medical case ii new
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Medical case II
Mr. Furqan Chan
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A 52-year old man present to your office for an accutevisit because of coughing and shortness of breath. He iswell-known to because of multiple office visit in the pastfew years for similar reason. He has chronic smokers
caugh,but reports in the past 2 days his cough hasincreased,his sputum has changed from white to greenin color and he has had to increase the frequency withwhich he uses his albuterol inhaler. He denies havingfever, chest pain, peripheral edema, or other symptoms.
His medical history is significant for hypertensio,pheripheral vascular disease, and 2 hospitalizationpneumonia in the past 5 years. He has a 60-pack-historyof smoking and continuous to smoke 2 packs ofcigarettes a day.
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On examination, he is in moderate respiratory distress.His temperature is 98.4F degree, his blood pressure is152/95 mm Hg, his pulse is 98 beats/min, his repiratoryrate is 24 breaths/min, and he has an oxygen saturation
of 94% on room air. His lung is significant for diffuseexpiratory wheezing and a prolonged expiratory phase ofrespiration. There are no sign of cyanosis. Theremindeer of his examination is normal. Chest x-raydone in your office shows an increased anteroposterior
(AP) diameter and flattened diaphragms, otherwise clearlung fields.
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introduction
In this time,there are a lot of problem aboutpulmonary dissease which increased theprecentage of mortality.
In this case we will talk about the obstruction
of respiratory way. Respiratory way can suffererof an acute obstruction which is happen insuperior of respiratory way (supraglotic), middleof respiratory way (intraglotic),or under ofrespiratory way(infraglotic). If the obstructionhappen in the under of the respiratory way so itmaybe cause by an asthma or COPD.
Yeah we will concern about the COPD it self
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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 anincreases of precentage of mortality cause
by COPD. As cause of the death COPD
has stay as the fourth grade after the heartattack and cerebrovascular disease.
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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, oreven dangerous gas.
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AIRFLOWLIMITATION
IN SMALL AIRWAYS
DEFINITION
COPD
PROGRESSIVE
IRREVERSIBLE
PARTIALREVERSIBLE
CHRONIC BRONCHITIS
EMPHYSEMATOUS LUNG
MIXED
CHRONICINFLAMMATIO
N
1
2
ALVEOLER STRUCTURE DAMAGED
DECREASED ELASTIC RECOIL
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INCREASE OF 51 % ACUTE EXACERBATIONIN HOSPITAL ADMISSION BETWEEN 1991 - 2000
INCREASINGPROBLEMSOF COPD
GOLD [ NHLBI WHO ]GUIDELINES MANAGEMENT STRATEGY
OF COPD
MORBIDITY& MORTALITY
IV in USA
WHO 2020MORTALITY
3 million/year
HOSPITALMORTALITY
10 %
WORSENHEALTH
STATUS
PREMATURE DEATH
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Why COPD can happened?
-chronic bronchitis
-emphisema
-both of them
Trigger factors:
-smoke of ciggarete
An active smoker
A passive smoker
-air polutionIndoor polution
Smoke of stove
Outdoor polution
smoke of vehicle
Iritation particle, chemicle stuff,dangerous gasoline.
-infection of under of respiratoryway
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PATOGENESIS of CHRONIC
BRONCHITIS
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PHATOGENESIS OF
EMPHYSEMA
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SIGN AND SYMPTOMS
Increases of sputums
volume
A progressive
dyspnea chest tightness
A purulent sputum
Increases ofbroncodilator indeeed
Weakness,tired
Physical examination
-fever
-wheezing
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SYMPTOMSCOUGHSPUTUMDYSPNEA
EXPOSURE TO
RISK FACTORSTobacco SmokeOccupation
Indoor / outdoorpollution
1 2
DIAGNOSIS
OF COPD
SPIROMETRY
3
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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 hisactivity
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
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Ro. Thorax
Hiperlusen
Flattened diaphragms
Increases of mark
bronkovaskulerBulla
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What intervention woud
be most helpful
to reduce the risk offuture exacerbation of
this condition ?
