MUHAMMAD ILYAS

Divisi Pulmonologi Bagian Ilmu Penyakit Dalam/

Departemen Pulmonologi dan Kedokteran Respirasi
Fakultas Kedokteran Universitas Hasanuddin
Identify normal changes of aging of
the respiratory system
 Lungs
Airways leading to the lungs
Blood vessels serving the lungs
Chest wall
 Respiratory Mucosa
lined with ciliated mucus
producing cells
125cc/ day
purifies air
is contiguous with all
structures
Nose
paranasal sinuses
frontal, maxillary,
sphenoid, ethmoid
lighten skull
sound resonant chambers
conchae (3 pairs)
warm & humidify air
lacrimal ducts
olfactory receptors
Pharynx
3 parts: Nasopharynx,
Oropharynx, Laryngopharynx
Tonsils(3 pairs)
pharyngeal (adenoids)
palatine
lingual
Eustachian (auditory) tubes
open into nasopharynx
equalizes pressure between
middle ear & the outside
Larynx
composed of pieces of cartilage
Thyroid cartilage= Adams
apple
epiglottis & glottis
 Trachea
composed of C- shaped cartilaginous rings
called windpipe
Bronchi, Bronchioles, Alveolar Duct,
Alveoli
gas exchange occurs in alveoli
occurs via Passive Diffusion
Respiratory Membrane
2 cell layers thick
surfactant = reduces surface tension
to keep alveoli distended
lining of alveolus (alveolar
epithelium)
lining of capillary ( capillary
endothelium)
 Lungs & Pleura

right lung = 3 lobes; left lung = 2 lobes

lower part of lung resting on diaphragm = Base
of lung
upper part of lung under clavicle = Apex of lung
pleura = serous membrane (i.e. secretes some
fluid)
parietal pleura lines thoracic cavity
visceral pleura lines organs (viscera)
 air moves by differences in air pressure
Inspiration
active process; get contraction of diaphragm &
external intercostal muscles
results in increase in size of chest cavity
Expiration
passive process with normal expiration
active process with forced expiration; get
contraction of abdominal & internal intercostal
muscles
results in decrease in size of chest cavity which
increases pressure & forces air out
 Stiffening of elastin and the collagen
connective tissue supporting the lungs
Altered alveolar shape resulting in increased
alveolar diameter
Decreased alveolar surfaces available for gas
exchange
Increased chest wall stiffness
Stiffening of the diaphragm
Reduced
Lung elasticity
Respiratory muscle strength
Chest wall compliance
FEV1 (declines before FVC)
Bronchial hyper-responsiveness
Perception of
bronchoconstriction
Diffusion capacity
Arterial oxygen pressure and
saturation
Ventilatory response to hypoxia
and (more worryingly)
hypercapnia
Increased
Residual volume
Lung compliance
Oxygen uptake on exercise
Unchanged
Total lung capacity
Airways resistance
Pulmonary arterial resistance
Arterial CO2 levels
 Tobacco smoking
Occupational exposure
Asthma
Atopy
Obesity
Excessive alcohol consumption
Respiratory infection in early life
Nutritional status at birth
Maternal or passive smoking
 Increased stiffness of the heart and blood
vessels, rendering these vessels less
compliant to increased blood flow demands
Diastolic dysfunction due to impaired
diastolic filling
Systolic dysfunction due to increased left
ventricular afterload
Decreased cardiac output with rest and with
exercise
 A decrease in the nature and quantity of
antibodies produced
A decrease in effectiveness of the protective
cilia of the respiratory tract in removing
debris (remains) from the airways, allowing
more foreign bodies to travel to the lungs
Use of medications that can suppress
immune function
 Loss of muscle tone
Exacerbated by deconditioning
Obesity
Sedentary lifestyle
Increased thoracic rigidity and osteoporotic
changes to the spine (kyphosis)
Deconditioning can be defined as the multiple,
potentially reversible changes in body systems
brought about by physical inactivity and disuse.
 Use of medications that can cause
Fatigue
Depression of the cough reflex
Insomnia
Dehydration
Bronchospasm
Common diseases of the
Respiratory System
 Age-related changes in the lungs
Years of exposure to air pollutants and
cigarette smoke
The presence of comorbidities (such as HT,
DM, CHF, CKD, Rheumatic disease, etc.)
 Reversible airflow inflammation
Increased mucous production
Increased airway responsiveness to a variety
of stimuli
Often ignored in the older person
Can present as a newly diagnosed disease or
as a chronic disease that the older person has
lived with for many years
 Coughing: may be worse at night
Wheezing: usually high-pitched whistling
sounds on expiration
Shortness of breath
Chest tightness
 Results of pulmonary function tests
(spirometry preferred than peak flow meter)
Chest radiography
Electrocardiography
Complete blood count with differential count
 Spirometry

