Medical Case II NEW

7/30/2019 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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Medical Case II NEW