Cachexia
Cause
The interaction of many different factors causes
cachexia. People with cachexia have abnormal
levels of certain substances in their body. These
imbalances cause weight loss and muscle wasting.
A number of factors contribute to cachexia,
including the levels of these substances, the
conditions that cause them, and the reaction they
provoke from the body.
These substances interact with each other and
lead to cachexia through several pathways,
including:
 increasing metabolism and the spending
of energy
 causing inflammation
 increasing the breakdown of muscle
 preventing muscle growth
Risk factors
There are certain chronic conditions linked to
cachexia, usually in the end-stages of the disease.
A person with one of the following conditions
should talk to their doctor about steps to prevent
the development of cachexia and how to improve
quality of life.
Examples of these conditions include:
 cancer, especially in the lung, pancreas,
and stomach
 chronic obstructive pulmonary disease
(COPD)
 chronic renal failure, with an
estimated fourth of all people with the
condition showing signs of
malnourishment
 congestive heart failure
 Crohn's disease
 cystic fibrosis
 HIV
 rheumatoid arthritis
Symptoms
Symptoms of cachexia include:
 Involuntary weight loss: Weight loss
occurs despite getting
adequate nutrition or a high number
of calories.
 Muscle wasting: This is the characteristic
symptom of cachexia. However, despite
the ongoing loss of muscle, not all people
with cachexia appear malnourished. A
person who was overweight before
developing cachexia may appear to be of
average size despite having lost a
significant amount of weight.
 Loss of appetite, or anorexia: Not only
does food become not appealing, but a
person with cachexia will also lose their
desire to eat any food at all.
 Reduced functional ability: Common
symptoms, such as malaise, fatigue, and
low energy levels make it hard for a
person to do the things they enjoy and
want to do. Often a person cannot
complete daily activities, such as getting
dressed and brushing the teeth.
 Swelling or edema: When there are low
levels of protein in the blood, fluid moves
into the tissues, causing swelling,
especially in the legs of people who are
still able to sit and stand.
As cachexia is sometimes difficult to recognize,
doctors use a variety of criteria for diagnosis. In
the most common system, the person must meet
the following criteria for a cachexia diagnosis:
 non-deliberately losing more than 5
percent of their body weight over six to
12 months
 a body mass index (BMI) of less than 20 in
a person under 65 years old, or a BMI of
less than 22 in a person over 65 years.
 less than 10 percent body fat
Complications
The fat and muscle wasting in cachexia is serious
and can potentially speed up death. Cachexia is a
significant factor in around one-fifth of deaths due
to cancer, according to a study from 2017Trusted
Source.
Complications of cachexia include:
 diminished quality of life and loss of the
ability to live independently
 impaired response to treatments
 reduced immunity
 escalating symptoms of the underlying
chronic condition
 a reduced life expectancy from the
underlying disease
Treatments
There is no single medicine or treatment plan that
has been shown to be effective for treating
cachexia.
Many factors contribute to its cause, so a
treatment plan incorporating several types of
therapy will most likely be necessary. Simply
increasing the number of calories or changing the
diet will not show results.
Some helpful steps include:
Focusing on the social aspects of eating: People
get pleasure from sitting together over a meal
even when they are not in the mood to eat.
Emphasizing the social importance of eating
instead of the amount of food may help a person
reposition their emotional and psychological
relationship to eating.
Eat frequent small, meals: People with cachexia
are more likely to tolerate eating high-calorie meals
in small portions throughout the day rather than
three set meals. Drinks containing nutritional
supplement drinks are available to increase calorie
intake between the small meals.
Emotional support: The family of a person with
cachexia should understand that as an underlying
disease progresses to its end stage, people will
sometimes not want to eat. Once they reach this
stage, friends and family should not force the
person with cachexia to eat. Muscle wasting and
weight loss will continue whether a person with the
condition eats or not.
Appetite stimulants: Medications, such as
dronabinol, megestrol, and glucocorticoids, may
improve appetite. However, eating more will not
stop the progression of symptoms or improve
muscle wasting. An increased appetite may help a
person participate in family and social meals and
feel a little less isolated, which has benefits
for mental health.
Light exercise: As long as the person can tolerate
it, exercise might help build some muscle mass.
However, evidence is not available as to the
effectiveness of exercise as a measure against
cachexia.
Prevention
Cachexia is usually a side effect of an underlying
medical condition, so the focus for prevention lies
in keeping the underlying chronic condition at
bay.
Some conditions, such as COPD or HIV, are
potentially preventable. However, other
conditions that cause cachexia are largely
unavoidable, such as cancer, rheumatoid arthritis,
or Crohn's disease.
An active lifestyle with balanced nutrition may
reduce the risk of a chronic condition that could
lead to cachexia.
What is cancer anorexia-cachexia syndrome?
People who have cancer sometimes experience a
condition known as cancer anorexia-cachexia
syndrome (CACS). It is cachexia, but
with anorexia as part of the syndrome. Like
cachexia, increasing calorie intake does not
reverse the severe muscle wasting CACS causes.
The characteristics of CACS include:
 muscle wasting
 weight loss
  loss of appetite
 severe weakness or loss of strength and
