Coronary Heart Disease (CHD)

A. Definition.
Coronary heart disease (CHD) / coronary artery disease (heart disease artherostrofik) is a specific manifestation and arterosclerosis in the coronary arteries. Plaque formed on the branching arteries aterion toward the left, right coronary artery and the artery is rather rare in sirromflex. Blood flow to distal obstruction can be permanent or temporary which is caused by the accumulation of plaque or clots. Developed collateral circulation around the obstruction arteromasus that inhibits the exchange of gases and nutrients to the myocardium.
The failure of collateral circulation to provide adequate oxygen supply to the cell that results in coronary artery disease, impaired blood flow due to obstruction is not permanent (angina pectoris and angina preinfark) and permanent obstruction (miocard infarct)

B. Causes, Mechanisms, and Symptoms of Coronary Heart Disease (CHD)

C. Risk and incidence
Coronary artery disease is the most prevalent health problem and is the leading cause of death in the USA. Although epidemiological data indicate changes in risk and mortality of this disease remains a challenge for health workers to conduct prevention and treatment efforts. Ischemic heart disease experienced by many individuals aged 40-70 years old with a mortality rate of 20%.
Risk factors associated with coronary heart disease can be logically classified as follows:

1. Personal atherogenic properties.
Atherogenic properties include blood lipids, blood pressure and diabetes mellitus. These factors together play a major role in determining the speed artero - genensis (Kaplan & Stamler, 1991).

2. Living habits or environmental factors not been determined arbitrarily.
Lifestyles that predispose individuals to coronary heart disease is a diet too rich in calories, saturated fat, cholesterol, salt as well as by physical inertia, weight gain is out of control, cigarette smoking and alcohol abuse (Kaplan & Stamler, 1991).

3. Small risks and other factors.
Because of the risk factors that set these days do not seem to explain the overall difference in mortality due to coronary heart disease, then there is a suspicion that there is a major risk factor bernar completely unknown there.
Various risk factors that exist among other oral contraceptives, host susceptibility, age and gender (Kaplan & Stamler, 1991).

D. Pathophysiology
Coronary heart disease and myocardial micardiail an ischemic response of myocardium caused by coronary artery narrowing is permanently or not permanently. Oxygen is needed by myocardial cells, for which aerobic metabolism Adenosine Triphospate in free energy for the heart at rest require the 70% oxygen. The amount of oxygen in the heart need to work on call as Myocardial Oxygen Cunsumption (MVO2), expressed by the acceleration of the heart, contraction miocardial and pressure on the heart wall.

Normal heart can easily adjust to the increased demands of oxygen tension and contraction of view adds acceleration to suppress the volume of blood to the heart of the partitions. At the heart of the obstructed blood flow miocardial, the blood supply can not meet the demands that occur. State of lethal or partial obstruction can cause a condition resembling anoxia and aerobic glycolysis seeks to meet the need of oxygen.

Analgesic

Analgesic is a drug or compound that is used to relieve pain or pain without losing consciousness. Awareness of pain consists of two processes, namely the acceptance of pain stimuli in the brain and emotional reactions and the individual against these stimulants. Barrier of pain medication (analgesic) affect the first process to heighten awareness of the feelings of pain threshold, while narcotics suppress psychis reactions caused by pain stimuli.

The pain in most cases only a symptom, whose function is to protect and give the alarm about the presence of disturbances in the body, such as inflammation (rheumatoid, gout), germ infections or muscle spasms.
The cause of pain is mechanical stimuli, physical, or chemical that can cause tissue damage and release of certain substances called mediators of pain that is located on free nerve endings in the skin, mucous membranes, or tissue- tissues (organs) other. From this place the stimulus flowed through sensory nerves to the Central Nervous System (CNS) through the spinal cord to the thalamus and then to the center of a big pain in the brain, where the stimulus is felt as pain. Mediators of pain the most important is histamine, serotonin, plasmakinin-plasmakinin, and prostaglandin-prostagladin, and potassium ions.
Based on the occurrence of pain, the pain can be combated in several ways, namely:

1. Hinder the formation of stimulus in the peripheral pain receptors, by peripheral analgesics or local anesthetic.
2. Hinder the distribution of pain stimuli in sensory nerves, for example by local anesthetic
3. Blockade of central pain in the Central Nervous System with central analgesics (narcotics) or general anesthetic.

