Top Ten Disease

Penyakit Paru Obstruktif

Kronik (PPOK)

Oleh :
Aldrin J Muskananfola

Pembimbing:
dr. Nikson Faot, Sp. P
 Introduction
Chronic Obstructive Pulmonary United States of America
Disease (COPD)
1. An estimated 15 million people
-Persistent and progressive airflow
suffer from COPD-
barriers
•↑ chronic airway inflammatory 2. 4-6% occurs in men
response by irritant gas or particles 3. 1-3% occurs in adult women

Indonesia
•Prevalence of 3.7% Attention to COPD is still
•↑ according to age
•Male (4.2%) >> female (3.3%)
low , causes ↑ disease
•Rank 6th out of the 10 most morbidity & mortality
common causes of death
 Case Report
• Name : Mr. ASM
• Age / Gender : 80 years / Male
• MRS through : IGD
• Take care of the emergency room : November 17, 2018 at 10:14
p.m.
• Take care of the room : Komodo
• No. MR : 013091
• Religion : Protestant Christianity
• Marital status : Married
• Job : Retired civil servant
• Address : Kuanino
 Anamnesis was carried out in an autoanamnesis with
the patient on 26-211-208 in Rg Komodo Hospital,
Prof. Dr. W. Z. Johannes Kupang.
Main complaint: Shortness of breath 1 day before entering the hospital
Current Disease History:
Patients complained of shortness of breath since yesterday before being
admitted to the hospital, then after that the patient complained that the
tightness was getting worse so that the patient was delivered by the
family to the emergency room of RSU Prof.W. Z Johannes. According to
the patient's tightness when while resting, it becomes more burdensome
when moving. Other symptoms are cough (+) dry. Patients have a history
of heart disease, PPok and shortness of breath before. According to
patients who had previously smoked while still young and for now
patients have stopped smoking.
Anamnesis

• Past medical history: Patients have a history of CAD +

COPD + CHF + hypertension
Anamnesis
• Treatment History: captopril 2x25 mg
Anamnesis
• Family History: There are no members of the same sick
family.
• Habit History: Patients claimed that when they were young
they smoked but now they have stopped smoking.
• Families of patients at home have smoked.
Anamnesis

• Social & Economic History: The patient is a retired civil

servant. Patients live with their children, for the needs of
their children.
 Physical examination
General state: Looks mildly ill
Awareness: Compos mentis Vital sign
(E4V5M6)
TD: 130/90 mmHg
Pulse: 82 times / minute,
regular, strong
lift
RR: 20 times / minute
Temperature: 36.5 oC
Pemeriksaan Fisik

head & neck

• Hair: Looks blackish in color • Mouth:
• Skin: Pale (-), cyanosis (-), icteric (-), • Moist lip mucosa
good skin turgor • Tongue: moist mucosa
• Eyes: • Ears: otorea - / -, signs of
• Conjunctiva: anemis - / - inflammation (-)
• Sklera: jaundice - / - • Neck:
• Pupil: isokor + / + • KGB enlargement (-)
• Direct light reflex: + / + • Use of respiratory aids (-)
• Cloudy lens: - / -
• Trachea in the middle
• Sunken eyes : -/-
• Nose: Rhinore - / -, no deformity, no
septal deviation
Pemeriksaan Fisik

Toraks
 Pulmo (anterior)
 Inspection: Development of left and right symmetrical
chest, respiratory aids muscle (-)
 Palpation: Tactile fremitus Dextra = Sinistra
 Percussion: Sonor in both lung fields
 Auskultasi:
Vesikuler : Ronkhi : Wheezing :
+ + - - - -
+ + - - - -
+ + + + - -
Pemeriksaan Fisik

Toraks
 Pulmo (posterior)
Pulmo (anterior)
Inspection: Development of left and right symmetrical
chest, respiratory aids muscle (-)
Palpation: Tactile fremitus Dextra = Sinistra
Percussion: Sonor in both lung fields
Auskultasi :
Vesikuler : + + Ronkhi : - - Wheezing
- - :
+ + - - - -
+ + + + - -
Pemeriksaan Fisik

