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Conflict of interest. Bilimsel Danışma Kurulu, Kongre/toplantı sponsorluğu, konuşmacı veya bilimsel araştırma desteği sağlanan kuruluşlar (Harf sırasına göre sıralanmışlardır) AstraZeneca Boehringer - Ingelheim Chiesi GSK Novartis Nycomed TÜBİTAK. - PowerPoint PPT Presentation
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Bilimsel Danışma Kurulu, Kongre/toplantı sponsorluğu, konuşmacı veya bilimsel araştırma desteği sağlanan kuruluşlar(Harf sırasına göre sıralanmışlardır)
AstraZenecaBoehringer-Ingelheim
ChiesiGSK
NovartisNycomedTÜBİTAK
Conflict of interest
Nonsmoking risk factors in COPDEnvironmental and occupational exposure
Dr. Mehmet Polatlı
Smoking is the most important risk factor in COPD. But not the only one.
COPD due to smoking “Population attributable fraction,PAF” is usually < % 80
COPD prevalance in never smokers % 3-15 (BOLD, PLATINO)
PAF is lower in young adults, women and lower developed economics
OTHER RISK FACTORS?
RISK FACTORS EXCEPT SMOKING
Genetics Chronic asthma Air pollution and passive smoking Occupational exposure Biomass Diet
Factors effecting lung function and COPD development
Speizer and Tager
Cellular inflammation in COPD
Lung and ambient air 400 L oxygen/day 10.000 L air inhalation/day İndoor and outdoor air pollution
Primary pollutants: SO2, NO2, CO, CO2, UOB, PM, NH3, Pb, etc
Secondary pollutants: Ozon (O3) ve NO2 Particulate matter (PM) suspended particles in the air
(diesel exhaust, energy sources)▪ < 10 µm PM10 2.5-10 µm course PM; ▪ <2.5 µm PM2.5 fine PM; < 100nm ultrafine PM
Proposed levels of pollutants for clean air
150 400 100 300 150 300 240Türkiye Hava Kalitesinin korunması yönetmeliği 1986
Increased populationUrbanizationIndustrilizationVarious consumptionConsumption fossil fuelVehicle trafficTopographic characteristics of the
landGeografical reasons
Ambient air pollution factors
Acute effects of air polllution
Increase in symptoms Decrease in lung function Increase in seeking medical advice Increase in emergency consult Hastaneye admission Mortality
Sunyer J, Eur Respir J 2001, Review conclusion
The effects of ambient air pollution on inflammation Increase in ROS and inflammation Direct toxic effects of the particulates İnflux of inflammatory cells in the airways Macrophages stimulation Intertitial stimulation Decrease in mucociliary clearance Increase in epitelial permeability Pulmonary vasculature
MacNee, Donaldson, Review in Eur Respir J, 2002 Ling SH el al. International Journal of COPD 2009:4
Is there chronic effects of air pollution?
When do the effects of the polutants begin?
How do the symptoms and pulmonary function change?
Does it effect on PFT after going away from the pollution area ?
Does the mortality increase?
The factors effecting lung function and development
Speizer and Tager
Air pollution and COPDSunyer J. ERJ 2001
Air pollution and COPD Sunyer J. ERJ 2001 …conclusion
CB and emphysema increase in NHANES and AHSMOG studies
Dyspnea and mucus hypersecretion in SAPALDIA
Lower PFT values in cross-sectional studies
air pollution is related to an increased prevalance in COPD.
