COPD

Chronic Obstructive Pulmonary Desease

By : Nur Basuki, M.Physio

Chronic obstructive pulmonary disease (COPD) refers to
diseases of the lungs in which the airways become narrowed.
This leads to a limitation of the flow of air to and from the
lungs causing shortness of breath.

COPD is also known as

 chronic obstructive lung disease (COLD),
 chronic obstructive airway disease (COAD),
 chronic airflow limitation (CAL) and
 chronic obstructive respiratory disease
 COPD is caused by noxious particles or gases, most
commonly from smoking, which trigger an abnormal
inflammatory response in the lung.
 The inflammatory response in the larger airways is
known as chronic bronchitis, which is diagnosed
clinically when people regularly cough up sputum.
 In the alveoli, the inflammatory response causes
destruction of the tissues of the lung, a process known
as emphysema.
 The natural course of COPD is characterized by
occasional sudden worsening of symptoms called acute
exacerbations, most of which are caused by infections
or air pollution
 Worldwide, COPD ranked sixth as the cause of
death in 1990.
 It is projected to be the third leading cause of death
worldwide by 2020 due to an increase in smoking rates
and demographic changes in many countries.
 COPD is the 4th leading cause of death in the U.S., and
the economic burden of COPD in the U.S. in 2007 was
$42.6 billion in health care costs and lost productivity.
DI INDONESIA

Belum ada angka prevalensi

Cenderung meningkat
- Tingginya infeksi saluran napas berulang
- Kebiasaan merokok tinggi
- Memburuknya tingkat polusi udara
 Signs & Symptoms
 One of the most common symptoms of COPD is shortness
of breath (dyspnea).
 People with COPD commonly describe this as:
 “My breathing requires effort”,
 “I feel out of breath”, or
 “I can not get enough air in”.
 People with COPD typically first notice dyspnea during
vigorous exercise when the demands on the lungs are
greatest. Over the years, dyspnea tends to get gradually
worse so that it can occur during milder, everyday
activities such as housework. In the advanced stages of
COPD, dyspnea can become so bad that it occurs during
rest and is constantly present.
 Other symptoms of COPD are a persistent cough,
sputum or mucus production, wheezing, chest
tightness, and tiredness.
 People with advanced (very severe) COPD sometimes
develop respiratory failure. When this happens,
cyanosis, a bluish discoloration of the lips caused by a
lack of oxygen in the blood, can occur.
 An excess of carbon dioxide in the blood can cause
headaches, drowsiness or twitching.
 A complication of advanced COPD is cor pulmonale
 Symptoms of cor pulmonale are peripheral edema,
seen as swelling of the ankles, and dyspnea.
KLASIFIKASI DERAJAD BERATNYA
COPD
Berat Gejala VEP-1
penyakit % prediksi)
Ringan - Tidak ada gejala saat > 70%
istirahat atau saat
bekerja
- Tidak ada gejala saat
istirahat tapi ada
gejala pada aktiviti
sedang (berjalan
cepat, menaiki tangga)
 Berat Gejala VEP-1
penyakit % prediksi)
Sedang - Tidak ada gejala saat 50 – 69%
istirahat, tapi ada
gejala pada aktivitas
ringan. (berpakaian)
- Gejala minimal saat
istirahat (saat duduk,
menonton TV,
membaca)
 Berat Gejala VEP-1
penyakit % prediksi)
Berat - Gejala sedang saat < 50%
istirahat
- Gejala berat saat
istirahat
- Tanda – tanda kor
pulmonale
Tidak banyak tanda-2 dr COPD yg dapat dideteksi,
bahkan beberapa px tak tampak tanda-2 berikut.
Beberapa tanda COPD yg umum adalah:

 tachypnea
 wheezing or crackles
 Prolonged expiration
 hyperinflation
 Increased accessory muscle activity
 breathing through pursed lips
 increased anteroposterior to lateral ratio of the chest
(i.e. barrel chest).
 Paradoxycally breathing (Hoover’s sign)
 Faktor Resiko
SMOKING
 Merokok adalah merupakan faktor resiko utama COPD.

