Control del Riesgo futuro: Fución pulmonar - … · AlergoMurcia, 24.05.2012 Future Risk. JM OLaguibel Control del Riesgo futuro: Fución pulmonar Dr. Jose Mª. Olaguibel Rivera

AlergoMurcia, 24.05.2012 Future Risk. JM OLaguibel

Control del Riesgo futuro: Fución pulmonar

Dr. Jose Mª. Olaguibel Rivera

Complejo Hospitalario de Navarra. Pamplona


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Airway hyperresponsiveness/Allergy

Bronchitis

Cough reflex hypersensitivity

Damage to the airway and surrounding lung

Extrapulmonary factors.


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Satisfacer las expectativas del

paciente y/o de sus familias en relación con el cuidado y tratamiento del

proceso


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Kitch BT, Paltiel AD, Kuntz KM, Dockery DW, Schouten JP, Weiss ST, et al. A single measure of FEV1 is associated with risk of asthma attacks in long-term follow-up. Chest. 2004 Dec;126(6):1875-82.


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Copyright ©2006 American Academy of Pediatrics

Fuhlbrigge, A. L. et al. Pediatrics 2006;118:e347-e355

FIGURE 3 Association between FEV1% and serious asthma exacerbations


ROC Curve

Diagonal segments are produced by ties.

1 - Specif icity

1,00,75,50,250,00

Se

nsiti

vity

1,00

,75

,50

,25

0,00

ROC Curve

1 - Specificity

1,00,75,50,250,00

Sen

sitiv

ity

1,00

,75

,50

,25

0,00

ROC Curv e

1 - Specif ic ity

1,0 0,75,50,250,0 0

Se

nsiti

vity

1,0 0

,75

,50

,25

0,0 0

ACT (AUC 0.863) FEV1 (AUC 0.590)

ACT+FEV1 (AUC 0.865 )

Vega JM, Badia X, Badiola C, Lopez-Vina A, Olaguibel JM, Picado C, et al. Validation of the Spanish version of the Asthma Control Test (ACT). J Asthma. 2007; 44(10): 867-72.


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Petsky HL, Cates CJ, Lasserson TJ, Li AM, Turner C, Kynaston JA, Chang AB. A systematic review and meta-analysis: tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils). Thorax2012;67(3):199-208.


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Olaguibel JM, Alvarez MJ, Garcia B, Igartua M, Uribe M. Inflammatory phenotypes in nonsmoking asthmatic patients. J Investig Allergol Clin Immunol 2011;21:249-50.


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Olaguibel JM, Alvarez MJ, Garcia B, Igartua M, Uribe M. Inflammatory phenotypes in nonsmoking asthmatic patients. J Investig Allergol Clin Immunol 2011;21:249-50.


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Olaguibel JM, Alvaez MJ, Garcia BE, Igartua M, Uribe P. Inflammatory phenotypes in Nonsmoking Asthmatic Patients. JIACI 2011 (in press)


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Olaguibel JM, Alvaez MJ, Garcia BE, Igartua M, Uribe P. Inflammatory phenotypes in Nonsmoking Asthmatic Patients. JIACI 2011 (in press)


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Es conveniente determinar el nivel de control del asma

mediante visitas médicas regulares de seguimiento

que consten de una anamnesis bien dirigida y completa, un examen físico detallado y una

espirometría forzada

R2

Se puede valorar el nivel de control de forma objetiva

mediante cuestionarios validados de síntomas (ACT, ACQ), y en casos individualizados mediante la

medición de biomarcadores inflamatorios

R2

Panel de recomendaciones


FeNO a predictive biomarker of loss of asthma control

Changes in FeNO provide high predictive values for exacerbations:

Increase > 30% PPV 89% for exacerbations

FeNO can predict loss of asthma control after ICS dose reduction:

Persistently low values (< 25 ppb in adults, and 20 ppb in

children are reasuring) Pijnenburg MW, Bakker EM, Lever S, Hop WC, De Jongste JC. High fractional concentration of nitric oxide in exhaled air despite steroid treatment in

asthmatic children. Clin Exp Allergy. 2005; 35(7): 920-5

Papaioannou AI, Minas M, Tanou K, Gourgoulianis KI, Kostikas K. Exhaled NO may predict loss of asthma control: the effect of concomitant allergic rhinitis.

Eur Respir J. 2009; 34(4): 1006-7.