The effects of air pollution begins antenatal period
Latzin P et al. Air pollution during pregnancy and lung function in newborns: a birth cohort study. ERJ 2009
The effects of air pollution begins antenatal period
> 200 chemical and pollutants’ presence in umblical cord suggests that placenta is not have a role in barrier agaşnst these substances
Low birth weight,, preterms and increased perinatal mortality
Sudden baby death syndrome commonLatzin P et al. ERJ 2009
Neonatal and childhood period
Neonatal period significant association between O3, CO, SO2, NO2 and respiratory problems
The most significant association is between NO2 and O3
Lung Function Growth in Children with Long-Term Exposure to Air Pollutants in Mexico City. AJRCCM 2007
3170 children, 3 years follow, 7 PFT measurement
Deficits in FVC and FEV1 growth over the 3-year follow-up period were significantly associated with exposure to O3, PM10
and NO2 increase in mean O3 concentration
was associated with an annual deficit in FEV1 of 12 ml in girls and 4 ml in boys
Chronic bronchitis symptoms are associated with COPD risk
11 years follow up Aged: 18-60 years COPD OR 1.23 after adjusted for age, sex,
education, smoking, asthma, wheezing
Probst-Hensch N et al. Swiss SAPALDIA Study, Thorax 2010;65:150-156
Asthma, CB and emphysema in the parents increase the effects of air pollution
20 years follow up in nonsmokers. PM, Sulfates, SO2 and O3 effects on PFT.
1391 nonsmokers. In case of asthma, bronchitis and empysema
history in family PM10>100g/m3 increase (54 days/year) FEV1
decrease associate with % 7.2 Mean 8 hours O3 23 ppb increase FEV1 decrease
% 6.3 Males SO4 density 1.6g/m3 increase FEV1 decrease
% 1.5 AM J RESPIR CRIT CARE MED 1998;158:289–298.
Improvements in PM10 Exposure and Reduced Rates of Respiratory Symptoms in a Cohort of Swiss Adults (SAPALDIA)
SAPALDIA 1991, 9651 adults SAPALDIA 2002, 7019/8047 adults PM10 decrease effect on symptoms. PM10 mean decrease level 6.2 µg/m3 Improvements in PM10 Exposure Reduced Rates
of Respiratory Symptoms in a Cohort of Swiss Adults
▪ Schindler et al. 179 (7): 579. (2009)
Respiratory Research 2005, 6:152
Seventh Day Adventist StudyAbbey DE et al. Environmental Health Perspectives
6102 adults follow up; obstructive airway disease and doctor diagnosed COPD
obstructive airway disease and chronic bronchitis total particulates >200 µg/m3 and exposure duration>1000 hours/year risk 1.36 ve 1.33.
European Prospective Study into Cancer and Nutrition (EPIC) Study
EPIC, 3904 adults in Atina 168 healthy control (mean FEV1/FVC:% 102) 168 COPD symptomatology(+) PFT and
examination 84 CB, empysema or COPD KOAH NO2 and black smoke index in the last 5 years Eposure ¼ increase, disease risk increase % 37
When most of the subjects exposed are
considered vs. all others, there is a twofold increase in disease risk
Karakatsani et al. J Epidemiol 2003;18(1):45-53
Naess et al . Relation between Concentration of Air Pollution and Cause-Specific Mortality: Four-Year Exposures to Nitrogen Dioxide and Particulate Matter Pollutants in 470 Neighborhoods in Oslo, Norway. Am J Epi 2007 143.842 aduts; 51-70 ve
70-90 years NO, PM10, PM2.5 effects Air pollution associated
with mortality NO2 > 40g/m3 significant chronic obstructive
pulmonary disease and the elderly seem to be susceptible to air pollution at lower levels than the general population
persons discharged alive with chronic obstructive pulmonary disease
PM10’da 10µg/m3 increase mortality % 22
Environmental Health 2008, 7:48
Strong evidence of association outdoor pollution and decreased lung growth in adolescence and childhood
Few study with spirometry but suggestive evidence with air pollution and COPD
The likelihood of the role of air pollution with COPD is high because of PFT results
PM ve FEV1, COPD
Sean H Ling, Stephan F van Eeden. International J COPD 2009.
PM ve COPD PM inhaled from cigarette smoke or ambient air
pollution particles from other sources both have been associated with the development and progressionof COPD
With the rapid urbanization of the population, a better understanding of the importance is necessary for educational and preventative measuresSean H Ling, Stephan F van Eeden. International J COPD 2009.
