Chronic Obstructive Pulmonary Diseases (COPD)

Penyakit Paru Obstruktif Kronik (PPOK)

Amira Permatasari Tarigan

2012
 CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(GOLD, PDPI)

The third leading cause of death worlwide by

2020
Risk Factor :
1. Genes
2. Age and gender
3. Lung growth and development
4. Exposure to particles : Cigarette, biomass,
chemical etc
5. Socio economic
6. Bronchial hyperactivity
7. Chronic Lung infections
8. Chronic bronchitis
 CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(GOLD, PDPI 2011)

a preventable and treatable disease

state characterised by airflow
limitation that is not fully reversible.
The airflow limitation is usually
progressive and associated with an
abnormal inflammatory response of the
lungs to noxious particles or gases,
primarily caused by cigarette smoking
 Pathogenesis of
Cigarette smoke COPD
Biomass particles
Particulates
Host factors
Amplifying
mechanisms

LUNG INFLAMMATION
Anti-oxidants
Anti-
proteinases
Oxidative
stress Proteinases

Repair
mechanisms

COPD
Source: Peter J. Barnes, MD
 Patogenesis PPOK (Siafakas, 2003)

Lingkungan / Faktor Host

gas beracun (rokok) (genetik)

Stress Inflamasi Kerusakan Perbaikan

jaringan

Oksidasi abnormal jaringan

abnormal/remodeling
Inflammatory Cells Involved in
COPD Cigarette smoke
(and other irritants)

Epithelial Alveolar macrophage

cells

Chemotactic factors

CD8+
Fibroblast lymphocyte

Neutrophil Monocyte
Neutrophil elastase
PROTEASES Cathepsins
MMPs

Fibrosis Alveolar wall destruction Mucus hypersecretion

(Obstructive (Emphysema)
bronchiolitis)
Source: Peter J. Barnes, MD
Figure. Mechanisms of airflow limitation in chronic obstructive pulmonary
disease (COPD). The airway in normal subjects is distended by alveolar
attachments, which contain elastin fibers during expiration, allowing alveolar
emptying and lung deflation. In COPD these attachments are disrupted due to
emphysema, thus contributing to airway closure during expiration, trapping
 AIR TRAPPING AND
HYPERINFLATION IN COPD
Norma Mild - Severe Very
l Moderate Severe COPD
Inspiration
COPD
small
airway

Air trapping and Hyperinflation

attachments
alveolar TLC loss of elasticity loss Exertional
of alveolar
Residual volume (RV)
Expiration
dyspnoea
attachments

FRC Exercise
Inspiratory capacity (IC) tolerance
closure
Inspiratory reserve volume (IRV)
Courtesy of Barnes P
 DYNAMIC HYPERINFLATION IN COPD

TL Exercis
C e IRV Healthy

VC IC

EELV

RV

TLC Exercis
e IC COPD
VC
EELV

Decreases in inspiratory capacity

RV (IC) & inspiratory reserve volume
(IRV) during exercise is dynamic
hyperinflation
ODonnell DE Eur Respir Rev 2006; 15:37-4
Figure. Vascular changes in chronic obstructive pulmonary disease.
Chronic hypoxia results in hypoxic pulmonary vasoconstriction and, over
time, leads to structural changes in pulmonary vessels that result in
secondary pulmonary hypertension. An inflammatory response similar to
that found in airways is also seen in the vessel wall. Over time, this may
lead to right-sided heart failure (cor pulmonale), which has a poor
AIRFLOW LIMITATION of COPD:

Peribronchial Fibrosis
Mucus Hypersecretion
Smooth Muscle
Constriction
airway obstruction airflow limitation

Alveoli Destruction
loss of lung elastic recoil collaps of small airways
THE BENEFITS OF SMOKING CESSATION

Adapted from: Fletcher C, Peto R. BMJ 1977; 1: 16458.

 COPD IS DIAGNOSED BASED ON
SYMPTOMS, RISK FACTORS AND
SPIROMETRY
RISK FACTORS
SYMPTOMS Tobacco
Cough Occupational
Sputum production + hazards
Shortness of breath Indoor/outdoor
pollution

Spirometry
FEV11/FVC < 0.70

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2010. Available from www.goldcopd.org
 KEY INDICATORS FOR CONSIDERING
A DIAGNOSIS OF COPD

Dyspnea that is Progressive (worsen over time)