low energy level/fatigue
 poor quality of life
 poor response to chemotherapy with
increased side effects
 poor prognosis
The diagnosis is made by meeting the following
three criteria:
 A person eats fewer than 20 calories/kg
of body weight or loses 5 lbs over 2
months.
 They want a better appetite, to eat more,
and to put on weight.
 The doctor believes that putting on
weight would be helpful for the person.
As with cachexia, there is no effective treatment
for CACS. The steps that can help people with only
cachexia might also work for people with CACS.
Bronchoscopy
Indikasi
Rigid bronchoscopy is now used only when
a wider aperture and channels are required
for better visualization and instrumentation,
such as when
 Investigating vigorous pulmonary
hemorrhage (in which the rigid
bronchoscope can better identify the
bleeding source and, with its larger
suction channel, can better suction the
blood and prevent asphyxiation)
 Viewing and removing aspirated
foreign bodies in young children
 Viewing obstructive endobronchial
lesions for possible laser debulking or
stent placement
Flexible bronchoscopes are nearly all color
video–compatible, facilitating airway
visualization and documentation of findings
(see table Indications for Flexible Fiberoptic
Bronchoscopy).
Diagnostically, flexible fiberoptic
bronchoscopy allows for
 Direct airway visualization down to,
and including, subsegmental bronchi
 Sampling of respiratory secretions and
cells via bronchial washings,
brushings, and lavage of peripheral
airways and alveoli
 Biopsy of endobronchial, parenchymal,
and mediastinal structures
Therapeutic uses include
 Suctioning of retained secretions
 Placing an endobronchial stent
 Removing foreign objects
 Using balloon dilation to relieve airway
stenoses
Kontraindikasi
Absolute contraindications to
bronchoscopy include
 Untreatable life-threatening
arrhythmias
 Inability to adequately oxygenate the
patient during the procedure
 Acute respiratory failure with
hypercapnia (unless the patient is
intubated and ventilated)
 High-grade tracheal obstruction
Relative contraindications to bronchoscopy
include
 Uncooperative patient
 Recent myocardial infarction
 Uncorrectable coagulopathy
Transbronchial biopsy should be done with
caution in patients with uremia, superior vena
cava obstruction, or pulmonary hypertension
because of increased risk of bleeding.
Inspection of the airways is safe in these
patients, however.
Procedure
Bronchoscopy should be done only by a
pulmonologist or trained surgeon in a
monitored setting, typically a bronchoscopy
suite, operating room, or intensive care unit
(for ventilated patients).
Patients should receive nothing by mouth for
at least 6 hours before bronchoscopy and
have IV access, intermittent blood pressure
monitoring, continuous pulse oximetry, and
cardiac monitoring. Supplemental oxygen
should be used.
Patients usually receive conscious sedation
with short-acting benzodiazepines, opioids, or
both before the procedure to decrease
anxiety, discomfort, and cough. In some
centers, general anesthesia (eg, deep
sedation with propofol and airway control via
endotracheal intubation or use of a laryngeal
mask airway) is commonly used before
bronchoscopy.
The pharynx and vocal cords are
anesthetized with nebulized or
aerosolized lidocaine (1 or 2%, to a maximum
of 250 to 300 mg for a 70-kg patient). The
bronchoscope is lubricated and passed either
through the nostril, the mouth with use of an
oral airway or bite block, or an artificial airway
such as an endotracheal tube. After
inspecting the nasopharynx and larynx, the
clinician passes the bronchoscope through
the vocal cords during inspiration, into the
trachea and then further distally into the
bronchi.
Several ancillary procedures can be done as
needed, with or without fluoroscopic
guidance:
 Bronchial washing: Saline is injected
through the bronchoscope and
subsequently aspirated from the
airways.
 Bronchial brushing: A brush is
advanced through the bronchoscope
and used to abrade suspicious lesions
to obtain cells.
 Bronchoalveolar lavage: 50 to 200
mL of sterile saline is infused into the
distal bronchoalveolar tree and
subsequently suctioned out, retrieving
cells, protein, and microorganisms
located at the alveolar level. Local
areas of pulmonary edema created by
lavage may cause transient
hypoxemia.
 Transbronchial biopsy: Forceps are
advanced through the bronchoscope
and airway to obtain samples from one
or more sites in the lung parenchyma.
Transbronchial biopsy can be done
without x-ray guidance, but evidence
supports increased diagnostic yields
and lower incidence of pneumothorax
when fluoroscopic guidance is used.
 Transbronchial needle aspiration: A
retractable needle is inserted through
the bronchoscope and can be used to
sample enlarged mediastinal lymph
nodes or masses. Endobronchial
ultrasonography (EBUS) can be used
to help guide the needle biopsy.
Patients are typically given supplemental
oxygen and observed for 2 to 4 hours after
the procedure. Return of a gag reflex and
maintenance of oxygen saturation when not
receiving supplemental oxygen are the two
primary indices of recovery.
Standard practice is to obtain a
posteroanterior chest x-ray after
transbronchial lung biopsy to
exclude pneumothorax.
Complication
Serious complications are uncommon; minor
bleeding from a biopsy site and fever occur in
10 to 15% of patients. Patients may have an
increase in cough after bronchoalveolar
lavage. Rarely, topical anesthesia causes
laryngospasm, bronchospasm, seizures,
methemoglobinemia with refractory cyanosis,
or cardiac arrhythmias or arrest.
Bronchoscopy itself may cause
 Minor laryngeal edema or injury with
hoarseness
 Hypoxemia in patients with
compromised gas exchange
 Arrhythmias (most commonly
premature atrial contractions,
ventricular premature beats, or
bradycardia)
  Transmission of infection from
suboptimally sterilized equipment
(very rare)

