Concept of Oxygenation

Respiratory System

Respiratory System

Chronic
Obstructive
Pulmonary
Disease

Chronic
(berlanjut, permanen,
tidak ada obatnya)

Obstructive
(sumbatan)

Pulmonary

(melibatkan paru-paru)

Disease

(kondisi dengan tanda dan gejala)

Secara umum, istilah COPD ditujukan

untuk kondisi yang mencakup:

bronkitis kronis
emfisema

Fakta-fakta mengenai COPD

COPD atau penyakit paru obstruktif kronik tidak memiliki

definisi tunggal

COPD adalah penyakit paru. Penyakit ini disebabkan oleh

sumbatan saluran udara pada paru dan tidak ada obatnya

COPD menunjuk pada sejumlah gangguan kronik paru yang

menyumbat saluran napas. Asma biasanya tidak dilihat
sebagai salah satu bentuk COPD oleh karena gejala asma
murni bersifat reversibel. COPD bersifat permanen.

Bentuk COPD yang paling umum adalah kombinasi antara

bronkitis kronis dan emfisema

 Bronkitis kronis terjadi ketika saluran udara dalam paru

menjadi sempit dan sebagian tersumbat oleh mukus
Pada bronkitis kronis, terdapat batuk dan sputum selama
lebih dari 3 bulan dalam 2 tahun berturut-turut. Jika
terdapat juga sumbatan saluran napas disamping
bronkitis kronis indikasi ke arah COPD
Emfisema terjadi ketika sejumlah kantong udara di dalam
paru-paru telah rusak
Emfisema adalah pembesaran dan destruksi alveoli
(kantong udara) dalam paru. Hal ini menyebabkan saluran
napas yang mengelilingi alveoli tersebut menjadi kolaps
Emfisema terkait alfa 1-antitripsin adalah suatu bentuk
penyakit paru kronik yang relatif tidak umum. Keadaan ini
disebabkan oleh kekurangan protein alfa 1-antitripsin
secara genetis

Fakta:
Berdasarkan penelitian, 80 sampai 90%dari seluruh kasus
emfisema dan bronkitis kronis disebabkan oleh kebiasaan
merokok. (Lung Facts 1994 Update. Canadian Lung Association,
1993)

Penyakit paru obstruktif kronik (COPD) mencakup

emfisema dan bronkitis kronis yang dicirikhaskan oleh
tersumbatnya aliran udara

Emfisema dan bronkitis kronik sering hadir bersamasama. Karenanya, dokter lebih menyukai istilah COPD.
Istilah ini tidak mencakup penyakit obstruksi lain
seperti asma

Di Amerika Serikat:
- Kira-kira 16,4 juta orang menderita COPD
- Penyebab kematian terbesar keempat
- 100.360 orang tewas tahun 1996 akibat COPD

Kira-kira 80 sampai 90% kasus COPD disebabkan oleh

merokok: seorang perokok memiliki kemungkinan 10
kali lebih besar untuk mati akibat COPD daripada non
perokok. Sebab lain adalah infeksi paru berulang dan
paparan terhadap polutan industri tertentu

Bronkitis Kronis
Bronkitis kronis adalah inflamasi dan
akhirnya pemarutan dari jaringan yang
membatasi saluran bronkus
Diperkirakan 14 juta orang menderita
bronkitis kronis, penyakit kronik terbesar
ketujuh di Amerika
Gejala bronkitis kronis mencakup batuk
kronis, peningkatan produksi mukus,
sering membersihan tenggorokan dan
pemendekan napas

Emfisema
Emphysema
menyebabkan kerusakan paru
yang
ireversibel.
Dinding
antar
alveolus
kehilangan kemampuannya untuk meregang
dan mengempis (kembali ke bentuk semula).
Dinding tersebut menjadi lemah dan rapuh.
Jaringan
paru
kehilangan
elastisitasnya
sehingga udara terperangkap dalam alveoli dan
mengganggu pertukaran oksigen dan karbon
diosida. Selain itu, saluran napas kehilangan
penyokong sehingga terjadi obstruksi aliran
udara
Gejala emfisema mencakup batuk, pemendekan
napas dan toleransi yang rendah terhadap
latihan fisik. Dx ditegakkan melalui tes fungsi
paru, anamnesis, pemeriksaan dan tes lain

