Smoking Cessation and COPD

1. A Health Awareness Lecture on
Smoking Cessation and COPD
August 23, 2022
ERNESTO E. PIGUING JR., RMT, MD
Internal Medicine

2. National Figures
240 Pilipino ang
namamatay araw-araw
dahil sa sakit na
dulot ng paninigarilyo

3. • Kahit na ang kita ng gobyerno mula sa
taxes ng sigarilyo ay umaabot sa PhP 23 billion
taun-taon
• Nababawasan ang ekonomiya
ng bansa dahil sa gastos na
pangkalusugan dulot ng
top 4 na sakit na dulot ng
paninigarilyo (Ca, CVD,
COPD, Diabetes) na umaabot sa
PhP 149 billion taun-taon.
SOURCE: Tobacco and Poverty Study, World Health Organization, 2008)

4. Bakit laganap sa Pilipinas ang
pag gamit ng SIGARILYO (tabacco)?
• MADALING MAKAKUHA
• AGGRESIBO AT LAGANAP NA KALAKAL
• KAKULANGAN SA KAALAMAN UKOL SA
PANGANIB SA KALUSUGAN
• KAKULANGAN SA PAGSASAGAWA NG
PATAKARAN AT PROGRAMA UPANG SUGPUIN
ANG EPIDEMYA NG SIGARILYO

5. SIGARILYO
ay ang natatanging LEGAL na produkto,
na kung ginamit base sa
manufacturers’ instructions,
ay siguradong papatayin ang kalahati
sa mga gumamit nito.

6. Ang usok ng sigarilyo ay merong
higit sa 7,000 chemicals,
higit sa 50 known or suspected carcinogens,
at maraming potent irritants.

7. OTHER TOXIC COMPONENTS

8. 3 PANGUNAHING SANGKAP
NG USOK NG SIGARILYO
•NICOTINE ay ang sangkap ng
sigarilyo na
nakakahumaling/nakaka-addict.
Ito ay naiiwan sa dugo at
nakaapekto sa utak sa loobng
10 segundo. Ito’y nagdudulot sa
naninigarilyo para gumanda ang
pakiramdam dahil sa kemikal na
ilinalabas
nagdudulot
ng utak. Ito’y
rin ng pagtaas ng
tibok ng puso, blood pressure, at
adrenaline na nakakaganda ng
pakiramdam.

9. •TAR ay makapal, malapot na sangkap, at kung malanghap
ito ay didikit sa mga maliliit na buhok sa baga (lungs), na
tinatawag na cilia. Normal nitong pinoprotektahan ang baga
laban sa mga dumi at impeksyon, pero kung ito’y mapupuno
ng tar ‘di nila magagawang protektahan ang baga. Tinatakpan
rin ng Tar ang mga bahagi ng buong respiratory system,
pinaliliit nito ang mga tubo na nagdadala ng hangin
(bronchioles) at nababawasan rin ang pagkabanat ng
baga.

10. • CARBON MONOXIDE ay
nakakalasong kemikal na makikita
sa mga usok ng tambutso ng mga
sasakyan. Binabawasan nito ang
dami ng oxygen sa dugo at pati na
rin sa ibang organs. Dahil konti na
ang oxygen sa dugo, ito’y nagiging
malapot at ito ang dahilan upang
pumuwersa ang puso na mag
buga ng dugo.

11. Ang PANINIGARILYO ay gumagawa
ng samo’t saring problema sa
kalusugan at komplikasyon….
W A R N I N G
Ang mga susunod na slides ay may mga imahe na
hindi angkop sa mga bata, patnubay ng magulang
ay kailangan.

12. Maagang namamatay ang
mga naninigarilyo.

13. Ang paninigarilyo ay ang pinaka dahilan ng mga karaniwang
uri ng kanser.

14. Ang paninigarilyo sa murang edad ay nakakapag pataas ng
panganib sa kanser sa baga (lung cancer) at bibig.

15. Smoking makes you about 10 times more likely
to die early from a major stroke or heart attack.
Pinatataas rin nito ang panganib na magkaroon ng diabetes.

16. Smokers suffer more frequently from
severe bronchitis and emphysema
(a disease where the chemicals in tobacco smoke severely damage
the lining of the lungs, and make it difficult to breathe).

17. Ang paninigarilyo ay nagdudulot ng pinsala sa mga maliliit
na ugat at pinipigilan nito ang pagdaloy sa mga kamay at
paa, na maaaring magkaroon ng gangrene at magdulot ng
pagkaputol ng paa at kamay.

