Epidemiology of COPD Prof. David M. Mannino, M.D.
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1 Epidemiology of COPD David M. Mannino, M.D. Professor Department of Preventive Medicine and Environmental Health College of Public Health University of Kentucky 1 Outline Definitions Severity Progression Prevalence Hospitalizations Mortality 2 COPD definition GOLD 2010 Characterized by chronic airflow limitation and a range of pathologic changes in the lung, significant extrapulmonary effects, and important comorbidities Features may include: Chronic bronchitis (cough and sputum production) Emphysema (destruction of gas exchanging surfaces of the lung) 3 The screen versions of these slides have full details of copyright and acknowledgements 1
2 COPD definition Chronic Bronchitis Emphysema Irreversible Airflow Obstruction 4 AJRCCM 1995 ; 152: S Asthma Reversible Airflow Obstruction Lung function categories FEV 1 % predicted Gold 1 Gold 2 Gold 3 Gold 0 (if symptoms) or normal Restricted 20 0 Gold 4 FEV 1 /FVC < 70% FEV 1 /FVC => 70% 5 GOLD Guidelines 2010, Mannino et al., Resp Med, 2006 FEV 1 /FVC (%) 74 Potentially underdiagnosed Lower limit of normal Potentially overdiagnosed Age ( Years ) 6 Mannino et al., Thorax 2007; 62: The screen versions of these slides have full details of copyright and acknowledgements 2
3 Lung function in 1000 COPD patients 14% 30% 7 Kohler, D. et al., Thorax 2003; 58: 825 COPD severity - U.S Current Smokers Former Smokers Never Smokers 8 GOLD 3 GOLD 2 GOLD 1 Mannino DM, Watt G, Hole D, et al., Eur Respir J. 2006; 27: COPD severity - England 9 Thorax 2006; 61: The screen versions of these slides have full details of copyright and acknowledgements 3
4 COPD severity - BOLD 10 Lancet 2007; 370: COPD progression 11 Fletcher et al., The Natural History of Chronic Bronchitis and Emphysema, 1976 COPD progression (2) Age Death FEV 1 (%) relative to age 25 Symptoms Disability Susceptible Smokers Not Susceptible Stopped smoking at 45 (mild COPD) Stopped smoking at 65 (severe COPD) Age (years) 12 Adapted from Fletcher CM, Peto R. Br Med J. 1977; 1: 1645 The screen versions of these slides have full details of copyright and acknowledgements 4
5 Natural history of chronic airflow obstruction 13 Med Clinics North America 1981; 65: FEV 1 decline from pivotal studies FEV 1 (% of age-predicted) Fletcher Peto: Smokers (modified) LHS: Usual care LHS: Smoking intervention UPLIFT: Tiotropium TORCH: SFC LHS UPLIFT TORCH Data from Fletcher C. Br Med J. 1977; 1 : ; Anthonisen NR et al., JAMA 1994; 272: ; Celli BR et al., AJRCCM 2008; 178: Disease progression by COPD severity FEV 1 (% of age-adjusted reference value) GOLD II GOLD III GOLD IV 15 Age (years) Adapted from Decramer M., Cooper CB., Thorax 2010; 65: The screen versions of these slides have full details of copyright and acknowledgements 5
6 What is progression of COPD? Health Incident Disease 16 0 At Risk Restriction I Mild Pneumonol. Alergol. Pol.2011; 79 (2): II Moderate III Severe Progressive Disease Prevalent Disease Death IV Very Severe??? Diagnosed lung disease and lung function impairment in the U.S. adult population Asthma 5.5% Chronic bronchitis 3.2% Emphysema 1.5% Airflow obstruction int. 1.6% Airflow obstruction ext. 3.1% NHANES III NHANES III Current Diseases as a Proportional Venn Diagram Soriano et al., Chest2003; 124: Outline Definitions Severity Progression Prevalence Hospitalizations Mortality 18 The screen versions of these slides have full details of copyright and acknowledgements 6
7 Prevalence of COPD Prevalence per Midpoint of age-range population studied 19 Halbert et al., Chest2003; 123: Opinion Diagnosis Symptoms Spirometry Prevalence of COPD 2006 update GOLD 2 + GOLD 1 + ERS (LLN) ATS (ratio 75%) Other Overall Halbert et al., ERJ 2006; 28: Prevalence of COPD 2006 update (2) Africa Americas E. Mediterranean Europe SE Asia W. Pacific???? Halbert et al., ERJ 2006; 28: The screen versions of these slides have full details of copyright and acknowledgements 7
8 22 BOLD sites 23 Prevalence of GOLD 2 COPD 25 Prevalence per Men Women South Africa Phillipines Turkey Poland USA Mannino and Buist, Lancet2007 Norway Austria Uraguay China Canada Australia Germany Iceland Venezuela Chile Brazil Mexico The screen versions of these slides have full details of copyright and acknowledgements 8
9 COPD prevalence, by sex, in U.S., (GOLD 2 or higher) Millions of adults aged 25 and older Mannino DM, et al., MMWR 2002; 51(SS-6): 1 20 Men - GOLD 2 Women - GOLD 2 Decreasing prevalence in Spain? 26 Eur Respir J. 2010; 36: No increase in Finland 27 Eur Respir J. 2010; 36: The screen versions of these slides have full details of copyright and acknowledgements 9
10 Risk of COPD among smokers 28 Buist et al., Lancet 2007 Risk of COPD by age (10 year increase) 29 Buist et al., Lancet Risk factors of GOLD 2 COPD in never smoking men Age Comorbid Disease BMI Lamprecht et al., Chest2011 The screen versions of these slides have full details of copyright and acknowledgements 10
