Professor Lutz BeckertAcademic Head

Department of Medicine Respiratory

University of Otago

Christchurch

7:00 - 8:00 GlaxoSmithKline Breakfast Session

The Big Five in Respiratory Medicine

Lutz Beckert

• I have not received an honorarium from GSK for this presentation

• I do not hold shares in GSK

What are the Big Five in Respiratory Medicine?

Pneumonia

Tuberculosis

Lung cancerCOPD

Asthma

Pneumonia

Tuberculosis

Lung cancerCOPD

Asthma

Pneumonia

• How did the UK achieve a reduction in the pneumonia mortality?✓ Perform a CXR within 4 hours of

presentation

✓ Assess the severity using the CURB65 score

✓ Administer the first dose of antibiotics within 4 hours

Who do you think did better?

• Pakistan and Afghanistan are among the countries were 49% of all child death occur.

• Lady Health Workers were trained to recognise and treat pneumonia

• Stop watch and thermometer• Amoxicillin

• Referral to hospital

Overall the study suggests that community identification and management of severe pneumonia in children 2 – 59 months with a 5 day course of oral amoxicillin was safe and clinically not inferior to referral to a health care facility or care provider

Local resistance profile

• Streptococcus Pneumonia 50%

• Mycoplasma, Chlamydia and Legionella Pneumonia 20 -30%

• Viral pneumonia 10 – 15%

• Haemophilus influenza pneumonia 5%

The role of vaccinations

Legionella pneumonia

Clinical case vignette – what would you do?

You are seeing a 67-year-old woman with mild Alzheimer's disease with a 2-day history of productive cough, fever, and SOB in a rest home.

Her temperature is 38.4°C, the blood pressure is 145/85 mm Hg, the respiratory rate is 30 breaths per minute, the heart rate is 120 beats per minute, and the oxygen saturation is 91% on air. Crackles are heard in both lower lung fields.

She is oriented to person only. Her WCC is 4; Na+130 mmol/L, and her urea 9.0 mmol/l. A radiograph of the chest shows infiltrates in both lower lobes.

How and where should this patient be treated?

Clinical case vignette – CAP

This patient has a CURB-65 score of 4, suggesting that she would benefit from inpatient therapy. She has at least four minor criteria for severe community-acquired pneumonia (confusion, respiratory rate ≥30 breaths per minute, multilobarinfiltrates, and uremia).

She would benefit from further evaluation. We would initiate treatment with beta-lactam antibiotic and azithromycin. Influenza testing should be requested if she has presented during the appropriate season.

Blood cultures or attempt to obtain sputum cultures should not delay treatment for the usual treatment for community-acquired pneumonia.

Pneumonia

Tuberculosis

Lung cancerCOPD

Asthma

TB – the voiceless and forgotten disease

New Zealand

• 6 / 100.000

• Stable for six years

• Lowest since 1980’s

• Case born outside NZ = 100%

• Use of DOT 100%

Globally

• 126 / 100.000

• Reduction by 1.5%

• The global goal to ‘hold TB’ has been achieved

• The reduction is falling short to reach the WHO goals• Cut TB death by 90% in 2025• Reduce TB burden by 80% in 2030

TB Notifications NZ and Wordwide

Stop TB complain - WHO

Humanitarian front

New Zealand

• In the UK 2320 cases of TB in Health Care workers were identified• 23 / 100.000 in Health Care workers• 16 / 100.000 in non- Health Care

workers• After stratifying by country of birth,

epidemiology and genotyping – only 10 confirmed nosocomial transmission occurred.

• Only two from the Health Care Work to the patient

Case Vignette TB

Case Vignette 2

Case Vignette 3

Case Vignette 4

Pneumonia

Tuberculosis

Lung cancerCOPD

Asthma

Probability of cancer in Pulmonary Nodules Detected on CT• http://www.nejm.org/do/10.1056/NEJMdo005003/full/

Health Pathways

Immunotherapy: third wave in cancer treatment

• Chemotherapy – 1980• Cisplatin or Carboplatin based regimes

• Targeted therapy – 2000 onwards • EGFR mutations• Tyrokinase inhibitors: Erlotinib, gefitanib, alfatinib, ….

• Immuno-oncology – last few years• Activating the own immune system• Nivolumab, atezolizumab, ipilimumab, ….

Cannabis – don’t smoke it!

Pneumonia

Tuberculosis

Lung cancerCOPD

Asthma

COPD

COPD

Non-smoking COPD

Five disadvantage of childhood lung disease

• Mother with asthma

• Father with asthma

• Asthma

• Smoking household

• Childhood infection (rhinovirus)

Stopping the Armageddon of COPD: “Breast feeding by asthmatic mothers has a protective effect for their infants and this protective effect is abrogated when formula milk, rather than complementary foods are were introduced”

Formula one – best no formula!

Comparative safety and effectiveness of long acting inhaled agents for treating chronic obstructive pulmonary disease: a

systematic review and network meta-analysis.

Tricco et al bmj open 2015:5:e009183

Effect on mortality compared to placebo

Tricco et al bmj open 2015:5:e009183

Effect on moderate to severe exacerbations for patients, who experienced an exacerbation in the past year.

Tricco et al bmj open 2015:5:e009183

Pneumonia

Tuberculosis

Lung cancerCOPD

Asthma

Asthma

Why do we prescribe 1 Million Salbutamol inhalers per year?

NZ Asthma guidelines

• Standard dose of inhaled corticosteroids is Fluticasone 200 – 250 mcg or equivalent

• Combination inhaler as fixed dose with salbutamol or SMART

• LABAs should not be prescribed as monotherapy in asthma

• GINA based asthma control test

• Up- and down titrate asthma inhaler treatment

Where is the evidence for step 1 of asthma treatment?

Asthma case vignette

Your next patient is Rachel, a 43 year old woman with asthma, eczema and food allergies all her life. She is currently taking a high dose combination inhaler with an inhaled corticosteroids and long acting beta-agonist. She also takes montelukastand as needed salbutamol. She has never smoked.

She is struggling with her asthma. Her asthma stops her from getting much done at work, she gets shortness of breath about five times a week on average, she wakes up coughing three nights a week on average, she uses he SABA inhaler twice daily and she feels her asthma is poorly controlled. Her asthma control test (ACT) score is 12/25

Asthma Case Vignette

Asthma case vignette – bmj learning

Further reading

Pneumonia

Tuberculosis

Lung cancerCOPD

Asthma

QuestionsLutz.Beckert@cdhb.health.nz