epoc 11 guías y 11 mitos

Oviedo, 11 – 11 -11 , 11:11 h. Dr. Josep MoreraOviedo, 11 – 11 -11 , 11:11 h. Dr. Josep Morera

Memorial Dr. J.M. CosíoMemorial Dr. J.M. Cosío

EPOC: 11 Guías y 11 MitosEPOC: 11 Guías y 11 Mitos

Murray JL, et al. Lancet 1997; 349: 1498–1504

PROFECÍA

ÍndiceÍndice

1) Las 11 Guías

2) Los 11 Mitos

3) Conclusiones

2. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, November 1986. Am Rev Respir Dis. 1987 Jul;136(1):225-44.

3. Siafakas NM, Vermeire P, Pride NB, Paoletti P, Gibson J, Howard P, Yernault JC, Decramer M, Higenbottam T, Postma DS, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European Respiratory Society Task Force. Eur Respir J. 1995 Aug;8(8):1398-420.

4. Montemayor T, Alfajeme I, Escudero C, Morera J, Sánchez Agudo L. [Guidelines on the diagnosis and treatment of chronic obstructive lung disease. The SEPAR

Working Group. The Spanish Society of Pneumology and Thoracic Surgery]. Arch Bronconeumol. 1996 Jun-Jul; 32 (6): 285-301.

5. BTS guidelines for the management of chronic obstructive pulmonary disease. The COPD Guidelines Group of the Standards of Care Committee of the BTS. Thorax. 1997 Dec;52 Suppl 5:S1-28.

Las 11 GuíasLas 11 Guías

1. Terminology, Definitions, and Classification of Chronic Pulmonary Emphysema and Related Conditions: A Report of the Conclusions of a Ciba Guest Symposium Thorax 1959;14:286-299)

6. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS; GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic

obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med. 2001 Apr;163(5):1256-76.

7. Barberà JA, Peces-Barba G, Agustí AG, Izquierdo JL, Monsó E, Montemayor T, Viejo JL; Sociedad Española de Neumología y Cirugía Torácica (SEPAR). [Clinical

guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease]. Arch Bronconeumol. 2001 Jun;37(6):297-316.

8. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J.

2004 Jun;23(6):932-46.

9. Halpin D. NICE guidance for COPD. Thorax. 2004 Mar;59(3):181-2.

10. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, Fukuchi Y, Jenkins C, Rodriguez-Roisin R, van Weel C, Zielinski J; Global Initiative for Chronic

Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007 Sep 15;176(6):532-55.


11. Peces-Barba G, Barberà JA, Agustí A, Casanova C, Casas A, Izquierdo JL, Jardim J, López Varela V, Monsó E, Montemayor T, Viejo JL. [Diagnosis and management of chronic obstructive pulmonary disease: joint guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Latin American Thoracic Society (ALAT)]. Arch Bronconeumol. 2008 May;44(5):271-81.

Grupo de Trabajo de GESEPOC. [Moving towards a new focus on COPD. The Spanish COPD Guidelines (GESEPOC)]. Arch Bronconeumol. 2011 Aug;47(8):379-81.

Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, Marciniuk DD, Denberg T, Schünemann H, Wedzicha W, MacDonald R, Shekelle P; American College of

Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary

disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European

Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.


Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease involving the airways or pulmonary parenchyma (or both) that results in airflow obstruction. Manifestations of COPD range from dyspnea, poor exercise tolerance, chronic cough with or without sputum production, and wheezing to respiratory failure or cor pulmonale. Exacerbations of symptoms and concomitant chronic diseases may contribute to the severity of COPD in individual patients. A diagnosis of COPD is confirmed when a patient who has symptoms of COPD is found to have airflow obstruction (generally defined as a postbronchodilator FEV1–FVC ratio less than 0.70, but taking into account that age-associated decreases in FEV1–FVC ratio may lead to overdiagnosis in elderly persons) in the absence of an alternative explanation for the symptoms (for example, left ventricular failure or deconditioning) or the airflow obstruction (for example, asthma). Clinicians should be careful to avoid attributing symptoms to COPD when common comorbid conditions, such as heart failure, are associated with the same symptoms…


Ann Intern Med. 2011;155:179-191.

Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease involving the airways or pulmonary parenchyma (or both) that results in airflow obstruction. Manifestations of COPD range from dyspnea, poor exercise tolerance, chronic cough with or without sputum production, and wheezing to respiratory failure or cor pulmonale. Exacerbations of symptoms and concomitant chronic diseases may contribute to the severity of COPD in individual patients. A diagnosis of COPD is confirmed when a patient who has symptoms of COPD is found to have airflow obstruction (generally defined as a postbronchodilator FEV1–FVC ratio less than 0.70, but taking into account that age-associated decreases in FEV1–FVC ratio may lead to overdiagnosis in elderly persons) in the absence of an alternative explanation for the symptoms (for example, left ventricular failure or deconditioning) or the airflow obstruction (for example, asthma). Clinicians should be careful to avoid attributing symptoms to COPD when common comorbid conditions, such as heart failure, are associated with the same symptoms…

449 palabras antes de nombrar

tabaco


Ann Intern Med. 2011;155:179-191.

No menciona tabaquismo en definición.

No menciona que el efecto del tabaco es dosis/efecto.

No se menciona la palabra “Smoke” hasta después de 688 palabras y 2 tablas, y 688 palabras más hasta repetirla.

No definen si en ensayos clínicos deben excluirse los no fumadores / ex.

Clasificación de severidad confusa / discutible


GOLD’2001

• Host Factors– Genes– Airway Hyperresponsiveness– Lung Growth

• Exposures– Tobacco Smoke– Occupational Dust and Chemicals– Outdoor and Indoor Air Pollution– Infections– Socioeconomic Status

RISK FACTORS


ÍndiceÍndice

1) Las 11 Guías

2) Los 11 Mitos

3) Conclusiones

Filosofía de la Ciencia: Método inductivo Vs método Refutacionista

Epidemiology: an introduction. Kenneth J. Rothman.KJ Rothman - Oxford University Press

What is Causation?. Cap. 2

EXCESIVA INFLUENCIA DE LA FILOSOFIA DE LA CIENCIA

Los 11 MitosLos 11 Mitos

La navaja de Occam (navaja de Ockham o principio de economía o de parsimonia) hace referencia a un tipo de razonamiento basado en una premisa muy simple: en igualdad de condiciones la solución más sencilla es probablemente la correcta. El postulado es entia non sunt multiplicanda praeter necessitatem, o «no ha de presumirse la existencia de más cosas que las absolutamente necesarias».

VS POSITIVISTAS / NOMINALISTES


1. Human experiments

2. Strength of association

3. Consistency of association

4. Temporal relationship

5. Dose-response gradient

6. Biological plausibility

7. Epidemiological plausibility

8. Specificity

9. Analogy

Coultas D.B & Samet J.M. Cigarrette Smoking. Ch 7 de Clinical epidemiology of COPD. M. Decker, N.Y. 1989, pp 109-138.

PRINCIPIS DE HILL


Martin J. Tobin. Chest. 2008 May;

133(5):1071-4; discussion 1074-7.


Basado en J. G. Scadding.Principles of definition in medicione. Lancet, 1959; 1: 323-325 .

Meaning of diagnostic terms in bronchopulmonary disease. BMJ, 1963; 2: 1425-1430.The semantics of medical diagnosis. Niomed. Comput, 1972; 3: 83-90.

Helath and disease: what can medicine do for philosophy?. J. Med. Ethics, 1988; 14: 118-124.Definition on asthma. In: Bronchial asthma, mechanisms and therapeutics, 3erd ed. Boston: Litle Brown; 1993. p.1-13.

Descripción Clínica1

Lesión AnatómicaCaracterística2

Desorden FuncionalCaracterístico3

Causa - Etiología4

SÍNDROME

ENFERMEDAD

DEFINICIÓN Y CATEGORIZACIÓN CLÍNICA


1. Miravitlles M, Morera J. It's time for an aetiology-based definition of chronic obstructive pulmonary disease. Respirology. 2007 May;12(3):317-9.

2. Morera J, Miravitlles M. [Chronic obstructive pulmonary disease: disease or Zugzwang's syndrome?] Med Clin (Barc). 2008 May 10;130(17):655-6.

3. Snider GL. Nosology for our day: its application to chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2003 Mar 1;167(5):678-83.

EPOC: NOSOLOGÍA


R. Pellegrino, V. Brusasco, G. Viegi, R.O. Crapo, F. Burgos, R. Casaburie, A. Coates, C.P.M. van der Grinten, P. Gustafsson, J. Hankinson, R. Jensen, D.C. Johnson, N. MacIntyreee, R. McKay***, M.R. Miller, D. Navajas, O.F. Pedersen

and J. Wanger.



