SMALL AIRWAY

Muhammad Amin

COPD Day 2018

Bronchus

Wall thickening ndash

inflammation --

mucus gland

hypertrophy

uarr Secretions

Alveoli

Wall thinning -

inflammation -

elastolysis

Coalescence darr

Elasticity

Bronchiole

Wall thickening

ndash inflammation

ndash repair

-- remodeling

Loss of alveolar

attachments

Udara masuk ke Paru

bull Kecepatan aliran udara yang masuk ke paru

menurun secara gradual sesuai dengan generasi

yang dilewati

bull Aliran dengan kecepatan tinggi terjadi di

bagian proksimal dan bersifat turbulen sedang

lebih ke distal kecepatan berkurang dan bersifat

laminar aliran tersebut tidak tergantung

densitas udara

Udara masuk ke Paru

bull Tahanan aliran udara di SA rendah pada

individu sehat sekitar 10-25 tahanan total

SN akan tetapi meningkat pada penyakit

tertentu

Small airway

bull Small airway adalah SN dengan diameter kurang dari 2 mm

bull Bagian perifer SP tersebut merupakan area yang pertama kali terjadi

kelainan patologis pada banyak penyakit paru

bull Kelainan patologis tersebut seringkali mendahului gejala

klinikspirometrifoto

Walaupun kelainan di SA penting tapi di dalam praktek amat sulit

dideteksi karena

Biopsi tidak mungkin

Pencitraan tidak dapat gambaran jelas

Spirometri masih normal

bull Disebut ldquosilent zonerdquo1

lt 2mm

Small airways disease

kebutuhan tak terpenuhi untuk diagnosis

managemen dan outcome yang lebih baik

Perbedaan utama antarta large dan

small airways

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Bronchus

Wall thickening ndash

inflammation --

mucus gland

hypertrophy

uarr Secretions

Alveoli

Wall thinning -

inflammation -

elastolysis

Coalescence darr

Elasticity

Bronchiole

Wall thickening

ndash inflammation

ndash repair

-- remodeling

Loss of alveolar

attachments

Udara masuk ke Paru

bull Kecepatan aliran udara yang masuk ke paru

menurun secara gradual sesuai dengan generasi

yang dilewati

bull Aliran dengan kecepatan tinggi terjadi di

bagian proksimal dan bersifat turbulen sedang

lebih ke distal kecepatan berkurang dan bersifat

laminar aliran tersebut tidak tergantung

densitas udara

Udara masuk ke Paru

bull Tahanan aliran udara di SA rendah pada

individu sehat sekitar 10-25 tahanan total

SN akan tetapi meningkat pada penyakit

tertentu

Small airway

bull Small airway adalah SN dengan diameter kurang dari 2 mm

bull Bagian perifer SP tersebut merupakan area yang pertama kali terjadi

kelainan patologis pada banyak penyakit paru

bull Kelainan patologis tersebut seringkali mendahului gejala

klinikspirometrifoto

Walaupun kelainan di SA penting tapi di dalam praktek amat sulit

dideteksi karena

Biopsi tidak mungkin

Pencitraan tidak dapat gambaran jelas

Spirometri masih normal

bull Disebut ldquosilent zonerdquo1

lt 2mm

Small airways disease

kebutuhan tak terpenuhi untuk diagnosis

managemen dan outcome yang lebih baik

Perbedaan utama antarta large dan

small airways

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Udara masuk ke Paru

bull Kecepatan aliran udara yang masuk ke paru

menurun secara gradual sesuai dengan generasi

yang dilewati

bull Aliran dengan kecepatan tinggi terjadi di

bagian proksimal dan bersifat turbulen sedang

lebih ke distal kecepatan berkurang dan bersifat

laminar aliran tersebut tidak tergantung

densitas udara

Udara masuk ke Paru

bull Tahanan aliran udara di SA rendah pada

individu sehat sekitar 10-25 tahanan total

SN akan tetapi meningkat pada penyakit

tertentu

Small airway

bull Small airway adalah SN dengan diameter kurang dari 2 mm

bull Bagian perifer SP tersebut merupakan area yang pertama kali terjadi

kelainan patologis pada banyak penyakit paru

bull Kelainan patologis tersebut seringkali mendahului gejala

klinikspirometrifoto

Walaupun kelainan di SA penting tapi di dalam praktek amat sulit

dideteksi karena

Biopsi tidak mungkin

Pencitraan tidak dapat gambaran jelas

Spirometri masih normal

bull Disebut ldquosilent zonerdquo1

lt 2mm

Small airways disease

kebutuhan tak terpenuhi untuk diagnosis

managemen dan outcome yang lebih baik

Perbedaan utama antarta large dan

small airways

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Udara masuk ke Paru

