Penyakit Paru Obstruktif Kronik

(PPOK)

FAKULTAS KEDOKTERAN
UNIVERSITAS SULTAN KHAIRUN
(UNKHAIR)
 COPD Guidelines
 “...is a common, preventable and treatable
disease that is characterized by persistent
respiratory symptoms and airflow limitation that
is due to airway and/or alveolar abnormalities
usually caused by significant exposure noxious
particles or gases.” “(GOLD, 2017)
 COPD should be considered in any patient with:
 History of exposure to risk factors (especially
cigarette smoke)
 Cough (sputum)
 Dyspnea

 Cough and sputum production may precede

development of airflow limitation
 COPD: Risk Factors

 Exposures
 Smoking (generally ≥90%)
 Passive smoking
 Ambient air pollution
 Occupational dust/chemicals
 Socioeconomic status

 Host factors
 Alpha1-antitrypsin deficiency (<1%)
 Hyperresponsive airways
 Differentiate Asthma and COPD
Asthma Is A Disease Of The Large
& COPD The Small Airways
Asthma Bronchitis

trachea

Emphysema Bronchitis
bronchi

alveoli
 Patofisiologi PPOK
a) Hipersekresi kelenjar mukus
(polutan inhalasi) 
merangsang ujung saraf
sensoris saluran nafas 
refleks lokal kolinergik 
↑ sekresi mukus, enzim
elastase, netrofil & khimase
 (jangka lama): hiperplasi
kelenjar submukosa &
proliferasi sel goblet

b) Obstruksi saluran nafas kecil

akibat inflamasi, pelepasan
dari makrofag IL-8 & LTB-4 
merangsang netrofil 
sekresi: mediator fibrogenik
 fibrosis saluran nafas kecil
& obstruksi ireversibel

c) Protease-antiprotease tidak
Sumber: NEJM, 2000 seimbang pada emfisema
Disease Pathology Asthma COPD
Reversible airflow obstruction + ++ +
Airway inflammation + ++ ++
Mucus hypersecretion + +++
Goblet cell metaplasia + ++
Impaired mucus clearance ++ ++
Epithelial damage ++ —
Alveolar destruction — ++
Smooth muscle hypertrophy ++ —

Basement membrane thickening +++ —

 Asthma COPD
Sensitizing agent Noxious agent

Asthmatic airway inflammation COPD airway inflammation

CD4+ T-lymphocytes CD8+ T-lymphocytes
Eosinophils Macrophages
Neutrophils

Completely Airflow Not fully

reversible reversible
limitation
 Physiologic Differences

Asthma COPD
 Normal DLCO  Abnormal DLCO
 Normal lung volume  Hyperinflation
 Normal elastic recoil  Decreased elastic recoil
 Flow dominant BD  Volume dominant BD
response response

Sciurba FC, CHEST 2004;117S-124S

 Response to Bronchodilators
 ASTHMA  COPD
 SABA  SABA

 Tolerance  No tolerance
 Dosed PRN  Regularly dosed
 LABA  LABA

 Monotherapy assoc.  Monotherapy assoc.

with increased with decreased
frequency of frequency of
exacerbations exacerbations
 Little tolerance  Little tolerance
 Anticholinergic  Anticholinergic

 Efficacious in acute  Efficacious in stable

attack disease
Donohue JF, CHEST 2004;125S-137S
 Assessment/Diagnosis

 Spirometry (pre- and post-bronchodilator)

 Chest radiography

 Lung volumes

 Carbon monoxide diffusing capacity

 Arterial blood gases

 Therapy at Each Stage of COPD
I: Mild II: Moderate III: Severe IV: Very Severe

 FEV1/FVC < 70%

 FEV1 < 30% predicted

or FEV1 < 50% predicted plus
 FEV1/FVC < 70% chronic respiratory failure
 FEV1/FVC < 70%  FEV1/FVC < 70%
 30% < FEV1 < 50%
50% < FEV1 < 80% predicted
 FEV1 > 80% predicted 
predicted

