Concept of OxygenationConcept of Oxygenation

Respiratory SystemRespiratory System

Respiratory SystemRespiratory System

CChronic hronic OObstructive bstructive PPulmonary ulmonary DDiseaseisease

CChronichronic (berlanjut, permanen, (berlanjut, permanen, tidak ada obatnya) tidak ada obatnya)

OObstructivebstructive (sumbatan)(sumbatan)

PPulmonaryulmonary (melibatkan paru-paru)(melibatkan paru-paru)

DDiseaseisease (kondisi dengan tanda dan gejala) (kondisi dengan tanda dan gejala)

Secara umum, istilah COPD ditujukan Secara umum, istilah COPD ditujukan untuk kondisi yang mencakup:untuk kondisi yang mencakup:

bronkitis kronisbronkitis kronisemfisemaemfisema

Fakta-fakta mengenai COPDFakta-fakta mengenai COPD COPD atau penyakit paru obstruktif kronik tidak memiliki COPD atau penyakit paru obstruktif kronik tidak memiliki

definisi tunggaldefinisi tunggal

COPD adalah penyakit paru. Penyakit ini disebabkan oleh COPD adalah penyakit paru. Penyakit ini disebabkan oleh sumbatan saluran udara pada paru dan tidak ada obatnyasumbatan saluran udara pada paru dan tidak ada obatnya

COPD menunjuk pada sejumlah gangguan kronik paru COPD menunjuk pada sejumlah gangguan kronik paru yang menyumbat saluran napas. Asma biasanya tidak yang menyumbat saluran napas. Asma biasanya tidak dilihat sebagai salah satu bentuk COPD oleh karena gejala dilihat sebagai salah satu bentuk COPD oleh karena gejala asma “murni” bersifat reversibel. COPD bersifat permanen.asma “murni” bersifat reversibel. COPD bersifat permanen.

Bentuk COPD yang paling umum adalah kombinasi antara Bentuk COPD yang paling umum adalah kombinasi antara bronkitis kronis dan emfisemabronkitis kronis dan emfisema

• Bronkitis kronisBronkitis kronis terjadi ketika saluran udara dalam paru terjadi ketika saluran udara dalam paru menjadi sempit dan sebagian tersumbat oleh mukusmenjadi sempit dan sebagian tersumbat oleh mukus

• Pada bronkitis kronis, terdapat batuk dan sputum selama Pada bronkitis kronis, terdapat batuk dan sputum selama lebih dari 3 bulan dalam 2 tahun berturut-turut. Jika lebih dari 3 bulan dalam 2 tahun berturut-turut. Jika terdapat juga sumbatan saluran napas disamping terdapat juga sumbatan saluran napas disamping bronkitis kronis bronkitis kronis indikasi ke arah COPD indikasi ke arah COPD

• EmfisemaEmfisema terjadi ketika sejumlah kantong udara di dalam terjadi ketika sejumlah kantong udara di dalam paru-paru telah rusakparu-paru telah rusak

• Emfisema adalah pembesaran dan destruksi alveoli Emfisema adalah pembesaran dan destruksi alveoli (kantong udara) dalam paru. Hal ini menyebabkan saluran (kantong udara) dalam paru. Hal ini menyebabkan saluran napas yang mengelilingi alveoli tersebut menjadi kolapsnapas yang mengelilingi alveoli tersebut menjadi kolaps

• Emfisema terkait Emfisema terkait alfa 1-antitripsinalfa 1-antitripsin adalah suatu bentuk adalah suatu bentuk penyakit paru kronik yang relatif tidak umum. Keadaan ini penyakit paru kronik yang relatif tidak umum. Keadaan ini disebabkan oleh kekurangan protein alfa 1-antitripsin disebabkan oleh kekurangan protein alfa 1-antitripsin secara genetissecara genetis

Fakta:Fakta: Berdasarkan penelitian, 80 sampai 90%dari seluruh kasus Berdasarkan penelitian, 80 sampai 90%dari seluruh kasus emfisema dan bronkitis kronis disebabkan oleh kebiasaan emfisema dan bronkitis kronis disebabkan oleh kebiasaan merokok. (merokok. (Lung Facts 1994 UpdateLung Facts 1994 Update. Canadian Lung Association, . Canadian Lung Association, 1993)1993)

