By

Dr. Hermawan Chrisdiono, Sp.P

RSUD Unit Swadana Pare Kabupaten Kediri

Facts About COPD• COPD is the 4th leading cause of death in

the United States (behind heart disease, cancer, and cerebrovascular disease).

• In 2000, the WHO estimated 2.74 million deaths worldwide from COPD.

• In 1990, COPD was ranked 12th as a burden of disease; by 2020 it is projected to rank 5th.

Leading Causes of DeathsU.S. 1998

All other causes of death 469,314All other causes of death 469,314

10.10. Chronic liver disease 24,936Chronic liver disease 24,936

9.9. Nephritis 26,295Nephritis 26,295

8.8. Suicide 29,264Suicide 29,264

7. 7. Diabetes 64,574Diabetes 64,574

6.6. Pneumonia and influenza 93,207Pneumonia and influenza 93,207

5.5. Accidents 94,828Accidents 94,828

4.4. Respiratory Diseases (COPD) 114,381Respiratory Diseases (COPD) 114,381

3.3. Cerebrovascular disease (stroke) 158,060Cerebrovascular disease (stroke) 158,060

2. 2. Cancer 538,947Cancer 538,947

1.1.

Cause of Death Number

Heart Disease 724,269

Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998

00

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

3.03.0

Proportion of 1965 Rate Proportion of 1965 Rate

1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998

–59%–59% –64%–64% –35%–35% +163%+163% –7%–7%

CoronaryHeart

Disease

CoronaryHeart

Disease

StrokeStroke Other CVDOther CVD COPDCOPD All OtherCauses

All OtherCauses

Age-Adjusted Death Rates for COPD, U.S., 1960-1998Age-Adjusted Death Rates for COPD, U.S., 1960-1998

6060

Deaths per 100,000Deaths per 100,000

19601960 19651965 19701970 2000200019751975 19801980 19851985 19901990 19951995

5050

4040

3030

2020

1010

00

Facts About COPD: U.S.

Facts About COPD: U.S.

Between 1985 and 1995, the number of physician visits for COPD increased from 9.3 to16 million.

The number of hospitalizations for COPD in 2000 was estimated to be 726,000.

Medical expenditures in 2002 were estimated to be $18.0 billion.

Between 1985 and 1995, the number of physician visits for COPD increased from 9.3 to16 million.

The number of hospitalizations for COPD in 2000 was estimated to be 726,000.

Medical expenditures in 2002 were estimated to be $18.0 billion.

Physician Office Visits for Chronicand Unspecified Bronchitis, U.S.

Physician Office Visits for Chronicand Unspecified Bronchitis, U.S.

Source: National Ambulatory Medical Care Survey, NCHSSource: National Ambulatory Medical Care Survey, NCHS

1515Number (Millions)Number (Millions)

YearYear19801980

1010

55

0019851985 19901990 19951995 19981998

COPD 1990 PrevalenceCOPD 1990 Prevalence

Established Market Economies 6.98 3.79 Formerly Socialist Economies 7.35 3.45 India 4.38 3.44 China 26.20 23.70 Other Asia and Islands 2.89 1.79 Sub-Saharan Africa 4.41 2.49 Latin America and Caribbean 3.36 2.72 Middle Eastern Crescent 2.69 2.83 World 9.34 7.33

*From Murray & Lopez, 1996

Established Market Economies 6.98 3.79 Formerly Socialist Economies 7.35 3.45 India 4.38 3.44 China 26.20 23.70 Other Asia and Islands 2.89 1.79 Sub-Saharan Africa 4.41 2.49 Latin America and Caribbean 3.36 2.72 Middle Eastern Crescent 2.69 2.83 World 9.34 7.33

*From Murray & Lopez, 1996

Male/1000Male/1000 Female/1000Female/1000

Table Death caused by the respiratory tract diseases (asthma, CB and emphysema) in hospital

Year % rank

1986 3.8 10 

1992 5.6 7 

1995 15.7 2

National Household Health Survey 1995 (NHHS)

Tabel Main causes of death as revealed by NHHS 1989 and 1992

Order

1

2

3

4

5

6

7

8

9

10

1986

Diarrhoea

Cardiovascular

Tuberculosis

Measles

Low Resp.Dis

Tetanus

Mental disorders

Injuries

Neoplasms

CB,Asthma,

Emphysema

%

12.0

9.7

8.6

6.7

6.2

6.0

5.3

4.7

4.3

3.8

1992

Cardiovascular

Tuberculosis

Not known

Resp.infection

Diarrhoea

Other inf.dis

CB, Asthma,emphy

Injuries

Gastro intestinal

Neoplasms

%

16.0

11

9.8

9.5

8.0

7.8

5.6

5.3

5.1

4.0

Indonesian Pneumobile Project (IPP-1989)

Prevalence of CB :

• 17% for male• 8.7% for female.

