INTRODUCTION

People with obstructive lung disease have shortness of breath due to

difficulty exhaling all the air from the lungs. Because of damage to the lungs or
narrowing of the airways inside the lungs, exhaled air comes out more slowly than
normal. At the end of a full exhalation, an abnormally high amount of air may still
linger in the lungs.
Obstructive lung disease makes it harder to breathe, especially during
increased activity or exertion. As the rate of breathing increases, there is less time
to breathe all the air out before the next inhalation.
Most commonly, people with obstructive disease seek a doctor because
they feel short of breath. Obstructive lung diseases are identified using pulmonary
function tests. In pulmonary function testing, a person blows air forcefully
through a mouthpiece. As the person performs various breathing maneuvers, a
machine records the volume and flow of air through the lungs. Pulmonary
function testing can identify the presence of obstructive lung disease as well as
their severity.
A doctor's interview (including smoking history), physical examination
and lab tests may provide additional clues to the cause of obstructive lung disease.
Imaging tests are almost always part of the diagnosis of obstructive lung disease.

The most common causes of obstructive lung disease are:

Chronic obstructive pulmonary disease (COPD), which includes
emphysema and chronic bronchitis
Asthma
Bronchiectasis

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 Chronic Obstructive Pulmonary Disease (COPD)

Definition

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 noxius particles or
gases. Exacerbations and comorbidities contribute to the overall severity in
individual patients.
COPD includes emphysema, an anatomically defined condition
characterized by destruction and enlargement of the lung alveoli; chronic
bronchitis, a clinically defined condition with chronic cough and phlegm; and
small airways disease, a condition in which small bronchioles are narrowed.
COPD is present only if chronic airflow obstruction occurs; chronic bronchitis
without chronic airflow obstruction is not included within COPD.
COPD is the fourth leading cause of death and affects 16 million persons
in the United States. COPD is also a disease of increasing public health
importance around the world. GOLD estimates suggest that COPD will rise from
the sixth to the third most common cause of death worldwide by 2020.

Symptomps

- Dyspnea
A cardinal symptomps of COPD is a major cause of disability and
anxiety associated with the disease. Typical COPD patients describe their
dyspnea as a sense of increased effort to breathe, heaviness, air hunger, or
gasping.

- Cough
Chronic cough is frequently discounted by the patient as an expected
consequence of smoking and/or enviromental exposures. Initially, the

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 cough may be intermittent, but later is present every day, often throughout
the day. The chronic cough of COPD may be unproductive.

- Wheezing and Chest Tightness

Wheeze may arise at a laryngeal level and need to be accompanied
by auscultatory abnormalities. Widespread inspiratory or expiratory
wheezes can be present on listening to the chest. Chest tighness often
follows exertion, is poorly localized is muscular in character and may arise
from isometric contraction of the intercostal muscle.

Medical History

- Patients exposure to risk factors, such as smoking and occupational or

environmental exposures
- Past medical history, including asthma, allergy, sinusitis or nasal polyps;
respiratory infections in childhood; other respiratory disease
- Family history of COPD or other chronic respiratory disease
- Impact of disease of patients life, including limitation of activity, missed
work and economic impact, effect on family routines, feelings of
depression or anxiety, well being and sexual activity

Diagnosis

A clinical diagnosis of COPD should be considered in any patient who has

dispnea, chronic cough or sputum production and a history of exposure to risk
factors for the disease. Spirometry is required to make diagnosis, the presence of a
post bronchodilator FEV/FVC <0,70 confirms the presence of persistence airflow
limitation and thus of COPD.

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Treatments
- Smoking cessation
- Beta-2 agonist
- Anticholinergics
- Methylxanthines
- Systemic corticosteroid1

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 Asthma

Definition

Asthma is a common and potentially serious chronic disease that causes

respiratory symptoms, limitation of activity, and attacks that sometimes require
urgent health care and may be fatal.
The most frequent form has its onset in childhood between the ages of 3
and 5 years and may either worsen or improve during adolescence. Classically
asthma has three characteristics:
a. airflow limitation which is usually reversible spontaneously or with
treatment
b. airway hyperresponsiveness to a wide range of stimuli (see below)
c. inflammation of the bronchi with T lymphocytes, mast cells, eosinophils
with associated plasma exudation, oedema, smooth muscle hypertrophy,
matrix deposition, mucus plugging and epithelial damage.
In chronic asthma, inflammation may be accompanied by irreversible
airflow limitation as a result of airway wall remodeling that may involve large and
small airways and mucus.

