Transcript the Presentation of ICS - Dr. S.N.

NATIONAL ALLERGY ASTHMA BRONCHITIS INSTITUTE
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Prof. A. G. Ghoshal
Perception and Practice of O…A…D…
- a field report
- preliminary observation
- lateral thoughts
CASE
THE CORRECT MANAGEMENT
REQUIRES AN ACCURATE DIAGNOSIS
CASE STUDY
• 67 year old female
• cough for four years
• SOB for 18 months
– slow not stopping
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occasional phlegm
pneumonia aged 18
0.5 pack years
“asthma” aged 35
prn salbutamol only
• overinflated
• quiet breath sounds
• CXR overinflated
post bronchodilator
FEV1 0.86 (32%)
FVC 2.46 (78%)
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STEROID TRIAL
FEV1 0.79 POST TRIAL (0.86 PRE)
BECOTIDE 400 mcg bd
AT SIX MONTHS: SOB ON INCLINES
LITTLE WHEEZE, DRY COUGH
SALMETEROL ADDED
AT TWO YEARS STABLE : FEV1 0.9
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14 YEARS AFTER PRESENTATION
NO EXACERBATIONS
NEW AF
RV DILATED
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AGED 83
16 YEARS AFTER PRESENTATION
SOB AND STOPS AT 50 METRES
SLIGHT COUGH
NO EXACERBATIONS
FEV1 0.67 (32%) (DECLINE OF 12 ML PER YEAR)
FVC 1.87 (74%)
KCO 0.68 (52%)
• ECHO : RV DILATATION
• PAP 58
• AF
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SC 400/12 BD
TIOTROPIUM
VENTOLIN
VERAP / WARFARIN / VALSARTIN/ FUROSAMIDE
No exacerbations and stable FEV1 over 14 years:
What’s your diagnosis?
• GOLD C COPD (with appropriate successful
initial treatment with the addition of LAMA as
exercise tolerance declined and treatment of
co-morbidities)?
• Asthma with late preventative therapy?
• Asthma COPD Overlap Syndrome?
RESPONSES
RESPONSES
Asthma with late preventive therapy
RESPONSES
• This is definitely not pure asthma! Out of the
other two options I would vote for COPD. Because:
Phenotype- Uniform course with gradual decline
in lung function. Onset at 35 years or later. No
documented FH/AR etc. No reversibility at all.
ACOS would definitely be the other option.
RESPONSES
• ….. going by the current definition I think this patient
initially had predominant asthma manifested by
significant steroid reversibility. Patient also had COPD
initially manifested by hyperinflation and partial control of
symptoms and exercise intolerance. In the later phase the
COPD component dominated with pulmonary
hypertension and reduced DLCO. So practically this is a
case of ACOS. But again I would rather want to describe
the case as an obstructive airway disease which initially
had a predominant airway component with later
development of parenchymal component.
RESPONSES
• The correct diagnosis could be neither of the options but
post infectious obliterative bronchiolitis as there is
previous history of "pneumonia". 5 pack year smoking
excludes COPD and development of Cor Pulmonale goes
against asthma. Overlap is also unlikely as both disease
components are unlikely. An HRCT showing mosaic
perfusion would clinch the diagnosis.
RESPONSES
What’s in a name?
• Total number of Dr participated in the survey: 150
– Chest: 75
– Non-chest: 75
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Total answers for Asthma: 55
Total answers for COPD: 71
Total answers for ACOS: 20
Total answers for OB : 02
• Among Chest the answers are :
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Asthma: 35
COPD: 18
ACOS: 18
OB: 02
What’s in a name? : 02
• Among Non-chest the answers are :
– Asthma: 20
– COPD: 53
– ACOS: 02
• There be no completely "unbiased, unfiltered"
perception.
• Perceptual experiences often shape our beliefs, but
those perceptions were based on existing beliefs.
• What we perceive (or think we perceive) is heavily
determined by what we know, and what we know (or
think we know) is constantly conditioned on what we
perceive (or think we perceive).
Predictive Coding ANDY CLARK
Philosopher and Cognitive Scientist, University of Edinburgh. Author: Supersizing the Mind: Embodiment,
Action, and Cognitive Extension
OAD means different thing to different people
Canadian practice assessment in chronic obstructive
pulmonary disease: Respiratory specialist physician
perception versus patient reality
• Differing perceptions about many aspects of
COPD among physicians and patients may
contribute to these care gaps.
