presentación realizada en el 39 Simposio de Neumología, Burgos 15 de Noviembre 2013.

1. EPOC:PERSPECTIVAS DE FUTURO
(Y UNA MIRADA AL PASADO)
1

2. “Nunca hago predicciones y nunca las
haré”
Paul Gascoigne
2

3. ÍNDICE
1. ¡Que es la demografía!
2. Tabaquismo: malas perspectivas
3. Las “noncommunicable”
4. Peligro: camino equivocado
5. Fenotipos o formas clínicas
6. 1,2,3,4......?
7. Nuevas tecnologías
8. Conclusiones
3

4. ¡Que es la demografía!
2011
Manila (Filipinas) 31 octubre 2011
Nace Danica May Manila Camacho
Es la ciudadana número 7mil millones del planeta
4

5. ¡Que es la demografía!
Sarajevo(Bosnia) 13 octubre, 1999
Nace Adnan Nevic, el ciudadano número 6 millones
5

6. ¡Que es la demografía!
El mundo en 2050.Todas las tendencias que canviaran el planeta
(The Economist).ed Franklin D. y Andrews J. 2012
6

7. Tabaquismo: malas perspectivas
Eriksen M. Judith Mackay Hana Ross EL ATLAS
DEL TABACO cuarta edición.
http://www.tobaccoatlas.org/uploads/Images/PDFs/
TA4Spanish.pdf
7

8. Tabaquismo: malas perspectivas
8
N Engl J Med. 2013 Jan 24;368(4):341-50

9. Tabaquismo: malas perspectivas
9
N Engl J Med. 2013 Jan 24;368(4):351-64

10. Tabaquismo: malas perspectivas
…More women die of lung cancer than of breast cancer. But
there is no “race for the cure” for lung cancer, no brown ribbon,
and no group analogous to the Susan G. Komen Breast Cancer
Foundation…
Thorax. 2011 Aug;66(8):645-6
10

11. Las “noncommunicable”
Noncommunicable Diseases David J. Hunter, M.B., B.S., M.P.H., Sc.D., and K. Srinath Reddy, M.D., D.M.N
New Engl J Med 2013; 369:1336-1343 October 3, 2013
11

12. Las “noncommunicable”
PLoS Med. 2006 Nov;3(11):e442.
Projections of global mortality and burden of disease from 2002 to 2030.
Mathers CD, Loncar D.
12

13. Las “noncommunicable”
PLoS Med. 2006 Nov;3(11):e442.
Projections of global mortality and burden of disease from 2002 to 2030 Mathers CD, Loncar D.
13

14. Las “noncommunicable”
14

15. Las “noncommunicable”
- Stockley RA. Am J Respir Crit Care Med. 2013 Apr 15;187(8):786-8
- Mathers CD, Loncar D. PLoS Med. 2006 Nov;3(11):e442.
Projections of global mortality and burden of disease from 2002 to 2030
15

16. Las “noncommunicable”
16

17. Peligro: camino equivocado
Thorax. 2011 Aug;66(8):643-5
17

18. Peligro: camino equivocado




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.
Thorax. 2011 Aug;66(8):645-6
18

19. Peligro: camino equivocado
19

20. Peligro: camino equivocado
Am J Respir Crit Care Med. 2012 Nov 15;186(10):975-81
20

21. Peligro: camino equivocado
• Host Factors
–
–
–
Genes
Airway Hyperresponsiveness
Lung Growth
• Exposures
1)
2)
–
Tobacco Smoke
–
Occupational Dust and Chemicals
–
Outdoor and Indoor Air Pollution
–
Infections
–
Socioeconomic Status
No menciona que el efecto del tabaco es dosis/efecto. !!!!!
No menciona la palabra “Smoke” hasta después de 688 palabras y 2 tablas, y
688 palabras hasta repetirla. !!!!!
Am J Respir Crit Care Med Vol 163. pp 1256–1276, 2001
21

22. Peligro: camino equivocado
…The adjusted differences in FEV1 between individuals who did not consume cured meats and those who consumed cured meats 1
to 2,3 to 4, 5 to 13, and 14 or more times per month were 37.6, 11.5, 42.0, and 110 ml, respectively (p for trend 0.001).Corresponding
differences for FEV1/FVC were 0.91,0.54, 1.13, and 2.13% (p for trend 0.001). These associations were not modified by smoking
status. The multivariate odds ratio for COPD (FEV1/FVC 0.7 and FEV1 80% predicted) was 1.78 (95% confidence interval, 1.29–2.47)
comparing the highest with the lowest category of cured meat consumption. The corresponding odds ratios for mild, moderate, and
severe COPD were 1.11, 1.46, and 2.41, respectively….
…High dietary nitrite intake warrants further evaluation in prospective, longitudinal studies as a novel risk factor for COPD.
Am J Respir Crit Care Med. 2007 Apr 15;175(8):798-804
22

23. Peligro: camino equivocado
Biochem. Soc. Trans. (2009) 37, 814–818;
Am J Respir Crit Care Med Vol 176. pp 1281–1288, 2007
23

24. Peligro: camino equivocado
Necesidad de criterio único
24

25. Peligro: camino equivocado
…This is clearly apparent if one keeps in mind that
two patients with FEV1 of 20 and 100% pred may
have the same FEV1/FVC ,0.70 or even, LLN,
depending on the associated reduction of FVC…
25
Eur Respir J. 2008 Mar;31(3):681-2