 Di AS 80 – 90% COPD disebabkan merokok.

 Tidak semua perokok  COPD, perokok yg terus

menerus mempunyai resiko 25% setelah 25 th merokok,
resiko ini akan semakin meningkat dg meningkatnya
usia

 Perokok pasif dapat juga menyebabkan gangguan

pertumbuhan paru  timbulnya COPD
Occupational exposures

Paparan yg terus menerus dari debu yg ada ditempat

kerja seperti : penambangan batu bara,
penambangan emas, industri textil dan bahan-2
kimia  implikasi berkembangnya obstruksi arus
udara pd sal napas
POLUSI UDARA
Studies in many countries have found that people who live in
large cities have a higher rate of COPD compared to people
who live in rural areas.
In many developing countries indoor air pollution from
cooking fire smoke (often using biomass fuels such as wood
and animal dung) is a common cause of COPD, especially in
women

GENETIC
Alpha 1-antitrypsin deficiency is a genetic condition that is
responsible for about 2% of cases of COPD.
 bronchoconstriction, Impaired ventilation
 Oedema membrana mukosa, Penurunan arus insp & exp
 Retensi mukus, Prolonged expiration
 Destruksi/dilatasi dari
saluran napas & jaringan
parenchim paru
Dynamic hyperinflation

VA/Q mismatch
High Lung Volume Breathing Pattern
Increased accessory muscle

Low PaO2
Hypoxaemia
Increased Work of Breathing
Hypercapnia

Dyspnea

Decreased Exercise Tolerance

 Fear of
breathlessness

Decrease exercise Depression Inactivity

tolerance

Decrease efficiency &

Coordination General Muscle weakness
Beberapa pasien COPD berusaha untuk
mengkompensasi dg bernapas lebih cepat  sesak.
Akibat dr low oxygen & High Carbondioxide 
headaches, drowsiness and heart failure.

Advanced COPD can lead to complications beyond the

lungs such as :
 weight loss (cachexia),
 pulmonary hypertension and
 heart failure (cor pulmonale).
Disamping itu bbrp penyakit berikut sering ditemukan
pd penderita COPD
Osteoporosis, heart disease, muscle wasting and
depression
 ?
PROBLEMATIKA
FISIOTERAPI
 Dyspnea
 Impaired airway clearance
 Airflow limitation
 Abnormal breathing pattern
 Muscle dysfunction
 Increased Work of Breathing
 Impaired oxygenation/gas exchange
 Decreased exercise tolerance
 ?
FISIOTERAPI
MANAGEMENT
Breathing Retraining

Pursed Lips Breathing

 Suatu tehnik pernapasan yang dapat memudahkan

pengeluaran udara pada penderita dengan problem air
flow limitation.
 Biasanya dilakukan secara insting
 Pasien tarik napas melalui hidung, dan
mengeluarkannya melalui mulut secara perlahan
lahan (4-6 detik) dengan mengatupkan kedua bibir
secara rileks. Tehnik ini dilakukan tanpa kontraksi otot
abdominal
Clinical outcomes of Pursed Lips Breathing

1. Decreased RR (Breaslin, 1992; Jones et al,

2003)
2. Decrease minute ventilation
3. Decrease PaCO2
4. Increased tidal volume (Vt)
5. Increased PaO2
6. Increased SaO2
7. Decreased Dyspnea
8. Increased Exercise Tolerance
9. Reduced limitations in ADL
Changes in Ventilation & Lung Volume

Motley, 1963 dalam penelitiannya pada 35 org dg

COPD berat (Residual volume > 200% predicted; VC =
72% predicted) menemukan bahwa PLB dapat :
 Menurunkan RR (15 – 9)
 Meningkatkan Vt (494 ml – 814 ml)
 Meningkatkan SaO2 (89,5% - 92.1%)
 Menurunkan PaCO2 (40 mmHg – 37 mmHg)

