COPD

DEFINITION / UNDERSTANDING

COPD is a chronic lung disease infected with airflow in progressive nonreversible or

partial reversible airways, COPD consists of chronic bronchitis and emphysema or a
combination.

Chronic bronchitis

Airway abnormalities that are chronic cough with mini phalms 3 months a year, at
least two consecutive years, no other illness.

Emphysema

An anatomical abnormality of the lung is maintained by widening distal air distal

cavities of the terminal bronchioles, accompanied by damage to the alveoli wall

Etiology : not clear.

Risk Factors:

• Smoking (important)

• Air pollution

• Bronchial hyperactivity

• recurrent respiratory tract diagnoses

• Alpha-1 antitrypsin deficiency (rare in Indonesia)

PATHOGENESIS

Chronic bronchitis :

Enlargement of the bronchial mucosa gland, goblet cell metaplasia, abnormal cilia
movement, inflammation, placebo smooth muscle hypertrophy and distortion due to fibrosis.
Emphysema :

Distal widening of the distal cavity of the terminal bronchioles, accompanied by

damage

Alveoli wall. Anatomically distinguished 3 types of emphysema:

• Sentriasinar emphysema, starting from the repellatory bronchioles and extending to

the periphery, especially regarding the pulmonary lobes, often due to the old smoking
habit.

• Thinema (panlobuler) emulisema, involves the entire alveoli evenly and mostly in
the distal lobe of the lung.

• Distal (paraseptal) asphalt emphysema, more about the distal airway, ducts and
alveolar sacs. The process is localized in septa or near the pleura, can form bulls in the
apex area and result in pneumothorax. Rarely result in airway obstruction.

CLINICAL MANIFESTATIONS

Diagnosis of COPD is established by :

A. Clinical features:

a. History :

• Complaints

• History of the disease

• Risk factors

b. Physical examination

B. Investigations

a. Regular checks:

• Pulmonary function (spirometry and bronchodilator test)

• Routine blood: Hb, Ht, leukocyte

• Chest and lateral PA images

b. Special check:

• Lung fungi : DLCO

• Bronchial provocation test

 • Blood gas analysis

• High-resolution CT scans

• Electrocardiography

• Sputum bacteriological examination

• Alpha-1 antitrypsin levels

COPD Classification :

Classification of diseases Symptoms Spirometry

LIGHT - no symptoms of time VEP1> 80% prediction

rest or activity VEP1 <75%
- no symptoms of time KVP
rest but mild symptoms
when activity is
(brisk walking, up stairs)

Mild - no symptoms of time VEP1 30 - 80% prediction

Rest, but there are symptoms VEP1 <75%
when light activity KVP
(Eg dressing)
- mild symptoms at rest

WEIGHT - symptoms are on time VEP1 <30% prediction

Rest VEP1 <75%
- severe symptoms at rest
- coroulmonal signs

There is a discrepancy between the VEP value, and the patient's symptoms, so
consider other conditions. Symptoms of breathlessness may not be predictable with VEP,
alone.

1. Clinical Features

• Blue bloater : a typical feature of chronic bronchitis. Patients appear to be fat cyanosis,
edema limb with wet ronki in basal lung, central and peripheral cyanosis
• Pink puffer : typical features of emphysema, skinny sufferers, skin redness and pursedlip
breathing

• Spontaneous pursedlip breathing: breathing with funny mouth and elongated expiration, as
the body's mechanism for secreting CO2 retention that occurs in chronic respiratory failure.

2. ANAMNESIS

• Shortness of breath or shortness of breath (shortness of breath)

• Cough with or without a cough

• Difficult to remove / cough

• Waking up at night due to cough or lots of phlegm or tightness'

• Difficulty sleeping due to cough or tightness

• When walking quickly fatigue or tightness

• When doing activities quickly fatigue or tightness

• Activity disturbed due to fatigue or shortness

• When climbing stairs arise congested

3. PHYSICAL EXAMINATION

• Respiratory frequency, Borg scale for shortness of breath, frequency of pulse

(regular / irregular), tension, height, body weight (Calculate BMI), JVP

• Suprastemal retraction, intercostal and abdominal muscle contraction, elongated

expiration

• Spasms of the secondary breathing muscles, upper trapezius and upper thorax.

• Changes in posture: kiposis, kiposkoliosis, barrel chest.

• Breathing (symmetrical / asymmetric), chest expansion (upper, middle and lower),

paradoxical breathing.

• Inspiring wheezing / expiration, rhonchi, phlegm, gallop

• Atrophy of the extremities, leg edema

Functional checks :

Training test:

• 6-minute road test (optional while resting, total distance count)

• Static bike (incremental or steady state)

• Treadmill (incremental or steady state)

From training test determined functional ability: meter / watt / VO2max

Standard examination :

1. Examination of lung physiology

2. Borg scale for shortness of breath and muscle fatigue

3. Test training with / or without tools

4. Specific quality of life measures, eg St George Respiratory Quesioner

DIAGNOSIS

Impairment :

• Local factors: Decreased lung function due to airway obstruction, alveolar wall
damage and decreased ventilatory pump function.

• Systemic factors: decreased muscle function due to damage / atrophy and impaired
muscle metabolism.

Disability

• Shortness of breath or shortness of breath

• Decreased physical capacity resulting in decreased ability to walk, climb stairs,

decrease in daily life activities.