Active reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting
bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term
oxygen if chronic
respiratory failure.
Consider surgical
treatments
 Manage Stable COPD

 Determine disease severity  Prescribe Treatment

 Implement step-wise  Pharmacologic
treatment plan
 Non-pharmacologic
 Educate the patient  Rehabilitation
 Improve skills
– Exercise training
 Improve ability to cope
with illness – Nutrition counseling
 Improve health status – education
– Oxygen therapy
 Surgical
interventions

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 GOLD Guidelines for COPD
Stage I: Mild

Diagnosis Treatment
 FEV1 >80% predicted  Avoid risk factors

 FEV1/FVC <70%  Short-acting

bronchodilator PRN
 With/without
symptoms
 GOLD Guidelines for COPD
Stage II: Moderate

Diagnosis Treatment
 50%  FEV1 <80%  Avoid risk factors
predicted
 Regular therapy with
 FEV1/FVC <70%  1 bronchodilators
 With/without  Inhaled corticosteroids if
symptoms significant symptoms
and lung function
response
 Rehabilitation
 GOLD Guidelines for COPD
Stage III:Severe

Diagnosis
 30%  FEV1 < 50%
predicted
 FEV1/FVC < 70%
 With/without symptoms
Treatment
 Avoid risk factors
 Regular therapy with
 1 bronchodilators
 Rehabilitation
 Inhaled corticosteroids if
significant symptoms
and lung function
response or if repeated
exacerbations
 GOLD Guidelines for COPD
Stage IV: Very Severe
Diagnosis Treatment
 FEV1 < 30% predicted  Avoid risk factors
 FEV1/FVC < 70%  Regular therapy with
1 bronchodilators
 Respiratory failure
 Inhaled corticosteroids if
 Right-side-of-the-heart
significant symptoms and
failure
lung function response or
repeated exacerbations
 Rehabilitation
 Treatment of complications
 Long-term O2 therapy for
hypoxic respiratory failure
 Evaluate for surgical
treatment
 Drugs

 Bronchodilators - beta adrenergic antagonist

theophylline, ipatropium bromide   a/w
resistance
 Corticosteriods -  edema
 Antibiotics - Rx infection
 Expectorants
 Flu vaccines, pneumococcal
 O2 Rx  low flow
Non-Pharmacologic Therapy
 Rehabilitation

 COPD patients at all stages of severity benefit from exercise training programs
 Improves both exercise tolerance and symptoms of dyspnea and fatigue

 Goals
 Reduce symptoms
 Improve quality of life
 Increase physical and emotional participation in everyday activities

 Comprehensive program should include several types of health professionals:

 Exercise training
 Nutrition counseling
 Education

 Minimum effective length of time = 2 months

 Setting: inpatient OR outpatient OR home
 Baseline and outcome assessments of each participant should be made to
quantify individual gains and target areas for improvement
 Measurement of spirometry before and after a bronchodilator drug
 Assessment of exercise capacity
 Assessment of inspiratory and expiratory muscle strength and lower limb
strength

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Oxygen Therapy

 Stage IV - Severe COPD

 PaO2 at or below 55 mm Hg or SaO2 at or below 88% with or
without hypercapnia OR
 PaO2 between 55-60 mm Hg or SaO2 89% IF pulmonary
hypertension, peripheral edema suggesting congestive
heart failure, or polycythemia (Hct > 55%)
 Based on awake PaO2 values

 GOAL
 Increase baseline PaO2 to at least 60 mm Hg at sea level
and rest and/or produce SaO2 at least 89%
 Need to use at least 15 hours per day in patients with
chronic respiratory failure to improve survival
 Can have a beneficial impact on hemodynamics,
hematologic characteristics, exercise capacity, lung
mechanics and mental state