Penyakit paru obstruktif kronik (COPD) mencakup Penyakit paru obstruktif kronik (COPD) mencakup emfisema dan bronkitis kronis yang dicirikhaskan oleh emfisema dan bronkitis kronis yang dicirikhaskan oleh tersumbatnya aliran udaratersumbatnya aliran udara

Emfisema dan bronkitis kronik sering hadir bersama-Emfisema dan bronkitis kronik sering hadir bersama-sama. Karenanya, dokter lebih menyukai istilah COPD. sama. Karenanya, dokter lebih menyukai istilah COPD. Istilah ini tidak mencakup penyakit obstruksi lain Istilah ini tidak mencakup penyakit obstruksi lain seperti asmaseperti asma

Di Amerika Serikat:Di Amerika Serikat:- Kira-kira 16,4 juta orang menderita COPD - Kira-kira 16,4 juta orang menderita COPD - Penyebab kematian terbesar keempat- Penyebab kematian terbesar keempat- 100.360 orang tewas tahun 1996 akibat COPD- 100.360 orang tewas tahun 1996 akibat COPD

Kira-kira 80 sampai 90% kasus COPD disebabkan oleh Kira-kira 80 sampai 90% kasus COPD disebabkan oleh merokok: seorang perokok memiliki kemungkinan 10 merokok: seorang perokok memiliki kemungkinan 10 kali lebih besar untuk mati akibat COPD daripada non kali lebih besar untuk mati akibat COPD daripada non perokok. Sebab lain adalah infeksi paru berulang dan perokok. Sebab lain adalah infeksi paru berulang dan paparan terhadap polutan industri tertentupaparan terhadap polutan industri tertentu

Bronkitis KronisBronkitis Kronis

Bronkitis kronis adalah inflamasi dan Bronkitis kronis adalah inflamasi dan akhirnya pemarutan dari jaringan yang akhirnya pemarutan dari jaringan yang membatasi saluran bronkusmembatasi saluran bronkus

Diperkirakan 14 juta orang menderita Diperkirakan 14 juta orang menderita bronkitis kronis, penyakit kronik bronkitis kronis, penyakit kronik terbesar ketujuh di Amerikaterbesar ketujuh di Amerika

Gejala bronkitis kronis mencakup batuk Gejala bronkitis kronis mencakup batuk kronis, peningkatan produksi mukus, kronis, peningkatan produksi mukus, sering membersihan tenggorokan dan sering membersihan tenggorokan dan pemendekan napaspemendekan napas

EmfisemaEmfisema EmphysemaEmphysema menyebabkan kerusakan paru menyebabkan kerusakan paru

yang yang ireversibelireversibel.. Dinding antar alveolus Dinding antar alveolus kehilangan kemampuannya untuk meregang kehilangan kemampuannya untuk meregang dan mengempis (kembali ke bentuk semula). dan mengempis (kembali ke bentuk semula). Dinding tersebut menjadi lemah dan rapuh. Dinding tersebut menjadi lemah dan rapuh. Jaringan paru kehilangan elastisitasnya Jaringan paru kehilangan elastisitasnya sehingga udara terperangkap dalam alveoli sehingga udara terperangkap dalam alveoli dan mengganggu pertukaran oksigen dan dan mengganggu pertukaran oksigen dan karbon diosida. Selain itu, saluran napas karbon diosida. Selain itu, saluran napas kehilangan penyokong sehingga terjadi kehilangan penyokong sehingga terjadi obstruksi aliran udaraobstruksi aliran udara

Gejala emfisema mencakup Gejala emfisema mencakup batuk,batuk, pemendekan pemendekan napasnapas dan dan toleransi yang rendah terhadap toleransi yang rendah terhadap latihan fisik.latihan fisik. Dx ditegakkan melalui tes fungsi Dx ditegakkan melalui tes fungsi paru, anamnesis, pemeriksaan dan tes lainparu, anamnesis, pemeriksaan dan tes lain

AAT deficiency-related AAT deficiency-related emphysemaemphysema

AlphaAlpha11 antitrypsin deficiency-related (AAT) antitrypsin deficiency-related (AAT) emphysemaemphysema is caused by the inherited deficiency of a is caused by the inherited deficiency of a protein called alphaprotein called alpha11-antitrypsin (AAT) or alpha-antitrypsin (AAT) or alpha11--protease inhibitor. AAT, produced by the liver, is a protease inhibitor. AAT, produced by the liver, is a "lung protector." In the absence of AAT, emphysema "lung protector." In the absence of AAT, emphysema is almost inevitable.is almost inevitable.

