1 / 14

Assessment

carlynda
Download Presentation

Assessment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Assessment

    2. The COPD Population Screener (COPD-PS) The COPD Population Screener (COPD-PS) Because COPD screening that focuses only on patients with a limited set of characteristics (eg, older smokers, current smokers) may fail to detect many individuals with COPD, there is a need for a simple method to help identify patients in the general population who might have this disease. The COPD Population Screener™ (COPD-PS™) is a simple, self-administered screening tool developed to identify patients with possible COPD in the general population. A survey consisting of 25 questions was developed and given to 697 patients. Logistic regression was used to identify items discriminating between patients with and without fixed airflow obstruction. The 5 items found to positively predict airway obstruction included breathlessness, productive cough, activity limitation, smoking history, and age. A total score greater than 5 on the COPD-PS™ was associated with a positive predicted value of 58.6% and a negative predictive value of 86.4% in the studied cohort. This tool offers a high correct classification rate for diagnosis of airway obstruction while maintaining a good trade-off between sensitivity and specificity. Thus, the COPD-PS™ provides a brief, accurate questionnaire that can be used in the clinical setting to identify patients likely to have COPD. Martinez FJ, Raczek AE, Seifer FD, et al; for the COPD-PS Clinician Working Group. Development and initial validation of a self-scored COPD Population Screener Questionnaire (COPD-PS). COPD. 2008;5:85-95. The COPD Population Screener (COPD-PS) Because COPD screening that focuses only on patients with a limited set of characteristics (eg, older smokers, current smokers) may fail to detect many individuals with COPD, there is a need for a simple method to help identify patients in the general population who might have this disease. The COPD Population Screener™ (COPD-PS™) is a simple, self-administered screening tool developed to identify patients with possible COPD in the general population. A survey consisting of 25 questions was developed and given to 697 patients. Logistic regression was used to identify items discriminating between patients with and without fixed airflow obstruction. The 5 items found to positively predict airway obstruction included breathlessness, productive cough, activity limitation, smoking history, and age. A total score greater than 5 on the COPD-PS™ was associated with a positive predicted value of 58.6% and a negative predictive value of 86.4% in the studied cohort. This tool offers a high correct classification rate for diagnosis of airway obstruction while maintaining a good trade-off between sensitivity and specificity. Thus, the COPD-PS™ provides a brief, accurate questionnaire that can be used in the clinical setting to identify patients likely to have COPD. Martinez FJ, Raczek AE, Seifer FD, et al; for the COPD-PS Clinician Working Group. Development and initial validation of a self-scored COPD Population Screener Questionnaire (COPD-PS). COPD. 2008;5:85-95.