Mortality is 1 to 4/10,000 patients. The

elderly and patients with serious
comorbidities (severe chronic obstructive
pulmonary disease [COPD], coronary artery
disease, pneumonia with hypoxemia,
advanced cancers, mental dysfunction)
are at greatest risk.

Transbronchial biopsy can cause

pneumothorax (2 to 5%), significant
hemorrhage (1 to 1.5%), or death (0.1%),
but doing the procedure can often avoid the
need for thoracotomy.

Cell Cycle

Cell cycle, the ordered sequence of

events that occur in a cell in
preparation for cell division. The cell
cycle is a four-stage process in which
the cell increases in size (gap 1, or G1,
stage), copies its DNA (synthesis, or
S, stage), prepares to divide (gap 2, or
G2, stage), and divides (mitosis, or M,
stage). The stages G1, S, and G2
make up interphase, which accounts
for the span between cell divisions. On
the basis of the stimulatory and
inhibitory messages a cell receives, it
“decides” whether it should enter the
cell cycle and divide.
Untuk bisa diberikan kemoterapi, pasien
terlebih dahulu harus periksa darah berupa
hemoglobin atau Hb (minimal lebih dari 10
gram/dL), leukosit (minimal 3 ribu), trombosit
(minimal 100 ribu), serta ureum dan kreatine
saat cek urine normal.

"Diperiksa juga fungsi jantung, hati, ginjal dan

sarafnya. Kenapa? Banyak obat-obat
kemoterapi yang bisa memengaruhi organ-
organ tersebut," ungkap dr Henry.

Tak cuma dari pasien, rumah sakit menurut dr

Henry juga berperan penting, yakni dengan
penyediaan ruang khusus kemoterapi yang
memadai. Ruang ini sebaiknya disediakan
khusus untuk pemberian kemoterapi dan
mengobati efek samping yang berat sehingga
perlu dirawat.

"Penting untuk membuat ruangan tersebut

senyaman dan sebersih mungkin. Bila perlu
diberi aromaterapi, musik yang santai dan
berhawa sejuk," tutur dr Henry.