Prevalence

In many countries the prevalence of asthma is increasing. This increase,

with its accompanying allergy, is particularly in children and young adults where
this disease may affect up to 15% of the population. There is also a geographical
variation, with asthma being commoner in more developed countries. Some of the
highest rates are in the UK, New Zealand and Australia, but the rates are lower in
Far Eastern countries such as China and Malaysia, Africa and Central and Eastern
Europe. However, long-term follow-up in developing countries suggests that the
disease may become more frequent as individuals adopt a more westernized
lifestyle, but the environmental factors accounting for this remain unknown.

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 Studies of occupational asthma suggest that a high percentage of the
workforce, 1520%, may become asthmatic if exposed to potent sensitizers.
World-wide, approximately 300 million people have asthma and this is
expected to rise to 400 million by 2025.

Etiology

- Viral infection
- Allergens (house dust mite, pollens, cockroach)
- Tobacco smoke
- Exercise
- Stress
- Some drugs (Beta blockers, aspirin, and other NSAIDs)

Classification

Asthma is a complex disorder of the conducting airways that

most simply can be classified as:
extrinsic implying a definite external cause
intrinsic when no causative agent can be identified.
Extrinsic asthma occurs most frequently in atopic individuals
who show positive skin-prick reactions to common inhalant allergens such as dust
mite, animal danders, pollens and fungi. Positive skin-prick tests to inhalant
allergens are shown in 90% of children and 70% of adults with persistent asthma.
Childhood asthma is often accompanied by eczema (atopic dermatitis). A
frequently overlooked cause of late-onset asthma in adults is sensitization to
chemicals or biological products in the workplace.
Intrinsic asthma often starts in middle age (late onset). Nevertheless,
many patients with adult-onset asthma show positive allergen skin tests and on
close questioning give a history of respiratory symptoms compatible with
childhood asthma. Non-atopic individuals may develop asthma in middle age
from extrinsic causes such as sensitization to occupational agents such as toluene

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diisocyanate, intolerance to nonsteroidal anti-inflammatory drugs such as aspirin
or because they were given -adrenoceptor-blocking agents for concurrent
hypertension or angina that block the protective effect of endogenous adrenergic
agonists. Extrinsic causes must
be considered in all cases of asthma and, where possible,avoided

Symptoms

- Shortness of breath
- Wheezing
- Chest tightness
- Cough

Diagnosis

- People with asthma generally have more than one of the symptoms above
- The symptoms occur variably over time and vary in intensity
- The symptoms often occur or are worse at night or on waking
- Symptoms are often triggered by exercise, allergens or cold air
- Expiratory airflow limitation (normally FEV/FEC ratio is more than 0.75-
0.80 in adults and more than 0.90 in children)
- Physical examination in people with asthma is often normal, but the most
frequent finding is wheezing in auscultation, especially on forced
expiration2

Medical Treatments
- Reliever
o SABA (Short Acting Beta-2 Agonist)
o Systemic corticosteroid
o Aminophilin
o Anticholinergic

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 - Controller
o Inhaled glucocorticosteroid
o Systemic glucocorticosteroid
o LABA (Long Acting Beta-2 Agonist)

Non Farmacological Treatments

- Smoking cessation
- Avoid asthma triggers (dust, pollen)
- Managed stress when it occur3

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 Bronchiectasis

Definition

Bronchiectasis is a congenital or acquired disorder of the large bronchi

characterized by permanent, abnormal dilation and destruction of bronchial walls. It
may be caused by recurrent inflammation or infection of the airways and maybe
localized or diffuse. Cystic fibrosis causes about half of all cases of bronchiectasis.
However, most patients with bronchiectasis have panhypogammaglobulinemia,
presumably reflecting an immune system response to chronic airway infection.treatmet
Although this definition is based on pathologic changes in the bronchi, diagnosis is
often suggested by the clinical consequences of chronic or recurrent infection in the
dilated airways and the associated secretions that pool within these airways.4

Clinical Findings

A. Symptoms and Signs

Symptoms of bronchiectasis include chronic cough with production of
copious amounts of purulent sputum, hemoptysis, and pleuritic chest pain. Dyspnea
and wheezing occur in 75% of patients. Weight loss, anemia, and other systemic
manifestations are common. Physical findings are nonspecific, but persistent
crackles at the lung bases are common. Clubbing is infrequent in mild cases but is
common in severe disease. Copious, foul-smelling, purulent sputum is
characteristic.5