Demikian juga penelitian yg dilakukan oleh Thoman et

al, 1966 serta penelitian yang dilakukan oleh Tiep et al
(1986) dan Chambel et al (1955) juga menunjukkan hasil
yang sama
Dyspnea Relief

Mueller et al, (1970) melakukan penelitian ttg mekanisme

penurunan sesak pd penderita COPD setelah diberikan PLB.
Dua belas penderita COPD dibagi dalam 2 kel, dimana kel I (7
org) adalah kel yang menyatakan bahwa PLB dapat
mengurangi sesaknya, sedang kelompok II (5 org) adalah
kelompok yang menyatakan bahwa PLB tak mengurangi
sesaknya.

Kedua kelompokmenunjukkan perbaikan pada PaO2 dan

SaO2 serta penurunan RR, namun demikian hanya kelompok
I yang menunjukkan adanya peningkatan Vt (0.75 L – 1.19 L)
Hasil penelitian ini menunjukkan bahwa penurunan sesak
napas bukan karena perbaikan pd pertukaran gas, tetapi
karena perubahan fungsi mekanika pernapasan.
Penelitian yang dilakukan oleh Ingram and Schilder,
(1967) menyimpulkan bahwa penurunan sesak napas
akibat dari pemberian PLB adalah kemungkinan adanya
penurunan dari transpulmonary pressure  penurunan
airways collapse.
Hasil penelitian ini juga didukung oleh penelitian dari
Motley (1963) dan Thoman et al, (1966).

Dari penelitian yg dilakukan oleh Dechman & Wilson,

(2004) disimpulkan bahwa, PLB does relief dyspnea in
selected subjects.
Pada pasien yg kesulitan untuk melakukan tehnik ini
seyogyanya latihan dihentikan.
Jika efek possitif dari PLB dapat pula dilakukan saat
aktivitas  toleransi aktivitas akanmembaik
 Pulmonary Rehabilitation Program

Definisi:
“A multi dimensional continuum of services directed
to persons with pulmonary diseases and their family,
usually by an interdisciplinary team of specialist with
the goal of achieving and maintaining the individual’s
maximal level of independence and functioning in the
community” (Fishman, 1994)
 Manfaat dari Program Rehabilitasi Paru

Beberapa penelitian terakhir yg dilakukan secara

random sampling menunjukkan manfaat positive
dari Program rehabilitasi paru (Goldstein, 1994;
Reardon et al, 1994; Wijkstra et al, 1995)
 Memperbaiki kualitas hidup
 Menurunkan kecemasan dan depresi
 Meningkatkan toleransi aktivitas
 Mengurangi sesak dan keluhan lain
 Memperbaiki kemampuan untuk melakukan
ADL
Disamping itu Rehab program juga bermanfaat
untuk mengurangi rawat inap di RS
Exercise training:
• Aerobic training
• Strength training (UE & LE)
• Ventilatory muscle training
• Breathing retraining
Education
• Energy conservation
• Medication
• Diet & nutrition
• Psychosocial support
Hui and Hewitt (2007) melakukan penelitian tentang manfaat dari
“A simple Pulmonary Rehabilitation Program” yang dilakukan pd 36
pasien COPD yang mengunjungi outpatient physiotherapy
department di Sydney, Australia.
Program diberikan oleh fisioterapis. Penelitian dilakukan selama 8
mg dengan frekwensi latihan 2X/minggu. Program latihan terdiri
dari Jalan dan static bucycle, serta latihan dengan beban untuk UE
dan LE.
Hasil:
• Peningkatan endurance
• Mengurangi sesak
• Meningkatkan QoL (Quality of Life)
• Tak ada perbaikan pada fungsi paru (FEV1)
• Mengurangi hospitalisasi
• Mengurangi masa rawat inap
Terimakasih