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Introduction
Chronic Obstructive Pulmonary Disease (COPD) is one of the top five causes of global mortality
COPD affects 210 million people worldwide and causes 3 million deaths annually (5% of all deaths worldwide)1
It is predicted to become the third leading cause of global mortality by 20302
The economic burden of COPD is high, with costs increasing as the disease progresses - Costs associated with severe COPD are up to 17 times higher than those associated with mild COPD3 - High costs are associated with treatment of exacerbations, such as hospitalisation3 - Indirect costs include loss of productivity in the workplace owing to symptoms3
Male/1000
Female/1000
10
12
Adapted from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2005.
1 2 3
1 2 5
HIV/AIDS
COPD Perinatal conditions Diarrhoeal diseases Tuberculosis Trachea, bronchus, lung cancers Road traffic accidents
4
5 6 7 8 9 10
3
4 9 16 23 6 8
Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines COPD as (2009): a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases
Key points: - COPD is preventable and treatable - Airway limitation is not fully reversible and is usually progressive - Extrapulmonary (systemic) effects play a significant role - Associated with chronic inflammation in response to inhaled noxious irritants
MUCOCILIARY APPARATUS
Airway inflammation
Mucociliary dysfunction
Structural changes
Systemic inflammation
Airway limitation
Neutrophil
Fibroblast
Fibrosis
CD8+ Tc cell
Proteases
Obstructive bronchiolitis
Emphysema
Mucus hypersecretion
Reproduced from The Lancet, Vol 364, Barnes PJ & Hansel TT, "Prospects for new drugs for chronic obstructive pulmonary disease", pp985-96. Copyright 2004, with permission from Elsevier.
Adapted from Barnes PJ, in Stockley, et al (editors), Chronic Obstructive Pulmonary Disease. Oxford, England: Blackwell Publishing; 2007:860.
NYC/DAXAS/10/012
COPD
Onset Inflammatory cells
Asthma
Airflow limitation
NYC/DAXAS/10/012
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org.
AIRWAY INFLAMMATION OCCURS FROM COPD ONSET AND INCREASES WITH DISEASE SEVERITY
100
GOLD Stage I GOLD Stages II and III
80
GOLD Stage IV
60
40
20
CD8+ cells
GOLD stage IV
NYC/DAXAS/10/012
NYC/DAXAS/10/012
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org.
CLASSIFICATION OF COUGH
Cough is classified into acute and chronic and Clinically subdivided into productive and dry cough. Productive cough
CLASSIFICATION OF COUGH
Acute
cough is defined as one lasting less than three weeks cough is defined as one lasting greater than eight weeks
Chronic
URTI : Sinusitis viral / bacterial URTI triggering exacerbations of Chronic Lung Disease eg Asthma; COPD Pneumonia Left Ventricular Heart Failure Foreign Body Aspiration
INDIKATOR KUNCI UTK MENDIAGNOSIS COPD Gejala Sesak Keterangan Progresif (sesak bertambah berat seiring berjalannya waktu) Bertambah berat dengan aktivitas Persisten (menetap sepanjang hari) Pasien mengeluh berupa perlu usaha untuk bernafas Berat, sukar bernafas, terengah-engah Hilang timbul dan mungkin tidak berdahak Setiap batuk kronik berdahak dapat mengindikasi COPD Asap rokok Debu Bahan kimia ditempat kerja Asap dapur Usia > 40 thn TES FAAL PARU DX PASTI
Diagnosis Anamnesis
Riwayat merokok Riwayat terpajan zat iritan Riwayat penyakit emfisema pada keluarga Terdapat faktor predisposis: BBLR; ISPA berulang; lingkungan asap rokok dan polusi udara Batuk berulang dahak Sesak mengi
Pemeriksaan Fisik
