CURRICULUM VITAE

NAMA ALAMAT PEKERJAAN : Prof.Dr.TAMSIL SYAFIUDDIN Sp.P (K) : Jln.KARSA No F 1 KOMPLEKS EKS KOWILHAN I SEI.AGUL MEDAN 20117 : Guru Besar FK- UISU / FK- USU Ketua Perhimpunan Dokter Paru Indonesia Sumut Penasihat Perhimpunan Dokter Paru Indonesia Pusat Anggota Kolegium Pulmonologi Indonesia Anggota Pokja Asma dan PPOK PDPI pusat Assesor Program Pendidikan Dokter Spesialis Paru Indonesia

RIWAYAT PENDIDIKAN : -Dokter Umum FK-USU Medan,1979 -Dokter Spesialis I Paru FK-UI Jakarta, 1990 -Dokter Spesialis II Paru Konsultan Asma/PPOK, 1995 Pendidikan tambahan:
- Pelatihan Kanker Paru, TSUKAGUCHI Hospital, Kobe- Japan 1989 - Pelatihan PPOK, AMAGASAKI Hospital, Kobe- Japan 1990 - Pelatihan Respiratory Physiologi, JAPAN RESPIRATORY PHYSIOLOGIST CLUB, Kyoto- Japan 1990 - Spirometry Training Course, Department of Respiratory Medicine, National University Hospital Singapore, Singapore 1997

- Workshop on Transbronchial Lung Biopsy and Trasbronchial Needle Aspiration PDPI Cabang Jakarta, RS Persahabatan Jakarta ,Jakarta Maret 1997 - Workshop on Respiratory Physiology and Its Clinical Application, RS Pusat Angkatan Darat Gatot Subroto Jakarta, Jakarta Juni 1997 - Workshop on Medical Thoracoscopy, The American College of Chest Physicians-The Indonesian Association of Pulmonologist, RS Persahabatan Jakarta, Jakarta November 1997 - Workshop on Reformation of Higer Education System,HEDS-JICA,Jakarta 1998 -Pulmonary Infections Course, Postgraduate Medical Institute, Singapore General Hospital, Singapore 2001 - Bronchoscopy &Thoracoscopy Workshop, Postgraduate Medical Institute, Singapore General Hospital, Singapore 2005 -Workshop of Bronchoscopy and Autofluorecent Bronchoscopy, RS Persahabatan Jakarta, Jakarta September 2005 -Training of the new interventional technique of bronchosfiberscopy (Optical Coherence Tommograhy) , Department of Thoracic Surgery, Tokyo Medical University Hospital,Tokyo - Japan 2007

Asthma
Prof.dr.Tamsil Syafiuddin,SpP(K)
Departemen Pulmonologi dan Ilmu Kedokteran Respirasi Fakultas Kedokteran Universitas Islam Sumatera Utara 2012

Levels of competence

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2012

Level of competence 4:
Mampu membuat diagnosis klinik berdasarkan
pemeriksaan fisik dan pemeriksaan tambahan yang diminta oleh dokter (misalnya: pemeriksaan laboratorum sederhana atau X-ray). Dokter dapat memutuskan dan mampu menangani

problem itu secara mandiri hingga tuntas.

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2012

Recent issues in asthma management

The Unmet Needs of asthma
Theme of World Asthma Day 2005/2006

You can control your asthma

Theme of World Asthma Day 2007/2012

Adherence
Self Management

UUD No 29 / 2004 : Praktik Kedokteran

Competency

Pharmacoeconomic consideration
Quality of Life

Asthma is an inflammatory diseases

Definition of asthma
Chronic inflammatory disease of airways (AW) responsiveness of tracheobronchial tree Physiologic manifestation: AW narrowing relieved spontaneously or with BD Cster Clinical manifestations: a triad of paroxysms of cough, dyspnea and wheezing.

Inflammation
Normal

( )

(+)

Asthma

Bronchial hyperreactivity ( - )

Bronchial hyperreactivity ( + )

Bronchoconstriction ( - )

Bronchoconstriction ( + )

Symptoms (-)
The pathogenesis of asthma

Symptoms (+)

KURIKULUM BERBASIS KOMPETENSI (Problem Based Learning) MASALAH/DATA/KELUHAN: PEMECAHAN MASALAH/ RENCANA(Planning):

IDENTIFIKASI MASALAH/ANALISIS:

MASALAH/DATA:

PEMECAHAN MASALAH/ RENCANA(Planning):

DATA LAIN RENCANA

Batuk Sesak napas Batuk darah Nyeri dada

Daftar keluhan Standar Kompetensi Dokter Indonesia

BERIKUT:PF,
Ro,PFR
IDENTIFIKASI MASALAH/ANALISIS:

OBSTRUKTIF INFEKSI KEGANASAN PENYAKIT ORGAN LAIN

1. Wheezing ?
2. Riwayat keluarga? 3. Riwayat obat terdahulu?

Sesak napas

4.Riwayat kebiasaan ?

