Ashtma and COPD
Similarities and differences
Postma D et al Clin Chest Med 2014 Asthma
Eosinophils Mast cells CD4* cells
85% AHR 70% Atopy
Steroids
Improve control, but not in all
COPD Neutrophils Macrophages
Mast cells CD8 + cells
60% AHR 40% Atopy
Steroids in subgroup effective
~20% Older, persistent
airflow obstruction Or brochodil.
response Neutrophils in
Subgroup ?%
Eosinophils in Subgroup
15-40%
Comorbidities and primary care
Anxiety / depression
Lung Cancer
Hypertension
Diabetes
Cardiovascular disease Muscle weakness
Osteoporosis
Ensayos a favor
• Numerous attempts to replicate these promising results: two trials
showed similar beneficial effects on hospital admissions and emergency and department visits, as well as health status
1) Rice et al. Am J Respir Crit Care Med 2010; 182: 890-96.
- DM program for severe COPD reduces hospitalizations and ED visits after one year by 41% (MD 0.34 [0.15, 0.52], p<0.001)
- education, exacerbation action plan, case manager 2) Koff et al. Eur Respir J 2009; 33: 1031-38
- Proactive integrated care (PIC) dramatically improved SGRQ by 10.3 units, compared to 0.6 units in UC group in severe COPD - education, self-management, enhanced communication by study coordinators, remote home monitoring
Positive trials
Ensayos en contra
• By contrast, increasing number of studies with mixed or negative results, revealing striking absence of positive effects in Scotland and the Netherlands (1-4), or even showing unsettling excess mortality in the self-management group in a well-designed trial by Fan et al. In the USA (5).
1) Bischoff et al. BMJ 2012; 345: e7642.
2) Bischoff et al. Thorax 2011; 66: 26-31.
3) Trappenburg et al. Thorax 2011; 66: 977-84.
4) Bucknall et al. BMJ 2012; 344: e1060.
5) Fan et al. Ann Intern Med 2012; 156: 673-83.
Negative trials
The Framingham ‘Fletcher-Peto” Lung Curves
FEV ₁ expressed as percentage of FEV₁ at age 25 yrs
19,6 mls/yr
38,2 mls/yr
17,6 mls/yr
23,9 mls/yr
The Framingham ‘Fletcher-Peto” Lung Curves
FEV₁ at 25 yrs
129 mls
lessWang et al . Am J Respir Cirit Care Med 2004; 69:941-949
19,6 mls/yr
38,2 mls/yr
17,6 mls/yr
23,9 mls/yr FEV₁ at 25 yrs
50 mls
lessWang et al . Am J Respir Cirit Care Med 2004; 69:941-949
Kohansal, et al. Am J Respir Crit Care Med 2009; 180:3-10
Needs
Social isolation
Inappropiate housing
Disabling symptoms
Depression Lack of information Loss of social functioning
“… it will eventually go down hill like so there is not really any future in it” [F.07.1]
Experiences of Living and Dying With COPD: A Systematic Review and
Synthesis of the Qualitative Empirical Literature
M Giacomini, D DeJean, D Simeonov, A Smith
Giacomini M, DeJean D, Simeonov D, Smith A. Experiences of living and dying with COPD: a
systematic review and synthesis of the qualitative empirical literature. Ont Health Technol Assess Ser [Internet]. 2012 March;12(13):1-47. Available from:
www.hqontario.ca/en/mas/tech/pdfs/2012/rev_COPD_Qualitative_March.pdf
Figure 4: COPD Disease Trajectory: Current Clinical View*
*Abbreviation: COPD, chronic obstructive pulmonary disease.
Adapted from Br J Gen Pract, Vol. 54; Lehman R: How Long Can I Go on Like This?
Dying from Cardiorespiratory Disease, p. 892–893 and verbal
characterization in Thorax, Vol. 55; Gore JM, Brophy CJ, Greenstone MA. How Well Do We Care for Patients with End Stage Chronic Obstructive
Pulmonary Disease (COPD)? A Comparison of Palliative Care and Quality of Life in COPD and Lung Cancer, p. 1000–1006.
Figure 5: COPD Disease Trajectory: Common Patient Experiences and Expectations*
*Abbreviation: COPD, chronic obstructive pulmonary disease.
Note: The clinical trajectory of Figure 4 appears in grey here, for comparison.
Adaptación a una forma de vida
Figure 2: COPD Disease Trajectory: Traditional View*
*Abbreviations: COPD, chronic obstructive pulmonary disease; FEV, forced expiratory volume.
Reprinted from BMJ, Vol. 6077; Fletcher C, Peto R: The Natural History of Chronic Airflow Obstruction, p. 1645–1648 with permission from BMJ
Publishing Group Ltd.
Figure 3: COPD Disease Trajectory: Updated Clinical View*
*Abbreviation: COPD, chronic obstructive pulmonary disease.
Reprinted from Br J Gen Pract, Vol. 54; Lehman R. How Long Can I Go on Like This? Dying from Cardiorespiratory Disease, p. 892–893, with permission from the Royal College of General Practitioners.
Teoría de las necesidades de BRADSHAW
• Necesidad normativa : los expertos o profesionales la percibe como necesidad en una situación determinada. El criterio de estos informantes puede ser imprescindible en muchos casos pero, a nuestro entender, no debe ser el exclusivo.
• Necesidad experimentada o sentida: es la necesidad percibida tanto individualmente como por los grupos o comunidades en que se organizan las personas. Es, por tanto, subjetiva y fundamental si se trabaja desde un modelo de Servicios Sociales que potencie el papel de los ciudadanos como sujetos protagonistas de los procesos de cambio.
• Necesidad expresada o demandada: es la necesidad sentida puesta en acción mediante una solicitud. A menudo este tipo de necesidad es la que condiciona la oferta de respuestas sociales pero desde nuestro punto de vista y en el ámbito que nos ocupa, los Servicios Sociales, la planificación no puede ir orientada sólo en función de la demanda.
• Necesidad comparada: es la deducida por el observador exterior en función de una comparación entre una situación de la población objetivo y la de otro grupo con circunstancias similares.
