Medical case II

Mr. Furqan Chan

 A 52-year old man present to your office for an accute visit because of coughing and shortness of breath. He is well-known to because of multiple office visit in the past few years for similar reason. He has chronic smokers caugh,but reports in the past 2 days his cough has increased,his sputum has changed from white to green in color and he has had to increase the frequency with which he uses his albuterol inhaler. He denies having fever, chest pain, peripheral edema, or other symptoms. His medical history is significant for hypertensio, pheripheral vascular disease, and 2 hospitalization pneumonia in the past 5 years. He has a 60-pack-history of smoking and continuous to smoke 2 packs of cigarettes a day.

 On examination, he is in moderate respiratory distress. His temperature is 98.4F degree, his blood pressure is 152/95 mm Hg, his pulse is 98 beats/min, his repiratory rate is 24 breaths/min, and he has an oxygen saturation of 94% on room air. His lung is significant for diffuse expiratory wheezing and a prolonged expiratory phase of respiration. There are no sign of cyanosis. The remindeer of his examination is normal. Chest x-ray done in your office shows an increased anteroposterior (AP) diameter and flattened diaphragms, otherwise clear lung fields.

introduction
In this time,there are a lot of problem about pulmonary dissease which increased the precentage of mortality. In this case we will talk about the obstruction of respiratory way. Respiratory way can sufferer of an acute obstruction which is happen in superior of respiratory way (supraglotic), middle of respiratory way (intraglotic),or under of respiratory way(infraglotic). If the obstruction happen in the under of the respiratory way so it maybe cause by an asthma or COPD. Yeah we will concern about the COPD it self

 In the past few years chronic obstructive pulmonary disease(COPD) or sometimes we call PPOK in bahasa is an interesting topic in this world, because there are an increases of precentage of mortality cause by COPD. As cause of the death COPD has stay as the fourth grade after the heart attack and cerebrovascular disease.

Main idea
What is COPD mean? COPD is a chronic obstructive pulmonary disease that marked by the blocked of respiratory way that not reversible at all. This inhibitation of the respiratory way is always progressive and related to the lungs inflamation cause by particle, or even dangerous gas.

DEFINITION

COPD
AIRFLOW LIMITATION IN SMALL AIRWAYS PROGRESSIVE

CHRONIC INFLAMMATIO N

PARTIAL REVERSIBLE

IRREVERSIBLE

ALVEOLER STRUCTURE DAMAGED

DECREASED ELASTIC RECOIL

CHRONIC BRONCHITIS MIXED

2 EMPHYSEMATOUS LUNG

GOLD [ NHLBI WHO ] GUIDELINES MANAGEMENT STRATEGY OF COPD WHO 2020 MORTALITY 3 million/year

MORBIDITY & MORTALITY IV in USA

HOSPITAL MORTALITY 10 %

INCREASING PROBLEMS OF COPD

WORSEN HEALTH STATUS

INCREASE OF 51 % ACUTE EXACERBATION IN HOSPITAL ADMISSION BETWEEN 1991 - 2000 PREMATURE DEATH

 Why COPD can happened? -chronic bronchitis -emphisema -both of them

Trigger factors: -smoke of ciggarete An active smoker A passive smoker -air polution Indoor polution Smoke of stove Outdoor polution smoke of vehicle Iritation particle, chemicle stuff, dangerous gasoline. -infection of under of respiratory way

PATOGENESIS of CHRONIC BRONCHITIS

PHATOGENESIS OF EMPHYSEMA

SIGN AND SYMPTOMS

Increases of sputums volume A progressive dyspnea
chest tightness A purulent sputum Increases of broncodilator indeeed Weakness,tired

Physical examination -fever -wheezing

DIAGNOSIS OF COPD
1
SYMPTOMS COUGH SPUTUM DYSPNEA

2
EXPOSURE TO RISK FACTORS Tobacco Smoke Occupation Indoor / outdoor pollution

SPIROMETRY

How to diagnose?
Taking a history Anamnesis Trigger factors Medical history PPOK in his family? A hospitalized in past time? The effect of this disease to his activity

Physical examination
pursed lips breathing Takipneu emfisematous chest or barrel chest Physical appearance pink puffer or blue bloater Flattened of sela iga Hiperthropy of otot bantu nafas Bunyi nafas vesikuler melemah Prolonged expiratory wheezing

 Ro. Thorax

Hiperlusen Flattened diaphragms Increases of mark bronkovaskuler Bulla

What intervention woud be most helpful to reduce the risk of future exacerbation of this condition ?