26. Peligro: camino equivocado
26
Thorax. 2009 Oct;64(10):894-900

27. Peligro: camino equivocado
Chest. 2006 Aug;130(2):318-25
27

28. Peligro: camino equivocado
4
ENFERMEDAD
S
Í
N
D
R
O
M
E
3
2
1
Causa - Etiología
Desorden Funcional
Característico
Lesión Anatómica
Característica
Descripción Clínica
Basat 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: Weiss EB, Stein M. Editors. Bronchial asthma, mechanisms and therapeutics, 3erd ed. Boston: Litle Brown;
1993. p.1-13.
28

29. Peligro: camino equivocado
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):6556.
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):67883.
29

30. Peligro: camino equivocado
30

31. Fenotipos o formas clínicas
P.G. Gibson, J.L. Simpson.Thorax 2009;64:728-735
The overlap syndrome of asthma and COPD: what are its features and how important
is it?
31

32. Fenotipos o formas clínicas
Miguel-Angel Martínez-García, et al.Prognostic Value of Bronchiectasis in
Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease
American Journal of Respiratory and Critical Care Medicine 2013 187: 823-831
32

33. Fenotipos o formas clínicas
Jose M. Marin, et al. "Outcomes in Patients with Chronic Obstructive Pulmonary
Disease and Obstructive Sleep Apnea", American Journal of Respiratory and
Critical Care Medicine, Vol. 182, No. 3 (2010), pp. 325-331.
33

34. Fenotipos o formas clínicas
John R. Hurst, Evaluation of COPD Longitudinally to Identify Predictive Surrogate
Endpoints (ECLIPSE)
Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease
New engl j med 363;12 september 16, 2010
34

35. Fenotipos o formas clínicas
Camp PG, et al.
COPD phenotypes in biomass smoke- versus tobacco smoke-exposed Mexican
females. Eur Respir J. 2013 Oct 10.
35

36. Fenotipos o formas clínicas
¿Paciente sano? o ¿Paciente no sano?
36

37. Fenotipos o formas clínicas
37

38. Fenotipos o formas clínicas
38

39. Fenotipos o formas clínicas
39

40. Fenotipos o formas clínicas
40

41. Fenotipos o formas clínicas
Almagro P, et al.
Comorbidities in patients hospitalized due to chronic obstructive
pulmonary disease. A comparative analysis of the ECCO and ESMI.
Rev Clin Esp. 2012 Jun;212(6):281-6
Morera Prat J, Martinez –Ortiz ML
Chronic obstructive pulmonary disease in the elderly: next phenotype
Med Clin (Barc)2012 Apr 28;138(11):478-9.
41

42. Fenotipos o formas clínicas
42
Am J Respir Crit Care Med. 2012 Jan 1;185(1):44-52

43. Fenotipos o formas clínicas
Guerra S, et al.Combined effects of parental and active smoking on early lung
function deficits: a prospective study from birth to age 26 years.
Thorax. 2013 Nov;68(11):1021-8.
43

44. Fenotipos o formas clínicas
Han MK, et al.
Chronic Obstructive Pulmonary Disease Exacerbations in the COPDGene Study:
Associated Phenotypes. Radiology. 2011 Oct;261(1):274-82
44

45. Fenotipos o formas clínicas
45

46. Fenotipos o formas clínicas
“Blue Bloater / Blow-up”
46
Inspirado en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.

47. 1, 2, 3, 4…?
47
N Engl J Med. 2007 Feb 22;356(8):775-89

48. 1, 2, 3, 4…?
48

49. 1, 2, 3, 4…?
49
N Engl J Med. 2011 Aug 25;365(8):689-98

50. 1, 2, 3, 4…?
50
Am J Respir Crit Care Med. 2012 Jan 15;185(2):152-9

51. 1, 2, 3, 4…?
51
N Engl J Med. 2010 Sep 23;363(13):1233-44

52. 1, 2, 3, 4…?
Thorax. 2010 Apr;65(4):298-302
52

53. 1, 2, 3, 4…?
53

54. 1, 2, 3, 4…?
The Lancet Respiratory Medicine, Early Online Publication, 6 December 2012
54

55. 1, 2, 3, 4…?
55
Chest. 2012 Nov;142(5):1300-7.

56. Nuevas tecnologías
Estépar RS, et al. Computed tomographic measures of pulmonary vascular
morphology in smokers and their clinical implications.
Am J Respir Crit Care Med. 2013 Jul 15;188(2):231-9
56

57. Nuevas tecnologías
Carlos H Martinez,et al. Relationship between quantitative CT metrics and health
status nd BODE in chronic obstructive pulmonary disease.
Thorax,2012,67,399-406
57

58. Nuevas tecnologías
58

59. Conclusiones
1. Debemos maximizar nuestros esfuerzos en la batalla del tabaquismo
y el diagnóstico precoz.
2. En un futuro, la comunidad científica deberá homogeneizar más los
conceptos de la EPOC.
3. Esperanzados con la medicina regenerativa, no sabemos cuando
será una realidad.
4. El fenotipo de la EPOC del futuro será el fenotipo de la EPOC del
anciano.
5. A nivel clínico es intrigante la comorbilidad con la obesidad.
59

60. MUCHAS GRACIAS
60