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Disease of COPD
Zulkarnain Arsyad
Pulmonology Subdivison
of Internal Medicine Medical FacultyAndalas University M D amil !os"ital
Padang
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INTRODUCTION
COPD is t#e $ t# leading cause of deat# in t#e UnitedStates %be#ind #eart disease& cancer& andcerebrovascular disease'(
In )***& t#e +!O estimated )(,$ million deat#s-orld-ide from COPD(
In .//*& COPD -as ranked .) t# as a burden ofdisease0 by )*)* it is "ro ected to rank 1 t#(
In Indonesia COPD in t#e no 2 t# of leading cause of
deat#
COPD is t#e $ t# leading cause of deat# in t#e UnitedStates %be#ind #eart disease& cancer& andcerebrovascular disease'(
In )***& t#e +!O estimated )(,$ million deat#s-orld-ide from COPD(
In .//*& COPD -as ranked .) t# as a burden ofdisease0 by )*)* it is "ro ected to rank 1 t#(
In Indonesia COPD in t#e no 2 t# of leading cause of
deat#
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Definition
Airflo- limitation t#at is 3O4 fully
reversibleProgressiveAssociated -it# an abnormal inflammatoryres"onse of t#e lungs to no5ious "articles orgases
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Pathogenesis
4#ree "rocesses6
O5idative stressImbalance of "roteinases and anti7"roteinasesC#ronic inflammation
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LUNG INFLAMMATIONLUNG INFLAMMATION
COPD PATHOLOGYCOPD PATHOLOGY
OxidativeOxidativestressstress ProteinasesProteinases
Re airRe air!e"hanis!s!e"hanis!s
Anti# roteinasesAnti# roteinasesAnti#oxidantsAnti#oxidants
Host fa"torsA! $if%ing !e"hanis!s
Cigarette s!o&e'io!ass arti"$es
Parti"($ates
Source : Peter J. Barnes,
Pathogenesis ofCOPD
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C#ronic Inflammation
C#ronic inflammation in air-ays&
"arenc#yma& "ulmonary vasculatureInflammatory cells involved are6
Macro"#ages leukotriene 8$
47lym"#ocytes %CD9' interleukin 9 3eutro"#ils 43F7:
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Cigarette s!o&eCigarette s!o&e)and other irritants*)and other irritants*
PROTEASESPROTEASESNeutrophil elastaseNeutrophil elastaseCathepsinsCathepsinsMMPsMMPs
Al eolar !all "estru#tionAl eolar !all "estru#tion$E%ph&se%a'$E%ph&se%a'
Mu#us h&perse#retiMu#us h&perse#retio
CD8CD8 ++lymphocytelymphocyte
Alveolar Alveolarmacrophagemacrophage
Epithelial Epithelial cellscells
(i)rosis(i)rosis$O)stru#ti e$O)stru#ti e
)ron#hiolitis')ron#hiolitis'
Fibroblast Fibroblast
Monocyte Monocyte Neutrophil Neutrophil
Che%ota#ti# *a#torsChe%ota#ti# *a#tors
In ammatory Cells Involved inCOPD
Source : Peter J. Barnes,MD
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;isk Factors
4obacco SmokeCigarettes&Pi"es& cigars < lo-er rates t#ancigarette smokers but #ig#ert#an non7smokers
Occu"ational dusts andc#emicals
=a"ors& irritants& fumes 3eed sufficiently intense or
"rolonged e5"osureIndoor air "ollution8iomass fuel used for cookingand #eating in "oorly ventedd-ellings
Outdoor air "ollutionMinor risk factor Passivecigarette smoke e5"osure
;es"iratory infections in earlyc#ild#ood>o-er socioeconomic status
association -it# COPDMay be secondary to cro-ding&
"oor nutrition& etc(
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Risk Factors for
COPDN(tritionN(trition
Infe"tionsInfe"tions
+o"io#e"ono!i"+o"io#e"ono!i"stat(sstat(s
Aging Po ($ationsAging Po ($ations
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Pat#ology
Central Air-ays6?nlarged mucus secretingglandsIncrease in goblet cells
Mucus #y"ersecretionPeri"#eral Air-ays
;e"eated cycles of in uryand re"air
Increased collagen@scarringin air-ay -all
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Pat#ology
Pulmonary vascular c#anges
4#ickening of vessel -all %intima'
Increase in smoot# muscle
Infiltration of vessel -all by inflammatory cellsAs COPD -orsens& more smoot# muscle& "roteoglycans andcollagen furt#er t#icken t#e vessel -all
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A$veo$ar ,a$$ destr("tion
Loss of e$asti"it%
Destr("tion of ($!onar%"a i$$ar% -ed
. Inf$a!!ator% "e$$s !a"ro hages/ CD0 1 $%! ho"%tes
Source : Peter J. Barnes, MD
Changes in Lung Parenchyma inCOPD
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Pat#o"#ysiology
Mucus #y"ersecretion
Ciliary dysfunction
Airflo- limitation
Pulmonary #y"erinflation
as e5c#ange abnormalities
Pulmonary #y"ertension
Cor "ulmonale
Mucus #y"erserection B ciliary dysfunction coug#& s"utum "roduction
