THE NUMBER OF NEUTROPHIL IN SPUTUM INDUCTION OF ASYMPTOMATIC SMOKERS AND SMOKERS WITH PULMONARY EMPHYSEMA BASED ON RADIOLOGIC FINDINGS FINAL ASSIGNMENT To fulfill the requirements for Degree of Bachelor of Medicine By : Uthaya Kumar Nallayan NIM : 0810714039 i
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THE NUMBER OF NEUTROPHIL IN SPUTUM INDUCTION OF ASYMPTOMATIC SMOKERS AND
SMOKERS WITH PULMONARY EMPHYSEMA BASED ON RADIOLOGIC FINDINGS
FINAL ASSIGNMENT
To fulfill the requirements for Degree of Bachelor of Medicine
First of all, I would like to thank God for blessing me to finish up my Final
Assignment to fulfill the precondition to achieve Medical Degree in Medical Faculty,
Brawijaya University. My title of final assignment is “THE NUMBER OF NEUTROPHIL
IN SPUTUM INDUCTION OF ASYMPTOMATIC SMOKERS AND SMOKERS WITH
PULMONARY EMPHYSEMA BASED ON RADIOLOGIC FINDINGS”.
Taking this opportunity, I would like to thank everyone whom always gives me
support and encouragement throughout my Final Assignment. I would like to thank :
1. Dr.dr Karyono Mintaroem, SpPA, as the Dean of Medical Faculty, Brawijaya
University for providing the facilities in Medical Faculty, Brawijaya University.
2. dr.Triwahju Astuti Sp,P,MKes as my first facilitator who spent her precious time
despite of her busy schedule helping and always supporting, advising and
correcting to make my research better.
3. dr.Maimun Zulhaidah A,Mkes,SpPK as my second facilitator who is full of
graciousness and willing to spend precious time for my final assignment and
providing necessary corrections.
4. My examiner, Dr.dr.Retty Ratnawati,M.Sc. who made me think out of the box
with her interesting questions and ideas relating to my thesis, and examining
my research with a smile.
5. My research advisor, dr Andreas Infianto, for helping and correcting my
mistakes despite of his busy schedule.
6. All the staffs in Respiratory Department and Pathology Clinic Laboratory of
Saiful Anwar who really helped a lot.
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7. My wonderful group mate, Kaviprathaa for always being there for me and
lending her help in completion of this thesis.
8. My family for their support, undying love and sacrifices. My heartfelt gratitude
goes to my parents Nallayan and Kaliammal as well as my three siblings,
Suresh Kumar, Balasubramaniam, Thunesh Kumar.
9. My dearest brother, Thunesh for the constant support and encouragement
through the thick and thin of my research.
10. All my friends whom never failed to lend a helping hand when I needed them the
most.
11. Final Assignment Team.
12. Those whom helped me directly and indirectly in completing this study.
Last but not least, I hope that my research will provide a great beneficial contribution
to society in the future. To accomplish that, I need critics and comment from everyone
who read my final assignment. Thank you very much.
Malang, February, 2012
Uthaya Kumar Nallayan
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ABSTRAK
Nallayan, Uthaya Kumar. 2011. Perbedaan jumlah neutrofil dalam induksi sputum perokok non symptomatis dan perokok emfisema berdasarkan gambaran radiologis.Tugas akhir Fakultas Kedokteran Universitas Brawijaya. Pembimbing: (1) dr.Triwahyu Astuti Sp,P.MKes (2) dr.Maimun Zulhaidah A,Mkes,SpPK
Rokok dengan kandungan radikal bebasnya dapat menyebabkan berbagai kerusakan di paru dan saluran nafas. Keadaan inflamasi yang terus menerus dapat berpengaruh pada keseimbangan neutrofil di alveoli pada perokok dan seterusnya dapat melandasi patogenesis terjadinya emfisema paru. Penelitian ini bertujuan untuk menentukan jumlah neutrophil dalam sputum pada perokok non simptomatis dan perokok dengan emfisema paru yang dipilih dengan menggunakan gambaran radiologis.Desain penelitian adalah Observational Cross Sectional dilakukan secara in vivo pada manusia. Terdapat 4 kelompok yang masing-masing terdiri dari 10 subyek yang dibahagi menjadi perokok ringan, perokok sedang, perokok berat dan untuk perokok simptomatis peserta yang dipilih adalah perokok berat dengan emfisema paru berdasarkan gambaran radiologis. Pada setiap subyek dicatat data klinisnya (darah lengkap, EKG, foto thoraks, spirometri) dan diambil sputum dan sampel darahnya sebanyak 5 ml untuk mengetahui kondisi badan peserta. Hasil penelitian menunjukkan bahawa hanya kelompok perokok simptomatis dengan emfisema paru yang memberi hasil signifikan (p<0.05) dan rerata jumlah neutrofil dalam kelompok lain tidak memberikan perbedaan yang bermakna. Di samping itu, berdasarkan Pearson test menunjukkan bahawa derajat merokok tidak mempengaruhi jumlah neutrofil pada sputum induksi perokok. Oleh yang demikian, kesimpulan daripada penelitian ini adalah, merokok akan meningkatkan jumlah neutrophil di alveolar tetapi derajat merokok tidak mempengaruhi jumlah neutrophil di alveolar yang ada di dalam sputum seseorang perokok.
