The inflammation in the respiratory tract of COPD patients appears to be a modification of the inflammatory response of the respiratory tract

to chronic irritants such as cigarette smoke. The mechanisms for this amplified inflammation are not yet understood but may be genetically determined. Patients can clearly develop COPD without smoking, but the nature of the inflammatory response in these patients is unknown. Oxidative stress and an excess of proteinases in the lung further modify lung inflammation. Together, these mechanisms lead to the characteristic pathological changes in COPD. Lung inflammation persists after smoking cessation through unknown mechanisms, although autoantigens and persistent microorganisms may play a role. Oxidative Stress. Oxidative stress may be an important amplifying mechanism in COPD. Biomarkers of oxidative stress (e.g., hydrogen peroxide, 8-isoprostane) are increased in the exhaled breath condensate, sputum, and systemic circulation of COPD patients. Oxidative stress is further increased in exacerbations. Oxidants are generated by cigarette smoke and other inhaled particulates, and released from activated inflammatory cells such as macrophages and neutrophils. There may also be a reduction in endogenous antioxidants in COPD patients as a result of reduction in a transcription factor called Nrf2 that regulates many antioxidant genes. Protease-Antiprotease Imbalance. There is compelling evidence for an imbalance in the lungs of COPD patients between proteases that break down connective tissue components and antiproteases that protect against this. Several proteases, derived from inflammatory cells and epithelial cells, are increased in COPD patients. There is increasing evidence that they may interact with each other. Protease-mediated destruction of elastin, a major connective tissue component in lung parenchyma, is believed to be an important feature of emphysema and is likely to be irreversible. Inflammatory Cells. COPD is characterized by a specific pattern of inflammation involving increased numbers of CD8+ (cytotoxic) Tc1 lymphocytes present only in smokers that develop the disease85. These cells, together with neutrophils and macrophages, release inflammatory mediators and enzymes and interact with structural cells in the airways, lung parenchyma and pulmonary vasculature. Inflammatory Mediators. The wide variety of inflammatory mediators that have been shown to be increased in COPD patients91 attract inflammatory cells from the circulation (chemotactic factors), amplify the inflammatory process (proinflammatory cytokines), and induce structural changes (growth factors). Differences in Inflammation Between COPD and Asthma. Although both COPD and asthma are associated with chronic inflammation of the respiratory tract, there are differences in the inflammatory cells and mediators involved in the two diseases, which in turn account for differences in physiological effects, symptoms, and response to therapy74. Some patients with COPD have features consistent with asthma and may have a mixed inflammatory pattern with increased eosinophils.