    3. ATS/ERS and GOLD Guidelines: Severity of COPD ATS/ERS and GOLD Guidelines: Severity of COPD According to the GOLD Guidelines, the severity of COPD is categorized on the basis of postbronchodilator FEV1 into 4 stages. Stage I, ( mild COPD), presents with an FEV1/FVC < 70% and an FEV1 = 80% of the predicted value. These patients have abnormal lung function, which may be accompanied by the production of sputum and a chronic cough. Stage II, (moderate COPD), shows an FEV1/FVC < 70% and an FEV1 = 50% and < 80% of the predicted value. Chronic symptoms may be present. Patients experience shortness of breath and increased airflow restriction. Sputum production also may be present. This is the stage at which many patients seek medical attention due to their chronic respiratory symptoms or a COPD exacerbation. Stage III, (severe COPD), presents with FEV1/FVC < 70% and FEV1 = 30% and < 50% of the predicted value. Patients may present with or without chronic symptoms and usually experience worsened airflow and shortness of breath as well as reduced exercise capacity, fatigue, and repeated exacerbations that typically impact patients’ quality of life. Stage IV, (very severe COPD), is characterized by FEV1/FVC < 70% and FEV1 < 30% of the predicted value. Airflow is severely limited, and patients may present with chronic respiratory failure. Quality of life is considerably impaired, and exacerbations may be life threatening. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2008. Available at: http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed April 2009. ATS/ERS and GOLD Guidelines: Severity of COPD According to the GOLD Guidelines, the severity of COPD is categorized on the basis of postbronchodilator FEV1 into 4 stages. Stage I, ( mild COPD), presents with an FEV1/FVC < 70% and an FEV1 = 80% of the predicted value. These patients have abnormal lung function, which may be accompanied by the production of sputum and a chronic cough. Stage II, (moderate COPD), shows an FEV1/FVC < 70% and an FEV1 = 50% and < 80% of the predicted value. Chronic symptoms may be present. Patients experience shortness of breath and increased airflow restriction. Sputum production also may be present. This is the stage at which many patients seek medical attention due to their chronic respiratory symptoms or a COPD exacerbation. Stage III, (severe COPD), presents with FEV1/FVC < 70% and FEV1 = 30% and < 50% of the predicted value. Patients may present with or without chronic symptoms and usually experience worsened airflow and shortness of breath as well as reduced exercise capacity, fatigue, and repeated exacerbations that typically impact patients’ quality of life. Stage IV, (very severe COPD), is characterized by FEV1/FVC < 70% and FEV1 < 30% of the predicted value. Airflow is severely limited, and patients may present with chronic respiratory failure. Quality of life is considerably impaired, and exacerbations may be life threatening. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2008. Available at: http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed April 2009.

    4. The BODE Index The BODE Index COPD is characterized by incompletely reversible airflow limitation. Although FEV1 is often used to grade the severity of COPD, many patients with this disease have clinical or systemic manifestations that are not reflected by a reduced FEV1. Celli and colleagues hypothesized that a multidimensional grading system that evaluated the respiratory, perceptive, and systemic expressions of COPD would better categorize the disease and predict outcome than FEV1 alone. 25 deaths occurred among the first 207 patients to be recruited into the study between 1995 and 1997. In this cohort, 4 factors predicted the risk of death: the body-mass index (B), the degree of airflow obstruction based on FEV1 (O), the severity of dyspnea (D), and exercise capacity (E), measured by the 6-minute–walk test. These variables were used to construct the BODE index. As depicted on the slide, it is a multidimensional 10-point scale with higher scores indicating a greater risk of death. The BODE index was prospectively validated in a cohort of 625 patients. Outcome variables were defined as death from any cause and death from respiratory causes. The BODE index was found to be superior to FEV1 alone for predicting the risk of death from any cause and from respiratory causes among patients with COPD. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005-1012. The BODE Index COPD is characterized by incompletely reversible airflow limitation. Although FEV1 is often used to grade the severity of COPD, many patients with this disease have clinical or systemic manifestations that are not reflected by a reduced FEV1. Celli and colleagues hypothesized that a multidimensional grading system that evaluated the respiratory, perceptive, and systemic expressions of COPD would better categorize the disease and predict outcome than FEV1 alone. 25 deaths occurred among the first 207 patients to be recruited into the study between 1995 and 1997. In this cohort, 4 factors predicted the risk of death: the body-mass index (B), the degree of airflow obstruction based on FEV1 (O), the severity of dyspnea (D), and exercise capacity (E), measured by the 6-minute–walk test. These variables were used to construct the BODE index. As depicted on the slide, it is a multidimensional 10-point scale with higher scores indicating a greater risk of death. The BODE index was prospectively validated in a cohort of 625 patients. Outcome variables were defined as death from any cause and death from respiratory causes. The BODE index was found to be superior to FEV1 alone for predicting the risk of death from any cause and from respiratory causes among patients with COPD. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005-1012.