AAT deficiency-related
emphysema
Alpha antitrypsin deficiency-related (AAT)
1

emphysema is caused by the inherited deficiency of a

protein called alpha1-antitrypsin (AAT) or alpha1protease inhibitor. AAT, produced by the liver, is a
"lung protector." In the absence of AAT, emphysema
is almost inevitable.
The onset of AAT deficiency emphysema,
between the 20's and 40's, is characterized by
shortness of breath and decreased exercise
capacity. Blood screening is used if the trait is
suspected and can determine if a person is a
carrier
or
AAT-deficient.
If
children
are
diagnosed as AAT-deficient through blood
screening, they may undergo a liver transplant.

Smoking significantly increases the severity of

emphysema in AAT-deficient individuals

COPD Treatment
The quality of life for a person suffering
from COPD diminishes as the disease
progresses. At the onset, there is
minimal shortness of breath. People
with COPD may eventually require
supplemental oxygen and may have to
rely
on
mechanical
respiratory
assistance.

 Depending on the severity of the

disease, treatments may include
bronchodilators, which open up air
passages in the lungs; antibiotics; and
exercise to strengthen muscles.
To reduce and control symptoms of
chronic bronchitis, sufferers should live
a healthy lifestyle by exercising,
avoiding cigarette smoke and other air
pollutants, and eating well.

 Pulmonary rehabilitation is a preventive

health-care program provided by a team of
health professionals to help people cope
physically, psychologically, and socially with
COPD.
Lung transplantation is being performed in
increasing numbers and may be an option for
people who suffer from severe emphysema.
Additionally, a new surgical procedure, lung
volume reduction surgery, shows promise
and is being performed with increasing
frequency.

 Special treatments for AAT deficiency

emphysema include AAT replacement
therapy (a life-long process).
Current research into COPD is focusing
on gene therapy; it is hoped that
clinical trials of this type of therapy will
take place within the decade.

Table of Symptoms
Severity
of COPD
MILD

MODER
ATE

SEVERE

Chronic Bronchitis
Dominating
Coughing and sputum for more
than 3 mos. for 2 consecutive yrs.
Shortness of breath (SOB) from
moderate exertion
Coughing and increased sputum
Recurrent chest infections or
bronchitis
Severe SOB
Coughing and excessive amounts
of sputum
Wheezing
Recurrent infections
Fluid build-up (swelling at the
ankles) and blue appearance to the
skin

Emphysema
Dominating
Possibly
no early
signs
SOB from
moderate
exertion

Severe
SOB
Barrelshaped
chest

 Etiology

Definite Causes
Cigarette Smoking (doseresponse relationship). (Only 10-15%
of heavy smokers will develop COPD)

Alpha-1 anti-trypsin deficiency

Certain occupational dusts and
gases/ fumes (mining, coal,
grain, cotton, wood)

Possible/Probable Causes
Air pollution (this is a more
important cause of
exacerbation of COPD)
Respiratory tract infections
Airway hyperreactivity
Some of these may be present
in childhood and result in
increased risk of COPD
decades later (not proven)

Two major types of COPD

Pink Puffer (Emphysema)

Blue Bloater

(Bronchitis)
Type A

Type B

Feature

Emphysema (Type A) PP

Bronchitis (Type B) BB

Age

Older

Younger

Stature

Tall, thin

More obese

Hypoxemia

Mild

Prominent

Hypercapnia

Late

Early

Cor pulmonale

Late

Early

Compliance

Increased

Normal

Hematocrit

Normal

Increased

Dyspnea

Prominent

Variable

Cough

Uncommon

Prominent

COPD Overview

Onset
usually after 5th decade

Symptoms
Shortness of breath
Cough

Diagnosis
History
Physical examination
Persistent airflow obstruction on PFT
X-ray changes (CXR, CT scan)

Pulmonary Function Test

Chest X-ray

Computerized Tomography

 Chest X-rays

Emphysema
Hyperinflation
Flattened diaphragms
Decreased vascular markings

Chronic Bronchitis
Usually normal

 Arterial Blood Gas (ABGs): An ABG is

done from a sample drawn from one of

your arteries. The blood is then
analyzed by a special machine, which
records the amount of carbon dioxide
(waste gas) and oxygen in your blood.
One of the uses of this test is to
determine whether or not you need any
extra oxygen.

