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By

Dr. Hermawan Chrisdiono, Sp.P


RSUD Unit Swadana Pare Kabupaten Kediri

Facts About COPD


COPD is the 4th leading cause of death in
the United States (behind heart disease,
cancer, and cerebrovascular disease).
In 2000, the WHO estimated 2.74 million
deaths worldwide from COPD.
In 1990, COPD was ranked 12th as a
burden of disease; by 2020 it is projected
to rank 5th.

Leading Causes of Deaths


U.S. 1998
Cause of Death
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Heart Disease
Cancer
Cerebrovascular disease (stroke)
Respiratory Diseases (COPD)
Accidents
Pneumonia and influenza
Diabetes

Suicide
Nephritis
Chronic liver disease
All other causes of death

Number

724,269
538,947
158,060
114,381
94,828
93,207
64,574
29,264
26,295
24,936
469,314

Percent Change in Age-Adjusted


Death Rates, U.S., 1965-1998
Proportion of 1965 Rate
3.0
2.5

Coronary
Heart
Disease

Stroke

Other CVD

COPD

All Other
Causes

59%

64%

35%

+163%

7%

2.0
1.5
1.0
0.5
0

1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998

Age-Adjusted Death Rates


for COPD, U.S., 1960-1998
Deaths per 100,000
60
50
40
30
20
10
0
1960

1965

1970

1975

1980

1985

1990

1995

2000

Facts About COPD:


U.S.

Between 1985 and 1995, the number


of physician visits for COPD
increased from 9.3 to16 million.

The number of hospitalizations for


COPD in 2000 was estimated to be
726,000.

Medical expenditures in 2002 were


estimated to be $18.0 billion.

Physician Office Visits for


Chronic
and
Unspecified
Bronchitis,
U.S.
Number (Millions)
15

10

1980

1985

Source: National Ambulatory Medical Care Survey,


NCHS

1990
Year

1995

1998

COPD 1990 Prevalence


Male/1000

Established Market Economies


Formerly Socialist Economies
India
China
Other Asia and Islands
Sub-Saharan Africa
Latin America and Caribbean
Middle Eastern Crescent
World

*From Murray & Lopez, 1996

6.98
7.35
4.38
26.20
2.89
4.41
3.36
2.69
9.34

Female/1000
3.79
3.45
3.44
23.70
1.79
2.49
2.72
2.83
7.33

National Household Health Survey 1995 (NHHS)


Table Death caused by the respiratory tract
diseases (asthma, CB and emphysema)
in hospital

Year

rank

1986

3.8

10

1992

5.6

1995

15.7

Tabel Main causes of death as revealed by


NHHS 1989 and 1992
Order

1986

1992

Diarrhoea

12.0

Cardiovascular

Cardiovascular

9.7

Tuberculosis

11

Tuberculosis

8.6

Not known

9.8

Measles

6.7

Resp.infection

9.5

Low Resp.Dis

6.2

Diarrhoea

8.0

Tetanus

6.0

Other inf.dis

7.8

Mental disorders

5.3

CB, Asthma,emphy

5.6

Injuries

4.7

Injuries

5.3

Neoplasms

4.3

Gastro intestinal

5.1

10

CB,Asthma,

3.8

Neoplasms

4.0

Emphysema

16.0

Indonesian Pneumobile Project (IPP-1989)


Prevalence of CB :

17% for male


8.7% for female.

% with symptoms

Figure 1 Characteristic of IPP Study Population:


Prevalence of Usual Cough or Phlegm

Prevalence of abnormal Pulmonary


Function :
60% of smokers
25% of non smokers

Cigarette smoking is the primary cause of


COPD.

In the US 47.2 million people (28% of


men and 23% of women) smoke.

The WHO estimates 1.1 billion smokers


worldwide, increasing to 1.6 billion by
2025. In low- and middle-income
countries, rates are increasing at an
alarming rate.

Facts About COPD

In India, it is estimated that 400-550


thousand premature deaths can be
attributed annually to use of biomass fuels,
placing indoor air pollution as a major risk
factor in the country.
In Algeria, the prevalence of tuberculosis
and acute respiratory infections has
decreased since 1965; an increase in COPD
and asthma has been observed in the last
decade.

GOLD Workshop Report


Evidence category Sources of evidence
A Randomized clinical trials
Rich body of data
B Randomized clinical trials
Limited body of data
C Non randomized trials
Observational studies
D Panel judgement
consensus

Chronic obstructive pulmonary disease


(COPD) is a disease state characterized by
airflow limitation that is not fully reversible.
The airflow limitation is usually both
progressive and associated with an
abnormal inflammatory response of the
lungs to noxious particles or gases.

Burden of COPD
Key Points

The burden of COPD is underestimated


because it is not usually recognized and
diagnosed until it is clinically apparent
and moderately advanced.

Prevalence, morbidity, and mortality vary


appreciably across countries but in all
countries where data are available,
COPD is a significant health problem in
both men and women.

Burden of COPD
Key Points
The global burden of COPD will
increase enormously over the
foreseeable future as the toll
from tobacco use in developing
countries becomes apparent.