Inspeksi: -pursed-lips breathing (mulut setengah terkatup/ mencucu) -Barrel chest -penggunaan otot bantu nafas -hipertrofi otot bantu nafas -pelebaran sela iga -bila telah terjadi gagal jantung kanan, terlihat denyut vena jugularis di leher dan edema tungkai -penampilan Pink puffer atau Blue bloater
Palpasi: fremitus melemah, sela iga melebar
Faal Paru
VEP 1 % merupakan parameter yang paling umum dipakai untuk menilai beratnya COPD dan mamantau perjalanan penyakit OBSTRUKSI: %VEP1 (VEP1/VEP1 pred) < 80%
Pink Puffer: gambaran khas pd emfisema, pasien kurus, kulit kemerahan dan pernafasan Pursed-lips breathing Blue bloater: gambaran khas pd bronkitis kronis, pasien gemuk sianosis, edema tungkkai, dan ronki basah basal
Diagnosis Banding Diagnosis COPD Gejala Onset pada usis pertengahan, GX progresif lambat, lamanya riwayat merokok, sesak saat aktivitas, sebagian besar hambatan aliran udara, ireversible Onset awal sering pada anak; GX bervariasi dari hari ke hari; GX malam hari/menjelang pagi; Disertai atopi, rinitis atau eksem; riwayat keluarga dengan asma; sebagian besar keterbatasan aliran udara reversible Ronki halus di bagian bawah; foto toraks: jantung membesar, edema paru, Uji Paal Paru: restriksi bukan obstruksi
Asma
Bronkiektasis
Sputum produktif dan purulen; umumnya terkait dgn infeksi bakteri; auskultasi ronki kasar; Foto toraks: pelebaran dan penebalan bronkus
Onset segala usia; foto toraks: infiltrat; Sputum BTA Onset pada usia muda;bukan perokok; mungkin punya riwayat rheumatoid arthritis atau pajanan asap Lebih banyak pada laki-laki bukan perokok; hampir semua menderita sinusitis kronik;
KLASIFIKASI Derajat Derajat 0 At Risk Derajat I: ringan Klinis Batuk kronik + sputum Batuk kronik + sputum (tidak sering) Sering tidak menyadari bahwa faal paru mulai menurun Faal Paru Still normal VEP1/KVP < 70% VEP1 80% prediksi
GX sesak mulai dirasakan saat aktivitas dan kadang ditemui GX batuk dan produksi sputum
GX sesak lebih berat, penurunan aktivitas, rasa lelah dan serangan eksaserbasi semakin sering dan berdampak pada kualitas hidup Gx derajat III + tanda-tanda gagal nafas atau gagal jantung kanan. Kualitas hidup memburuk dan dapat mengancam jiwa
SEVERE AND LIFETHREATENING Yes, may have paradoxical chest wall movement > 120 / min Likely to be present
Wheeze intensity
Peak expiratory flow (% predicted)
variable
. 75%
Moderate
50 75%
Often quiet
< 50 %
Yes
Prevent and treat exacerbations Prevent disease progression Prevent and treat complications Reduce mortality
NYC/DAXAS/10/012
Adapted from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org.
75
50
Disabilit y
Stopped at 45
Stopped at 65
NYC/DAXAS/10/012
NYC/DAXAS/10/012
NYC/DAXAS/10/012
1. From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org. 2. Seemungal TA et al, 2000. 3. Perera et al, 2007. 4. Papi et al, 2006.
Number of exacerbations
p<0.0001
0
Patients WITH chronic cough and sputum Patients WITHOUT chronic cough and sputum
NYC/DAXAS/10/012
DEFINITIONS OF EXACERBATIONS
COPD exacerbations were classified in clinical studies as follows:
EFFECTS
Systemic inflammation
Exacerbation symptoms
Dynamic hyperinflation
32
Reprinted from The Lancet, 370, Wedzicha JA, Seemungal TA, COPD exacerbations: defining their cause and prevention, 786-796, Copyright 2007, with permission from Elsevier.
Sputum retention Bronchospasm Infection Pneumothorax Large bullae Uncontrolled O2 - administration Pulmonary embolism Left-ventricular failure End-stage disease
PATH-PHYSIO..CONTD
ALVEOLAR DISTORTION AND DESTRUCTION
LOSS OF CAUSING
HYPOXIA
CAPILLARY BED
VASOCONSTRICTION
PULMONARY
Stage I: Mild
FEV1/FVC<0.70 FEV1 80% predicted
Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical procedures
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org.