In the treatment of pain with analgesics, psychological factors play a role, such as patience and resources of individuals receiving pain from the patient. In general analgesic is divided into two groups, namely non-narkotinik analgeti or non-opioid analgesics or integumental analgesics (eg asetosal and paracetamol) and narcotic analgesics or opioid analgesics or visceral analgesics (eg morphine).

Narcotics analgesics
These substances have a strong power blocking pain once the level of employment is located in the Central Nervous System. Generally reduced consciousness (relieving properties and lull) and cause uncomfortable feelings (euphoria). Can lead to tolerance and habits (habituation) as well as psychological and physical dependence (addiction addiction) with abstinensia symptoms when treatment is stopped. Because of the dangers of this addiction, then most of central analgesics such as narcotics included in the Narcotics Act and its use is strictly controlled .
Chemically, these drugs can be divided into several groups as follows:
1. Natural and synthetic opiate alkaloids morphine and codeine, heroin, hidromorfon, hidrokodon, and dionin.
2. Morphine substitutes consisting of:
a. Pethidine and its derivatives, fentanyl and sufentanil
b. Methadone and its derivatives: dekstromoramida, bezitramida, piritramida, and d-ptopoksifen
c. Fenantren and its derivatives also include pentazosin levorfenol.
Morphine antagonists are substances that can fight the side effects of narcotic analgesics without reducing labor analgesic and is mainly used in overdose or intoksiaksi with these medications. These substances themselves are also efficacious as an analgesic, but can not be used in therapy, because he himself cause side effects similar to mrfin, including respiratory depression and psychotic reactions. Frequently used is nalorfin and naloxone.
Side effects of morphine and other central analgesics at usual doses are gastric disturbances, intestinal (nausea, vomiting, obstipasi), as well as other central effects such as restlessness, sedation, drowsiness, and mood changes to euphoria. At higher doses the effects occurred more dangerous is respiratory depression, decreased blood pressure, and impaired blood circulation. Finally, can occur coma and respiratory standstill.

Effects of morphine on the Central Nervous System in the form of analgesia and narcosis. Analgesia by morphine and other opioids has been incurred before the person is sleeping and analgesia often occur without sleep. Small doses of morphine (15-20 mg) caused euphoria in patients who are suffering pain, sorrow and anxiety. Conversely, the same dose in normal people often creates a feeling of dysphoria worry or fear is accompanied by nausea, and vomiting. Morphine also cause drowsiness, can not concentrate, difficulty thinking, apathy, decreased motor activity, decreased visual acuity, ektremitas tersa weight, body feels hot, hot itchy and dry mouth, respiratory depression and miosis. The hunger is lost and can not always accompanied by vomiting nausea. In a quiet environment people are given a therapeutic dose (15-20 mg) of morphine will fall asleep quickly and soundly with a dream, slow breath and miosis.
Between pain and analgesic effects (respiratory depressant effects as well) contained morphine and other opioid antagonism, that pain is an antagonist faalan for analgesic effect and respiratory depressant effects of morphine. When pain is experienced for some time before administration of morphine, analgesic effects of these drugs are not so great. Conversely, if the stimulus of pain inflicted after reaching maximum analgesic effect, morphine dose required to abolish the pain was much smaller. Patients who are experiencing severe pain and require mofin with large doses to relieve pain, respiratory depression can be resistant to morphine. But when the pain was suddenly gone, then most likely symptoms of respiratory depression by morphine.

Peripheral analgesics (non-narcotic)
Drugs this drug is also called peripheral analgesics, because it does not affect the Central Nervous System, do not lose consciousness or lead to addiction. All the peripheral analgesic antipyretic also have work: lower body temperature in febrile conditions, it is also known antipyretic analgesics. Usefulness based on the excitement of the heat regulating center in the hypothalamus, resulting in peripheral vasodilatation (in skin) with the increase in spending a lot of heat and accompanied by the release of sweat.
Chemical classification of peripheral analgesics are as follows:
1. salicylates, salicylate, Na-salicylate, asetosal, salisilamida, and benirilat
2. Derivatives of p-aminofenol: fenasetin and paracetamol
3. Derivatives pirozolon: antipirin, aminofenazon, dipiron, phenylbutazone danturunan-derivatives
4. Derivatives antranilat: glafenin, mefenamic acid, and acid nifluminat.