Zacharasiewicz A, Wilson N, Lex C, Erin EM, Li AM, Hansel T, et al. Clinical use of noninvasive measurements of airway inflammation in steroid reduction in

children. Am J Respir Crit Care Med. 2005; 171(10): 1077-82.

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ACQ-5 ACQ5+FEV1 ACQ-5+FEV1+FENO

Ni la espirometría ni el FeNO parecen añadir valor a la medición del control según ACQ-5


Historia natural de la función pulmonar

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El aparato respiratorio un sistema muy expuesto a la agresión

Piel: 2 m2

Aparato respiratorio: 400 m2

Aparato digestivo: 800 m2

Superficie total


Eisner MD, Anthonisen N, Coultas D, Kuenzli N, Perez-Padilla R, Postma D, Romieu I, Silverman EK, Balmes JR, Environmental obot, COPD OHACoN. An Official American Thoracic Society Public Policy Statement: Novel Risk Factors and the Global Burden of Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine2010 September 1, 2010;182(5):693-718.

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Wang X, Dockery DW, Wypij D, Gold DR, Speizer FE, Ware JH, Ferris BG, Jr. Pulmonary function growth velocity in children 6 to 18 years of age. Am Rev Respir Dis1993 Dec;148(6 Pt 1):1502-8.


Sears MR, Greene JM, Willan AR, et al. A longitudinal, population-based, cohort study of childhood asthma followed to adulthood. N Engl J Med 2003;349:1414-22.

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Bronquio reactivo

BD +


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Covar R, Robert S, Robert SZ, Laura AW, Andrew HL, Scott W, et al. Predictors of remitting, periodic, and persistent childhood asthma. The Journal of allergy and clinical immunology. 2010; 125(2): 359-66.e3.


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Sharma S, Augusto AL, Kelan GT, et al. Clinical predictors and outcomes of

consistent bronchodilator response in the childhood asthma management

program. The Journal of allergy and clinical immunology 2008;122:921-8.e4.

…Una respuesta

broncodilatadora consistente

(fenotipo BD) se asocia a a un

peor pronóstico en especial la

aparicion de exacerbaciones

frecuentes que requieren

corticoides orales…..


Lung function growth and evolution

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FEV 1 % of normal value at de age of 25

4 6 12 25 40 70 Age (yr)

100%

0%

Normal Mild asthma Severe persistent asthma


Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med 1998;339:1194-200. 36


Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med 1998;339:1194-200. 37


James AL, Palmer LJ, Kicic E, Maxwell PS, Lagan SE, Ryan GF, Musk AW. Decline in lung function in the Busselton Health Study: the effects of asthma and cigarette smoking. Am J Respir Crit Care Med2005 Jan 15;171(2):109-14.


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Olaguibel Rivera JM, Alvarez-Puebla MJ, Uribe P, Tallens ML. Duration of asthma and lung function in life-long nonsmoking adults. J Investig Allergol Clin Immunol. 2007;17(4):236-41.


Mean annual change in FEV1 in ml/year (with 95% confidence interval) for men and women for low and

high mean daily dosage of inhaled corticosteroid use (<720 and ⩾720 μg/day).

Dijkstra A et al. Thorax 2006;61:105-110

©2006 by BMJ Publishing Group Ltd and British Thoracic Society


Lung function growth and evolution

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4 6 12 25 40 70 Age (yr)

100%

0%

Normal Mild asthma Severe persistent asthma


Lung function evolution

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4 6 12 25 40 70 Age (yr)

100%

0%

Normal Mild asthma Persistent asthma Severe persistent asthma


Original Article Effect of Bronchoconstriction on Airway Remodeling

in Asthma

Christopher L. Grainge, Ph.D., Laurie C.K. Lau, Ph.D., Jonathon A. Ward, B.Sc., Valdeep Dulay, B.Sc., Gemma Lahiff, B.Sc., Susan Wilson, Ph.D., Stephen

Holgate, D.M., Donna E. Davies, Ph.D., and Peter H. Howarth, D.M.

N Engl J Med Volume 364(21):2006-2015

May 26, 2011

•Airway remodeling in asthma has been classically

considered to be the result of inflammatory changes.

•In this study, the investigators show that

bronchoconstriction alone can result in changes

consistent with airway remodeling.


Study Timeline and Changes in Forced Expiratory Volume in 1 Second (FEV1) after Inhalation Challenges in

Subjects with Asthma.

Grainge CL et al. N Engl J Med 2011;364:2006-2015


Changes in Markers of Eosinophilic Inflammation and Airway Remodeling after Repeated Inhalation

Challenges.



