PATHOPHYSIOLOGY,CLINICAL

MANIFESTATION,DIAGNOSTIC AND
MANAGEMENT OF
OBSTRUCTIVE LUNG DISEASE
(Penyakit Paru Obstruktif)
Sumardi
Pulmonology and Critical Care Division
Internal Medicine Departement
Faculty of Medicine
Gadjah Mada University /
RSUP Dr. Sardjito Yogyakarta
 INTRODUCTION

➔ Disease of respiratory tract and few

parenchymal involvement
➔ Limitation diameter of respiratory tract Obstruction:
➔ fully reversible (asthma) or
➔ partially reversible (COPD)
Obstructive Lung Disease

● Asthma
● Chronic Obstructive Pulmonary
Disease/COPD (Penyakit Paru Obstruktif
KronikPPOK): Chronic Bronchitis &
Emphysema
● Syndrome Obstructive Post TBC (SOPT-
Squelae Post TB)
● Bronchiectasis
ASTHMA (GINA 2015)

● Bronchial chronic inflamation with

bronchocontriction clinical manifestation and
sputum production
● Inflamation fluctuated severity
● Stimulated by: dust, flu, smelling, smog, cold,
food allergy, psychologic, etc
PATHOPHYSIOLOGY

ERS Handbook of Respiratory Medicine 2014; Warner O. Am J Resp Crit Care Med 2003; 167: 1465–1466
 The inflammatory reaction
The “Allergic Effector Unit”

Allergen
APC

Eosinophil

Bacteria
Viruses
CD4+ T cell

Endothelial
Th2 cell Fibroblasts Epithelial cells cells
Smooth muscle cells
IL-4 Myofibroblasts

B cell
Chronic

IgE phase
Late phase
Mast cell
Acute-Early phase
-------------------------------------Time-------------------------------
Mast cells Inflammation, Angiogenesis, tissue remodeling, fibrosis
precursors
ERS Handbook of Respiratory Medicine 2014
Pathology of bronchial obstruction
in asthma

Normal Mild/moderate
Severe Asthma
bronchus Asthma
 Pathology of bronchial obstruction in Asthma

Asthma: chronic Inflamation of bronchus due to bronchial hyperresponsiveness

short-term consequences… …and long-term consequences

Gejala & obstruksi saluran

napas karena:
SYMPTOMS&SIGNS
 Bronchoconstriction Remodelling:
 Mucus plug
 Mucosal edema Increase vascularisation

epithelial dysfunction

Hyperplasia muscular tissue

Thickening of basal mrmbrane

Infiltration and activasion of
inflamatory cells

Bousquet J et al. Am J Respir Crit Care Med 2000;161:1720–1745;

GINA Report 2012 (www.ginasthma.org); Beckett PA et al. Thorax 2003;58:163–174
ASTHMA

Clinical Manifestation :
● Dyspnea, prolonged expiration
● wheezing,
● cough
● Sneezing
● Chest tighness
● Difficult expectoration of sputum
● Onset in the early morning
● febrile if infection
GINA 2015
ASTHMA

CLASSIFICATION (GINA 2008-2015):

1. Intermittent : 1-2x/weeks
2. Mild Persistent Asthma > 1x/day >Tx
bronchodilator > improve
3. Moderate Persistent Asthma > Tx
bronchodilator + steroid inhaled> improve
4. Severe Persistent Asthma : Tx bronchodilator +
inhaled steroid + oral steroid > controled
VARIATION of
BRONCHOCONTRICTION
(individual)
ASTHMA

TREATMENT:
1. Anti-inflamation: steroid (controller)
Oral: methylprednisolon, prednison,
dexamethason, triamsinolon
Inhaled: budesonide, fluticason, beclometason
2. Bronchodilator (reliever):
Oral: salbutamol, terbutalin, aminophyllin,
Inhalasi: salbutamol, terbutalin, ipatrium
bromide
Injection: adrenalin, terbutalin, salbutamol,
aminophyline
3. Alternative steroid: zafirlucast, montelucast,
clarithromycin replacement
ASTHMA
Management Acute Exacerbation:
1. Bed rest Fowler + 02 : 3-4 liter/menit
2. Anti inflamation systemic : methylprednisolon oral 40-60
mg or injection methylprednisolon 60-120 mg iv
3. Anti inflamation inhaled : budesonid/fluticason 1-2 mg
4. Bronchodilator inhalation : salbutamol 200-800 mcg +
ipatrium bromide 200-400 mcg
5. 1+2+3+4 simultanous, if needed continuous 2-4 hours
6. Evaluation every 1- 2 hours
7. If first 2 hour no improve, 1+2+3+4 repeated
8. If 3 x evaluation no improve > ICU (non-invasive
ventilation / NIV)
9. Aminophyllin drip 0.2-0.6 mg/KGBW/hour
ASTHMA
Clinical improvement:
1. If febrile + ILI > Tx antibiotics : macrolid, quinolon,
penicillin
2. STEROID oral 40-60 mg/day methylprednisolon : 7-10
days > tapper off
3. Inhaled steroid : budesonide/fluticason 1-2 mg/day for 1-
2 months and tapper off to optimal dose (individual)
4. Bronchodilator inhaled/oral if needed : salbutamol,
terbutalin
5. Aminophylline slow release tab : 200 - 400 mg tab>
2x/day
Asthma management goals