The onset of AAT deficiency emphysema, The onset of AAT deficiency emphysema, between the 20's and 40's, is characterized by between the 20's and 40's, is characterized by shortness of breath and decreased exercise shortness of breath and decreased exercise capacity. Blood screening is used if the trait is capacity. Blood screening is used if the trait is suspected and can determine if a person is a suspected and can determine if a person is a carrier or AAT-deficient. If children are carrier or AAT-deficient. If children are diagnosed as AAT-deficient through blood diagnosed as AAT-deficient through blood screening, they may undergo a liver transplant. screening, they may undergo a liver transplant.

Smoking significantly increases the severity of Smoking significantly increases the severity of emphysema in AAT-deficient individualsemphysema in AAT-deficient individuals

COPD TreatmentCOPD Treatment

The The quality of lifequality of life for a person suffering for a person suffering from COPD diminishes as the disease from COPD diminishes as the disease progresses. progresses. At the onset, there is At the onset, there is minimal shortness of breath.minimal shortness of breath. People People with COPD may eventually require with COPD may eventually require supplemental oxygensupplemental oxygen and may have to and may have to rely on mechanical respiratory rely on mechanical respiratory assistance.assistance.

Depending on the severity of the Depending on the severity of the diseasedisease, treatments may include , treatments may include bronchodilators,bronchodilators, which open up air which open up air passages in the lungs; passages in the lungs; antibioticsantibiotics; and; and exerciseexercise to strengthen muscles. to strengthen muscles.

To reduce and control symptoms of To reduce and control symptoms of chronic bronchitis, sufferers should live chronic bronchitis, sufferers should live a a healthy lifestylehealthy lifestyle by exercising, by exercising, avoiding cigarette smokeavoiding cigarette smoke and other and other air air pollutantspollutants, and , and eating well.eating well.

Pulmonary rehabilitation is a preventivePulmonary rehabilitation is a preventive health-care program provided by a team of health-care program provided by a team of health professionals to help people cope health professionals to help people cope physically, psychologically, and socially with physically, psychologically, and socially with COPD. COPD.

Lung transplantationLung transplantation is being performed in is being performed in increasing numbers and may be an option increasing numbers and may be an option for people who suffer from severe for people who suffer from severe emphysema. Additionally, a new surgical emphysema. Additionally, a new surgical procedure, lung volume reduction surgery, procedure, lung volume reduction surgery, shows promise and is being performed with shows promise and is being performed with increasing frequency.increasing frequency.

Special treatments for AAT deficiency Special treatments for AAT deficiency emphysema include emphysema include AAT replacementAAT replacement therapy (a life-long process). therapy (a life-long process).

Current research into COPD is focusing Current research into COPD is focusing on on gene therapy;gene therapy; it is hoped that it is hoped that clinical trials of this type of therapy will clinical trials of this type of therapy will take place within the decade.take place within the decade.

Table of SymptomsSeverityof COPD

Chronic BronchitisDominating

EmphysemaDominating

MILD Coughing and sputum for more

than 3 mos. for 2 consecutive yrs.

Possiblyno earlysigns

MODERATE

Shortness of breath (SOB) frommoderate exertion

Coughing and increased sputum Recurrent chest infections or

bronchitis

SOB frommoderateexertion

SEVERE

Severe SOB Coughing and excessive amounts

of sputum Wheezing Recurrent infections Fluid build-up (swelling at the

ankles) and blue appearance to theskin

SevereSOB

Barrel-shapedchest

EtiologyEtiology Definite Causes Definite Causes

Cigarette Smoking (dose-Cigarette Smoking (dose-response relationship). response relationship). (Only 10-15% (Only 10-15% of heavy smokers will develop COPD)of heavy smokers will develop COPD)

Alpha-1 anti-trypsin deficiency Alpha-1 anti-trypsin deficiency

Certain occupational dusts and Certain occupational dusts and gases/ fumes (mining, coal, gases/ fumes (mining, coal, grain, cotton, wood)grain, cotton, wood)

