PPOK PADA MANULA

The 2011 Revised Version of COPD

International Guidelines

REVISED 2011
 PPOK adalah penyakit dapat dicegah dan
diobati dengan beberapa efek ekstrapulmoner
yang berkontribusi signifikan terhadap tingkat
keparahan
 PPOK ditandai dengan keterbatasan aliran udara
yang tidak sepenuhnya reversibel. Keterbatasan
aliran udara biasanya progresif dan berhubungan
dengan respon inflamasi abnormal dari paru-paru
terhadap partikel dan gas beracun
Risk Factors for COPD
Nutrition

Infections

Socio-economic
status

Aging Populations
GOLD Update 2011
 PATHOGENESIS OF COPD
PARTICLE
NOXIOUS GASES

HOST FACTORS
ANTI OXIDANTS
[ environmental ]

LUNG INFLAMMATION

ANTI OXIDANTS ANTI PROTEINASES

[ genetic ]

OXIDATIVE STRESS PROTEINASE IMBALANCE

REPAIR REPAIR
MECHANISM MECHANISM

COPD ANTI PROTEASE ENZYME

1-Antitrypsin
 Mechanism underlying
Airflow limitation in COPD
INFLAMMATION

Small airway disease Parenchymal destruction

Airway inflammation Loss of alveolar attachments
Airway remodeling Decrease of elastic recoil

AIRFLOW LIMITATION

GOLD guidelines, 2009

 Mechanisms Underlying
Airflow Limitation in COPD

Small Airways Disease Parenchymal Destruction

• Airway inflammation • Loss of alveolar attachments
• Airway fibrosis, luminal plugs • Decrease of elastic recoil
• Increased airway resistance

AIRFLOW LIMITATION
GOLD Revision 2011
 Air trapping
Airway obstruction
Lung hyperinflation

Normal COPD
 Assessment of COPD

 Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations

 Assess comorbidities

GOLD Revision 2011

 Symptoms of COPD

The characteristic symptoms of COPD are chronic and

progressive dyspnea, cough, and sputum production.

Dyspnea: Progressive, persistent and characteristically

worse with exercise.

bChronic cough: May be intermittent and may be

unproductive.

Chronic sputum production: COPD patients commonly cough

up sputum.

GOLD Revision 2011

 ASTHMA COPD
Allergens Cigarette smoke

Ep cells Mast cell Alv macrophage Ep cells

CD4+ cell Eosinophil CD8+ cell Neutrophil

(Th2) (Tc1)

Bronchoconstriction Small airway narrowing

AHR Alveolar destruction

Airflow Limitation
Reversible Irreversible

Source: Peter J. Barnes, MD

 COPD is a Multicomponent disease
Mucus-hypersecretion Goblet cell hyperplasia/
Reduced muco-ciliary metaplasia
transport Mucous gland
Mucosal damage hypertrophy
Muco-ciliary Structural Increased smooth
dysfunction changes muscle mass
Airway fibrosis
Alveolar destruction
Airway
inflammation Systemic
Airflow
limitation component
Poor nutritional
status
Reduced BMI
Loss of alveolar
Increased numbers of inflammatory Impaired skeletal
attachments
cells/ activation: muscle:
Loss of elastic recoil - CD8+ lymphocytes
- weakness
Increased smooth - monocytes/macrophages
- neutrophils - wasting
muscle contraction
Elevated inflammatory mediators:
IL-8, TNF, LTB4 and oxidants
Protease/anti-protease imbalance
 Indonesia - 3 Besar Negara
Pengkonsumsi Rokok
 Jumlah perokok no. 3 di dunia &
Negara Jumlah % Pria no. 1 di ASEAN
Perokok Perokok
(Sumber: (Sumber:
 70% perokok mulai merokok
WHO) WHO)
sebelum usia 19 tahun dan 12,77
% sudah merokok sejak SD
China 350,000,000 53.4%
 Penkonsumsi tembakau no. 5 di
dunia (215 miliar batang/tahun)
India 120,000,000 29.4%

Indonesia 62,800,000 69.0%

Source:
1.http://bola.okezone.com/index.php/ReadStory/2008/05/02/50/105935/50/beijing-mulai-
 Assessment of COPD

 Assess symptoms
Assess degree of airflow limitation using spirometry
Use the
Assess riskCOPD Assessment Test(CAT)
of exacerbations
Assess comorbidities
or
mMRC Breathlessness scale

