Asma y epoc

Asma y EPOC: Ni Junt@s Ni Revuelt@s

(Si no todo lo contrario)

Asma y EPOC: Ni Junt@s Ni Revuelt@s

(Si no todo lo contrario)

Josep Morera i Prat

Granada, 9 de Junio de 2010

Josep Morera i Prat

Granada, 9 de Junio de 2010

ÍNDICE

1) Principio de la Confusión

2) No Parece tan Difícil

3) Nuevas Tecnologías

4) También Asma Sistémica y ¿Qué hay de los Gemelos?

5) Si no todo lo contrario

6) Conclusiones

Principio de la ConfusiónPrincipio de la Confusión


Am J Respir Crit Care Med,2006; 174: 238–244.

Kraft M. DOES DISTINCTION BETWEEN ASTHMA AND COPD MATTER?

…Therefore, I implore you not to ask what your country can do for you, but what you can do for your patients!...

…Therefore, I implore you not to ask what your country can do for you, but what you can do for your patients!...


Chronic Obstructive Pulmonary Disease (COPD) is a preventable and

treatable disease with some significant extrapulmonary effects that may

contribute to the severity in individual patients. Its pulmonary component

is characterized by airflow limitation that is not fully reversible. The

airflow limitation is usually progressive and associated with an

abnormal inflammatory response of the lung to noxious particles or

gases.

Rabe KF, Hurd S, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary. Am J Respir Crit

Care Med. 2007;176(6):532-55.

DEFINICIÓN


www.ginasthma.org

Is a chronic inflammatory disorder of the airways in which many cells

play a role, in particular mast cells, eosinophils, and T lymphocytes. In

susceptible individuals this inflammation causes recurrent episodes of

wheezing, breathlessness, chest tightness, and cough particularly at

night and / or in the early morning. These symptoms are usually

associated with widespread but variable airflow limitation that is at

least partly reversible either spontaneously or with treatment. The

inflammation also causes an associated increase in airway

responsiveness to a variety of stimuli.

DEFINICIÓN


Basado en J. G. Scadding.Principles of definition in medicione. Lancet, 1959; 1: 323-325 .

Meaning of diagnostic terms in bronchopulmonary disease. BMJ, 1963; 2: 1425-1430.The semantics of medical diagnosis. Niomed. Comput, 1972; 3: 83-90.

Helath and disease: what can medicine do for philosophy?. J. Med. Ethics, 1988; 14: 118-124.Definition on asthma. In: Weiss EB, Stein M. Editors. Bronchial asthma, mechanisms and therapeutics, 3erd ed. Boston: Litle Brown; 1993. p.1-13.

Descripción ClínicaDescripción Clínica11

Lesión AnatómicaCaracterística

Lesión AnatómicaCaracterística

22

Desorden FuncionalCaracterístico

Desorden FuncionalCaracterístico

33

Causa - EtiologíaCausa - Etiología44

SÍNDROME

SÍNDROME

ENFERMEDADENFERMEDAD

EPOC: NOSOLOGÍA

NO SE MENCIONA TABACO NO SE MENCIONA ALERGIA O MEDIACIÓN POR IgE


Causas de Dificultad: Diagnóstico Diferencial

El asma crónico puede cursar con obstrucción crónica al flujo aéreo.

El asma crónico puede cursar con pérdida acelerada de FEV1.

Aprox. El 30% de los asmáticos crónicos, fuman.

El asmático fumador tiene peor evolución y mayor resistencia al tratamiento.

El tabaco no es la única causa de mala evolución del asma.

Lange P, et al. N Engl J Med. 1998; 339(17): 1194-200.James AL, et al. Am J Respir Crit Care Med. 2005; 171(2): 109-14.

Chaudhuri R, et al. Am J Respir Crit Care Med. 2003; 168(11): 1308-11.Gibson PG, Simpson JL.Thorax. 2009; 64(8): 728-35.