Side effects that usually emerge are disturbances of the stomach-intestine, blood damage, liver damage, and kidney as well as allergic skin reactions. These side effects occur mainly on the use of long or in large doses, then you should not use these analgesics continuously.

Analgesic-Antipyretics
Analgesics are drugs that reduce or eliminate pain without losing consciousness. While antipyretics is a drug that can lower high-temperature body. Thus, analgesic-antipyretic drug dalah which reduces pain and simultaneously reduce high body temperature.
As a mediator of pain, among others, are as follows:
1. Histamine
2. Serotonin
3. Plasmokinin (including bradykinin)
4. Prostaglandins
5. Potassium Ion

Analgesics given to patients to reduce pain that can be caused by various stimuli mechanical, chemical, and physical that goes beyond a certain threshold value (the value of pain threshold). The pain is caused by the release of pain mediators (eg bradykinin, prostaglandins) from the damaged tissue which then stimulates pain receptors in the peripheral nerve endings or elsewhere. From these places later excitatory pain forwarded to the pain center in the cerebral cortex by sensory nerves through the spinal cord and thalamus.

Compressed as to relieve the pain

Body parts are often wracked complaints of pain are the neck, legs, and arms. In addition to medication and therapy, first aid can be done to compress. Of its kind, compress divided into two, namely the cold and warm compresses, which has the following benefits:

Warm Compresses

• Can be done by attaching a rubber bag filled with warm water or a towel that has been soaked in warm water, to the painful body part.
• There should be followed by movement exercises or massage.
• Physiological effects of a warm compress is the softening of fibrous tissue, making the body more relaxed muscles, reduce or eliminate pain, and facilitate the supply of blood flow.

Cold Compress

• The use is a bag of ice cubes (cold pack), could also be a towel dipped in cold water.
• Physiological effects are vasoconstriction (narrowing of blood vessels) and a decrease in metabolic, help control bleeding and swelling due to trauma, reduce pain, and decrease the activity of nerve endings in the muscles.

Compress should be careful because it can cause skin tissue had necrosis (cell death). It is recommended to perform a cold compress no more than 30 minutes.

Rational Treatment

According to the World Health Organization (WHO, 1987), the use of drugs said to be rational if it meets the criteria:
• According to indications of disease
• Available at all times at affordable prices
• Given the correct dosage
• Route of administration by giving the appropriate time interval
• Duration of the right
• Given drug should be effective, with guaranteed quality and safety.

Thus the use of drugs said to be rational if it satisfies several requirements as follows:

• Accuracy of diagnosis
• Accuracy of the drug indication
• The accuracy of the selection of drugs: therapeutic class, drug type, usefulness, safety, risk SE, price and quality.

The term rational in the treatment if the treatment is done correctly, ie correct diagnosis, appropriate indications, right drug, right dose, method and duration of administration, proper assessment of the condition of the patient, proper information and appropriate follow-up.
.
Symptoms The Irrational Drug Use
• Prescribing excess (over-prescribing)
- Cough common cold were given antibiotics
- Provision of vitamins in children with an ideal weight
• Prescribing less (under prescribing)
- Giving antibiotics for 3 days
- Patients with diarrhea were not given ORS
• Prescribing compound (muliple prescribing)
- Children were given CTM fever cough runny nose, Ephedrine,Glycerin Guaiacolat ( GG ), sedatives
• Prescribing the wrong (incorrect prescribing)
- Children 4 years with cholera given Tetracycline
- Injection vitamin B12 for people with stiff

The Impact of Irrational Drug Use

• Quality treatment and care
• The cost of treatment services
• Possible side effects and other effects are not expected (resistance, the risk of disease transmission, injecting drug penggunakaan not lege artis, and the danger of allergic / anaphylactic shock)
• Psychosocial conditions.