Can Respir J Vol 20 No 2 March/April 2013
THE SCHOOL EFFECT
GINA
GOLD
Non-pulmonologists are –
1) Reluctant to use the label “ASTHMA”.
2) Familiar to make use of the term “COPD”.
1) For manifestation of an overall clinical
impression of chronic airflow limitation, not a
statement for a distinct disease entity.
Cardiologist use the term COPD
1) Age-effect
2) COPD is accommodated as a distant relative
to the family of ischemic heart diseases.
THE CHRONICITY(HELPLESS) EFFECT
• We have reported in the PLATINO population that
23% of the subjects with COPD report prior
medically diagnosed asthma.
• Subjects with COPD Asthma overlap had more
respiratory symptoms; worse lung function; and
more use of lung medication, hospitalization, and
exacerbations as worse GHS
for the PLATINO Team
CHEST 2014; 145(2):297–304
• People with more utilizations of health care
had an increased opportunity to receive both
an Asthma and COPD diagnosis, with the
correct conclusion being that people who had
more utilization of health care (for whatever
reason) are more likely to receive diagnosis of
both Asthma and COPD, rather than that
people who have received diagnoses of both
Asthma and COPD have more utilization of
healthcare.
Chest 2008; 134:14-19
Chestm2008; 134:1-2
• The diagnosis of Asthma depends on what we
mean by the word.
Clinical & Experimental Allergy, 2009 (39) 1652–1658.
• Reported prevalence rates of asthma vary
within and among countries worldwide---- the
comparison between studies is complicated by
the use of different definitions of asthma.
PLATINO
“Medical diagnosis of asthma” as definition for Asthma
Asthma
- A Physician’s Diagnosis
A diagnosis of asthma during their lifetime
(Positive answers to both of the questions
‘‘Have you ever had asthma?’’
and
‘‘Was this confirmed by a doctor?’’)
Cerveri I et al, Eur Respir J 2009; 34: 568-573
Asthma and Asthma-like Symptoms in
Adults Assessed by Questionnaires
• When validated in relation to bronchial challenge
tests, the questions about self-reported asthma
have a mean sensitivity of 36% (range, 7-8%) and
a mean specificity of 94% (range, 74-100%). The
questions about “physical-diagnosed asthma”
have even higher specificity, 99%.
• Specificity of the “asthma” –related questions
could be increased by restricting the study to
younger segment of the population.
Chest 1993;104:600-608
• Primary care clinicians have reported patients
with acute bronchitis that changes into
chronic asthma and later into severe COPD.
Hahn DL. Evaluation and management of acute
bronchitis. In:
Hueston WJ, ed. 20 common problems in
respiratory disorders.
New York, NY: McGraw-Hill, 2002: 141–53.
Salvi Lancet 2009; 374: 733–43
Diagnosis and Assessment
• A clinical diagnosis of COPD should be considered in any patient
who has dyspnea, chronic cough or sputum production,
and a history of exposure to risk factors for the disease.
Symptoms
Etiology
• Spirometry is required to make the diagnosis; the presence of a
post-bronchodilator FEV1/FVC < 0.70 confirms the presence of
persistent airflow limitation and thus of COPD.
?Sensitive
Not specific
• The degree of reversibility has never been shown to add to the
diagnosis, differential diagnosis with Asthma, or to predicting
the response to long-term treatment with bronchodilators or
corticosteroids.
