BE THE CHANGE YOU WANT

TO SEE11/3, Dr. Biresh Guha Street, 2nd Floor, IMA House, Beside No. 4 Bridge,

Park Circus, Before Institute of Child Health, Kolkata 700 017

E-mail : naabikolkata@gmail.com ; agghosal@yahoo.com

Prof. A. G. Ghoshal

NATIONAL ALLERGY ASTHMA BRONCHITIS INSTITUTEwww.naabi.org

24 Hrs. Helpline : 033-2290 2305, 98303 30404

Perception and Practice of O…A…D…

- a field report

- preliminary observation

- lateral thoughts

CASE

THE CORRECT MANAGEMENT REQUIRES AN ACCURATE DIAGNOSIS

CASE STUDY

• 67 year old female• cough for four years• SOB for 18 months

– slow not stopping

• occasional phlegm• pneumonia aged 18• 0.5 pack years • “asthma” aged 35• prn salbutamol only

• overinflated• quiet breath sounds• CXR overinflated

FEV1 0.86 (32%)FVC 2.46 (78%)

post bronchodilator

• STEROID TRIAL• FEV1 0.79 POST TRIAL (0.86 PRE)• BECOTIDE 400 mcg bd• AT SIX MONTHS: SOB ON INCLINES• LITTLE WHEEZE, DRY COUGH• SALMETEROL ADDED • AT TWO YEARS STABLE : FEV1 0.9

• 14 YEARS AFTER PRESENTATION• NO EXACERBATIONS• NEW AF• RV DILATED

• AGED 83• 16 YEARS AFTER PRESENTATION• SOB AND STOPS AT 50 METRES• SLIGHT COUGH• NO EXACERBATIONS• FEV1 0.67 (32%) (DECLINE OF 12 ML PER YEAR)• FVC 1.87 (74%)• KCO 0.68 (52%)

• ECHO : RV DILATATION• PAP 58• AF

• SC 400/12 BD• TIOTROPIUM• VENTOLIN• VERAP / WARFARIN / VALSARTIN/ FUROSAMIDE

No exacerbations and stable FEV1 over 14 years: What’s your diagnosis?

• GOLD C COPD (with appropriate successful initial treatment with the addition of LAMA as exercise tolerance declined and treatment of co-morbidities)?

• Asthma with late preventative therapy?

• Asthma COPD Overlap Syndrome?

RESPONSES

Asthma with late preventive therapy

RESPONSES

RESPONSES

• This is definitely not pure asthma! Out of the other two options I would vote for COPD. Because: Phenotype- Uniform course with gradual decline in lung function. Onset at 35 years or later. No documented FH/AR etc. No reversibility at all. ACOS would definitely be the other option.

RESPONSES• ….. going by the current definition I think this patient

initially had predominant asthma manifested by significant steroid reversibility. Patient also had COPD initially manifested by hyperinflation and partial control of symptoms and exercise intolerance. In the later phase the COPD component dominated with pulmonary hypertension and reduced DLCO. So practically this is a case of ACOS. But again I would rather want to describe the case as an obstructive airway disease which initially had a predominant airway component with later development of parenchymal component.

RESPONSES

• The correct diagnosis could be neither of the options but post infectious obliterative bronchiolitis as there is previous history of "pneumonia". 5 pack year smoking excludes COPD and development of Cor Pulmonale goes against asthma. Overlap is also unlikely as both disease components are unlikely. An HRCT showing mosaic perfusion would clinch the diagnosis.

RESPONSES

What’s in a name?

• Total number of Dr participated in the survey: 150– Chest: 75– Non-chest: 75

• Total answers for Asthma: 55• Total answers for COPD: 71• Total answers for ACOS: 20• Total answers for OB : 02

• Among Chest the answers are :– Asthma: 35– COPD: 18– ACOS: 18– OB: 02– What’s in a name? : 02

• Among Non-chest the answers are :– Asthma: 20– COPD: 53– ACOS: 02

• There be no completely "unbiased, unfiltered" perception.

• Perceptual experiences often shape our beliefs, but those perceptions were based on existing beliefs.

• What we perceive (or think we perceive) is heavily determined by what we know, and what we know (or think we know) is constantly conditioned on what we perceive (or think we perceive).