B. Imaging
Radiographic abnormalities include dilated and thickened bronchi that
may appear as tram-tracks or as ring-like markings. Scattered irregular
opacities, atelectasis, and focal consolidation may be present. High-resolution CT
is the diagnostic study of choice.tree

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 Although the chest radiograph is important in the evaluation of suspected
bronchiectasis, the findings are often nonspecific. At one extreme, the radiograph
may be normal with mild disease. Alternatively, patients with saccular
bronchiectasis may have prominent cystic spaces, either with or without air-liquid
levels, corresponding to the dilated airways.

These may be difficult to distinguish from enlarged airspaces due to

bullous emphysema or from regions of honeycombing in patients with severe
interstitial lung disease.

C. Laboratory Finding
Examination of sputum often reveals an abundance of neutrophils and
colonization or infection with a variety of possible organisms. Appropriate
staining and culturing of sputum often provide a guide to
antibiotic therapy.5

Diagnosis

- Chronic productive cough with dyspnea and wheezing

- Recurrent pulmonary infections requiring antibiotics
- A preceding history of recurrent pulmonary infections orinflammation, or
a predisposing condition
- Radiographic findings of dilated. Thickened airways and scattered,
irregular opacities5

Treatment

Treatment of acute exacerbations consists of antibiotics (selected on the

basis of sputum smears and cultures), daily chest physiotherapy with postural drainage
and chest percussion and inhaled bronchodilators. Hand-held flutter valve devices may
be as effective as chest physiotherapy in clearing secretions. Empiric oral antibiotic

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therapy for 1014 days with amoxicillin or amoxicillin-clavulanate (500 mg every 8
hours), ampicillin or tetracycline (250500 mg four times daily), or trimethoprim-
sulfamethoxazole (160/800 mg every 12 hours) is reasonable therapy in an acute
exacerbation if a specific bacterial pathogen cannot be isolated.
Preventive or suppressive treatment is sometimes given to stable outpatients
with bronchiectasis who have copious purulent sputum. Clinical trial data to guide this
practice are scant. Common regimens include macrolides (azithromycin, 500 mg three
times a week; erythromycin,500 mg twice daily), high-dose (3 g/d) amoxicillin or
alternating cycles of the antibiotics listed above given orally for 24 weeks. Inhaled
aerosolized aminoglycosides reduce colonization by Pseudomonas species. In patients
with underlying cystic fibrosis, inhaled antibiotics improve FEV1 and reduce
hospitalizations, but these benefits are not consistently seen in the noncystic fibrosis
population.
Complications of bronchiectasis include hemoptysis, cor pulmonale,
amyloidosis, and secondary visceral abscesses at distant sites (eg, brain).
Bronchoscopy is sometimes necessary to evaluate hemoptysis, remove retained
secretions,and rule out obstructing airway lesions. Massive hemoptysis may require
embolization of bronchial arteries or surgical resection. Surgical resection is otherwise
reserved for the few patients with localized bronchiectasis and adequate pulmonary
function in whom conservative management fails.5

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 CONCLUSION

Obstructive lung disease make people hard to breathe, especially during

increased activity or exertion. As the rate of breathing increases, there is less time
to breathe all the air out before the next inhalation. Most commonly, people with
obstructive disease seek a doctor because they feel short of breath.
The most common causes of obstructive lung disease are chronic
obstructive pulmonary disease (COPD), which includes emphysema and chronic
bronchitis, asthma and bronchiectasis.
The treatments are consist of medical treatments and non farmacological
treatments. The non farmacological treatments such as avoid the triggers of the
disease (smoking, dust, pollen, exercise and managed stress).

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 REFERENCE

1. Decreamer M. Global Iniative for Chronic Obstructive Lung Disease.2015

2. Fitzgerald JM. Global Initiation for Asthma.2015
3. Weinberger S.E. Bronchiectasis in Kaspers DL, Fauci AS, Longo DL,
Barunwald E, Hauser SL, Jameson JL. Harrisons Principle of Internal
Medicine.16th Ed.2005.
4. Mcphee S.J. Brochiectasis. Lange Current Medical Diagnosis and
Treatment.48th ed.2009.

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