1 .Pemeriksaan fisik Wheezing ?

2. Spirometri/PFR?
3. Radiologi?

1.Air way sistem: Kelainan obstruktif/Asma 2

Problem Based Learning

Anti Inflammations is the mainstay therapy

Inflammation
Controller
Bronchial hyperreactivity

Bronchoconstriction

Reliever
Symptoms
Medicines and Pathogenesis of asthma

Asthma Therapy Evolution

Large use of short-acting 2-agonists 1975 ICS treatment introduced 1972 Adding LAA to ICS therapy
Kips et al, AJRCCM 2000 Pauwels et al, NEJM 1997 Greening et al, Lancet 1992

1980

Fear of short-acting 2-agonists

Single inhaler therapy ICS+LABA

1985 1990
Bronchospasm Inflammation

2000

1995
Remodelling

ICS : Inhaled Corticosteroids

LABA : a Long-Acting Beta2 Agonist

ASTHMA MANAGEMENT: CLINICAL QUICK RELIEVE MEDICATION LONG TERM TREATMENT

Guidelines on Asthma Management: Past and Current Trends

Severe persistent Old classification

Intermittent
Total control

Mild persistent
Partially control

Moderate persistent

Exacerbation
Uncontrol

New classification

SABA / Rapid onset of action LABA

GINA 1998 (adapted) GINA 2011

ICS

LABA and ICS LABA+ICS

Stable condition

Inhalation therapy is the mainstay therapy

Because minimally side effect

Controller: Anti inflammation

Non steroid
sodium chromoglicate
(Intal) ketotifen

Inhaled Cortico Steroid

budesonide (Pulmicort) (Inflamid)
beclomethasone dipropionate (Becotide) triamcinolone acetonide fluticasone(Flexotide)

sodium nedocromil

Reliever
Bronchodilator
2 - agonist Xanthin

Anticholinergic

BRONCHODILATOR
Short Acting 2 AGONIST (SABA): salbutamol/albuterol (Ventolin ) terbutaline (Bricasma) procaterol fenoterol orciprenaline, etc Long Acting 2 AGONIST: (LABA) salmoterol

formoterol

ANTICHOLINERGIC: atropine sulfate ipratropium bromide tiotropium bromide

ephedrine adrenaline, etc

XANTHINE: theophylline aminophylline

OTHER SYMPHATOMIMETIC:

Combination therapy

Symbicort
Budesonide + Formoterol

Seretide
Fluticasone + Salmoterol

Ig E

YY
Methyl transferase

Ag

Ca++ Histamin
Phosphatidyl ethanolamine Phosphatidyl choline

Phospholipid

Arachidonic acid lypoxygenase cyclooxygenase

5-HETE Leucotrienes LTB4 LTC4 LTD4 LTE4

Phospho ++ Ca lipase A2

Histamin ECF, NCF

Thromboxanes Prostaglandins PGD TXA2 PGF2

Mediator release in asthma reactions

Disease Pattern
Episodic --- acute exacerbations
interspersed with symptom-free periods Chronic --- daily AW obstruction which may be mild, moderate or severe

superimposed acute exacerbations

Life-threatening--- slow-onset or fast-onset (fatal within 2 hours)

Inapropriate Treatment

AIRWAY REMODELLING IN ASTHMA

Eosinophil

Desquamations of epithelium MBP, ECP

Epithelium

Thickening of basement membrane Increase in airway smooth muscle

Epithelial Damage

P Jeffery, in: Asthma, Academic Press 1998

Basement Membrane Thickening

P Jeffery, in: Asthma, Academic Press 1998

Smooth Muscle Hyperplasia

P Jeffery, in: Asthma, Academic Press 1998

The Beginning of Treatment

Exacerbation

x ?

The beginning of treatment

Stable condition

Asthma management

* Stable condition

* Long-term therapy

Assessment of treatment Objective value

Asthma Control Test

Peak flow meter

Objective value

600-700 ( normal )

300

Inflammation can also be present during symptom-free periods

Rate of response of different measures of asthma control over 18 months of ICS treatment

% Reduction

AHR is a marker of inflammation AHR Night symptoms Rescue medication use Impaired FEV1 Impaired am PEF

Start of treatment

18

Months

Adapted from Woolcock A. Clin Exp Allergy Rev 2001; 1: 6264.