11

5

8

9

10

6 7

3 4

1 2

Snider GL. Defining chronic obstructive pulmonary disease. In: Calverley PMA, Pride NB, eds. Chronic obstructive pulmonary disease. London, UK: Chapman & Hall, 1995; 1–8.

EmphysemaChronic

Bronchitis

Asthma

Airflow Obstruction

COPD


228 228

16% Obstrucción16% Obstrucción

43% Reversible43% Reversible

41% Curación41% Curación

2133 a2133 a


ÍNDICE






6) Conclusiones


Differences in Airway Inflammation in Patients with Fixed Airflow Obstruction Due to Asthma or Chronic Obstructive Pulmonary

Disease

Differences in Airway Inflammation in Patients with Fixed Airflow Obstruction Due to Asthma or Chronic Obstructive Pulmonary

Disease

M. Fabbri, et al. Am. J. Respir. Crit. Care Med. 2003;167 418-424

No Parece Tan DifícilNo Parece Tan Difícil

EPOC Asma

Differences in Airway Inflammation in Patients with Fixed Airflow Obstruction Due to Asthma or Chronic Obstructive

Pulmonary Disease

Differences in Airway Inflammation in Patients with Fixed Airflow Obstruction Due to Asthma or Chronic Obstructive

Pulmonary Disease

M. Fabbri, et al. Am. J. Respir. Crit. Care Med. 2003;167 418-424.


Área bajo ROC

Revers. broncodilatadores 0.71Revers. corticoides 0.73DLCO 0.66KCO 0.65VK 0.63PaO2 0.61

% Eosinófilos en BAL 0.95% Eosinófilos en esputo 0.88NO exhalado 0.86

Punto de corte eosinófilos en esputo 4.6%Punto de corte NO exhalado 16 ppb

Revers. broncodilatadores 0.71Revers. corticoides 0.73DLCO 0.66KCO 0.65VK 0.63PaO2 0.61

% Eosinófilos en BAL 0.95% Eosinófilos en esputo 0.88NO exhalado 0.86

Punto de corte eosinófilos en esputo 4.6%Punto de corte NO exhalado 16 ppb

M. Fabbri, et al. Am. J. Respir. Crit. Care Med. 2003;167 418-424


Am J Respir Crit Care Med. 2005; 171(2):109-14.

Hombres Mujeres



N Engl J Med, 1998;339:1194-200.


N Engl J Med, 1998;339:1194-200.

EX- SMOKERS = N

ONSMOKERS

Eur Respir J 2007; 30: 452–456

Proc Am Thorac Soc Vol, 2007; 4: 591–596.


Eur Respir J 2000; 15: 470-477.

SELF SELECTION

OR

Smoking Initiation Favouring quitting

NO ENTRAN EN ENSAYOS CLÍNICOS !!NO ENTRAN EN ENSAYOS CLÍNICOS !!


Am J Respir Crit Care Med, 2003; 168; 1308–1311.


Am J Respir Crit Care Med, 2009; 180: 1170–1178.






ÍNDICE






6) Conclusiones


Chest 2004; 126:117S–124S.

Nuevas TecnologíasNuevas Tecnologías

Chest 2004; 126:117S–124S.

DLCO → 77% Sensibilidad / 71% Especificidad


Proc Am Thorac Soc, 2008; 5: 940–945.


Proc Am Thorac Soc, 2008; 5: 940–945.


Chest 2009; 136:797–804.


Ohno Y, et al. AJRCCM. 2008;177(10):1095-102.


Thiberville L, et al. Human in vivo fluorescence microimaging of the alveolar ducts and sacs during bronchoscopy. ERJ.

2009;33(5):974-85.




Thorax 2009;64:444–450.


Thorax 2009;64:444–450.


Liesker JW, et al. International Journal of COPD 2009:4 127–135.

Results: Mean (SD) RBM thickness was not signifi cantly different between asthma and COPD 5.5 (1.3) vs 6.0 (1.8) μm, but signifi cantly larger than in their healthy counterparts, ie, 4.7 (0.9) and 4.8 (1.2) μm, respectively. Collagen I and laminin stained signifi cantly stronger in asthma than in COPD. Tenascin stained stronger in asthma than in healthy controls of similar age, and stronger in COPD controls than in asthma controls (p 0.05).


