Approach to airways disease and smoke related disease

ผศ. นพ. วชัรา บุญสวสัดิ์ M.D., Ph.D.ภาควชิาอายุรศาสตร ์คณะแพทยศ์าสตร์

มหาวทิยาลัยขอนแก่น

วตัถปุระสงค์• ใหก้ารวนิิจฉัย รกัษา Airway diseases ได้• รูโ้ทษของบุหรี่• ใหค้ำาแนะนำาในการงดบุหรีไ่ด้

Http://eac2.dbregistry.com

Obstructive airway disease

FLOWPressure

Resistance

Definition of COPD

1 211

5

3 48

6 7

910

Asthma

COPD

Airflowobstruction

EmphysemaChronicbronchitis

Reversible FEV1 Δ>15%

Irreversible FEV1 Δ <15%

????

การตรวจสมรรถภาพปอด (spirometry)

Spirometry FEV1/ FVC <70%

Spirometry FEV1/ FVC <70%

Peak Flow meter (เครื่องวดัความเรว็สงูสดุ)

Bronchodilator Test

• เป่าสมรรถภาพปอด หรอื Peak Flow ก่อนและหลังพน่ยาขยายหลอดลม 15 นาที

• FEV1 เพิม่ขึน้มากกวา่ 12 % ถือวา่เป็นโรคหืด• PEFR เพิม่ขึน้มากกวา่ 15 % ถือวา่เป็นโรคหืด

PEFR =300 L/min

•Salbutamol inhaler 2 puff•รอเวลา 15 นาที

PEFR =390 L/min

PEFR เพิม่ขึ้น

300

390-300

= 30%

Reversible airway obstruction

•Cough•Wheeze•Dyspnea

Reversible airway obstruction

Reversible airway obstruction

Airway Hyperresponsiveness

Stimuli

การทดสอบความไวของหลอดลม

Methacholine dose response curve

0

20

40

60

0.5 1 1.6 3.2 6.4 13 26 52 100 200

dose of methacholine (umol)

FEV1

%dr

op

Normalasthma

PD20

Pathology of asthma

•Smooth muscle hypertrophy•Mucosal disruption•Mucus plug•Cells infiltration

Bronchospasm

Airway hyperresponsive

ความรูเ้ก่ียวกับโรคหืด 1980Before

Smooth muscle hypertrophy

Normal Asthma

Allergen inhalation challengeAllergen inhalation challenge

020406080

100120

015

min30

min 2hr

3hr

4hr

5hr

6hr

8hr

10hr

24hr

times

FEV1

%pr

edic

ted

Early asthma tic response

Late asthmati c responseIncreas e AHR Increase inflam

matory cells

Bronchospasm

Airway hyperresponsive

Inflammation

ความรูเ้ก่ียวกับโรคหืด - 19801990

Change in FEV1 in asthmatic

Early intervention with inhaled steroidEarly intervention with inhaled steroid

2. Agertoft and Pedersen, Respir Med 19941. Selroos et al, Chest 19951. Selroos et al, Chest 1995

0

2

4

6

8

1010

12

<2 2-3 3-5 > 5

Annual change in %predicted FEV1

p = 0.02 for correlation

Children2Adults1

6-12<6 1-2 5-10 >102-5

10

20

30

4040

0

years months months Duration of symptomsDuration of symptoms Duration of symptoms (years)Duration of symptoms (years)

Maximum increase in PEF (%)

p = 0.0006 for correlation

Haahtela T et al. N Engl J Med 1994;331:700-5.

Airway remodelling

•Sub-basement membrane thickening•Smooth muscle hypertrophy and hyperplasia•Mucus metaplasia•Increase vascularity•Epithelium damageNormal Asthma

Airway remodelling

Normal Asthma

1. Persistent airway obstruction

2. Persistent airway hyperresponsiveness

Bronchospasm

Airway hyperresponsive

Remodelling

Inflammation

ความรูเ้ก่ียวกับโรคหืด 1990-2000

1975 1980 1985 1990 1995 2000

Changing concept in asthma treatmentChanging concept in asthma treatment

Airway Hyperresponsiveness

Bronchospasm Inflammation

Remodelling

short-acting b2-agonists Inh corticosteroid Combination

1995

1994

1997

2002

2004

Is it Asthma?Is it Asthma?