Representative Photomicrographs of Respiratory Epithelium from Bronchial-Biopsy Specimens before and

after Repeated Inhaled Methacholine Challenge.



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Basic mechanisms involved in airways narrowing:

1) accumulation of fluid, cells or mucus

2) encroachment of a thickened airway wall

with or without smooth muscle shortening

3)shortening of the smooth muscle surrounding

the airway

4)collapse of the airway wall


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48 years-old. Severe and short evolution intrinsic asthma with poliposis


.

Sorkness R L et al. J Appl Physiol 2008;104:394-403

©2008 by American Physiological Society


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van Veen IH, ten Brinke A, Sterk PJ, Sont JK, Gauw SA, Rabe KF, et al. Exhaled nitric oxide predicts lung function decline in difficult-to-treat asthma. Eur Respir J. 2008; 32(2): 344-9. Results: In patients with baseline FEV1 ≥80% of predicted: 90 versus 29% had accelerated decline in FEV1 (FeNO ≥20 ppb versus FeNO <20 ppb respectively; relative risk 3.1 (95% CI, 1.7–3.4).


Original Article Changes in Forced Expiratory Volume in 1 Second

over Time in COPD

Jørgen Vestbo, Dr.Med.Sc., Lisa D. Edwards, Ph.D., Paul D. Scanlon, M.D., Julie C. Yates, B.S., Alvar Agusti, M.D., Ph.D., Per Bakke, Ph.D., Peter M.A. Calverley, M.B., Ch.B., M.D., Bartolome Celli, M.D., Harvey

O. Coxson, Ph.D., Courtney Crim, M.D., David A. Lomas, M.D., Ph.D., William MacNee, M.B., Ch.B., M.D., Bruce E. Miller, Ph.D., Edwin K. Silverman, M.D., Ph.D., Ruth Tal-Singer, Ph.D., Emiel Wouters, M.D., Ph.D.,

Stephen I. Rennard, M.D., for the ECLIPSE Investigators

N Engl J Med Volume 365(13):1184-1192

September 29, 2011

• In patients with chronic obstructive pulmonary disease (COPD), lung function decreases rapidly.

• Analysis of data from a large observational study of COPD showed that the rate of such loss is highly variable, and current smoking was associated with a rapid loss.


Effects of Patient Characteristics on Baseline Forced Expiratory Volume in 1 Second (FEV1) and on Annual

Rate of Change in FEV1.

Vestbo J et al. N Engl J Med 2011;365:1184-1192


Effects of Biomarkers on Forced Expiratory Volume in 1 Second (FEV1).

Vestbo J et al. N Engl J Med 2011;365:1184-1192


Brusselle G. N Engl J Med 2009;361:2664-2665

Effects of Genetic Factors and Environmental Exposure on Lung Function in Childhood and Adulthood


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La hipótesis holandesa: Origen común de las enfermedades que cursan con obstrucción crónica al flujo aéreo

ATOPIA / HIPERREACTIVIDAD

VIRUS

TABACO

ALERGENOS POLUCIÓN

OBSTRUCCIÓN

BRONQUIAL

CHRONIC NONSPECIFIC LUNG

DISEASE

EJERCICIO

Factores del Huésped: sexo

edad


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Mast cell

CD4+ cell

(Th2)

Eosinophil

Allergens

Ep cells

ASTHMA

Bronchoconstriction AHR

Alv macrophage Ep cells

CD8+ cell

(Tc1) Neutrophil

Cigarette smoke

Small airway narrowing Alveolar destruction

COPD

Reversible Irreversible Airflow Limitation

Source: Peter J. Barnes, MD


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La hipótesis holandesa: Origen común de las enfermedades que cursan con obstrucción crónica al flujo aéreo

Interacción gen-gen-medioambiente

VIRUS

TABACO ALERGENOS

POLUCIÓN

EJERCICIO

DIETA

Daño estructural

Expresión clínica

Proceso inflamatorio


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Espirometria forzada: FVC, FEV1/FVC (LNN)

Respuesta broncodilatadora persistente

Valoración del daño estructural:

Respuesta broncodilatadora máxima

Respuestra broncodilatadora máxima tras tratamiento intenso corticoideo (Triancinolona depot).

Fenotipado Funcional del paciente


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Documents

Control del Riesgo futuro: Fución pulmonar - … · AlergoMurcia, 24.05.2012 Future Risk. JM OLaguibel Control del Riesgo futuro: Fución pulmonar Dr. Jose Mª. Olaguibel Rivera