 prevent asthma exacerbations

 achieve and maintain control of symptoms
 maintain pulmonary function as close to normal as
possible
 maintain normal activity levels, including exercise
 prevent asthma mortality
 Avoid adverse effects from asthma medications
 Prevent airway remodeling
GINA 2016
 Definition of COPD
(Chronic Obstructive Pulmonary Disease)

• COPD: a common preventable and treatable

disease, is characterized by persistent airflow
limitation that is usually progressive and
associated with an enhanced chronic
inflammatory response in the airways and the
lung to noxious particles or gases.
• Exacerbations and comorbidities contribute to
the overall severity in individual patients
Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive
Pulmonary Disease. GOLD: 2016. Page 2 Downloaded from: www.goldcopd.com
COPD (PPOK)
(caused by smoking, air pollution, biomass pollution)

Chronic Bronchitis
Chronic Cough + sputum > 2 years caused
by smoking or air polution, less dyspnea and
prolonged expiration
Emphysema
chronic dyspnea (prolonged expiration)+
cough >2 years caused by smoking or air
polution
ERS Handbook of Respiratory Medicine 2014
 Chronic BRONCHITIS

● Main anomaly at bronchus until terminal

bronchus
● Disturbance of :
# mucus
# submucosa thickening
# infiltration of lecocyte netrophyl
● Smooth muscle+ fibrosis increase
● Narrowing Lumen
● CXR: normal lung
● Spirometry: FEV1 <70% normal predicted,
reversibility post bronchodilator <12%
18
ERS Handbook of Respiratory Medicine 2014
 PATHO- PHYSIOLOGY….
COPD
FACTORS AFFECTING AIR-FLOW

• Mucosal edema
• Hypertrophy of mucosa
• Increased secretions
• Increased bronchospasm
• incr. Airway tortuosity
• More airway turbulance
• Loss of lung recoil
* 19
 Emphysema. Graphic depiction of centrilobular
versus panlobular emphysema

20 *
COPD/PPOK: symptoms&signs

Acute Exacerbation
1. More cough+ sputum expectoration
2. coloured sputum : yellowish, redish
brownish and smelling
3. Febrile > infection
4. Dyspnea more in emphysema (prolonged
expiration)
COPD Acute Exacaserbation

Management:
1. Fowler bedrest + O2 > 2-3 liter/mnt
2. High calori Diet, high protein, low carbohydrate
3. Antibiotics: macrolide, quinolon, penisiline
4. Ora Steroid: methyl prednisolon, prednison 40-60
mg/day >7-10 days
5. Steroid inhalation: budesonid/flutikason 1-2 mg/day
6. Bronchodilator Inhalation: salbutamol/terbutalin 600-
1200 mcg/day
7. Aminophyline controled release 200-400 mg > 2x/day
8. Mucolityc: N-asetyl sistein, ambroxol, OBH, GG
 CHRONIC MANAGEMENT OF COPD

1. EDUCATION
2. MEDICATION:
 Inhaled Bronchodilator (Long Acting Beta Agonist&Long
Acting Muscarinic Agonist)
 Inhaled steroid (budesonide/fluticasone)
 Oral treatment : oral phosphodiesterase-4 inhibitors
3. Nutrition
4. Chest physiotherapy
5. Pulmonary rehabilitation
6. Prevent Exacerbation
7. Maintaince quality of life

Calverley PM, et al 2016. Early efficacy of budesonide/formoterol in patients with moderate-to-very-severe COPD Int J Chron Obstruct Pulmon Dis. 19;12:13-25..

