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By Dr Hetty van Dijk, IPCRG web editor
Vienna, September 27 - October 1 2003
Last week 14,800 lung disease specialists from over 100 countries met in Austria's capital Vienna to attend the 13th Annual Congress of the European Respiratory Society. We offer you a closer look on some subjects of this scientific summit where respiratory clinicians, scientists, physiotherapists, medical equipment manufacturers and pharmaceutical industry representatives looked at how to stop the dramatic increase in respiratory diseases.
While Viennese inhabitants could have a free spirometry in an enormous tent on Herbert-von-Karajan Square, we made a personal selection out of 110 scientific sessions and over 4200 unpublished abstracts.
Dr. G. Thomson, WHO, Geneva, Switzerland: How SARS spread and was controlled Classic topics as asthma, COPD, tuberculosis, lung cancer were of course widely represented, but also the hot topic of SARS was in detail presented by Dr. D. Hui in whose hospital in Hong Kong, China, many patients and healthcare workers -who were special at risk- suffered from the disease. Very impressive equential X-rays and unsuccessful therapies passed by...... All speakers complimented the WHO for its rapid and professional control over SARS by unusual methods. Dr. A. Osterhaus from Rotterdam, The Netherlands, said the daily exchange of details between several leading virus institutes were until then very uncommon among scientists and it was due to efforts and support from WHO that this could happen. None of the speakers wanted to state that SARS will come back next year, but regarding the possible source and seasonal influences experts said they would be surprised if SARS would NOT return.
Round table discussion: Future in COPD. From left to right: Professor Rob Stockley, UK, Dr. Malcolm Johnson, UK, Professor Leo Fabbri, Italy COPD deserves great attention as it is the fifth leading cause of death now and is estimated to be the third leading cause of mortality within the next 20 years. Underdiagnosis is common, estimated as accounting for 50% of cases in USA and even 75% in Europe. This could be due to underreporting by patients who are ashamed about smoking habits or think their symptoms are the result of normal ageing and by physicians who think that COPD is untreatable. GOLD, the Global Initiative for Chronic Obstructive Lung Disease wants to stop this fatalistic views by informing patients and physicians that obstructive lung diseases should be treated to prevent exacerbations, progression and mortality and to improve patient's health status. Dr. O.C.P. van Schayck and others, from Maastricht, The Netherlands, provided a clear path for general practitioners in evaluating patients with potential obstructive lung disease. He suggests an age-stratified approach to the diagnosis based on asthma and COPD guidelines en epidemiology. In adults under age 40 (in whom asthma is the most common Obstructive Lung Disease) the challenge for physicians is to collect and properly interpret clinical information leading to the diagnosis or exclusion of asthma. In adults ages 40 years and older (in whom COPD is more common than asthma) persons presenting with respiratory symptoms and a positive history of exposure to respiratory irritants are candidates for a COPD case-finding approach, while an approach that focuses on differentiating COPD from asthma is more appropriate for persons presenting with prior evidence of respiratory disease. GOLD's 2003 updated guidelines now recommend long-acting beta2-agonists (LABA) and inhaled corticosteroid (ICS) combination therapy for patients with severe COPD (FEV1 < 50% predicted normal). Both patients with moderate and severe COPD experienced a reduction in COPD exacerbations and improvement in health status during LABA and ICS in combination therapy. The potential long-term effect of such treatment on the progressive and accelerated decline of lung function in COPD has yet to be determined. Tobacco cessation is the leading treatment of lung disease. Prof. B. Dautzenberg from Paris, France, is coordinator of the European Network for Smoke-free Hospitals (ENSH) who tries to implement standard therapy in European Hospitals. More than 1000 hospitals throughout Europe are in the process of becomeing smoke-free hospitals, following the 10-item ENSH code, a path that lasts 5-10 years. Dr. Eva Kralikova from Prague, Czech Republic, stated that tobacco dependence is a chronic and lethal disease, known as diagnosis F 17 according to international WHO-classification, and therefore, as any other disease, needs prevention and treatment. According to evidence based guidelines and WHO recommendation this treatment (psychobehavioral intervention + pharmacotherapy) should be implemented into health care systems. Doctors should be paid for this treatment and patients reimbursed for the pharmacotherpy, according to Dr. Kralikova. Professor Sonia Buist from Portland, USA, reported that COPD has historically been thought of as a disease that affects men. Until the past few years virtually all studies have shown higher prevalence and mortality from COPD in men than women. This picture has been changing since smoking has become more common in women, but is still not appreciated by many health care providers. Besides, heavy exposures to indoor air pollution as a risk factor (especially in developing countries) were not recognized as important risk for COPD. Therefore women are less likely to be given the diagnosis COPD and are less likely to have their lung function measured. Professor Buist stated that