Possible/Probable Causes Possible/Probable Causes Air pollution (this is a more Air pollution (this is a more

important cause of important cause of exacerbation of COPD) exacerbation of COPD)

Respiratory tract infections Respiratory tract infections Airway hyperreactivity Airway hyperreactivity Some of these may be present Some of these may be present

in childhood and result in in childhood and result in increased risk of COPD increased risk of COPD decades later (not proven)decades later (not proven)

Two major types of COPDTwo major types of COPD

Pink Puffer (Emphysema) Blue Bloater Pink Puffer (Emphysema) Blue Bloater (Bronchitis) (Bronchitis)

Type A Type A Type BType BFeatureFeature Emphysema (Type A) PPEmphysema (Type A) PP Bronchitis (Type B) Bronchitis (Type B) BBBBAgeAge OlderOlder YoungerYoungerStatureStature Tall, thinTall, thin More obeseMore obeseHypoxemiaHypoxemia MildMild ProminentProminentHypercapniaHypercapnia Late Late EarlyEarlyCor pulmonaleCor pulmonale LateLate EarlyEarlyComplianceCompliance IncreasedIncreased NormalNormalHematocritHematocrit NormalNormal IncreasedIncreasedDyspneaDyspnea ProminentProminent VariableVariableCoughCough UncommonUncommon ProminentProminent

COPD Overview COPD Overview OnsetOnset

usually after 5th decade usually after 5th decade SymptomsSymptoms

Shortness of breath Shortness of breath Cough Cough

DiagnosisDiagnosis History History Physical examination Physical examination Persistent airflow obstruction on PFT Persistent airflow obstruction on PFT X-ray changes (CXR, CT scan)X-ray changes (CXR, CT scan)

Pulmonary Function Test Chest X-ray Computerized Tomography

Chest X-rays Chest X-rays

Emphysema Emphysema Hyperinflation Hyperinflation Flattened diaphragms Flattened diaphragms Decreased vascular markings Decreased vascular markings

Chronic Bronchitis Chronic Bronchitis Usually normalUsually normal

Arterial Blood Gas (ABGs):Arterial Blood Gas (ABGs): An ABG is An ABG is done from a sample drawn from one of done from a sample drawn from one of your arteries. The blood is then your arteries. The blood is then analyzed by a special machine, which analyzed by a special machine, which records the amount of carbon dioxide records the amount of carbon dioxide (waste gas) and oxygen in your blood. (waste gas) and oxygen in your blood. One of the uses of this test is to One of the uses of this test is to determine whether or not you need any determine whether or not you need any extra oxygen. extra oxygen.

Pulse Oximetry: Pulse Oximetry: This test is performed This test is performed by placing a special light clip on you by placing a special light clip on you finger, earlobe or forehead. The pulse finger, earlobe or forehead. The pulse oximeter uses light waves to oximeter uses light waves to indirectly indirectly measure the amount of oxygen in your measure the amount of oxygen in your blood.blood. Done without the use of needles, Done without the use of needles, the pulse oximetry can be performed at the pulse oximetry can be performed at rest, while you are walking or even rest, while you are walking or even overnight while you sleep.overnight while you sleep.

X-Ray Appearance in COPD:X-Ray Appearance in COPD: In the early In the early stages of the disease the x-ray of the chest stages of the disease the x-ray of the chest may be completely normal. But in the may be completely normal. But in the moderate to severe cases a reasonably moderate to severe cases a reasonably accurate diagnosis of COPD can be made with accurate diagnosis of COPD can be made with the plain chest x-ray and C.T. (Computerized the plain chest x-ray and C.T. (Computerized Axial Tomography) scanningAxial Tomography) scanning.. The most The most common appearances in the chest x-rays are common appearances in the chest x-rays are hyperinflationhyperinflation of the lung, of the lung, depressed depressed diaphragmsdiaphragms, , loss of blood vessel markingsloss of blood vessel markings, , reduced size of the heartreduced size of the heart, the presence of , the presence of bullaebullae and sometimes increased lung and sometimes increased lung markings.markings.