Toraks
• Cor
• Inspection: Ictus Cordis is not visible
• Palpation: Ictus Cordis palpated in ICS 5 line in the left
midclavicularis
• Percussion: Dim
• upper cardiac limit: ICS 2 right parasternal line
• lower heart border: ICS 5 line midclavicularis sinisira
• right heart border: ICS 4 right parasternal line
• left heart border: ICS 5 line midway midclavicularis
• Auscultation: S1S2 single, regular, murmur (-), gallop (-)
Pemeriksaan Fisik

Abdomen
• Flat, supple, distention (-) inspection
• Auscutation: BU (+) 12x / m, normal
• Palpation:
• Pain in the epigastric region (-)
• The liver is not palpable under the costus
arc
• Lien Schuffner (0)
• Percussion: Timpani, liver span 8 cm
Pemeriksaan Fisik

Punggung
•Normal vertebrae Ekstremitas
• Lordosis, kyphosis or
scoliosis do not appear • Akral is warm
•Tenderness (-)
•Pain tap CVA (-) • CRT < 2”
• Edema

• Motorik 55/55
POMR
 Planning Planning
Key and Clue Problem List DD Planning Therapy Planning Education
Diagnostic Monitoring
History ˗
1.1 Chronic 1.1.1. Spirometri
-nebulisasi Keluhan - Explain to the patient
Lung Disease PPOK ˗ TTV
Male, 80 years old 1.1.2. combiven- about the disease.
Shortness of breath since Asma -O2 masker 8 - Explain to patients to
1 week of SMRS always eat foods that are
lpm,
Have experienced it often sufficiently nutritious
-Injeksi
Shortness of breath is felt and balanced.
to be getting better. Ciprofloxcacin - Explain to patients to
Dry cough (+) 2x200 mg (iv) routinely control and
Patients with a history of -injeksi take the drugs given.
smoking since they were metilpredniso - Explain to patients to
young have now stopped lon 1x6,25 mg take precautionary
Patients with COPD (iv) measures to prevent
history -retaphyl sr disease by not smoking,
always use masks while
1x1 PO
Pemfis working and avoid
-N ACE 3X1
Vital Signs smoke or pollution or
TD: 130/90 PO 3x 2 mg other irritant materials.
Temperature: 36.5 C
Pulse: 82x / m
RR: 20x / m
The ribs seemed to widen
Ronkhi in the basal lung.
 Literature Review of Chronic
Obstructive Pulmonary Disease (COPD)
 Definition
Chronic Obstructive Pulmonary Disease
(COPD) is a chronic respiratory disease that
can be prevented and can be treated,
characterized by persistent airway resistance
and usually progressively nonreversible or
partially reversible and associated with an
increase in the airway's chronic inflammatory
response caused by gas or certain irritant
particles.
 Epidemiologi
• nited States of America
• 1. An estimated 15 million people suffer from COPD-
• 2. 4-6% occurs in men
• 3. 1-3% occurs in adult women

Indonesia

•Prevalence of 3.7%
•↑ according to age
•Male (4.2%) >> female (3.3%)
•Rank 6th out of the 10 most common causes of death
 Etiologi dan risk factor
• Host Factor • Environmental factor
• Gen • Smoking habit
• Airway • Exposure to dust and
hyperresponsiveness chemicals in the
• Lung Growth and workplace
Development • Exposure to indoor and
outdoor air pollution
• Infection
• Socioeconomic status
Patogenesis
Diagnosis
 Anamnesis
• History of risk factor exposure.
• Chronic cough and phlegm.
• Shortness of breath as an increase in effort to
breathe, feeling heavy when breathing
 Physical examination
. Inspection
1.Pursed-lips breathing (half-closed mouth joking)
2.Barrel chest
3.Use of airway muscles
4.Airway muscle hypertrophy
5.Widening between ribs
6.When right heart failure occurs, the jugular vein is
visible in the neck and leg edema
7. Pink puffer appearance or blue bloater
 Physical
examination

