COPD

Chronic Obstructive Pulmonary Desease

By : Nur Basuki, M.Physio

Chronic obstructive pulmonary disease

(COPD) refers to diseases of the lungs in which the
airways become narrowed. This leads to a limitation
of the flow of air to and from the lungs causing
shortness of breath.
COPD is also known as
chronic obstructive lung disease (COLD),
chronic obstructive airway disease
(COAD),
chronic airflow limitation (CAL) and
chronic obstructive respiratory disease

 COPD is caused by noxious particles or gases,

most commonly from smoking, which trigger an
abnormal inflammatory response in the lung.
The inflammatory response in the larger
airways is known as chronic bronchitis,
which is diagnosed clinically when people
regularly cough up sputum.
In the alveoli, the inflammatory response
causes destruction of the tissues of the lung, a
process known as emphysema.
The natural course of COPD is characterized by
occasional sudden worsening of symptoms
called acute exacerbations, most of which are
caused by infections or air pollution

 Worldwide, COPD ranked sixth as the

cause of death in 1990.
It is projected to be the third leading cause of
death worldwide by 2020 due to an increase in
smoking rates and demographic changes in
many countries.
COPD is the 4th leading cause of death in the
U.S., and the economic burden of COPD in the
U.S. in 2007 was $42.6 billion in health care
costs and lost productivity.

DI INDONESIA
Belum ada angka prevalens
Cenderung meningkat

- Tingginya infeksi saluran napas

berulang
- Kebiasaan merokok tinggi
- Memburuknya tingkat polusi udara

Signs &
One of the Symptoms
most common symptoms of COPD is
shortness of breath (dyspnea).
People with COPD commonly describe this as:
My breathing requires effort,
I feel out of breath, or
I can not get enough air in.
People with COPD typically first notice dyspnea
during vigorous exercise when the demands on
the lungs are greatest. Over the years, dyspnea
tends to get gradually worse so that it can occur
during milder, everyday activities such as
housework. In the advanced stages of COPD,
dyspnea can become so bad that it occurs during
rest and is constantly present.

 Other symptoms of COPD are a persistent

cough, sputum or mucus production,
wheezing, chest tightness, and tiredness.
People with advanced (very severe) COPD
sometimes develop respiratory failure. When
this happens, cyanosis, a bluish discoloration
of the lips caused by a lack of oxygen in the
blood, can occur.
An excess of carbon dioxide in the blood can
cause headaches, drowsiness or twitching
(asterixis).
A complication of advanced COPD is cor
pulmonale, a strain on the heart due to the
extra work required by the heart to pump
blood through the affected lungs.
Symptoms of cor pulmonale are peripheral

KLASIFIKASI DERAJAD
BERATNYA COPD
Berat
penyaki
t
Ringan

Gejala

VEP-1
%
prediksi)

Tidak ada gejala

saat istirahat atau
saat bekerja
Tidak ada gejala
saat istirahat tapi
ada gejala pada
aktiviti sedang
(berjalan cepat,
menaiki tangga)

> 70%

Berat
penyaki
t
Sedang

Gejala

Tidak ada gejala

saat istirahat, tapi
ada gejala pada
aktivitas ringan.
(berpakaian)
Gejala minimal saat
istirahat (saat
duduk, menonton
TV, membaca)

VEP-1
%
prediksi)
50 69%

Berat
penyaki
t
Berat

Gejala

Gejala sedang saat

istirahat
Gejala berat saat
istirahat
Tanda tanda kor
pulmonale

VEP-1
%
prediksi)
< 50%

Tidak banyak tanda-2 dr COPD yg dapat

dideteksi, bahkan beberapa px tak tampak
tanda-2 berikut.
Beberapa tanda COPD yg umum adalah:

tachypnea
wheezing sounds or crackles
Prolonged expiration
hyperinflation
Increased accessory muscle activity
breathing through pursed lips
increased anteroposterior to lateral ratio of the
chest (i.e. barrel chest).
Paradoxycally breathing (Hoovers sign)

SMOKING

Faktor
Resiko

Merokok adalah merupakan faktor resiko utama

COPD.

Di AS 80 90% COPD disebabkan merokok.

Tidak semua perokok COPD, perokok yg terus
menerus mempunyai resiko 25% setelah 25 th
merokok, resiko ini akan semakin meningkat dg
meningkatnya usia

Perokok pasif dapat juga menyebabkan

gangguan pertumbuhan paru timbulnya
COPD

Occupational exposures
Paparan yg terus menerus dari debu yg
ada ditempat kerja seperti : penambangan
batu bara, penambangan emas, industri
textil dan bahan-2 kimia implikasi
berkembangnya obstruksi arus udara pd
sal napas

POLUSI UDARA
Studies in many countries have found that people
who live in large cities have a higher rate of COPD
compared to people who live in rural areas.
In many developing countries indoor air pollution
from cooking fire smoke (often using biomass fuels
such as wood and animal dung) is a common cause
of COPD, especially in women

GENETIC
Alpha 1-antitrypsin deficiency is a genetic
condition that is responsible for about 2% of cases
of COPD.

 bronchoconstriction,
Oedema membrana
mukosa,
Retensi mukus,
Destruksi/dilatasi dari
saluran napas & jaringan
parenchim paru

VA/Q mismatch

Low PaO2
Hypoxaemi
a
Hypercapni
a

Impaired ventilation
Penurunan arus insp & exp
Prolonged expiration
Dynamic hyperinflation

