CGMH, Chiayi
CHRONIC. ASTHMA
BRONCHITIS
?
CHRONIC
BRONCHIOLITIS
EMPHYSEMA
IRREVERSABLE REVERSABLE
Asthma and COPD
Thoracic Medicine
CGMH, Chiayi
Revised
2006
Definition
Cellular
immunity
Epithelium
defense barrier
Neurogenic
inflammation
ASM
Remodelling
Air pollutants, Chemicals
Thoracic Medicine
CGMH, Chiayi
• Normal airway
• Asthmatic airway
Pathophysiology: Asthma
Thoracic Medicine
CGMH, Chiayi
Airway remodeling
Thickening
of basement
membrane
(BM)
↑mucous
glands Hypertrophy
& hyperplasia
↑extracellular Neovascularisation
matrix (ECM)
Global Initiative for Chronic
Obstructive Lung Disease
Thoracic Medicine
CGMH, Chiayi
In collaboration with:
National Heart, Lung, and
Blood Institute, NIH
and
World Health Organization
Aug, 2005
Definition Thoracic Medicine
CGMH, Chiayi
Noxious particles
and gases
Host factors
Lung inflammation
Anti-oxidants Anti-proteinases
Repair mechanisms
COPD pathology
CELLULAR MECHANISMS OF COPD
Perforin
Granzyme B Cigarette smoke
TNF-α
? Alveolar macrophage
CD8 +
MCP-1
lymphocyte
Neutrophil chemotactic factors
Cytokines (IL-8)
Mediators (LTB4)
Neutrophil
α 1-Antitrypsin
SLPI
Elafin
Neutrophil elastase TIMPs
Cathepsins
MMP-1, MMP-9, MMP-12
Granzymes, perforins
Others……..
Free Radicals in COPD
Pathophysiology: COPD
COPD Airways
Epithelial
metaplasia
Goblet cell
hyperplasia
Fibrosis
A Diffuse Small Airway Disease
reversible irreversible
Pathological Characteristics
of COPD Patients
Flattening diaphragm
Decreased contractility of diaphragm
Increased Breathing Work in COPD
Inspiratory
IRV effort
IRV
IRV VT
VT
VT
ERV
ERV
ERV Air-Trapping
No enough expiratory time to return to ERV
Exercise capacity in COPD
75 n = 41 75 n = 41
r = 0.56 r = 0.66
p = 0.0002 p < 0.0001
50 50
FEV1 %
FEV1%
25 25
0 0
0 100 200 300 400 500 600 700 50 60 70 80 90 100
Walking Distance (meters) O2 Saturation (end of exercise)
Hyperinflation
Muscle wasting
Disability
Social withdrawl
Depression and anxiety
Differential diagnosis Thoracic Medicine
Overview: Clinical aspects & lung function CGMH, Chiayi
COPD Asthma
• Affects elderly, • Affects all ages,
especially smokers including children
• Slowly progressive • Episodic course
• Partially reversible • Fully reversible
• AHR: ± ≈
• AHR: often +
• Lung volume: 10% • Lung volume:
hyperinflation variable
• Diffusion: decrease • Diffusion: normal
• Chest X-ray: • Chest X-ray:
hyperinflation normal
Wheezy bronchitis
Adapted from Barnes PJ. Chest 2000;117(suppl):10S
Differential diagnosis Thoracic Medicine
Overview: Inflammatory cells and mediators CGMH, Chiayi
COPD Asthma
• Inflammatory cells • Inflammatory cells
–Neutrophils –Eosinophils
–Macrophages –Mast cells
–CD8+ cells –CD4+
• Mediators
≈
–Macrophages
–IL-8 10% –Neutrophils
–TNF-a • Mediators
–LTB4 –Th2 cytokines
–Eotaxin
–LTC4-E4
Wheezy bronchitis
Adapted from Barnes PJ. Chest 2000;117(suppl):10S
Thoracic Medicine
CGMH, Chia-Yi
10/23/08
Thoracic Medicine
CGMH, Chiayi
10/23/08
Similar Management? Thoracic Medicine
CGMH, Chiayi
Oxygen
Theophyllines
Bronchodilators
Corticosteroids
Avoidance of inhaled stimulants
Thoracic Medicine
Asthma - GINA
Asthma Management and Prevention
Program: Five Components
1. Develop Patient/Doctor