Respons inflamasi akibat oksidan melibatkan berbagai sel inflamasi dan mediator inflamasi (leukotrien,prostaglandin, platelet activating factor (PAF), reactive oxygen spesies (ROS), kemokin, sitokin, growth factor,endotelin, neuropeptidase dan protease. Pajanan asap rokok atau bahan berbahaya menyebabkan inflamasi paru dengan bertambahnya sel neutrofil, makrofag dan limfosit T CD8+ pada dinding jalan napas dan parenkim paru. Inflamasi pada paru akan mengakibatkan stres oksidasi dan beberapa protease dikeluarkan oleh neutrofil seperti neutrofil elastase (NE), kaptensin G dan protease mengakibatkan kerusakan parenkim berupa elastolisis yaitu hilangnya daya elastik paru sedangkan protease dan NE mengakibatkan hipersekresi mukus. Asap rokok dan stres oksidatif menyebabkan proses inflamasi yang menyebabkan peningkatan histoneacetyltransferase (HAT) sehingga terjadi ketidakseimbangan antara histonedeacetylase (HDAC) dan acetylase. Mekanisme ini menjadi dasar memahami regulasi gen inflamasi yang teraktivasi pada berbagai penyakit inflamasi. Histonacetylase berhubungan dengan peningkatan ekspresi gen inflamasi yang akan dihambat oleh aktiviti HDAC. Faktor transkripsi proinflamasi misalnya natural killer kaffa B (NF-kB) yang teraktivasi akan berikatan dengan DNA dan berinteraksi dengan molekul koaktivator misalnya cyclic binding protein (CBP) dan p300/CBP-associated factor (PCAF). Asetilasi memungkinkan kromatin bertransformasi dari bentuk tidak aktif/ tertutup menjadi bentuk aktif/ terbuka (gambar 2) Kelainan paru yang disebabkan oleh ROS antara lain penyakit paru obstruktif kronik (PPOK), asma, emfisema, fibrosis kistik, adult respiratory distress syndrome (ARDS), idiopathic pulmonary fibrosis (IPF), pulmonary reperfusion injury, silikosis, asbestosis fibrosis karena xenobiotik. Pada PPOK terjadi aktivasi neutrofil, makrofag, eosinofil, dan epitel bersama-sama ROS, NO2, asap rokok, ozon dan beberapa oksidan lainnya lainnya sehingga terbentuk stres oksidatif yang mengakibatkan peningkatan respons inflamasi. Respons inflamasi terjadi melalui berbagai jalan antara lain raeaksi langsung dan tidak langsung antara ROS dan oksidan pada sel saluran napas, terhadap berbagai sel inflamasi seperti interleukin (IL)-8, tumor necrosis factor- (TNF-), matrix mettaloproteinase (MMP)-9, mitogen activated protein (MAP).2 Setijadi dkk.8 dalam penelitiannya terhadap 24 pasien perokok dan bukan perokok ditemukan korelasi kuat antara jumlah makrofag, neutrofil dan kadar MMP-9 pada cairan kurasan bronkoalveolar perokok. Pada asma, inflamasi saluran napas berhubungan dengan peningkatan inducible nitric oxide synthase (iNOS) dan membran oksidase sehingga membuat superoksid, dan nitric okside secara cepat membentuk peroksinitrit yang mengakibatkan kerusakan jaringan dan respons inflamasi. Pasien dengan emfisema, terjadi pelepasan NE sesuai dengan meningkatnya reaksi oksidan sehingga protein jaringan tidak terkontrol dan terjadi kerusakan struktur matriks alveolar. Zat-zat yang berbahaya tidak hanya mengakibatkan degradasi kolagen tetapi juga mengakibatkan hambatan terhadap protease seperti 1antitripsin.2 Pada pasien fibrosis kistik, terjadi peningkatan neutrofil 100-1000 kali dibanding orang normal. Pasien ARDS, terjadi kerusakan jaringan paru karena interaksi antara neutrofil dengan endotel vaskular paru dan pada pemeriksaan saat ekspirasi didapatkan konsentrasi H2O2 yang tinggi. Pemeriksaan kurasan bronkoalveolar (BAL) pasien ARDS, asbestosis dan IPF didapatkan hasil yang

hampir sama yaitu peningkatan akrofag alveolar relatif 40% dan peningkatan absolut neutrofil 80%. Peranan antioksidan Seperti organ tubuh yang lain sistem pernapasan mempunyai berbagai sistem pertahanan terhadap stres oksidatif yaitu sistem enzimatik dan non enzimatik. Pertahanan enzimatik antara lain superoxidismutase (SOD), katalase, glutation peroksidase/reduktase sedangkan sistem nonenzimatik antara lain vitamin E, asam askorbat, asam urat, karoten, thiols (N-acetylcystein), ubikuinon,transferin, albumin (gambar 3).1 Berbagai aktiviti antioksidan antara lain menurunkan konsentrasi oksigen lokal, menetralkan aktiviti radikal bebas, menetralkan peroksida dengan memblok aktiviti radikal bebas, menghambat reaksi terbentuknya lipoperoksidasi. Peran antioksidan golongan thiol seperti erdostein, NAC, sistein adalah membantu memudahkan glutathione (GSH) melintasi membran sel. Glutathion berfungsi dalam reaksi biokimia dalam metabolisme H2O2 atau peroksida lainnya. 1. MacNee W. Treatment of stable COPD : antioxidants. Eur Respir Rev 2005;14:94: 12-22 2. Braga PC. Oxidative stress: Respiratory disease and thiol compounds.1th ed. Milan: Grafiche Pacini, 2006.p.9-77. 3. Kirkham P, Rahman I. Oxidative stress in asthma and COPD: Antioxidants as a therapeutic strategy; J Pharmacology & Therapeutics 2006: 476 94. 4. Mohanty KC, Thiappanna G, Singh V, Mancini C. Evaluation of efficacy and safety of erdostein in patients affected by exacerbation of chronic bronchitis and receiving ciprofloxacin as basic treatment. Journal of Clinical Research 2001;4:35-9. 5. Anthonisen NR, Connett JE, Murray RP. Smooking and lung function of lung health study participants after 11 years. Am J Respir Crit Care Med 2002;166:675-9. 6. Barnes PJ, Addock IM, Ito K. Histoneacetylation and deacetylation: importance in inflammatory lung disease. Eur Respir J 2005 ;25:552-63. 7. Foronjy R, Wallace A, DArmientoP J. The pharmacokinetic limitations of antioxidant treatment for COPD.J Pulm Pharm & Therapeutics 2008: 3709. 8. Setijadi AR, Suradi, Suryanto E, Yunus F. Korelasi antara jumlah makrofag, neutrofil dan kadar enzim MMP-9 pada cairan kurasan bronchial perokok. J Respir Indo 2007:43-7. 9. Widiyawati IN, Suradi, Suryanto E, Yunus F. Peran N-Acetylcysteine dosis tinggi jangka pendek pada perubahan klinis dan kadar C-Reactive Protein penderita PPOK eksaserbasi akut di RSUD Dr. Moewardi Surakarta.J Respir Indo 2007:186-96. 10. Subrata G. High dose N-Acetylcysteine for Interstitial Pulmonary Fibrosis. Presented at: 13TH Congress of APSR & 2nd Joint Congress of APSR/ACCP. Queen Sirikit National Convention Center, Thailand, Bangkok 19-22 November 2008. 11. Rahmawati I, Mangunnegoro H, Yunus F. Peran erdostein pada PPOK eksaserbasi yang mendapatkan levofloksasin, evaluasi efikasi dan keamanan.J Respir Indo 2007:85-90.

