Scientific Program

Day 1 :

Keynote Forum

Nanshan Zhong

First Affiliated Hospital of Guangzhou Medical University, China

Keynote: Early Management of cChronic Obstructive Pulmonary Disease

Time : 10:00-10:40

Biography:

Nanshan Zhong is an Academician of Chinese Academy of Engineering, Medical Professor of Guangzhou Medical College, and a PhD tutor of respiratory medicine. Over the past decades, Prof Nanshan Zhong has been a leading scientist in promoting China’s respiratory medicine towards the forefront of international advances. In a systemic review of aetiology of chronic cough in China, he elucidated the neuroinflammatory mechanisms to gastroesophageal reflux-induced cough. For the first time, his methods for diaphragm function assessment during exercise demonstrated protein-energy malnutrition in even 60% of patients with early to middle stage COPD, which generated a correction equation of basic energy intake in this cohort. A national epidemiological study steered by him showed the unprecedented prevalence of COPD in China. His famous research found that hydro sulfuryl-containing expectorants (carbocysteine) can be effective in preventing or reducing acute exacerbation of COPD.

Abstract:

Prevalence of COPD increased by 67% from 2004 to 2015 in China (13.7% in >40 years population). [1, 2] Among patients population >92% were characterized as stage I & II, which are always neglected by physicians and patients.

By using Endobronchial Optical Coherence Tomography and exercise test, those patients present with apparent small air way remodeling and less exercise tolerance.  [3] The earlier the staging, the faster the annual declining of FEV1. [4] Patients may not present with dyspnea (even exercise dyspnea) until their FEV1 dropped to ≤50% predicted. Early intervention may ameliorate disease progression. Community based integrated intervention (medical education, smoking cessation, improved air pollution and short cause SAMA) significantly reduced the incidence of COPD and annual decline of FEV1.[5] In a two-years “Tie-COPD” study, we have firstly demonstrated that regular use of inhaled Tiotropium (18 µg qd  two yrs )significantly improved trough FEV1 (127-169ml), FVC (116-164ml), annual post bronchodilator FEV1 decline rate, CAT score, CCQ score and exacerbation rate in stage I to II patients, even in the subgroup with CAT <10 [6], suggesting an active intervention of stage I to II COPD may greatly improve lung function and reverse (or partly reverse) disease progression.

We suppose that the strategy of the management of COPD may move to the upstream of the disease, which may alleviate the progression of COPD ,similar to the management of early stage of hypertension or diabetes .

Keynote Forum

Masaaki Kusunose

National Center for Geriatrics and Gerontology, Japan

Keynote: Frailty and patient-reported outcomes in subjects with chronic obstructive pulmonary disease

Time : 10:40-11:20

Biography:

Masaaki Kusunose is a pulmonologist working at the Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan. A few years ago, he used to work on basic experiment about the mechanism by which lung cancer cells acquire worse phynotype and how to intervene that alteration at the Department of Respiratory Medicine, Nagoya University Graduate School of Medicine. He is now working as a physician and also engaged in clinical research related to the association between chronic lung diseases and frailty.

 

 

 

Abstract:

Introduction: Age is known to be a risk factor for COPD and also a predictor of mortality and hospital admission for exacerbations. Frailty is a geriatric syndrome recognized as a clinical state of physical, psychological and social vulnerability that embodies an increased risk of the requirement of care. The purpose of this study is to explore the relationship between frailty and physiological and patient-reported outcomes (PROs) in subjects with stable COPD.

Methods: We administered the Kihon Checklist that has been validated for frailty screening. We also assessed patient-reported measurements of health status and dyspnea using the COPD Assessment Test (CAT), the St. George’s Respiratory Questionnaire (SGRQ), the Hyland Scale, the Medical Outcomes Study 36-item short-form (SF-36), the Baseline Dyspnea Index (BDI) and the Dyspnea-12 (D-12). We also measured pulmonary function.

