
The prevalence of
post-bronchodilator
FEV1/FVC < 0.70
increases steeply
with age in 5 Latin
American Cities
Source: Menezes AM et al. Lancet 2005
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
–59%
–64%
–35%
+163%
–7%
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0 0
Source: NHLBI/NIH/DHHS
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
Factors that Exacerbate Asthma






Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Mechanisms Underlying the
Definition of Asthma
Risk Factors
(for development of asthma)
INFLAMMATION
Airway
Airflow Obstruction
Hyperresponsiveness
Risk Factors
(for exacerbations)
Symptoms
Risk Factors for COPD
Genes
Exposure to particles
● Tobacco smoke
● Occupational dusts, organic and
inorganic
● Indoor air pollution from heating
and cooking with biomass in
poorly ventilated dwellings
● Outdoor air pollution
Lung growth and development
Oxidative stress
Gender
Age
Respiratory infections
Socioeconomic status
Nutrition
Comorbidities
Risk Factors for COPD
Nutrition
Infections
Socio-economic
status
Aging Populations
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, MD
Cellular Mechanisms of COPD
Asthma
Sensitizing agent
COPD
Noxious agent
Asthmatic airway inflammation
CD4+ T-lymphocytes
Eosinophils
COPD airway inflammation
CD8+ T-lymphocytes
Macrophages
Neutrophils
Small airway disease
Parenchymal destruction
Airway inflammation
Airway remodeling
Loss of alveolar attachments
Decrease of elastic recoil
Completely
reversible
Airflow limitation
Completely
irreversible
Inflammation and remodeling in asthmatic airway
•
•
•
•
•
Inflammation (I)
Mucus Plugging (MP)
Subepithelial Fibrosis (SF)
Myocyte Hypertrophy And Hyperplasia (MH)
Neovascularization (N)
Asthma
Epithelial loss
Thickened RBM
COPD
Epithelial metaplasia
Normal RBM
Asthma 與 COPD 之診斷
Asthma Diagnosis


History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow

Measurement of airway responsiveness

Measurements of allergic status to identify risk factors

Extra measures may be required to diagnose asthma
in children 5 years and younger and the elderly
FEV1
PEFR
Typical Spirometric (FEV1)
Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
1
2
3
4
Time (sec)
5
Note: Each FEV1 curve represents the highest of three repeat measurements
Daily Variability of PEFR
PEFR at night – PEFR at morning
--------------------------------------------------------- x 100%
½ (PEFR at night + PEFR at morning)
Measuring Variability of Peak
Expiratory Flow
Monitoring of asthma treatment
Zone
PEF
(% of best)
Daily variability
of PEF
Green
> 80%
< 20%
Yellow
60-80%
20-30%
<60%
>30%
Red
Measuring Airway Responsiveness
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
sputum
shortness of breath
tobacco
occupation
indoor/outdoor pollution

SPIROMETRY
Spirometry: Normal and
Patients with COPD
Differential Diagnosis:
COPD and Asthma
COPD
ASTHMA
• Onset in mid-life
• Onset early in life (often childhood)
•
• Symptoms vary from day to day
• Symptoms at night/early morning
Symptoms slowly
progressive
• Long smoking history
• Dyspnea during exercise
• Largely irreversible airflow
limitation
• Allergy, rhinitis, and/or eczema also
present
• Family history of asthma
• Largely reversible airflow limitation
Asthma 與 COPD 之治療
1997 NAEPP Guidelines
Classification of Asthma Severity
4
3
2
1
Severe Persistent
Moderate Persistent
Mild Persistent
Mild Intermittent
氣喘病的嚴重度分級標準
治療前之臨床症狀
日間症狀
夜間症狀
尖峰呼氣流速
經常性
低於預測值的 60%
變異度大於 30%
4. 嚴重持續性
日常活動受限
3. 中度持續性
每天都有,每天都用乙
二型交感興奮吸入劑
大於每週一次
2. 輕度持續性
每週都有，但少於
每天一次
大於每月二次 大於預測值的 80%,
1. 輕度間歇性
少於每週一次 , 氣
喘發作之間無症狀
介預測值的 60-80%,
變異度大於 30%
變異度介於 20-30%
每月二次或
二次以下
大於預測值的
80%, 變異度小
於 20%
只要符合症狀或尖峰呼氣流速值標準之一即可列入嚴重度分類，不必同時符合。 GINA 2002
Levels of Asthma Control
Partly controlled
Characteristic
Controlled
Daytime symptoms
None (2 or less /
week)
More than
twice / week
Limitations of
activities
None
Any
Nocturnal symptoms /
awakening
None
Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if known)
on any day
Exacerbation
None
One or more / year
(Any present in any week)
Uncontrolled
3 or more
features of
partly
controlled
asthma present
in any week
1 in any week
Component 4: Asthma Management and Prevention Program
Controller Medications