    5. Survival in COPD This slide presents the Kaplan-Meier survival curves from the study by Celli and colleagues (2004) for the 3 stages of COPD based on FEV1 according to the staging system of the American Thoracic Society (on the left) and the 4 quartiles of the BODE index (on the right). As the curves on the left illustrate, survival differed significantly among patients with stage I, stage II, and stage III COPD based on FEV1 (P < 0.001 by log-rank test). Survival also differed significantly among patients grouped by BODE index quartiles (P < 0.001 by log-rank test). Each quartile increase in the BODE score was associated with increased mortality (P < 0.001). At 52 months, the highest quartile (ie, a BODE score of 7 to 10) was associated with a mortality rate of 80%. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005-1012. Survival in COPD This slide presents the Kaplan-Meier survival curves from the study by Celli and colleagues (2004) for the 3 stages of COPD based on FEV1 according to the staging system of the American Thoracic Society (on the left) and the 4 quartiles of the BODE index (on the right). As the curves on the left illustrate, survival differed significantly among patients with stage I, stage II, and stage III COPD based on FEV1 (P < 0.001 by log-rank test). Survival also differed significantly among patients grouped by BODE index quartiles (P < 0.001 by log-rank test). Each quartile increase in the BODE score was associated with increased mortality (P < 0.001). At 52 months, the highest quartile (ie, a BODE score of 7 to 10) was associated with a mortality rate of 80%. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005-1012.

    6. Underdiagnosis of COPD in the United States Underdiagnosis of COPD in the United States Mannino and colleagues reported that during 2000, an estimated 10 million adults in the US reported physician-diagnosed COPD; about 24 million adults had evidence of airflow limitation, indicating that COPD is largely underdiagnosed.1 The prevalence of moderate obstructive lung disease (FEV1/FVC < 70% and FEV1 < 80% predicted) was 7.2% in the 45 to 54 years age-group, 14% at age 55 to 64 years, 20.7% at age 65 to 74 years, and 22.9% at age = 75 years. A study in the northern part of Sweden performed by Lundbäck and colleagues2 also reported a prevalence of chronic airflow limitation (FEV1/FVC < 70% and FEV1 < 80% predicted) of 14% above age 45 years and 50% in elderly smokers. These studies, which use an objective measurement of airflow limitation, show the high prevalence of COPD and the frequent underdiagnosis and undertreatment. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance--United States, 1971-2000. MMWR Morb Mortal Wkly Rep. 2002;51(SS-6):1-16. Lundbäck B, Lindberg A, Lindström M, et al. Not 15 but 50% of smokers develop COPD?—Report from the Obstructive Lung Disease in Northern Sweden Studies. Respir Med. 2003;97:115-122. Underdiagnosis of COPD in the United States Mannino and colleagues reported that during 2000, an estimated 10 million adults in the US reported physician-diagnosed COPD; about 24 million adults had evidence of airflow limitation, indicating that COPD is largely underdiagnosed.1 The prevalence of moderate obstructive lung disease (FEV1/FVC < 70% and FEV1 < 80% predicted) was 7.2% in the 45 to 54 years age-group, 14% at age 55 to 64 years, 20.7% at age 65 to 74 years, and 22.9% at age = 75 years. A study in the northern part of Sweden performed by Lundbäck and colleagues2 also reported a prevalence of chronic airflow limitation (FEV1/FVC < 70% and FEV1 < 80% predicted) of 14% above age 45 years and 50% in elderly smokers. These studies, which use an objective measurement of airflow limitation, show the high prevalence of COPD and the frequent underdiagnosis and undertreatment. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance--United States, 1971-2000. MMWR Morb Mortal Wkly Rep. 2002;51(SS-6):1-16. Lundbäck B, Lindberg A, Lindström M, et al. Not 15 but 50% of smokers develop COPD?—Report from the Obstructive Lung Disease in Northern Sweden Studies. Respir Med. 2003;97:115-122.