NECESIDAD ÚNICO CRITERIO

Can Global Initiative for Chronic Obstructive Lung Disease Stage 0 Provide Prognostic Information on Long-term Mortality in Men?

Stavem K, et al. Chest, 2006; 130: 318-25


¿Y LOS SÍNTOMAS?

BODE: Celli BR, Cote CG, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004 Mar 4;350(10):1005-12.

ADO: Puhan MA, Garcia-Aymerich J, et al. Expansion of the prognostic assessment of patients with chronic obstructive

pulmonary disease: the updated BODE index and the ADO index. Lancet. 2009 Aug 29;374(9691):704-11.

DOSE: Jones RC, Donaldson GC, et al.. Derivation and Validation of a Composite Index of Severity in Chronic Obstructive Pulmonary Disease - The DOSE Index. Am J Respir Crit Care Med. 2009 Sep 24.

http://www.goldcopd.com.


Asma Insuficiencia cardíaca Bronquiectasias Tuberculosis Bronquiolitis obliterante Panbronquiolitis difusa

GOLD – DIAGNÓSTICO DIFERENCIAL

Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Update 2003 (GOLD). http://www.goldcopd.com.


¿Y LOS SÍNTOMAS?

200-500 Causas ?!200-500 Causas ?!


CAUSAS EPOC-SÍNDROME

Am J Respir Crit Care Med. 2009 Aug 1;180(3):257-64.



Chest. 2004 Aug;126(2):622-9.


Respiration 2005;72:221

Clinical Bronchiolitis Obliterans in Workers at a Microwave-Popcorn Plant

Kreiss K, et al. NEJM, 2002; 347: 330-338

100 Volatile Organic Compounds

Diacetyl (2,3-butanedione)

100 Volatile Organic Compounds

Diacetyl (2,3-butanedione)


Does Distinction Between Asthma

and COPD Matter?

Does Distinction Between Asthma

and COPD Matter?

Kraft M. AJRCCM, 2006; 174: 238-244.


… Potentially, the common mechanism by which major risk factors such as smoking, hyperlipidaemia, obesity, and

hypertension lead to chronic disease is systemic inflammation…

… Potentially, the common mechanism by which major risk factors such as smoking, hyperlipidaemia, obesity, and

hypertension lead to chronic disease is systemic inflammation…

CONFUSIÓN

Lancet. 2007 Sep 1;370(9589):797-9.


Hernia inguinalHernia inguinal

Neuropatia S. vegetativo

Neuropatia S. vegetativo

Rinitis / SinusitisRinitis / SinusitisProzacProzac


N Engl J Med. 2010 Jan 21;362(3):217-27.

Biochem. Soc. Trans. (2009) 37, 814–818;

Am J Respir Crit Care Med Vol 176. pp 1281–1288, 2007


Am J Respir Crit Care Med. 2011 Aug 11.


N Engl J Med. 2011 Sep 29;365(13):1184-92.


COPD: the dangerous underestimate of 15%. Rennard SI, Vestbo J.

Lancet. 2006 Apr 15;367(9518):1216-9.


Decline in FEV1 and airfl ow limitation related to occupational exposures in men of an urban community.

Humerfelt S, Gulsvik A, Skjaerven R, et al. Eur Respir J 1993; 6: 1095–103.


Lancet. 2006 Apr 15;367(9518):1216-9.



Lancet. 2006 Apr 15;367(9518):1216-9.


Decline in FEV1 and airfl ow limitation related to occupational exposures in men of an urban community.

Humerfelt S, Gulsvik A, Skjaerven R, et al. Eur Respir J 1993; 6: 1095–103.

A homeopathic remedy for early COPD

Enright P. Respir Med. 2011 Nov;105(11):1573-5.

Proc Am Thorac Soc. 2006;3(1):58-65.

Enright P. Prim Care Respir J. 2011 Mar;20(1):6-8.


Chest. 2009 Jan;135(1):173-80.


Inspirados en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.


FENOTIPOS

Homes Homes DonesDones

Cortesía Dr. de Torres


FENOTIPOS

El fenotipo está determinado fundamentalmente por el genotipo, o por la identidad de los alelos, los cuales, individualmente, cargan una o más posiciones en los cromosomas. Algunos fenotipos están determinados por los múltiples genes, y además influidos por factores del medio. De esta manera, la identidad de uno, o de unos pocos alelos conocidos, no siempre permite una predicción del fenotipo. En este sentido, la interacción entre el genotipo y el fenotipo ha sido descrita usando la simple ecuación que se expone a continuación:

Ambiente + Genotipo + Ambiente* Genotipo = Fenotipo

En conclusión, el fenotipo es cualquier característica detectable de un organismo (estructural, bioquímico, fisiológico o conductual) determinado por una interacción entre su genotipo y su medio.

