EMPHYSEMA - COPD

MUHAMMAD ILYAS

DEPARTEMEN OF PULMONOLOGY AND RESPIRATORY MEDICINE

FACULTY OF MEDICINE UNIVERSITY OF HASANUDDIN
DR. WAHIDIN SUDIROHUSODO HOSPITAL

PULMONOLOGY 2020
 INTRODUCTION
COPD is one of the major
causes of morbidity and
mortality throughout the
world
Preventable and treatable
disease.
Airway and/or alveolar
abnormalities, caused by
significant exposure to
noxious particles or gases

Characterized by
persistent airflow
limitation that is usually
progressive
Prevalence of COPD
appreciably higher in
smoker and ex-smoker
than in non smoker, in
those over 40 yo and in
men
Wang L, et al. Chin Med J 2017;130:2107-11
Cellular Mechanisms of COPD
The vicious-circle hypothesis of infection and inflammation in COPD
INITIATING
INITIATING FACTOR
FACTOR
e.g.
e.g. smoking,
smoking,
childhood
childhood
respiratory
respiratory disease
disease

impaired
impaired
innated
innated lung
lung Acute
Acute
defense
defense exacerbation
exacerbation

Airway
Airway Microbial
Microbial
epithelial
epithelial injury
injury colonization
colonization

Microbial
Microbial Inflamatory
Inflamatory
antigen
antigen response
response
Progression
Progression
of
of COPD
COPD

Altered
Altered protease
protease Increased
Increased
anti
anti protease
protease proteolytic
proteolytic
balanced
balanced activity
activity
Sethi S, Murphy TF. N Engl J Med 2008;359:2356
 Goals of treatment for stable COPD

• Relieve symptoms
• Improve exercise tolerance REDUCE SYMPTOMS
• Improve health status

and

• Prevent disease progression

• Prevent and treat exacerbations REDUCE RISK
• Reduce mortality

GOLD 2017
 Metode penilaian ABCD
Konfirmasi Penilaian Penilaian
diagnosa via keterbatasan gejala/risiko
spirometri aliran udara eksaserbasi
0 eksaserbasi sejak 1 tahun
terakhir Klasifikasi PPOK untuk Bapak B:
Riwayat
Bapak B eksaserbasi
sedang atau GOLD 4, kelompok B
berat
≥2 atau
Paska- ≥1
bronkodikatasi menyeba
FEV1/FVC < 0.7 b
hospitalis
asi
0 atau 1
(tidak
menyebab
kan
FEV1 hospitalis
Skor
< 30% asi)
CAT 18
Gejala

Global Initiative for Chronic Obstructive Lung Disease 2019

8. Non-pharmacologic interventions
Correct diagnosis and early treatment are important
for patients with COPD

Prevent or delay progression to

Early detection of
symptomatic COPD
asymptomatic COPD
through smoking cessation

Early detection of Smoking cessation and other

symptomatic COPD interventions to reduce progression

Improve current health status and disease

impact using proven healthcare interventions

Reduce risk of exacerbations and potentially

deaths through proven healthcare
interventions

Soriano JB, et al. Lancet 2009

 Management of stable COPD:
non-pharmacologic
Treatment Who
Essential
Smoking cessation All patients who smoke
(can include pharmacologic treatment)
Pulmonary rehabilitation GOLD B,C,D patients
Recommended
Daily physical activity All patients
Depending on local guidelines
Flu vaccination Depending on local guidelines
Pneumococcal vaccination
Other treatments
Oxygen To patients with PaO2 ≤7.3 kPa (55 mmHg)/
SaO2 ≤88%* or PaO2 7.3–8.0 kPa
(55–60 mmHg)/SaO2 88%†
*With or without hypercapnia confirmed twice over a 3-week period; †if there is evidence of pulmonary hypertension, peripheral edema
suggesting congestive cardiac failure, or polycythemia (hematocrit >55%) GOLD = Global initiative for chronic Obstructive Lung Disease; PaO2 =
partial pressure of oxygen in arterial blood; SaO2 = saturation of oxygen in arterial blood
GOLD 2017
 Breathing
techniques

Diaphragmatic breathing: During inspiration

diaphragm descends down and abdomen moves
Pursed lip breathing out. Patient exhales through nose with abdomen
drawing in

SUPPLEMENT TO JAPI 2012 • VOL. 60 ; 49

Oxygen Therapy & Ventilatory Support
in Stable COPD
► During exacerbations of COPD. Noninvasive ventilation
(NIV) in the form of noninvasive positive pressure
ventilation (NPPV) is the standard of care for decreasing
morbidity and mortality in patients hospitalized with an
exacerbation of COPD and acute respiratory failure

© 2017 Global Initiative for Chronic Obstructive Lung Disease

 Long-term oxygen therapy
• The Nocturnal Oxygen Therapy Trial (NOTT) and Medical Research
Council (MRC) trials demonstrated that LTOT (>15 hours/day) is
associated with improved survival in patients with severe resting
hypoxaemia, with no benefits seen in moderate hypoxaemia PO2 >8
kPa (60 mmHg). Indications for LTOT include the following:

• PaO2 = 7.3 kPa or SaO2 ≤88%, with or without

hypercapnia.
• PaO2 between 7.3 kPa (55 mmHg) and 8 kPa (60 mmHg
or SaO2 88%), if there is evidence of pulmonary arterial
hypertension, peripheral oedema suggestive of
congestive heart failure or polycythaemia
Nici L, Donner C, Wouters E, et al.Am J Respir Crit Care Med 2006;173:1390-1414.
Types of noninvasive ventilation with
proposed settings

Antonelli M, Con ti G. Crit Care 2000; 4:15–22

Conclusions NPPV should be the first line
intervention in addition to usual medical care to
manage respiratory failure secondary to an acute
exacerbation of chronic obstructive pulmonary
disease in all suitable patients. NPPV should be tried
early in the course of respiratory failure and before
severe acidosis, to reduce mortality, avoid
endotracheal intubation, and decrease treatment
failure.
Lightowler JV, et al. BMJ 2003: 326; 1-5
 SUMMARY
• COPD can be prevented and can be treated. And to treat the
COPD patient, we need to assess Symptoms, Degree of
airflow limitation, Risk of exacerbation, and Comorbidities
• Combined assessment of symptoms and risk of
exacerbations is the basis for management of COPD
– FEV1 < 50% and Exacerbation ≥ 2 times/year or any
hospitalization for exacerbation of COPD would put a
patient in a high risk category
– the recommended pharmacological treatments are now
categorized as “recommended first choice option”,
“alternative options” and “other options”
• Treat COPD exacerbations to minimize impact and prevent
the development of subsequent exacerbations