    7. Role of High Resolution Computed Tomography (HRCT) in Diagnosis and Research Role of High Resolution Computed Tomography (HRCT) in Diagnosis and Research There has been an increased interest over the last few decades in diagnosing emphysema and chronic bronchitis using high-resolution computed tomography (HRCT).1 HRCT can aid in the characterization of emphysema (eg, identifying differential presentation of focal areas of low attenuation in centriacinar emphysema versus panacinar emphysema versus paraseptal emphysema). Although small airways are not normally visible, bronchiolar thickening due to mucosal edema allows for visualization by HRCT. Thus this measurement tool can be used (as a research application) to help phenotype emphysema versus airways disease. HRCT can also be used to monitor structural integrity of pulmonary tissue in patients with COPD. COPD may increase the risk of lung cancer and is associated with lung cancer mortality.2 It may thus be prudent to use HRCT to screen for lung cancer in patients with COPD or during assessment of the patient with suspected COPD, although the cost-effectiveness of this application has not been established.3 Gupta PP, Yadav R, Verma M, Gupta KB, Agarwal D. High-resolution computed tomography features in patients with chronic obstructive pulmonary disease. Singapore Med J. 2009;50:193-200. Turner MC, Chen Y, Krewski D, Calle EE, Thun MJ. Chronic obstructive pulmonary disease is associated with lung cancer mortality in a prospective study of never smokers. Am J Respir Crit Care Med. 2007;176:285-290. Hatayama O, Kobayashi T, Fujimoto K, Kubo K. Utility of single-slice high-resolution CT in upper lung field combined with low-dose spiral CT for lung-cancer screening in the detection of emphysema. Intern Med. 2007;46:1519-1525. Role of High Resolution Computed Tomography (HRCT) in Diagnosis and Research There has been an increased interest over the last few decades in diagnosing emphysema and chronic bronchitis using high-resolution computed tomography (HRCT).1 HRCT can aid in the characterization of emphysema (eg, identifying differential presentation of focal areas of low attenuation in centriacinar emphysema versus panacinar emphysema versus paraseptal emphysema). Although small airways are not normally visible, bronchiolar thickening due to mucosal edema allows for visualization by HRCT. Thus this measurement tool can be used (as a research application) to help phenotype emphysema versus airways disease. HRCT can also be used to monitor structural integrity of pulmonary tissue in patients with COPD. COPD may increase the risk of lung cancer and is associated with lung cancer mortality.2 It may thus be prudent to use HRCT to screen for lung cancer in patients with COPD or during assessment of the patient with suspected COPD, although the cost-effectiveness of this application has not been established.3 Gupta PP, Yadav R, Verma M, Gupta KB, Agarwal D. High-resolution computed tomography features in patients with chronic obstructive pulmonary disease. Singapore Med J. 2009;50:193-200. Turner MC, Chen Y, Krewski D, Calle EE, Thun MJ. Chronic obstructive pulmonary disease is associated with lung cancer mortality in a prospective study of never smokers. Am J Respir Crit Care Med. 2007;176:285-290. Hatayama O, Kobayashi T, Fujimoto K, Kubo K. Utility of single-slice high-resolution CT in upper lung field combined with low-dose spiral CT for lung-cancer screening in the detection of emphysema. Intern Med. 2007;46:1519-1525.