El conjunto de la variabilidad fenotípica recibe el nombre de polifasia o polifenismo.

http://es.wikipedia.org/wiki/Fenotipo

FENOTIPOS


http://es.wikipedia.org/wiki/Alelo

http://es.wikipedia.org/wiki/Cromosoma

http://es.wikipedia.org/wiki/Gen

http://es.wikipedia.org/wiki/Medio_ambiente

http://es.wikipedia.org/wiki/Alelo

http://es.wikipedia.org/wiki/Ser_vivo

http://es.wikipedia.org/wiki/Genotipo

http://es.wikipedia.org/wiki/Medio_ambiente

http://es.wikipedia.org/wiki/Polifenismo

Phenotype classically refers to any observable characteristic of an organism, and up until now, multiple disease characteristics have been termed COPD phenotypes. We, however, propose the following variation on this definition: ‘‘a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes (symptoms, exacerbations, response to therapy, rate of disease progression, or death).’’

Am J Respir Crit Care Med 2010; 182: 589–604.


Thorax. 2008 September ; 63(9): 761–767.


Respirology (2011) 16, 264–268


Thorax. 2009; 64(8): 728-35.


Thorax. 2009; 64(8): 728-35.

Marin, et al. Am J Respir Crit Care Med Vol 182. pp 325–331, 2010



Am J Respir Crit Care Med, 2004; 170: 400–407

Martínez-García MÁ , et al. Chest. 2011 Nov;140(5):1130-7.

¿Paciente sano? o ¿Paciente no sano?



DIAGNÓSTICO Y PRONÓSTICO

Muy fumadores (hasta ahora predominio varón) 50 paquetes/año acumulados Disnea de esfuerzo “Velcro” basales Acropaquia >50% > 65 años DLCO Espirometría / volúmenes = desconcertantes Tx tórax = tórax sucio TAC = >enfisema paraseptal !! HAP Carcinoma Enfermedad coronaria +++

DIAGNÓSTICO Y PRONÓSTICO: CUADRO CLÍNICO


Previamente catalogados de EPOC (leves / moderados)

Enfisema precede 5 años a fibrosis

Espirometría poco reveladora

Efecto “joven/vieja”

TAC (no siempre fácil de interpretar)

(No hacemos ni TAC ni difusión = guías)

No sabíamos que el humo del cigarrillo producía fibrosis pulmonar !!!???


DIAGNÓSTICO Y PRONÓSTICO: CUADRO CLÍNICO (DIFICULTADES)

Combined pulmonary fibrosis and emphysema: a distinct underrecognised entity.

Cottin V, Nunes H, Brillet PY, Delaval P, Devouassoux G, Tillie-Leblond I, Israel-Biet D, Court-Fortune I, Valeyre D, Cordier JF; Groupe d'Etude et de Recherche sur les

Maladies Orphelines Pulmonaires (GERM O P).

Eur Respir J. 2005 Oct;26(4):586-93.



¿Coincidente o relación causal?¿Cita o encuentro?Humo de cigarrillo

¿Coincidente o relación causal?¿Cita o encuentro?Humo de cigarrillo

The spectrum of smoking-related interstitial lung disorders: the never-ending story of smoke and disease.

Selman M. Chest. 2003 Oct;124(4):1185-7.

Smoking: an injury with many lung manifestations. Flaherty KR, Hunninghake GG. Am J Respir Crit Care Med. 2005 Nov 1;172(9):1070-1.

LECCIONES PASADAS DE LA HISTORIA


Relation of smoking and age to findings in lung parenchyma: a microscopic study. Auerbach O, Garfinkel L, Hammond EC. Chest. 1974 Jan;65(1):29-35.

Smoking Habits And Age In Relation To Pulmonary Changes. Rupture Of Alveolar Septums, Fibrosis And Thickening Of Walls Of Small Arteries And Arterioles.

Auerbach O, Stout Ap, Hammond Ec, Garfinkel L. N Engl J Med. 1963 Nov 14;269:1045-54.