Factors influencing the occurrence of Irrational Drug Use
Recipes Maker :

• The lack of SOPs
• Experience everyday practice
• Information from pharmaceutical companies
• Pressure from patients dal; am the form of a request to prescribe certain drugs based on the patient's own choice
• Recipes maker are less sure of the diagnosis is established. .
• Lack of time for doctors / nurses / midwives to carry out careful examination because of the many patients waiting to be examined.

Patient / community

• Some patients feel belim recovered from his illness when not injected
• Some parents ask their children with diarrhea patients were injected, or given antibiotics or antidiarrheal.

System planning and management of drug

• Limited funding
• Limited number of medications available
• Planning and procurement of drugs does not fit the needs of drugs in health centers
• Wisdom of the drug and health services
• Delegation of authority to conduct the practice of medicine is not based on knowledge of the drug.
• Health services delivering drugs to patients without a prescription

Other

• • The unceasing drug information in the form of advertising
• • Competition practice

More generally irrational use of drugs that will give the general characteristics as follows:

• Where the drug is actually an indication of its use in medical non-existent or vague.
• Selection of the wrong drug for specific disease indications
• Way of drug administration, dose, frequency and duration of administration are not appropriate.
• Use of medications with potential toxicity or side effects is greater when other drugs similar usefulness (efficacy) with the potential effect is smaller as well.
• The use of expensive drugs when cheaper alternatives with the same benefits and security available.
• Does not provide treatment that is already known and accepted usefulness and safety.
• Providing treatment with drugs that expediency and safety is still questionable.
• Use of drugs that primarily based solely on individual experience without reference to sources of scientific information is feasible, or only based on information sources that can not be ascertained truth.
• Use of drugs that do not consider the patient's condition, such as whether there are contraindications, whether dose adjustment should be made in connection with the patient's condition.

Ovarian cancer

Ovarian cancer is a malignant tumor of the ovary are often found in women aged 50-70 years. Ovarian cancer can spread to other parts, pelvis and abdomen through the lymphatic system and spread through the vascular system to the liver and lungs.

Etiology
The cause of ovarian cancer is not known with certainty. However, many theories that explain the etiology of ovarian cancer, including:
1. Incessant ovulation hypothesis
The theory states that there is damage to ovarian epithelial cells for wound healing at the time of ovulation. The healing process of epithelial cells are disrupted can lead to the process of transformation into tumor cells.
2. Hypothesis androgen
Androgens have an important role in the formation of ovarian cancer. It is based on the experiment results that contain epithelial ovarian androgen receptor. In experiments in vitro, androgens can stimulate the growth of normal ovarian epithelium and ovarian cancer cells.

Pathophysiology
Every day, normal ovary will form several small cysts called follicles de Graff. In mid-cycle, dominant follicle with a diameter of more than $ 2.8 cm will release the mature oocyte. Follicle rupture would be the corpus luteum, which when cooked has a structure of 1.5 to 2 cm with cysts in the middle. If fertilization does not occur in the oocyte, the corpus luteum will experience a progressive fibrosis and shrinkage. However, when fertilization occurs, the corpus luteum will first swell and then gradually decreases during pregnancy.
Ovarian cysts originating from the normal ovulation process called functional cysts and are always benign. Cysts can be either follicular and luteal sometimes called Theca-lutein cysts. Cysts can be stimulated by gonadotropins, including FSH and HCG. Multiple functional cysts can be formed due to gonadotropin stimulation or excessive sensitivity to gonadotropins.
In tropoblastik gestational neoplasia (hydatidiform mole and choriocarcinoma) and sometimes in multiple pregnancies with diabetes, causing a condition called HCG hiperreactif lutein. Patients in the treatment of infertility, ovulation induction using gonadotropins (FSH and LH) or sometimes clomiphene citrate, ovarian hyperstimulation syndrome can cause, especially when accompanied with HCG administration.
Neoplasia cyst can grow from excessive cell proliferation and uncontrolled in the ovaries and can be malignant or benign. Malignant neoplasia which can be derived from all types of cells and ovarian tissue. So far, the most common malignancy originating from the surface epithelium (mesothelium) and most of the partial cystic lesions. Similar type of benign cyst with malignancy is serous and mucinous cistadenoma. Other malignant ovarian tumors that can be composed of cystic areas, including this type granulosa cell tumor of sex cord cells and germ cell tumors from primordial germ cells. Teratomas derived from germ cell tumor that contains elements from the three embryonic germ layers; ektodermal, endodermal, and mesodermal.
Endometrioma is a cyst containing blood from ectopic endometrium.

