Diskusi Topik 2

PPOK
Disusun :
Nafisa Zulpa Elhapidi -406202067
Pembimbing:
dr. Samuel Halim, Sp. PD
Kepanitraan Klinik Ilmu Penyakit Dalam
PJJ Periode 5 April-17 April 2021
Fakultas Kedokteran Universitas Tarumanagara Jakarta
COPD : Definition
Chronic Obstructive Pulmonary Disease (COPD) is a common,
preventable and treatable disease that is characterized by persistent
respiratory symptoms and airflow limitation that is due to airway
and/or alveolar abnormalities usually caused by significant exposure to
noxious particles or gases and influenced by host factors including
abnormal lung development. Significant comorbidities may have an
impact on morbidity and mortality

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : Epidemiology
Burden of COPD
• COPD  leading cause of morbidity and mortality worldwide that induces an
economic and social burden that is both substantial and increasing
• COPD prevalence, morbidity and mortality vary across countries and across
different groups within countries
• COPD  result of a complex interplay of long-term cumulative exposure to
noxious gases and particles, combined with a variety of host factors 
genetics, airway hyper-responsiveness and poor lung growth during
childhood.
• Based on BOLD and other large scale epidemiological studies Globally,
there are around 3 million deaths annually
© 2020 Global Initiative for Chronic Obstructive Lung Disease
COPD

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : Etiology
the risk of developing COPD is related to the following factors:
• Tobacco smoke
• Indoor air polution
• Occupational exposures
• Outdoor air pollution
• Genetic factors
• Age & Sex ; aging & female sex
• Lung growth & development
• Socioeconomic status
• Asthma & airway hyper-activity
• Chronic bronchitis
• Infections

© 2020 Global Initiative for Chronic Obstructive Lung Disease

 COPD :
Pathophysiology

Sumber: http://calgaryguide.ucalgary.ca/wp-
content/uploads/2014/09/COPD-
Pathogenesis.jpg
COPD: IMUNOLOGY

Barnes PJ. Immunology of asthma and COPD. Nature Review2008

COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT
COPD should be considered in
any patient who has
• dyspnea
• chronic cough or sputum
production
• a history of recurrent lower
respiratory tract infections
• and/or a history of exposure
to risk factors for the disease

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT

© 2020 Global Initiative for Chronic Obstructive Lung Disease

 COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT
Physical finding
• Early stage of COPD  normal physical examination
• Current smokers  active smoking , odor of smoke or nicotine staining of fingernails
• Severe disease prolonged expiratory phase & may include expiratory wheezing
• Sign of hyperinflation barrel chest, enlarge lung volumes + poor diaphragmatic
excursion (assesed by percussion)
• Severe airflow obstruction  exhibit use of accessory muscle respiration, sitting “tripod”
posisition to facilitate the act sternocleoidomatoid, scalen & intercostal muscles.
• Advanced diseasecachexia, with significant weigth loss, bitemporal wasting, diffuse loss
of subcutaneous adipose tissue.this syndrome ; inadecuat intake, elavated levels TNF-𝛼
• Paradoxical inward movement of the rib cage with inspiration (hoover’s sign)
• Chronic hyperinflation

Loscalzo J. Harrison's Pulmonary and Critical Care Medicine, 2e. McGraw-Hill Publishing; 2013 Mar 26.
 COPD : DIAGNOSIS, DIFFERENTIAL DIAGNOSIS
AND ASSESSMENT

Sumber :https://calgaryguide.ucalgary.ca/copd-clinical-findings/
COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT
Laboratory findings
• Spirometry is required to
make the diagnosis; the
presence of a post-
bronchodilator FEV1/FVC <
0.70 confirms the presence
of persistent airflow
limitation

© 2020 Global Initiative for Chronic Obstructive Lung Disease

 COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT
• Imaging
• Chest x-ray not useful to establish dx COPD,
• lung hyperinflation (flattened diaphragm and an increase in the
volume of the retrosternal air space), hyperlucency of the lungs, &
rapid tapering of the vascular markings.
• valuable in exlcluding alternative dx & establishing the presence
comorbidities  concomitant repiratory (pulmonary fibrosis,
bronchiectasis, pleural diseases), skeletal (e.g., kyphoscoliosis),
cardiac diseases (e.g., cardiomegaly)
• Computed Tomography (CT) not routinely
recommended except for detection of bronchiectasis and
COPD patients that meet the criteria for lung cancer risk Chest CTscan patient with COPD who
assessment. underwent a left single lung transplant*
• Helpful for DD
• Evaluation for lung transplantation