GOLD 2013
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Table 2: Asthma on clinical diagnosis, n=648
Total asthma patients with acceptable spirometry
n=648
Asthma patients with airflow obstruction in spirometry
n=250
Asthma patients without airflow obstruction in spirometry
n=398
Male
356(54.9%)
164(65.6%)
192(48.2%)
Average age
40.5 yrs
(SD 17.3 yrs)
47.6yrs
(SD 19 yrs)
36.1 yrs
( SD 18.9yrs)
Socioeconomic status
(low= <5000/month, middle=5000-20000/month, high=>20000/month of monthly income)
Low – 272(41.9%)
Middle-150(23.1%)
High-226(34.8%)
Low-118(47.2%)
Middle-50(20%)
High-82(32.8%)
Low-154(38.7%)
Middle-100(25.1%)
High- 144(36.1%)
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Table 4: Symptoms of asthma phenotypes, smoking history and airway obstruction, n=125
Gr A <5% reversibility of FEV1
n=64
Gr B
6-12 % reversibility of FEV1 n=58
Gr C >12%,<200 ml reversibility of FEV1
n=26
Gr A+B+C group of ‘patients without reversibility’ n=148
Group of ‘patients with reversibility’ or
>12%, >200ml reversible group
n=102
P value of difference of ‘patients without reversibility’ and ‘patients with reversibility’
Childhood asthma
44(68.7%)
36(62%)
14(53.8%)
94(63.5%)
64(62.7%)
0.92
Family history of asthma
42(65.6%)
30(51.7%)
12(46.1%)
84(56.7%)
74(72.5%)
0.1
Running nose
60(93.5%)
48(82.7%)
26(100%)
134(90.5%)
90(88.2%)
0.90
Eczema
8(12.5%)
8(13.7%)
6(23%)
22(14.8%)
22(21.5%)
0.46
Nocturnal awakening >1 /wk
40(62.5%)
38(65.5%)
20(76.9%)
98(66.2%)
32(31.3%)
0.0003
Allergic Rhinitis versus Bronchodilator
Reversibility in the Diagnosis of Asthma.
A G Ghoshal1, Shelly Shamim2, Sushmita Kundu3, Subhasis Mukherjee4, Raja
Dhar5, Niranjan Sit6
Sensitivity and specificity of AR and BR for asthma diagnosis
Sensitivity of AR for asthma diagnosis 93.9%
specificity of AR for asthma diagnosis
87.5%
Sensitivity of BR for asthma diagnosis
30.4%
specificity of BR for asthma diagnosis
97.1%
• Prevalence of COPD with reversible
obstruction in first spirometries, among
patients with obstructive airways disease in
western Maharashtra, India.
Abhyankar A, Salvi S. Oct 4–8, 2008.ERS Abstr E456
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COPD. 2014 Feb;11(1):2-9. doi: 10.3109/15412555.2013.800853. Epub 2013 Jul 11.
Chronic obstructive pulmonary disease in non-smokers: a case-comparison study.
Sexton P1, Black P, Wu L, Sommerville F, Hamed M, Milne D, Metcalf P, Kolbe J. .
Asthma was nearly universal among nonsmokers
and was the commonest identifiable cause of COPD
in that group. Nonsmokers also exhibited a high
prevalence of objective eosinophilic inflammation
(raised ENO and eosinophil counts, positive skinprick
tests).
New Definition
COPD, a common preventable and treatable
disease, is characterized by persistent
airflow limitation that is usually progressive
and associated with an enhanced chronic
inflammatory response in the airways and
the lung to noxious particles or gases.
Exacerbations and co-morbidities contribute
to the overall severity in individual patients.
GOLD 2013
Exposure
Smoking
Air pollution
Inhaled toxins
Genes
Oxidative
stress
Carbonyl
stress
Inflammation
Airway
remodeling
Auto
immunity
Corticosteroid
resistance
? Infection
Differences in inflammation
between COPD and Asthma
Although both COPD and asthma are associated
with chronic inflammation of the respiratory tract,
there are differences in the inflammatory cells and
mediators involved in the two diseases, which in
turn account for differences in physiological effects,
symptoms, and response to therapy.
Am J Respir Crit Care Med 2003;167:418-24
• The pathology of chronic airflow limitation in
asthmatic non smokers and non asthmatic
smokers is markedly different, suggesting that
the two disease entities may remain different
even when presenting with similarly reduced
lung function.
GOLD 2013
Chronic obstructive pulmonary disease in non-smokers:
a case-comparison study
• Asthma was nearly universal among nonsmokers
and was the commonest identifiable cause of
COPD in that group.
COPD 2014 Feb;11(1):2-9
The trade-off with simplicity and ease of
remembrance of the 0.70 fixed cutoff point
could come at the expense of misclassification.
