Early intervention with inhaled steroid 2. Agertoft and Pedersen, Respir Med Selroos et al, Chest < > 5 Annual change in % predicted FEV 1 p = 0.02 for correlation Children 2 Adults < > yearsmonths Duration of symptoms Duration of symptoms (years) Maximum increase in PEF (%) p = for correlation
Changing concept in asthma treatment Airway Hyperresponsiveness Bronchospasm Inflammation Remodelling short-acting b 2 -agonists Inh corticosteroidCombination
Is it Asthma? Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants Colds “go to the chest” or take more than 10 days to clear
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.
Diagnosis of COPD GOLD = Global Initiative in Obstructive Lung Disease 2001 Exposure to risk factors Tobacco occupation pollution Symptoms •Cough •Sputum •dyspnea +/- Spirometry post bronchodilator FEV 1 / FVC <70%
At-Risk Stage (Stage 0) No spirometric changes Chronic symptoms (cough, sputum) Mild (Stage I ) FEV 1 /FVC < 70% FEV 1 > 80% predicted Moderate (Stage II ) FEV 1 /FVC < 70% 50% < FEV 1 <80% predicted Severe (Stage III ) Very Severe (Stage IV) 30% < FEV 1 <50% predicted FEV 1 <30% predicted or presence of respiratory insufficiency or right hart failure GOLD = Global Initiative in Obstructive Lung Disease 2003 GOLD classification of COPD
Pathophysiology COPD Airflow obstruction Ventilatory capacity Work of breathing Exercise limitation (Dyspnea) V/Q Mismatching VD/VTPaO2 Ventialatory requirement
Treatment •Retard the progression of airflow obstructionRetard the progression of airflow obstruction •Minimizing airflow obstructionMinimizing airflow obstruction •Prevent complicationPrevent complication •Optimizing functional capacityOptimizing functional capacity
Causes of death related to smoking Causes of deathno.of deathmortality ratio CA lung * CA esophagus,larynx, mouth, toung,lip1147.0* CA bladder902.17* CA prostrate CA liver,gall bladder Hammond EC and Horn. JAMA 1958; 166:1172 N= f/u 44 months
Causes of death related to smoking Causes of deathno.of deathmortality ratio Coronary artery disease * Cerebrovascular disease * aortic aneurysm902.72* other vascular diseases274.5* Pneumonia/influenza1243.9* Hammond EC and Horn. JAMA 1958; 166:1172 N= f/u 44 months
Number of daily cigarettes and risk for lung cancer UK doctor n =34440Doll R BMJ 1976
Carcinogenic substances in cigarette smoke n Polyaromatic hydrocarbon n aromatic amines n aldehydes n inorganic compounds n N-nitrosamines
COPD mortality in relation to cigarette smoking British doctor standardized mortality ratio never smoke former smoke current smoke Doll. BMJ 2: ;1976
n Tobacco use results in true drug dependence n Effective treatment exist n Treatment are cost- effective
5A’s for Promoting Smoking Cessation n Ask about tobacco use at every visit n Advice to quit n Assess readiness to quit n Assist cessation by providing evidence-based aids n Arrange follow-up.
ASK ADVISEASSESS ASSISTARRANGE Follow-up Never Ex- smoker Commend. Congratulate. Encourage cessation Not ready Current smoker Motivate Prescribe Rxs Repeat advise Monitor compliance Ready to quit
Effective Treatments Are Available n Counselling / behavioural support n Pharmacotherapy
Counselling Works n Brief supportive advice to quit from doctor is effective n Counselling by other health professionals is effective n Group and individual both effective n The greater the support, the greater the chances of success n Every smoker should be offered at least brief advice
Pharmacotherapy Works n First-line pharmacotherapies u Bupropion SR u Nicotine replacement therapy n Second-line pharmacotherapies u Clonidine u Nortriptyline
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.
Who should receive pharmacotherapy? l All smokers trying to quit except for special circumstances l Special considerations include: - medical contraindications - smoke < 10 cigarettes/day - pregnant/breastfeeding - adolescent smokers
Implementation of treatment is unsatisfactory n Smoker insufficiently aware n Treatment is not easily accessible n Reimbursement is limited
Conclusions n More than 10 million smokers in Thailand. n Smoking is a major health hazard n Effective treatment for tobacco use is exist but under utilized n we can do better, we must do better!