Assessment

1
Assessment
2
The COPD Population Screener (COPD-PS)
1. During the past 4 weeks, how much of the time
did you feel short of breath?
None of the time
0
2. Do you ever cough up any stuff, such as
mucus or phlegm?
Yes, every day
0
3. Please select the answer that best describes
you in the past 12 months, I do less
than I used to because of my breathing problems.
Strongly disagree
2
4. Have you smoked at least 100 cigarettes in
your ENTIRE LIFE?
Dont know
Yes
No
2
0
0
5. How old are you?
Age 70
1
2
2
0
Martinez FJ, et al. COPD. 2008585-95.
3
ATS/ERS and GOLD Guidelines Severity of COPD
COPD is defined as FEV1/FVC lt 70
100
I(Mild)
80
II(Moderate)
FEV1
50
III(Severe)
30
IV(Very Severe)
0
ATS/ERS American Thoracic Society/European
Respiratory Society GOLD Global initiative for
chronic Obstructive Lung Disease
GOLD Guidelines. Available at http//www.goldcopd
.com/Guidelineitem.asp?l12l21intId2003.
Accessed April 2009.
4
The BODE Index
Variable Points on BODE
Index
BODE body mass index, obstruction, dyspnea, and
exercise capacity MMRC Modified Medical
Research Council
Celli BR, et al. N Engl J Med. 20043501005-1012.
5
Survival in COPD
FEV1 Stage
BODE
1.0
0.8
0.6
Probability of Survival
0.4
P lt 0.001
P lt 0.001
0.2
0.0
0
4
8
12
16
20
24
28
32
36
40
44
48
52
0
4
8
12
16
20
24
28
32
36
40
44
48
52
Months
Quartile 1 (BODE 0-2)
Stage I (gt 50) predicted
Quartile 2 (BODE 3-4)
Stage II (36-50) predicted
Quartile 3 (BODE 5-6)
Quartile 4 (BODE 7-10)
Stage III (? 35) predicted
Celli BR, et al. N Engl J Med. 20043501005-1012.
6
Underdiagnosis of COPD in the United States
22.9
20.7
14
Rate per 1000 of Population
7.2
45-54
55-64
65-74
75
25- 44
Age (years)
Mannino DM, et al. MMWR Morb Mortal Wkly
Rep. 2002511-16.
7
Role of High Resolution Computed Tomography
(HRCT) in Diagnosis and Research

• Characterization of emphysema
• Identification
• Regional distribution
• Quantitation
• Presence of large bullae
• Pre-operative assessment tool for lung volume
  reduction surgery
• Phenotyping of emphysema vs airways disease
  (research application)
• Monitoring of structural integrity
• Potential assessment of lung cancer (more common
  in patients with COPD). Application for lung
  cancer screening has not yet been established

8
Characteristics of Asthma and COPD

• Progressive airflow obstruction
• Smaller bronchodilator and corticosteroid
  response
• Most patients have increased bronchial
  responsiveness
• Cellular inflammation incl. neutrophils,
  macrophages, eosinophils mast cells may occur
• Cytokine, chemokine, protease responses
• Emphysema frequent

• Usually intermittent airflow obstruction but
  often less reversible obstruction
• Bronchodilators and corticosteroids improve
  airway obstruction
• High bronchial responsiveness
• Cellular inflammation w/ eosinophils, mast cells,
  T lymphocytes neutrophils in severe disease
• Broad inflammatory responses
• Airway remodeling (epithelial injury
  fibrosis)

Asthma
COPD
Bleecker ER. Chest. 200412693S-95S.
9
Clinical Features Differentiating COPD and Asthma
10
Distinguishing Between Asthma and COPD

• Based on an analysis of ICD-9 electronic claims
  data over a 2-year period, approximately 40 of
  patients diagnosed with COPD also had an asthma
  diagnosis1
• Some patients with asthma cannot be distinguished
  from those with COPD using current diagnostic
  tests management of these patients should be
  similar to that of patients with asthma2

1. Surveillance Data Inc. (SDI). COPD/Asthma
Diagnoses Overview 2001-2003. March 2004. 2.
Celli BR, et al. Eur Respir J. 200423932-946.
11
Physiologic Similarities and Differences Between
Asthma and COPD

• In general and in the extremes of presentation,
  asthma and COPD appear to be easily
  distinguished however, on structural and
  functional evaluation, significant proportions of
  patients are indistinguishable
• In individual patients, significant overlap
  exists in airway wall thickening, abnormalities
  on CT scans, reversibility with bronchodilators,
  airway hyperreactivity, and other measurements

Sciurba FC. Chest. 2004126(2 suppl)117S-124S.
12
Asthma as a Risk Factor for COPD

• Objective
• To evaluate the association between
  physician-diagnosed asthma and the subsequent
  development of COPD in a cohort of 3099 adult
  subjects ( 20 years old)
• Design and methods
• Prospective observational study
• Participants were selected from a random,
  stratified, cluster sample of white,
  nonMexican-American households
• Participants completed up to 12 respiratory
  questionnaires and 11 spirometry measurements
  over a period of 20 years
• Kaplan-Meier curves were compared

Silva GE, et al. Chest. 200412659-65.
13
Time to Development of COPD by Asthma Categories
Inactive asthma
No asthma
Proportion of Patients COPD-Free
Active asthma
Time in Years
Adjusted for age, sex, smoking, log lgE, and skin
test reactivity
Silva GE, et al. Chest. 200412659-65.
14
Biomarkers for COPD

• Sputum
• Neutrophil count
• Inflammatory mediators (IL-8, Groa, LT-B4,
  neutrophil elastase, MCP-1,
• neutrophil lipocalin)
• Myeloperoxidase (MPO)
• Matrix metalloproteases 8, 9, 12
• Exacerbation markers TNFa, IL-8, IL-6, MPO
• Chemokines CXCR3 and CCR5
• BAL
• Polymorphonuclear cells
• Percent CD8 T cells higher, CD4 lower
• Inflammation markers elevated (IL-8, IL-6,
  TNFa, MPO, eotaxin-1, ECP)
• Blood
• CRP (prognostic but not specific)
• Fibrinogen
• Leukocytes
• TNFa

Snell N, Newbold P. Curr Opin Pharmacol.
20088222-235.