Usually worse with exercise
Persistent (present every day)
Described by patients as: increased
effort to breath, heaviness, air
Spirometry is neededhunger
to establish
or gasping a diagnosis
Chronic cough May be intermittent and may be
of COPD.
unproductive
Chronic sputum Any pattern of chronic sputum
production production may indicate COPD
History of exposure to Tobacco smoke
risk factors, especially
Occupational dusts and chemicals
Smoke from home cooking and
heating fuels
Rabe KF et al. GOLD 2007. Am J Respir Crit Care Med 2007;176:532-55
COPD POPULATION SCREENER (COPD-
PS)
Simple, validated
questionnaire

Can help identify people age

35 years in the general
population who are at risk of
COPD

Identifies COPD symptoms

and risks and considers age
as a screening factor

This tool may:

Increase awareness of COPD
Help with earlier symptom
recognition
Facilitate case identification
Lead to the use of spirometry Martinez FJ et al. J COPD 2008;5:8595.
 PEMERIKSAAN FISIS

Dada tong, jari tabuh, napas mencucu

Ekspirasi memanjang, wheezing

Tanda hiperinflasi: hipersonor, SP melemah

Ronki basah basal

Sianosis
 RADIOLOGI BRONKITIS KRONIK

Umumnya normal

21% corakan bronkoalveolar bertambah

 RADIOLOGI EMFISEMA

Stadium awal : normal

Stadium lanjut tanda-tanda hiperinflasi
~ radiolusen
~ diafragma mendatar
~ iga mendatar, sela iga lebar
~ jantung pendulum
What can
What can we
we do
do ???
???
 GOLD Guideline 2011:
Global Strategy for Diagnosis,
Management, and Prevention of COPD
The GOLD document
Chapter 1. Definition and
overview
Chapter 2. Diagnosis and
assessment
Chapter 3. Therapeutic
options
Chapter 4. Manage stable
COPD
Chapter 5. Manage
exacerbations
Chapter 6. COPD
comorbidities
 Definition of COPD
COPD, a common preventable and treatable
disease, is characterized by persistent
airflow limitation that is usually
progressive and associated with an enhanced
chronic inflammatory response in the
airways and the lung to noxious particles or
gases.

Exacerbations and comorbidities contribute

to the overall severity in individual patients.

Source: GOLD guideline 2011 Update

 Prevention of COPD
Primary and Secondary
A number of risk factors for COPD have been
identified several of these enable primary
prevention of COPD; e.g., smoking, indoor air
pollution and poorly managed asthma.
Smoking cessation is the single most
important intervention in the smoking COPD
patient
As COPD is the result of cumulative harmful
exposures, other exposures to dust, fumes and
smoke should be reduced whenever possible

Source: GOLD guideline 2011 Update

 Diagnosis of COPD
A clinical diagnosis of COPD should be
considered in any patient who has dyspnea,
chronic cough or sputum production, and/or
a history of exposure to risk factors for the
disease.
Spirometry is required to make the
diagnosis in this clinical context; the
presence of a post-bronchodilator FEV1/FVC
<0.70 confirms the presence of persistent
airflow limitation and thus of COPD

Source: GOLD guideline 2011 Update

 Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using
spirometry
Assess risk of exacerbations
Assess comorbidities

Source: GOLD guideline 2011 Update

 Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using
Use the COPD Assessment Test
spirometry
(CAT), risk
Assess or the mMRC Breathlessness
of exacerbations
scale
Assess comorbidities

Notes: The CAT score is preferred since it provides a

more comprehensive assessment of the symptomatic
impact of the disease.

Source: GOLD guideline 2011 Update

 mMRC Dyspnoe scale
(modified Medical Research Council)

Tidak terganggu oleh sesak napas

Tingk
kecuali pada keadaan olah-raga
at 1
yang berat.
Terganggu dengan sesak napas
Tingk ketika terburu-buru berjalan di
at 2 tanah yang datar atau mendaki
tanjakan.
Berjalan lebih lambat pada
permukaan yang datar
dibandingkan orang lain yang
Tingk
seusia karena sesak napas atau
at 3
harus berhenti untuk bernapas
ketika berjalan pada kecepatan
sendiri di permukaan yang datar.
Berhenti untuk bernapas setelah
Tingk berjalan 90 meter atau setelah
at 4 beberapa menit di permukaan
yang datar

Terlalu sesak untuk meninggalkan

Tingk
rumah atau sesak saat berpakaian
at 5
atau berganti pakaian.
 Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using
Use spirometry for grading severity
spirometry
according
Assess risk ofto spirometry, using four
exacerbations
gradescomorbidities
Assess split at 80%, 50% and 30% of
predicted value

Source: GOLD guideline 2011 Update

 Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using
spirometry
Userisk
Assess history of exacerbations &
of exacerbations
spirometry.
Assess 2 exacerbation or more
comorbidities
within the last year or an FEV1 <
50% of predicted value are
indicators of high risk

