copd fixing the fixables in 2003慢性阻塞性肺疾病的fixables固定2003课件

COPD: Reversing the Reversible in 2014 Donald M. Pell M. D., FCCP Introduction nPrevalence 5.9% of U.S. population or about 24,000,000 adults (ATS Gold Paper 2004) nIn 2000 there were 122,000 deaths (CDC data) nFor the first time more women than men n2nd to heart disease as a cause of disability nAnnual cost 2002 est. $32.1 billion n70% of the patients were less than 65 Introduction nBy 2005, there were 126,000 deaths and the number of male deaths had increased by 8%. nThe number of female deaths had increased by 11% (CDC data) Spectrum of COPD COPD 80% PURE EMPHYSEMA 10% CHRONIC BRONCHITIS 10% REVERSIBLE COMPONENTS of COPD nSPUTUM nSPASM nSWELLING Differentiating COPD and Asthma nNo diagnostic test for either is conclusive nFrequent coexistence of both problems n10% overlap Autonomic Effects on Respiratory Tract DMP-2000 Short Acting Beta 2 Agonist BRONCHODILATOR Medication Dose Duration Isuprel Isoproterenol 130mcg/p 2pq3-4h .5-2h Bronkosol Isoetharine 3-40mcg/p 2pq4h 2-4h Alupent Metaproterenol 65mcg/p 2pq4-6h 4-6h Brethine Terbutaline 200mcg/p 2pq4-6h 4-6h Proventil Albuterol 90mcg/p 2pq4-6h 4-6h Maxair Pirbuterol 200mcg/p 2pq4-6h 4-6h Tornolate Bitolterol 370mcg/p 2pq4-6h 5-8h Lancet, Feb 2003 Long Acting Beta 2 Agonist BRONCHODILATOR Medication Dose Duration Serevent Diskus Inhale 1 BID 12h Foradil (Fomoterol) Inhale 1 BID 12h Advair 50/500 Inhale 1 BID 12h Symbicort160/4.5 Inhale 2 BID 12h Theophylline nMechanisms of effects nImproved efficiency of the diaphragm nAnti-inflammatory nBronchodilator nRespiratory center stimulant nNarrow therapeutic window nFrequent drug interactions FEV1 and Aging nHealthy lungs lose about 20 cc year after age 25 nCOPD patients lose about 80 cc year Summary of New Therapies nNon pharmaceutical supplements (Boswellia) nSupplemental Oxygen (Oximizer) nCOPD rehab nLeukotriene modifiers nCilomilast nTioproprium Bromide nForadil nStatins nACE Inhibitors Leukotriene Modifiers and COPD nReports at international and national meetings nProposed mechanism nLocal experience 18 patients with severe COPD n2 week trial LM nAverage response to SABA before trial 9% nAfter trial 40% Statins Vast improvement in lung transplant survival 91% vs 54% Johnson Am J Crit Care Med (167), 1271-1278 2003 Statins Marked reduction in number of exacerbations by 2/3 ACE Inhibitors Additional improvements when added to statins Proposed Pathophysiology Barnes, NEJM, 2000 Barnes, NEJM, 2000 Barnes, NEJM, 2000 Mancini, JACC, vol 27, 2006 Effects of statins on COPD and Influenza mortality n150,000 patients, 90 days of statins minimum nLow dose group 4 mg/day nUsual dose 10 mg/day n2 year USA HMO study Floyd& Foster, Chest (131), 1006-1012 Effects of statins on COPD and Influenza mortality nDeaths by disease category Low Moderate No Statin Pneumonia 11 18 94 COPD 8 5 84 Influenza 8 16 80 All statin users RR.23 for COPD No COPD, moderate dose RR .54 Floyd & Foster, Chest (131), 1006-1012 Effects of statins nHospitalized patient deaths due to influenza/pneumonia nPneumonia All statins 73, Low dose 89, High dose 49 COPD All statins 29, Low dose 58, High dose 17 Floyd & Foster, Chest (131), 1006-1012 Protection from loss of lung function in COPD nDecrease in FEV1 85 cc/ year in COPD nDecrease in FEV1 5 cc/ year in statin group with or without smoking cessation Keddissi, Chest (132) 1764-1771 Effect of statin on COPD Mortality nNorwegian study n854 patients mean age 70.8 nFollow up 1.9 years n51.5% females Soyseth European Resp J (29) 279-283 2007 Effects of statin on COPD Mortality n333 died all with severe COPD nStatin group 110 died nNon-statin group 191 died nHazard reduction statin vs nonstatin 57% nStatins alone 69% nStatins plus ICS 39% Soyseth European Resp J (29) 279-283 2007 Effect of statins on COPD deaths nJapanese study nAll cause mortality results 65 years and older COPD deaths 152/100,000 in non statin group 8/100,000 in statin group Tohoku Experimental Med (212) 265- 273 2007 Effects of statins nCanadian study nAll patients over 65 nHigh risk had been revascularized nLow risk had no MI in prior 5 years and no NSAIDs nMust have had 3 Rx in prior year for statin & 1 Rx in prior 60 days Mancini J Amer Col of Cardiology (47) 12 2006 Effects of statins nCOPD hospitalizations decreased 12-21% in both groups nDeath from COPD decreased 38% with satins nDeath or MI decreased 47% in high risk group Mancini J Amer Col of Cardiology (47) 12 2006 Effects of statins nVA study from1998-2004 n483,733 patients 33% on statins n7,280 Lung cancer nRisk of lung cancer decreased 55% in statin group nRR .45 Khurana Chest (131) 1282-1288 2007 Decreased Exacerbations and Intubations in patients on statins nNew Jersey community hospital 185 COPD pts n90 on statins 95 not on statins nAverage age 70, Duration 1 year nAverage FEV1 38% predicted nExacerbations reduced 90% in statin group nIntubations reduced 90% in statin group Blamoun International J Clin Pract (62) 1373-78 2008 Safety of statins nStudy from 1985-2006 n1/10,000 risk of myopathy nRisk increases with fibrates nOther drug interactions nHypothyroid nDecreased GFR nOver age 80 Lancet June 2007 SUMMARY nSputum, Spasm