Partnership
2. Identify and Reduce
Exposure to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma
Exacerbations
Revised
2006
5. Special Considerations
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health
care providers, the patient, and the patient’s
family
Patient education program in Singapore
Prabhakaran et al, Singapore med J. 2006, 47(3):225-31
Nation-wide campaign:
1980s: New Zealand, Australia, National
Asthma Council
China: 2001, Easy Asthma mnagement
2002, Breathe Easy Centres
Korea: 2003, Korea Asthma Foundation
Taiwan: 2003, Asthma Watch; Asthma Grid
Web-based net
Government support ( 國家高速電腦網路 )
Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors
Reduce exposure to indoor allergens
Avoid tobacco smoke
Avoid vehicle emission
Identify irritants in the workplace
Explore role of infections on asthma
development, especially in children and
young infants
Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors
避開或掌控氣喘危險因子
改善生活環境
避免非過敏原的因素
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma
評估及監測 :
尖峰流量 ( 或尖峰呼氣流速 ; PEF)
10/23/08
Difference in GINA guideline 2006
Levels of Asthma Control
Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)
A stepwise approach
The least possible medication
Traditional methods of healing are not
recommended
Severity is no longer used as the basis for
treatment decision
Component 3: Assess, Treat and Monitor Asthma
Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled β2-agonists
Theophylline
Cromones
Long-acting oral β2-agonists
Anti-IgE
Systemic glucocorticosteroids
Component 3: Assess, Treat and Monitor Asthma
Reliever Medications
bronchospasm
19 1980 1 1 1 2000
75 985 990 995
Bronchodilators Thoracic Medicine
CGMH, Chiayi
Anticholinergic
M1
M2
M3
Contraction Relaxation
↑cAMP
AMP
SMOOTH MUSCLE CELL
β-agonist
theophylline
Thoracic Medicine
CGMH, Chiayi
Thoracic Medicine
CGMH, Chiayi
GR
AP
Gene (DNA)
Nucleus
GRE
© P J Barnes 2005
Corticosteroids
Dendritic cell
Numbers Cytokines Numbers Cytokines
(apoptosis)
Numbers
Effects of Inhaled Glucocorticoids
on Inflammation
2.0
1.5
1.0
0.5
0.0
0 1 2 3 4 5 6 7 8 9 10 11 12
Canisters of Inhaled Glucocorticoids/yr
Adapted from Suissa S et al. N Engl J Med. 2000;343:332
Inhaled Glucocorticoids Reduce
Asthma-Related Hospitalizations
8
β 2-agonists Inhaled Glucocorticoids
7
Total Total
6 Age 0–17 Age 0–17
Relative Risk
5
4
3
2
1
0
None 0–1 1–2 2–3 3–5 5–8 8+
Prescriptions/Person-yr
Donahue JG et al. JAMA.1997;277:887
Inhaled Corticosteroids:
The mainstay of current treatment for
bronchial asthma
Long-actingβ2-agonists Thoracic Medicine
CGMH, Chiayi
1980s
Formoterol: full β2-agonists
Salmeterol: partial β2-agonists
# Action: > 12 hours
Long-actingβ2-agonists Thoracic Medicine
CGMH, Chiayi
Smooth Airway
muscle inflammation/
LABA dysfunction remodelling ICS
Symptoms\exacerbations
0.8
no. / patient / y
0.6
0.4
0.2
30
change in PEF (l/min)
BUD800+F
20
BUD200+F
10
0 BUD800
-10 BUD200
-20
-10 0 10 1 3 6 9 12
Run-in (days) Treatment (days) Treatment (months)
Xanthines
(Theophyllines)
Methylxanthines Thoracic Medicine
CGMH, Chiayi
Related to caffeine
Used in asthma since 1930
Orally active, slow-releasing preparations
Less role?