TREATMENT FOR COPDTREATMENT FOR COPD An important self help maneuver must be An important self help maneuver must be

emphasized at this time: emphasized at this time: Pursed Lip BreathingPursed Lip Breathing.. Non-medical therapy Non-medical therapy

Smoking cessationSmoking cessation! ! Supplemental OSupplemental O22 for patients who qualify by for patients who qualify by

having a low enough arterial POhaving a low enough arterial PO22 Pulmonary rehabilitationPulmonary rehabilitation

Medical therapy for chronic symptoms Medical therapy for chronic symptoms DrugsDrugs

Supplemental OSupplemental O22 for patients who qualify by for patients who qualify by having a low enough arterial POhaving a low enough arterial PO22

Relieves dyspnea Relieves dyspnea Improves survival Improves survival Stabilizes pulmonary hypertension Stabilizes pulmonary hypertension Number of hours per day correlates with Number of hours per day correlates with

benefit benefit Improves cognitive deficits Improves cognitive deficits May be helpful in patients with nocturnal May be helpful in patients with nocturnal

or exercise associated Oor exercise associated O22 desaturation desaturation

Pulmonary rehabilitation Pulmonary rehabilitation Whole body exercise Whole body exercise Inspiratory muscle trainingInspiratory muscle training

Medical therapy for chronic Medical therapy for chronic symptomssymptoms

Bronchodilators Bronchodilators Adrenergic agents Adrenergic agents AnticholinergicAnticholinergic Methylxanthines (i.e. theophylline) Methylxanthines (i.e. theophylline)

Corticosteroids Corticosteroids

Mucolytics Mucolytics

DiureticsDiuretics

Adrenergic agentsAdrenergic agents Beta-agonists bind to BBeta-agonists bind to B2 2 receptors on receptors on

airway and result in smooth muscle airway and result in smooth muscle relaxation and bronchodilation relaxation and bronchodilation

Inhaled route is preferred Inhaled route is preferred Acute relief of symptomsAcute relief of symptoms

Beta-agonistsBeta-agonists This class of medication is most commonly used in an This class of medication is most commonly used in an

inhaled form. inhaled form. This can be either as a small canister that sprays a fine This can be either as a small canister that sprays a fine

mist when pushed (known as an metered dose inhaler mist when pushed (known as an metered dose inhaler or MDI), or in a liquid form made into a mist to breathe or MDI), or in a liquid form made into a mist to breathe by a machine at home. by a machine at home.

There are short and long-acting forms of both the There are short and long-acting forms of both the inhaled and pill forms. NEVER USE THE LONG-ACTING inhaled and pill forms. NEVER USE THE LONG-ACTING FORMS (salmeterol) TO HELP ACUTE SYMPTOMS!! FORMS (salmeterol) TO HELP ACUTE SYMPTOMS!!

They take much, much longer to work than the short They take much, much longer to work than the short acting versions, and your symptoms may get worse acting versions, and your symptoms may get worse before your medication takes effect. The advantage of before your medication takes effect. The advantage of the inhaled forms is that the medication is absorbed the inhaled forms is that the medication is absorbed directly by the lung. This leads to fewer side effects directly by the lung. This leads to fewer side effects from the medication. from the medication.

Anti-cholinergic agentsAnti-cholinergic agents Bind to acetylcholine receptors and Bind to acetylcholine receptors and

result in bronchodilation (of mostly larger result in bronchodilation (of mostly larger airways) airways)

Reduces sputum production Reduces sputum production Inhaled route is preferred Inhaled route is preferred More important in COPD than in asthmaMore important in COPD than in asthma

AnticholinergicsAnticholinergics (Ipratropium bromide)(Ipratropium bromide) This is a type of medication most commonly This is a type of medication most commonly

given by the given by the inhaled routeinhaled route. There is also a . There is also a liquid form available which can be used in a liquid form available which can be used in a nebulizer. This medication can also help the nebulizer. This medication can also help the small airways of the lung relax and open small airways of the lung relax and open further, thereby making it easier to breathe. further, thereby making it easier to breathe. This type of medication works best when This type of medication works best when used on a regular basis and is not for acute used on a regular basis and is not for acute symptoms.symptoms.