Loscalzo J. Harrison's Pulmonary and Critical Care Medicine, 2e. McGraw-Hill Publishing; 2013 Mar 26.
© 2020 Global Initiative for Chronic Obstructive Lung Disease
COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT
• Lung volumes and diffusing capacity
• Oximetry and arterial blood gas measurement
• arterial oxygen saturation & supplemental oxygen therapy
• Exercise testing and assessment of physical activity
• reduction in self-paced walking distance powerful indicator of health status impairment and
predictor of prognosis
• Composite scores
• Several variables identify patients at increased risk for mortality including FEV1, exercise tolerance
assessed by walking distance or peak O2 consumption, weight loss, and reduction in arterial O2
tension
• Biomarker
• C- reactive protein (CRP) and procalcitonin  restricting antibiotic usage during exacerbations
• Eosinophils use corticosteroids (prevention of some exacerbations)

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :
DIFFERENTIAL
DIAGNOSIS

© 2020 Global Initiative for Chronic Obstructive Lung DiseaseV

COPD : ASSESSMENT
COPD assessment determine the level of airflow limitation*, and
Theraphy
• presence and severity of the spirometric abnormality
• Current nature and magnitude of the patient’s symptoms
• History of moderate and severe exacerbations
• Presence of comorbidities

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : ASSESSMENT
Classification of severity of airflow limitation

© 2020 Global Initiative for Chronic Obstructive Lung Disease

 COPD : ASSESSMENT
• Assesment of symtomps

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :
ASSESSMENT
“ABCD” assessment
toolcombines the
symptomatic assessment
with the patient’s spirometric
classification and/or risk of
exacerbations
• severity of airflow limitation
(spirometric grade 1 to 4)
• (groups A to D) symptom
burden and risk of
exacerbation which can be
used to guide therapy

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS AND ASSESSMENT
Role of spirometry for the diagnosis, assessment and follow-up of COPD

© 2020 Global Initiative for Chronic Obstructive Lung Disease

 COPD : THERAPY
Evidence supporting Prevention and
maintenance therapy
• Smoking cessationPharmacotherapy and
nicotine replacement reliably ↑long-term
smoking abstinence rates,
Legislative smoking bans and counselling;
effective in ↑quit rates and reducing harm
from second-hand smoke exposure
• Effectiveness and safety of e-cigarettes
(smoking cessation aid) uncertain at
present

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : THERAPY ;Vaccination

© 2020 Global Initiative for Chronic Obstructive Lung Disease

 COPD : THERAPY

Pharmacological therapy for

COPD
• Reduce symptoms
• Reduce the frequency and
severity of exacerbations
• Improve exercise tolerance
and health status

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : THERAPY,

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :
THERAPY,

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :
THERAPY,

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : THERAPY; REHABILITATION, EDUCATION & SELF-
MANAGEMENT

Effective therapeutic strategy to improve shortness of breath, health status and exercise tolerance
© 2020 Global Initiative for Chronic Obstructive Lung Disease
COPD; SUPPORTIVE, PALLIATIVE, END-
OF-LIFE & HOSPICE CARE
Palliative care approaches to symptom control as well as management of
terminal patients close to death.
• to prevent and relieve suffering,
• to support the best possible quality of life for patients and their families,
regardless of the stage of disease or the need for other therapies.

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : other
Treatment

Surgical Intervention

© 2020 Global Initiative for Chronic Obstructive Lung Disease

MANAGEMENT OF COPD
Management of COPD
• The management strategy for stable COPD should be predominantly
based on the individualized assessment of symptoms and future risk
of exacerbations.
• All individuals who smoke should be strongly encouraged and
supported to quit.
• The main treatment goals are reduction of symptoms and future risk
of exacerbations.
• Management strategies include pharmacologic and non-
pharmacologic interventions.

