CORSI DI AGGIORNAMENTO PER MMG
Modena 12 aprile 2002
Criteri decisionali fra
Global Initiatives on Asthma (GINA) e
Obstructive Lung Disease (GOLD)
Prof. Leonardo M. Fabbri
Clinica di Malattie dell’Apparato Respiratorio
Global
INitiative for
Asthma
www.ginasthma.com
G lobal Initiative for Chronic
O bstructive
L ung
D isease
www.goldcopd.com
Global Initiative on Obstructive
Lung Disease
EXECUTIVE COMMITTEE
Chair: Romain Pauwels
S. Buist, US
P. Calverley, UK
B. Celli, US
L. Fabbri, Italy
Y. Fukuchi, Japan
S. Hurd, US
L. Grouse, US
C. Jenkins, Australia
N. Khaltaev, CH
C. Lenfant, US
J. Luna, Guatemala
W. McNee, UK
R. Rodriguez Roisin, E
N.Zhong, China
Global Initiative on Obstructive Lung Disease
SCIENTIFIC COMMITTEE
Chair: Leonardo M. Fabbri
P. Barnes, UK
S. Buist, US
P. Calverley, UK
Y. Fukuchi, Giappone
W. McNee, UK
R. Pauwels, Belgium
K. Rabe, Germany
Roberto Rodrigues Roisin, Spain
N. Zielinski, Poland
Third Quarter, 2000: Publication Date from 2000/07/01 to 2000/09/30
Search COPD NOT ASTHMA: All Fields.
Limits: All Adult: 19+ years, only items with abstracts, English, Clinical Trial, Human
Sort by: Authors (20 citations)
No star = Clinical Trial, One * = Randomized Clinical Trials (15 citations)
Two ** = Randomized Clinical Trials and Core Clinical Journals (7 citations)
ASSIGNMENTS, REVIEWER, PUBLICATION NUMBER
Peter Barnes, 8
Sonia Buist, 16, 17
Leo Fabbri, 14, 20, 10, 19
Yoshi Fukuchi, 5, 7, 10, 12, 19, 20
Bill MacNee, 1, 5, 8, 15
Romain Pauwels, 16, 17
Klaus Rabe, 2, 3, 4, 11, 14
Roberto Rodriguez-Roisin, 2, 3, 4, 11, 13, 18
Jan Zielinski, 1, 7, 10, 15, 19
GOLD REPORT – Section 4
Page 32, left column, end of para 2,
ORIGINAL TEXT
…. tract inflammation57-61. It is likely that
indoor air pollution derived from the
burning of biomass fuels will prove to
have similar effects.
SUGGESTED REVISION
…. tract inflammation57-61. It is likely that
indoor air pollution derived from the
burning of biomass fuels will prove to
have similar effects. Also bacterial
colonization contributes to the
airway inflammation in patients with
stable COPD. The degree of
inflammation also relating to the
bacterial load and to the bacterial
species (Hill at et al, 2000).
Consequences of such colonization
and enhanced inflammation on
morbidity and lung function is not
clear
Hill AT, Campbell EJ, Hill SL, Bayley DL, Stockley RA. Association between airway
bacterial load and markers of airway inflammation in patients with stable chronic
bronchitis. Am J Med 2000 Sep;109(4):288-95
Levels of evidence
Level
Source
A
Randomized clinical trials
(RCT). Several, consistent
B
Randomized clinical trials
(RCT). Few, inconsistent
C
Non-randomized clinical
trials. Small and/or
observational studies
D
Opinion of experts
Severity of
symptoms
No of puffs of
albuterol
Threshold for
Increasing
control
medication
Poor control
Poor compliance
Good control
Good compliance
Time
Exacerbations
Classification of Asthma Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms
Nighttime Symptoms
PEF
STEP 4
Severe
Persistent
Continuous
Limited physical
activity
STEP 3
Moderate
Persistent
Daily
>1 time week
Use 2-agonist daily
Attacks limit activity
60-80% predicted
Variability >30%
STEP 2
Mild
Persistent
≥1 time a week
but <1 time a day
>2times a months
≥80% predicted
Variability 20-30%
≤2 times a month
≥80% predicted
Variability <20%
<1 time a week
STEP 1
Intermittent Asymptomatic and
normal PEF between
attacks
Frequent
≤60% predicted
Variability >30%
One of the features of severity is sufficient to place a patient in that category
Treatment
MANAGEMENT OF ASTHMA
Oral steroids
Long-acting bronchodilators and/or LTRA