Bronchodilator (10-20 mg/L)
Anti-inflammatory (5-10 mg/L)
Mechanisms of action Thoracic Medicine
CGMH, Chiayi
of theophyllines
Phosphodiesterase (PDE) inhibition
Adenosine receptor antagonist
Stimulation of catecholamine release
Mediator inhibition
Inhibition of intracellular calcium release
Thoracic Medicine
CGMH, Chiayi
Leukotriene
modifier
Leukotriene
in Asthma
From phospholipids
via FLAP and 5-LO
Pathway irresponsive
to steroids
LTB4: chemotaxis for
leukocytes
LTC4, LTD4 (Cys-
LTs)
Thoracic Medicine
CGMH, Chiayi
Anti-IgE
New Anti-IgE antibody Thoracic Medicine
CGMH, Chiayi
INCREASE
uncontrolled step up until controlled
REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
Component 3: Assess, Treat and Monitor Asthma
More about
Management for Asthma
Choice of patients
ICS in asthma: Smoker vs. non-smoker
Figure 2 Mean (95% CI) difference between non-smokers and smokers with asthma in change in
morning PEF (l/min) on different doses of inhaled beclomethasone. *p
high (>800 µg/day beclomethasone (BDP)); moderate (400-800 µg/day); low (<400
µg/day)
Treatment:
long-term pantoprazole
50
40
30
20
10
0
USA Europe Asia Pacific Japan
Patients with severe persistent symptoms Rabe et al. Eur Respir J 2000;
www.asthmainamerica.com;
Lai et al. J Allergy Clin Immunol 2003;
Adachi et al. Arerugi 2002
Asthma control in practice in Taiwan
the prescription patterns of anti-asthmatic medications for children
Sun et al, J Formos Med Assoc. 2006, 105(4)
225,537 anti-asthma prescriptions were collected from the National Health
Insurance Research Database from January 1, 2002 to March 31, 2002
Asthma control in practice in Taiwan
the prescription patterns of anti-asthmatic medications for children
Sun et al, J Formos Med Assoc. 2006, 105(4)
Asthma control in practice in Taiwan
the prescription patterns of anti-asthmatic medications for children
Sun et al, J Formos Med Assoc. 2006, 105(4)
New strategies
Can we do better?
Asthma is a variable disease
Undertreatment
Excessive rescue use
Courses of inhaled/oral steroids
Poor Asthma
control
control
Fixed
dosing
Optimal
control
Time
(months, weeks, days)
Overtreatment
Unnecessary drug intake
Unnecessary drug costs
+ reliever as needed
Hypothesis: AMD; SMART
The right dose of Symbicort® at the right time
Symbicort® Asthma
worsening Asthma control
inhalations
Quickly
gain
control
Step down to adequate
Maintain dose that maintains control
2 inh.
control
4 inh.
bid bid*
1 inh. 1 inh. or 2 inh.
bid bid od
Time
+ reliever as needed (months, weeks, days)
*The dosage 4 inh. bid is within the SPC of the
monocomponents but outside the current SPC for Symbicort inh. = inhalation(s)
Adjustable maintenance dosing
reduced severe exacerbations
Number of
exacerbations p=0.018
70
60 p=0.08
50
Hospitalisation/
40 ER visits
30 Oral steroid course
20
10
0
Symbicort® Symbicort® Seretide™
AMD FD FD
SUND study: Aalbers R et al. Allergy Clin Immunol Int, 15, Suppl. 1 (2003):49-50
As-needed reliever use
Daytime Symbicort® AMD
reliever use 3.2 Symbicort® FD
(occasions) Seretide™ FD
2.8
2.4
2.0
1.6
1.2
0.8
-30 -20 -10 0 10 20 30
Days relative to exacerbation
Aalbers R, et al (2003)
Symbicort® adjustable maintenance dosing
more cost-effective
Cost (€)
Ställberg B, et al (2003)
500
p<0.001
450
400
350
300
250
200
AMD Fixed
dosing
AMD in asthma: INSPIRE study
SFC 50/500
Step 1
or FP 500
SFC 50/250
or FP 250 Step 3
Strata 1 & 2
SFC 50/100
or FP 100 Step 2
5068 3421
Step 1
Visit 1 2 3 4 5 6 7 8 9
Week -4 0 4 12 24 36 52 56
SFC, salmeterol/fluticasone propionate combination; FP, fluticasone propionate GSK data on file, 2003
Patients can achieve total control
regardless of asthma severity
100 Seretide Phase 2
% patients achieving total controlled
Seretide Phase 1
80 FP Phase 2
FP Phase 1
60
asthma
50% *
40%
44% *
40 *
28% 29%
16%
20
0
Steroid naïve Low dose Moderate dose
ICS ICS
*p < 0.001 (Phase 1)
Approximately 50% patients achieved Total Control
More patients achieved well controlled
asthma with Seretide versus FP
Seretide Phase 2
100 Seretide Phase 1
% patients achieving well-controlled
FP Phase 2
80 78% * 75% * FP Phase 1
70%
60% 62% *
60
asthma
47%
40
20
0
Steroid naïve Low dose Moderate dose
*p < 0.001 (Phase 1) ICS ICS
Aiming for TOTAL CONTROL
reduced exacerbations
0.6
0.5
0.4 0.36
*
0.3 0.27
0.2 0.17 *
0.12 0.12
0.1 *
0.07
0
Steroid naïve (S1) Low dose ICS (S2) Moderate dose ICS (S3)
Exacerbations during study defined as requiring either oral steroids or hospitalisation
Seretide achieves
better levels of quality of life
Seretide
Maximum achievable score = 7 FP
6.5
*
6.0
AQLQ Score
5.5
* p < 0.008
5.0
4.5
4.0
B/L 4 12 24 36 48 52
Week
By aiming for TOTAL CONTROL,
many more patients achieve
WELL CONTROLLED
asthma
5% 75%
Assessment of Asthma
Control
Management
for
COPD - GOLD
GOLD Workshop Report, 2005
Four Components of COPD
Management
Thoracic Medicine
CGMH, Chia-Yi
• Manage exacerbations
GOLD Workshop Report
Management:
Assess and monitor disease
Thoracic Medicine
CGMH, Chia-Yi
GOLD Workshop Report
Management:
Reduce risk factor
Thoracic Medicine
CGMH, Chia-Yi
GOLD Workshop Report
Management:
Manage stable COPD
Thoracic Medicine
CGMH, Chia-Yi
● Education
Health education (Evidence A).