© 2020 Global Initiative for Chronic Obstructive Lung Disease

© 2020 Global Initiative for Chronic Obstructive Lung Disease
 Management COPD :IDENTIFY AND REDUCE
EXPOSURE TO RISK FACTORS

Treatment and Prevention of COPD

• Cigarette smoking smoking cessation
• Reduction of total personal exposure
to occupational
• dusts, fumes, and gases, and to indoor and
outdoor air pollutants

© 2020 Global Initiative for Chronic Obstructive Lung Disease

TREATMENT OF STABLE COPD:
PHARMACOLOGICAL TREATMENT
Pharmacological therapies reduce symptoms, and the risk and severity of
exacerbations, as well as improve the health status and exercise tolerance of
patients with COPD

© 2020 Global Initiative for Chronic Obstructive Lung Disease

TREATMENT OF STABLE COPD:
PHARMACOLOGICAL TREATMENT

© 2020 Global Initiative for Chronic Obstructive Lung Disease

Algorithms for the assessment, initiation and follow-up
management of pharmacological treatment

© 2020 Global Initiative for Chronic Obstructive Lung Disease

follow-up recommendations:
• designed to facilitate management of
patients taking maintenance
treatment(s)whether early after initial
treatment or after years of follow-up.
• incorporate recent evidence from clinical
trials and the use of peripheral blood
eosinophil counts as a biomarker to guide
the use of ICS therapy for exacerbation
prevention.

© 2020 Global Initiative for Chronic Obstructive Lung Disease

TREATMENT OF STABLE COPD: NON-PHARMACOLOGICALTREATMENT

© 2020 Global Initiative for Chronic Obstructive Lung Disease

MANAGEMENT COPD: OXYGEN THERAPY & SURGIGAL TREATMENT

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD : Key points for the use of non-
pharmacological treatments

© 2020 Global Initiative for Chronic Obstructive Lung Disease

Management of COPD
Exacerbations
 Management of Exacerbations

COPD exacerbations are defined as an acute worsening of respiratory

symptoms that result in additional therapy.

► They are classified as:

• Mild (treated with short acting bronchodilators only, SABDs)

• Moderate (treated with SABDs plus antibiotics and/or oral
corticosteroids) or
• Severe (patient requires hospitalization or visits the emergency room).
Severe exacerbations may also be associated with acute respiratory
failure.

© 2019 Global Initiative for Chronic Obstructive Lung Disease

COPD
:EXACERBATIONS

https://calgaryguide.ucalgary.ca/copd-
triggers-and-signs-symptoms-of-acute-
exacerbations/
COPD : EXACERBATIONS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :EXACERBATIONS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :EXACERBATIONS

Initiative for Chronic Obstructive Lung Disease© 2020 Global

COPD :EXACERBATIONS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :EXACERBATIONS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :EXACERBATIONS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :EXACERBATIONS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD
:EXACERBATIO
NS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

COPD :EXACERBATIONS

© 2020 Global Initiative for Chronic Obstructive Lung Disease

Daftar Pustaka
• 2020 Global Initiative for Chronic Obstructive Lung Disease – GOLD
• Loscalzo J. Harrison's Pulmonary and Critical Care Medicine, 2e.
McGraw-Hill Publishing; 2013 Mar 26.
• Barnes PJ. Immunology of asthma and COPD. Nature Review2008
• https://calgaryguide.ucalgary.ca
Terima Kasih
Pertanyaan ppok stase IPD
• Dalam PF bagaimana mengetahui bahwa terdapat penurunan suara napas
bila kedua paru sama sama menurun?
• Bagaimana membedakan pasien copd dan emfisema yang belum memiliki
gejala spesifik (pink puffer and blue bloater)?
• bagaimana cara membedakan sesak napas karena copd dengan yang
lainnya? apa yang khas dari copd?
• apa yang harus diperhatikan dan difollowup dari pasien pada pengobatan
COPD termasuk efek samping obat yang mungkin timbul?
• Apakah dari anamnesis dan PF dapat menegakkan pasien PPOK ?
• Apa saja indikasi pemberian vaksin terhadap pasien PPOK ?
• bagaimana cara membedakan sesak napas karena copd dengan yang lainnya? apa yang
khas dari copd?
• Cara membedakan sesak nafas karena copd dan laiinya yaitu pastikan saat anamnesi
mengenai sesak nafas tanyakan mengenai
• Awal mula keluhan,
• Lamanya
• Progresivitas
• variabilitas
• Derajat beratnya
• Faktor-faktor yg memperberat /memperingan dan keluhan yg berkaitan
• Contoh perbedaan pasien ASMA, PPOK, DAN sindrom obstruksi pasca TB (SOPT)
• Sesak asma  dapat berulang , sesak hanya dalarn waktu beberapa jam atau hari
• Sesak ppok sesak bertahan dan semakin memberat secara progresif dalam waktu beberapa jam atau
hari bahkan rninggu, bulan atau tahun  khas ppok dyspnea kronik dan progresif
Apakah dari anamnesis dan PF dapat
menegakkan pasien PPOK?