Peak Flow Meter /PEFR/APE

Must be avilable

PEFR Monitoring: A Major Tool in Asthma Self-Management

Chronic Diseases Hypertension Monitor Blood pressure

Diabetes

Serum glucose

Asthma

PEFR

Asthma Control Test

(ACT)

Target of treatment

Old Classification of Asthma Severity GINA 2003

CLASSIFY SEVERITY
Clinical Features Before Treatment Nighttime PEF Symptoms Symptoms Continuous <60% predicted Frequent Limited physical Variability >30% activity
Daily 2-agonist
dailyAttacks affect activity

STEP 4 Severe Persistent

STEP 3 Moderate Persistent STEP 2 Mild Persistent

STEP 1 Intermittent

>1 time week

>60%-<80% predicted Variability >30%

>1 time a week but <1 time a day

>2 times a month

>80% predicted Variability 2030% >80% predicted Variability <20%

< 1 time a week Asymptomatic and normal PEF between attacks

<2 times a month

Global Initiative for Asthma (GINA) WHO/NHLBI, 2003

Treatment targets in common chronic diseases

Clear therapeutic targets exist for many chronic diseases Philosophy of treat to target

Hypertension
Diabetes Dyslipidaemia

BP 140/90 mmHg or less

HbA1c 7% or less LDL-cholesterol <100 mg/dl

Asthma treatment is designed to meet specific targets and achieve CONTROL

Control Level Based on GINA 2008

New Asthma Characteristics Classification
CONTROLLED
PARTLY CONTROLLED

UNCONTROLLED

Daytime symptoms Limitations of activities

Nocturnal symptoms / awakening

None (2 or less / week) None None

None (2 or less / week)

More than twice / week

Any Any
More than twice / week
< 80% predicted or personal best (if known) on any day

Need for rescue / reliever treatment

Lung function (PEF or FEV1) Exacerbation

3 or more features of partly controlled asthma present in any week

Normal
None

Once/more per year

One in any week

GINA updated 2008

DIFFERENTIAL DIAGNOSIS
1. Upper airway obstruction glottic dysfunction. 2. Acute LV failure pulmonary oedema. 3. Pulmonary embolism. 4. Endobronchial disease. 5. Chronic bronchitis. 6. Eosinophilic pneumonia. 7. Carsinoid syndrome. 8. Vasculitis.

Life is not problem to be solved, but a reality to be experienced

( Soren Kierkegaard)

Syafiuddin San : You are the Inspiring woman Imah San : You are the Wind beneath my wings

DIAGNOSIS EXACERBATION : CLINICAL

Episodic asthma: Paroxysms of wheeze, dyspnoea and cough, asymptomatic between attacks. Acute severe asthma: upright position, use accessory resp muscles, cant complete sentences in one breath, tachypnea > 25/min, tachycardia > 110/min, PEF 33-50% of pred or best, pulsus paradoxus, chest hyperresonant, prolonged expiration, breath sounds decreased, inspiratory and expiratory rhonchi, cough.

Life-threatening features:

PEF < 33% of pred or best,silent chest, cyanosis, bradycardia, hypotension, feeble respiratory effort, exhaustion, confusion, coma, PaO2 < 60, PCO2 normal or increased, acidosis (low pH or high [H+]).

Chronic asthma:

Dyspnea on exertion, wheeze, chest tightness and cough on daily basis, usually at night and early morning; intercurrent acute severe asthma (exacerbations) and productive cough (mucoid sputum), recurrent respiratory infection, expiratory rhonchi throughout and accentuated on forced expiration.

MANAGEMENT 2
No improvement after 15-30 min: Nebulized 2 agonist every 15-30 min + Ipratropium. Still no improvement: Aminophyllin infusion 750mg/24H (small pt), 1 500mg/24H (large pt), or alternatively salbutamol infusion. Monitor Rx:

Aminophyllin blood levels + PEF after 15-30 min +

oxymetry (maintain SaO2 > 90) + repeat blood gases after 2 hrs if initial PaO2 < 60, PaCO2 normal or raised and patient deteriorates. Deterioration:
ICU, intubate, ventilate + muscle relaxant.

 Acute severe asthma:

MANAGEMENT 1 1.Immediate Rx:
O2 40-60% mask or cannula + SABA (salbutamol 5mg)/ nebulizer + ICS 200 mcg/ nebulizer or hydrocortisone

200mg IV. With lifethreatening features add 0.5mg

ipratropium to nebulized 2 agonist + Aminophyllin 250mg iv over 20 min or salbutamol 250ug over 10 min. 2. Subsequent Rx: Nebulized SABA 6 hourly + ICS 200mcg or hydrocortisone 200mg 6 hourly IV + 40-60% O2.