bull Tahanan aliran udara di SA rendah pada

individu sehat sekitar 10-25 tahanan total

SN akan tetapi meningkat pada penyakit

tertentu

Small airway

bull Small airway adalah SN dengan diameter kurang dari 2 mm

bull Bagian perifer SP tersebut merupakan area yang pertama kali terjadi

kelainan patologis pada banyak penyakit paru

bull Kelainan patologis tersebut seringkali mendahului gejala

klinikspirometrifoto

Walaupun kelainan di SA penting tapi di dalam praktek amat sulit

dideteksi karena

Biopsi tidak mungkin

Pencitraan tidak dapat gambaran jelas

Spirometri masih normal

bull Disebut ldquosilent zonerdquo1

lt 2mm

Small airways disease

kebutuhan tak terpenuhi untuk diagnosis

managemen dan outcome yang lebih baik

Perbedaan utama antarta large dan

small airways

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Small airway

bull Small airway adalah SN dengan diameter kurang dari 2 mm

bull Bagian perifer SP tersebut merupakan area yang pertama kali terjadi

kelainan patologis pada banyak penyakit paru

bull Kelainan patologis tersebut seringkali mendahului gejala

klinikspirometrifoto

Walaupun kelainan di SA penting tapi di dalam praktek amat sulit

dideteksi karena

Biopsi tidak mungkin

Pencitraan tidak dapat gambaran jelas

Spirometri masih normal

bull Disebut ldquosilent zonerdquo1

lt 2mm

Small airways disease

kebutuhan tak terpenuhi untuk diagnosis

managemen dan outcome yang lebih baik

Perbedaan utama antarta large dan

small airways

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

lt 2mm

Small airways disease

kebutuhan tak terpenuhi untuk diagnosis

managemen dan outcome yang lebih baik

Perbedaan utama antarta large dan

small airways

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Perbedaan utama antarta large dan

small airways

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Percabangan lebih dalam diameter

lebih kecil

generasi 0-8

diameter gt 2mm

Large airways

generas 9-23

diameter lt 2mm

Small airways

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Percabangan lebih dalam area permukaan

lebih besar

httpnewsweavercoukhorizonmedicale_article001251726cfm

140m2

150

100

50

0

Luas permukaan m2

Small airways

290 cm2

Large airways

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Ressiten perifer meningkat walaupun pada

asma ringan dengan spirometri normal

p=0013 vs healthy subjects

Wagner EM et al Am Rev Respir Dis 1990

Ave

rage p

erip

hera

l re

sis

tan

ce

(cm

H2O

mL

min

)

Healthy

subjects

Patients with

mild asthma

0069

n=15 0

0009

0069

002

004

006

008

0

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Laminar Flow is streamlined such

that the fluid at the center of the

tube moves

the fastest Flow in small airways

(diameter lt 2mm) is laminar silent

and slow

Turbulent Flow results in fluid flow in

both axial and radial direction and the

velocity of the fluid is on average the

same everywhere in the tube In the

large airways such as the trachea air

flow is turbulent fast and noisy

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Laminar airflow - the subject invests

and direction relatively little energy in airflow

characteristic to the small airways that

are distal to terminal bronchioles

Transitional airflow - it takes extra

energy to produce vortices 1048774 the

effective resistance increases airflow

is transitional throughout most of the

tracheo-bronchial tree

Turbulent airflow - is proportional to radicΔP the

effective resistance to airflow is the highest

only in the trachea where the airway radius is

large and

linear air velocities may be extremely high

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

MATEMATIK FISIOLOGI

bull r = 075

bull r4 = 03164

bull R1 = 316V

bull r = 0375

bull r4 = 00198

bull R2 = 5057

bull R2 divide R1 = 16

bull P = 25

bull R1 = 316

bull = 079

bull P = 25

bull R2 = 5057

bull = 0049

bull Flow by 94

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Fisiologi RESISTEN SN

R1 R2 R3

SERI

RTOT = 001 + 002 + 003 = 006 units

PARALEL

R1

R2

= 001

= 001

1RTOT = 1 001 + 1001 = 200

RTOT = 0005 units 68

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Pengukuran kelainan Small Airways

