Day 2 :
- Track-4: COPD and its Co-Morbidities
Track-8: Developments in COPD Management
University of Newcastle, Australia
Maastricht UMC+, Netherlands
Joaquim Gea obtained his MD (1979) and PhD (1989) degrees at the Universitat de Barcelona, being specialist in both Internal Medicine (1981) and Respiratory Medicine (1985). He is the Head of the Respiratory Department at Hospital del Mar, Full Professor and Dean of the School of Medicine at Universitat Pompeu Fabra and Deputy Director at the Spanish Network of Excellence for Research in Respiratory Diseases (CIBERES). He has been funded by 65 competitive grants, including 4 projects funded by the European Commission, and published more than 260 Original Articles and Reviews in peer reviewed journals as well as 50 book chapters.
Nutritional abnormalities are often associated with Chronic Obstructive Pulmonary Disease (COPD). Their early detection is important, since they determine the patient's prognosis independently of the degree of lung function impairment. In addition, nutritional abnormalities are involved in muscle dysfunction, which in turn leads to exercise limitation, loss of quality of life and increased mortality. However, the presence/absence of malnutrition is a factor that has not been included in the majority of clinical guidelines. The diagnostic techniques include both anthropometry and measurement of body composition (mainly through bioelectrical impedance). The most commonly used anthropometric variables are body mass index (BMI) and the percentage of ideal body weight, while fat-free mass index (FFMI) is the most commonly used impedance variable. The causes of malnutrition associated with COPD include smoking, systemic inflammation, imbalance between nutrient intakes and energy consumption, impairment in respiratory gas exchange and the effects of anabolic hormones, effects of some drugs, decreased physical activity and comorbidities. All these causes lead mainly to an imbalance between protein synthesis and destruction and a predominance of bone resorption, with loss of muscle, fat and bone mass. The treatment includes an improvement in lifestyle (avoid tobacco smoking, better quality in nutrient intake, increase in physical activity, exercise training) and, if necessary, the use of nutritional support (enteral or even parenteral) and anabolic agents (eg, selective androgen receptor modulators [SARM] or secretagogues of the growth hormone). These drugs seem to be more effective when associated with training.
Mayo Clinic College of Medicine
Time : 10:25 - 10:50
Prof. Ping Yang has completed her MD from Beijing Medical College in China and PhD at Johns Hopkins University in USA. She has been leading a comprehesive lung cancer research program at Mayo Clinic since 1997, emphasizing patient-centered outcome research with COPD as one of the key interaested areas. She has published more than 200 peer-reviewed papers and has been serving as an editorial board member of Jounal of Clinical Oncology and Associate Editir of Journal of Thoracic Oncology.
COPD is present in 40-60% of LC patients; some existed long before LC diagnosis and others were identified at the time of LC diagnosis. Our clinical research team has been evaluating the impact of different diagnostic time (prior vs. concurrent), severity of COPD, and a subgroup of CT-defined emphysema on long-term survival of patients with early stage non-small cell lung cancer (NSCLC). Two patient cohorts include ~1400 NSCLC with known COPD status and ~1100 with known emphysema status. COPD was defined according to pulmonary function tests (post-bronchodilator FEV1/FVC<0.70) or recorded medical diagnosis; severity was grouped by GOLD criteria (Global Initiative for Chronic Obstructive Lung Disease). Emphysema was based on standard-dose CT scan; percentage quantification was determined through direct inspection and categorized into <5%, 6-24% and 25-60%. Five key findings are summarized as follows: (1) Patients with a prior COPD had a significantly higher proportion of former smokers and moderate airflow obstruction than those with concurrent COPD. (2) Worse survival was significantly associated with prior COPD and moderate to severe airflow obstruction regardless of COPD diagnosis time. (3) In surgically-treated patients, the overall postoperative complications were higher in patients with a greater emphysema score. (4) Increasing emphysema score was significantly associated with worse survival. (5) More specific to resected LC in the predominant emphysematous region, patients with >6% emphysema experienced a mild decrease in FEV1 and an increase in FEV1/FVC. We conclude that COPD in general and emphysema in particular should be taken into careful consideration in LC treatment
Maastricht University, Netherlands
Time : 11:10 - 11:35
Geertjan Wesseling has studied Biology and Medicine at the Free University of Amsterdam, Netherland. He has completed his Training in Respiratory Medicine in 1991 and obtained his PhD in 1993. He is a Professor of Respiratory Medicine in Maastricht and coordinates the International Master in Medicine of Maastricht University. He is a former President of the Dutch Pulmonology Society
Comorbidities are very common in COPD. Of patients referred for pulmonary rehabilitation more than 50% report at least one chronic comorbid disorder that is of importance for the rehabilitation and its outcomes. Also, comorbidities have a huge impact on the disease burden, on the risk of hospitalization and on mortality. Recently it was reported that comorbidities come in clusters of which cardiovascular and psychological comorbidities are the most frequently seen. It appears that these comorbidities are in part related to systemic inflammation. Other mechanisms may be relevant as well. Several studies have demonstrated effects of comorbidities on outcomes of pulmonary rehabilitation. These may implicate differentiation of rehabilitation programs according to clusters of comorbidities.