Burden of COPD
Key Points

The economic costs of COPD are


high and will continue to rise in
direct relation to the ever-aging
population, the increasing
prevalence of the disease, and the
cost of new and existing medical
and public health interventions.

Direct Medical Cost:

$18.0

Total Indirect Cost:


Mortality related IDC
Morbidity related IDC

Total Cost

$ 14.1
7.3
6.8
$32.1

Source: NHLBI, NIH,


DHHS

Risk Factors for COPD


Host Factors

Genes (e.g. alpha1-antitrypsin


deficiency)
Hyperresponsiveness
Lung growth

Exposure

Tobacco smoke
Occupational dusts and

chemicals

Infections
Socioeconomic status

Pathogenesis of COPD
NOXIOUS AGENT

(tobacco smoke, pollutants, occupational


agent)
Genetic factors
Respiratory
infection
Other

COPD

Noxious particles
and gases
Host factors
Anti-oxidants

Lung inflammation

Oxidative stress

Anti-proteinases

Proteinases
Repair mechanisms

COPD pathology

INFLAMMATION

Small airway disease


Airway inflammation
Airway remodeling

Parenchymal destruction
Loss of alveolar attachments
Decrease of elastic recoil

AIRFLOW LIMITATION

ASTHMA
Sensitizing agent

Asthmatic airway inflammation


CD4+ T-lymphocytes
Eosinophils

Completely
reversible

COPD
Noxious agent

COPD airway inflammation


CD8+ T-lymphocytes
Macrophages
Neutrophils

Airflow limitation

Completely
irreversible

Irreversible
Fibrosis and narrowing of the
airways
Loss of elastic recoil due to
alveolar destruction
Destruction of alveolar support
that maintains patency of small
airways

Reversible
Accumulation of inflammatory cells,
mucus, and plasma exudate in
bronchi
Smooth muscle contraction in
peripheral and central airways
Dynamic hyperinflation during
exercise

1. Assess and monitor


disease
2. Reduce risk factors
3. Manage stable COPD

Education

Pharmacologic

Non-pharmacologic

4. Manage exacerbations

Objectives of COPD
Management

Prevent disease progression


Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent and treat exacerbations
Prevent and treat complications
Reduce mortality
Minimize side effects from
treatment

Assess and Monitor


Disease: Key Points
Diagnosis of COPD is based on a
history of exposure to risk factors and
the presence of airflow limitation that is
not fully reversible, with or without the
presence of symptoms.

Assess and Monitor


Disease: Key Points
Patients who have chronic cough
and sputum production with a
history of exposure to risk factors
should be tested for airflow
limitation, even if they do not have
dyspnea.

Assess and Monitor


Disease: Key Points
For the diagnosis and assessment of
COPD, spirometry is the gold
standard.
Health care workers involved in the
diagnosis and management of COPD
patients should have access to
spirometry.

Assess and Monitor


Disease: Key Points
Measurement of arterial blood gas
tension should be considered in
all patients with FEV1 < 40%
predicted or clinical signs
suggestive of respiratory failure or
right heart failure.

Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution

SYMPTOMS
cough
sputum
dyspnea

SPIROMETRY

FEV1

Normal
COPD

Liter

FVC

FEV1/ FVC

4.150

5.200

80 %

2.350

3.900

60 %

FEV1

COPD
4

FEV1

Normal

5
1

FVC

FVC
4

6 Seconds

Severity of symptoms
Severity of airflow limitation
Frequency and severity of exacerbations
Presence of complications of COPD
Presence of respiratory insufficiency
Comorbidity
General health status
Number of medications needed to manage the
disease

Stage
0: At risk

Classification by
Severity
Characteristics
Normal spirometry
Chronic symptoms (cough, sputum)

I: Mild

FEV1/FVC < 70%; FEV1 80% predicted


With or without chronic symptoms (cough, sputum)

II: Moderate

FEV1/FVC < 70%; 50% FEV1 < 80% predicted


With or without chronic symptoms (cough, sputum, dyspnea)

III: Severe

FEV1/FVC < 70%; 30% FEV1 < 50% predicted


With or without chronic symptoms (cough, sputum,
dyspnea)

IV: Very Severe

FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1


< 50% predicted plus chronic respiratory failure

WORLD COPD DAY


November 19, 2003

Raising COPD Awareness


Worldwide

Could it be COPD?
Do you know what COPD is? This chronic lung disease is a major cause of illness,
yet many people have it and dont know it.
If you answer these questions, it will help you find out if you could have COPD.
1. Do you cough several times most days?

Yes ___ No ___

2. Do you bring up phlegm or mucus most days?

Yes ___ No ___

3. Do you get out of breath more easily than others your age? Yes ___ No ___
4. Are you older than 40 years?

Yes ___ No ___

5. Are you a current smoker or an ex-smoker?

Yes ___ No ___

If you answered yes to three or more of these questions, ask your doctor if you
might have COPD and should have a simple breathing test. If COPD is found
early, there are steps you can take to prevent further lung damage and make you
feel better.
Take time to think about your lungsLearn about COPD!