Risk Factors

• High-fat diet
• Smoke
• Alcohol
• Perineal use of talc powder
• History of breast cancer, colon, or endometrial
• Family history of breast or ovarian cancer
• Nulliparous
• Infertility
• Early menstruation
• Never given birth

Signs & Symptoms

Common symptoms are varied and not specific. At an early stage in the form:

• Irregular menstruation
• Menstrual tension continues to rise
• Menorrhagia
• Tenderness in the breast
• Early menopause
• Discomfort in the abdomen
• Dyspepsia
• Pressure in the pelvis
• Frequent urination
• Flatulenes
• Feeling of fullness after eating small meals
• Increasing abdominal girth

Staging
Primary ovarian cancer staging according to FIGO (Federation InternationalofGinecologies and Obstetricians) in 1987, is:

STAGE I -> growth limited to ovaries

1. Stage 1A: growth limited to one ovary, no ascites containing malignant cells, no growth on the outer surface, capsule intact.
2. Stage 1B: growth limited to both ovaries, no ascites, contain malignant cells, no tumor on external surface, capsule intact.
3. Stage 1C: tumors with stage 1a and 1b, but there is a tumor or a second outer surface of the ovary or capsule rupture or by ascites containing malignant cells or with positive peritoneal washings.

STAGE II -> Growth in one or two ovaries with extension to the pelvis

1. Stage 2A: expansion or metastasis to the uterus, or fallopian
2. Stage 2B: expansion of other pelvic tissues
3. Stage 2C: 2a and 2b tumor stage but on the surface of the tumor with one or both ovaries, capsule ruptured, or with ascites containing malignant cells with positive peritoneal washings.

STAGE III -> tomor on one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal. Tumor confined within the small pelvis but cell histology proved to extend to the bowel or omentum.

1. Stage 3A: tumor confined in the small pelvis with negative nodes but histologically and microscopically confirmed there is a growth (seeding) surface of the abdominal peritoneum.
2. Stage 3B: a tumor on one or both ovaries with peritoneal implants surface and proved microscopically, the diameter exceeds 2 cm, and lymph nodes negative.
3. Stage 3C: implants in abdoment with a diameter> 2 cm or lymph node positive retroperitoneal or inguinal.

STAGE IV -> growth on one or both ovaries with distant metastases. When the pleural effusion and positive sitologinya results in stage 4, as well as metastasis to the liver surface.

Enforcement of Medical Diagnosis

The majority of ovarian cancer stems from a cyst. Therefore, if a woman found an ovarian cyst have to do further tests to determine whether the cyst is benign or malignant (ovarian cancer).

The characteristics cysts that are malignant are the circumstances:

• Rapidly enlarging cyst
• Cysts in adolescence or postmenopausal
• Cysts with thick walls and are not sequential
• Cyst with solid parts
• Tumors of the ovary

Strengthens the case for further investigation towards ovarian cancer such as:

• Ultrasound with Doppler to determine blood flow
• If necessary, a CT-Scan / MRI
• Examination of tumor markers such as Ca-125 and Ca-724, beta - HCG and alfafetoprotein

All of the above checks have not been able to confirm the diagnosis of ovarian cancer, but only as a handle to perform surgery.

Colon Cancer (Colorectal Cancer)

Definition
Colon cancer is a cancer in the colon.
Colon cancer is the second leading cause of death in the United States after lung cancer (ACS 1998)
These diseases including the deadly disease because the disease is often not known until a more severe level. Surgery is the only way to change the Colon cancer.