Source: GOLD guideline 2011 Update

 Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using
spirometry
Assess risk of exacerbations
Assess
Assess comorbidities and treat
comorbidities
them appropiately.
The most frequent comorbidities
are CVD, depression and
osteoporosis
 Combined assessment of
COPD
Assess symptoms
Assess degree of airflow limitation using
spirometry
Assess risk of exacerbations

An opportunity to combine these

assessments for the purpose of
improving management of COPD
 Combined assessment of

COPD

2 or
RISK (C) (D) more
(GOLD 3 RISK
Classific
(Exacer
ation of
bation
Airflow
2 1 history)
Limitati
on) (A) (B)

1 0

mMRC 0-1 mMRC 2+

CAT <10 CAT 10+

SYMPTOMS
(mMRC or CAT score)

Note: When assessing risk, choose the highest risk according to GOLD

(GOL (E
4 2 or
D xa

Combined
(C) (D) mor
Class 3 ce
e
ificat rb
RI ion 2 1
R at
S of
K Airfl
ow (A) (B)
IS io
K n
hi
assessme
nt of
Limi 1 0 st
tatio or
n) y)

COPD
mMRC 0-1 mMRC 2+
CAT <10 CAT 10+
SYMPTOMS
(mMRC or CAT score)

Spirometr
Exacerbati
Patie ic mMR
Characteristic on per CAT
nt classificat C
year
ion
A Low risk, less GOLD 1-2 1 0-1 < 10
symptoms
B Low risk, more GOLD 1-2 1 2+ 10
symptoms
C High risk, less GOLD 3-4 2+ 0-1 < 10
symptoms
 Management of COPD
Pharmacological First choice

GOLD 4
Airflow Limitation

ICS + ICS + 2 or
LABA or LAMA LABA or LAMA more
Classification of

GOLD 3
C D Exacerbatio
ns per
year

GOLD 2 1

SABA or SAMA prn LABA or LAMA

GOLD 1 0
A B
mMRC 0-1 mMRC 2+
CAT <10 CAT 10+

Source: GOLD guideline 2011 Update

 Management of COPD
Pharmacological First alternatives
GOLD 4 LABA ICS and LAMA
and LAMA ICS/LABA and
LAMA
Airflow Limitation

ICS/LABA and 2 or
Classification of

GOLD 3 PDE4-inh more

LAMA and LABA
C 4- Exacerbatio
LAMA and PDE D
inh ns per year

GOLD 2 LABA or 1
LAMA or
LABA and LAMA
GOLD 1 SABA and SAMA 0

mMRC 0-1 mMRC 2+

CAT <10 CAT 10+
A B

Source: GOLD guideline 2011 Update

 Management of COPD
Pharmacological
Patie Other
First choice First alternatives
nt alternatives
LABA or LAMA or
A SABA or SAMA prn Theophylline
SABA and SAMA
SABA and/or
B LABA or LAMA LABA and LAMA SAMA
Theophylline
PDE4-inh
SABA and/or
ICS + LABA or
C LABA and LAMA SAMA
LAMA
Theophylline

ICS & LAMA or

ICS+LABA and
Carbocysteine
LAMA or
ICS + LABA or SABA and/or
D ICS+LABA & PDE4-
LAMA SAMA
inh or LABA and
Source: GOLD guideline 2011 Update Theophylline
LAMA or
 Bronkhodilator
SABA- Short Acting B2 Agonist:
- Terbutaline (Bricasma)
Fenoterol (Berotec)
Salbutamol (Ventolin)
Procaterol ( Meptin )

Obat PPOK LABA : Indacaterol (Onbrez)

SAMA : Ipratropium bromide (Atrovent)
yg Diberikan LAMA - Long acting Antiholinergik
secara Tiotropium bromide (Spiriva)

Inhalasi ICS/ Inhalasi Kortikosteroid

Budesonide (Pulmicort)
Fluticasone Propionate (Flixotide)
Kombinasi
Formoterol + Budesonide (Symbicort)
salbutamol + ipratropium (combivent)
salmeteroll + futicasone (seretide)
Mukolitik
Acetyl cysteine
Bromhexine Hcl
Perhimpunan Dokter Paru IndonesiaTeknik Penggunaan Obat Inhalasi Yang Bena
(The Indonesia Society of Respirology) Akan Memeperbaiki Pengobatan PPO
 Management of COPD
Non-pharmacological
Depending on
Patie Recommende
Essential local
nt d
guidelines
Smoking cessation (can Flu vaccination
A include pharmacological Physical activity Pneumococcal
treatment) vaccination
Smoking cessation (can
Flu vaccination
include pharmacological
B-D Physical activity Pneumococcal
treatment)
vaccination
Pulmonary rehabilitation