    8. Characteristics of Asthma and COPD In the past COPD was defined by irreversible and progressive airway obstruction, but more recently it has been recognized that patterns of COPD overlap with those of asthma. Furthermore, acute and chronic reversibility of airflow obstruction has been found to occur in patients with COPD, and a fixed or irreversible component to airway obstruction may occur in some patients with asthma. Such findings may make it more difficult to differentiate between asthma and COPD. This slide compares some of the features of asthma and COPD. Asthma is usually associated with intermittent airflow obstruction but often is associated with a less reversible obstruction. In contrast, COPD is associated with progressive airflow obstruction. Bronchodilators and corticosteroids improve airway obstruction to a greater degree in asthma than in COPD. Cellular inflammation in asthma is characterized by the presence of eosinophils, mast cells, and T lymphocytes; neutrophils may be present in severe disease. In patients with COPD, cellular inflammation including neutrophils, macrophages, eosinophils, and mast cells may occur. Whereas broad inflammatory responses occur in asthma, COPD is associated with cytokine, chemokine, and protease responses. Airway remodeling, including epithelial injury and fibrosis, may occur in patients with asthma. Emphysema is frequent in patients with COPD. Bleecker ER. Similarities and differences in asthma and COPD. Chest. 2004;126:93S-95S. Characteristics of Asthma and COPD In the past COPD was defined by irreversible and progressive airway obstruction, but more recently it has been recognized that patterns of COPD overlap with those of asthma. Furthermore, acute and chronic reversibility of airflow obstruction has been found to occur in patients with COPD, and a fixed or irreversible component to airway obstruction may occur in some patients with asthma. Such findings may make it more difficult to differentiate between asthma and COPD. This slide compares some of the features of asthma and COPD. Asthma is usually associated with intermittent airflow obstruction but often is associated with a less reversible obstruction. In contrast, COPD is associated with progressive airflow obstruction. Bronchodilators and corticosteroids improve airway obstruction to a greater degree in asthma than in COPD. Cellular inflammation in asthma is characterized by the presence of eosinophils, mast cells, and T lymphocytes; neutrophils may be present in severe disease. In patients with COPD, cellular inflammation including neutrophils, macrophages, eosinophils, and mast cells may occur. Whereas broad inflammatory responses occur in asthma, COPD is associated with cytokine, chemokine, and protease responses. Airway remodeling, including epithelial injury and fibrosis, may occur in patients with asthma. Emphysema is frequent in patients with COPD. Bleecker ER. Similarities and differences in asthma and COPD. Chest. 2004;126:93S-95S.

    9. Clinical Features Differentiating COPD and Asthma Clinical Features Differentiating COPD and Asthma Asthma and COPD are both major chronic obstructive airway diseases involving underlying inflammation of the airways.1,2 Asthma and COPD can coexist in the same patient.1 This slide highlights clinical features that can help differentiate between the two conditions. COPD is almost always associated with a long history of cigarette smoking. The onset is usually in mid-life for COPD and early in life (often in childhood) for asthma. A chronic productive cough is common in COPD but is uncommon in asthma.1,2 COPD is characterized by persistent and slowly progressive breathlessness, with dyspnea during exercise.1 Unlike with COPD, asthma symptoms (breathlessness, wheezing) tend to present at night/early morning and may thus cause night time wakening. Asthma, but not COPD, is commonly associated with atopic symptoms (eg, eczema) and seasonal allergies. Symptoms tend to vary from day to day or during the day in patients with asthma but are more consistent in those with COPD. Finally, effects of both inhaled and oral glucocorticoids are much less dramatic in COPD than in asthma. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2008. Available at: http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed April 2009. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2008. Available at: http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60. Accessed April 2009. Clinical Features Differentiating COPD and Asthma Asthma and COPD are both major chronic obstructive airway diseases involving underlying inflammation of the airways.1,2 Asthma and COPD can coexist in the same patient.1 This slide highlights clinical features that can help differentiate between the two conditions. COPD is almost always associated with a long history of cigarette smoking. The onset is usually in mid-life for COPD and early in life (often in childhood) for asthma. A chronic productive cough is common in COPD but is uncommon in asthma.1,2 COPD is characterized by persistent and slowly progressive breathlessness, with dyspnea during exercise.1 Unlike with COPD, asthma symptoms (breathlessness, wheezing) tend to present at night/early morning and may thus cause night time wakening. Asthma, but not COPD, is commonly associated with atopic symptoms (eg, eczema) and seasonal allergies. Symptoms tend to vary from day to day or during the day in patients with asthma but are more consistent in those with COPD. Finally, effects of both inhaled and oral glucocorticoids are much less dramatic in COPD than in asthma. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2008. Available at: http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed April 2009. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2008. Available at: http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60. Accessed April 2009.