 Pulse Oximetry:

This test is performed

by placing a special light clip on you
finger, earlobe or forehead. The pulse
oximeter uses light waves to indirectly
measure the amount of oxygen in your
blood. Done without the use of needles,
the pulse oximetry can be performed at
rest, while you are walking or even
overnight while you sleep.

X-Ray Appearance in COPD: In the early

stages of the disease the x-ray of the chest
may be completely normal. But in the moderate
to severe cases a reasonably accurate
diagnosis of COPD can be made with the plain
chest x-ray and C.T. (Computerized Axial
Tomography) scanning. The most common
appearances in the chest x-rays are
hyperinflation of the lung, depressed
diaphragms, loss of blood vessel markings,
reduced size of the heart, the presence of
bullae and sometimes increased lung
markings.

 TREATMENT FOR COPD

An important self help maneuver must be

emphasized at this time: Pursed Lip Breathing.

Non-medical therapy

Smoking cessation!

Supplemental O2 for patients who qualify by

having a low enough arterial PO2

Pulmonary rehabilitation

Medical therapy for chronic symptoms

Drugs

Supplemental O2 for patients who qualify by

having a low enough arterial PO2

Relieves dyspnea

Improves survival

Stabilizes pulmonary hypertension

Number of hours per day correlates with

benefit

Improves cognitive deficits

May be helpful in patients with nocturnal

or exercise associated O2 desaturation

Pulmonary rehabilitation

Whole body exercise

Inspiratory muscle training

 Medical therapy for chronic

symptoms

Bronchodilators
Adrenergic agents
Anticholinergic
Methylxanthines (i.e. theophylline)

Corticosteroids

Mucolytics

Diuretics

 Adrenergic agents

Beta-agonists bind to B2 receptors on

airway and result in smooth muscle
relaxation and bronchodilation

Inhaled route is preferred

Acute relief of symptoms

Beta-agonists

This class of medication is most commonly used in an

inhaled form.

This can be either as a small canister that sprays a fine

mist when pushed (known as an metered dose inhaler
or MDI), or in a liquid form made into a mist to breathe
by a machine at home.

There are short and long-acting forms of both the

inhaled and pill forms. NEVER USE THE LONG-ACTING
FORMS (salmeterol) TO HELP ACUTE SYMPTOMS!!

They take much, much longer to work than the short

acting versions, and your symptoms may get worse
before your medication takes effect. The advantage of
the inhaled forms is that the medication is absorbed
directly by the lung. This leads to fewer side effects
from the medication.

 Anti-cholinergic agents

Bind to acetylcholine receptors and

result in bronchodilation (of mostly larger
airways)

Reduces sputum production

Inhaled route is preferred

More important in COPD than in asthma

 Anticholinergics
(Ipratropium bromide)
This

is a type of medication most commonly

given by the inhaled route. There is also a
liquid form available which can be used in a
nebulizer. This medication can also help the
small airways of the lung relax and open
further, thereby making it easier to breathe.
This type of medication works best when
used on a regular basis and is not for acute
symptoms.

 Methylxanthines (i.e.

theophylline)

Weak bronchodilator

Other mechanisms may be important

Delays respiratory muscle fatigue
Improves respiratory muscle
mechanics

Theophylline
Theophylline is a type of medication that can
have multiple effects on your body's ability to
breathe better. It can cause your airways to
relax and open further, thereby making it easier
to breathe. It can also improve the diaphragm's
ability to contract. Also, theophylline can
increase the clearance of mucus from your
airways and help you clear excessive phlegm.
That is why your doctor may want to check the
blood level from time to time to ensure that you
are getting the correct dose. Theophylline can
be given either in a pill form or as a continuous
infusion when you are in the hospital.