Pathophysiology
Changes in Pathology
Tumors occur in a place which roughly follow the colon in part (Sthrock 1991 a):
• 26% in the caecum and ascending colon
• 10% in colon transfersum
• 15% in colon desending
• 20% in the sigmoid colon
• 30% in the rectum
The figure below illustrates the occurrence of cancer of the sigmoid and right colon and reduce the incidence of disease in the rectum in 30 years (Sthrock).
Colon carcinoma mostly produce adenomatus polyps. These tumors usually grow not detected until symptoms appear slowly and looked dangerous. The disease is spread in several metode.Tumor might spread in a certain spot on the inner lining of the stomach, reach the serosa and mesenteric fat. Then tumors begin to attach to the organ that is around, then extends into the lumen of the colon or spread to the spleen or the circulatory system. This circulation system directly into the primary tumor through the blood vessels of the colon by the spleen, after the tumor cells enter the circulatory system, typically cells move into the liver. The second place is a place far later metastases to the lungs. Metastases to other places including:
- Adrenal gland
- Kidney
- Leather
- Bones
- Brain
The addition to direct infection and spread through the lymphatic and circulatory system, colon tumors can also spread to parts peritonial tumor before surgery has not been done. The spread occurs when the tumor is removed and the cancer cells from tumor rupture into the cavity peritonial.

Complication
Complications occurred in connection with the increase in growth at the tumor site or through the spread of metastases which include:

•  bowel perforation caused by peritonitis
•  abscess formation
•  fistula formation in the urinary bladder or vagina

Usually the tumor and surrounding blood vessels invade the cause perdarahan.Tumor grow into the large intestine and gradually helps the large intestine and in the end not at all. Extension of tumor beyond the stomach and may be pressing on disekitanya organs (uterus, urinary bladder, and ureters) and the cause of the symptoms covered by the cancer.

Etiology
Causes of Colon cancer is unknown. Diet and reduction of the circulation time of the colon (feces forward flow) which includes the causative factor. Appropriate precautionary instructions recommended by the American Cancer Society, The National Cancer Institute, and other cancer organizations.
Foods must contain at suspected chemical substances that cause cancer of the colon. These foods also reduce the circulation time in the stomach, which accelerates colon cancer causes. Foods that are high in fat, especially animal fat from red meat, causing the secretion of acid and anaerobic bacteria, causing the incidence of cancer within the colon. The meat in frying and in baked can also contain chemicals that cause cancer. Diet with refined carbohydrates that contain fiber in large quantities can reduce the circulation time in the colon. Some groups suggested a diet that containing little animal fat and high in vegetables and fruits (eg, Mormons, Seventh Day Adventists).

Foods to avoid:

• Red meat
• Animal fats
• Fatty foods
• Meat and fish fried or grilled
• Carbohydrates are filtered (example: the filtered juice)

Food should be consumed:

• Fruits and vegetables are particularly Craciferous Vegetables from the cabbage group (such as broccoli, brussels sprouts)
• Grain rice is intact
• Liquid water is sufficient, especially

Since most tumors produce Colon adenoma, the main factor causing harm to the Colon cancer adenoma. There are three types Colon adenomas: tubular, villous and tubulo villous (will be discussed in polyps). Although most of the Colon cancers derived from adenomas, only 5% of all adenomas become manigna Colon, villous adenomas have a high potential to become manigna.
Factors leading to adenoma or benign tumor of unknown manigna clustered polyposis is a hereditary autosomal dominant gene spread. Risk of cancer in polyposis femiliar place close to 100% of persons aged 20-30 years.
People who have had ucerative colitis or Crohn's disease are also at risk of Colon cancer. The addition of risk at the beginning of a younger age and higher rates of colon involvement. Risk of Colon cancer will be 2 / 3 times greater if a family member suffering from the disease

Genesis.
Approximately 152,000 people in the United States diagnosed with Colon cancer in 1992 and 57,000 people die from this cancer in the same year (ACS 1993). Most of the clients on Colon cancer has the same frequency between men and women. Cancer in the right colon usually occurs in women and Ca in the rectum usually occurs in males.

Transcultural alternative.
Colon Ca incident on the USA seems to have a setback from all other nations except in African men and greater amerika.Kejadian happened to these cancers occur in industrial areas to the west and partly Japanese and African firlandia this is thought to relate to diet . Regions whose inhabitants have a low incidence of colon have a high dietary Ca of fruits, vegetables, fish and some meats.

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COPD (Chronic Obstructive Pulmonary Disease)

Definition COPD (Chronic Obstructive Pulmonary Disease) is:

1. Clinical syndrome of chronic dyspnea with expiratory airflow obstruction due to bronchitis and or emphysema
2. Chronic lung disease characterized by airflow resistance of the airways due to chronic bronchitis or emphysema and pulmonary
3. Chronic Obstructive Pulmonary Disease [COPD] is a lung disease with obstruction of lung airflow that lasts long.