    10. Distinguishing Between Asthma and COPD Based on an analysis of ICD-9 electronic claims data over a 2-year period, approximately 40% of patients diagnosed with COPD also had an asthma diagnosis1 Some patients with asthma cannot be distinguished from those with COPD using current diagnostic tests; management of these patients should be similar to that of patients with asthma2 Distinguishing Between Asthma and COPD Based on an analysis of ICD-9 electronic claims data over a 2-year period, approximately 40% of patients diagnosed with COPD also had an asthma diagnosis.1 COPD is usually associated with mid-life onset, slowly progressing symptoms, and a long history of smoking.2 Features suggestive of asthma include early onset; varying symptoms; symptoms that occur during the night/early morning; allergy, rhinitis, and/or eczema; a family history of asthma; and airflow limitation that is largely reversible. Some patients with asthma cannot be distinguished from those with COPD using current diagnostic tests; management of these patients should be similar to that of patients with asthma.2 Surveillance Data Inc. (SDI). COPD/Asthma Diagnoses Overview; 2001-2003. March 2004. Celli BR, MacNee W, and the ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946. Distinguishing Between Asthma and COPD Based on an analysis of ICD-9 electronic claims data over a 2-year period, approximately 40% of patients diagnosed with COPD also had an asthma diagnosis.1 COPD is usually associated with mid-life onset, slowly progressing symptoms, and a long history of smoking.2 Features suggestive of asthma include early onset; varying symptoms; symptoms that occur during the night/early morning; allergy, rhinitis, and/or eczema; a family history of asthma; and airflow limitation that is largely reversible. Some patients with asthma cannot be distinguished from those with COPD using current diagnostic tests; management of these patients should be similar to that of patients with asthma.2 Surveillance Data Inc. (SDI). COPD/Asthma Diagnoses Overview; 2001-2003. March 2004. Celli BR, MacNee W, and the ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.

    11. Physiologic Similarities and Differences Between Asthma and COPD In general and in the extremes of presentation, asthma and COPD appear to be easily distinguished; however, on structural and functional evaluation, significant proportions of patients are indistinguishable In individual patients, significant overlap exists in airway wall thickening, abnormalities on CT scans, reversibility with bronchodilators, airway hyperreactivity, and other measurements Physiologic Similarities and Differences Between Asthma and COPD In general and in the extremes of presentation, asthma and COPD appear to be easily distinguished. However, on structural and functional evaluation, significant proportions of patients are indistinguishable. In individual patients, significant overlap exists in airway wall thickening, abnormalities on CT scans, reversibility with bronchodilators, airway hyperreactivity, and other measurements. It may not be possible to distinguish patients with COPD who have an airway-dominant phenotype from asthmatic individuals with reversible disease that evolves into an incompletely reversible pattern. The inability to clearly distinguish between asthma and COPD may compromise the clinician’s ability to select the most appropriate treatment regimen for the individual patient. Furthermore, because patients who cannot be clearly categorized as having asthma versus COPD are typically excluded from clinical trials, therapeutic interventions may not be adequately evaluated in large subgroups of patients. Sciurba FC. Physiologic similarities and differences between COPD and asthma. Chest. 2004;126(2 suppl):117S-124S. Physiologic Similarities and Differences Between Asthma and COPD In general and in the extremes of presentation, asthma and COPD appear to be easily distinguished. However, on structural and functional evaluation, significant proportions of patients are indistinguishable. In individual patients, significant overlap exists in airway wall thickening, abnormalities on CT scans, reversibility with bronchodilators, airway hyperreactivity, and other measurements. It may not be possible to distinguish patients with COPD who have an airway-dominant phenotype from asthmatic individuals with reversible disease that evolves into an incompletely reversible pattern. The inability to clearly distinguish between asthma and COPD may compromise the clinician’s ability to select the most appropriate treatment regimen for the individual patient. Furthermore, because patients who cannot be clearly categorized as having asthma versus COPD are typically excluded from clinical trials, therapeutic interventions may not be adequately evaluated in large subgroups of patients. Sciurba FC. Physiologic similarities and differences between COPD and asthma. Chest. 2004;126(2 suppl):117S-124S.