All COPD-patients benefit from exercise
training programs, improving with respect
to both exercise tolerance and symptoms of
dyspnea and fatigue (Evidence A).
GOLD Workshop Report
Management:
Manage stable COPD
Thoracic Medicine
CGMH, Chia-Yi
● Pharmacologic
None of the existing medications for COPD
has been shown to modify the long-term
decline in lung function (Evidence A).
Pharmacotherapy is used to decrease
symptoms and/or complications.
GOLD Workshop Report
Management:
Manage stable COPD
Thoracic Medicine
CGMH, Chia-Yi
● Pharmacologic: bronchodilators
Central to the symptomatic management of COPD
(Evidence A).
Principal bronchodilator: Beta2-agonists,
anticholinergics, theophylline, and a combination
of these drugs (Evidence A).
Long-acting bronchodilators are more convenient.
Combining bronchodilators may improve efficacy
and decrease the risk of side effects (Evidence A).
Patient-centred outcomes:
LABAs versus placebo
Duration (W eeks)
Exacerbations
Medication
Dose (μg)
Dyspnea
Exercise
Rescue
HRQL
Study
N
versus placebo
Jones 1997 283 16 S 50 ↑ - - ↑ -
Boyd 1997 674 16 S 50 ↑ ↑ NS - NS
Mahler 1999 411 12 S 50 ↑ NS - ↑ ↑
Rutten Van Molken 1999 144 12 S 50 - - - NS -
Van Noord 2000 144 12 S 50 ↑ - - - NS
Rennard 2001 405 12 S 50 ↑ NS NS NS NS
Chapman 2002 408 24 S 50 NS - - NS NS
Mahler 2002 691 24 S 50 ↑ NS - NS NS
Brusasco 2003 1207 26 S 50 - ↑ - NS NS
Calverley 2003 1465 52 S 50 ↑ NS - NS ↑
Hanania 2003 723 26 S 50 - ↑ - NS NS
Dahl 2001 780 12 F 12/24 ↑ - - ↑ NS
Aalbers 2002 687 12 F 4.5/9/18 NS/↑/↑ NS/↑/↑ NS - NS
Rossi 2002 854 52 F 12/24 ↑ - - ↑ ↑
Szafranski 2003 812 52 F 9 - - - - NS
Action of anti-cholinergics
on Muscarinic receptors
Thoracic Medicine
CGMH, Chiayi
Pre-ganglionic
nerve
Sub-types Receptor dissociation
Parasympathetic
(T½, h)
ACh M (+)
ganglion 1
Ipratropium Tiotropium
M1 0.11 14.6
M2(-)
M2 0.03 3.6
ACh
M3 0.26 34.7
Airway M3(+)
smooth muscle
0.1
-0.1
0 2 4 6 8 10 12 14 16 18 20 22 24
Time post-administration (hours)
Maesen et al, Eur Respir J 1995
Effect of tiotropium on
symptom scores in COPD Thoracic Medicine
CGMH, Chiayi
6.0
Global evaluation score
5.6
5.2
Tiotropium (n=276)
4.8
Placebo (n=188)
4.4
4.0
1 8 29 50 71 92
Test day Casaburi et al, 2000
Tiotropium improves
Exercise Endurance Time Thoracic Medicine
CGMH, Chiayi
10 ∆ =105 s (21.4%)
∆ =1 min 7 s
ET (sec)
(13.6%)
8 min 12 s
8
-5 0 5 10 15 20 25 30 35 40 45
Day
Baseline
24
Number of
0.73
0.8
%
Year
0.6
0.4
0.2
0.0
Ipratropium Tiotropium
(n=179) (n=356)
Improvement in health stautus in
COPD with tiotropium
Thoracic Medicine
CGMH, Chiayi
Placebo Tiotropium
0
∆ SGRQ total score
-2
-4
*
-6
● Pharmacologic: corticosteroids
The addition of regular treatment with inhaled
glucorticosteroids to bronchodilator treatment is
appropriate for symptomatic COPD patients with