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Medical !istory
?5"osure to ris& fa"tors & incl(intensity@duration!istory of e5acerbations or "revious
#os"itali ations for res"iratorydisorder Past medical #istory
Ast#ma& allergies& sinusitis@nasal "oly"s& res"iratory infections inc#ild#oodPresence of co7morbid conditions
!eart disease;#eumatic disease
Family !istoryCOPDOt#er c#ronic res"iratory diseases
Social !istoryIm"act of disease on "atientEs life&inc( activity& missed -ork andeconomic im"act?ffect on family routinesDe"ression@an5ietySocial and family su""ort availableto t#e "atient
Ot#er6A""ro"riateness of current medicaltreatmentsPossibilities for reducing riskfactors& es"( smoking cessation
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!istory of Present Illness
C#ronic Coug#Intermittently or every dayPresent t#roug#out t#e day0seldom only nocturnal
C#ronic s"utum "roductionAny "attern
;e"eated e"isodes of acute bronc#itis
C#ronic coug# and s"utum "roduction often "recede develo"mentof airflo- limitation by many years
3ot all "atients -it# t#ese sym"toms develo"COPD
Dys"nea on e5ertionProgressivePersistent+orse -it# e5ercise+orse during res"iratoryinfections
!istory of e5"osure to riskfactors
4obacco smokeOccu"ational dusts andc#emicalsSmoke from #ome cooking and#eating fuels
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P#ysical ?5amination
4#ora568arrel c#est
>ungsDecreased breat# sounds+#ee ing
Cardiac;ig#t7sided #eart failure
?dema& tender liver&distended abdomen
P#ysical signs are rarely a""arentuntil significant im"airment of lung
function #as occurred
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Diagnostic 4ests
C#est 7rayFlattened dia"#ragmsUse to e5clude ot#er diagnoses
!ig# resolution C4 3ot routinely recommendedIf in doubt about diagnosis ofCOPDIf considering bullectomy or lungvolume reduction surgery
C8CMay see increased#emoglobin@#ematocrit secondary to#emoconcentration
A8S"irometry
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S"irometry
Measure of F=C and F?= .F=C G forced vital ca"acity
Ma5imum volume of air forcibly e5#aled from t#e "oint of ma5imalin#alationF?= . G forced e5"iratory volume in . second
=olume of air e5#aled in t#e . st second of t#e F=C maneuver
Calculate t#e F=C@F?= . ratio
3ormal ratio G ,*@9*HCOPD ratio G ,*H "re7bronc#odilator F=C B F?= areCOPD ratio G 9*H "ost7bronc#odilator bot# decreased
?ssential to making t#e diagnosis of COPD
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Classi cation of COPDSeverity
y S!irometryStage I" #ild F$% &'F%C ( )*+)F$%& , -). !redicted
Stage II" #oderate F$% &'F%C ( )*+) /). ( F$% & ( -). !redicted
Stage III" Severe F$% &'F%C ( )*+)
0). ( F$% & ( /). !redicted
Stage I%" %ery Severe F$% &'F%C ( )*+) F$% & ( 0). !redicted or
F$%& ( /). !redicted plus
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Differential Diagnosis of
COPDAst#ma
;eversible airflo- limitation?arly onset %c#ild#ood'
Sym"toms vary day to dayCongestive #eart failure=olume restriction& 3O4 airflo-limitationC ; -it# dilated #eart& "ulmonaryedema
8ronc#iectasis>arge volumes of "urulent s"utumCommonly associated -it# bacterialinfection8ronc#ial dilation and bronc#ial-all t#ickening on C ; or C4
4uberculosisOnset at all agesC#est 57ray -it# infiltrate ornodular lesions
Obliterative bronc#iolitisJounger "atients@non7smokersMay #ave a #5 of r#eumatoidart#ritis or fume e5"osureC4 s#o-s #y"odense areas -it#e5"iration
Diffuse "anbronc#iolitisMale@non7smokersC#ronic sinusitisC ; and #ig# resolution C4 s#o-diffuse small centrilobular nodularo"acities and #y"erinflation
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COPD Management Program
O>D % lobal Initiative for C#ronicObstructive >ung Disease'
uidelines
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oals
Prevent disease "rogression;elieve sym"toms
Im"rove e5ercise toleranceIm"rove #ealt# statusPrevent and treat com"licationsPrevent and treat e5acerbations;educe mortalityPrevent or minimi e side effects from treatmentCessation of cigarette smoking
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eneral Princi"les
Determine disease severityIm"lement ste"7-ise
treatment "lan?ducate t#e "atient
Im"rove skillsIm"rove ability to co"e -it#illnessIm"rove #ealt# status
Prescribe 4reatmentP#armacologic
3on7"#armacologic;e#abilitation
?5ercise training 3utrition counseling
educationO5ygen t#era"y
Surgical interventions
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