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

COPD competetion 3aAble to make diagnose(history taking,physical diagnostic,laboratory and x-ray)Emergency treatConsult to spesialist

Primary care visitPatient present w/ symptom: chronic cough,chronic sputum production,dyspnoe w/ or w/o wheezingHistory of risk fc for COPD

Risk fcCigarette smokingAgeDusty occupationEnvironmental pollution-1 antitrypsin deficiencyLow birthweightFrequent childhood infections

smoke

Smoking historyCurrent smokersEx-smokersAge they started smokingAverage number of cigarettes smoked per dayIf they stopped when this occurredTerm of pack year: 20 cigarettes per day for 12 months

How does smoking affect the lungMore rapid loss of lung function in a proportion of smokersThe 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 lungTobacco 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 COPDTobacco 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 COPD2% of cases of severe COPDFc associated with the development of emphysema in non smokerIs the mayor protease inhibitor in serum and in the lungIt protects tissue againts enzymatic digestion by several enzymes released by activated neutrophills.

diagnosisSymptomMedical historyLung function testChest radiograph suggest COPD

Severity assessmentTypes/degree of symptomResult of lung function testPresence of complication

classificationMildModerateSevereVery severe

mildFEV1/FVC< 70%FEV1 80% predictedw/ or w/o chronics symptomsAvoid risk fc and administer vaccination

moderateFEV1/FVC< 70%50% FEV1 < 80% predictedw/ or w/o chronics symptomsAvoid risk fc and administer vaccinationAdd rehabilitation

severeFEV1/FVC< 70%30% FEV1 < 50% predictedw/ or w/o chronics symptomsAvoid risk fc and administer vaccinationAdd rehabilitation

Very severeFEV1/FVC< 70%FEV1< 30% predicted or FEV1< 50% predicted plus chronic respiiratory failure or right heart failureAvoid risk fc and administer vaccinationAdd long-term O2 if chronic respiratory failure

Severity of assessmentClassification of COPD severityMildModerateSevereVery severe

treatmentGenerally symptom drivenNon-pharmacologicalpharmacological

Does patient smokeIf smoke plan to cessation smokeIf no smoke.treat COPD

Non pharmacologicalFor all level of severityExercisePatient education(disease state,pharmacotherapy,nutrition,smoking cessation)

pharmacotherapy Stepwise approach based on levels of severity

Oxygen therapyLong 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%

rehabilitationGoalsDecrease symptomImprove qulity of lifeIncrease level of activity

Targeted at the following areasExercise trainingNutrition conselingeducation

educationBasic knowledge of COPDDrug(benefit and side effect )How to prevent worsening diseaseAvoid risk fc Appropriate activity

Diffrential diagnosePost tuberculose obstructive syndromeAsthmaPeumotoraxChronic heart failureBronchiectasisDestroyed lung

asthma and COPDasthmaCOPDUsually youngAtophySensitive substanceSmoking +/_HypersensitivereversibleOldNon atophyNoxius agentSmoking

irreversible

Fact about copdOf 1000 registered,2-3 ne cases of COPD are found each year30-45 COPD patients under treatmentMayor cause of morbidity and mortalityPreventable disease

emphysemaPathological 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 bronchitisIs a state of chronic mucus hyperscretionAssociated with an increase in the volume and number of submucosal glands and number of goblet cells in the mucosaCough productive of sputum for at least 3 months in each year for not less than 2 successive years.

Medical research council dyspnoe scaleGrade 1.not troubled by breathlessness except on strenuous exerciseGrade 2.Short of breath when hurrying or walking up a slight hillGrade 3.walks slower than contemporaries on the level because of breathlessness,or has to stop for breath when walking at own paceGrade 4.stop for breath after walking about 100 m or few minutes on the levelGrade 5.too breathless to leave the house,or breathless when dressing or undreassing

Clinical signs of COPDNoneHyperinflated chestWheeze or quiet breath soundsPursed lip breathingUse of accessory musclesPeripheral oedemaCyanosisRaised jugular venous pressurecachexia

exacerbationsOccur in all stages of diseaseSymptom: increased breathlessness,increased sputum volume,increased sputum purulenceMany exacerbations are related to infections,both viral and bacterial,but inhalation of air pollutants and changes in the weather may also be important

Classification exacerbationType I patient presenting w/ all three smptomType II patient w/ two symptomType III patient has only one of the above symptoms

Exacerbation riskPoor underlying lung function(

preventionSmoking cessationFamilial -1 antitrypsin deficiencyoccupation

Smoking cessationCongratulate for quittingDiscuss benefits of quittingDiscuss problems that trigger relapse;withdrawl symptoms,weight gain,depression,lack of social support

Smoking cessation techniquesMake a systematic effort to identify smokersMark smokers files as a reminder to aise the issue of smoking cessationBrief interventions(personalized advice,asking and listening the patient) increased the smokers chances of smoking cessationOffer to help set a quitting date

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

immunizationInfluenza vaccin 1 dose 0.5 ml/IM annually usually in fall/hajj sessionPneumococcal vaccin 1 dose 0.5 ml/IMIndication for adult at higher risk