Kata kunci : Rokok, neutrofil di alveolar, emfisema paru
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ABSTRACT
Nallayan, Uthaya Kumar. 2011.The Number of Neutrophil in Sputum induction of Asymptomatic Smokers And Smokers With Pulmonary Emphysema Based on Radiologic Findings Final assignment Fakultas Kedokteran Universitas Brawijaya. Pembimbing: (1) dr.Triwahyu Astuti Sp,P.MKes (2) dr.Maimun Zulhaidah A,Mkes,SpPK.
Cigarette contains various substances and free radicals that may be harmful to the smoker. Continous and progressive state of inflammation cause the recruitment of Neutrophil in alveolar in the smoker and this induces the pathogenesis of the pulmonary emphysema in the smoker.The study was aimed to determine the correlation of smoking with the number of neutrophil in alveolar that are recruited in the smokers. This study was a Cross Sectional Observational study which was carried out in vivo in humans. There were four groups each consisting of 10 patients where the asymptomatic smokers are grouped into three different groups which were classified as mild, moderate and severe smoker and the fourth group was the smoker with pulmonary emphysema based on radiologic findings. In each patient recorded the clinical data (complete blood count, ECG, chest X-ray, spirometry), sputum and 5ml of blood samples were taken. Based on the study, only the smoker with pulmonary emphysema group gave a significant result (p<0.05) whereas the other groups have an average distribution of neutrophil approximately the same. Despite of that, based on the Pearson test that was done to identify the correlation of smoking with the number of neutrophil, it revealed that, the stages of smoking are not proportional to the number of neurophil in the sputum induction of the smoker.Therefore, based on this study, it can be concluded that, smoking will increase the number of neutrophil in alveolar in the smoker but the stages of smoking has no effect on the number of neutrophil in alveolar from the sputum induction of the smoker.
Keywords: Cigarette, neutrophil in alveolar, pulmonary emphysema
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TABLE OF CONTENTS
Pages
Title ……….....................................................................................................................…. i
1.2 Statement of Study Problem...................................................................................4
1.3 Objectives of the Study...........................................................................................4
1.3.1 General Purpose............................................................................................4
1.3.2 Specific Purpose............................................................................................4
1.4 Significance of the Study........................................................................................5
CHAPTER II REVIEW OF RELATED LITERATURE 2.1 Smoking................................................................................................................6
2.2.3 Mechanism of Production and Regulation………………………………….21
2.2.4 Biological Function of Neutrophil……………………………………………24
2.2.5 The Role of Neutrophil In Pulmonary Emphysema………………………..28
CHAPTER III CONCEPTUAL FRAMEWORK AND HYPOTHESIS3.1 Conceptual Framework........................................................................................31
3.2 Hypothesis of the Study.......................................................................................32
CHAPTER IV METHODOLOGY4.1 Study Design........................................................................................................33
4.2 Population and Sample of Study..........................................................................33
5.5.2 Neutrophils Comparative hypothesis with using Mann Whitney U Test........47
5.5.3 One way Anova Test....................................................................................48
5.5.4 Correlation Test of Different Stages of Smoking..........................................48
CHAPTER VI DISCUSSION
6.1 Characteristic of Study Subjects...........................................................................50
6.2 Neutrophils Counting in the Sputum Induction......................................................51
6.3 The Correlation between smoking stages and number of Neutrophils..................52
6.4 The Weakness of The Study.................................................................................53
CHAPTER VII CONCLUSION AND SUGGESTION7.1 Conclusion............................................................................................................54
Data on the total and the mean (+ SD) (source: study)
5.4 Neutrophil counting in the sputum induction of the subjects
The average counting of neutrophils from the sputum induction of the subjects
has the highest value in moderate group at a number of 1369.4 + 1362.2/mm3 (p<0,05),
and severe smokers about 953.9 + 749.9/mm3 (p>0,05) and then pulmonary
emphysema group at about 789.44 + 571.5/mm3 (p>0,05) and finally mild smokers at a
number 617.8 + 600.7/mm3 (p<0,05). Only severe smokers pulmonary emphysema
group and another group which is the severe smokers gave the significant result and
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normally distributed compared to the other group which are the mild and moderate
smokers.