Recurrent episodes of wheezingRecurrent episodes of wheezingTroublesome cough at nightTroublesome cough at nightCough or wheeze after exerciseCough or wheeze after exerciseCough, wheeze or chest tightness after Cough, wheeze or chest tightness after exposure to airborne allergens or pollutantsexposure to airborne allergens or pollutantsColds “go to the chest” or take more than 10 Colds “go to the chest” or take more than 10 days to cleardays to clear

Definition of asthmaDefinition of asthma

• Airway inflammation

• Airway hyperresponsiveness

• Reversible airway obstruction

• Symptoms (cough, wheeze, dyspnea)

Asthma DiagnosisAsthma Diagnosis

History and patterns of symptoms

Physical examination

Measurements of lung function

เป้าหมายของการรกัษาโรคหืด• สามารถควบคมุอาการของโรคให้สงบลงได้• ป้องกันไมใ่ห้โรคกำาเรบิ• ทำาให้สมรรถภาพปอดไกล้เคียงคนปกติมาก

ท่ีสดุ• ทำาให้ผู้ป่วยดำารงชวีติได้เหมอืนคนปกติ• หลีกเล่ียงผลแทรกซอ้นจากยา• ป้องกันการเสื่อมของสมรรถภาพปอดจน

เกิดการอุดกลัน้อยา่งถาวร• ป้องกันการเสยีชวีติจากโรคหืด

1994

2004

ขัน้ตอนการดำาเนินการในการรกัษา

1 .ให้ความรูแ้ก่ผู้ป่วยและญาติ2. หลีกเล่ียงสิง่ท่ีก่อให้เกิดการหอบ3. จำาแนกความรุนแรงของโรค4. จดัแผนการรกัษาท่ีเหมาะสม5. จดัแผนการรกัษาเมื่อมกีารหอบเฉียบพลัน6. ให้การดแูลรกัษาต่อเน่ือง

1994

2004

Pharmacological therapy Controllers

Inhaled corticosteroids

Inhaled long-acting 2-agonists

Oral anti-leukotrienes Oral theophyllines

Relievers Inhaled fast-acting

2-agonists

Inhaled corticosteroidsBeclomethasoneBudesonideFluticasone

Classification of asthma severity: GINA 1995

Day symptoms

Night symptoms

PEFR

PF variability

Intermittent1< /wk<2/mo80> %20< %

1> /wk2> /mo

80> %-2030%

daily1> /wk-6 0 8 0 %

30> %

dailyfrequent60< %30> %

Mildpersistent

Moderatepersistent

SeverePersistent

High dose ICS+other controller

B2 agonist prnLevel 1

ICS

high dose ICS

ICS+LABA+other controller

Level 2

Level 3

Level 4

ICS+LABA

GINAGINA19951995GINA GINA 20022002

•Monitoring to maintain control•Manage Asthma Exacerbations

•Day symptoms•Night symptoms•Reliever•PEFR•Exacerbation•Limitation of activity

2006

1. B2-agonist prn2. ICS3. ICS (low dose) + LABA4. ICS (high dose) + LABA5. ICS (high dose) + LABA + prednisolone

•Controlled•Partly controlled•Uncontrolled

Definition of COPD• 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.

Diagnosis of COPDGOLD = Global Initiative in Obstructive Lung Disease 2001

Exposure to risk factorsTobaccooccupationpollution

Symptoms•Cough•Sputum•dyspnea+/-

Spirometry post bronchodilator FEV1/ FVC <70%

At-Risk Stage (Stage 0) No spirometric changesChronic symptoms (cough, sputum)

Mild (Stage I ) FEV1/FVC < 70%FEV1 > 80% predicted

Moderate (Stage II ) FEV1/FVC < 70% 50% < FEV1 <80% predicted

Severe (Stage III )

Very Severe (Stage IV)

30% < FEV1 <50% predicted

FEV1 <30% predicted or presence of respiratory insufficiency or right hart failure

GOLD = Global Initiative in Obstructive Lung Disease 2003

GOLD classification of COPD

PathophysiologyCOPD

Airflow obstruction

Ventilatory capacity

Work of breathing

Exercise limitation (Dyspnea)