Cerveri I et al, Eur Respir J 2009; 34: 568-573
The recommendation of different thresholds
for the
definition of airflow obstruction in COPD (0.70
ratio) and
asthma (0.75–0.80 ratio) is even more difficult
to justify and has
resulted in ongoing confusion. The higher
threshold for
asthma than for COPD has probably been
chosen because of
the different distributions of age and the
physiological decline
in FEV1/FVC in the two diseases, even though
asthma may
also have a late onset.
(Cerveri I et al, Eur Respir J 2009; 34: 568-573)
Asthma misdiagnosed as COPD
• 128 confirmed asthmatics in SARA study
• 20% were wrongly diagnosed as COPD
• Thus 1:5 elderly asthmatics receive an inappropriate
diagnosis of COPD
• Older age main factor contributing to misdiagnosis
• Distinction specially arduous in the elderly
• Distinction vital when therapeutic choices exist
Chest 2003; 123: 1066–72. 38
• IRAO has always been equated with COPD.
Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in
adults in the United States: data from the National Health and Nutritional Examination Survey, 19881994; Arch Intern Med 2000; 160: 1683-1689.
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The PLATINO team found that
23% of the subjects with COPD had self-reported
medically diagnosed asthma. 8
Marsh et al 9 estimated
the prevalence of asthma in a COPD cohort to be
55.2% using a composite defi nition of asthma
(postbronchodilator
[post-BD] increase in FEV 1 . 15%,
or peak fl ow variability . 20% during 1 week of testing,
or physician diagnosis of asthma in conjunction with
current symptoms).
• A subgroup of asthmatics may experience vary
steep rates of decline in forced expiratory
volume in one second leading to severe
nonreversible airflow obstruction, whereas no
indication was found that long-standing
asthma may lead to the development of
emphysema.
Ulrik CS, Backer V. Nonreversible airflow
obstruction in life-long nonsmokers with
moderate to severe asthma. Eur Respir J 1999;
14(4):892–896.
Genes
Lack of controller therapy
Persistence of triggers
• The incidence of incomplete reversibility of airway
obstruction in asthma has never been systematically
studied as it is excluded by definition
Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the
United States: data from the National Health and Nutritional Examination Survey, 1988-1994; Arch Intern
Med 2000; 160: 1683-1689.
• Different names : Fixed airway obstruction in asthma(FAOA)
Incomplete reversibility of airway obstruction (IRAO).
• Various criteria : Post bronchodilator FEV1 /FVC of less than
70% and/or less than 75% at a minimum of two consecutive
annual visits , or FEV1 below the normal range (eg,≤75%)
after optimal treatment.
• Fixed obstruction has been reported to occur in 30% of a large
population of patients with the diagnosis of asthma†
†Kesten
S,RebuckAS. Is the short-term response to inhaled beta-adrenergic agonist sensitive or specific for
distinguishing between asthma and COPD? Chest 1994;105:1042–1045
.
• Subjects with fixed airflow obstruction have distinct airway
inflammation depending on their history of Asthma or COPD.
• The differential diagnosis between asthma and COPD in patients
with fixed airflow obstruction may be important as the natural
history(1) as well as the response to treatment(2) are different.
Burrows B, Bloom JW, Traver GA, Cline MG. The course and prognosis of different forms of chronic airays
obstruction in a sample from the general population. New Engl J Med 1987; 317: 1309-1314.
2. Kerstjens HA, Brand PL, Hughes MD, Robinson NJ, Postoma DS, Sluiter HJ, Bleecker ER, Dekhuijzen PN, de
Jong PM, Mengelers HJ et al. A comparison of bronchodilator therapy with or without inhaled
corticosteroid therapy for obstructive airways disease: Dutch Chronic No Specific Lung Disease Study
Group. N Engl J Med 1992; 327: 1413-1419.
1.
• Asthmatic airway inflammation does not change with the
development of fixed airflow obstruction and thus does not
become similar to the airway inflammation characteristics of
COPD.
M.Fabbri , Micaela Romagnoli, Lorenzo Corbetta , Am J Respir Crit Care Med Vol
167.pp 418-424,2003.
