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Mulyadi
Pulmonology Dept. Faculty of MedicineSyiah Kuala University Dr. Zainoel Abidin General Hospital Banda Aceh
Penyakit yg ditandai : Hambatan aliran udara Tidak reversibel/reversibel parsial Progresif Respons inflamasi abnormal paru Partikel noxiuos atau gas
Penyebab
Faktor risiko
Host Lingkungan
- Rokok sigaret - Occupational dust dan chemical - Polusi indoor,outdoor - Infeksi sal napas
Future asthmatic
PATHOGENESIS OF COPD
NOXIOUS
HOST FACTORS ANTI OXIDANTS [ environmental ]
PARTICLE GASES
LUNG INFLAMMATION
ANTI OXIDANTS ANTI PROTEINASES [ genetic ]
OXIDATIVE STRESS
REPAIR MECHANISM
PROTEINASE IMBALANCE
REPAIR MECHANISM
Bronchus
Bronchiole
Alveoli
Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms.
DIAGNOSIS OF COPD
SPIROMETRY
FEV1/ FVC
80 % 60 %
Normal COPD
FEV1
4.150 2.350
Liter
COPD
4 5 1 2 FEV1 FVC
Normal
3 4
FVC 5 6 Seconds
A CXRs are seldom diagnostic, it can be useful for excluding other diseases
GOLD Workshop Report Four components of COPD management 1. Assess and monitor disease 2. Reduce risk factors 3. Manage stable COPD
4. Manage exacerbations
COPD management
Established diagnosis Asses symptoms Stop smoking
Healthy lifestyle
Immunization BRONCHODILATORS
Treat obstruction
Assess hypoxemia
Long-term oxygen
therapy
There is no evidence for using The following for diagnosis or as Indicators of severity of AECOPD: 1. Acute spirometry 2. Acute PEFR 3. Pulse oximetry
Patient presents at ER or hospital Examine patient for three Diagnostic criteria for AECOPD : 1.Increase in dyspnea 2.Increase in sputum volume 3.Increase in sputum purulence Criteria present ? yes One or more criteria present ? two or more Two or more diagnostic criteria present ? three Three criteria : treat for severe excacerbation Management : 1.CXR 2. Inhaled bronchodilators (1) 3.Systemic corticosteroids (2) 4.Antibiotics (4) 5.O2 PRN 6.NPPV PRN (3) two only one only no
Use anticholinergic bronchodilators first, once at maximum dose, then add b 2 agonists bronchodilators. 2. Dosing regimen used in the SCCOPE trial : 3 days intravenous Methylprednisolone, 125 mg every 6 hours followed by oral Prednisone, tapper to complete the 2 week course (60mg/day on days 4-7, 40 mg/day on days 8-11, and 20 mg/day on days 12-15). 3. NPPV should be administered under the supervision of the traited physician 4. Use narrow spectrum antibiotics ; the agent favored in the trials were Amoxicillin and trimethopin-sulfamethoxazole, and tetracycline.
One diagnostic criterion with at least one of the following ? 1. URI in the past 5 days. 2. Fever without apparent cause. 3. Increased wheezing 4. Increased cough 5. 20 % increase in heart rate or respyratory rate over baseline yes Two criteria only : treat for moderate excacerbation Management : 1.CXR 2. Inhaled bronchodilators (1) 3.Systemic corticosteroids (2) 4.O2 PRN 5.NPPV PRN (3) Yes. Treat for mild excacerbation of COPD
no
Acute Exacerbations
Chronic obstructive pulmonary disease Inhaled bronchodilators and (COPD) is characterized by chronic systemic corticosteroids are airflow obstruction with acute recommended for acute excacerbation (dyspnea, cough, and excacerbations of COPD. Systemic sputum production). Acute corticosteroids should not be used exacerbation may be triggered by for more than 2 weeks. tracheobronchial infections or Appropriate use of antibiotics in environmental exposure. acute excacerbations of COPD is Nearly half of patients discharged from imperative to help control the hospital after acute excacerbations are emergence of multidrug-resistant readmitted more than once within 6 organisms. months. Identifying patients at high risk for relapse should help guide decisions about hospital admission and follow-up appointments.
been shown that up to 23 % of patients admitted had changes in management related to findings on chest radiography. Chest radiography in patients visiting the emergency department may also be useful. To date, there is no evidence for or against the utility of chest radiography in the office setting.
2. For patients hospitalized with an acute excacerbation of COPD, acute spirometry should not be used to diagnose an excacerbation or to asses its severity.
Therapy at each stage of COPD (GOLD) Stage All Chronic symptoms (cough, sputum) Exposure to risk factors Normal spirometry FEV1 / FVC < 70 % FEV1 80 % predicted With or without symptoms II A FEV1 / FVC < 70 % 50%<FEV1< 80% predict With or without symptoms II B FEV1 / FVC < 70 % 30% FEV1>50% predict With or without symptoms Short acting bronchodilator when needed Characteristic Recommended treatment Avoidance of risk factors, Infuenza vaccination, Exercise, Patient education.
O : at risk
I : mild COPD
II : moderate COPD
Regular treatment with one or more bronchodilators. Rehabilitation Regular treatment with one or more bronchodilators. Rehabilitation Regular treatment with one or more bronchodilators. Inhaled glucocortico steroids if significant symptoms and lung function response, or if repeated excacerbations. Treatment of complications. Rehabilitation Long term oxygen therapy if respiratory failure. Consider surgical treatment.
Inhaled glucocortico steroids if significant symptoms and lung function response, or if repeated excacerbations.