Predictive Coding ANDY CLARKPhilosopher and Cognitive Scientist, University of Edinburgh. Author: Supersizing the Mind: Embodiment, Action, and Cognitive Extension

OAD means different thing to different people

Canadian practice assessment in chronic obstructive pulmonary disease: Respiratory specialist physician

perception versus patient reality

• Differing perceptions about many aspects of COPD among physicians and patients may contribute to these care gaps.

Can Respir J Vol 20 No 2 March/April 2013

THE SCHOOL EFFECT

GINA GOLD

Non-pulmonologists are –

1) Reluctant to use the label “ASTHMA”.

2) Familiar to make use of the term “COPD”.

3) For manifestation of an overall clinical impression of chronic airflow limitation, not a statement for a distinct disease entity.

Cardiologist use the term COPD

1) Age-effect

2) COPD is accommodated as a distant relative to the family of ischemic heart diseases.

THE CHRONICITY(HELPLESS) EFFECT

• We have reported in the PLATINO population that 23% of the subjects with COPD report prior medically diagnosed asthma.

• Subjects with COPD Asthma overlap had more respiratory symptoms; worse lung function; and more use of lung medication, hospitalization, and exacerbations as worse GHS

for the PLATINO Team

CHEST 2014; 145(2):297–304

• People with more utilizations of health care had an increased opportunity to receive both an Asthma and COPD diagnosis, with the correct conclusion being that people who had more utilization of health care (for whatever reason) are more likely to receive diagnosis of both Asthma and COPD, rather than that people who have received diagnoses of both Asthma and COPD have more utilization of healthcare.

Chest 2008; 134:14-19Chestm2008; 134:1-2

• The diagnosis of Asthma depends on what we mean by the word.

Clinical & Experimental Allergy, 2009 (39) 1652–1658.

• Reported prevalence rates of asthma vary within and among countries worldwide---- the comparison between studies is complicated by the use of different definitions of asthma.

PLATINO

“Medical diagnosis of asthma” as definition for Asthma

A diagnosis of asthma during their lifetime

(Positive answers to both of the questions

‘‘Have you ever had asthma?’’ and

‘‘Was this confirmed by a doctor?’’)

Cerveri I et al, Eur Respir J 2009; 34: 568-573

Asthma- A Physician’s Diagnosis

Asthma and Asthma-like Symptoms in Adults Assessed by Questionnaires

• When validated in relation to bronchial challenge tests, the questions about self-reported asthma have a mean sensitivity of 36% (range, 7-8%) and a mean specificity of 94% (range, 74-100%). The questions about “physical-diagnosed asthma” have even higher specificity, 99%.

• Specificity of the “asthma” –related questions could be increased by restricting the study to younger segment of the population.

Chest 1993;104:600-608

• Primary care clinicians have reported patients with acute bronchitis that changes into chronic asthma and later into severe COPD.

Salvi Lancet 2009; 374: 733–43

Hahn DL. Evaluation and management of acute bronchitis. In:Hueston WJ, ed. 20 common problems in respiratory disorders.New York, NY: McGraw-Hill, 2002: 141–53.

Diagnosis and Assessment• A clinical diagnosis of COPD should be considered in any patient

who has dyspnea, chronic cough or sputum production,

• Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.

• The degree of reversibility has never been shown to add to the diagnosis, differential diagnosis with Asthma, or to predicting the response to long-term treatment with bronchodilators or corticosteroids.

GOLD 2013

and a history of exposure to risk factors for the disease.

?Sensitiv

e

Not specific

SymptomsEtiology

• Table 2: Asthma on clinical diagnosis, n=648• • Total asthma patients with acceptable spirometry • n=648• Asthma patients with airflow obstruction in spirometry n=250• Asthma patients without airflow obstruction in spirometry n=398• Male • 356(54.9%) • 164(65.6%)• 192(48.2%)• Average age • 40.5 yrs (SD 17.3 yrs)• 47.6yrs (SD 19 yrs)• 36.1 yrs ( SD 18.9yrs)• Socioeconomic status (low= <5000/month, middle=5000-20000/month, high=>20000/month of monthly income)• Low – 272(41.9%)• Middle-150(23.1%)• High-226(34.8%) • Low-118(47.2%)• Middle-50(20%)• High-82(32.8%)• Low-154(38.7%)• Middle-100(25.1%)• High- 144(36.1%)