Corticosteroids

Reduce airway inflammation

Efficacy and role in stable COPD

uncertain

Anti-Inflammatories (Steroids)

(prednisone, methylprednisolone)

Since COPD may have an inflammatory component, your

doctor may prescribe a steroid containing medication. The
type of steroid contained in these preparations is not the
type that builds muscle. Your body normally makes its own
anti-inflammatory steroids, however, extra doses may
benefit selected patients.

Steroids also can be given in several forms. The inhaled

form delivers the medication right where you want it,
straight to the lungs. If your breathing does not respond to
the inhaled form your doctor may chose to place you on a
pill form. An intravenous form is also available. Steroids
have many side effects. This is why your doctor will try to
get you off steroids as soon as possible. There is much
less concern with side effects when using inhaled steroids,
and this is the preferred form.

Mucolytics

Alter viscosity of sputum

May reduce symptoms in some patients

Do not improve objective parameters of

respiratory function

 Diuretics

Only for peripheral edema with right

heart failure

Must be used carefully (i.e. avoiding

hypotension)

COPD Exacerbations

Range in severity

Increase of symptoms

Increase cough

Increased sputum production

Shortness of breath increases

May progress to acute respiratory failure (requiring

mechanical ventilation)

Etiology

Infection (Viral/Bacterial)

Non-compliance with therapeutics

Exposure to physical / chemical irritants, including

cigarette smoke

Fatigue of the inspiratory muscles (this is unproven)

Chronic Bronchitis (CB)

Presence of cough/sputum production for most days for at

least 3 consecutive months during 2 consecutive years
Major features
Cough
Sputum production

Unlike patients with asthma, patients with CB have residual

clinical disease (symptoms, wheezes, abnormal PFTs)
between exacerbations

Asthmatic bronchitis
CB with a prominent airway hyperreactivity component

 Pathology of CB

Large airways involved

Increase in the number and size of mucus
glands in bronchi
Reid index increased

REID INDEX
Provides a measure of the proportion of
bronchial glands relative to thickness of
bronchial walls

Excess mucus in airways

Semi-solid plugs may occlude some small bronchi

Influx of inflammatory cells

Thickened airway walls
Narrowing of airways

Impaired clearance of mucus

Loss of cilia
Loss of function
Contribute to chronic cough and sputum
production

Emphysema

Enlargement of airspaces distal to terminal

bronchiole
Destruction of alveolar walls

Types of emphysema

(divisions based on pathological findings)

Centriacinar (centrilobular)
Panacinar (panlobular)
Bullous

Pathogenesis of emphysema

Cigarette smoke

Recruits neutrophils (and macrophages to a lesser extent)

Inflammatory cells produce elastase

Destroys connective tissue of alveolar walls

Alpha-1 anti-trypsin (or alpha-1 protease inhibitor) is a

protein produced by the liver that circulates in the blood
and limits the action of elastase

Inactivates anti-proteases (oxidation of amino acids affects

binding of these protein inhibitors)

Alpha-1 anti-trypsin deficiency

Autosomal recessive

Pathophysiology of COPD

Abnormalities in respiratory mechanics

Reduced expiratory airflow

In CB

Excessive secretions

Smooth muscle contraction (bronchospasm) Airway

inflammation / bronchial wall edema

In emphysema

Reduction of elastic recoil Loss of lung's natural

tendency to resist expansion

Supporting structures for the airways is decreased

DYSPNEA CUES

SOB Management

Metered dose inhalers (MDIs) or hand held

inhalers are a convenient, effective and safe
way to deliver medications to the lungs.
Because they are delivered locally and
directly to the lungs, smaller doses of
medication can be used. The beneficial
effects of the medication can occur while the
side effects are minimized. But... if the
inhalers are not used correctly the medication
will not get to the right place. At best, using
perfect technique, only 10-20% of the
medication gets to the right place. So, you
see why it's important to use good technique

Metered Dose Inhaler (MDI)

with Spacer

MDI

spacer

Proper Use of MDI

TURBOHALER

ROTAHALER