approach to airways disease and smoke related disease
TRANSCRIPT
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Approach to airways disease and smoke related disease
ผศ. นพ. วชัรา บุญสวสัดิ์ M.D., Ph.D.ภาควชิาอายุรศาสตร ์คณะแพทยศ์าสตร์
มหาวทิยาลัยขอนแก่น
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วตัถปุระสงค์• ใหก้ารวนิิจฉัย รกัษา Airway diseases ได้• รูโ้ทษของบุหรี่• ใหค้ำาแนะนำาในการงดบุหรีไ่ด้
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Http://eac2.dbregistry.com
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Obstructive airway disease
FLOWPressure
Resistance
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Definition of COPD
1 211
5
3 48
6 7
910
Asthma
COPD
Airflowobstruction
EmphysemaChronicbronchitis
Reversible FEV1 Δ>15%
Irreversible FEV1 Δ <15%
????
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การตรวจสมรรถภาพปอด (spirometry)
Spirometry FEV1/ FVC <70%
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Spirometry FEV1/ FVC <70%
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Peak Flow meter (เครื่องวดัความเรว็สงูสดุ)
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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%
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Reversible airway obstruction
•Cough•Wheeze•Dyspnea
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Reversible airway obstruction
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Reversible airway obstruction
Airway Hyperresponsiveness
Stimuli
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การทดสอบความไวของหลอดลม
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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
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Pathology of asthma
•Smooth muscle hypertrophy•Mucosal disruption•Mucus plug•Cells infiltration
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Bronchospasm
Airway hyperresponsive
ความรูเ้ก่ียวกับโรคหืด 1980Before
Smooth muscle hypertrophy
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Normal Asthma
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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
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Bronchospasm
Airway hyperresponsive
Inflammation
ความรูเ้ก่ียวกับโรคหืด - 19801990
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Change in FEV1 in asthmatic
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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
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Haahtela T et al. N Engl J Med 1994;331:700-5.
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Airway remodelling
•Sub-basement membrane thickening•Smooth muscle hypertrophy and hyperplasia•Mucus metaplasia•Increase vascularity•Epithelium damageNormal Asthma
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Airway remodelling
Normal Asthma
1. Persistent airway obstruction
2. Persistent airway hyperresponsiveness
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Bronchospasm
Airway hyperresponsive
Remodelling
Inflammation
ความรูเ้ก่ียวกับโรคหืด 1990-2000
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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
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1995
1994
1997
2002
2004
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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
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Definition of asthmaDefinition of asthma
• Airway inflammation
• Airway hyperresponsiveness
• Reversible airway obstruction
• Symptoms (cough, wheeze, dyspnea)
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Asthma DiagnosisAsthma Diagnosis
History and patterns of symptoms
Physical examination
Measurements of lung function
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เป้าหมายของการรกัษาโรคหืด• สามารถควบคมุอาการของโรคให้สงบลงได้• ป้องกันไมใ่ห้โรคกำาเรบิ• ทำาให้สมรรถภาพปอดไกล้เคียงคนปกติมาก
ท่ีสดุ• ทำาให้ผู้ป่วยดำารงชวีติได้เหมอืนคนปกติ• หลีกเล่ียงผลแทรกซอ้นจากยา• ป้องกันการเสื่อมของสมรรถภาพปอดจน
เกิดการอุดกลัน้อยา่งถาวร• ป้องกันการเสยีชวีติจากโรคหืด
1994
2004
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ขัน้ตอนการดำาเนินการในการรกัษา
1 .ให้ความรูแ้ก่ผู้ป่วยและญาติ2. หลีกเล่ียงสิง่ท่ีก่อให้เกิดการหอบ3. จำาแนกความรุนแรงของโรค4. จดัแผนการรกัษาท่ีเหมาะสม5. จดัแผนการรกัษาเมื่อมกีารหอบเฉียบพลัน6. ให้การดแูลรกัษาต่อเน่ือง
1994
2004
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Pharmacological therapy Controllers
Inhaled corticosteroids
Inhaled long-acting 2-agonists
Oral anti-leukotrienes Oral theophyllines
Relievers Inhaled fast-acting
2-agonists
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Inhaled corticosteroidsBeclomethasoneBudesonideFluticasone
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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
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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
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•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
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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.
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Diagnosis of COPDGOLD = Global Initiative in Obstructive Lung Disease 2001
Exposure to risk factorsTobaccooccupationpollution
Symptoms•Cough•Sputum•dyspnea+/-
Spirometry post bronchodilator FEV1/ FVC <70%
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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
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PathophysiologyCOPD
Airflow obstruction
Ventilatory capacity
Work of breathing
Exercise limitation (Dyspnea)
V/Q Mismatching
VD/VT PaO2
Ventialatory requirement
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Treatment
• Retard the progression of airflow obstruction
• Minimizing airflow obstruction
• Prevent complication
• Optimizing functional capacity
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Prevent disease progression
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Minimizing airflow obstruction
Bronchodilators
1. Anticholinergics
2. B2 agonist
3. Theophylline
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Corticosteroids
• Oral
• Inhaled
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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
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Corticosteroids
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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%
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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
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GINA asthma guidelines
Short acting bronchodilator as needed
ICS
Intermittent
Moderate persistent
Mild persistent
Severe persistent
LABAICS
LABA ICS
prednisolone
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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
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สารพษิในควนับุหรี่6000 ชนิด
ทาร์นิโคติน
คารบ์อนมอน๊อกไซด์
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โรคสำาคัญที่เกิดจากการสบูบุหรี่
• โรคหลอดเลือดตีบ• มะเรง็• ถงุลมปอดโป่งพอง
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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
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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
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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
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Carcinogenic substances in cigarette smoke Polyaromatic hydrocarbon aromatic amines aldehydes inorganic compounds N-nitrosamines
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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
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Tobacco use results in true drug dependence
Effective treatment exist
Treatment are cost-effective
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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.
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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
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Effective Treatments Are Available Counselling / behavioural support
Pharmacotherapy
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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
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Pharmacotherapy Works
First-line pharmacotherapies Bupropion SR Nicotine replacement therapy
Second-line pharmacotherapies Clonidine Nortriptyline
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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.
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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
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Implementation of treatment is unsatisfactory Smoker insufficiently aware
Treatment is not easily accessible
Reimbursement is limited
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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!