Results: Of 79 consecutive COPD outpatients, 38 (48.1%), 24 (30.4%) and 17 (21.5%) subjects were classified as robust, prefrail and frail, by using the total score of the Kihon Checklist. That score was significantly correlated with the CAT score (Spearman’s rank correlation coefficient (Rs)=0.38, p<0.01), the SGRQ total score (Rs=0.65, p<0.01), the Hyland Scale score (Rs=-0.54, p<0.01), all subscale scores of the SF-36 (Rs=-0.64 to -0.31, p<0.01), the BDI score (Rs=-0.46, p<0.01) and the D-12 score (Rs=0.41, p<0.01). We found no or only weak correlations between the total score of the Kihon Checklist and lung function measurements. Using stepwise multiple regression analyses to identify the variables that predicted the total score of the Kihon Checklist, the SGRQ total score alone significantly explained 49.1% of the variance (p<0.01).

Conclusions: Frailty seems to be associated with PROs, especially health status, unlike lung function. Frailty should be assessed in addition to PROs separately from lung function as part of multidimensional analyses of COPD.

Biography:

Dr. Luo is a director of Respiratory Physiological Laboratory and Sleep Center of the First Affiliated Hospital of Guangzhou Medical University. He has served as a member of the expert committee of National Natural Science foundation of China (NSFC).  He graduated in 1984 with a Bachelor degree of Medicine from Guangdong Medical University and obtained a PhD degree from King’s College of London University in 2001.  He joined State Key Laboratory of Respiratory Disease of China in 2004 and has been a Professor of Respiratory Medicine since then.  His research interests focus on neural respiratory drive in patients with COPD, sleep disordered breathing and has published more than 100 peer review papers in the leading international journals. He owned more than ten patents and has developed a system for measurement of neural respiratory drive, which has been worldwide used

 

Abstract:

Background:  In COPD, functional status is improved by pulmonary rehabilitation (PR), but requires specific facilities.  Tai-Chi, which combines psychological treatment and physical exercise and requires no special equipment, is widely practised in China and is getting more and more popular in the rest of the world. We hypothesized that Tai-Chi is equivalent (i.e difference < ±4 SGRQ points) to PR.  Methods:  120 patients (mean forced expiratory volume in one second, FEV1, 1.11±0.42 l, 43.6 % predicted) bronchodilator naïve patients were studied.  Two weeks after starting indacaterol 150µg daily, they randomly received either standard PR thrice weekly or group Tai-Chi five times weekly, for 12 weeks.  Primary endpoint was change in SGRQ before and after the exercise intervention; measurements were also made 12 weeks after the end of intervention. Results:  The between group difference for SGRQ at the end of the exercise interventions was -0.48 (95% confidence interval (95%CI) PR vs Tai-Chi -3.6 to 2.6, p=0.76) excluding a difference exceeding the minimal clinically important difference.  Twelve weeks later the between group difference for SGRQ was 4.5 (95%CI 1.9 to 7.0, p<0.001), favouring Tai Chi.  Similar trends were observed for six minute walk distance; no change in FEV1 was observed.  Conclusion:  Tai-Chi is equivalent to PR for improving SGRQ in COPD.  12 weeks after exercise cessation, a clinically significant difference in SGRQ emerged favouring Tai-Chi.  Tai-Chi is an appropriate substitute for PR.

Session Introduction

Camilo Corbellini

Milan University, Italy

Title: Measurements of Diaphragmatic Mobility in COPD Patients
Speaker
Biography:

Camilo Corbellini is a skilled Respiratory Physiotherapist, with experience in the treatment and research of respiratory diseases, in adult and elderly patients. Graduated in Brazil in 2002, since 2010 living, studying and working in Italy. MSc in Medical Sciences (Brazil) and in Respiratory Physiotherapy (Italy). PhD in Physiology at Milan University. Happy father.

