Professional Documents
Culture Documents
Biomed
Fakultas Farmasi
Universitas Pancasila Jakarta
Definitions:
Asthma: It's a chronic respiratory condition
Diagnosis of COPD
It should be considered in patients over the
a. Riwayat merokok
- Perokok aktif
- Perokok pasif
- Bekas perokok
b. Derajat berat merokok dengan Indeks Brinkman (IB), yaitu perkalian jumlah ratarata batang rokok dihisap sehari dikalikan lama merokok dalam tahun :
- Ringan : 0-200
- Sedang : 200-600
- Berat : >600
2.
3.
4.
5.
Pathogenesis
Three processes:
Chronic inflammation
Imbalance of proteinases and anti-proteinases
Oxidative stress
Chronic Inflammation
Chronic inflammation in airways, parenchyma,
pulmonary vasculature
Inflammatory cells involved are:
Macrophages
T-lymphocytes (CD8)
Neutrophils
leukotriene B4
interleukin 8
TNF-
Pathology
Central Airways:
Enlarged mucus
secreting glands
Increase in goblet cells
Mucus hypersecretion
Peripheral Airways
Repeated cycles of
Increased
collagen/scarring in
airway wall
Pathology
Pulmonary vascular changes
Thickening of vessel wall (intima)
Increase in smooth muscle
Infiltration of vessel wall by inflammatory cells
As COPD worsens, more smooth muscle,
Pathophysiology
Mucus hypersecretion
Ciliary dysfunction
Airflow limitation
Pulmonary hyperinflation
Gas exchange abnormalities
Pulmonary hypertension
Cor pulmonale
Mucus hyperserection & ciliary dysfunction cough, sputum production
Diagnosis
A. Gambaran klinis
a. Anamnesis
- Keluhan
- Riwayat penyakit
- Faktor predisposisi
b. Pemeriksaan fisis
B. Pemeriksaan penunjang
a. Pemeriksaan rutin
b. Pemeriksaan khusus
Physical Examination
Thorax:
Barrel chest
Lungs
Decreased breath sounds
Wheezing
Cardiac
Right-sided heart failure
Diagnostic Tests
Chest X-ray
Flattened diaphragms
Use to exclude other diagnoses
High resolution CT
Not routinely recommended
If in doubt about diagnosis of
COPD
If considering bullectomy or
lung volume reduction surgery
CBC
May see increased
hemoglobin/hematocrit
secondary to
hemoconcentration
ABG
Spirometry
Spirometry
Measure of FVC and FEV1
FVC = forced vital capacity
are
COPD ratio = <80% post-bronchodilator
decreased
Spirometry
Bronchodilator Reversibility Testing
Perform in the initial assessment of COPD in
order to:
Exclude asthma
Establish best attainable lung function
Gauge patient prognosis
Guide treatment decisions
predicted OR
Clinical signs of respiratory or right heart
failure
Central cyanosis, ankle swelling, increase in
Respiratory Failure:
PaO2 < 60 mm Hg with or without PaCO 2 > 45
Technique:
Obtain by arterial puncture; DO NOT USE finger
or ear oximeters
Other Tests
Alpha-1 antitrypsin
Consider in patients with COPD < age 45
Strong family hx of early COPD or with alpha-1
antitrypsin deficiency
Differential Diagnosis of
COPD
Asthma
limitation
CXR with dilated heart,
pulmonary edema
Bronchiectasis
Large volumes of purulent
sputum
Commonly associated with
bacterial infection
Bronchial dilation and bronchial
wall thickening on CXR or CT
Tuberculosis
nodular lesions
Obliterative bronchiolitis
Younger patients/non-smokers
May have a hx of rheumatoid
Diffuse panbronchiolitis
Male/non-smokers
Chronic sinusitis
CXR and high resolution CT
Medications
Goals
Prevent and control symptoms
Reduce frequency and severity of exacerbations
Improve health status
Improve exercise tolerance
Bronchodilators
Central to symptom management
Used in all stages of COPD severity
reduce symptoms
Long-acting inhaled bronchodilators are more effective and
convenient (but are more expensive)
Combining drugs with different mechanisms and durations
of action may increase the degree of bronchodilation for
equivalent or lesser side effects
All categories of bronchodilators have been show to increase
exercise capacity without necessarily producing significant
changes in FEV1
Bronchodilators
Beta2-agonists
Short-acting: albuterol
Long-acting: salmeterol (Serevent), formoterol
(Foradil)
Anticholinergics
Short acting: ipratropium bromide (Atrovent)
Long acting: tiotropium bromide (Spiriva)
Methylxanthines (Theophylline)
Combination bronchodilators
Fenoterol/ipratropium (Duovent)
Salbutamol/ipratropium (Combivent)
Glucocorticosteroids
Use if FEV1 < 50% predicted and repeated exacerbations,
Inhaled Glucocorticoids
Beclomethasone (Vanceril)
Budesonide (Pulmicort)
Fluticasone (Flovent)
Triamcinolone (Azmacort)
Immunizations
Vaccines
Influenza yearly
Reduces serious illness and death in COPD patients
by approximately 50%
Give once yearly: autumn OR twice yearly: autumn
and winter
Pneumovax
Other Medications?
Alpha-1 Antitrypsin Augmentation Therapy
Only if this deficiency is present in an individual should they
undergo treatment
Antibiotics
Prophylactic use is NOT recommended
Can be used in the treatment of infectious exacerbations of
COPD
Mucolytic agents
Overall benefits are small, so currently not recommended for
widespread use
Types:
Ambroxol
Erdosteine (Erdostin, Mucotec)
Carbocysteine (Mucodyne)
Iodinated gylerol (Expigen)
Other Medications?
Antioxidant agents
N-acetylcysteine (Bronkyl, Fluimucil, Mucomyst)
Have been shown to reduce the frequency of exacerbations and could
Immunoregulators
Not recommended at this time
No reproducible studies are available
Antitussives
Regular use is contraindicated in stable COPD since cough has a
Vasodilators
Inhaled nitric oxide
Can worsen gas exchange because of altered hypoxic regulation of ventilationperfusion balance and is contraindicated in stable COPD
Other Medications?
Respiratory stimulants
Doxapram (IV)
Almitrine bismesylate
Not recommended in stable COPD
Narcotics
Oral and parenteral opioids are effective for treating dyspnea in
Miscellaenous:
Nedocromil
Leukotriene modifiers
Alternative healing methods
None have been adequately studied in COPD patients at this time