• Table 4: Symptoms of asthma phenotypes, smoking history and airway obstruction, n=125• • Gr A <5% reversibility of FEV1 n=64• Gr B 6-12 % reversibility of FEV1 n=58• Gr C >12%,<200 ml reversibility of FEV1 n=26• Gr A+B+C group of ‘patients without reversibility’ n=148• Group of ‘patients with reversibility’ or >12%, >200ml reversible group n=102• P value of difference of ‘patients without reversibility’ and ‘patients with reversibility’• Childhood asthma• 44(68.7%)• 36(62%)• 14(53.8%)• 94(63.5%)• 64(62.7%)• 0.92• Family history of asthma• 42(65.6%)• 30(51.7%)• 12(46.1%)• 84(56.7%)• 74(72.5%)• 0.1• Running nose• 60(93.5%)• 48(82.7%)• 26(100%)• 134(90.5%)• 90(88.2%)• 0.90• Eczema• 8(12.5%)• 8(13.7%)• 6(23%)• 22(14.8%)• 22(21.5%)• 0.46• Nocturnal awakening >1 /wk• 40(62.5%)• 38(65.5%)• 20(76.9%)• 98(66.2%)• 32(31.3%)• 0.0003• Never smoker• 46(71.8%)• 36(62%)• 22(84.6%)• 104(70.2%)• 78(76.4%)• 0.57• Ex smoker• 18(28.1%)• 10(17.2%)• 2(7.6%)• 30(20.2%)• 14(13.7%)• 0.48• Current smoker• 0• 4(6.8%)• 2(7.6%)• 6(4%)• 10(9.8%)• 0.35• • • • • • • • • • •

Allergic Rhinitis versus Bronchodilator Reversibility in the Diagnosis of Asthma.

A G Ghoshal1, Shelly Shamim2, Sushmita Kundu3, Subhasis Mukherjee4, Raja

Dhar5, Niranjan Sit6

Sensitivity and specificity of AR and BR for asthma diagnosis

Sensitivity of AR for asthma diagnosisspecificity of AR for asthma diagnosis

93.9%87.5%

Sensitivity of BR for asthma diagnosisspecificity of BR for asthma diagnosis

30.4%97.1%

• Prevalence of COPD with reversible obstruction in first spirometries, among patients with obstructive airways disease in western Maharashtra, India.

Abhyankar A, Salvi S. Oct 4–8, 2008.ERS Abstr E456

• COPD. 2014 Feb;11(1):2-9. doi: 10.3109/15412555.2013.800853. Epub 2013 Jul 11. Chronic obstructive pulmonary disease in non-smokers: a case-comparison study. Sexton P1, Black P, Wu L, Sommerville F, Hamed M, Milne D, Metcalf P, Kolbe J. .

Asthma was nearly universal among nonsmokers and was the commonest identifiable cause of COPD in that group. Nonsmokers also exhibited a high prevalence of objective eosinophilic inflammation (raised ENO and eosinophil counts, positive skinprick tests).

New Definition

COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.

Exacerbations and co-morbidities contribute to the overall severity in individual patients.

GOLD 2013

Exposure

Smoking Air pollution Inhaled toxins

Genes

Inflammation

Corticosteroid resistance

Auto immunity

Airway remodeling

Carbonyl stress

Oxidative stress

? Infection

Differences in inflammation between COPD and Asthma

Although both COPD and asthma are associated with chronic inflammation of the respiratory tract, there are differences in the inflammatory cells and mediators involved in the two diseases, which in turn account for differences in physiological effects, symptoms, and response to therapy.

Am J Respir Crit Care Med 2003;167:418-24

• The pathology of chronic airflow limitation in asthmatic non smokers and non asthmatic smokers is markedly different, suggesting that the two disease entities may remain different even when presenting with similarly reduced lung function.

GOLD 2013

Chronic obstructive pulmonary disease in non-smokers: a case-comparison study

• Asthma was nearly universal among nonsmokers and was the commonest identifiable cause of COPD in that group.