When comparing the non pulmonary emphysema group and pulmonary emphysema
group, it can be shown that the numbers are 981.0 + 376.3 /mm3 and 789.4 + 571.6
/mm3 that are shown in the picture.
5.5 Data Analysis
5.5.1 Normality Test
Normality test was done to identify whether neutrophils are distributed normally
in the different stages of smoking such as mild,moderate and severe and also the
pulmonary emphysema group.From the Shapiro –Wilik with Liliefors correlation test,
only pulmonary emphysema group and asymptomatic severe smokers group are
normally distributed with p > 0.05. Because the other stages do not give normal
distribution, so further test that is Mann Whitney test was done.
5.5.2 Neutrophils Comparative Hypotesis Test with Using Mann Whitney U Test
Based on the Mann- Whitney test that was done on the neutrophils counting by
taking pulmonary emphysema group as one group and the combination group of mild,
moderate and severe smokers as another group, the value obtained was p
>0.05.Therefore it can be concluded that there is no any differences between the
groups or in other word, there value is not significant.
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5.5.3 One Way Anova Test
This observation used variable that is the neutrophils counting in the sputum
induction from all the groups of smokers based on the different stages of smokers ( > 2
unpaired groups ) without involving the fourth group which is the severe smokers with
pulmonary emphysema.
With considering the result of the test of homogeneity of neutrophils or on the
other word the Levene test, with an arrangement of p >0.05, it can be concluded that
there is no variable differences of the data of the groups that are compared and can be
further continued with the one way Anova test.
Based on the Levene variant test it can be concluded there is no differences in
the neutrophils variable from the different groups according to the stages of smoking
with a distribution of p> 0.05. Since the data of the variants are the same, one way
Anova test is valid with a value of p >0.05 from the neutrophils variable and therefore
can be concluded there is no significant differences between the variable of all the three
groups.
5.5.4 Correlation Test Of Different Stages Of Smoking
Correlation test was done to identify the influence of the different stages of
smoking with the neutrophils variable by using normally distributed Product Momen
Pearson numerical correlative hypothesis test. It can be shown clearly that only BMI
and age give significant result with the value p < 0.05. The correlation of the stages of
smoking with the BMI value has negatively correlation value, therefore it can be said
that the bigger the stage of smoking, the lower the value of the BMI of the person.
Contrarily for this statement, the age of the smoker has positive correlation with the
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stages of smoking. So, the bigger the stage of smoking, the higher the age of the
smoker.
It was found out that, the stages of smoking with the counting of the neutrophils
from the sputum induction has positive correlation with p > 0.05, so therefore it is not
significant also.
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Chapter 6
Discussion
6.1 Characteristic of the Research Subjects
Based on the characteristic of the respondent from all the groups, it can be
found out that all the respondents are male with an average age of 60,775 + 7,816
years old and most of them are retired PNS who have smoking habit currently. T.B.
Grydeland et al, (2009) concluded that emphysema is more frequently occurs in male
compared to female. The higher emphysema score in males could have several
explanations. Emphysema quantification is very sensitive to the level of inspiration, but
even though males have larger lung, there are no indications that males inspired
deeper. Environmental cause is another possible explanation, as males are more
exposed to occupational airborne agents, which are potentially harmful to the lungs.
The prevalence of smoking is more prominent in developing countries such as China
and India compared to developed countries such as United States and United
Kingdom. This is due to most of the people who practice routine smoking hailed from
low social-economical status society who are low in literacy and do not have proper job
and eventually have low per capital income.
The type of cigarettes smoked by the smokers are clove, filtered, hand rolled
and most of the respondent has the habit of smoking a combination of kretek and
filtered cigarettes. Smoking filtered cigarettes has many beneficial such as reduced
lavel of nicotine and tar compared to the non-filtered cigarettes, however the level of
carbon monoxide is stil the same in both filtered and non-filtered, so the amount of
hazardous toxic effect that are produced by both the cigarettes are the same. Hence
neither type will protect the airway of the person.