Derom E, Brusselle GG, Joos GF 2016 Efficacy of tiotropium-olodaterol fixed-dose combination in COPD. COPD Int J Chron Obstruct Pulmon Dis 11: 3163-77
 CHRONIC MANAGEMENT OF STABLE COPD

1. EDUCATION
2. MEDICATION:
 Inhaled Bronchodilator (Long Acting Beta Agonist&Long
Acting Muscarinic Agonist)
 Inhaled steroid (budesonide/fluticasone)
 Oral treatment: FDA-approved roflumilast and
cilomilast, the oral phosphodiesterase-4 inhibitors.
The drugs did significantly reduce exacerbations
with an odds ratio of 0.78 -- as good or better than
currently available inhalers

Calverley PM, et al 2016. Early efficacy of budesonide/formoterol in patients with moderate-to-very-severe COPD Int J Chron Obstruct Pulmon Dis. 19;12:13-25..

Derom E, Brusselle GG, Joos GF 2016 Efficacy of tiotropium-olodaterol fixed-dose combination in COPD. COPD Int J Chron Obstruct Pulmon Dis 11: 3163-77
Sindroma Obstruktif Pasca TBC Paru /SOPT
(Squelae post TB)

● History of lung TBC

● Chronic Cough + sputum
● Chronic dyspnea
● Cahexia
SOPT

Classification (radiologic):
1. Minimal lesion (local): fibrosis, calsification
2. destroyed lung: severe fibrosis, multiple
cavernae, tracheal deviation, penebalan
pleura
 RONTGEN THORAX EVALUATION
(Post OAT)

MAN 51 YO
SMOKER
5 YEARS POST OAT
SOPT
(destroyed lung)

Woman
51 yo
Smoker
4 years post oat
SOPT (fibrosis apex pulmo)
Symptoms&signs SOPT

Acute Exacerbation (COPD like symptoms)

1. More cough+sputum> negative AFB
sputum
2. Often bloody sputum
3. febrile > infection
4. Dyspnea and prolonge expiration
SOPT

Management (negative AFB sputum)

Aute Exacerbation (like COPD):
1. Fawler position + O2 : 2-3 liter/minute
2. Diet high calori,high protein, lower carbohidrate
3. Antibiotics: makrolide, quinolon, penisilin
4. Steroid oral: metil prednisolon, prednison 40-60 mg/day
> 7-10 days
5. Steroid inhalation: budesonid/flutikason 1-2 mg/day
6. Bronkodilator inhalation: salbutamol/terbutalin 600-1200
mcg/day
7. Aminofilin slow release 200-400 mg > 2x/day
8. Mucolytic: N asetil sistein, ambroksol, OBH, GG
9. Chest physiotherapy & pulmonary rehabilitation
 Bronchiectasis

Dysarrangement of bronchial elastic tissue with

diameter < 3 mm, made saccus
Cause of bronchiectasis:
– Chronic lung infection duration adolescent
– tbc involving bronchus
– smoker
BRONCHIECTASIS APEX DEXTRA POST TB

FIBROSIS
BRONCHIECTASIS BASAL OF LUNG (CLASIC)
BILATERAL BRONCHIECTASIS IN BASAL OF LUNG (CLASIC)
Bronchiectasis

Symptoms&signs:
1. Chronic bloody sputum
2. Chronic dyspnea
3. Auscultation: rales crepitation basal of lung
4. cachexia
5. Clubing finger if severe condition
Bronchiectasis

Acute exacerbation (infected bronchiectasis)

1. Haemoptysis
2. Fever symptoms of infection
3. Aware if severe dyspnea may aspiration
blood clott
 Bronchiectasis

Management:
1. bedrest + O2 → 2-3 l/minute, head laydown below chest or
left/right side position
2. Anti tussive: DMP 3-4x1-2tab/day, codein 3-4 x 10-20 mg/day
3. Antibiotics: makrolide (clarithromycin), penisilline, quinolone
4. Mucolityc: NAC,GG,OBH,ambroxol
5. Sputum Drainage
6. Transfusion, if Hb < 8 gr%
7. Antibiotics inhalation: colistine, amikasin, tobramisin,
gentamisin
8. Lobectomy or pneumectomy if hemoptysis >500 cc/24 hour
 Current therapies for bronchiectasis displayed according to Cole's vicious cycle hypothesis.

Recomended clarithromycin

Recomended clarithromycin

James D. Chalmers et al. Eur Respir J 2015;45:1446-1462

©2015 by European Respiratory Society

 TERIMA KASIH
thank you

ATAS PERHATIANNYA
For your atention