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Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled β2-agonists
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral β2-agonists
Anti-IgE
Systemic glucocorticosteroids
Component 4: Asthma Management and Prevention Program
Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
REDUCE
LEVEL OF CONTROL
TREATMENT OF ACTION
maintain and find lowest controlling
step
partly controlled
consider stepping up to
gain control
uncontrolled
exacerbation
INCREASE
controlled
step up until controlled
treat as exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
STEP
STEP
1
2
3
4
5
Treating to Achieve Asthma Control
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of short
duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or worsen
periodically, patients require regular controller
treatment (step 2 or higher)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller treatment for
patients of all ages (Evidence A)
 Alternative controller medications include
leukotriene modifiers (Evidence A) appropriate for
patients unable/unwilling to use inhaled
glucocorticosteroids
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-acting
β2-agonist either in a combination inhaler device or as
separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used as
monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid combined
with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
 Selection of treatment at Step 4 depends on prior
selections at Steps 2 and 3
 Where possible, patients not controlled on Step 3
treatments should be referred to a health
professional with expertise in the management of
asthma
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence A)
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline added to
medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence B)
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
 Addition of oral glucocorticosteroids to other
controller medications may be effective (Evidence
D) but is associated with severe side effects
(Evidence A)
 Addition of anti-IgE treatment to other controller
medications improves control of allergic asthma
when control has not been achieved on other
medications (Evidence A)
Treating to Maintain Asthma Control
 When control as been achieved, ongoing
monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored by
the health care professional and by the
patient
Severity of COPD (GOLD July 2003)
Stage
Characteristics
0: At Risk
normal spirometry, chronic symptoms (cough,
sputum production)
I: Mild COPD
FEV1/FVC < 70%
FEV1  80% predicted
II: Moderate COPD
FEV1/FVC < 70%
50%  FEV1 < 80% predicted
III: Severe COPD
FEV1/FVC < 70%
30%  FEV1 < 50% predicted
IV: Very Severe COPD FEV1/FVC < 70%, FEV1 < 30% predicted or
FEV1 < 50% predicted plus chronic respiratory
failure
Therapy at Each Stage of COPD
I: Mild
II: Moderate
III: Severe
IV: Very Severe
 FEV1/FVC < 70%
 FEV1/FVC < 70%
 FEV1 > 80% predicted
 FEV1/FVC < 70%
 50% < FEV1 < 80%
predicted
 FEV1/FVC < 70%
 30% < FEV1 < 50%
predicted
 FEV1 < 30% predicted
or FEV1 < 50% predicted
plus chronic
respiratory failure
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators
(when needed); Add rehabilitation
Add inhaled glucocorticosteroids if repeated
exacerbations
Add long term oxygen if
chronic respiratory
failure. Consider
surgical treatments
Management of Stable COPD
Other Pharmacologic Treatments
 Antibiotics: Only used to treat infectious
exacerbations of COPD
 Antioxidant agents: No effect of n-acetylcysteine
on frequency of exacerbations, except in patients
not treated with inhaled glucocorticosteroids
 Mucolytic agents, Antitussives, Vasodilators: Not
recommended in stable COPD
THANKS FOR YOUR ATTENTION