FEV1<50% predicted (Stage III to IV) and
repeated exacerbations (Evidence A)
Chronic treatment with systemic
glucorticosteroids should be avoided (Evidence A)
ISOLDE study: Exacerbations
1.4
Exacerbations/patient/year (mean)
1.32
1.2 25
%
n=751 1.0
40-75 yrs 0.99
FEV1 1.3 L 0.8
0.6
0.4
0.2
0
Placebo Fluticasone 1 mg
75 ∆ FEV1
50
25
0 BUD 400 µg bid
N=1277 -25
FEV1 (ml)
-50
FEV1 2.5 l,
-75
77% pred. -100
-125
-150 Placebo
-175
-200
-225
-6 -3 0 3 6 9 12 15 18 21 24 27 30
33 36
–2%
–5
–10
–15
–15%
–20
*p<0.05 vs placebo
–25
–24% †
p<0.05 Symbicort vs formoterol
*†
–30
Symbicort improves health-related quality of life
(SGRQ Total score)
Adjusted mean
Symbicort Budesonide Formoterol Placebo
change from 0
run-in
–1
–2
–3
–4 MCID
–5
–6 *
MCID = minimum clinically important difference
*p<0.05 vs placebo
Fluticasone/Salmeterol in COPD
FEV1 Thoracic Medicine
CGMH, Chiayi
160
120
80
40
0
-40
-80
0 2 4 8 16 24 32 40 52
week
TRISTAN, Lancet, 2003
Fluticasone/Salmeterol in COPD
Moderate and/or severe exacerbations
1.30
number/patient/year
1.5
1.04 1.05
** 0.97
**
1 *
0.5
0
PLA SAL50 FP500 SFC50/500
-1
-2
-3
-4
-5 *
-6
● Non-pharmacologic: O2
The long-term administration of oxygen (> 15
hours per day) to patients with chronic
respiratory failure has been shown to increase
survival (Evidence A).
Thoracic Medicine
CGMH, Chia-Yi
10/23/08
GOLD Workshop Report
Management:
Manage stable COPD
Thoracic Medicine
CGMH, Chia-Yi
● Non-pharmacologic: Rehabilitation
Improves exercise capacity
Reduces the intensity of breathlessness
Improves quality of life
Reduces hospitalizations and hospital stay
Reduces anxiety and depression
(All evidence A).
GOLD Workshop Report
Management:
Manage stable COPD
Thoracic Medicine
CGMH, Chia-Yi
● Non-pharmacologic: Surgery
Bullectomy
Lung volume reduction surgery (LVRS)
Lung transplantation
GOLD Workshop Report
Four Components of COPD
Management
Thoracic Medicine
CGMH, Chia-Yi
• Manage exacerbations
Common Causes of Acute Exacerbations of COPD
Primary
Tracheobronchial infection
Air pollution
Secondary
Pneumonia
Pulmonary embolism
Pneumothorax
Rib fractures/chest trauma
Inappropriate use of sedatives, narcotics, β-blocking agents
Right and/or left heart failure or arrhythmias
NHLBI/NIH. Global Initiative for Chronic Obstructive Lung Disease. NHLBI/WHO Workshop Report 2005.
Infectious Agents in COPD Exacerbations
Other 10%–25%
eg, air pollution Atypical bacteria 5%–10%
C. pneumoniae
GOLD – COPD severity predicts
hospitalisation rate
12
Patients with ≥ 1 hospitalisation
because of COPD in 3 yrs (%)
10
0
GOLD 3/4 GOLD 2 GOLD 1 GOLD 0
Mannino ERJ 2006
AGE
205 patients hospitalized for AECOPD, follow-up for 3 years
No exacerb.
1-2 exacerb.
>3 exacerb.
COPD as a
Systemic Disease
Systemic Inflammation
in COPD ?