Diagnosis of COPD

A common complaint in COPD :

• Shortness of breath
• Chronic Cough
• Productive sputum

Confirmed by spirometry test:

• VEP1 (FEV 1) post bronkhodilator = <80%, and VEP1/KVP (FEV1/FVC) = <70% 

Types of COPD:
Chronic Bronchitis and Emphysema.
Inchronic bronchitis there is inflammation in the airway wall so as to produce too much mucus. As a result of airway narrowing that affected the air exchange in the lungs. In chronic bronchitis there is also damage to the cilia that function to clear excess mucus in the airways.
In emphysema, there was enlargement and extensive damage to the alveoli, resulting in disruption of air exchange in the lung.

Chronic bronchitis
Syndrome a chronic productive cough (at least 3 consecutive months and at least for 2 years) with no other identifiable cause.
Emphysema
Pathological diagnosis characterized by enlargement of airspaces distal to bronchioli terminal (terminal bronchi) is accompanied by alveolar wall destruction.

History and physical examination

• Chronic productive cough
• Shortness of breath (Tachypnea)
• Breathing with the lips contract
• History of smoking which means
• Alpha-1 antitrypsin deficiency in non-smokers
• On chest percussion hiperesonansi
• Respiratory sound may be weakened

Chest X-ray photographs

• Low and flat diaphragm -->Useful for acute exacerbations to exclude complications such as pneumonia or pneumothorak

ECG changes

• Low QRS voltage
• If there is cor pulmonale occur deviations in delivery II, III and aVF

Examination of lung function

• FEV1 and all measurements of expiratory air is reduced Residual volume (RV) and total lung capacity increases
• Vital Capacity (KV) is reduced

Examination AGD

• Pa CO2 increased
• Hemoglobin saturation decreased
• Respiratory acidosis

Factors that influence the incidence of chronic bronchitis and emphysema
1. Smoking

• Hyperplasia of mucous glands bronchi
• Respiratory tract epithelial metaplasia skuamus
• Inhibition activity of the hair cells vibrate, alveolar macrophages, surfactant

2. Infection
Most bacteria are Haemophilus influenzae and Streptococcus pneumonia

3. Pollution
Chemicals that can cause bronchitis are: N2O, Hydrocarbons, Aldehydes, Ozone, O2
4. Offspring
Not known except dipengaruhnya deficiency of alpha-1 anti-trypsin is a disorder inherited in an autosomal recessive ang
5. Social and Economy
Patients with chronic bronchitis mortality more in lower socioeconomic groups

Pathophysiology

• In the lung there is a balance between proteolytic enzymes elastase and anti-elastase to prevent tissue damage
• Sources elastase: PMN cells, alveolar macrophages
• Sources elastase influenced by: cigarette smoke, infection
• Anti-elastase in the form of the enzyme alpha-1 anti-trypsin
• When anti-elastase elastase increases, decreases
• Because there is an imbalance between elastase and anti-elastase is elastin lung tissue damage and emphysema occur
• Refinement sal. respiration occurs PPOM
• In chronic bronchitis airway constriction occurs in small and large because the process of hypertrophy, hyperplasia of mucous glands
• In emphysema narrowing due to reduced lung elastisistas
• In the lung there is an interesting balance between the pressure of lung tissue with a pull out into the
• Exit by intra-pleural pressure and chest wall muscles
• Into the lung elasticity B
• Balance they form a functional residual capacity

Management COPD

There are four components of the management of COPD according to WHO 1998

• Assessment and monitoring of disease
• Reduce risk factors
• Stable COPD Therapy
• Therapy of acute exacerbations

When described then management of these become:

1. Stop smoking
2. Pharmacologic Therapy
3. Oxygen therapy
4. Mechanical ventilation
5. Rehabilitation
6. Nutrition
7. Surgery
8. Vaccination
9. Education

The objectives of the management of COPD are:

1. Prevent disease progression
2. Eliminate complaints
3. Increase activity tolerance
4. Improve health status
5. Prevent and treat exacerbations
6. Prevent and treat complications
7. Reduce mortality