bull Volume statik dan dinamik (Spirometri dan

Body Plethysmography)

bull Forced oscillation technique dan impulse

oscillometry

bull Multiple and single breath nitrogen washout

test

bull Staticdynamic lung compliance and esophageal

balloon

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Pengukuran small airways

bull FEV1 refleksi diameter di larger airway

bull FEF25-75

bull Air trapping

bull IOS resistance

bull Uneven ventilation

ndash N2 washout small airway diameter

ndash Multiple breath N2 washout small airway diameter

bull HRCT scan

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

cekung

cekung

obstruksi small airways

obstruksi small airways

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

IOS Impulse Oscillometry

R5 Resisten SN total

R20 Resisten SN sentral

R5-R20 Resisten SN perifer

R5-R20 = Kelainan Small Airway

IOS mengukur resisten SN pada level berbeda dengan perbedaan

frekuensi (Hz)

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

23

Dewasa

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

SHIFT VOLUME

87

Gambaran skematik loop resisten spesifik a) subjek normal b)subjek dengan peningkatan

resisten di large airway c) subjek dengan chronic airflow obstruction d) dan subjek dengan

obstruksi upper airway

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Closing volume Phase III

20

10

0

TLC

Expired volume (L)

2 4 6

CVVC = 20

Nit

rog

en

co

nce

ntr

ati

on

(

)

CVVC = 30 Mild COPD

RV

Single breath N2 washout

ENHANCED AIRWAY CLOSURE IN MILD COPD

Does airway closure cause peripheral airway injury

Compression of airway epithelial cells

Release of inflammatory and fibrogenic mediators

What is the effect of bronchodilators

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

ldquoSmall Airways Dysfunctionrdquo

F

l

o

w

Volume

Expiratory flow

limitation

On forced

exhalation

During exercise

At rest

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Mekanik Pernapasan

Paru Zona Perifer

bull SN terbuka tidak sampai menutup Resisten rendah

bull Rekoil paru cukup kuat untuk melakukan ekpirasi tidal (passive)

bull Kerja pernapasan minimal

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

PPOK Perubahan Mekanik Paru

bull Penebalan dinding SN

dan cenderung kolap

resisten tinggi

bull Alveoli menipis

rekoil elastik jelek

bull Keterbatasan aliran

ekspirasi

bull Residual volume

meningkat

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Time Constants of

Breathing

Δ

Vol

Time (seconds)

A B C

A Wide airway good lung recoil

B Narrowed airway good lung recoil

Wide airway poor lung recoil

C Narrowed airway poor lung recoil

L

i

t

e

r

s

Keterbatasan

arus ekspirasi

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Resisten sepanjang SN

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Airway

Resistance

Normal Central Air

way Obst

Small Air-

way Obst

Central 80 160 80

Peripheral 20 20 40

R total 100 180 120

Silent Zone

PPOK dan distribusi

resisten SN

Large airway

Small airway

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Keadaan istirahat

Obstruksi berat+

penurunan berat rekoil

elastik rekoil

Obstruksi ringan

+penurunan ringan

rekoil elastik l

PPOK

EFL and Hyperinflation

Normal

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

EFL and Dynamic Hyperinflation

Siklus pernapasdan awal

Air is trapped

Selama

latihan PPOK

Normal

Normal

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

EFL and Dynamic Hyperinflation

Initial breathing cycle siklus selanjutnya

Hiperinflasi memburuk

Selama

latihan PPOK Normal

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

Tidal Volume Lu

ng

Vo

lum

e

Normal Time

Resting Exercise

Hyperventilation Static and Dynamic

Total Lung Capacity

COPD

INSP

IRA

TOR

Y C

APA

CIT

Y

END

EX

PIR

ATO

RY

LU

NG

VO

L

FRC

FRC

IC

Airway obstruction and low elastic recoil

Expiratory flow limitation

Hyperinflation at rest worsened by exercise

Limited inspiratory ldquospacerdquo

Dyspnea

End Expiratory Volume

TERIMA KASIH

TERIMA KASIH