Detection of wheezing during maximal forced exhalation in patients with obstructed airways.


Fiz J.A., et al. Chest, 2002; 122: 188-191.


±Std. Dev.

±Std. Err.

Mean

Groups

Whe

ezes

num

ber

0

4

8

12

16

Controls COPD Asthma

p<0.004 (Anova)

Fiz J.A., et al. Chest, 2002; 122: 188-191.




ÍNDICE






6) Conclusiones


Modificado de: Boulet LB, ERJ, 2009; 33: 897-906.

Chrurg StraussChrurg Strauss

NECNEC

Inf. Eos. PróstataInf. Eos. Próstata

También Asma Sistémica y ¿Qué hay de los Gemelos?


Hernia inguinalHernia

inguinalNeuropatia

S. vegatativo

Neuropatia S.

vegatativo

Rinitis / SinusitisRinitis / Sinusitis

ProzaProzacc

Biochem. Soc. Trans. (2009) 37, 814–818.


Thomsen SF, et al. Risk factors for asthma in young adults: a co-twin control study.

Allergy. 2006; 61(2): 229-33.

Willemsen G, et alHeritability of self-reported asthma and allergy: a study in adult Dutch twins, siblings and parents.

Twin Res Hum Genet. 2008; 11(2): 132-42.



Bouzigon, et al. N Engl J Med 2008; 359: 1985-94.



11

5

8

9

10

6 7

3 4

1 2

EmphysemaChronic Bronchitis

Asthma

Airflow Obstruction

FIP

OBESITY

S A

O S

Snider GL. Defining chronic obstructive pulmonary disease. In: Calverley PMA, Pride NB, eds. Chronic obstructive pulmonary disease. London, UK: Chapman & Hall, 1995; 1–8

(??!!)

11

5

8

9

10

6 7

3 4

1 2

EmphysemaChronic Bronchitis

Asthma

Airflow Obstruction

FIP

OBESITY

S A

O S

Snider GL. Defining chronic obstructive pulmonary disease. In: Calverley PMA, Pride NB, eds. Chronic obstructive pulmonary disease. London, UK: Chapman & Hall, 1995; 1–8

(??!!)

ÍNDICE






6) Conclusiones


Radiology 1990; 175:715-719

Si no Todo lo ContrarioSi no Todo lo Contrario

34% 31% 33%

Mariotti F et al. Congress. Florencia, December 2007

.


CFCl3 CFCl2 + Cl

Cl + O3 ClO + O2

O3 + O (1 molécula de Cl, puede destruir 100.000 de moléculas de O3)

Freones = Clorofluorocarbonados

(freón 11)

Agujero de Ozono

http://es.wikipedia.org/wiki/Agujero_de_ozonoMontreal Protocol [Accessed 2002, Apr 19] on line. Available

from: www.unep.org/ozone/pdf/montreal-protocol2000.pdf.


If you have library access to old copies of Nature (try inter-library loan), the original paper on the theory is Rowland and

Molina [Nature, 249, 810 (1974)].


Tecnología Modulite: características

• Aerosol en solución basado en el propelente HFA-134a• Permite reducción de la dosis (partículas extrafinas)• Menor velocidad de la nube de aerosol

– Menor depósito orofaríngeo– Mayor depósito pulmonar

– Mayor tiempo para la inhalación – Menor necesidad de coordinación

• No precisa agitación antes de su uso


CFC Suspension

HFA Suspension

HFA Solution

Non-Extrafine Extrafine


Ito K, et al. N Engl J Med 2005;352:1967-76.


ÍNDICE






6) Conclusiones


1) Es importante filiar siempre que sea posible entre asma y EPOC, aunque en muchas ocasiones los tratamientos sean equivalentes

CONCLUSIONES:

ConclusionesConclusiones

GraciasGracias

Health & Medicine

Asma y epoc