Peak flow meter

 Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)

More than
Daytime symptoms None (2 or less / week)
twice / week

Limitations of activities None Any 3 or more

features of partly
Nocturnal symptoms / controlled asthma
None Any
awakening present in any
Need for rescue / More than week
None (2 or less/ week)
reliever treatment twice / week
< 80% predicted or
Lung function
Normal personal best (if known)
(PEF or FEV1)
on any day

Perhimpunan Dokter Paru Indonesia Diagnosis dan Penatalaksanaan Asma dari PDPI dan
(The Indonesia Society of Respirology) Implementasi GINA di Indonesia
 Reduce the frequency and severity of
symptoms
Improve results of spirometry testing
 Allergen Food allergy
Air pollution Food preservation
Respiratory Drugs
infection Stress
Exercise Rhinitis, sinusitis &
Hyperventilation polyposis
Climate change GERD
Sulphur dioxyde
 Inhaled corticosteroid therapy
Oral corticosteroids
Inhaled beta2-agonists
Methylxanthine (theophylline)
Ipratropium bromide
Inhalation therapy
 Used for two closely related diseases of the
respiratory system, chronic bronchitis and
emphysema
Chronic bronchitis
Narrowing of the large and small airways, making it
more difficult to move air in and out of the lungs
Emphysema
Permanent destruction of the alveoli because of
irreversible destruction of elastin, a protein in the
lung that is important for maintaining the strength
of the alveolar walls, risk factor is smoking
 Walls of the small airways and alveoli lose
their elasticity and thicken
Closes off some of the smaller air passages
and narrows the larger ones
Air can enter the alveoli but becomes trapped
due to the collapsed airways
Affects gas exchange and pathological changes
occur
 Blood is poorly oxygenated and tissue
perfusion is less efficient
Carbon dioxide may accumulate to critical
levels
Respiratory acidosis
Respiratory failure
Strains the heart due to pulmonary
hypertension
Right ventricle can enlarge and thicken
Abnormal rhythms called cor pulmonale
 ASTHMA COPD
Allergens Cigarette smoke

Ep cells Mast cell Alv macrophage Ep cells

CD4+ cell Eosinophil CD8+ cell Neutrophil

(Th2) (Tc1)

Bronchoconstriction Small airway narrowing

AHR Alveolar destruction

Reversible Irreversible
Airflow Limitation

Source: Peter J. Barnes, MD

 Early
Early morning cough with clear sputum
Periods of wheezing during or after colds
Shortness of breath on exertion
 Late
Mouth breathing
Puffing
Use of accessory muscles of breathing
Inability to finish sentence without catching ones
breath
Sleep in semi-sitting position
 Spirometry preferred than peak flow meter
Arterial blood gases (ABGs)
Can be difficult to obtain
 Oxygen
Medications
Bronchodilators
Corticosteroids
Antibiotics
First sign of infection
Yellow or green sputum
 Other treatments
Bullectomy or lung reduction
Pulmonary rehabilitation
Exercise
Oxygen
Nutritional support
Intermittent mechanical ventilator support
 Airborne disease
Spread by droplets when an infected person
coughs, sneezes, speaks, sings, or laughs
Adequate ventilation is the most important
measure to prevent transmission
 Can be a reactivation of old disease
Can be a new infection due to exposure to an
infected individual
 Living in an institution
Diabetes mellitus
Use of immunosuppressive drugs
Malignancy
Malnutrition
Renal failure
 Anamnesis & Physical examination
Microbiology (sputum smear, and culture of
Mycobacterium tb.)
Chest X-ray
Chest x ray :
Fibroinfiltrate in
upper & medial of
left hemithorax
 Anti TB drugs based on Directly Observed
Treatment Short-ccourse (DOTS)
Fixed dose combination (FDC) preferred than
monotherapy
 Responsible for almost one third of all cancer
deaths worldwide
At least 12 different types of tumors are
included in the broad heading of lung cancer
Squamous cell
Adenocarcinomas
Large cell carcinomas
Small cell carcinomas (oat cell)
Growth rate and metastasis rate vary by tumor type
 Vague and mimic the symptoms of other
pulmonary illnesses
Chronic cough
Hemoptysis
Chest pain
Shortness of breath
Fatigue, weight loss
Frequent lung infections
 Anamnesis & Physical examination
Chest radiography
CT scan
MRI scan
Pulmonary function tests
Trans thoracal biposy/needle aspiration
(TTB/TTNA)
Bronchoscopy with collection of lung tissue,
cells, or fluids for analysis
 Surgical removal of the tumor or lung
Chemotherapy
Radiation
Palliative care
 Older adults may not cough, exhibit an
elevated temperature, or show other classic
signs of a respiratory infection
Atypical symptoms include lethargy, falling,
exhibiting loss of cognitive or physical
function, or simply not eating or drinking
 Most common type of infectious disease of
the lung
 KLASIFIKASI PNEUMONIA