COPD 2014 Feb;11(1):2-9

The trade-off with simplicity and ease of remembrance of the 0.70 fixed cutoff point could come at the expense of misclassification.

Cerveri I et al, Eur Respir J 2009; 34: 568-573

The recommendation of different thresholds for thedefinition of airflow obstruction in COPD (0.70 ratio) andasthma (0.75–0.80 ratio) is even more difficult to justify and hasresulted in ongoing confusion. The higher threshold forasthma than for COPD has probably been chosen because ofthe different distributions of age and the physiological declinein FEV1/FVC in the two diseases, even though asthma mayalso have a late onset.

(Cerveri I et al, Eur Respir J 2009; 34: 568-573)

Asthma misdiagnosed as COPD

• 128 confirmed asthmatics in SARA study• 20% were wrongly diagnosed as COPD• Thus 1:5 elderly asthmatics receive an

inappropriate diagnosis of COPD • Older age main factor contributing to

misdiagnosis• Distinction specially arduous in the elderly• Distinction vital when therapeutic choices

exist

Chest 2003; 123: 1066–72. 38

• IRAO has always been equated with COPD.

Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutritional Examination Survey, 1988-1994; Arch Intern Med 2000; 160: 1683-1689.

• The PLATINO team found that• 23% of the subjects with COPD had self-reported• medically diagnosed asthma. 8• Marsh et al 9 estimated• the prevalence of asthma in a COPD cohort to be• 55.2% using a composite defi nition of asthma

(postbronchodilator• [post-BD] increase in FEV 1 . 15%,• or peak fl ow variability . 20% during 1 week of testing,• or physician diagnosis of asthma in conjunction with• current symptoms).

• A subgroup of asthmatics may experience vary steep rates of decline in forced expiratory volume in one second leading to severe nonreversible airflow obstruction, whereas no indication was found that long-standing asthma may lead to the development of emphysema.

Ulrik CS, Backer V. Nonreversible airflow obstruction in life-long nonsmokers with moderate to severe asthma. Eur Respir J 1999; 14(4):892–896.

Genes

Lack of controller therapy

Persistence of triggers

• The incidence of incomplete reversibility of airway obstruction in asthma has never been systematically studied as it is excluded by definition

Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutritional Examination Survey, 1988-1994; Arch Intern Med 2000; 160: 1683-1689.

• Different names : Fixed airway obstruction in asthma(FAOA) Incomplete reversibility of airway obstruction (IRAO).

• Various criteria : Post bronchodilator FEV1 /FVC of less than 70% and/or less than 75% at a minimum of two consecutive annual visits , or FEV1 below the normal range (eg,≤75%) after optimal treatment.

• Fixed obstruction has been reported to occur in 30% of a large population of patients with the diagnosis of asthma†

†Kesten S,RebuckAS. Is the short-term response to inhaled beta-adrenergic agonist sensitive or specific for distinguishing between

asthma and COPD? Chest 1994;105:1042–1045.

• Subjects with fixed airflow obstruction have distinct airway inflammation depending on their history of Asthma or COPD.

• The differential diagnosis between asthma and COPD in patients with fixed airflow obstruction may be important as the natural history(1) as well as the response to treatment(2) are different.

1. Burrows B, Bloom JW, Traver GA, Cline MG. The course and prognosis of different forms of chronic airays obstruction in a sample from the general population. New Engl J Med 1987; 317: 1309-1314.

2. Kerstjens HA, Brand PL, Hughes MD, Robinson NJ, Postoma DS, Sluiter HJ, Bleecker ER, Dekhuijzen PN, de Jong PM, Mengelers HJ et al. A comparison of bronchodilator therapy with or without inhaled corticosteroid therapy for obstructive airways disease: Dutch Chronic No Specific Lung Disease Study Group. N Engl J Med 1992; 327: 1413-1419.

• Asthmatic airway inflammation does not change with the development of fixed airflow obstruction and thus does not become similar to the airway inflammation characteristics of COPD.

M.Fabbri , Micaela Romagnoli, Lorenzo Corbetta , Am J Respir Crit Care Med Vol 167.pp 418-424,2003.