00.5

11.5

22.5

33.5

44.5

5

% males %females

AGE 13-19

AGE 20-29

AGE 30-39

AGE 40-49

AGE 50+

Figure 1 Characteristic of IPP Study Population: Prevalence of Usual Cough or Phlegm

% with symptoms

Prevalence of abnormal Pulmonary Function : • 60% of smokers • 25% of non smokers

Cigarette smoking is the primary cause of COPD.

In the US 47.2 million people (28% of men and 23% of women) smoke.

The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are increasing at an alarming rate.

Cigarette smoking is the primary cause of COPD.

In the US 47.2 million people (28% of men and 23% of women) smoke.

The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are increasing at an alarming rate.

Facts About COPDFacts About COPD In India, it is estimated that 400-550

thousand premature deaths can be attributed annually to use of biomass fuels, placing indoor air pollution as a major risk factor in the country.

In Algeria, the prevalence of tuberculosis and acute respiratory infections has decreased since 1965; an increase in COPD and asthma has been observed in the last decade.

In India, it is estimated that 400-550 thousand premature deaths can be attributed annually to use of biomass fuels, placing indoor air pollution as a major risk factor in the country.

In Algeria, the prevalence of tuberculosis and acute respiratory infections has decreased since 1965; an increase in COPD and asthma has been observed in the last decade.

GOLD Workshop ReportGOLD Workshop Report

Evidence category Sources of evidence A Randomized clinical trials

Rich body of data B Randomized clinical trials

Limited body of data  C Non randomized trials

Observational studies  D Panel judgement

consensus

   

Chronic obstructive pulmonary disease(COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with anabnormal inflammatory response of thelungs to noxious particles or gases.

Burden of COPD Key PointsBurden of COPD Key Points

The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced.

Prevalence, morbidity, and mortality vary appreciably across countries but in all countries where data are available, COPD is a significant health problem in both men and women.

The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced.

Prevalence, morbidity, and mortality vary appreciably across countries but in all countries where data are available, COPD is a significant health problem in both men and women.

Burden of COPD Key PointsBurden of COPD Key Points

The global burden of COPD will increase enormously over the foreseeable future as the toll from tobacco use in developing countries becomes apparent.

The global burden of COPD will increase enormously over the foreseeable future as the toll from tobacco use in developing countries becomes apparent.

Burden of COPD Key PointsBurden of COPD Key Points

The economic costs of COPD are high and will continue to rise in direct relation to the ever-aging population, the increasing prevalence of the disease, and the cost of new and existing medical and public health interventions.

The economic costs of COPD are high and will continue to rise in direct relation to the ever-aging population, the increasing prevalence of the disease, and the cost of new and existing medical and public health interventions.

Direct Medical Cost:$18.0

Total Indirect Cost: $ 14.1

– Mortality related IDC

7.3

– Morbidity related IDC

6.8

Total Cost $32.1

Direct Medical Cost:$18.0

Total Indirect Cost: $ 14.1

– Mortality related IDC

7.3

– Morbidity related IDC

6.8

Total Cost $32.1

Source: NHLBI, NIH, DHHS

Risk Factors for COPDRisk Factors for COPD

Host Factors Genes (e.g. alpha1-antitrypsin deficiency)

Hyperresponsiveness

Lung growth

Exposure Tobacco smoke

Occupational dusts and chemicals

Infections

Socioeconomic status

Host Factors Genes (e.g. alpha1-antitrypsin deficiency)

Hyperresponsiveness

Lung growth

Exposure Tobacco smoke

Occupational dusts and chemicals

Infections

Socioeconomic status

Pathogenesis of COPDPathogenesis of COPD

NOXIOUS AGENT(tobacco smoke, pollutants, occupational

agent)