Source: GOLD guideline 2011 Update

 Management of COPD the
aims
Relieve symptoms
Reduce
Improve exercise tolerance sympto
Improve health status ms

Prevent disease progression

Prevent and treat exacerbationsReduce
risk
Reduce mortality

Source: GOLD guideline 2011 Update

 COPD and co-morbidities
COPD patients are at increased risk for:
Cardiovascular diseases a major comorbidity in COPD and
probably both the most frequent & most important disease coexisting
with COPD

Osteoporosis Osteoporosis & depression are also major

comorbidities in COPD & are often under-diagnosed & associated with
poor QoL & prognosis

Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer frequently seen in patients with COPD and has
been found to be the most frequent cause of death in patients with
mild COPD
These co-morbid conditions may influence mortality and
 Definition of COPD exacerbation

Worsening condition

Three cardinal symptoms of exacerbation :

1. worsening dyspnea
2. increased sputum purulence
3. increased sputum volume

Minor symptoms included:

1. fever
2. increased cough
3. increased wheeze
4. URI within the preceding 5 days
5. heart rate 20% above baseline.
Exacerbations types based on severity:

type I (severe), three cardinal

symptoms
type II (moderate), two cardinal
symptoms
type III (mild), one cardinal symptom
plus
one minor symptom.
 Most exacerbations are due to
infection
80% of all exacerbations are
infectious
Predominant bacterial pathogens: 4050% of infectious
exacerbations
Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pneumoniae
Atypical bacteria: 510% of infectious exacerbations
Chlamydia pneumoniae
Mycoplasma pneumonia
Occasional causes of infectious exacerbations
Haemophilus parainfluenzae
Pseudomonas aeruginosa
Staphylococcus aureus
Enterobacteriaceae
Viral infection: 30% of infectious exacerbations
20% of all exacerbations are non-
infectious
Sethi.
31525CHEST 2000; 117: 380S385S; Miravitlles et al. Arch Bronchoneumol 2004; 40:

Environmental factors
50
Non-compliance with medications
More than 80% exacerbation can be
managed in outpatient.

3 Medications in exacerbation:
- Bronchodilators Short Acting
- Corticosteroids
- Antibiotics
 Indication for Hospital
Admission
Increase in intensity of symptoms
Severe underlying COPD
Onset of new phisical signs (cyanosis,
peripheral oedema)
Failure to respons to initial medical
management
Presence of serious comorbidities
Frequent exacerbation
Older age
Insufficient home support
 Therapetic components of Hospital
Management:
Respiratory Support:
Oxygen Therapy
Ventilator : non invasive ventilator
invasive ventilator

Pharmacologic Treatment:
Bronchodilators
Corticosteroids
Antibiotics
Adjunct therapies
 Management of Severe but
Not Life Threatening Exacerbations
Asses severity of symptom, blood gases and CXR
Administer supplemental oxygen therapy and obtain serial arterial blood
gases measurement
Bronchodilators:
- increase dose and/or frequency of short acting bronchodilators
- combine saba and sama
- use spacers or air driven nebulizers
Add oral or intravenous corticosteroids
Consider antibiotics (oral or intravenous) when signs of bacterial
infection
Consider non invasive mechanical ventilation
At all times: - check fluid balance and nutrition
- consider subcutaneous heparin/low molecule heparin
- identify and treat associated condition (heart failure)
- Closely monitor condition of patient
 COPD: IMPACT ON QUALITY OF
LIFE

Airflow Decreased Exacerbations

Limitation Exercise Capacity

Insomnia, Burden of
Fatigue Quality of Life Medical Care

Social Isolation,
Loss of Dyspnea,
Depression,
Independence Cough
Anxiety
 Conclusions
COPD is a leading cause morbidity and mortality worldwide and results in a
social and economic burden that is both substantial and increasing.
Inhaled cigarette and other noxious particle can cause lung inflammation
Chronic inflammatory respons may induce destruction tissue parenchymal
(resulting in emphysema) and disrupt normal repair and defense
mechanisms (resulting in small airway fibrosis)
Prevention of COPD is to a large extent possible and should have high
priority
A clinical diagnosis of COPD should be considered if patient have dyspnea,
chronic cough or sputum productions and/or history of exposure to risk
factors.
Spirometry is required to make the diagnosis of COPD; the presence of a
post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent
airflow limitation and thus of COPD.
Assessment of COPD requires assessment of Symptoms, Degree of airflow
limitation, Risk of exacerbation, and Comorbidities
The combined assessment of symptoms and risk of exacerbations is the
basis for management of COPD, both non-pharmacological and
pharmacological

Source: GOLD guideline 2011 Update

 SEKIAN
&
TERIMAKASIH