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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 bersama-sama. 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
Alpha1 antitrypsin deficiency-related (AAT) emphysema is caused by the inherited
deficiency of a protein called alpha1-antitrypsin (AAT) or alpha1-protease
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.

Etiology
Definite Causes
Cigarette Smoking (dose-response 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)
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

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
Proper Use of MDI