20 Early intervention with inhaled steroid 24681012<22-33-5> 5Annual change in %predicted FEV1p = 0.02 for correlationChildren2Adults16-12<61-25-10>102-5203040yearsmonthsDuration of symptomsDuration of symptoms (years)Maximum increase inPEF (%)p = for correlation1. Selroos et al, Chest 19952. Agertoft and Pedersen, Respir Med 1994
27 Is it Asthma? Recurrent episodes of wheezing Troublesome cough at nightCough or wheeze after exerciseCough, wheeze or chest tightness after exposure to airborne allergens or pollutantsColds “go to the chest” or take more than 10 days to clear
36 Definition of COPDCOPD 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.
41 +/- Diagnosis of COPD Spirometry post bronchodilator FEV1/ FVC <70% GOLD = Global Initiative in Obstructive Lung Disease 2001Diagnosis of COPDExposure to risk factorsTobaccooccupationpollutionSymptomsCoughSputumdyspnea+/-Spirometry post bronchodilator FEV1/ FVC <70%
42 GOLD classification of COPD At-Risk Stage (Stage 0)No spirometric changesChronic symptoms (cough, sputum)Mild (Stage I )FEV1/FVC < 70%FEV1 > 80% predictedModerate (Stage II )50% < FEV1 <80% predictedSevere (Stage III )Very Severe (Stage IV)30% < FEV1 <50% predictedFEV1 <30% predictedor presence of respiratory insufficiency or right hart failureGOLD = Global Initiative in Obstructive Lung Disease 2003
59 Causes of death related to smoking Causes of death no.of death mortality ratioCA lung *CA esophagus,larynx,mouth, toung,lip *CA bladder *CA prostrateCA liver,gall bladderN= f/u 44 monthsHammond EC and Horn. JAMA 1958; 166:1172
60 Causes of death related to smoking Causes of death no.of death mortality ratioCoronary artery disease *Cerebrovascular disease *aortic aneurysm *other vascular diseases *Pneumonia/influenza *N= f/u 44 monthsHammond EC and Horn. JAMA 1958; 166:1172
61 Number of daily cigarettes and risk for lung cancer UK doctor n =34440Doll R BMJ 1976
62 Carcinogenic substances in cigarette smoke Polyaromatic hydrocarbonaromatic aminesaldehydesinorganic compoundsN-nitrosamines
63 COPD mortality in relation to cigarette smoking standardized mortality rationeversmokeformersmokecurrentsmoke34440 British doctorDoll. BMJ 2: ;1976
68 Effective Treatments Are Available Counselling / behavioural supportPharmacotherapy
69 Counselling WorksBrief supportive advice to quit from doctor is effectiveCounselling by other health professionals is effectiveGroup and individual both effectiveThe greater the support, the greater the chances of successEvery smoker should be offered at least brief advice
70 Pharmacotherapy Works First-line pharmacotherapiesBupropion SRNicotine replacement therapySecond-line pharmacotherapiesClonidineNortriptyline
71 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.
72 Who should receive pharmacotherapy? All smokers trying to quit except for special circumstancesSpecial considerations include:- medical contraindications- smoke < 10 cigarettes/day- pregnant/breastfeeding- adolescent smokers
73 Implementation of treatment is unsatisfactory Smoker insufficiently awareTreatment is not easily accessibleReimbursement is limited
74 Conclusions More than 10 million smokers in Thailand. Smoking is a major health hazardEffective treatment for tobacco use is exist but under utilizedwe can do better, we must do better!