18. Naaapektuhan ng paninigarilyo ang iyong panlasa at pang amoy.

19. Ito’y nakakapagdulot ng pagkabulok ng ngipin, at nagiging kulay
dilaw ang ngipin at kamay.

20. Ang paninigarilyo ay nakakaapekto rin sa kutis at balat;
nakakapagdulot ito ng maagang pagtanda ng balat at
pagkakaroon ng mga kulubot (wrinkles).

21. Men who smoked for years were often unable
to have an erection due to low penile blood pressure.
Male smokers also have a lower sperm count and
more abnormal sperm than non-smokers.

22. PATAY ANG
KINABUKASAN
KO!?!
ART by Antonio Totto, Jr.

27. Tobacco Smoke
10 Filipinos die
by the hour due to
tobacco-related diseases

28. Sa kada stick ng sigarilyo na nagagamit,
nawawalan ng 5 to 10 minutes ng buhay ang taong naninigarilyo
at ilinalagay rin nya sa panganib ang mga inosenteng tao sa
kanyang paligid.

29. URI NG USOK NG SIGARILYO
•MAINSTREAM SMOKE Ito ay combinasyon ng hinithit at
ibinugang usok matapos itong sindihan.

30. SECONDHAND SMOKE

31. • THIRD-HAND SMOKE ay
kombinasyon ng usok at amoy
ng sigarilyo na dumidikit sa
buhok at damit ng naninigarilyo,
pati na rin sa sahig, mga kurtina,
appliances, mga gamit sa bahay,
mga laruan ng bata – kahit na
wala ng naninigarilyo.

32. Other Health Hazards

33. SECONDHAND SMOKE EXPOSURE
TO INFANTS AND CHILDREN

34. • Sudden infant death syndrome (SIDS)
• Reduced lung function
• Increased blood pressure
• Headaches
• Acute lower respiratory infection –
bronchitis, pneumonia
• Respiratory irritation –
cough, phlegm, wheeze
• Difficulty in breathing
• Burning eyes and throat
• Ear infections
• Nose bleeds
• Frequency and severity of asthma
• Childhood cancers –
leukemia, lymphoma, brain tumor

35. ALAM ‘NYO BA?
The original “Marlboro Man”
may not
have been that macho or masculine
as his advertisements projected.
David Millar, Jr.
died from emphysema in 1987
after years of bad health.
Three more men who appeared
in Marlboro advertisements
– Wayne McLaren,
David McLean & Dick Hammer –
all died of lung cancer.

36. ALAM ‘NYO BA?

37. YOUTH AS REPLACEMENT SMOKERS

38. Studies say that
Filipino children
start smoking
at the age of
7

39. • In 2003, the Philippines enacted Republic Act 9211
aimed to:
- Promote smoke-free areas
- Inform public of the health risks
of tobacco use
- Ban all tobacco
advertisement and
sponsorship and restrict
promotions
- Regulate labelling of tobacco products
- Protect youth from being initiated
to smoking

40. • SMOKING BAN in public conveyances like jeepneys,
buses, taxis and tricycles.
• OTHER SMOKING BAN in elevators and stairwells,
locations in which fire hazards are present, health and
hospital facilities, public conveyances, and food
preparation areas.
• These places cannot have designated smoking areas.

41. A N O A N G P W E D E M O N G
GAWIN?…
Kung ikaw ay naninigarilyo, itigil
ito sa pinakamabilis na paraan.
Huwag mong hahayaan na may
manigarilyo sa loob ng inyong
bahay – protektahan mo ang
iyong sarili at iba laban sa
Secondhand smoke.
Makisali sa mga anti-smoking
campaigns – kailangan malaman
ng iba ang mga masamang
naidudulot ng paninigarilyo.