    12. Asthma as a Risk Factor for COPD Objective: – To evaluate the association between physician-diagnosed asthma and the subsequent development of COPD in a cohort of 3099 adult subjects (= 20 years old) Design and methods: – Prospective observational study – Participants were selected from a random, stratified, cluster sample of white, non–Mexican-American households – Participants completed up to 12 respiratory questionnaires and 11 spirometry measurements over a period of 20 years – Kaplan-Meier curves were compared Asthma as a Risk Factor for COPD In this prospective observational study, Silva and colleagues evaluated the association between physician-diagnosed asthma and the subsequent development of COPD in a cohort of 3099 adult subjects (= 20 years old). The participants were selected from a random, stratified, cluster sample of white, non–Mexican-American households in Tucson, Arizona. They completed up to 12 respiratory questionnaires and 11 spirometry measurements over a period of 20 years. Survival curves were compared. Silva GE, Sherrill DL, Guerra S, Barbee RA. Asthma as a risk factor for COPD in a longitudinal study. Chest. 2004;126:59-65. Asthma as a Risk Factor for COPD In this prospective observational study, Silva and colleagues evaluated the association between physician-diagnosed asthma and the subsequent development of COPD in a cohort of 3099 adult subjects (= 20 years old). The participants were selected from a random, stratified, cluster sample of white, non–Mexican-American households in Tucson, Arizona. They completed up to 12 respiratory questionnaires and 11 spirometry measurements over a period of 20 years. Survival curves were compared. Silva GE, Sherrill DL, Guerra S, Barbee RA. Asthma as a risk factor for COPD in a longitudinal study. Chest. 2004;126:59-65.

    13. Time to Development of COPD by Asthma Categories Time to Development of COPD by Asthma Categories During the initial survey, subjects were asked if they ever had asthma. Those who responded, “yes, and I still have it” were classified as having active asthma (N = 192), those who answered, “yes, but I no longer have it” were considered to have inactive asthma (N = 156), and subjects who replied, “no” were considered to have no asthma (N = 2751). Subjects with active asthma were only included in the analyses if they had consulted a physician about their asthma. After adjustment for age, sex, smoking, log IgE, and skin test reactivity, cumulative survival (without developing COPD) was much lower for subjects with active asthma than for those with inactive asthma or no asthma. The hazard ratio for the development of COPD for active asthma versus no asthma was 12.5 (95% CI, 6.84 to 22.84). Similar results were seen when chronic bronchitis and emphysema were looked at independently. These results suggest that physician-diagnosed active asthma is significantly associated with an increased risk of developing COPD. Silva GE, Sherrill DL, Guerra S, Barbee RA. Asthma as a risk factor for COPD in a longitudinal study. Chest. 2004;126:59-65. Time to Development of COPD by Asthma Categories During the initial survey, subjects were asked if they ever had asthma. Those who responded, “yes, and I still have it” were classified as having active asthma (N = 192), those who answered, “yes, but I no longer have it” were considered to have inactive asthma (N = 156), and subjects who replied, “no” were considered to have no asthma (N = 2751). Subjects with active asthma were only included in the analyses if they had consulted a physician about their asthma. After adjustment for age, sex, smoking, log IgE, and skin test reactivity, cumulative survival (without developing COPD) was much lower for subjects with active asthma than for those with inactive asthma or no asthma. The hazard ratio for the development of COPD for active asthma versus no asthma was 12.5 (95% CI, 6.84 to 22.84). Similar results were seen when chronic bronchitis and emphysema were looked at independently. These results suggest that physician-diagnosed active asthma is significantly associated with an increased risk of developing COPD. Silva GE, Sherrill DL, Guerra S, Barbee RA. Asthma as a risk factor for COPD in a longitudinal study. Chest. 2004;126:59-65.