Target organs
Respiratory system
Systemic
inflammation
Hypothesis Systemic Inflammation
Inactivity
Malnutrition
Inflammation
Intrinsic change
Blood flow redistribution
To respiratory muscle Decreased tolerance of
Exercise
20
80% 41
32
60%
49
40%
48
55
20%
31
11
0%
Healthy subjects FEV1>50% pred FEV1<50% pred
n=38 n=35 n=46
Bolton et al. AJRCCM 2004
Cardiovascular dysfunction in COPD
Abnormal blood gas tension
Disruption of
Endothelial pulmonary vascular bed
dysfunction
Abnormal
Increased
pulmonary mechanics
Blood velocity
Change in Increased
Blood volume Cardiac output
TORCH 3-year follow-up
Mod-to-severe COPD
"Mild" COPD – causes of death
Lung:35%
Cardiovascular:27%
Carcinoma:21%
[%]
50 25 % – 39 %
40
30
20
10
0
COPD cardiovascular Lung other
carcinoma
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5
COPD studies
(n=14)
Markers of
systemic
inflammation
CRP
RBF
Dopamine
↓ Effective renal plasma flow
↑Filtration fraction
↓ PaO2 ↑ Tubular Na -H + +
Dopamine
ANP ↑ Plasma renin activity
PRA (PRA)
Digoxin-like
substance
ANP ↑ Angiotensin II
Na+ retention
Ang II Natriuresis ANP
oedema
↑ Plasma aldosterone
Dopamine
↓ FRC
COPD SAHS
↓ V/Q matching
2-4% 10%
associated with REM ?
Anxiety in COPD
Psychosomatic Medicine 65:963-970 (2003)
2% -- 51%
Study Instrument Participants Results
Aghanwa et al., 2001 Clinical evaluation based on ICD-10 N = 30 patients with 10% of COPD patients met ICD-10 criteria
(6) COPD and 30 healthy for Generalized Anxiety Disorder compared
controls with 3.3% of health controls
Aydin et al., 2001 (7) Composite international Diagnostic N = 38 COPD patients 15.8% met DSM-IV criteria for Generalized
Interview (CIDI) Anxiety Disorder
Borak et al., 1998 Manifest Anxiety Scale (MAS) N = 49 COPD patients 49% had high levels of anxiety (scored 7–
(15) 10 on MAS); 51% had moderate levels of
anxiety (scored 4–6 on MAS)
Engtrom et al., 1996 Hospital Anxiety and Depression Scale N = 68 COPD patients 13% had pathological levels of anxiety
(16) (HADS) (>10 on HAD)
Karajgi et al., 1990 Structured Clinical Interview for DSM-III-R N = 50 COPD patients 16% had some anxiety disorder; 8% had
(10) (SCID) panic disorder
Kim et al., 2000 (17) Beck Anxiety Inventory (BAI) N = 43 COPD patients 32.6% had moderate to severe anxiety
(BAI > 15)
Kvaal et al., 2001 State-Trait Anxiety Inventory (STAI) N = 98 geriatric patients, COPD patients had higher on STAI than
(20) including 17 with COPD patients with heart disease, cancer, and
other medical problems
Light et al., 1985 (21) State-Trait Anxiety Inventory (STAI) N = 45 COPD patients 2% had moderate anxiety (>2 SD above
mean on STAI); 13% had mild anxiety (1–2
SD above mean on STAI)
Moore & Zebb, 1999 Panic Attack Questionnaire-Revised; N = 28 COPD patients 32% met DSM-IV criteria for panic disorder
(12) Anxiety Disorders Interview Schedule-IV
modified for self-report
Porzelius et al., 1992 Self-report frequency of panic attacks in N = 48 COPD patients 37% reported a panic attack
(13) last 3 weeks
Prigatano et al., 1984 Profile of Moods States (POMS) N = 985 COPD patients COPD patients scored significantly higher
(51) and 25 healthy controls than healthy controls on tension-anxiety
scale
Withers, Rudkin, & Hospital Anxiety and Depression Scale N = 95 COPD patients 29.2% had significant anxiety
White, 1999 (18) (HADS)
Yellowlees et al., Clinical psychiatric interview N = 50 COPD patients 24% had Panic Disorder; 10% had
1987 (5) Generalized Anxiety Disorder
Yohannes, Baldwin, & Geriatric Mental State Schedule N = 137 COPD patients 18% were clinically anxious
Connolly, 2000 (19)
Systemic Effects of COPD
COPD is a systemic disease that affects many
organs