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Surgical Treatment

 Bullectomy
 Effective in reducing dyspnea and improving lung function in
appropriately selected patient
 Lung volume reduction surgery
 Parts of the lung are resected to reduce hyperinflation
 Does not improve life expectancy
 Does improve exercise capacity in patients with
predominantly upper lobe emphysema and a low post-
rehabilitation exercise capacity
 May improve global health status in patients with
heterogeneous emphysema
 High hospital costs; still experimental/palliative

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Surgical Treatment

 Lung transplantation
 Improves quality of life and functional capacity in
appropriately selected patient
 Criteria for referral:

 FEV1 < 35% predicted all 4

 PaO2 < 55-60 mm Hg criteria
 PaCO2 > 50 mm Hg must be
 Secondary pulmonary hypertension present

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 COPD Patients and Surgery

 Increased risk of post-operative pulmonary complications

 Risk of complications increases as the incision approaches
the diaphragm
 Epidural and spinal anesthesia have a lower risk than
general anesthesia
 Postpone surgery if the patient has a COPD exacerbation

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Manage Exacerbations
 Proses Inflamasi Selama Eksaserbasi
Sumber: White, 2003

Inflamasi netrofil terjadi selama proses eksaserbasi; (A) aktivasi makrofag melepaskan LTB4 dan
TNFα, (B) aktivasi epitelial (melepaskan TNFα dan IL-8), (C) aktivasi endotel karena peningkatan
TNFα meningkatkan adhesi molekul, (D) migrasi netrofil (karena adhesi molekul, IL-8/LTB4
kemotaksis gradien, pelepasan elastase dan kerusakan jaringan, (E) pelepasan netrofil elastase
pada saluran nafas (terjadi kerusakan epitel, protein leakage, peningkatan sekresi mukus,
penurunan klirens mukosilier. ICAM-1= intercellular adhesive molecule-1
 General Points
 Most common causes of exacerbations are:
 Infection of the tracheobronchial tree
 Air pollution
 In 1/3 of severe exacerbations a cause cannot be identified

 Inhaled bronchodilators, theophylline, and systemic (preferably oral)

glucocorticosteroids are effective treatments
 Patients with clinical signs of airway infection may benefit from
antibiotic treatment
 Increased volume of sputum
 Change in color of sputum
 Fever

 Non-invasive intermittent positive pressure ventilation (NIPPV) in

exacerbations is helpful:
 Improves blood gases and pH
 Reduces in-hospital mortality
 Decreases the need for invasive mechanical ventilation and
intubation
 Decreases the length of hospital stay

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Diagnosis and Assessment of Severity

 History
 Increased breathlessness
 Chest tightness
 Increased cough and sputum
 Change of color and/or tenacity of sputum
 Fever
 Non-specific:
 Malaise, insomnia, sleepiness, fatigue,
depression, or confusion
 Assessment of Severity
 Lung Function Tests
 PEF < 100 L/min. or FEV1 < 1
L = severe exacerbation
 Arterial Blood Gas
 PaO2 < 60 mmHg and/or
SaO2 < 90% with or without
PaCO2 < 50 mmHg when
breathing room air =
respiratory failure
 PaO2 < 50 mmHg, PaCO2 <
70 mmHg and ph < 7.3 = life-
threatening episode
 Chest x-ray
 Look for complications
 Pneumonia
 Alternative diagnoses
GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
 ECG
 Right ventricular hypertrophy
 Arrhythmias
 Ischemia
 Sputum
 Culture/sensitivity
 Comprehensive Metabolic
Profile
 Assess for electrolyte
disturbances, diabetes
 Albumin to assess nutrition
 Home?
 Hospital admission?
 Floor?
 ICU?