NYC/DAXAS/10/012
Invasive
MANAGEMENT NONINVASIVE
# BRONCHODILATORS ROUTINELY GIVEN HELP RESIDUAL BRONCHODILATION
AND
MUCO-CILIARY CLEARANCE
CONSERVATIVE MANAGEMENT
.contd
# ANTIBIOTICS
MINI TRACHEOSTOMY/ CRICOTHYROTOMY FOR SUCTION ENDOTRACHEAL INTUBATION * FOR BETTER ACCESS * FOR VENTILATORY SUPPORT TRACHEOSTOMY * IF VERY THICK SECRETIONS * INTUBATION > SEVEN DAYS
Emphysema
Emphysema The fourth leading cause of death in the US 34 million people in the US suffer from emphysema Current treatment is limited in efficacy
Emfisema paru-paru adalah keadaan di mana paru mengalami distensi yang abnormal yang disebabkan rupturnya dinding alveoli dengan atau tanpa disertai lolosnya udara ke jaringan interstisial sehingga menyebabkan berkurangnya ruang udara dan sulit bernapas (Blood, 1963).
-Pelebaran alveoli -kerusakan pada dinding alveoli bronkioli kehilangan struktur penyangganya pada saat udara dikeluarkan, bronkioli akan mengkerut; -Struktur saluran udara menyempit dan sifatnya menetap -pembesaran paru-paru yang disebabkan oleh menggembungnya alveoli secara berlebihan +/- robeknya dinding alveoli -Udara pernafasan akan terdapat di dalam rongga jaringan
Emfisema Paru-paru merupakan penyakit paru obstruktif kronik dgn gejala utamanya adalah penyempitan (obstruksi) saluran napas, karena kantung udara di paru menggelembung secara berlebihan dan mengalami kerusakan yang luas.
acinar emfisema
terbatas pada ujung distal alveolus di sepanjang septum interlobularis dan di bawah pleura membentuk bula.
Panacinar emfisema
pembesaran rongga udara yang relatif seragam di seluruh acinus. Merupakan bentuk yang jarang, gambaran khas nya adalah tersebar merata di seluruh paru-paru, meskipun bagian-bagian basal cenderung terserang lebih parah. Tipe ini sering timbul pada hewan dengan defisiensi alfa-1 anti tripsin Ciri khasnya yaitu memiliki dada yang hiperinflasi dan ditandai oleh dispnea saat aktivitas, dan penurunan berat badan.
Irregular emfisema
kerusakan pada parenkim paru tanpa menimbulkan kerusakan pada asinus.
The Concept of lung Volume Reduction Lung volume Reduction 1. Removal of the most destroyed hyperinflated poorly perfused areas of the lung can enhance the function of the remaining normal lung and leads to functional and symptomatic improvement 2. Applicable in heterogeneous emphysema (upper lobe predominant) Multiple retrospective and prospective studies reported success with surgical lung volume reduction
SUMMARY
COPD
is a debilitating disease that presents a huge healthcare and economic burden around the world
encompasses damage to the airways, and chronic pulmonary and systemic inflammation
The
COPD
The
Chronic
inflammation in the airways and systemic circulation contributes to the pathology of COPD
inflammation is characterised by increased neutrophils, CD8+ T-lymphocytes and macrophages, as well as cytokines and other inflammatory mediators
Inflammatory
COPD-specific
inflammation is present from the onset of COPD and increases with disease progression. Airway inflammation increases during exacerbations
Effective
Chronic
COPD management should include agents that target the chronic inflammation underlying the disease
COPD is diagnosed based on medical history, exposure to risk factors and assessment of lung function by spirometry GOLD guidelines recommend seven goals for COPD management, including reducing the frequency of exacerbations Non-pharmacological management of COPD includes smoking cessation GOLD guidelines recommend stepwise addition of pharmacological treatments based on the severity of COPD
DEATH
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
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