National Institute of Diseases of Chest & Hospital
Time : 11:35 - 12:40
Md Rashidul Hassan is the Director cum Professor at National Institute of Diseases of the Chest & Hospital, Dhaka. He has completed his MD Respiratory Medicine from Dhaka University in the year 1995. He is currently a Professor at the Department of Respiratory Medicine, National Institute of Diseases of the Chest and Hospital [NIDCH], Dhaka, Bangladesh. He is also a Founding President of Bangladesh Lung Foundation and Founding Vice President of Evidence Based Clinical Practice Society of Bangladesh. He has published 63 papers in reputed journals and has been serving as Editorial Board Member of Journal of Asia Pacific Society of Respirology (APSR).
Background: Understanding of basic concept of COPD is an important issue for the practicing physicians. Seamless management of COPD needs to understand basic concept of asthma. Use of simile is the best way to understand any basic concepts. A positive role of physicians after proper understanding of basic concept is essential for successful management of COPD. To achieve this goal in Bangladesh, we developed a module COPD presentations and carried out several seminars entitled “COPD: BASIC CONCEPT AND MANANAGEMENT” in different regions of the country. The outcome is encouraging and we assume the module can be used for general physicians as an effective instrument in switching to standard treatment of COPD from conventional treatment. Objectives: Similarity between water movement air movement and pathophysiology of COPD helps in understanding the basic mechanism of COPD and thereby physicians can be easily motivated to switch over to standard treatment of COPD. Methods: An audio-visual module comprising of an interactive lecture were prepared and presented in front of the primary care physicians and respiratory specialists. For this a nation-wide campaign will be out entitled “COPD: BASIC CONCEPT AND MANANAGEMENT” in different regions of Bangladesh including all medical colleges. Atleast two pulmonologists of Bangladesh presented the papers and answered the different questions of the audiences. Discussion: Water movement, like conduction, convection and Diffusion can be easily described and resulting in difficulty in breathing. After water movement simile it is described clearly irritation of smoke and recurrent infection is the main cause of sputum production and exacerbations. After an episode of COPD exacerbation small airway and alveolar destruction leads to different types of emphysema formations and mismatch of Ventilation Perfusion ratio and right to left shunt. This V/Q mismatch and shunted blood leads to progressive exertional dyspnea, Hypoxemia, Hypoventilation, Polycythemia or anemia and ultimately leads to Respiratory Failure. Conclusions: What we don’t see through our necked eyes (pathophysiology of COPD) may be understandable by drawing simile with an event, which we can see with our eyes. The lesson can be remembered like stories by anybody even a layman. This may help to facilitate patient education programs. Recommendations: We may carry this mode pf presentation to popularize COPD management and Update knowledge of physicians. 1.Attract physicians “towards Basic Cocept of COPD” by using such simple simile like water movement 2.Integrate physicians with appropriate knowledge of COPD Management 3.Deal with physicians to take care patients’ value regarding COPD management.
