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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 1
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Where There’s Smoke…There’s Obstruction
Stephen G. Basheda, D.O., F.C.C.P.
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Disclosures• Dr. Basheda is an independent contractor for AstraZeneca
Pharmaceuticals, LP and GlaxoSmithKline and on the speaker’s bureau for Boehringer-Ingelheim and AstraZeneca Pharmaceuticals, LP.
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Outline•Asthma update
•COPD update
•Smoking alternatives
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 2
#POMAD8#ChoosePOMA
Airway Obstruction
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Airway Obstruction - Spirometry
• FEV1-Forced Expiratory Volume at 1 second
• FVC-Forced Vital Capacity
• FEV1/FVC < 0.7
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 3
#POMAD8#ChoosePOMA
#POMAD8#ChoosePOMA
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Asthma-Definition
•Intermittent•Persistent
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 4
#POMAD8#ChoosePOMA
Cough Asthma
•Triggers: talk/laughter, cold air, exercise, deep breath
•Spirometry-Normal
•Chest exam-No wheezing
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Cough Asthma-Treatment
•Recognition
•Asthma medications (bronchodilators/steroids)
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Asthma-Treatment Options
•Anti-inflammatory therapy-inhaled steroids (ICS)
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 5
#POMAD8#ChoosePOMA
Asthma-Treatment (continued)
LABA/ICS combination
LABA=Long Acting Bronchodilators
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Asthma Treatment-Monoclonal Antibodies
•Omalizumab (Xolair) – anti-IgE
•Mepolizumab (Nucala) -anti-Interleukin-5 (IL-5/eosinophils)
•Benralizumab (Fasenra)
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 6
#POMAD8#ChoosePOMA
Asthma Management
•History and physical
•Asthma Control Test (ACT)
•Spirometry
•Nitric oxide
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Fe No (Fractional Exhaled Nitric Oxide)
• Increased with eosinophilic airway inflammation
•50 parts/billion (ppb) – adults
•Monitoring (20% change/change 10 ppb)
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 7
#POMAD8#ChoosePOMA
Tobacco Induced Chronic Obstructive Pulmonary Disease (COPD)
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COPD Management
•Smoking cessation
•Medications
•Pulmonary rehabilitation
•Interventional therapy
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 8
#POMAD8#ChoosePOMA
COPD Management – Alphabet Soup
LABA
LAMA
ICS
SABA
SAMA
LABA/LAMA
LABA/ICS
SABA/SAMA
LABA/LAMA/ICS
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COPD - Dual Bronchodilator Therapy
LABA=long acting bronchodilator agent
LAMA=long acting muscarinic agent
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 9
#POMAD8#ChoosePOMA
COPD Therapy – LABA/ICS
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COPD Therapy-Triple Therapy
• LABA/LAMA/ICS
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Phosphodiesterase-4-Inhibitor
•Rofumilast (Daliresp)
•Severe obstruction
•Exacerbations
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 10
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COPD-Interventional Therapy
•Lung Volume Reduction Surgery (LVRS)
•Bullectomy
•Lung transplantation
•Bronchoscopic Intervention (valves/coils)
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COPD-Treatment
•Oxygen (>15 hours/day)
•Nocturnal ventilation (hypercapneicrespiratory failure)
•Hospice care
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COPD Treatment-Delivery
•Dry powder inhalers
•Propellant inhalers (+spacer)/soft mist inhaler
•Nebulizer
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 11
#POMAD8#ChoosePOMA
Smoking Alternatives
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Smoking Alternatives
•Vaping/electronic cigarettes
•Heated liquid→vapor
•Flavoring (8000) +/- nicotine
•1% “toxic chemicals” of cigarette smoke
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 12
#POMAD8#ChoosePOMA
E-Cigarettes-Usage
•Smoking cessation
•Recreational use
•“Healthier” than cigarettes
•Circumvent “smoke-free” laws
•Cost
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E-Cigarettes-Problems
•Gateway to tobacco smoking
•Heavy metals/”toxicants”
•Alternative use (marijuana/drugs)
•Persistent cardiovascular risks?
•Battery explosion
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 13
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E-Cigarettes-Benefits
•Decreased carcinogens
•? Improving lung function
•Decreased respiratory symptoms
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Lung Cancer Screening-Low Dose Chest CT Scan
•Age 55→74-80
•Current smokers/quit within 15 years
• 30 pack-year smoking history
• ?length/frequency of screening
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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 14
#POMAD8#ChoosePOMA
Lung Cancer Screening-Chest CT
•Suggests decrease mortality
•Detection at earlier stage
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Marijuana and Lung Health• Toxins/carcinogens (similar to tobacco)
• ?second-hand exposure risks
• Asthma/chronic bronchitis
• Blebs/bullae formation
• Immunosuppression (Aspergillus)
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