WHY DOES MY NEVER-SMOKER PATIENT HAS COPD?

Transcription

1 WHY DOES MY NEVER-SMOKER PATIENT HAS COPD? Nour Assad,MD Pulmonary and Critical Care Fellow University of New Mexico Health Sciences Center Department of Internal medicine Division of Pulmonary, Critical Care and Sleep Medicine

2 History of Presenting Illness 75 y/o female presented with the complaint of SOB since 2 years She gets short of breath walking 5-8 meters which has been progressive over 2 years. Occasional cough and wheezing. She moved here from Mexico about 15 years ago and has had asthma and allergy problems since then. States that she has been to ED several times in the past for bronchitis thrice and for pneumonia twice and has been on prednisone and antibiotics. She takes advair and loratidine for her asthma and is compliant with them, does not like taking steroids though. She will take her albuterol up to 10 times a day to try to get some relief.

3 Medications NKDA Advair 250/50 twice a day Albuterol 3-4 times/day Synthroid 88 micrograms once/day Benicar 40 milligrams /day OTC allergy medicines Prednisone 20 milligrams taper she completed that.

4 Past Medical and Surgical HX Past Medical: Past Surgical: Asthma (no hx of childhood asthma or allergies) Potential allergic rhinitis Hypertension Hypothyroidism Diverticulosis Abdominal hernia Hemorrhoidal Banding

5 Family and Social Hx Social History: Family History: No hx of smoking. She denies any pets at home or any smoker in the household She did have a wood burning stove in Mexico which she has not used for 15 years now. No IVDU She has 16 children and several of them have allergic rhinitis symptoms. No hx of asthma or allergy symptoms, no premature heart disease in family.

6 Review of Systems Constitutional: No fevers, night sweats or chills HEENT: No visual changes, sore throat or sinus tenderness, nasal congestion Respiratory: SOB on exertion, wheezing and cough. No hemoptysis CVS: No palpitations or chest pain GI: hx of GERD, no N/V,. She does have umbilical hernia. Endocrine: No diabetes, heat or cold intolerance. Takes thyroid medications. MSK: No arthralgias or myalgias Skin: No rash or hives

7 Physical Exam Vitals; BP 130/69, pulse 82, RR 18, afebrile HEENT: nares with moderately edematous turbinates, no polyps or mucous Oropharynx: clear without thrush or exudate Neck: supple, no adenopathy, thyromegaly or mass. Chest: equal air entry, no wheezes or signs of consolidation, no prolonged expiratory phase. CV: RRR. No murmurs, no gallops Abdomen: Soft, non-tender Extremities: no cyanosis or clubbing Skin: no rashes or hives

8 Relevant Labs CBC: WNL CMP: WNL IgE: 2.5 ANCA: Negative Sputum x3: negative for AFB

9 PFTs 7/30/2012

10 CXR

11 Chest CT scan

12 Bronchoscopy Findings A. BRONCHUS INTERMEDIUS; BIOPSY: - CILIATED RESPIRATORY EPITHELIUM WITH FOCAL SQUAMOUS METAPLASIA AND UNDERLYING ANTHROCOTIC PIGMENTED MACROPHAGES - NEGATIVE FOR MALIGNANCY.

13 BIOMASS SMOKE LEADING TO HOUSEHOLD AIR POLLUTION

14 Disease Burden ~ 3 Billion people worldwide rely on biomass fuel for cooking and heating. (WHO 2013 data) Sub-Saharan Africa is the most affected region in the world.

