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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