Inhaled steroids
Short-acting 2 agonists prn
Severity of asthma
PREVENTION
Classification by severity
Stage
Characteristics
0 : At risk
Normal spirometry. Chronic symptoms
(cough, sputum),
I : Mild
FEV1/FVC < 70%, FEV1 > 80% predicted with
or without symptoms (cough, sputum)
II : Moderate
FEV1/FVC < 70%, 30% < FEV1 < 80%
predicted with or without chronic symptoms
(cough, sputum, dyspnea)
(IIA: 50% < FEV1 < 80; IIB: 30 < FEV1 < 50)
IV : Severe
FEV1/FVC < 70%, FEV1 < 30% predicted or
presence of respiratory failure or clinical
signs of right heart failure
GOLD guidelines 2001
MANAGEMENT OF COPD
Theophylline
Oral steroids
Inhaled Steroids
Anti-cholinergics  long-acting 2 Agonists
Short-acting 2 agonists prn
Severity of COPD
PREVENTION
CORSI DI AGGIORNAMENTO PER MMG
Modena 5 aprile 2002
Criteri decisionali fra
Global Initiatives on Asthma (GINA) e
Obstructive Lung Disease (GOLD)
Prof. Leonardo M. Fabbri
Clinica di Malattie dell’Apparato Respiratorio
Differences and similarities between
asthma and COPD
ASTHMA
Sensitizing agent
COPD
Noxious agent
Asthmatic airway
inflammation
CD4+ T-lymphocytes
COPD airway inflammation
CD8+ T-lymphocytes
Marcrophages
Eosinophils
Neutrophils
Completely
reversible
Airflow
Airflowlimitation
limitation
Completely
irreversible
Bronchial biopsies from 2 asthmatics of similar
age and with similar degree of fixed airflow
limitation
Characteristics of patients with fixed
airflow limitation
Number
Age
Males/Females
NS/ExS/S
Atopy
FEV1
Reversibility
COPD
ASTHMA
29
67 + 1.7
19/10
2/23/4
3/29
56 + 3
4.7 + 0.9
19
64 + 1.9
12/7
14/5/0
16/19
56 + 2
8.7 + 2.4*
Fixed airflow limitation in Asthma and COPD
FEV1 changes after bronchodilator
300
History
of Asthma
No history
of Asthma
16
14
250
200
*
12
10
8
150
6
4
100
2
0
History
of Asthma
No history
of Asthma
*
Fixed airflow limitation in Asthma and
COPD
FEV1 changes after oral corticosteroids
History
of Asthma
No history
of Asthma
History
of Asthma
No history
of Asthma
400
14
200
**
% predicted
ml
300
12
10
8
6
4
100
2
0
0
**
Fixed airflow limitation in Asthma and COPD
Airway Responsiveness to methacholine
History
of Asthma
Methacholine PC20FEV1
(mg/ml)
10
1
0,1
No history
of Asthma
Fixed airflow limitation in Asthma and COPD
Residual Volume
L
3,0
History
of Asthma
*
No history
of Asthma
150
125
2,5
2,0
1,5
100
History
of Asthma
*
No history
of Asthma
Fixed airflow limitation in Asthma and COPD
Carbon monoxide diffusion capacity (Kco)
***
***
120
History
of Asthma
1,5
No history
of Asthma
110
100
90
80
70
1,0
60
50
40
0,5
30
History
of Athma
No history
of Asthma
Fixed airflow limitation in Asthma and COPD
SPUTUM
120
*
110
***
100
90
History of
Asthma
80
No history
of asthma
70
60
50
40
30
20
10
0
Macrophages
Neutrophils
Eosinophils
Lymphocytes
Fixed airflow limitation in Asthma and COPD
Exhaled Nitric Oxide
***
60
(ppb)
Exhaled NO
50
40
30
20
10
0
History
of Asthma
No history
of Asthma
HIGH RESOLUTION COMPUTED TOMOGRAPHY
(HRCT) IS DIFFERENT IN PATIENTS WITH FIXED
AIRFLOW LIMITATION DUE TO SMOKING OR TO ASTHMA
Patients with fixed airflow limitation due to smoking
maintain distinct radiological and functional
characteristics from patients with a history of asthma,
even when they develop fixed airflow limitation,
suggesting that fixed airflow limitation
does not define a unique disease entity.
Romagnoli M et al, American Thoracic Society 2002, Atlanta, submitted
CORSI DI AGGIORNAMENTO PER MMG
Modena 12 aprile 2002
Criteri decisionali fra
Global Initiatives on Asthma (GINA) e
Obstructive Lung Disease (GOLD)
Prof. Leonardo M. Fabbri
Clinica di Malattie dell’Apparato Respiratorio