15 What is Biomass Fuel? Assad et al. Semin Respir Crit Care Med 2015; 36(03):

16 Fuel and Socioeconomic Status Assad et al. Semin Respir Crit Care Med 2015; 36(03):

17 How Common is Biomass Fuel Use in High-Income Countries? 28% of an urban high-elevation cohort based in New Mexico,USA reported wood smoke exposure in a 2010 report. Sood et al. Am J Respir Crit Care Med 2010, 182: In the rural Navajo-American town of Shiprock, New Mexico, 77% homes had indoor heating stoves that used a mixture of coal & wood Bunnell et al. J Environ Public Health 2010, 2010: Up to 18% of a Canadian population reported at least a 10 year history of biomass fuel use for heating and/or cooking in a recent population cohort study Tan et al. 2015, 70:

18 What Chronic Lung Diseases are Associated with the Exposure? Chronic inhalation of biomass smoke is associated with : COPD Interstitial lung disease Lung cancer Asthma Tuberculosis Perez-Padilla et al. Int J Tuberc Lung Dis 2010, 14:

19 What is in Biomass Smoke? Air Pollutants Emitted by Biomass Fuel Combustion PM 10 WHO Air Quality Guidelines 20 µg/m³ (annual mean) 50 µg/ m³ (24 h mean) PM µg/ m³ (annual mean) 25 µg/ m³ (24 h mean) Carbon monoxide 60 mg/ m³ (30 min mean) 30 mg/ m³ (1 h mean) 10 mg/ m³ (8 h mean) Nitrogen dioxide 40 µg/ m³ (annual mean) 200 µg/ m³ (1 h mean) Sulfur dioxide 20 µg/ m³ (24 h mean) 500 µg/ m³ (10 min mean) Others: Benzene, formaldehyde, 1,3-butadiene, polycyclic aromatic hydrocarbons such as benzo(α)pyrene, free radicals, aldehydes, volatile organic compounds, chlorinated dioxins, oxygenated and chlorinated organic matter, and endotoxin WHO, International Programme on Chemical Safety/ Air pollution available at

20 BIOMASS SMOKE AND COPD

21 Disease Burden In high -income countries, tobacco smoke is the biggest risk factor for COPD. Worldwide and in low-income countries however, the biggest risk factor for COPD is household air pollution, primarily from biomass smoke exposure. Household air pollution from biomass smoke exposure is estimated to kill 2 million women and children each year. Salvi et al. Chest 2010, 138:3-6. World Health Organization Programmes. Indoor air pollution.

22 How Strong is the Association between Biomass Smoke and COPD? Multiple cross sectional and case control studies and various metaanalyses show odds ratios (OR) in the range of for airflow obstruction in exposed subjects in low-income countries. Several studies also demonstrate that cigarette smokers constitute a uniquely susceptible population for the adverse respiratory effects of biomass smoke Studies from moderate- and high-income countries, although smaller in number, demonstrate similar strengths of association. Various studies demonstrate a dose-response relationship between the biomass smoke exposure and the severity of airflow obstruction (exposure quantified by hour-years)

23 Summary of the differences between biomass smoke-associated COPD and tobacco smoke-associated COPD. Characteristic Biomass smoke-related COPD Tobacco smoke-related COPD Gender [1] Women (58%) Men (91%) Age [1] Predominant COPD phenotype [1] Chronic bronchitis COPD-asthma overlap state Small airway disease Emphysema phenotype Chronic bronchitis Rate of annual FEV1 decline [2] 23 ml/year 42 ml/year Self reported quality of life [3] Worse Better Mortality [4] Same Same T helper cell inflammatory profile[5] Th2 Th17 1. Golpe, R., et al. Arch Bronconeumol, Ramirez-Venegas, A., et al. Am J Respir Crit Care Med, Camp, P.G., et al. Eur Respir J, Ramirez-Venegas, A., et al. Am J Respir Crit Care Med, Solleiro-Villavicencio, H., et al. Clin Immunol, 2015.

24 ASTHMA-COPD OVERLAP SYNDROME

25 Biomass Smoke and Asthma-COPD Overlap Syndrome (ACOS) ACOS is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Individuals affected by ACOS tend to demonstrate greater airway hyperreactivity than subjects with COPD; but unlike asthmatics they show incomplete reversibility of their airflow obstruction. Additionally, these individuals tend to have more frequent respiratory exacerbations than subjects with COPD alone

26 Biomass Smoke and Asthma-COPD Overlap Syndrome (ACOS) Golpe et al. found a significantly higher prevalence of the overlap state among subjects exposed to biomass smoke compared to tobacco smoke (21% vs. 5% respectively); most affected subjects were women. Findings of a recent study that biomass smoke-exposed subjects develop a strong Th2 inflammatory response provide a pathophysiological basis for the predisposition towards this syndrome in exposed individuals. 1. Golpe, R., et al. Arch Bronconeumol, Solleiro-Villavicencio, H., et al. Clin Immunol, 2015.