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The weight of the respondents were taken to identify the level of Body Mass
Index (BMI).BMI is the index used to categorize the person into underweight, normal,
overweight, and obese category. From the studies it is identified that most of the
respondents have higher BMI level compared to the controlled group which is the
smoker with emphysematous lung. Similarly, Verbeken et al, (1992) also found out that
BMI level of the normal healthy smoker is higher compared to the level of
emphysematous patients. Hence, emphysema together with smoking increase the
workload of the lung, and the airway muscles, so much energy will be used to
compensate this process and this causes the smoker with pulmonary emphysema to be
thinner.
6.2 Neutrophil Counting In Sputum Induction
The counting of neutrophils of the sputum induction is higher in the fourth group
which is the severe smokers with pulmonary emphysema. Apparently Morrison et al,
(1998) also found out that neutrophils are normally higher in emphysematous patient
compared to healthy smoker. This is because the underlying mechanisms of
emphysema include inflammatory processes in the lung and airways. Cigarette smoke
and other irritants activate macrophages and airway epithelial cells in the respiratory
tract, which release neutrophil chemotactic factors, including IL-8 and leukotriene (LT)
B4. Neutrophils and macrophages then release proteases that break down the
connective tissue in the lung parenchyma, resulting in emphysema. Therefore the
higher number of neutrophil in emphysematous patient is because of increased activity
of inflammation in the lung compared to healthy smoker.
Based on Mann –Whitney test that was conducted on the neutrophils counts of
the two groups which are the pulmonary emphysema group and the non pulmonary
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emphysema group which is the combination group of mild, moderate and severe
smokers, it can be concluded that there is no any significant differences between the
both groups. Apparently, this result is quite parallel to the research done by Domagala
et al, (2003) where they counted the neutrophils level in smokers with emphysematous
lung and healthy ex-smokers and they showed that there are no significant differences
in the cellular profile of induced sputum of the samples between patients with COPD
who are active smokers and those who have ceased smoking.
Based on the one way Anova test, which was done among the mild, moderate
and severe smokers, there is no any difference between the groups and it can be
concluded that the neutrophils level is not significantly variable among the groups, so
the values are approximately the same. It also can be clearly identified that smoking
stages do not directly affect the variability of the observation subjects, unless subjects
that are studied are non-smoker or not smoking currently.
6.3 The correlation between smoking stages and number of neutrophil in
alveolar
Pearson test was used to identify the correlation of stages of smoking to the
level of neutrophils and it was found that there is no any correlation of the stages of
smoking that was characterized according to Brinkman Index as mild, moderate and
severe smokers to the quantity of neutrophils in the person. It is because the value of p
> 0.05, therefore, it is not significance. From the research, it can be concluded that, the
number of neutrophil increases significantly even in the mild stage and therefore, the
severity of smoking is the same regardless the number of cigarette smoked per day.
lxiv
6.4 The Weakness of the Study
The study was done in a population of 40 candidates and this can be referred as
a small population to do this study. Therefore, the result would have been more
accurate and reliable if the study population was bigger. Apart from that, the smokers
with pulmonary emphysema were chosen based on the solitary confirmation from x-ray
radiologic findings. This would have created lesser accuracy because not any further
diagnosis was done to confirm the candidates are having pulmonary emphysema.
Hence, if more examinations were done, then it would have increase the accuracy of
the study.
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CHAPTER 7
CONCLUSION
7.1 Conclusion
From the study result, it can be concluded that:
1. Smoking does influence the level of macrophages in sputum induction of a
smoker compared to the healthy person
2. The numbers of neutrophils do not increase proportionally according to
Brinkman Index from mild, moderate and severe smoker, hence, there is a
significant increase of macrophage even in mild smoker
3. There neutrophil counts in sputum induction of smoker with pulmonary
emphysema or non-pulmonary emphysema smoker (mild, moderate,
severe) are approximately the same.
4. Different stages of smoking are inversely proportional to the level of BMI of
the smoker
5. Different stages of smoking are directly proportional to the age of the
smoker.
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7.2 Suggestions
From this study, suggestion or opinions in future study are:
1. Further study should be done to identify how actually stages of smoking
influence the recruitment of neutrophils in the sputum induction of the
smoker.
2. Further study should be done to identify the correlation of smoking to the
level of neutrophils in the sputum induction of the smoker.
3. The number of the candidates used should be increased to decrease the
unwanted error in the study.
4. Another research should be done to identify how the mechanism of
recruitment of neutrophil in the sputum induction from the alveolar of a
smoker.
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