Berdasarkan Berdasarkan Berdasarkan

Sumber Infeksi
Pneumonia yg didapat di
masyarakat
(Community-acquired pn.)
Pneumonia yg didapat di
RS (Hospital-acquired pn. )
Ventilatory associated
pneumonia
Kuman penyebab Predileksi / tempat
infeksi
Pneum. bakterial Pneumonia lobaris
Pneum. atipikal (lobar pneumonia)
Pneum. ok virus Bronchopneumonia
Pneum. ok jamur Pneum interstitialis
/ patogen lainnya (interstitial pneumonia)

Pneumonia aspirasi
Pne. Immunocompr. host
 Definition
An acute infection of the pulmonary
parenchyma that is associated with some
symptoms of acute infection, accompanied
by the presence of an acute infiltrate on a
chest radiograph, or auscultatory findings
consistent with pneumonia, in a patient not
hospitalized or residing in a long term care
facility for > 14 days before onset of
symptoms.
Bartlett. Clin Infect Dis 2000;31:347-82.
 History of nosocomial pneumonia within the
last 6 to 12 months
Diagnosed lung disease (COPD)
Recent hospitalization
Nursing home residence
Smoking
Alcoholism
Neurologic disease
 Age Immunocompromised patients
Chronic illness Asplenia (splenectomy,
Cardiovascular disease sickle cell disease)

Pulmonary disease Haematologic neoplams

Diabetes Generalized malignancies

Liver disease CRF, SN

HIV
Immunosuppressive therapies
Risk of decompensation of underlying disease
Increased risk of severe pneumococcal disease
Older, weaker, more at risk
More comorbidities
Gradual deterioration of immune system with age
May be malnourished, poor accommodation
More likely to harbour resistant organisms as more
likely to have been
Hospitalised
in nursing home
Exposed to multiple antibiotics
 Pathophysiology of bacterial pneumonia
Sources of bacteria Route of inoculation Response Outcome

Colonization of
Naso/oropharynx Microaspiration Sterile
lung

Air
Inhalation
Lung
Non-pulmonary defenses
infection Bloodstream

Contiguous Pneumonia
Direct extension
infection
 Streptococcus pneumonia
Haemophilus influenza
Staphylococcus aureus
Enterobacteriaceae
Pneumonia di Indonesia
By: Arifin Nawas
 Cough
Fever
Sputum production
Fever may be absent in the older person
Changes in function, appetite, continence,
and other subtle symptoms may be the first
signs of the onset of illness in the older adult
 Anamnesis
Physical examination :
Assess vital signs
Assess the skin for cyanosis
Inspect the thorax
Auscultate the lungs
Examination on other organ system
 Chest X-ray
Blood culture
Sputum specimen : smear & culture
Pulse oximetry (oxygen saturation)
Blood chemistry analysis
Chest x ray :
Infiltrate in
medial right
hemihorax
 Insidens tinggi
Kebanyakan kasus butuh perawatan
Mortalitas masih tinggi

Sir William Oslers infamous view was that

pneumonia was the friend of the aged that often
allowed patients with advanced illness to die
peacefully
Treatment of CAP
 Mild
Macrolide (azithromycin, clarithromycin)
Macrolide + -lactam
Doxycycline
Quinolone (moxifloxacin, levofloxacin,
gemifloxacin)

Severe
-lactam + macrolide
-lactam + quinolone (moxifloxacin,
levofloxacin, gatifloxacin)
 Physiotherapy : Chest percussion
Oxygen
Rehydration
Inhaled beta-adrenergic agonists
a. Vaccination
- All persons 50 years of age, others at risk for influenza
complications, household contacts of high-risk persons, and
health care workers
- Pneumococcal polysaccharide vaccine is recommended for
persons 65 years of age and for those with selected high-
risk concurrent diseases
b. Smoking cessation should be a goal for persons hospitalized
with CAP who smoke
c. Respiratory hygiene measures, including the use of hand
hygiene and masks or tissues for patients with cough
d. Implementing standard precautions and isolation in special
cases
 An occlusion of a portion of the pulmonary
vascular bed by an embolus consisting of a
thrombus, an air bubble, or a fragment of
tissue or lipids
Result is shortness of breath, heart failure, or
death
 Clotting disorders
Immobility
Dehydration
Recent surgery
Atherosclerotic changes in the circulatory
system
Obesity
 Intravenous administration of heparin
Other anticoagulant therapy
Warfarin therapy may be continued 3 to 6
months after discharge to prevent the
formation of another pulmonary embolus