12. Isbaniah F, Wiyono WH, Yunus F, Setiawati S, Totzke U, Verbruggen MA. Echinacea purpurea along with zinc, selenium and vitamin C to alleviate exacerbations of chronic obstructive pulmonary disease : results from a randomized controlled trial. J of Clin Pharm and Ther 2010: 1-9 13. Imansyah B, Yunus F, Wiyono WH. Efek pemberian UBIQUINON pada penyakit paru obstruktif kronik. J Respir Indo 2008:206-18. 14. Sussan TE, Rangasamy T, Blake DJ, Malhotra D, El-Haddad H, Bedja D et all. Targeting Nrf2 with the triterpenoid CDDO imidazolide attenuates cigarette smoke-induced emphysema and cardiac dysfunction in mice. Proc Natl Acad Sci USA 2009;106(1):250-5. 15. Hanta I, Kocabas A, Canacankatan N, Kuleci S, Seydaoglu G. OxidantAntioxidant Balance in Patients with COPD. Lung 2006:515.

The use of antioxidants may be an interesting strategy in the prevention of radicalinduced damage. The lung protects itself through several antioxidant systems, including thiol compounds, vitamins and enzymes. Enzymes such as SOD and catalase are large mass polymers, which prevents their intracellular transport and their use by the oral route; therefore their use has been limited to experimental studies. Only thiols and vitamins have been studied in the clinical setting. Thiols GSH and cysteine are the most important antioxidant thiols in the lung. Intracellular synthesis of GSH depends on the availability of its natural precursor, L-cysteine [31]. Cysteine has a poor resorption, it is rapidly oxidized and is toxic. These disadvantages are prevented by acetylation of the molecule. Exogenous GSH must be broken down to the constituent aminoacids. A GSH preparation is available for intravenous use but has never been tested in chronic pulmonary diseases. N-acetylcysteine N-acetylcysteine (NAC) is a sulphydryl group (SH) containing aminoacid residue with an acetyl group on the nitrogen. The thiol group is crucial for its therapeutic effect. NAC has been used in Europe as a mucolytic agent. The mucolytic action, a result of cleavage of disulphide bonds between mucines and consequent decrease of the viscosity of the mucus, was described by Sheffner et al. [32] in the 1970s. More recently, the therapeutic effect of NAC has been primarily ascribed to its antioxidant properties. NAC is biotransformed very effectively, which explains its low bioavailability. After oral administration, NAC is deacetylated to L-cysteine. Cysteine has a central role in the endogenous thiol metabolism and may be transformed into a large number of molecules, including GSH. In analogy with the well-established mechanism of action of NAC against liver toxicity resulting from paracetamol (acetaminophen) intoxication [33], GSH has been seen as a link between NAC and therapeutic effects in chronic bronchitis.