COPD MANAGEMENT
1
ESTABLISH DIAGNOSIS ASSESS SYMPTOMS STOP SMOKING HEALTHY LIFESTYLE IMMUNISATION

2
TREAT OBSTRUCTION BRONCHODILATORS

3
ASSESS FOR HYPOXIA LONG TERM OXYGEN THERAPY

4 PULMONARY REHABILITATION PROGRAMME

1 STOP SMOKING
TRIAL OF BUPROPION NICOTINE REPLACEMENT

LONG TERM OXYGEN THERAPY [ SELECTED PATIENT ]

COPD PHARMACOTHERAPY
2 4
INHALED CORTICOSTEROIDS ONLY FOR CONCOMITANT ASTHMA

NEW ANTI INFLAMMATORY TREATMENT NEEDED

BRONCHODILATORS

ANTICHOLINERGICS [ TIOTROPIUM SOON AVAILABLE ] LABA THEOPHYLLINE [ ANTI INFLAMMATORY EFFECT ]

CARBOCYSTINE BROMHEXOL AMBROXOL

MUCOLYTIC S 1

ANTIOXIDANTS 2
N-ACETYLCYSTEINE

OTHER TREATMENT IN COPD

ANTI LEUCOTRIENT S PROPHYLACTI C ANTIBIOTICS
NO EVIDENCE

ANTI INFLAMMATORY DUGS INHALED CORTICOSTEROID ?

Treatment for COPD

step 1 : Ipratropium bromida (MDI) or nebulizer, 2-6 puff 4 x sehari, show the way to use this stuff. Advice about the important of use it, and the complication (mulut kering & rasa pahit), if it good trial : perbaikan FEV1 < 20% step 2 step 2 : adding -agonis MDI or nebulizer, show how to use it,, advice about the important of use it, and the complication (takikardi, tremor) if there are no progreesion : stop -agonis, if there are any progrresion even small step 3

step 3: adding teofilin, start from 400 mg/day check ESO takikardi , tremor, nervous, efek GI; if there are no progression stop teofilin dan go to step 4 Tahap 4: try kortikosteroid : prednison 30-40 mg/hari for 2-4 minggu, chcek spirometery (progression 20%),titrasi doxe to doze smaller efectivity(< 10 g sehari), if there are no progreesion kembali ke steroid oral

NEW BRONCHODILATORS
2 MEDIATOR ANTAGONISTS 3 PROTEASE INHIBITORS

TRIOTROPIUM

NEW DRUG FOR COPD

4 NEW ANTI INFLAMMATOR Y DRUGS 5 ALVEOLAR REPAIR DRUGS

CONTROL OF THE AIRWAYS

pharmacology
Antikolinergik inhalasi first line therapy, dosis

harus cukup tinggi : 2 puff 4 6x/day; jika sulit, gunakan nebulizer 0.5 mg setiap 4-6 jam prn, exp: ipratropium or oxytropium bromide Simpatomimetik second line therapy : terbutalin, salbutamol Kombinasi antikolinergik dan simpatomimetik untuk meningkatkan efektifitas

 Metil ksantin banyak ADR, dipakai jika yang lain tidak

mempan
Mukolitik membantu pengenceran dahak, namun tidak

memperbaiki aliran udara masih kontroversi, apakah bermanfaat secara klinis atau tidak. Kortikosteroid benefit is very limited, laporan tentang efektivitasnya masih bervariasi, kecuali jika pasien juga memiliki riwayat asma Oksigen untuk pasien hipoksemia, cor pulmonale. Digunakan jika baseline PaO2 turun sampai < 55 mmHg

Antibiotik digunakan bila ada tanda

infeksi, bukan untuk maintenance therapy Vaksinasi direkomendasikan untuk highrisk patients: vaksin pneumococcus (tiap 5-10 th) dan vaksin influenza (tiap tahun) 1-proteinase inhibitor utk pasien yang defisiensi 1antitripsin digunakan per minggu, masih mahal contoh: Prolastin

prognose
Depends on age and the progresivity of this illness if there are hipoksia and cor pulmonale bad prognosis Dyspneu, bad obstruction of respiratory way 50% patient has risk of death in 5 years.

conclusion
COPD is a disease that can be prevent potentialy stop smoking If COPD happened in once time patient need the complicated therapy. This disease is progressive and ireversible need an expensive price for a personal or public it self.

Any question?

Thanks for your kindly attention

See you in next time bye