COPD(CHRONIC OBSTRUCTIVE

PULMONARY DISEASE )

KELOMPOK D

DEFINITION

Chronic Obstructive Pulmonary Disease is a preventable and treatable disease with some significant extrapulmonary effects.

The pulmonary component is characterized by airflow limitation that is not fully reversible.

Healthy Alveolus

COPD

The airflow limitation in COPD is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles and gases

Severe COPD leads to respiratory failure, hospitalization and eventually death from suffocation

PATHOLOGY

Pathological changes characteristic of COPD are found in the airways, lung parenchyma, and pulmonary vasculature. The pathological changes include chronic inflammation, with increased numbers of specific inflammatory cell types in different parts of the lung, and structural changes resulting from repeated injury and repair.

PATHOLOGY

In general, the inflammatory and structural changes in the airways increase with disease severity and persist on smoking cessation

PHATOGENESIS

Oxidative stress Protease – antiprotease imbalance Inflammatory cells Inflammatory mediators Differences in inflammatory between

COPD and Asthma

PHATOPHYSIOLOGY

Airflow limitation and air trapping Gas exchange abnormalities Mucus hypersecretion Pulmonary hypertension Exacerbation Systemic features

DIAGNOSIS

Risk Factors for COPD

Aging Populations

Nutrition

Infections

Socio-economic status

SYMPTOMS

Dyspnea Cough Sputum Wheezing and Chest Tightness Additional features in severe disease

DIAGNOSIS

Medical hystory Physical examination Spirometry

ASSESSMENT OF DISEASE

ASSESSMENT OF SYMPTOMS Modified Medical Research Council

(mMRC) COPD Assessment Test (CAT) Clinical COPD Questionnaire (CCQ)

SPIROMETRIC ASSESSMENT

Classification of COPD Severity by Spirometry

Stage I: Mild FEV1/FVC < 0.70

FEV1 > 80% predicted

Stage II: Moderate FEV1/FVC < 0.70

50% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.70

30% < FEV1 < 50% predicted

Stage IV: Very Severe FEV1/FVC < 0.70

FEV1 < 30% predicted or

FEV1 < 50% predicted plus

chronic respiratory failure

Differential Diagnosis

COPD and its Differential DiagnosisDiagnosis Suggestive FeaturesCOPD Onset in mid-life,symptoms slowly

progressive, history of tobacco smoking or exposure to other types of smoke

Asthma Onset early in life (often childhood),symptoms vary widely from day to day, symptoms worse at night/ early morning, allergy/rhinitis and or eczema also present,family history of asthma

Congestive Heart failure Chest X-ray shows dilated heart, pulmonary edema, pulmonary function tests indicate volume restriction,not airflow limitation

Bronchiectasis Large volumes of purulent sputum, commonly associated with bacterial infection, chest x-ray/ CT shows bronchial dilation, bronchial wall thickening

Differential Diagnosis

COPD and its Differential Diagnosis

Diagnosis Suggestive FeaturesTuberculosis Onset all ages, Chest x-ray shows lung infiltrate,

microbiological comfirmation, high local prevalence of tuberculosis

Obliterative Bronchiolitis

Onset at younger age, nonsmokers, may have history of rheumatoid arthritis or acute fume exposure, seen after or bone marrow transplantation, CT on expiration shows hypodense areas

Diffuse Panbronchiolitis Predominantly seen in patients of asian descent, Most patients are male and nonsmokers, almost all have chronic sinusitis, chest X-ray and HRTC show diffuse small centrilobular nodular opacities and hyperinflation.

These features tend to be characteristic of the respective diseases, but are not mandatory. For example, a person who has never smoked may develop COPD (especially in the developing world where other risk factors may be more important than cigarette smoking); asthma may develop in adult and even in elderly patients.

THERAPEUTIC OPTIONS

SMOKING CESSATIONSmoking cessation is the intervention with the greatest capasity to influence the natural history of COPD. Evaluation of the smoking cessation component in a longterm, multicenter study indicates that if effective resources and time are dedicated to smoking cessation, 25% longterm quit rates can be achieved

Pharmacotherapies for Smoking Cessation:

Nicotine Replacement Products (nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet, or lozenge)Realibly increases long term smoking abstinence ratesSignificantly more effective than placebo

Pharmacologic Varenicline,bupropion, nortriptyline have

been shown to increase long term quit rates.

Recommendations for treating tobacco use and dependence are summarized in table.• Treating tobacco Use and Dependence: A clinical Practice Guidline-Major

findings and Recommendations• Tobacco dependence is a chronic condition that warrants repeated treatmenrt

until long term or permanent abstinence is achieved• Effective treatments for tobacco dependence exist and all tobacco users should

be offered these treatments• Clinicians and health care delivery systems must inztitutionalize the consistent

identification, documentation, and treatment of every tobacco user at every visit

• Brief smoking cessation counseling is effective and every tobacco user should be offered such advise at every contactwith health care providers

• There is a strong dose response relaton between the intensity of tobacco dependence counseling and its effectiveness.

• Three types of counseling have been found to be especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment.

• First line pharmacotherapies for tobacco dependence-varenicline,bupropion,SR, nicotone gum, nicotone inhaler, nicotine nasal spray, and nicotine patch- are effective and at least one of these medications should be prescribed in the absence of contraindications.

• Tobacco dependence treatments are cost effective relative to other medical and disease prevention interventions.

BRIEF STRATEGIES TO HELP THE PATIENT WILLING TO QUIT

ASK: systematically identify all tobacco users at every visit. Implement an office wide system that ensures that, for EVERY patient at EVERY clinic visit,tobacco use status is queried and documented.

ADVISE: strongly urge all tobacco users to quit. In clear, strong, and personalized manner, urge every tobacco users to quit

ASSES: ddetermine willingness to make a quit attempt. Ask every tobacco user if he or she willing to make a quit attempt at this time

ASSIST: aid the patient in quitting. Help the patient with a quit plan; provide practical counseling; provide intra treatment social support; help the patient obtain extra treatment social support; recommend use of approved pharmacotherapy except in special circumtances; provide suplementary materials

ARRANGE: schedule follow up contact. Schedule follow up contact, either in person or via telephone.

PHARMACOLOGIC THERAPY FOR STABLE COPD

Overview of the medications: Pharmacologis therapy for COPD is used to reduce symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.

Bronchodilators Beta2-agonist Anticholinergics Methylxanthines

PHARMACOLOGIC THERAPY FOR STABLE COPD

Combination Bronchodilator therapy Corticosteroids Combination Inhaled

corticosteroid/bronchodilator therapy Oral corticosteroid Phosphodiesterase-4 Inhibitor Other pharmacologic treatments

(Vaccines,alpha-1 antitrypsin augmentation therapy, antibiotics,mucolytic, immunoregulators, antitussives, vasodilators,narcotics,etc)

NON PHARMACOLOGIC THERAPIES

Rehabilitation : Exercise training Education Assesment and follow up Nutrition Counseling

OTHER TREATMENTS

Oxygen therapy Ventilatory support Surgical treatments Lung Volume Reduction Surgery (LVRS)

OTHER TREATMENTS

Bronchoscopic Lung Volume Reduction (BVLR)

Lung Transplantation Bullectomy Palliative care, End of Life care, and

Hospice care.

REFEENCES

Global initiative for Chronic Obstructive Pulmonary Disease Updated 2013.

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