Methylxanthines (i.e. Methylxanthines (i.e. theophylline)theophylline)

Weak bronchodilator Weak bronchodilator Other mechanisms may be important Other mechanisms may be important

Delays respiratory muscle fatigue Delays respiratory muscle fatigue Improves respiratory muscle Improves respiratory muscle

mechanicsmechanics

TheophyllineTheophylline Theophylline is a type of medication that can Theophylline is a type of medication that can

have multiple effects on your body's ability to have multiple effects on your body's ability to breathe better. It can cause your breathe better. It can cause your airways to airways to relaxrelax and open further, thereby making it and open further, thereby making it easier to breathe. It can also easier to breathe. It can also improve the improve the diaphragm's ability to contract.diaphragm's ability to contract. Also, Also, theophylline can increase the clearance of theophylline can increase the clearance of mucusmucus from your airways and help you clear from your airways and help you clear excessive phlegm. That is why your doctor excessive phlegm. That is why your doctor may want to check the blood level from time may want to check the blood level from time to time to ensure that you are getting the to time to ensure that you are getting the correct dose. Theophylline can be given either correct dose. Theophylline can be given either in a in a pillpill form or as a form or as a continuous infusioncontinuous infusion when when you are in the hospital.you are in the hospital.

Corticosteroids Corticosteroids Reduce airway inflammation Reduce airway inflammation Efficacy and role in stable COPD Efficacy and role in stable COPD

uncertainuncertain

Anti-Inflammatories (Steroids) Anti-Inflammatories (Steroids) (prednisone, methylprednisolone)(prednisone, methylprednisolone) Since COPD may have an inflammatory component, your Since COPD may have an inflammatory component, your

doctor may prescribe a steroid containing medication. The doctor may prescribe a steroid containing medication. The type of steroid contained in these preparations is type of steroid contained in these preparations is not the not the type that builds muscle.type that builds muscle. Your body normally makes its Your body normally makes its own anti-inflammatory steroids, however, extra doses may own anti-inflammatory steroids, however, extra doses may benefit selected patients. benefit selected patients.

Steroids also can be given in several forms. The Steroids also can be given in several forms. The inhaledinhaled form delivers the medication right where you want it, form delivers the medication right where you want it, straight to the lungs. If your breathing does not respond to straight to the lungs. If your breathing does not respond to the inhaled form your doctor may chose to place you on a the inhaled form your doctor may chose to place you on a pillpill form. An form. An intravenousintravenous form is also available. Steroids form is also available. Steroids have many side effects. This is why your doctor will try to have many side effects. This is why your doctor will try to get you off steroids as soon as possible. There is much get you off steroids as soon as possible. There is much less concern with side effects when using inhaled less concern with side effects when using inhaled steroids, and this is the preferred form.steroids, and this is the preferred form.

MucolyticsMucolytics Alter viscosity of sputum Alter viscosity of sputum May reduce symptoms in some patients May reduce symptoms in some patients Do not improve objective parameters of Do not improve objective parameters of

respiratory functionrespiratory function

Diuretics Diuretics Only for peripheral edema with right Only for peripheral edema with right

heart failure heart failure Must be used carefully (i.e. avoiding Must be used carefully (i.e. avoiding

hypotension)hypotension)

COPD ExacerbationsCOPD Exacerbations Range in severity Range in severity Increase of symptoms Increase of symptoms Increase cough Increase cough Increased sputum production Increased sputum production Shortness of breath increases Shortness of breath increases May progress to acute respiratory failure (requiring May progress to acute respiratory failure (requiring

mechanical ventilation) mechanical ventilation)

Etiology Etiology Infection (Viral/Bacterial) Infection (Viral/Bacterial) Non-compliance with therapeutics Non-compliance with therapeutics Exposure to physical / chemical irritants, including Exposure to physical / chemical irritants, including

cigarette smoke cigarette smoke Fatigue of the inspiratory muscles (this is unproven)Fatigue of the inspiratory muscles (this is unproven)

Chronic Bronchitis (CB)Chronic Bronchitis (CB) Presence of cough/sputum production for most days for at Presence of cough/sputum production for most days for at

least 3 consecutive months during 2 consecutive years least 3 consecutive months during 2 consecutive years Major features Major features

Cough Cough Sputum production Sputum production

Unlike patients with asthma, patients with CB have residual Unlike patients with asthma, patients with CB have residual clinical disease (symptoms, wheezes, abnormal PFTs) clinical disease (symptoms, wheezes, abnormal PFTs) between exacerbations between exacerbations