V/Q Mismatching

VD/VT PaO2

Ventialatory requirement

Treatment

• Retard the progression of airflow obstruction

• Minimizing airflow obstruction

• Prevent complication

• Optimizing functional capacity

Prevent disease progression

Minimizing airflow obstruction

Bronchodilators

1. Anticholinergics

2. B2 agonist

3. Theophylline

Corticosteroids

• Oral

• Inhaled

Number of exacerbations per year stratified by baseline FEV1

2.5

1.9

1.2

1.71.4

1.2

0

0.5

1

1.5

2

2.5

3

<1.25 1.25-1.54 >1.54

FEV1

Exac

erba

tions

per

yea

r

PlaceboFluticasone

ISOLDE. BMJ2000;320:1297-1303

Corticosteroids

GOLD pharmacological treatment

Short acting bronchodilator as needed

Regular bronchodilator treatment inhaled corticosteroids

Oxygen therapy

Regular bronchodilator treatmentConsider inhaled corticosteroids

Regular bronchodilator treatment

FEV1>80%

FEV1 30-50%

FEV1 50-80%

FEV1 <30%

GOLD pharmacological treatment

Short acting bronchodilator as needed

Regular bronchodilator treatment inhaled corticosteroids

Oxygen therapy

Regular bronchodilator treatmentConsider inhaled corticosteroids

Regular bronchodilator treatment

FEV1>80%

FEV1 30-50%

FEV1 50-80%

FEV1 <30%

LABAICS

LABA ICS

Oxygen therapy

GINA asthma guidelines

Short acting bronchodilator as needed

ICS

Intermittent

Moderate persistent

Mild persistent

Severe persistent

LABAICS

LABA ICS

prednisolone

จำานวนคนไทยท่ีสบูบุหรี(่ อายุ 11ปีขึ้นไป)

ปีประชากร คนสบูบุหรี่ รอ้ยละ ชายหญิง

2519 28,685,940 8,629,510 30.12529 39,245,800 10,377,000 26.448.84.12536 45,680,300 10,406,200 22.843.22.52542 49,905,600 10,230,600 20.538.92.4

สำานักงานสถิติแหง่ชาติ

สารพษิในควนับุหรี่6000 ชนิด

ทาร์นิโคติน

คารบ์อนมอน๊อกไซด์

โรคสำาคัญที่เกิดจากการสบูบุหรี่

• โรคหลอดเลือดตีบ• มะเรง็• ถงุลมปอดโป่งพอง

Causes of death related to smoking Causes of death no.of death mortality

ratio

CA lung 309 31.0*CA esophagus,larynx,

mouth, toung,lip 114 7.0*CA bladder 90 2.17*CA prostrate 134 1.75CA liver,gall bladder 47 4.52

1958 1661172Hammond EC and Horn. JAMA ; : m mmmmm=1 8 7 7 8 3 / 4 4

Causes of death related to smoking

Causes of death no.of death mortality ratio

Coronary artery disease 5297 1.7*Cerebrovascular disease 1050 1.3*aortic aneurysm 90 2.72*other vascular diseases 27 4.5*Pneumonia/influenza 124 3.9*

1958 1661172Hammond EC and Horn. JAMA ; : 187783 44N= f/u months

Number of daily cigarettes and risk for lung cancer

051015202530

non-smoker 1-14 /day 15-24/day >25 / day

Cigarettes per day

Relativ

e risk

34440UKdoctorn= 1976DollRBMJ

Carcinogenic substances in cigarette smoke Polyaromatic hydrocarbon aromatic amines aldehydes inorganic compounds N-nitrosamines

COPD mortality in relation to cigarette smoking

34440 British doctor 1.0 14.7 16.7

standardized mortality ratio

never smoke

former smoke

current smoke

Doll. BMJ 2:1525-1536;1976

Tobacco use results in true drug dependence

Effective treatment exist

Treatment are cost-effective

5A’s for Promoting Smoking Cessation

Ask about tobacco use at every visit

Advice to quit

Assess readiness to quit

Assist cessation by providing evidence-based aids

Arrange follow-up.  

ASK ADVISE ASSESS ASSIST ARRANGE Follow-up

Never

Ex-smoker

Commend .

Congratulate.

Encouragecessation

Not ready

Current smoker

Motivate

Prescribe Rxs

Repeatadvise

Monitorcompliance

Ready to quit

Effective Treatments Are Available Counselling / behavioural support

Pharmacotherapy

Counselling Works Brief supportive advice to quit from doctor is effective

Counselling by other health professionals is effective

Group and individual both effective

The greater the support, the greater the chances of success

Every smoker should be offered at least brief advice

Pharmacotherapy Works

First-line pharmacotherapies Bupropion SR Nicotine replacement therapy

Second-line pharmacotherapies Clonidine Nortriptyline

Treating tobacco dependence: Approximate long-term quit rates‘Cold turkey’ 3–7%Brief clinical intervention 10%More intensive counselling 15%Medication (bupropion SR/NRT) 20–30%Medication + counselling 25–35%

Source: Fiore MC, et al. Treating Tobacco use and dependence. Clinical Practice Guideline. US DHHS, 2000.

Who should receive pharmacotherapy?

All smokers trying to quit except for special circumstances

Special considerations include: - medical contraindications - smoke < 10 cigarettes/day - pregnant/breastfeeding - adolescent smokers

Implementation of treatment is unsatisfactory Smoker insufficiently aware

Treatment is not easily accessible

Reimbursement is limited

Conclusions

More than 10 million smokers in Thailand.

Smoking is a major health hazard

Effective treatment for tobacco use is exist but under utilized

we can do better, we must do better!