• Anxiety to depression
Handicap :

Disorders of sleep patterns and insomnia, decreased self-esteem, disruption of social activity,
increased work-loss days.

GOVERNANCE

Aim :

• Overcoming shortness of breath

• Helps sputum expectoration if necessary

• Prevent decondition syndrome

Management (at the hospital)

• Medicamentosa to overcome shortness of breath: oxygen (if necessary),

bronchodilators, steroids, mucolytics and antibiotics (if necessary) are administered
orally, parenterally or inhaled.

• Education for reducing shortness of positions (lying down, sitting, standing)

• Relaxation with imagery and pursed lip breathing (with music suggestion)

• Active / passive ankle pumping exercises

• Exercise the scope of motion of the joints into 4 extremities

• Postural drainage, vibration, assited coughing (if necessary)

• Early mobilization when shortness is reduced

Recovery phase :

Objectives : preventing and reducing exacerbation frequency, improving breathing patterns,

increasing exercise tolerance, improving the ability of AKS / work activities.

Management (in hospital, outpatient, home program):

Education:

• Stop smoking program

• Drug use and exercise goals / benefits

• Optimal breathing strategy.

 • Energy conservation and work simplification techniques:

- Right body position

- Adjustment of activity with breath pattern

- Technique paced breathing

- Planning and priority activities / work

- Use of tools

Training program:

• Relaxation breathing exercises (PLB and inspiration in tolerance) and Jacobson

relaxation

• Chest physical therapy:

• Muscle flexibility of neck, shoulders and chest wall mobility and posture correction
(if necessary).

• Deep breathing and thoracic / diaphragmatic exercises, segmental breathing

exercises

• Postural drainage, vibration, huffing / coughing is effective (if necessary)

• Combination training: active cycle breathing technique

Recondition Exercise:

• Cardiorespiratory recondition: road, static bicycle, treadmill

• Recondition of upper and lower extremity muscle groups

• Unsupported arm exercises with or without weights

• Quadriceps muscle strengthening exercises

• Abdominal strengthening exercises with half sit ups

• Recondition of respiratory muscle with Muller or incentive spirometry

• Consider the use of oxygen during exercise (if necessary)

Advanced phase

Aim:

• Prevent acute exacerbations

• Maintain optimal function / training capacity

• Maintaining the capacity of AKS / work / psychosocial activities with optimal coping skills

Management (outpatient, home program, group practice in the community):

• Education:

Medication use, risk factor control, continuous exercise program, especially

reconditioning practice

• Continue training in the recovery phase.

For reconditioning exercises: increase intensity, maintain frequency and duration of

exercise

Frequency: 3 - 5 x / week

Duration: 30 minutes, in the form of continuous or interval training

Intensity is determined according to periodic training test (2-3 months)

• Follow group asthma exercise

Follow Up / Evaluation:

• Spirometry: every month, if stable every 3 months, or when an acute exacerbation.

• Functional capability: with practice test, if stable every 3 months.

• Quality of life: life quality specific St George Respiratory Quesioner (every 6 months),
improves when total value is lower.

Referral System

• Lung specialist if an acute exacerbation

• Cardiologist if there are signs of cor pulmonalenale

Prevention of secondary complications

Medical : influenza vaccination

Exercise therapy : avoid over-exercise, adequate nutrition

Education : avoid risk factors, psychological support and motivation for

Doing lifelong exercises.

 DIAGNOSIS ALGORITHM AND COOPERATIVE MANAGEMENT
History:
• Shortness of breath or
shortness of breat (shortness
of breat)
• Cough with or without a
cough
• Difficult to remove / cough
• Waking up at night due to
cough or a lot of phlegm or
tightness'
• Difficulty sleeping due to
cough or tightness
• When walking quickly
fatigue or tightness
• When doing activities
quickly fatigue or tightness
• Activity disturbed due to
fatigue or shortness
• When climbing stairs arise
congested
Management (at the hospital)
 medical
 positioning
 Relaxation
 LGS Exercises
 Postural
vibration, assited coughing
 early mobilization
shortness
reducedberkurang
Physical examination: Pemeriksaan fungsional:
• RR, Borg scale for shortness of
breath, pulse (regular / irregular), Uji latih:
tension, height, weight, JVP.
• Suprastemal retraction, intercostal • uji jalan 6 menit
and abdominal muscle contraction, • sepeda statik
elongated expiration
• treadmill
• Secondary respiratory muscle
spasms, upper trapezius & thorax Standard pemeriksaan :
above.
• Changes in posture: kiposis, 1. Pemeriksaan faal paru
kiposkoliosis, barrel chest. 2. Skala Borg untuk sesak napas
• Breathing (symmetrical / dan kelelahan otot tungkai
asymmetric), chest expansion (upper,
bawah
middle and lower), paradoxical
breathing. 3. Uji latih dengan/atau tanpa
• Inspiring wheezing / expiration, alat
rhonchi, phlegm, gallop
4. Alat ukur kualitas hidup
• • Atrophy of the extremities, leg
edemaAtrofi otot-otot ekstremitas, spesifik, misal: St George
edema tungkai Respiratory Quesioner
Recovery Phase
Training program:
 Relaxation breathing exercises
 Chest physical therapy:
 Muscle flexibility
drainage,  Deep breathing and thoracic /
diaphragm exercises,
when  Segmental breathing exercises
is  Postural drainage, vibration, huffing /
coughing is effective
 Recondition Exerciseefektif