• trade-off• with simplicity and ease of remembrance of the 0.70 fixed cutoff• point could come at the expense of misclassification [13, 23–• 28]. The recommendation of different thresholds for the• definition of airflow obstruction in COPD (0.70 ratio) and• asthma (0.75–0.80 ratio) is even more difficult to justify and has• resulted in ongoing confusion. The higher threshold for• asthma than for COPD has probably been chosen because of• the different distributions of age and the physiological decline• in FEV1/FVC in the two diseases, even though asthma may• also have a late onset.

Eur Respir J 2009; 34: 568–573

Copenhagen City Lung Study found no difference between

groups.

Lung Health Study found a small reduction in some symptoms,

although this did not translate into any improvement in health

status.

ISOLDE study showed fewer exacerbations, a reduced rate of decline in health status, and higher FEV1 values than placebotreatment.

Effect of inhaled and Oral Glucocorticoids on Inflammatory Indices in Asthma and COPD

Vera M. Keatings, Anon Jatakanon, Y. Min Worsdell, & Peter J. Barnes

The inflammatory process in COPD is resistant to the antiinflammatory effect of glucocorticoids.

Am J Respir Crit Care Med 1997;155:542-548

There were some significant differences between the ISOLDE

study and the other three long term studies. The dose of inhaled

corticosteroid was high in the ISOLDE study. Bronchodilator

reversibility was also fairly high, raising the question of whether

the ISOLDE study included subjects with element of asthma.

“any information which adversely and seriously affects an individual's view of his or her future” [13]. Bad news is always, however, in the “eye of the beholder,” such that one cannot estimate the impact of the bad news until one has first determined the recipient's expectations or understanding.

The Oncologist August 2000vol. 5 no. 4 302-311

“It is difficult to change things in India unless the system breaks down completely because in a large democracy it’s only when things reach breaking point that people are willing to change the system.”

DAMAN SINGH“Strictly Personal, Monmohan and Gurusharan”

• American Thoracic• Society [4]. The wide variations over short

periods

Personalized Medicine

Treatment approach based on genetics and biomarkers:

The approach to personalized medicine emphasizes the following:

• Early diagnosis to prevent unnecessary morbidity or mortality associated with the disease.

• Prediction of the severity and prognosis for the individual.• Determination of the optimal treatment approach for the

individual.• Establishment of appropriate monitoring tools to evaluate

therapy.

J Allergy Clin Immunol. 2006;118(3):565-568

GENOTYPE PHENOTYPE BIOMARKER

THE PERSON

“The whole is greater than the sum of its parts."

NICHOLAS A. CHRISTAKISPhysician and Social Scientist, Harvard University; Coauthor, Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives

Man is a social animal

An Indian is a family animal

Inhalation in the elderly-challenges Why is it more difficult to train the elderly than

a child?

Inner SelfEducationEnvironmentBelief

Personality

Inhaler therapy

• Anti-Nature!

• Personal and social inhibition.

• Needs lot of training.

AoRM 2009; 000:(000). Month 2009

Issues of inhaler technique overshadow all other considerations when trying to

achieve satisfactory maintenance inhaler therapy in elderly patients with

Asthma and COPD.

• Actuation and Inhalation are essentially two different tasks.

• We, being highly ritualistic, focus more on the protocol rather than the purpose.

• If somebody else does the actuation, patient is not only relieved but also can concentrate fully on inhalation.

• Co-ordination becomes the caregiver’s job.

Recommended devices in elderly

• BAI• pMDI + large volume spacer• DPI (an option for those who find assembling

pMDI + spacer difficult)• Nebuliser

Prim Care Resp J 2010; 19 (1): 10-20

Assisted administration

The triangle of influences on inhaler-device usage by patients with chronic obstructive pulmonary disease

Caregiver

Eur Respir Rev 2005; 14: 96, 85–88

Inhalation in the elderly-challenges

How many elderly patients do we have ?

What is at stake?

Everything!

Households in the Family

The Gre

at Indian Fa

mily

Households in the Family

Whose interest does it serve?

Patient’s/Your’s/Physician’s

PROF. A.G.GHOSHAL MD,DNB,FCCP, Ex WHO FELLOW, FELLOW ICS

ACKNOWLEDGEMENTSRichard Harrison

Peter J BarnesBimala Ghoshal

agghosal@yahooo.com