42. Kapag ikaw ay tumigil sa
pagyosi…
Sa loob ng 20 Minutes:
 Bababa ang blood pressure sa normal
 Magiging normal ang pulso
 Body temperature ng kamay at paa ay tumataas at nagiging normal
Sa loob ng 8 oras:
 Carbon Monoxide level sa dugo ay baba sa normal
 Oxygen level sa dugo ay tataas sa normal
 Smoker's breath ay nawawala
Sa loob ng 24 oras:
 Ang chance ng pagkakaroon ng heart attack ay nababawasan
Sa loob ng 48 oras:
Ang mga ugat-ugat ay nagsisimula na ulit na tumubo
Ang abilidad sa pangamoy at panlasa ay bumabalik

43. Sa loob ng isang taon:
 Ang panganib sa coronary heart disease ay kalahati
kaysa sa naninigarilyo
Sa loob ng 2 taon:
 Panganib sa Heart attack ay bababa sa normal
Sa loob ng 5 taon:
 Lung cancer death rate para sa average pack-a-day
smoker ay bababa ng halos kalahati
 Panganib sa Stroke risk ay mababawasan
 Panagnib mula sa mouth, throat at esophageal cancer
ay bababa ng kalahati kaysa sa mga naninigarilyo pa
Kapag ikaw ay tumigil sa
pagyosi…

44. Sa loob ng 10 taon:
 Lung cancer death rate ay
parehas na sa mga taong hindi
naninigarilyo.
 Ang mga nabuong pre-cancerous
cells ay napalitan na.
Sa loob ng 15 taon:
 Panganib mula sa coronary heart
disease ay parehas na sa mga
taong hindi man lang nanigarilyo.
Kapag ikaw ay tumigil sa
pagyosi…

45. The choice is yours !
Help us in our crusade
and save lives !
.

46. COPD

47. Definition
 COPD is a preventable and treatable lung
disease with significant extrapulmonary
effects
 Pulmonary component
 airflow limitation
 not fully reversible
 usually progressive
GOLD Definition
http://goldcopd.org

48. RaisingCOPDAwarenessWorldwide
15November 2018

49. COPD
 Associated with
 Abnormal inflammatory response of the lungs
 To noxious particles and gases
 Severe COPD leads to
 Respiratory failure
 Repeated hospitalization
 Death

50. Airflow
Limitation COPD
Components

51. Chronic Bronchitis
 Productive cough, for
 at least 3 months
 at least 2 consecutive years
 Absence of any other identifiable cause of
excessive sputum production
 Airflow limitation that is not fully reversible
 Abnormal inflammatory response to noxious
agent - e.g., smoking

52. Emphysema
 Alveolar wall destruction
 Irreversible enlargement of air spaces
 Distal to the terminal bronchioles
 Without evidence of fibrosis

53. Burden of Disease: Epidemiology
 In 2010, estimated 384 million patients
 Leading cause of morbidity and mortality
 Induces substantial economic and social burden
 Second leading cause of death
 Annual deaths due to COPD
 About 3 million
 4.5 million by 2030

54. Mortality due to COPD – 2005 & 2016

55. Risk factors
 Exposure
 Tobacco smoke
 Bio mass fuel smoke, open fires
 Chronic uncontrolled asthma
 Occupational dusts and chemicals
 Infections, overcrowding, damp
 Low socioeconomic status
 Host Factors
 Genes (alpha1- anti-trypsin↓)
 Hyper responsiveness
 Lung growth, low BW
 Advanced age

56. COPD Increasing Worldwide
Increase in exposure to risk factors (especially
tobacco) in developing countries & in women
Changing demographics globally, with more
people living into the COPD age range

59. PREGNANT SMOKERS

60. Pathology of COPD

61. Pathogenesis
Small Airway Disease
Cellular infiltration
Airway Remodeling
Parenchymal Destruction
Loss of alveolar attachments
Decreased elastic recoil

62. Airway Pathology
Normal bronchial architecture
1. Mucous gland hypertrophy
2. Smooth muscle hypertrophy
3. Goblet cell hyperplasia
4. Inflammatory infiltrate
5. Excessive mucus
6. Squamous metaplasia
COPD

63. Parenchymal Pathology
Normal parenchymal architecture Emphysematous lung architecture

64. Clinical Features of COPD

65. Chronic Bronchitis
 Mild dyspnea
 Cough is prominent
 Copious, purulent sputum
 More frequent infections
 Cor pulmonale common

66. Emphysema
 Severe dyspnea
 Cough after dyspnea
 Scant sputum
 Less frequent infections
 Terminal respiratory failure
 Cor pulmonale rare

67. mMRC Grading of Dyspnea
Grade Description
0 Dyspnea only with strenuous exercise
1 Dyspnea when hurrying or walking up a slight hill
2
Walks slower than people of the same age because of
dyspnea or has to stop for breath when walking at own pace
3 Stops for breath after walking 100 m or after a few minutes
4 Too dyspneic to leave house or breathless when dressing