women are more equal than men in COPD and plead for better information for healthcare providers as well as the lay public showing that COPD is a common disease in women, is becoming more common, and that lung function should be measured in all who present with symptoms suggestive of COPD. Menopausal hormone treatment also known as hormonal replacement therapy (HRT), may lead to asthma or respiratory allergy, according a Norwegian study, presented by Cecilie Svanes from Bergen, Norway. HRT is under fire since earlier data showed that it is ineffective to prevent heart disease and might give rise to a higher risk of breast cancer. The responses of 2589 women from Norway, Sweden, Denmark, Estonia and Iceland aged over 45 were analysed for this study. The results show that women following HRT are 40 to 50% more likely to suffer from asthma or to exhibit asthma symptoms. The increased risk rises even to 60% in the case of allergic asthma. Women on HRT were 30% more often affected by hay fever and when the study was restricted to non-smoking women HRT practically doubled the likelihood of having asthma or hay fever! The Norwegian study also considered the possible link between asthma and oral contraceptives by analysing data from 6512 women aged under 45. The findings show that asthma and hay fever increase by about a third among women who take oral contraceptives. Dr. Svanes warned however not to be over-hasty in interpreting these findings and not to advise women against using a type of contraception that is believed to be effective, until we know more about what mechanisms are involved. It was during the Congress as a whole remarkable how carefully most scientists presented their conclusions and how carefully they considered some critical remarks from the audience. Concerning asthma scientists have regularly referred to the so-called "hygiene hypothesis" according to which bacterial exposure early in life may protect children against allergies in general and asthma in particular. This theory is bolstered by the results of Dr. Christine Cole Johnson and her team of the Biostatistics & Research Epidemiology Department at the Henry Ford Health System from Detroit, USA. This institution, founded by the automotive pioneer, has today over 2800 clinicians and 2.5 million patients. The study presented at the Congress includes 448 children monitored from birth to seven years. Nearly half of them received oral antibiotics within six months of birth. Results are quite striking as the increased risk of allergies or allergic asthma connected with the use of any antibiotic is no less than 73% and rises to 91% ( almost twice the background risk) for children whose mother had a history of allergies. For the use of broad spectrum antibiotics these figures are even worse: the relative risk is multiplied by 8.9 or even 11.5 in children who did not have two or more pets (believed to provide some protection against subsequent allergies). Specialists suggest that changes in the intestinal flora may be to blame as they have an impact on the development of the immune system. Dr. Johnsons message is clear: antibiotic use in early life is a risk factor for allergy in children, particularly those who already have other risk factors. Regarding asthma control Professor Tim Clark from London, UK, stated that there is still some way to go before the goals of guidelines are met and asthma control is achieved in the majority. GINA, the Global Initiative for Asthma, introduced guidelines to improve the awareness, diagnosis and management of the disease. Nevertheless implementation of the recommendations is poor and in particular the use of inhaled corticosteroids remains low. Dr. Peter Kardos from Frankfurt, Germany was even firmer in his statements. He said that the currently available asthma therapy is highly effective which enables even lifelong asthmatics with chronic airflow obstruction to have a normal life. Doctors however do not follow guideline recommendations, underestimate asthma severity and equate therapeutic success with a reduction in symptoms rather than aiming for complete control. Patients often underestimate their asthma: up to 50% of patients with severe persistent symptoms still consider themselves as well or even completely controlled. From fear of corticosteroids they may not follow doctor's advice to increase ICS dosage if necessary. ICS with or without LABA is now gold standard in the treatment of asthma, Kardos said, and appropriate treatment should allow the vast majority of patients to achieve complete control of their disease. Professor Eric Bateman from Cape Town, SA, pointed out that individual clinical endpoints alone are not enough to achieve asthma control. Recent studies provide evidence of superior control with bronchial challenge tests or markers of inflammation, but Professor Bateman admitted that such tests have obvious practical limitations in primary care setting. He therefore advised the use of questionnaire-based instruments with and without spirometry and some of them are currently being validated for wider use. Dr. Paul Dorinsky and his team from Raleigh, USA, analysed the relationship between asthma severity and asthma exacerbation risk in patients with persistent asthma. He stated that asthma is variable and unpredictable. From 51 patients who died of asthma 35% were diagnosed as having severe, 32% as moderate and 33% as mild asthma. Mild asthma is not always as mild as it seems and even patients with mild or moderate symptoms patients are at risk, said Dr. Dorinsky. He made clear that the severity of asthma can only be determined before