J Occup Med. 1988 Jan;30(1):33-9).


LECCIONES PASADAS DE LA HISTORIA: AVISOS

Relation of smoking and age to findings in lung parenchyma: a microscopic study. Auerbach O, Garfinkel L, Hammond EC. Chest. 1974 Jan;65(1):29-35.

Smoking Habits And Age In Relation To Pulmonary Changes. Rupture Of Alveolar Septums, Fibrosis And Thickening Of Walls Of Small Arteries And Arterioles.

Auerbach O, Stout Ap, Hammond Ec, Garfinkel L. N Engl J Med. 1963 Nov 14;269:1045-54.

J Occup Med. 1988 Jan;30(1):33-9).

Cigarettes – Packs/Day

No. In group0

20

40

60

80

100

0 <1 1 _ 2 2+

Age

36 52 32 87 87 38 205 200 43 83 96 15

Seve

re P

ulm

onar

y Fi

bros

is %

6,9

32,7

62,7

<60

1,9

39,1

82,590,660-69

50

90,7 93,370+


LECCIONES PASADAS DE LA HISTORIA: AVISOS

Diagnosis of usual interstitial pneumonia and distinction from other fibrosing interstitial lung diseases.

Katzenstein AL, Mukhopadhyay S, Myers JL.

Hum Pathol. 2008 Sep;39(9):1275-94.

23 piezas lobectomía por tumor pulmonar

20 fumadores

Examen histológico: fibrosis >25% slides. En 12/20 (60%) fumadores 0 en no fumadores

Describe SRIF (Smoking-Related Fibrosis Disease)

ÚLTIMAS NOTICIAS


Idiopathic pulmonary fibrosis and emphysema: decreased survival associated with severe pulmonary arterial hypertension.

Mejía M, Carrillo G, Rojas-Serrano J, Estrada A, Suárez T, Alonso D, Barrientos E, Gaxiola M, Navarro C, Selman M.

Chest. 2009 Jul;136(1):10-5. 30% !!!30% !!!

ÚLTIMAS NOTICIAS


5% por año

5.000 nuevos casos por año (UK) =

[ 4.000 en España ?!]

5.000 +/a

>+ que por cáncer ovárico, linfoma, leucemia, hipernefroma o mesotelioma.

Thorax. 2011 Jun;66(6):462-7.

The rising incidence of idiopathic pulmonary fibrosis in the U.K.Navaratnam V, Fleming KM, West J, Smith CJ, Jenkins RG, Fogarty A, Hubbard RB.

The rising incidence of idiopathic pulmonary fibrosis in the U.K.Navaratnam V, Fleming KM, West J, Smith CJ, Jenkins RG, Fogarty A, Hubbard RB.

YA NO ES HUÉRFANA…YA NO ES HUÉRFANA…


ÚLTIMAS NOTICIAS

N Engl J Med 2011;364:897-906.


Inspirados en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.

“Blue Bloater / Blow-up”

ESPECULACIONES


Thorax. 2011 Aug;66(8):643-5.


N Engl J Med. 2011 May 12;364(19):1795-806.



Petersen & Niklason

Thorax. 2011 Aug;66(8):645-6.


Even more effective tobacco legislation, including prevention of passive smoking exposure for children in cars and at home. Legislation works17dor, if it does not, let us prorogue parliament at once!

Recognition that airborne pollution is a human rights issuedif you live in a Western city you cannot avoid air pollution.

The roots of much disease are in povertydand yet it is not only low and middle income countries that are affected. All major Western countries still have substantial poverty affecting children.

Finally, invest in research to understand early lung development, and devise interventions to operate before the lungs are shot to pieces.

ÍndiceÍndice

1) Las 11 Guías

2) Los 11 Mitos

3) Conclusiones

ConclusionesConclusiones

1) Factor de Riesgo o Causa

2) Cociente Fijo

3) Es Fácil de Diagnosticar

4) El Gran Síndrome Inflamatorio

5) La Irreversibilidad

6) La Comorbilidad

MITOS

ConclusionesConclusiones

MITOS

7) La Suscetibilidad

8) La Importancia de los Genes

9) Envejecimiento

10) Los Fenotipos

11) El Cigarrillo no Produce Fibrosis

Muchas GraciasMuchas Gracias

epoc 11 guías y 11 mitos

Health & Medicine

chronic obstructivelungdisease

montemayor t

morera j

copd guidelines group

j respir critcare

guas las

j respir crit care

denberg t