Abstract:

The COPD causes a not fully reversible airway obstruction and also changes in the rib cage structure. Those modifications lead to respiratory muscles functional inefficiency that is strongly correlated to lung function loss. Specifically, the diaphragm undergoes a progressive process of muscle fibers shortening, a consequence of lung hyperinflation and dead space increase. This results in a chronic mechanical disadvantage that impairs diaphragm’s mobility. This impairment may worse in COPD exacerbations, improving after pulmonary rehabilitation. The diaphragmatic mobility (DM) is mostly assessed with techniques that exposes the patient to risks. The ultrasonography in M-mode is easy to use, is safe and measures directly the diaphragmatic dome displacement. The study aimed to determine whether the COPD, according to the subject’s COPD severity, impairs the DM and to verify DM improvements after an inpatient pulmonary rehabilitation. We performed lung function tests and diaphragmatic M-mode ultrasonography in COPD individuals and healthy subjects. Ultrasonography was performed during rest breathing and deep inspirations. The COPD subjects underwent a six-minute walk test and arterial blood gas analyzes. After initial screening, 46 COPD patients ended the rehabilitation. The mean characteristics of healthy individuals and COPD subjects. The DM during Rest Breathing and Deep Inspirations were correlated to FEV1 decrease (r=0.74; p<0.01 and r= - 0.8; p<0.01, respectively). (figure 1). The correlation were also positives between the Deep Inspiration and the Inspiratory Capacity (r= 0.64 with p<0.001). After the rehabilitation the DM increases during deep inspiration from 4.58cm±1.83cm to 5.45cm±1.56cm (p<0.01). We concluded that M-mode ultrasonography showed that DM impairment is correlated to lung function loss in COPD subjects. The patients who completed the rehabilitation improved the diaphragmatic mobility verified during deep inspirations.

Alan Kaplan

Family Physician Airways Group of Canada, Canada

Title: Anti-Inflammatory Reliever; A new Paradigm in Asthma Treatment
Speaker
Biography:

Dr Alan Kaplan is a Family Physician working in York Region, Ontario, Canada and the Chairperson of the Family Physician Airways Group of Canada (www.fpagc.com), the Past- Chairperson of the Respiratory Section of the College of Family Physicians of Canada, and Senate member of the International Primary Care Respiratory Group. He co-chaired the Community Standards of COPD program for Health Quality Ontario. He is the medical director of the Pulmonary Rehabilitation program for the local health integration network

Abstract:

Despite advances in Asthma management, we still have remarkable levels of poor control, asthma exacerbations and even death. We need to rethink how we approach Asthma and the recent Lancet commission on Asthma has supported this[i]. Basic issues such as inhaler technique and adherence[ii] continue to be major issues.

Dr. O'Byrne and all have recently written a paper[iii] on the Paradoxes of Asthma management, which highlights some of the common issues which include:

a)  SABA (short acting beta agonist) as foundation/initial therapy

b)  overuse of LABAs a concern, but SABAS are not?

c) poor patient self control in GINA stage > 2

d) asthma is an inflammatory disease, so why do we rely so on bronchodilators

e) patients and clinicians do not agree on what 'Asthma Control' means to them.

As adherence to the key treatment, inhale corticosteroids  (ICS)is often low, solutions to the adherence issue are needed. One of the solutions, is to work with the patient's own behaviors to improve adherence. As such, using an Anti-inflammatory reliever rather than a SABA to ensure the that ICS are used.

There is a great deal of data on inhaled budesonide/formoterol as controller and reliever in GINA stages 3-4, and now there is evidence in stages 1 and 2 as well[iv],[v]. This will be reviewed and you will rethink how you use reliever therapy in Asthma, even in mild cases!

 

Speaker
Biography:

Miss Tadsawiya Padkao is a lecturer in physical therapy program at Burapha university. She has been experienced in clinical rehabilitation of COPD patients and elderly, and also, she interests investigate on impact of air pollution in northern and eastern of Thailand to pulmonary functions

 

 

 

Abstract:

Statement of the Problem: Expiratory airflow limitation is the pathophysiological significant of COPD that leads to air trapping and increases in dynamic hyperinflation (DH), consequently causes dyspnea during exercise and prolongs recovery time. Positive expiratory pressure (PEP) has been widely used in the management of lung where airway collapse is a problem. Therefore, the purpose of this study was to examine the effects of Conical-PEP, a new PEP device, on DH and recovery time in COPD. Methodology: A crossover study, which had been approved by the local ethics committee, was carried out in 8 patients with mild to moderate COPD (Age 55.75±9.82 yrs, FEV1 58.00±8.77 %predicted, FEV1%  66.38±12.91). Patients undertook five-minute knee extension exercise at 30% of 1RM while breathing out through the mouth with (Conical-PEP) or without (Control) the device.  DH was evaluated by change in the inspiratory capacity (IC) measured immediately at the end of exercise compared pre-exercise values. Recovery time was record when their  heart rate was returned to HR resting. Respiratory rate (RR), expiratory time (Te) and mouth pressure were also measured during exercise. Conclusion & Significance: During exercise with Conical-PEP, positive expiratory mouth pressure was 12.85±4.03 cmH2O.  IC was larger 0.18±0.10 liters in Conical-PEP than Control (2.8±0.1 vs 2.6±0.1liters, respectively, p<0.05).  Te was prolonged compared to the Control condition (2.2±0.3 vs 1.5 ±0.2 s, respectively, p<0.05). RR in the Conical-PEP condition was slower compared to Control (19.0±1.7 vs 25.1±1.7  bpm, respectively, p<0.05). Recovery time of Conical-PEP was reduced 88.0±43.6 s compared to Control  (290±51.4 vs 378±79 s, respectively, p<0.05). This study provides data indicating that Conical-PEP generates sufficiently high positive expiratory pressures to allow effective lung emptying and prevent DH during exercise and contribute to decrease recovery period  in COPD.  Further studies are indicated to determine how useful Conical-PEP can be for a wider population.

 

Speaker
Biography:

Buckingham,MD, FACP, practising internist for 39 years, author, and patient advocate, has dedicated a lifetime to the understanding of how chronic inflammation is evoked within interstitial spaces. Through his recently published books, he exposes the chronic inflammatory underworld and how it does its dirty business to transform end organ interstitial spaces into a sea of diseases. These books dissect what is currently known about inflammation to clarify how chronic inflammation disables the signalling apparatus of the protective capillary cells and then proceeds to dismantle all of the cells within the interstitial space that capillaries are allied with. In the end, after mission accomplished, the interstitial space footprint now belongs to chronic inflammation and the anti-organ. In this final apocalypse, capillary cells have long since stopped dancing, and their feedback loop signals to the allied partners have been replaced by rogue influences. White blood cells, cytokines, platelets, and immunoglobulins within the darkened corners of end-organ interstitial spaces now belong to chronic inflammation. The interstitial spaces become barren and lifeless as we know it. A perfect backdrop for cancer, pain, fatigue and ageing.  

Abstract:

Unfortunately, with chronic particulate/smoke inhalation, the immune arsenal sequencing with lung alveoli breaks down as the capillary cell dance is nullified and its infrastructure, outer membrane receptors and mitochondrial mass decline. As capillary cell choreography fails and their outer membranes enable the leaking of additional hostile influences into the interstitial space, proinflammatory chain reactions develop. Capillary (and endothelial) cell mitochondria overheat, as they get stuck in energy combustion. This increases production of superoxide free radicals (or reactive oxygen species or ROS), which subsequently drain antioxidants used to neutralize them and then damages DNA in its path. This disrupts protein synthesis coding utilized for repair/replacement of anything worn out within the capillary cell.

Capillary cell infrastructure cracks feed proinflammatory momentum as they perpetuate more and more rogue immune arsenal entrance into the interstitial space thereby punctuating an even greater disparity of useful cytokines signaling. Eventually these devious signals become so prominent that when coupled by a crippled capillary cell feedback loop signalling system, they overrun the interstitial space with their own hostile brand of rogue signalling. This welcomes the chronic inflammatory matrix into the interstitial space. 

In the lung alveolus, persistently inhaled hydrocarbon particulates, gases or allergens from dirty air serve as vascular inflammatory free radical fuel. In aggregate, they fester within interstitial spaces to trigger the eventual takeover by hostile white blood cells of interstitial space feedback loops, while they hijack disabled capillary cell outer membranes. Together, the particulate/hydrocarbon fuel, the rebel white blood cells, and the feedback loops signalling system they elicit become the tools of a chronic inflammatory agenda.  As chronic inflammation within lung alveolar surfaces unfolds, cough, bronchitis and wheezing eventually breed scarring (COPD), cancer, and serious infections (pneumonia).