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Indications for Hospital Admission

 Marked increase in intensity of symptoms such as sudden

development of resting dyspnea
 Severe background COPD
 Onset of new physical signs
 Cyanosis, peripheral edema

 Failure of exacerbation to respond to initial medical management

 Significant co-morbidities
 Newly occurring arrhythmias
 Diagnostic uncertainty
 Older age
 Insufficient home support
 Indications for ICU Admission

 Severe dyspnea that responds inadequately to initial

emergency therapy
 Confusion, lethargy, coma
 Persistent or worsening hypoxemia (PaO2 < 50 mm Hg)
and/or
 Severe/worsening hypercapnia (PaCO2 > 70 mm Hg) and/or
 Severe/worsening respiratory acidosis (pH < 7.30) despite
supplemental oxygen and NIPPV

 NIPPV = non-invasive positive pressure ventilation

 Management of Exacerbations

 Risk of dying from an exacerbation is closely

related to:
 Development of respiratory acidosis
 Presence of significant co-morbidities
 Need for ventilatory support
Severe Exacerbation, Non Life Threatening

 Assess severity of symptoms

 Obtain arterial blood gas and chest x-ray
 Administer controlled oxygen therapy
 Repeat ABG after 30 minutes

 Bronchodilators
 Glucocorticosteroids
 Consider antibiotics
 Consider non-invasive mechanical ventilation
 Monitor fluid balance and nutrition
 Consider subcutaneous heparin therapy
 Identify and treat associated conditions (CHF, arrhythmias)
 Management of COPD Exacerbations

 Controlled oxygen therapy

 Administer enough to maintain PaO2 > 60 mmHG or
SaO2 > 90%
 Monitor patient closely for CO2 retention or acidosis

 Bronchodilators (inhaled)
 Increase doses or frequency
 Combine ß2 agonists and anticholinergics
 Use spacers or air-driven nebulizers
 Consider adding IV methylxanthine (aminophylline) if
needed

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Management of COPD Exacerbations

 Glucocorticosteroids (oral or IV)

 Recommended as an addition to bronchodilator therapy
 If baseline FEV1 < 50% predicted
 30-40 mg oral prednisolone x 10 days OR nebulized
budesonide (Pulmicort™)
 Antibiotics
 IF breathlessness and cough are increased AND sputum is
purulent and increased in volume
 Choice of antibiotics should reflect local antibiotic sensitivity
for the following microbes:
 S. pneumoniae
 H. influenzae
 M. catarrhalis

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Management of COPD Exacerbations

 Manual or mechanical chest percussion and

postural drainage may be beneficial in patients
producing > 25 mL sputum per day OR with lobar
atelectasis.

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Management of COPD Exacerbations

 Ventilatory Support
 Decrease mortality and morbidity
 Relieve symptoms
 Used most commonly in Stage IV, Very Severe COPD
 Forms:

 Non-invasive using negative or positive pressure

devices
 invasive/mechanical with oro- or naso-tracheal tube
OR tracheostomy

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 NIPPV

 Success rates of 80-85%

 Increases pH, reduces PaCO2, reduces severity of
breathlessness in the first 4 hours of treatment
 Decreases length of hospital stay
 Decreases mortality/intubation rate
 NIPPV (C-PAP, Bi-PAP)

 Selection criteria
 Moderate to severe dyspnea with use of
accessory muscles and paradoxical abdominal
motion
 Moderate to severe acidosis (pH < 7.35) and
hypercapnia (PaCO2 > 45 mmHg)
 Respiratory frequency > 25 breaths/minute
 NIPPV

 Exclusion criteria
 Respiratory arrest
 Cardiovascular instability
 Hypotension
 Arrhythmias
 Myocardial infarction

 Somnolence, impaired mental status, lack of cooperation

 High aspiration risk – viscous/copius secretions
 Recent facial or gastroesophageal surgery
 Cranio-facial trauma, fixed nasopharyngeal abnormalities
 Extreme obesity
 Indications for Invasive Mechanical
Ventilation

 Severe dyspnea with use of accessory muscles and paradoxical

abdominal motion
 Respiratory rate > 35 breaths/minute
 Life-threatening hypoxemia: PaO2 < 40 mm Hg
 Severe acidosis (pH < 7.25) and hypercapnia (PaCO2 > 60 mm Hg)
 Respiratory arrest
 Somnolence, impaired mental status
 Cardiovascular complications
 Hypotension/shock/heart failure