COPD

Genetic factors

Respiratory infection

Other

Noxious particles

and gases

Lung inflammation

Host factors

COPD pathology

ProteinasesOxidative stress

Anti-proteinasesAnti-oxidants

Repair mechanisms

INFLAMMATION

Small airway diseaseAirway inflammationAirway remodeling

Parenchymal destructionLoss of alveolar attachments

Decrease of elastic recoil

AIRFLOW LIMITATION

ASTHMAASTHMASensitizing agent

COPDCOPDNoxious agent

Asthmatic airway inflammationCD4+ T-lymphocytes

Eosinophils

COPD airway inflammationCD8+ T-lymphocytes

MacrophagesNeutrophils

Airflow limitationCompletelyreversible

Completelyirreversible

• Irreversible– Fibrosis and narrowing of the

airways– Loss of elastic recoil due to

alveolar destruction– Destruction of alveolar support

that maintains patency of small airways

• Reversible

– Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi

– Smooth muscle contraction in peripheral and central airways

– Dynamic hyperinflation during exercise

1. Assess and monitor disease

2. Reduce risk factors

3. Manage stable COPD Education Pharmacologic Non-pharmacologic

4. Manage exacerbations

1. Assess and monitor disease

2. Reduce risk factors

3. Manage stable COPD Education Pharmacologic Non-pharmacologic

4. Manage exacerbations

Objectives of COPD Management

• Prevent disease progression • Relieve symptoms• Improve exercise tolerance• Improve health status• Prevent and treat exacerbations• Prevent and treat complications• Reduce mortality• Minimize side effects from

treatment

Assess and Monitor Disease: Key Points

• 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.

Assess and Monitor Disease: Key Points

• Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea.

Assess and Monitor Disease: Key Points

• For the diagnosis and assessment of COPD, spirometry is the gold standard.

• Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry.

Assess and Monitor Assess and Monitor Disease: Disease: Key PointsKey Points

• Measurement of arterial blood gas tension should be considered in all patients with FEV1 < 40% predicted or clinical signs suggestive of respiratory failure or right heart failure.

SYMPTOMS

coughcoughsputumsputumdyspneadyspnea

EXPOSURE TO RISKFACTORS

tobaccotobaccooccupationoccupation

indoor/outdoor pollutionindoor/outdoor pollution

SPIROMETRYSPIROMETRY

Diagnosis of COPDDiagnosis of COPD

0

5

1

4

2

3

Lit

er

1 65432

FVC

FVC

FEV1

FEV1

Normal

COPD

3.900

5.200

2.350

4.150 80 %

60 %NormalCOPD

FVCFEV1 FVCFEV1/

Seconds

Severity of symptoms Severity of airflow limitation Frequency and severity of exacerbations Presence of complications of COPD Presence of respiratory insufficiency Comorbidity General health status Number of medications needed to manage the

disease

Classification by SeverityClassification by Severity

Stage Characteristics

0: At risk Normal spirometry Chronic symptoms (cough, sputum) 

I: Mild FEV1/FVC < 70%; FEV1 80% predicted With or without chronic symptoms (cough,

sputum)

II: Moderate FEV1/FVC < 70%; 50% FEV1 < 80% predicted With or without chronic symptoms (cough, sputum,

dyspnea) III: Severe FEV1/FVC < 70%; 30% FEV1 < 50% predicted

With or without chronic symptoms (cough, sputum, dyspnea)

IV: Very Severe FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

WORLD COPD DAYNovember 19, 2003

WORLD COPD DAYNovember 19, 2003

Raising COPD Awareness WorldwideRaising COPD Awareness Worldwide

Do you know what COPD is? This chronic lung disease is a major cause of illness, yet many people have it and don’t know it.

If you answer these questions, it will help you find out if you could have COPD.

 1. Do you cough several times most days? Yes ___ No ___

 2. Do you bring up phlegm or mucus most days? Yes ___ No ___

 3. Do you get out of breath more easily than others your age? Yes ___ No ___

 4. Are you older than 40 years? Yes ___ No ___

 5. Are you a current smoker or an ex-smoker? Yes ___ No ___

If you answered yes to three or more of these questions, ask your doctor if you might have COPD and should have a simple breathing test. If COPD is found early, there are steps you can take to prevent further lung damage and make you feel better.

 Take time to think about your lungs……Learn about COPD!

Do you know what COPD is? This chronic lung disease is a major cause of illness, yet many people have it and don’t know it.

If you answer these questions, it will help you find out if you could have COPD.

 1. Do you cough several times most days? Yes ___ No ___

 2. Do you bring up phlegm or mucus most days? Yes ___ No ___

 3. Do you get out of breath more easily than others your age? Yes ___ No ___

 4. Are you older than 40 years? Yes ___ No ___

 5. Are you a current smoker or an ex-smoker? Yes ___ No ___

If you answered yes to three or more of these questions, ask your doctor if you might have COPD and should have a simple breathing test. If COPD is found early, there are steps you can take to prevent further lung damage and make you feel better.

 Take time to think about your lungs……Learn about COPD!

Could it be COPD?Could it be COPD?