Asthmatic bronchitis Asthmatic bronchitis CB with a prominent airway hyperreactivity componentCB with a prominent airway hyperreactivity component

Pathology of CB Pathology of CB Large airways involved Large airways involved

Increase in the number and size of mucus Increase in the number and size of mucus glands in bronchi glands in bronchi

Reid index increasedReid index increased

REID INDEXREID INDEX Provides a measure of the proportion of bronchial Provides a measure of the proportion of bronchial

glands relative to thickness of bronchial walls glands relative to thickness of bronchial walls

Excess mucus in airways Excess mucus in airways Semi-solid plugs may occlude some small bronchi Semi-solid plugs may occlude some small bronchi Influx of inflammatory cells Influx of inflammatory cells

Thickened airway walls Thickened airway walls Narrowing of airways Narrowing of airways

Impaired clearance of mucus Impaired clearance of mucus Loss of cilia Loss of cilia Loss of function Loss of function Contribute to chronic cough and sputum Contribute to chronic cough and sputum

productionproduction

EmphysemaEmphysema

Enlargement of airspaces distal to terminal Enlargement of airspaces distal to terminal bronchiole bronchiole

Destruction of alveolar wallsDestruction of alveolar walls

Types of emphysemaTypes of emphysema (divisions based on pathological findings)(divisions based on pathological findings)

Centriacinar (centrilobular) Centriacinar (centrilobular) Panacinar (panlobular) Panacinar (panlobular) BullousBullous

Pathogenesis of emphysemaPathogenesis of emphysema Cigarette smoke Cigarette smoke Recruits neutrophils (and macrophages to a lesser extent) Recruits neutrophils (and macrophages to a lesser extent) Inflammatory cells produce elastase Inflammatory cells produce elastase Destroys connective tissue of alveolar walls Destroys connective tissue of alveolar walls Alpha-1 anti-trypsin (or alpha-1 protease inhibitor) is a Alpha-1 anti-trypsin (or alpha-1 protease inhibitor) is a

protein produced by the liver that circulates in the blood protein produced by the liver that circulates in the blood and limits the action of elastase and limits the action of elastase

Inactivates anti-proteases (oxidation of amino acids affects Inactivates anti-proteases (oxidation of amino acids affects binding of these protein inhibitors) binding of these protein inhibitors)

Alpha-1 anti-trypsin deficiency Alpha-1 anti-trypsin deficiency

Autosomal recessiveAutosomal recessive

Pathophysiology of COPDPathophysiology of COPD Abnormalities in respiratory mechanics Abnormalities in respiratory mechanics Reduced expiratory airflow Reduced expiratory airflow

In CBIn CB Excessive secretions Excessive secretions Smooth muscle contraction (bronchospasm) Airway Smooth muscle contraction (bronchospasm) Airway

inflammation / bronchial wall edema inflammation / bronchial wall edema In emphysema In emphysema

Reduction of elastic recoil Loss of lung's natural Reduction of elastic recoil Loss of lung's natural tendency to resist expansion tendency to resist expansion

Supporting structures for the airways is decreased Supporting structures for the airways is decreased

DYSPNEA CUESDYSPNEA CUES

SOB ManagementSOB Management

Metered dose inhalers (MDIs)Metered dose inhalers (MDIs) or hand held or hand held inhalers are a convenient, effective and safe inhalers are a convenient, effective and safe way to deliver medications to the lungs. way to deliver medications to the lungs. Because they are delivered locally and Because they are delivered locally and directly to the lungs, smaller doses of directly to the lungs, smaller doses of medication can be used. The beneficial medication can be used. The beneficial effects of the medication can occur while the effects of the medication can occur while the side effects are minimized. But... if the side effects are minimized. But... if the inhalers are not used correctly the medication inhalers are not used correctly the medication will not get to the right place. At best, using will not get to the right place. At best, using perfect technique, only 10-20% of the perfect technique, only 10-20% of the medication gets to the right place. So, you medication gets to the right place. So, you see why it's important to use good techniquesee why it's important to use good technique

Metered Dose Inhaler (MDI) Metered Dose Inhaler (MDI) with Spacerwith Spacer

MDI

spacer

Proper Use of MDIProper Use of MDI

TURBOHALER

ROTAHALER