“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 1

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Where There’s Smoke…There’s Obstruction

Stephen G. Basheda, D.O., F.C.C.P.

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Disclosures• Dr. Basheda is an independent contractor for AstraZeneca

Pharmaceuticals, LP and GlaxoSmithKline and on the speaker’s bureau for Boehringer-Ingelheim and AstraZeneca Pharmaceuticals, LP.

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Outline•Asthma update

•COPD update

•Smoking alternatives

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 2

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Airway Obstruction

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Airway Obstruction - Spirometry

• FEV1-Forced Expiratory Volume at 1 second

• FVC-Forced Vital Capacity

• FEV1/FVC < 0.7

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 3

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Asthma-Definition

•Intermittent•Persistent

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 4

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Cough Asthma

•Triggers: talk/laughter, cold air, exercise, deep breath

•Spirometry-Normal

•Chest exam-No wheezing

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Cough Asthma-Treatment

•Recognition

•Asthma medications (bronchodilators/steroids)

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Asthma-Treatment Options

•Anti-inflammatory therapy-inhaled steroids (ICS)

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 5

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Asthma-Treatment (continued)

LABA/ICS combination

LABA=Long Acting Bronchodilators

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Asthma Treatment-Monoclonal Antibodies

•Omalizumab (Xolair) – anti-IgE

•Mepolizumab (Nucala) -anti-Interleukin-5 (IL-5/eosinophils)

•Benralizumab (Fasenra)

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 6

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Asthma Management

•History and physical

•Asthma Control Test (ACT)

•Spirometry

•Nitric oxide

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Fe No (Fractional Exhaled Nitric Oxide)

• Increased with eosinophilic airway inflammation

•50 parts/billion (ppb) – adults

•Monitoring (20% change/change 10 ppb)

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 7

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Tobacco Induced Chronic Obstructive Pulmonary Disease (COPD)

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COPD Management

•Smoking cessation

•Medications

•Pulmonary rehabilitation

•Interventional therapy

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 8

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COPD Management – Alphabet Soup

LABA

LAMA

ICS

SABA

SAMA

LABA/LAMA

LABA/ICS

SABA/SAMA

LABA/LAMA/ICS

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COPD - Dual Bronchodilator Therapy

LABA=long acting bronchodilator agent

LAMA=long acting muscarinic agent

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 9

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COPD Therapy – LABA/ICS

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COPD Therapy-Triple Therapy

• LABA/LAMA/ICS

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Phosphodiesterase-4-Inhibitor

•Rofumilast (Daliresp)

•Severe obstruction

•Exacerbations

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 10

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COPD-Interventional Therapy

•Lung Volume Reduction Surgery (LVRS)

•Bullectomy

•Lung transplantation

•Bronchoscopic Intervention (valves/coils)

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COPD-Treatment

•Oxygen (>15 hours/day)

•Nocturnal ventilation (hypercapneicrespiratory failure)

•Hospice care

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COPD Treatment-Delivery

•Dry powder inhalers

•Propellant inhalers (+spacer)/soft mist inhaler

•Nebulizer

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 11

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Smoking Alternatives

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Smoking Alternatives

•Vaping/electronic cigarettes

•Heated liquid→vapor

•Flavoring (8000) +/- nicotine

•1% “toxic chemicals” of cigarette smoke

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 12

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E-Cigarettes-Usage

•Smoking cessation

•Recreational use

•“Healthier” than cigarettes

•Circumvent “smoke-free” laws

•Cost

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E-Cigarettes-Problems

•Gateway to tobacco smoking

•Heavy metals/”toxicants”

•Alternative use (marijuana/drugs)

•Persistent cardiovascular risks?

•Battery explosion

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 13

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E-Cigarettes-Benefits

•Decreased carcinogens

•? Improving lung function

•Decreased respiratory symptoms

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Lung Cancer Screening-Low Dose Chest CT Scan

•Age 55→74-80

•Current smokers/quit within 15 years

• 30 pack-year smoking history

• ?length/frequency of screening

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“Where There’s Smoke…There’s Obstruction”Stephen G. Basheda, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 14

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Lung Cancer Screening-Chest CT

•Suggests decrease mortality

•Detection at earlier stage

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Marijuana and Lung Health• Toxins/carcinogens (similar to tobacco)

• ?second-hand exposure risks

• Asthma/chronic bronchitis

• Blebs/bullae formation

• Immunosuppression (Aspergillus)

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