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trade-off
with simplicity and ease of remembrance of the 0.70 fixed cutoff
point could come at the expense of misclassification [13, 23–
28]. The recommendation of different thresholds for the
definition of airflow obstruction in COPD (0.70 ratio) and
asthma (0.75–0.80 ratio) is even more difficult to justify and has
resulted in ongoing confusion. The higher threshold for
asthma than for COPD has probably been chosen because of
the different distributions of age and the physiological decline
in FEV1/FVC in the two diseases, even though asthma may
also have a late onset.
Eur Respir J 2009; 34: 568–573
Copenhagen City Lung Study found no difference between
groups.
Lung Health Study found a small reduction in some symptoms,
although this did not translate into any improvement in health
status.
ISOLDE study showed fewer exacerbations, a reduced rate of
decline in health status, and higher FEV1 values than placebo
treatment.
Effect of inhaled and Oral Glucocorticoids on
Inflammatory Indices in Asthma and COPD
Vera M. Keatings, Anon Jatakanon, Y. Min Worsdell, & Peter J. Barnes
The inflammatory process in COPD is resistant to
the antiinflammatory effect of glucocorticoids.
Am J Respir Crit Care Med 1997;155:542-548
There were some significant differences between the ISOLDE
study and the other three long term studies. The dose of inhaled
corticosteroid was high in the ISOLDE study. Bronchodilator
reversibility was also fairly high, raising the question of whether
the ISOLDE study included subjects with element of asthma.
“any information which adversely and seriously
affects an individual's view of his or her future”
[13]. Bad news is always, however, in the “eye
of the beholder,” such that one cannot
estimate the impact of the bad news until one
has first determined the recipient's
expectations or understanding.
The Oncologist
August 2000vol. 5 no. 4 302-311
“It is difficult to change things in India unless the
system breaks down completely because in a
large democracy it’s only when things reach
breaking point that people are willing to change
the system.”
DAMAN SINGH
“Strictly Personal, Monmohan and Gurusharan”
• American Thoracic
• Society [4]. The wide variations over short
periods
Personalized Medicine
GENOTYPE
PHENOTYPE
BIOMARKER
Treatment approach based on genetics and biomarkers:
The approach to personalized medicine emphasizes the
following:
• Early diagnosis to prevent unnecessary morbidity or mortality
associated with the disease.
• Prediction of the severity and prognosis for the individual.
• Determination of the optimal treatment approach for the
individual.
• Establishment of appropriate monitoring tools to evaluate
therapy.
J Allergy Clin Immunol. 2006;118(3):565-568
THE PERSON
“The whole is greater than the sum of its parts."
NICHOLAS A. CHRISTAKIS
Physician and Social Scientist, Harvard University; Coauthor, Connected: The Surprising Power of
Our Social Networks and How They Shape Our Lives
Man is a social animal
An Indian is a family animal
Inhalation in the elderly-challenges
Why is it more difficult to train the elderly
than a child?
Inner Self
Education
Environment
Belief
Personality
Inhaler therapy
• Anti-Nature!
• Personal and social inhibition.
• Needs lot of training.
Issues of inhaler technique overshadow
all other considerations when trying to
achieve satisfactory maintenance inhaler
therapy in elderly patients with
Asthma and COPD.
AoRM 2009; 000:(000). Month 2009
• Actuation and Inhalation are essentially two
different tasks.
• We, being highly ritualistic, focus more on the
protocol rather than the purpose.
• If somebody else does the actuation, patient is
not only relieved but also can concentrate
fully on inhalation.
• Co-ordination becomes the caregiver’s job.
Recommended devices in elderly
• BAI
• pMDI + large volume spacer
• DPI (an option for those who find assembling
pMDI + spacer difficult)
• Nebuliser
Prim Care Resp J 2010; 19 (1): 10-20
Assisted administration
The triangle of influences on inhaler-device usage by patients
with chronic obstructive pulmonary disease
Caregiver
Eur Respir Rev 2005; 14: 96, 85–88
Inhalation in the elderly-challenges
How many elderly patients do we have ?
What is at stake?
Everything!
Households in the Family
Households in the Family
Whose interest does it serve?
Patient’s/Your’s/Physician’s
[email protected]
PROF. A.G.GHOSHAL
MD,DNB,FCCP, Ex WHO FELLOW, FELLOW ICS
ACKNOWLEDGEMENTS
Richard Harrison
Peter J Barnes
Bimala Ghoshal