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COPD MANAGEMENT
PULMONARY REHABILITATIONPROGRAMME
ESTABLISH DIAGNOSISASSESS SYMPTOMS
STOP SMOKING
HEALTHY LIFESTYLEIMMUNISATION
TREAT OBSTRUCTION
ASSESS FOR HYPOXIA
BRONCHODILATORS
LONG TERM
OXYGEN THERAPY
1
2
3
4
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COPD
PHARMACOTHERAPY
INHALED CORTICOSTEROIDSONLY FOR CONCOMITANT
ASTHMA
LONG TERMOXYGEN THERAPY
[ SELECTED PATIENT ]
ANTICHOLINERGICS[ TIOTROPIUM SOON AVAILABLE ]
LABATHEOPHYLLINE
[ ANTI INFLAMMATORY EFFECT ]
BRONCHODILATORS
NEW ANTIINFLAMMATORY
TREATMENT NEEDED
TRIAL OF BUPROPION
NICOTINE REPLACEMENT
STOP SMOKING
1
2
3
4
5
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OTHER TREATMENT
IN COPD
ANTILEUCOTRIENT
S
PROPHYLACTIC
ANTIBIOTICSNO EVIDENCE
N-ACETYLCYSTEINE
ANTI INFLAMMATORYDUGS
INHALED CORTICOSTEROID ?
ANTIOXIDANTSCARBOCYSTINE
BROMHEXOL
AMBROXOL
MUCOLYTICS 1
2
3
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Treatment for COPD
step 1 : Ipratropium bromida (MDI) or nebulizer, 2-6puff 4 x sehari, show the way to use this stuff.
Advice about the important of use it, and thecomplication (mulut kering & rasa pahit), if it good
trial : perbaikan FEV1 < 20%
step 2
step 2 : adding -agonis MDI or nebulizer, show howto use it,, advice about the important of use it, andthe complication (takikardi, tremor)if there are no
progreesion : stop -agonis, if there are anyprogrresion even small step 3
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step 3: adding teofilin, start from 400 mg/day
check ESO takikardi , tremor, nervous, efek GI; ifthere are no progression stop teofilin dan go tostep 4
Tahap 4: try kortikosteroid : prednison 30-40 mg/harifor 2-4 minggu, chcek spirometery (progression 20%),titrasi doxe to doze smaller efectivity(< 10 gsehari), if there are no progreesion kembali kesteroid oral
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NEW DRUG
FOR COPD
PROTEASEINHIBITORS
NEW BRONCHODILATORS
MEDIATORANTAGONISTS
ALVEOLARREPAIRDRUGS
NEW ANTIINFLAMMATOR
YDRUGS
1
2
45
TRIOTROPIUM 3
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CONTROL OF THE AIRWAYS
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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
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Metil ksantin banyak ADR, dipakai jika yang lain tidakmempan
Mukolitik membantu pengenceran dahak, namun tidakmemperbaiki aliran udara masih kontroversi, apakah
bermanfaat secara klinis atau tidak. Kortikosteroid benefit is very limited, laporan tentang
efektivitasnya masih bervariasi, kecuali jika pasien jugamemiliki riwayat asma
Oksigen untuk pasien hipoksemia, cor pulmonale.
Digunakan jika baseline PaO2 turun sampai < 55 mmHg
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Antibiotik digunakan bila ada tandainfeksi, bukan untuk maintenance therapy
Vaksinasi direkomendasikan untuk high-
risk patients: vaksin pneumococcus (tiap5-10 th) dan vaksin influenza (tiap tahun)
1-proteinase inhibitorutk pasien yang
defisiensi 1-antitripsin digunakan per minggu, masihmahal contoh: Prolastin
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prognose
Depends on age and the progresivityof this illness
if there are hipoksia and corpulmonale bad prognosisDyspneu, bad obstruction ofrespiratory way
50% patient has risk of death in 5years.
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conclusion
COPD is a disease that can be preventpotentialy 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.
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Any question?
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Thanks for your kindly attention
See you in next time
bye
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