Title: Effects of ICS in combination with LABA on improving symptoms and lung function in COPD with airway eosinophilia
Time : 12:40 - 13:05
Hiroaki Kume obtained his MD from Toyama Medical and Pharmaceutical University in 1982. He has completed his PhD in Department of Medicine (II), Nagoya University School of Medicine in 1990, and postdoctoral studies from School of Veterinary Medicine, University of Pennsylvania (Dr. Michael I. Kotlikoff’s Lab). Currently, he works at Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine and Department of Respiratory Medicine, Rinku General Medical Center, Izumisano City, Osaka 598-8577, Japan, and focuses on investigating the characteristics of COPD with the goal of rational therapy for COPD
Rationale: Eosinophil inflammation in the airways is observed in some patients with chronic obstructive pulmonary disease (COPD) independent of asthma. However, little is known about not only mechanisms but also therapy in this clinical phenotype of COPD. This clinical study was designed to determine whether inhaled glucocorticosteroids (ICS) are useful for airway eosinophilia in COPD. Methods: Once-daily inhalation of indacaterol (LABA) was firstly administrated to the patient with COPD. After symptoms were stable, sputum examination was done. When a percentage of eosinophil in the induction sputum is >3%, once-daily inhalation of ciclesonide (ICS) was administered. Results: 20 patients with COPD (GOLD 2-3) with airway eosinophilia were enrolled. After administration of indacaterol, COPD Assessment Test (CAT) score was decreased from 15.1 to 7.9 (P<0.05), and frequency of SABA on demand for symptom relief was also decreased from 1.6 to 0.8 puffs/week (P<0.05). In lung function test, forced expiratory volume in 1 sec (FEV1) and inspiratory capacity (IC) were increased by 210.0 (P<0.05) and 311.5 mL (P<0.01), respectively. After addition to ciclesonide, values of CAT score and frequency of SABA were markedly decreased to 4.9 points and 0.3 puffs/week, respectively (each P<0.05 vs LABA). Moreover, FEV1 and IC were further increased by 147.0 and 227.6 mL, respectively (each P<0.05 vs LABA). Conclusions: Not only LABA but also ICS is needed to improve lung function and to achieve better maintenance in COPD with airway eosinophilia. Ciclesonide is effective for these cases. Eosinophil infiltration to airways may be indication of ICS therapy for COPD.
Linnaeus University Campus
Title: Chronic obstructive pulmonary disease: A study of the relationship between patients’ feeling of guilt due to their belief of the disease being self inflicted
Time : 13:50 - 14:15
Gunilla Lindqvist is a Registered Nurse (RN), Master´s degree in Public Health, Senior Lecturer, Doctor of Philosophy (PhD) and Post doctor within the subject of Health and Caring Science. Gunilla is working as a Senior Lecturer at School of Health and Caring Sciences, Linnaeus University Campus Kalmar and Växjö and has now a postdoctoral position at Linnaeus University. Gunilla Lindquist’s research focuses on Chronic Obstructive Pulmonary Disease, the sufferer themselves and their spouses. Gunilla works in a research project focusing on innovative solutions to meet future healthcare needs and preferences of older people and their carers.
Chronic obstructive pulmonary disease (COPD) is an increasing health problem that affects about 600 million people globally, and it is expected to be the third most common cause of death worldwide by 2020. COPD is a chronic long-term condition that is irrevocable. Cigarette smoking is the most commonly encountered risk factor for COPD, and it has also been shown that passive smoking impairs lung function. When the disease progresses, not only is the lung fiction impaired, but there are also other consequences as physical, psychological and social. Aim The aim of the study was to generate a theory, grounded in empirical data, to reveal the main concerns of people who suffer from COPD and how they handle everyday life. Method The constant comparative method of grounded theory, developed by Glaser and Strauss (1967), was used. Data was collected by interviewing 23 people with COPD all having different grades of the disease, from mild to severe. Findings A substantive theory was generated showing that the main concern for people suffering from COPD was feelings of guilt due to self-inflicted disease associated with smoking habits. This includes feelings of living in the shadow of death. This core category was linked to five categories termed making sense of existence, adjusting to bodily restrictions, surrendering to faith, making excuses for the smoking related cause, and creating compliance with daily medication. These categories form a pattern of behavior that explains how feelings of guilt were handled by people living with COPD.
Dr. Qian Zeng made Self-research on anti-inflammatory therapy for chronic inflammatory diseases from 2001 to 2011, and Working as a general practitioner at Medi7 Clinic Bentleigh, Melbourne and continuing research on anti- inflammatory therapy from 2012 until now. His main Interest is to combine Modern Western Medicine with Traditional Chinese Medicine to develop a new anti-inflammatory therapy for treating chronic inflammatory diseases.