68. Physical Examination
 Physical exam may be normal in some
 Hyper-inflated chest, barrel chest
 Wheezes or quiet breathing
 Pursed lip / accessory muscles resp.
 Peripheral edema
 Cyanosis, ↑ JVP
 Cachexia
 Cough, wheeze, dyspnea, sputum

69. Investigations
 Blood counts
 Spirometry
 Chest X-ray
 Arterial Blood Gases
 CT Scan of Thorax

70. COPD & Asthma: Reversibility
COPD Asthma

71. Chest X-ray
Normal Chest X-ray Emphysema

72. CT Scan of thorax

73. Management
 Risk reduction
 Smoking cessation:
 Reduces the rate of decline in lung
function
 Results in clinical improvement

74. Goals of Management
Reduce
Risk
Reduce
Symptoms
 Relieve symptoms
 Improve exercise tolerance
 Improve health status
 Prevent disease progression
 Prevent and treat complications
 Reduce mortality

75. Principles of Management
 Stable COPD
 Inhalation treatment is preferred
 LAMA (long acting antimuscarinic agent) is the FIRST choice
 LABA (long acting beta agonists) are the SECOND best choice
 ICS (inhaled corticosteroids) are the THIRD choice
 SABA and SAMA (salbutamol, ipratropium) for short bursts
 NO systemic steroids in stable COPD

76. Pharmacotherapy
 Short acting relievers
 Short-acting beta agonists (SABA)
 Salbutamol, levosalbutamol,
terbutaline
 Short-acting antimuscarinic (SAMA)
 ipratropium
 Long acting relievers & controllers
 Long-acting beta agonists (LABA)
 Salmeterol, formoterol
 Long-acting antimuscarinin (LAMA)
 tiotropium
 Inhaled corticosteroids (ICS)
 Beclomethasone, budesonide, fluticasone

77. Inhaled therapy
 The mainstay of COPD therapy
 Drugs are delivered as aerosols or powders
 delivered direct to the airways
 first-pass metabolism in the liver is avoided
 lower doses are necessary
 unwanted systemic effects are minimized

78. Delivery systems
 Metered dose inhalers
 Dry powder inhalers (Rotahaler)
 Spacers / Holding chambers
 Nebulisers

79. Nebulization

80. Remember mMRC grading?
 mMRC grading is for assessing the severity of
1. Breathlessness
2. Angina
3. Chest pain
4. Fatigue
Grade Description
0 Dyspnea only with strenuous exercise
1 Dyspnea when hurrying or walking up a slight hill
2
Walks slower than people of the same age because of dyspnea or has to stop for
breath when walking at own pace
3
Stops for breath after walking 100 m or after a few
minutes
4
Too dyspneic to leave house or breathless when dressing

81. Assessment & Management of COPD
Grade FEV1 (%pred)
Gold 1
Gold 2
Gold 3
Gold 4
> 80
50 - 79
30 - 49
<30
Assessment of
Airflow limitation
Exacerbation
History
0 or 1
NOT
requiring
admission
Assessment of Symptoms
mMRC 0-1 mMRC 2+
> 2 or > 1
requiring
admission
C D
A B
Diagnosis
FEV1 / FVC
< 0.7

82. C D
A B
Smoking cessation + Pulmonary rehabilitation
Physical activity
Influenza & Pneumococcal vaccine
Regular follow up and spirometry
Bronchodilator
salbutamol - SABA
ipratropium - SAMA
Long acting bronchodilator
LABA - salmeterol, formoterol
LAMA - tiotropium
LABA + LAMA
LAMA
LAMA + LABA
LAMA + ICS
Budesonide, fluticasone
LAMA + LABA + ICS
Roflumilast (if FEV1 < 50%)
Macrolides (if smoker)

83. Management of exacerbations
 Most common causes
 infections of the bronchial
tree
 air pollution
 increase in smoking
 In ~35%, unknown cause
 Treatment
 Antibiotics
 Systemic steroids
 Mechanical ventilation, if
required
 Oxygen*
 Avoid high flow oxygen!

84. Management of complications
 Respiratory failure
 Pulmonary hypertension
 Cor pulmonale
 Cardiac failure
 Pneumothorax

85. COPD is a complicated
illness
Prefer prevention

87. “Everything is lawful for me,”
but not everything is beneficial.
“Everything is lawful for me,”
but I will not let myself be
dominated by anything..
I Corinthians 6:12 ESV