 Other complications
 Metabolic abnormalities/sepsis/pneumonia/pulmonary
embolism/barotrauma/massive pleural effusion
 NIPPV failure
 Use of Invasive Ventilation in End-Stage
COPD

 Hazards:
 Ventilator-acquired pneumonia

 Increased prevalence of multi-resistant organisms

 Barotrauma
 Failure to wean to spontaneous ventilation

 Mortality among COPD patients with respiratory failure is

no greater than mortality among patients ventilated for non-
COPD reasons
 Weaning from Ventilator

 Methods still debated

 Whatever clinical protocol is adopted, weaning is shorted
as long as a protocol is used!
 NIPPV used during the weaning process has shortened
weaning time, reduced stay in the ICU, decreased the
incidence of nosocomial pneumonia, and improved 60-day
survival rates
 Discharge Criteria

 Inhaled Beta2-agonist use is at most every 4 hours

 Patient is able to walk across the room
 Patient is able to eat and sleep without frequent awakening
 Patient has been clinically stable for 12-24 hours
 ABGs are stable for 12-24 hours
 Patient/home caregiver fully understands correct use of
medications
 Follow-up and home care arrangements have been completed
 Patient, family, and physician are confident that patient can
manage successfully
 Follow-Up Assessment after Hospital
Discharge

 4-6 weeks after discharge

 Assess:
 Ability to cope in usual environment
 Inhaler technique
 Understanding of recommended treatment regimen

 Measure FEV1
 Determine need for long-term oxygen therapy and/or home
nebulizer (for patients with very severe COPD, Stage IV)

 Follow-up after this is the same as for Stable COPD monitoring

Complications of COPD

 Hypoxemia

 Cor pulmonale

 Hypercapnia

 Dyspnea
 Hypoxemia

 Adversely affects cellular metabolism;

may lead to
 Hypoxia
 Pulmonary hypertension
 Cor pulmonale
 Nonspecific signs/symptoms
 Accurate identification requires arterial
blood gas measurements
 Nocturnal symptoms present in 25%– 45% of
patients with severe COPD
 Oxygen supplementation mainstay treatment
 Hypercapnia

 Usually well tolerated in COPD patients

 Treatment goals
 Improve airflow
 Reduce breathing effort
 Improve abnormalities affecting respiratory
muscle function

 Noninvasive ventilation suggested therapy

 Long-term data conflicting

 Cor Pulmonale
 Primary cause – hypoxemia
 Poor prognosis
 Oxygen therapy and treating underlying
disease are key
 Pulmonary vasodilators offer no clear benefits;
may worsen hypoxemia
 Diuretics may improve ventricular function
 Closely monitor for side effects
 Digoxin contraindicated unless left-sided
congestive heart failure present
 Long-Term Oxygen Therapy: Guidelines
Indications Treatment Goals
Absolute
Pa O2 ≤55 mm Hg or Sa O2 ≤88% Pa O2 ≥60 mm Hg or Sa O2
≥90%; Appropriately adjusted
O2 dose during sleep and
exercise
In patients with cor pulmonale
Pa O2 55–59 mm Hg or Sa O2 ≥89% Same as above
ECG evidence of P pulmonale,
hematocrit >55%, and CHD
Specific Indications
Appropriately adjusted O2
Nocturnal hypoxemia
dose during sleep

Sleep apnea with nocturnal Same as above

desaturation not corrected by
constant positive airway pressure
or bilevel positive airway pressure
No hypoxemia at rest, but Appropriately adjusted O2
desaturation during exercise or dose during sleep
sleep (PaO2 <55 mm Hg)
 COPD Summary

 disorders of airways obstruction

 inflammatory
 COPD is chronic progressive
 1st line therapy for COPD are Bronchodilator
 Attend to comorbidities
Thanks