PS.

PANDIA
ASMA &COPD
CONSULTANT
PULMONARY AND RESPIROLOGY DEPARTMENT
MEDICAL FACULTY SUMATERA UTARA
UNIVERSITY
H. ADAM MALIK TEACHING HOSPITAL MEDAN

COPD competetion 3a
Able to make diagnose(history

taking,physical diagnostic,laboratory
and
x-ray)
Emergency treat
Consult to spesialist

Primary care visit

Patient present w/ symptom:

chronic cough,chronic sputum

production,dyspnoe w/ or w/o
wheezing
History of risk fc for COPD

Risk fc
Cigarette smoking
Age
Dusty occupation
Environmental pollution
-1 antitrypsin deficiency
Low birthweight
Frequent childhood infections

smoke

Smoking history
Current smokers
Ex-smokers
Age they started smoking
Average number of cigarettes

smoked per day

If they stopped when this occurred
Term of pack year: 20 cigarettes per
day for 12 months

How does smoking affect

the lung
More rapid loss of lung function in a

proportion of smokers
The airflow limitation due to smoking
developed gradually,individually and
patients had airfllow limitation for many
years before becoming symptomatic.
Chronic exposure to tobacco smoke
leads to an influx of inflamatory cell in
to the lung

How does smoking affect

the lung
Tobacco smoke contains over 4000

chemicals,many of which are potentially

toxic,but it is thought that the oxidants it
contains,combined with the oxidant
burden from the reactive oxidant released
from the inflamatory cell it recruits as a
mayor factor in causing COPD
Tobacco smoke leads to the release of
proteases and elstases from neutrophills
and macrophages and may inhibit
protective antiprotease mechanisms

-1 antitrypsin deficiency
Genetic risk factor for COPD
2% of cases of severe COPD
Fc associated with the development

of emphysema in non smoker

Is the mayor protease inhibitor in
serum and in the lung
It protects tissue againts enzymatic
digestion by several enzymes
released by activated neutrophills.

diagnosis
Symptom
Medical history
Lung function test
Chest radiograph suggest COPD

Severity assessment
Types/degree of symptom
Result of lung function test
Presence of complication

classification
Mild
Moderate
Severe
Very severe

mild
FEV1/FVC< 70%
FEV1 80% predicted
w/ or w/o chronics symptoms
Avoid risk fc and administer

vaccination

moderate
FEV1/FVC< 70%
50% FEV1 < 80% predicted
w/ or w/o chronics symptoms
Avoid risk fc and administer

vaccination
Add rehabilitation

severe
FEV1/FVC< 70%
30% FEV1 < 50% predicted
w/ or w/o chronics symptoms
Avoid risk fc and administer

vaccination
Add rehabilitation

Very severe
FEV1/FVC< 70%
FEV1< 30% predicted or
FEV1< 50% predicted plus chronic

respiiratory failure or right heart

failure
Avoid risk fc and administer
vaccination
Add long-term O2 if chronic
respiratory failure

Severity of

assessment

Classification of COPD severity

Mild
Moderate
Severe
Very severe

treatment
Generally symptom driven
Non-pharmacological
pharmacological

Does patient smoke

If smoke plan to cessation smoke
If no smoke.treat COPD

Non pharmacological
For all level of severity
Exercise
Patient education(disease

state,pharmacotherapy,nutrition,smo
king cessation)

pharmacotherapy
Stepwise approach based on
levels of severity

Oxygen therapy
Long term O2 administration(>15 hr/day)
indicated for stage III:severe COPD

patient w/:PaO2 7.3 kPa(55mmhg),

SaO2 88% w/ or w/o hypercapnia.PaO2
between 7.3 kPa& 8 kPa or SaO2 89%
w/ evidence of pulmonary
hypertension,peripheral edema,CHF or
polycythemia.
Goal : PaO2 8 kPa(60 mmhg) &/ or
SaO2 90%

rehabilitation
Goals
Decrease symptom
Improve qulity of life
Increase level of activity

Targeted at the
following areas
Exercise training
Nutrition conseling
education

education
Basic knowledge of COPD
Drug(benefit and side effect )
How to prevent worsening disease
Avoid risk fc
Appropriate activity

Diffrential diagnose
Post tuberculose obstructive

syndrome
Asthma
Peumotorax
Chronic heart failure
Bronchiectasis
Destroyed lung

asthma and COPD

asthma

COPD

Usually young
Atophy

Old
Non atophy
Noxius agent

Sensitive substance
Smoking +/_
Hypersensitive
reversible

Smoking
irreversible

Fact about copd

Of 1000 registered,2-3 ne cases of

COPD are found each year

30-45 COPD patients under
treatment
Mayor cause of morbidity and
mortality
Preventable disease

emphysema
Pathological changes that occur as a

condition of lung characterized by

abnormal,permanent enlargement of
airspaces distal to the terminal
bronchiole accompanied by
destruction of their walls and without
obvious fibrosis.

Chronic bronchitis
Is a state of chronic mucus

hyperscretion
Associated with an increase in the
volume and number of submucosal
glands and number of goblet cells in
the mucosa
Cough productive of sputum for at
least 3 months in each year for not
less than 2 successive years.

Medical research council

dyspnoe scale
Grade 1.not troubled by breathlessness

except on strenuous exercise

Grade 2.Short of breath when hurrying or
walking up a slight hill
Grade 3.walks slower than contemporaries
on the level because of breathlessness,or
has to stop for breath when walking at own
pace
Grade 4.stop for breath after walking about
100 m or few minutes on the level
Grade 5.too breathless to leave the
house,or breathless when dressing or
undreassing

Clinical signs of COPD

None
Hyperinflated chest
Wheeze or quiet breath sounds
Pursed lip breathing
Use of accessory muscles
Peripheral oedema
Cyanosis
Raised jugular venous pressure
cachexia

exacerbations
Occur in all stages of disease
Symptom: increased

breathlessness,increased sputum
volume,increased sputum purulence
Many exacerbations are related to
infections,both viral and bacterial,but
inhalation of air pollutants and
changes in the weather may also be
important

Classification
exacerbation
Type I patient presenting w/ all three

smptom
Type II patient w/ two symptom
Type III patient has only one of the
above symptoms

Exacerbation risk
Poor underlying lung function(<50%

predicted)
Age over 65%
Comorbid medical illness: congestive
heart failure,diabetes,chronic liver
disease,chronic renal disease,hronic
corticosteroid
use,malnutrition,prolonged duration of
disease)
4 or more exacerbations/year

prevention
Smoking cessation
Familial -1 antitrypsin deficiency
occupation

Smoking cessation
Congratulate for quitting
Discuss benefits of quitting
Discuss problems that trigger

relapse;withdrawl symptoms,weight
gain,depression,lack of social
support

Smoking cessation
techniques
Make a systematic effort to identify

smokers
Mark smokers files as a reminder to
aise the issue of smoking cessation
Brief interventions(personalized
advice,asking and listening the
patient) increased the smokers
chances of smoking cessation
Offer to help set a quitting date

Smoking cessation
techniques
Consider nicotine replacement

therapies: gum,transdermal
patch,inhaler lozenge,nasal spray or
oral non nicotine agent bupropion
Monitor patient for 1-3 weeks by
recording the time and place of
cigarette prior to lighting it

immunization
Influenza vaccin 1 dose 0.5 ml/IM

annually usually in fall/hajj session

Pneumococcal vaccin 1 dose 0.5
ml/IM
Indication for adult at higher risk