After oral intake of 600 mg/day, the intestinal absorption of NAC is rapid; it can be measured in the plasma after 60 min. NAC is partially deacetylated at intestinal mucosa level and undergoes an intense metabolism after the first hepatic passage. As a consequence, the bioavailability of the unchanged molecule is apparently low (10%). At this dose, NAC could not be detected in BAL fluid. It is important to bear in mind, however, that it is at the hepatic level that its principal conversion into GSH takes place. An increase in bioavalability has been reported after higher doses. After administration of NAC, plasma level increases in cysteine, GSH and thiolic groups have been measured. Also, increased levels of GSH in the lung were measured. However, in COPD patients, after an oral dose of 600 mg NAC, the plasma concentrations of GSH were unchanged, whereas 600 mg NAC three times daily increased GSH plasma concentrations. These data were confirmed by Behr et al. In patients with IPF, who also demonstrated a significant increase in total concentration of GSH both in ELF and in the cells after oral administration of 1800 mg/day NAC. Pendyala and Creaven found a significant increase in GSH in the circulating lymphocytes in healthy volunteers after a single administration of 800 mg/m2. Repeated administrations caused an increase in GSH concentration of approximately 20% over baseline. To understand the effect of NAC on cysteine and GSH levels it is important to note that plasma levels are often non-representative of the situation in the lung because of compartmentalization of GSH need and availability. Furthermore, studies performed after coadministration of NAC (2 g) and paracetamol (2 g) to healthy volunteers showed an increase in cysteine and GSH levels in plasma, when a single administration of NAC was without effect. This result suggests that the incorporation of NAC into GSH is dependent on the increased demand, as during oxidative stress.

Rationale for the use of NAC in COPD NAC can interfere in the pathophysiology of COPD in different ways. Thiol groups are rich in electrons and can act as scavengers, reductans and antioxidants. NAC exerts a direct antioxidant effect through its free thiol group interacting with electrophilic groups of ROS [41]. Aruoma et al. [42] investigated the antioxidant action of NAC against hydrogen peroxide, hydroxyl radical, superoxide and hypochlorous acid. NAC is a powerful scavenger of hypochlorous acid and hydroxyl radical, while the reaction with hydrogen peroxide was noted to be slow. NACs effect in reducing elastase activity was ascribed to the property of scavenging hypochlorous acid. Vitamin There is clear epidemiological evidence that dietary intake of antioxidant vitamins (vitamins E and C and - tocopherol) is positively associated with lung function and respiratory symptoms. Large epidemiological studies such as NHANES 13 demonstrated that higher levels of antioxidant nutrients are associated with better lung function. Vitamin E in particular could be important in protecting surfactant lipids against oxidation and subsequent lung injury. A temporary vitamin E deficiency induces a reversible change of the expression of pro- and antiinflammatory markers and of markers defining apoptosis, and reduces surfactant lipid synthesis in alveolar type II cells. The question is whether supplementation of vitamins, outside the dietary

intake, can provide benefit to patients. Fairfield and Fleicher. in a recent review, found little convincing evidence in favour of supplementation for chronic disease prevention; fruit and vegetables contain a variety of other compounds that may be protective. Bender, in an editorial in the British Medical Journal. concluded that supplementation will be of little benefit unless intake is inadequate as a result of poor diet. Kesimpulan Smoking, acute exacerbation of COPD and asthma are all associated with a marked oxidantantioxidant imbalance and with signs of oxidative stress. COPD and asthma are growing worldwide, and represent an ever-increasing burden on national health costs. However, it is not easy to obtain definitive proof that oxidants have a decisive role in the pathogenesis and evolution of these diseases. Because asthma and COPD are chronic progressive diseases, longterm studies in large case series are required. One of the most significant aspects is that the lung oxidantantioxidant balance is abnormal in cigarette smokers; however, it remains unclear why only certain cigarette smokers develop COPD while others do not. The answer to this question is related to an improved understanding of the nature of the oxidant antioxidant balance, as well as of the genetic factors and other intrinsic factors, including dietary, that control this balance. In view of these uncertainties, it is not possible to date to specifically document the benefit of antioxidant therapy. Nevertheless, there are some antioxidants that have been sufficiently well investigated and appear very close to giving a definitive positive response concerning their efficacy in the treatment of COPD. In this context, in vitro and in vivo data show that NAC protects the lungs against toxic agents by increasing pulmonary defence mechanisms through its direct antioxidant role in the rate and severity of exacerbations, and its indirect role as a precursor of GSH synthesis. The long-term use of the drug in COPD patients results in an improvement in respiratory symptoms and in a decrease in the exacerbation rate. It should be emphasized that there are numerous and important studies in progress, unfortunately often limited to the experimental setting, on new substances that will have an important role in antioxidant therapy in the future.