2. Palpation in fremitus emphysema is

weakened.
3. Percussion in hypersonor emphysema and
the cardiac border shrinks, the diaphragm is
low, the liver is pushed down.
4. Auscultation
Normal or weak vesicular breath sounds
There are crackles and / or wheezing during
normal breathing or forced expiration.
 Supporting investigation
1. Faal Paru
• Spirometri
Pada pasien dengan FEV1 /FVC <0,7

GOLD 1 mild FEV1 ≥ 80% prediksi

GOLD 2 moderate 50% ≤ FEV1 < 80% prediksi

GOLD 3 severe 30% ≤ FEV1 < 50% prediksi

GOLD 4 Very severe FEV1 < 30% prediksi

 Supporting
investigation

2. Laboratory includes complete blood and

blood gas analysis
3. Radiology
Emphysema Hyperinflation, Hyperlusen,
Widespread retrosternal space, Flat
diaphragm, Heart hanging (pendulum heart /
tear drop / eye drop appearance)
Chronic bronchitis Normal, increased
bronchovascular appearance
The picture above shows a chest X-ray of a
bullous type of emphysema patient. An arrow
indicates a bull wall that looks like a curved
line
the picture above shows a chest X-ray of a patient
with heatinar emphysema. It can be seen the
picture of lusen in the field below the left and right
lungs
 Klasifikasi
Mild copd
Clinical symptoms:
With or without coughing
With or without sputum
production
Shortness of breath 0 to the
degree of tightness 1
Spirometry:
VEP1 ≥ 80% prediction
(normal spirometry) or
VEP1 / KVP <70%
Moderate copd
Clinical symptoms:
With or without coughing
With or without sputum
production
Shortness of breath: degree of
tightness 2 (tightness arises
during activity).
Spirometry:
VEP1 / KVP <70% or
50% <VEP1 <80% prediction
Klasifikasi