FEV1 / FVC < 70 % FEV1<30% predicted or presence of respiratory failure or right heart failure.
Sympatomimetic bronchodilators
Drug
SHORT ACTING Albuterol Tablets : 2 mg, 4 mg (Proventil, ventolin, generics) Tablets, extended release : 4 mg (proventil), 8 mg (Volmax) Syrup : 2 mg / 5 ml ( Proventil, Ventolin) MDI : 80 mg / actuation (Proventil HVA, Ventolin) Solution for inhalation : 0,083 % (0,83 mg/ml), 0,5%(5mg/ml) Ventolin, Capsules for inhalation::200 mg/ml (Ventolin rotocaps) Bitolterol MDI : 0,8%. 0,37mg/actuation (Tornalate) Solution for inhalation : 0,2% (Tornalate) b1 < b2 PO PO PO Inh Inh Inh b1 < b2 2 or 4 mg tid or qid 4 - 8 mg q 12 h 2or 4 mg tid or qid 3 1 - 2 inh q 4 - 6h 2.5mg tid or qid by nebulization over 5-15 minutes. Note: 0.5% solution must be diluted to total 3 ml volume with steril normal saline before nebulization. 200 mcg inh q 4 to 6h using Rotohaler device 4 2 inh tid 0.5 - 1 ml (1-2 mg) tid by intermittent flow nebulization 32 mg in DD 16 mg q 12h 8 mg qid
Inh Inh
Epinephrine Solution for inhalation: 1:100 and 1:1000 (Adrenalin) Solution for inhalation: 2,25 % racepinephrineHCl (equivalen to 1,125% epinephrine base), (Asthma Nephrin, Micro Nephrin) Isoproterenol Solution for inhalation:0,5%(1:200), 1%(1:100) (Isuprel). MDI:0.25%, 103 mcg/dose (Isuprel), 80 mcg/actuation (Medihaler) Levalbuterol HCl. Solution for inhalation 0.63mg/3ml and 1.25/3ml Metaproterenol Tablets : 10 mg, 20 mg Syrup : 10 mg / 5 ml (Alupent) MDI : 75mg and 150 mg (0,68 mg / actuation) (Alupent) Solution for inhalation 0.4%, 0.6%, 5% (Alupen)
b1b2
Inh Inh
8-10 drops added to nebulizer. Administer 1-3 inh 4-6 times daily(3hr intervals) (hand pump nebulizer). Add 0.5ml (10 drops) to 3ml diluent4 or 0.2 - 0.4 ml ( 4 - 8 drops) of MicroNefrin to 4.6 to 4.8 ml water.1 Administer for 15 min. q 3 - 4 h. 5 -15 deep inh using 1:200 solution in handbulb nebulizer. 0.5ml of 1:200 diluted to 2-2.5ml by nebulizer or IPPB; may repeat 5 times daily. 1-2 Inh 6-8 times daily (q 3-4h) 0.63 -1.25 mg tid (every 6-8h) by nebulization 20 mg tid or qid 6 2-3 inh q 3-4h 0.2-0.3 ml (5% sol) diluted to 2.5ml with diluent, given by IPPB device, 3-4 time daily (4h) 12 inh
b1b2
b1 < b2
PO Inh Inh
b1 < b2
b1 < b2
Inh
PO Inh SC
12 inh
15 mg 0.5 mg in 4 h
b1 < b2
Inh Inh
2 Inh (42 mcg) twice daily (q 12 h) 1 Inh (50 mcg) twice daily (q 12 h)
DD = devided dose Inh = inhalation IPPB = inntermittent positive pressure breathing MDI = metered dose inhalaler Dose for adult and children 12 years unless otherwise noted. 2. Dose for asthma/bronchospasm listed when spesific dosing recommendations for bronchoospasm associated with COPD not available. 3 Adults and children >14 years. 4 Adults and children > 14 years. 5 Adult and children > 15 years. 6 Adult and children > 9 years or > 60 lb.
Ipratropium bromide MDI : 18 mcg / actuation (Atroven). Solution for inhalation : 0,02 % (Atroven, various)
Inh
12 Inh.
Ipratropium bromide and albuterolsulfate MDI : 18 mcg / Ipratropium. 103 mcg albuterol / actuation (Combivent).
inh
12 Inh.
INHALED CORTICOSTEROID
Drug
Beclomethasone (Beclovent, Vanceril) MDI:42 mcg/actuation 84 mcg/actuation
(Vanceril Double Strength)
Adult dosing
Starting 84mcg 3-4 times daily or 168 mcg twice daily Maximum 840 mcg in divided doses
200-400 mcg twice daily1 200-400 mcg twice daily2 400-800 mcg twice daily3 500 mcg (2 inhalations) twice daily.
MDI: 88 mcg twice daily1 : 88-220 mcg twice daily2 : 880 mcg twice daily3 DPI: 100 mcg twice daily1 :100-200 mcg twice daily2 : 1000 mcg twice daily3
DPI = dry powder inhaler MDI = metered dose inhaler. 1Used with inhaled bronchodilators only. 2Used with inhaled corticosteroids. 3For patients currently receiving chronic oral corticosteroid therapy.
Management (GOLD) 1. Bronchodilator medications are central to the symptomatic management of COPD. They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms. 2. The principal bronchodilator treatment are b2 agonists, anti cholinergics theophylline, and a combination of one or more of these drugs. Long- acting inhaled bronchodilators are more convinient. Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.
3.
Stop smoking is difficult No currently available drugs slow progression Corticosteroids are in effective Slow progressive destruction process