GOLD Revision 2011

 CAT

 COPD Assessment
Test (CAT): An 8-
item measure of
health status
impairment in COPD
(http://catestonline.or
g).
 Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess
Usecomorbidities
spirometry for grading severity
according to spirometry, using four
grades split at 80%, 50% and 30% of
predicted value

GOLD Revision 2011

 Classification of Severity
of Airflow Limitation in
COPD*
In patients with FEV1/FVC < 0.70:

GOLD 1: Mild FEV1 > 80% predicted

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1

GOLD Revision 2011
 Assessment of COPD

 Assess symptoms
 Assess degree of airflow limitation using spirometry
 Assess risk of exacerbations
Assess comorbidities
Use history of exacerbations and spirometry.
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk

GOLD Revision 2011

Combined Assessment of COPD

(GOLD Classification of Airflow Limitation)

4
>2
(C) (D)

(Exacerbation history)
3

Risk
Risk

2
1
(A) (B)
1 0

mMRC 0-1 mMRC > 2

CAT < 10 CAT > 10
Symptoms
(mMRC or CAT score) GOLD Revision 2011
 Combined Assessment
of COPD
When assessing risk, choose the highest
risk according to GOLD grade or
exacerbation history

Patient Characteristic Spirometric Exacerbations mMRC CAT

Classification per year
Low Risk
A GOLD 1-2 ≤1 0-1 < 10
Less Symptoms
Low Risk
B GOLD 1-2 ≤1 >2 ≥ 10
More Symptoms
High Risk
C GOLD 3-4 >2 0-1 < 10
Less Symptoms
High Risk ≥ 10
D GOLD 3-4 >2 >2
More Symptoms
GOLD Revision 2011
 Assess COPD Comorbidities
COPD patients are at increased risk for:
• Cardiovascular diseases
• Osteoporosis
• Respiratory infections
• Anxiety and Depression
• Diabetes
• Lung cancer
These comorbid conditions may influence mortality and
hospitalizations and should be looked for routinely, and
treated appropriately.
GOLD Revision 2011
 DIAGNOSIS
OF COPD

1 2

EXPOSURE TO
SYMPTOMS RISK FACTORS
COUGH Tobacco Smoke
SPUTUM Occupation
DYSPNEA Indoor / outdoor
pollution

SPIROMETRY
 Manage Stable COPD:
Goals of Therapy

 Relieve symptoms
 Improve exercise tolerance Reduce
 Improve health status symptoms

 Prevent disease progression

 Prevent and treat exacerbations Reduce
 Reduce mortality risk

GOLD Revision 2011

 Manage Stable COPD:
All COPD Patients
 Avoidance of risk factors
- smoking cessation
- reduction of indoor pollution
- reduction of occupational exposure
 Influenza vaccination

GOLD Revision 2011

 Manage Stable COPD :
Pharmacologic Therapy
Patient First choice Second choice Alternative Choices

LAMA
SAMA prn or
A or LABA Theophylline
SABA prn or
SABA and SAMA
LAMA
SABA and/or SAMA
B or LAMA and LABA
Theophylline
LABA
ICS + LABA
PDE4-inh.
or
C LAMA and LABA SABA and/or SAMA
LAMA
Theophylline

ICS and LAMA or

ICS + LABA
ICS + LABA and LAMA or Carbocysteine
or
D ICS+LABA and PDE4-inh. or SABA and/or SAMA
LAMA
LAMA and LABA or Theophylline
LAMA and PDE4-inh.
 GOALS OF
2
COPD TREATMENT
SHORT
GLOBAL GOLD TERM
1 GOALS
SMOKING IMMEDIATE BENEFITS
CESSATION 3 RELIEF OF SYMPTOMS
[ BREATHLESSNESS ]
LONG TERM
GOALS

PREVENT DISEASE PROGRESSIVE

REDUCE EXACERBATIONS

IMPROVE QUALITY OF LIFE

IMPROVE EXERCISE TOLERANCE

REDUCE MORTALITY
 COPD MANAGEMENT

1
STOP SMOKING
ESTABLISH DIAGNOSIS HEALTHY LIFESTYLE
ASSESS SYMPTOMS IMMUNISATION

2
TREAT OBSTRUCTION BRONCHODILATORS

3
ASSESS FOR HYPOXIA LONG TERM
OXYGEN THERAPY

4
PULMONARY REHABILITATION
PROGRAMME
The Vicious Cycle of COPD
Shortness of
breath

Reduced
Anxiety activities

Reduced Muscle
activities weakness

Depression &
Malnutrition
social isolation
COPD
Prevention is always better than
cure