COPD is a chronic progressive inflammatory lung disease. It is caused by various stimuli, like smoking, air pollution, exposing to noxious chemicals and recurrent infections. All these stimuli can cause small airway and lung tissue injury, which induces an inflammatory reaction. Prolonged inflammation further damages small airway and lung tissue, subsequently the inflammation becomes self-perpetuating, i.e. the inflammation will last for ever even when the initial stimuli are eliminated. The activated neutrophil and alveolar macrophage produce neutrophil elastase and macrophage elastase, these two proteolytic enzymes cause disruption of the wall of alveoli and fusion of alveoli, resulting in decreased gas-exchanging surface. Activated inflammatory cells also produce various inflammatory factors, which stimulate secretion of mucus and cause fibrosis and thickening of the wall of small airway, all these increase the obstruction of small airway, reduce the air flow. The ongoing inflammation in small airway and lung tissue will continue to cause tissue damage, as a result, the lung function in COPD patients will progressively deteriorate. The key in treating COPD is to treat the inflammation. Current treatment of COPD are LAMA, LABA and ICS. LAMA and LABA only treat the symptoms of COPD by dilating the small airway, they do not target the underlying mechanism of COPD (the inflammation). ICS can only temporarily supress the inflammation in COPD, cannot really terminate the inflammatory reaction and therefore it cannot stop the progression of COPD, though it is the mainstay of treatment of COPD. The inflammation in COPD is partially resistant to steroid. The underlying mechanism sustaining the chronic inflammation in COPD is due to a bidirectional intercellular reactions between T cell and alveolar macrophage and/or neutrophil. The activated T cell produces cytokines, which activate alveolar macrophage and/or neutrophil, in turn, activated alveolar macrophage and neutrophil produce interleukins XII and other cytokines to activate T cell. Once this vicious intercellular reaction established, it cannot be disrupted and will last for ever. This is the common mechanism of all self-perpetuating chronic inflammation, no matter what the initial stimuli are or in what tissue or organ the inflammatory reaction occurs. Steroid resistant is a big issue in treating COPD and other chronic inflammatory lung diseases, like asthma, pulmonary fibrosis. In order to effectively treat COPD, we must find new anti-inflammatory therapies or developing new anti-inflammatory drugs.
Geertjan Wesseling (1956) studied biology and medicine at the Free University of Amsterdam. He completed his training in Respiratory Medicine in 1991 and obtained his PhD in 1993. He is a professor of Respiratory Medicine in Maastricht and coordinates the international master in medicine of Maastricht University. He is a former president of the Dutch Pulmonology Society
Chronic Obstructive Pulmonary Disease causes significant morbidity and mortality worldwide. Most patients can be treated in primary care. However, even in patients with relatively mild airflow obstruction referral to a specialist may lead to important findings, both related to the COPD and to comorbidities. Several classifications and gradings have been proposed throughout the years that help in categorizing patients, yet not all have direct consequences for the management, that typically includes lifestyle changes, of which smoking cessation and increased physical activity or even rehabilitation are paramount, and pharmacotherapy. Inhaled medication is aimed at improving expiratory flow, reducing hyperinflation and inflammation, to slow-down disease progression and improve quality of life and prognosis. Longacting bronchodilators have clinically significant effects and are widely used, also in mild-to-moderate disease. In recent years the Astma COPD Overlap Syndrome has been proposed, which is a misnomer and often an excuse to skip an adequate diagnostic process and prescribe triple-therapy in patients who would do well with only one or two different drugs. Unfortunately, the majority of COPD patients are on inhaled steroids, but effects are small, often not clinically relevant and side-effects such as an increased risk of pneumonia should warrant clinicians to be more prudent in prescribing those. Selfmanagement is considered an important component of management strategies, even if effects on various outcomes are limited. Repeated lung function measurements are often performed both in primary care and in the hospital.with limited if any effects on management. Taken together, appropriate COPD management is not only about what we should do but certainly also about what we shouldn’t.
Chronic obstructive pulmonary disease (COPD) is a complex multi-component condition whose clinical presentation is often complicated by co-morbidities and extrapulmonary clinical features. This presentation will highlight three of them. Affecting between 17% and 78% of people is gastro-oesophageal reflux disease (GORD). Due to the possibility of pulmonary microaspiration GORD may influence lung disease severity and is a predictor of acute exacerbations. Pain is common in people with COPD, affecting 66% of individuals with moderate to very severe disease. Higher pain intensity is associated with increased dyspnea, fatigue, poorer quality of life, lower levels of physical activity and a greater number of comorbidities. Pain imposes limitations on exercise behaviour and participation in pulmonary rehabilitation. The common locations of pain are the upper and lower back and lower limbs. In COPD, postural alterations may be influenced by musculoskeletal comorbidities including osteoarthritis and osteoporosis. Common postural abnormalities include alterations in the degree of cervical lordosis and thoracic kyphosis, and altered scapula position. Postural alterations are associated with reduced pulmonary function and may contribute to exercise limitations and increased functional impairment.