Environmental tobacco smoke
Ventilation decreases the cigarette smoke indoors but doesn’t decrease health risks
TC Sağlık Bakanlığı. Türkiye Kronik Hava Yolu Hastalıklarını Önleme ve Kontrol Programı.Kasım 2010
Environmental tobacco smoke and CB (SAPALDIA) ETS (+) and (-) 4.197 nonsmoker (18-60 yaş) Cross-sectional analysis
CB OR 1.65 (1.26-2.14) Dispnea OR 1.43 (1.18-1.74)
Leuenberger et al. AJRCCM 1994
Environmental tobacco smoke and COPD 2.113 adults , 55-75 aged; telephoned
ETS history Prenatal, home and work place Doctor diagnosed CB, Empysema, COPD
OR 1.55 (CI 1.09-2.21) PAF home ETS % 11, work % 7
public policies aimed at preventing public smoking may reduce the burden of COPD-related death and disability, both by reducing direct smoking and ETS exposure.Eisner MD et al. Environmental Health: A Global Access Science Source 2005, 4:7
Passive smoking exposure and risk of COPD among adults in China
Yin et al. Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study.Lancet 2007; 370: 751–57.
ETS and COPD risk
Exposure level ETS in home and work
Outcomes Chronic respiratory symptoms COPD (FEV1/FVC < % 70)
Exposure densitySmokers in homeSmokers in work
Exposure duration
Hours/weekExposure
duration (yıl)
Exposure burdenLow<2 yıl;40
s/hfMod 2-5 yıl; 40
s/hfHigh>5 yıl; 40
s/hf
Yin et al. Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study.Lancet 2007; 370: 751–57.
ETS and COPD
Yin et al. Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study.Lancet 2007; 370: 751–57.
ETS and Symptoms
Lancet 2007; 370: 751–57
ATS statementETS and COPD
American Thoracic Society Documents: An Official American Thoracic Society Public Policy Statement: Novel Risk Factors and the Global Burden of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med Vol 182. pp 693–718, 2010
ETS and COPD in Sivas
74 COPD females and 74 healthy controles Biomass > 30 years OR 6.61 (%95 CI 2.17-
20.18) ETS> 30 years OR 4.96 (% 95 CI 1.65-
14.86)
ETS in South East Turkey
> 40 years of age males, 63/348 COPD (% 18.1)
Cafe for regularly OR 5.37 Cafe visit/week OR 2.72 Cafe visit/month OR 2.33
Turk J Med Sci 2010; 40 (3): 349-355
PAR %11
PAR % 7
Environmental Tobacco Exposure Are Enhanced by Bronchial Hyperreactivity(SAPALDIA 1991-2002)
Am J Respir Crit Care Med Vol 174. pp 1125–1131, 2006
Occupational dust and chemicals
Organic and inorganic dusts and chemicals, gases
Some agents in experimental studies CBendotoxin, mineral dust, SO2, vanadium) emphysema Kadmium, coal, endotoxin, silica
An Official American Thoracic Society Public Policy Statement: Novel Risk Factors and the Global Burden of Chronic Obstructive Pulmonary Disease 2010
Multifactorial (host, others) Differantiation is difficult from the disease
caused by other agents Most workers are smokers and/or irritants in work Healthy workers effect Follow up difficulties after leaving work There is no subgroup like occupational asthma.
Chronic, slow progression Irreversibl after leaving work
Difficulties in the assessment occupational and COPD association
Kuempel ED et al. Contributions of Dust Exposure and Cigarette Smoking to Emphysema Severity in Coal Miners in the United States. AJRCCM 2009
Sigara içmeyen grup Sigara içen grup
Kauffmann, F. J Epidemiol 1979
Additif effects
Only occupational exposure OR 1.4 Only smoking OR 2.8 Smoking and occupational exposure
OR 6.2
▪ Trupin et al. ERJ 2003
median PAR % 19
median PAR % 15
KOAH Median PAR % 15
Occupational exposure and PAF
ATS statement 2010: median PAF % 15-20
GOLD 2009 Hnizdo 2002, NHANES III Study Occupational PAF % 19.2 but in nosmokers % 31.1.
Conclusion Classical example for interactive relation
of gene and environment.Toxic gasses and particules effect the lung additively.
Defining risk factors other than smoking and taking measures is important
ETS and ambient air pollution contribute COPD.
Occupational exposure should be taken into account.