Severe COPD
Clinical symptoms:
-Shortness of breath 3 and 4 degrees with chronic respiratory failure
-Exacerbations are more common
-Accompanied by cor pulmonary complications or right heart failure
Spirometry:
VEP1 / KVP <70%
VEP1 <30% prediction or
VEP1> 30% with chronic respiratory failure
-Chronic respiratory failure in COPD is indicated by results
blood gas analysis check, with criteria:
-Hypoxemia with normokapnia or
-Hypoxaemia with hypercapnia
 Management
Non Farmakologi Farmakologi
1. Education 1. Bronchodilator
2. Nutrition 2. Methylxanthine
3. Corticostroids
3. Rehabilitation
4. Phosphodiesterase 4 inhibitors
(PDE-4 inhibitors)
5. Antimuscarinic
6. Combination of β2 agonists
and antimuscarinic
7. Antibiotics
8. Mukolitik and antioxidants
9. Oxygen therapy
 Tatalaksana Eksaserbasi Akut
• SABA is inhaled with / without SAMA.
• Oral corticosteroids can improve lung function (FEV1),
tissue oxygenation and length of stay. Therapy should not be
given more than 5-7 days.
• Antibiotics can be given because they can speed up recovery
time, reduce the risk of relapse faster, reduce therapy failure
and length of stay. Antibiotics should not be given more than
5-7 days.
• Methylxanthine is not recommended because it increases side
effects.
• Non-mechanical ventilation is the first choice in COPD
patients with acute respiratory failure.
 Onset in middle age
Slow progressive symptoms
PPOK The duration of smoking history
Diagnosis Banding Shortness during activity
Ireversible air flow resistance
Onset in childhood
Symptoms vary from day to day
Symptoms at night / early morning
Asma
Accompanied by allergies, rhinitis or eczema
Family history of asthma
Reversible airflow resistance
Auscultation sounds fine crackles on the basal part, there can be gallops and
Gagal jantung murmurs
kongestif Chest X-ray appears cardiomegaly, pulmonary edema
Lung function tests show restriction not obstruction
purulent sputum in large amounts
Generally associated with bacterial infections
Bronkiektasis
Auscultation sounds rough / clubbing crackles
Chest X-ray / CT scan shows bronchial dilatation, bronchial wall thickening
Onset at all ages
Chest X-ray shows an infiltrate or lesion of nodules in the lung
Tuberkulosis
Confirmed by microbiology examination
Patients live in areas with a high prevalence of tuberculosis
Onset at a young age, not a smoker
Bronkiolitis
Has a history of rheumatoid arthritis or exposure to smoke
obliteratif
CT scan of expiration appears to be a hypodense area
Kebanyakan pasien adalah pria dan bukan perokok
Panbronkiolitis Almost all of them have a history of chronic sinusitis
difus Chest X-ray and HRCT appear diffuse small centrilobular nodular opacities and
hyperinflation
 Komplikasi
1. Breath failure
2. Recurrent infection
3. Pulmonary Cor
4. Pneumothorax
 Pencegahan
1. Prevents COPD
Avoid cigarette smoke
Avoid air pollution
Avoid repeated airway infections
2. Prevent COPD worsening
Quit smoking
Using adequate medicines
Prevents repeated exacerbations
 DISCUSSION
Case = In the case, patients came to the
emergency room with complaints of shortness
of breath that had been felt since yesterday,
the SMRS, then after that the congestion was
felt heavy the next day. Shortness
accompanied by a dry cough (+), the patient
has a history of heart disease and shortness
beforehand. Patients also have a history of
smoking in their youth.
• THEORY =
• This is consistent with the theory that COPD
has a history of coughing, tightness and a
history of exposure to irritants from cigarette
smoke. Acute exacerbations in COPD are
characterized by increasing congestion,
increased sputum production and purulent
sputum discoloration.
CASE = From physical examination, blood
pressure was 130/90 mmHg, temperature 36.5
and respiration 20x / minute. On examination
of the thorax, intercostal retraction and ribs
seemed to widen. From auscultation, there is a
ronchi at the basal of both lungs.
THEORY = From physical examination can be
found the use of respiratory muscles, the
shape of the chest barrel chest, between the
ribs widened and there is ronchhi or wheezing.
CASE = In this patient nebulisation combivent,
O2 mask 8 lpm, injection of ciprofloxcacin
2x200 mg (iv) and injection of
methylprednisolone 1x6,25 mg (iv), retaphyl sr
1x1 PO, N ACE 3X1 PO
THEORY = Management of acute exacerbation of
COPD is by administering oxygen, short-acting
B2 agonists can be combined with short-acting
anticholinergics, antibiotics and corticosteroids
as antinflammatory...
 conclussion
• Chronic Obstructive Pulmonary Disease (COPD) is a chronic
respiratory disease that can be prevented and can be treated,
characterized by persistent airway resistance and usually
progressively nonreversible or partially reversible and associated
with an increase in the airway's chronic inflammatory response
caused by gas or certain irritant particles.
• The World Health Organization (WHO) reports that there are 600
million people suffering from COPD in the world with 65 million
people suffering from moderate to severe COPD.
• In Indonesia based on the RISKESDAS in 2013, the prevalence of
COPD was 3.7%. The incidence of this disease increases with age
and is higher in men (4.2%) compared to women (3.3%). COPD
ranks 6th out of the 10 most common causes of death in Indonesia.
conclussion

• There are two risk factors that can cause COPD to include
host factors and due to environmental exposure.
• COPD can be diagnosed based on history, physical
examination and investigation.
• To prevent disease progression, eliminate symptoms,
improve activity tolerance / exercise, improve health status,
prevent and treat complications, prevent and treat
exacerbations and reduce disease mortality, good
management includes disease assessment and monitoring,
reducing risk factors, stable COPD management, and
management of COPD exacerbations.
conclussion

• COPD can cause severe complications, one of which is

respiratory failure. So that necessary precautionary
measures so that complications do not occur. Prevention
that can be done include stopping smoking, avoiding air
pollution, and avoiding repeated airway infections, using
adequate drugs, and preventing repeated exacerbations.
 summary
Thus the top ten diseases of chronic obstructive
pulmonary disease (COPD). In this top ten disease,
definitions, epidemiology, etiology and risk factors
have been described, pathogenesis, classification,
diagnosis, management, differential diagnosis, and
complications and prevention that can be done. Thus
the top ten disease is made as a learning material and
reference or guideline for young doctors or readers in
handling cases of chronic obstructive pulmonary
disease (COPD).
Terima Kasih..