treatment. Professor Leonardo Fabbri from Modena, Italy, presented an overview of new data in asthma therapy today. Key dilemmas facing many physicians are the choice of initial therapy and how to manage patients who are symptomatic on ICS. Asthma is regarded as a two-component disease, consisting of both chronic airway inflammation and acute bronchoconstriction. The advent of combination therapy by adding LABA to ICS has made a significant impact on asthma therapy today. Regarding the combination salmeterol/fluticasone propionate (SFC) Fabbri spoke from "really revolutionary". Recent data suggest that this treatment approach may be advantageous as initial maintenance therapy. Professor Bo Lundback from Stockholm, Sweden, demonstrated that also in mild or moderate asthma SFC is superior to the use of salmeterol and fluticasone proprionate administered alone in controlling patients' asthma. Existing data suggests also that the two components in combination work together in synergy to produce greater improvements in lung function than the two drugs given separately, which means that one plus one is more than two. Summarized is step one in asthma treatment daily low dose ICS (FDA advises never to give salmeterol alone in asthma). If patients remain symptomatic on low doses ICS do not enhance ICS, but add LABA and if necessary leukotriene antagonists (not in severe COPD). Dr. K.P. Hui and dr. R. Ihsan from Singapore, Singapore, showed that language is a significant risk factor for severe persistent asthma (according GINA classification grade 4). Diagnosis and assessment of asthma is heavily dependent on history. A major symptom of asthma is wheeze, for which the linguistic equivalent may not be available in many languages. For example it is not available in the three major languages in Singapore: Chinese, Malay and Tamil. Data of 200 patients with high risk asthma were studied and the results show that patients who were unable to speak English when compared to English-speaking patients within the same ethnic groups, were more likely to have severe asthma. The authors suggest that impediment of language in communication is likely to have an impact on asthma at multiple levels, including delayed diagnosis, underestimation of severity and undertreatment of asthma. Speaker told physicians to be aware of linguistic impact in multi-ethnic communities with patients who are unable to speak English and verbalize wheeze or other symptoms well. Dr. Boris Vengerov from Kiev, Ukraine, presented a poster about pharma-economic implications of an asthma educational programme (EP) for GPs in Ukraine. This programme was launched in 10 bigger cities in 2000 with the aim to improve diagnosis and treatment of asthma (switch to inhaled beta-agonists from systemic treatment and introduction of inhaled maintenance therapy). In cities with EP there was a statistically significant decrease in average cost of hospital spend per patient (from 183 to 87 USD pp) as well as costs of emergency care (from 52.3 to 16.7 USD pp) but increase in cost of pharmacotherapy (from 2.9 to 44.7 USD pp). This was to be expected as GPs inhalation therapy prescriptions increased from 17.4% end 1999 to 91.4% at the end of 2002. Interesting factor is that the introduction of new treatment led to a shift from government-born spends to costs of pharmacotherapy which for 87.5% are patients-born costs due to poor re-imbursement. In a second poster ("Can asthma patients cope with new treatment regimens in Ukraine?") dr. Vengerov explained however that an absolute majority of patients were found to be extremely reluctant to switch back to systemic treatment.
German swimmer Sandra Voelker Famous and ordinary patients told their story about the burden of having a respiratory disease. German swimmer Sandra Voelker (29) (63 international medals, 11 world records) was diagnosed as having asthma three months before the Olympic Games in 2000. She showed however that asthma does not stand in the way of achieving her goals. Sandra declared that incidentally she has "bad days" of which she thinks psychological factors play an important role. Those days interfere with her life as a top level athlete, but on the other hand on good days she doubts the docter's diagnosis. Her asthma seems well controlled with the use of a combination of ICS and LABA. Being asked after her next goals she mentioned the 2004 Olympic Games in Athens, "and I want to win medals" she added. Even impressive was Dr. Voshaar's COPD patient from Germany. This 45 year old man first got the diagnosis asthma but as treatment failed after 18 months he went to another chest physician and was confronted with the diagnosis COPD. Specific treatment improved his symptoms but he still had audible and visible symptoms of breathlessness due to which he was unable to work. 3,700 square metres were hardly enough to house visitors and more than 100 booths in the commercial exhibition where one could find the newest instruments, medications, books and other medical equipment. Handhold spirometers, lightweight oxygen bottles, snore and exhaled NO analysers were tested, inhalation techniques exercised, autofluorescence bronchoscopes practised, quiz questions puzzled out and many many trees fell to provide the visitors with tremendous amount of information materials. An interesting Congress, perfectly organised, in pleasant inside and outside surroundings provided us with lots of new ideas for practice and patients within the next future.
Dr. Anne Greenough, UK: Prediction of chronic lung disease in prematurely born infants
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