11 100 Risk factors of GOLD 2 COPD in never smoking women Age Comorbid Disease BMI Lamprecht et al., Chest2011 Biomass fuel and COPD in China 32 Liu et al., Thorax 2007; 62: Early life exposures For stage 2 or higher COPD 33 Svanes et al., Thorax 2010 The screen versions of these slides have full details of copyright and acknowledgements 11
12 Early life exposures (2) For stage 2 or higher COPD 34 Svanes et al., Thorax 2010 Outline Definitions Severity Progression Prevalence Hospitalizations Mortality 35 A paradigm of exacerbations Death Hospitalizations Exacerbations Symptoms Population at risk 36 Johnston et al., Epidemiology of COPD Exacerbations in Exacerbations of COPD, Informa 2008 The screen versions of these slides have full details of copyright and acknowledgements 12
13 COPD Asthma At risk Symptoms Exacerbations Hospitalizations Death 37 Johnston et al., Epidemiology of COPD Exacerbations in Exacerbations of COPD, Informa COPD exacerbation rate Mean rates per person per year Studies ordered chronologically Johnston et al., Epidemiology of COPD Exacerbations in Exacerbations of COPD, Informa 2008 COPD hospitalization rate 3 Hospitalizations per person per year Population-based Hospital based 39 Johnston et al., Epidemiology of COPD Exacerbations in Exacerbations of COPD, Informa 2008 The screen versions of these slides have full details of copyright and acknowledgements 13
14 End-of-Life disease C Each event in a COPD patient has the potential to be lethal 40 Lorenz et al., Ann Intern Med : COPD hospitalizations U.S. ( ) 41 Mannino DM, et al., MMWR 2002; 51 (SS-6): 1 20 COPD hospitalizations U.S. ( ) 42 Brown DW, et al., JCOPD 2010 The screen versions of these slides have full details of copyright and acknowledgements 14
15 Long-term follow-up of U.S. cohorts Garcia-Aymerich et al., Thorax 2011 Time to COPD hospitalization Analysis time gold = normal gold = restrictive gold = gold 0 gold = gold 1 gold = gold 2 gold = gold 3/4 Risk of death following COPD hospitalization Hazard ratio (95% CI) Long-term follow-up of U.S. cohorts Time to death following a COPD hospitalization 45 Garcia-Aymerich et al., Thorax 2011 The screen versions of these slides have full details of copyright and acknowledgements 15
16 Risk of hospitalization 100 With 3 comorbid diseases With 2 comorbid diseases With 1 comorbid disease With no comorbid disease 10 1 GOLD 3/4 GOLD 2 GOLD 1 Restricted GOLD 0 Normal 46 Models adjusted for age, sex, race, smoking status, education level, and body mass index Mannino et al., ERJ 2008 Outline Definitions Severity Progression Prevalence Hospitalizations Mortality 47 End-of-Life disease C Each event in a COPD patient has the potential to be lethal Lorenz et al., Ann Intern Med 2008: 148: The screen versions of these slides have full details of copyright and acknowledgements 16
17 Survival by lung function impairment Normal GOLD 1 GOLD 0 Restricted GOLD 2 GOLD 3 or 4 49 Mannino et al., Resp Med 2006 What do COPD patients die from? (rate per 1,000 person-years) Normal Restricted GOLD 0 GOLD 1 GOLD 2 GOLD 3/ COPD ASCVD Lung cancer Other Mannino et al., Resp Med, Jan 2006 COPD consequences and comorbidities 51 COPD 2008; 5: The screen versions of these slides have full details of copyright and acknowledgements 17
18 Risk of death within 5 years from baseline 100 With 3 Comorbid Diseases With 2 Comorbid Diseases With 1 Comorbid Disease With No Comorbid Disease 10 1 GOLD 3/4 GOLD 2 GOLD 1 Restricted GOLD 0 Normal 52 Models adjusted for age, sex, race, smoking status, education level, and body mass index Mannino et al., ERJ 2008 Mortality following exacerbation 53 Roede et al., Thorax 2008 COPD deaths by sex, race; U.S., Mannino DM, et al., MMWR 2002; 51(SS-6): 1 20 The screen versions of these slides have full details of copyright and acknowledgements 18
19 COPD deaths by region; U.S., Southern All except California California NJ, NY 55 Polednak, AP, JCOPD 2010 Spain improving survival after COPD hospitalization 56 Thorax 2010; 65: Improving COPD mortality in U.S. 57 Chest2011 (In press) The screen versions of these slides have full details of copyright and acknowledgements 19
20 Conclusions The epidemiology of COPD continues to evolve Prevalence is related to different factors in different parts of the world, although tobacco smoke remains the most important exposure COPD hospitalizations are important and costly They may be decreasing 58 Conclusions (2) COPD is a leading cause of mortality Risk of death may be decreasing in the US and other countries 59 Chronic obstructive pulmonary disease COPD is a PREVENTABLE and TREATABLE disease 60 ATS/ERS Guidelines for the Treatment of COPD, 2004 The screen versions of these slides have full details of copyright and acknowledgements 20
21 61 The screen versions of these slides have full details of copyright and acknowledgements 21
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