High Lung Volume Breathing

Pattern
Increased accessory muscle
Increased Work of Breathing

Dyspnea

Decreased Exercise Tolerance

Fear of
breathlessness

Depressi
on

Decrease
exercise
tolerance

Decrease
efficiency &
Coordination

Inactivity

General Muscle
weakness

Beberapa pasien COPD berusaha untuk

mengkompensasi dg bernapas lebih cepat
sesak.
Akibat dr low oxygen & High Carbondioxide
headaches, drowsiness and heart failure.
Advanced COPD can lead to complications
beyond the lungs such as :
weight loss (cachexia),
pulmonary hypertension and
heart failure (cor pulmonale).
Disamping itu bbrp penyakit berikut sering
ditemukan pd penderita COPD
Osteoporosis, heart disease, muscle wasting and
depression

PROBLEMATIKA
FISIOTERAPI

 Dyspnea
Impaired airway clearance
Airflow limitation
Abnormal breathing pattern
Muscle dysfunction
Increased Work of Breathing
Impaired oxygenation/gas exchange
Decreased exercise tolerance

FISIOTERAPI
MANAGEMENT

Breathing Retraining
Pursed Lips
Breathing
Suatu tehnik pernapasan yang dapat
memudahkan pengeluaran udara pada
penderita dengan problem air flow limitation.
Biasanya dilakukan secara insting
Pasien tarik napas melalui hidung, dan
mengeluarkannya melalui mulut secara
perlahan lahan (4-6 detik) dengan
mengatupkan kedua bibir secara rileks. Tehnik
ini dilakukan tanpa kontraksi otot abdominal

Clinical outcomes of Pursed Lips

Breathing
1. Decreased RR (Breaslin, 1992; Jones
et al, 2003)
2. Decrease minute ventilation
3. Decrease PaCO2
4. Increased tidal volume (Vt)
5. Increased PaO2
6. Increased SaO2
7. Decreased Dyspnea
8. Increased Exercise Tolerance
9. Reduced limitations in ADL

Changes in Ventilation & Lung

Volume
Motley, 1963 dalam penelitiannya pada 35
org dg COPD berat (Residual volume >
200% predicted; VC = 72% predicted)
menemukan bahwa PLB dapat :
Menurunkan RR (15 9)
Meningkatkan Vt (494 ml 814 ml)
Meningkatkan SaO2 (89,5% - 92.1%)
Menurunkan PaCO2 (40 mmHg 37 mmHg)
Demikian juga penelitian yg dilakukan oleh
Thoman et al, 1966 serta penelitian yang
dilakukan oleh Tiep et al (1986) dan Chambel et
al (1955) juga menunjukkan hasil yang sama

Dyspnea Relief
Mueller et al, (1970) melakukan ttg mekanisme
penurunan sesak pd penderita COPD setelah
diberikan PLB.
Dua belas penderita COPD dibagi dalam 2 kel,
dimana kel I (7 org) adalah kel yang menyatakan
bahwa PLB dapat mengurangi sesaknya, sedang
kelompok II (5 org) adalah kelompok yang
menyatakan bahwa PLB tak mengurangi sesaknya.
Kedua kelompokmenunjukkan perbaikan pada
PaO2 dan SaO2 serta penurunan RR, namun
demikian hanya kelompok I yang menunjukkan
adanya peningkatan Vt (0.75 L 1.19 L)
Hasil penelitian ini menunjukkan bahwa
penurunan sesak napas bukan karena perbaikan
pd pertukaran gas, tetapi karena perubahan
fungsi mekanika pernapasan.

Penelitian yang dilakukan oleh Ingram and

Schilder, (1967) menyimpulkan bahwa
penurunan sesak napas akibat dari pemberian
PLB adalah kemungkinan adanya penurunan dari
transpulmonary pressure penurunan airways
collapse.
Hasil penelitian ini juga didukung oleh penelitian
dari Motley (1963) dan Thoman et al, (1966).
Dari penelitian yg dilakukan oleh Dechman &
Wilson, (2004) disimpulkan bahwa, PLB does
relief dyspnea in selected subjects.
Pada pasien yg kesulitan untuk melakukan
tehnik ini seyogyanya latihan dihentikan.
Jika efek possitif dari PLB dapat pula dilakukan
saat aktivitas toleransi aktivitas
akanmembaik

Pulmonary Rehabilitation Program

Definisi:
A multi dimensional continuum of services
directed to persons with pulmonary diseases
and their family, usually by an
interdisciplinary team of specialist with the
goal of achieving and maintaining the
individuals maximal level of independence
and functioning in the community (Fishman,
1994)

Manfaat dari Program Rehabilitasi Paru

Beberapa penelitian terakhir yg dilakukan
secara random sampling menunjukkan
manfaat positive dari Program rehabilitasi
paru (Goldstein, 1994; Reardon et al,
1994; Wijkstra et al, 1995)
Memperbaiki kualitas hidup
Menurunkan kecemasan dan depresi
Meningkatkan toleransi aktivitas
Mengurangi sesak dan keluhan lain
Memperbaiki kemampuan untuk
melakukan ADL
Disamping itu Rehab program juga
bermanfaat untuk mengurangi rawat inap

Exercise training:
Aerobic training
Strength training (UE & LE)
Ventilatory muscle training
Breathing retraining
Education
Energy conservation
Medication
Diet & nutrition
Psychosocial support

Hui and Hewitt (2007) melakukan penelitian tentang

manfaat dari A simple Pulmonary Rehabilitation
Program yang dilakukan pd 36 pasien COPD yang
mengunjungi outpatient physiotherapy department di
Sydney, Australia.
Program diberikan oleh fisioterapis. Penelitian dilakukan
selama 8 mg dengan frekwensi latihan 2X/minggu.
Program latihan terdiri dari Jalan dan static bucycle, serta
latihan dengan beban untuk UE dan LE.
Hasil:
Peningkatan endurance
Mengurangi sesak
Meningkatkan QoL
Tak ada perbaikan pada fungsi paru (FEV1)
Mengurangi hospitalisasi
Mengurangi masa rawat inap