27 BRONCHIAL ANTHRACOFIBROSIS

28 Introduction Bronchial anthracofibrosis (BAF) is characterized by a bronchoscopic finding of multiple dark anthracotic pigmentations on large airway mucosa with or without bronchial narrowing or obliteration. The disease was classically described as a presentation of active or old infection with tuberculosis. Recent evidence however, suggests that heavy biomass smoke exposure is the main risk factor for the disease. Kim YJ, Jung CY, Shin HW, Lee BK: Biomass smoke induced bronchial anthracofibrosis: presenting features and clinical course. Respir Med 2009, 103:

29 Clinical, Physiologic and Radiographic Features Subjects present with dyspnea, cough and occasionally hemoptysis. The most common spirometric finding is an obstructive ventilatory defect (defined as FEV 1 /FVC <0.7) Chest CT findings include bronchial narrowing or atelectasis and parenchymal abnormalities; such as consolidations, interstitial infiltrations, inactive tuberculous and mass lesions. Although BAF may be viewed as a variant of biomass smokeassociated COPD, the distinct radiological and bronchoscopic features suggest that it might be a distinct pulmonary response to heavy biomass smoke exposure. Kim YJ, Jung CY, Shin HW, Lee BK: Biomass smoke induced bronchial anthracofibrosis: presenting features and clinical course. Respir Med 2009, 103:

30 Possible causative factors Gupta A: Bronchial anthracofibrosis: an emerging pulmonary disease due to biomass fuel exposure. Int J Tuberc Lung Dis May;15(5): doi: /ijtld Epub 2011 Mar 16.

31 Prevention and Treatment This is possibly an occupational lung disorder, so strategies to prevent exposure to dust at work must be developed. Treatment for TB should be only after obtaining bacteriological confirmation and that there is no role for empirical treatment. The role of corticosteroids was evaluated in 14 patients with nontuberculous BAF, 9 of whom showed clinical improvement. Prevent and treat associated conditions.

32 INTERVENTIONS TO PREVENT BIOMASS SMOKE-ASSOCIATED LUNG DISEASE

33 The most effective intervention is to witch to clear source of fuel. Not always feasible or affordable.

34 Interventions in Low-Income Countries The Plancha Over 60% reduction in personal carbon monoxide levels compared to open fire Reduction in the occurrence of wheeze in non-smoking women by approximately 60% A beneficial effect of reduced exposure on FEV 1 at 18 months of follow up. Smith-Sivertsen T et al.: the RESPIRE Randomized Trial, Guatemala. Am J Epidemiol 2009

35 Interventions in High-Income Countries. A shift in heating fuels from biomass to natural gas and electricity. Tasmania, Australia 38% reduction in winter PM 10 and corresponding mortality reductions Replacing conventional wood stoves with improved technology stoves. Plug-in air filter devices Libby, Montana Semi-urban to very rural areas of the northern Rocky Mountains (Montana and Idaho) and Fairbanks (AK), Reduction of winter ambient levels of PM 2.5 and reductions in frequency of children s respiratory symptoms overall 63% reduction in indoor PM Johnston, F.H., et al.m BMJ, : p. e Noonan, C.W., et al. Occup Environ Med, (5): p Ward, T.J., et al. J Expo Sci Environ Epidemiol, 2015.

36 Key Points 3 billion people around the world rely on coal and biomass fuel for cooking and heating. Biomass smoke exposure is associated with COPD, asthma-copd overlap syndrome, usual interstitial pneumonitis, hut lung, and bronchial anthracofibrosis. Biomass smoke-related COPD has several differences compared to tobacco smoke-related COPD. Biomass smoke- related respiratory diseases are being increasingly described in high income countries. Interventions that decrease exposure to biomass smoke potentially improve respiratory health outcomes.