    14. Biomarkers for COPD Sputum – Neutrophil count – Inflammatory mediators (IL-8, Groa, LT-B4, neutrophil elastase, MCP-1, neutrophil lipocalin) – Myeloperoxidase (MPO) – Matrix metalloproteases 8, 9, 12 – Exacerbation markers TNFa, IL-8, IL-6, MPO – Chemokines CXCR3 and CCR5 BAL – Polymorphonuclear cells – Percent CD8+ T cells higher, CD4+ lower – Inflammation markers elevated (IL-8, IL-6, TNFa, MPO, eotaxin-1, ECP) Blood – CRP (prognostic but not specific) – Fibrinogen – Leukocytes – TNFa – Endothelin-1 (also in exhaled breath condensate) Gene Expression Biomarkers for COPD In recent years, extensive research has focused on the identification and validation of diagnostic biomarkers for COPD as well as markers of disease activity and therapeutic response.1 An ideal biomarker for COPD would be one that (1) is primarily produced in the lungs (and is reliably measurable in the peripheral circulation); (2) changes along with the patient’s clinical status or with relevant exposures; and (3) demonstrates inherent functional attributes that indicate possible causal role in the pathogenesis or pathophysiology of COPD.2 Biomarkers for COPD may be derived from biofluids, such as sputum, bronchoalveolar lavage (BAL), and blood. Measurement of exhaled gases and mediators in exhaled breath condensate permits noninvasive assessment of potential inflammatory biomarkers. Endothelin-1 (ET-1) levels are increased in the blood of patients with COPD,1 and recent data demonstrate significantly increased ET-1 levels in exhaled breath condensate of patients with COPD and pulmonary hypertension compared with normal controls or patients with COPD only.3 Serum levels of surfactant protein D may also have utility as a biomarker for COPD.2 Further research is necessary to establish the clinical utility of biomarkers for COPD. In particular, there is a need to identify biomarkers to predict clinical efficacy of novel treatments early in development, to enable better patient management, and to identify patients most likely to benefit from specific therapies.1 Snell N, Newbold P. The clinical utility of biomarkers in asthma and COPD. Curr Opin Pharmacol. 2008;8:222-235. Sin DD, Pahlavan PS, Man SF. Surfactant protein D: a lung specific biomarker in COPD? Ther Adv Respir Dis. 2008;2:65-74. Carratu P, Scoditti C, Maniscalco M, et al. Exhaled and arterial levels of endothelin-1 are increased and correlate with pulmonary systolic pressure in COPD with pulmonary hypertension. BMC Pulm Med. 2008;8:20. Biomarkers for COPD In recent years, extensive research has focused on the identification and validation of diagnostic biomarkers for COPD as well as markers of disease activity and therapeutic response.1 An ideal biomarker for COPD would be one that (1) is primarily produced in the lungs (and is reliably measurable in the peripheral circulation); (2) changes along with the patient’s clinical status or with relevant exposures; and (3) demonstrates inherent functional attributes that indicate possible causal role in the pathogenesis or pathophysiology of COPD.2 Biomarkers for COPD may be derived from biofluids, such as sputum, bronchoalveolar lavage (BAL), and blood. Measurement of exhaled gases and mediators in exhaled breath condensate permits noninvasive assessment of potential inflammatory biomarkers. Endothelin-1 (ET-1) levels are increased in the blood of patients with COPD,1 and recent data demonstrate significantly increased ET-1 levels in exhaled breath condensate of patients with COPD and pulmonary hypertension compared with normal controls or patients with COPD only.3 Serum levels of surfactant protein D may also have utility as a biomarker for COPD.2 Further research is necessary to establish the clinical utility of biomarkers for COPD. In particular, there is a need to identify biomarkers to predict clinical efficacy of novel treatments early in development, to enable better patient management, and to identify patients most likely to benefit from specific therapies.1 Snell N, Newbold P. The clinical utility of biomarkers in asthma and COPD. Curr Opin Pharmacol. 2008;8:222-235. Sin DD, Pahlavan PS, Man SF. Surfactant protein D: a lung specific biomarker in COPD? Ther Adv Respir Dis. 2008;2:65-74. Carratu P, Scoditti C, Maniscalco M, et al. Exhaled and arterial levels of endothelin-1 are increased and correlate with pulmonary systolic pressure in COPD with pulmonary hypertension. BMC Pulm Med. 2008;8:20.

More Related