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N AM A

ALAMAT
PEKERJAAN

CURRICULUM VITAE
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 Cabang SUMUT

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
Gatot Subroto
Jakarta,The
Jakarta
JuniCollege
1997 of Chest
- Angkatan
WorkshopDarat
on Medical
Thoracoscopy,
American
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
-Workshop of New Technique of Bronchoscopy , Postgraduate Medical
Intitute,Singapore General Hospital 2008

Asthma
Pemberi Kuliah:

Departemen Pulmonologi & Kedokteran Respirasi


Fakultas Kedokteran
Universitas Sumatera Utara
2010

Levels of competence

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006

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, 2006

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 2007/2008/2009/2010

Adherence
Self Management

UUD No 29 / 2004 : Praktik Kedokteran


Competency

Pharmacoeconomic consideration
Quality of Life

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.

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)

Asthma is an inflammatory diseases

Inflammation

(+)

Asthma

Bronchial hyperreactivity ( - )
Bronchoconstriction ( - )

Symptoms (-)

Triggers

Triggers

Normal

()

Bronchial hyperreactivity ( + )
Bronchoconstriction ( + )

Symptoms (+)

pathogenesis of asthma from inflammation to symptoms

Ag

Ig E

Ca++ Histamin

YY

Phospholipid

Methyl
transferase

Phosphatidyl
ethanolamine

Phosphatidyl
choline

Phospho Ca++
Arachidonic acid lipase A2
lypoxygenase
cyclooxygenase
5-HETE

Leucotrienes
LTB4
LTC4
LTD4
LTE4

Histamin
ECF, NCF

Thromboxanes Prostaglandins
TXA2
PGD
PGF2

HOW TO DIAGNOSIS?

KURIKULUM BERBASIS KOMPETENSI


(Problem Based learning)
MASALAH/KELUHAN:
PEMECAHAN MASALAH/
RENCANA(Planning):

IDENTIFIKASI MASALAH/DIFF DIAGNOSIS

MASALAH/KELUHAN:

PEMECAHAN MASALAH/
RENCANA(Planning):

DATA LAIN

Daftar keluhan Standar


Kompetensi Dokter Indonesia

RENCANA
BERIKUT
Ro

Batuk
Sesak napas
Batuk darah
Nyeri dada

PF,
IDENTIFIKASI MASALAH/DD:

OBSTRUKTIF
INFEKSI
KEGANASAN
PENYAKIT ORGAN LAIN

MASALAH/KELUHAN:
PEMECAHAN MASALAH/
RENCANA(Planning):
DATA LAIN:
Usia :Semua usia

Batuk
Sesak napas
Batuk darah
Nyeri dada

Riwayat Keluarga
Riwayat Mengi
Riwayat Obat (BD)
RENCANA BERIKUT

IDENTIFIKASI MASALAH/DD
Pem Fisik :Tanda Obtruktif:

OBSTRUKTIF : ASMA, PPOK

Eksirasi memanjang/Mengi INFEKSI

KEGANASAN
RO
: Normal

PENYAKIT ORGAN LAIN


Spirometri : Tanda obstruktif

HOW TO MANAGE?

Inflammation
Controller
Bronchial hyperreactivity

Bronchoconstriction
Reliever
Symptoms
Medicines and Pathogenesis of asthma

Anti Inflammations is
the mainstay therapy

Asthma Evolution Therapy, Based on Pathology


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

Single
inhaler
therapy
ICS+LABA
(GINA 2009)

Fear of
short-acting
2-agonists

1980

1985
1990
Bronchospasm

1995
Inflammation

Remodelling

2000

ASTHMA MANAGEMENT: CLINICAL


QUICK RELIEVE MEDICATION
(Exacebation)
LONG TERM TREATMENT
(Stable condition)

Guidelines on Asthma Management:


Past and Current Trends

Severe
Moderate
persisten persisten
t
t

Mild
Intermittent persisten
t
Total control

Partially control

Uncontrol

Old
classification

Exacerbation
New
classification

SABA / Rapid onset of action LABA

GINA 1998
(adapted)
GINA 2009

ICS

LABA and
ICS
LABA+ICS

Stable condition

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.

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.

Inhalation therapy is
the mainstay therapy

Because minimally side effect

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

Controller:
Anti inflammation
Non steroid:

Inhaled Cortico Steroid


( ICS ) :

sodium chromoglicate
(Intal)
budesonide
ketotifen
sodium nedocromil

(Pulmicort)
(Inflamid)

beclomethasone
dipropionate
(Becotide)
triamcinolone

Reliever
Bronchodilator
2 - agonist
Xanthin
Anticholinergic

BRONCHODILATOR
1.SYMPHATOMIMETIC , 2 AGONIST :
Short Acting 2 AGONIST (SABA):

Long Acting 2 AGONIST:

salbutamol/albuterol (Ventolin )
terbutaline (Bricasma)
procaterol
fenoterol
orciprenaline, etc

(LABA)

2.ANTICHOLINERGIC:
atropine sulfate
ipratropium bromide
tiotropium bromide

salmoterol
formoterol

3.XANTHINE:
theophylline
aminophylline

4.OTHER SYMPHATOMIMETIC:

ephedrine
adrenaline, etc

Combination therapy ICS + LABA


Symbicort
Budesonide + Formoterol

Seretide
Fluticasone + Salmoterol

The Beginning of
Treatment

Exacerbation

The beginning of treatment

Stable condition

Asthma management

* Stable condition
* Long-term therapy

Guidelines on Asthma Management:


Past and Current Trends

Severe
Moderate
persisten persisten
t
t

Mild
Intermittent persisten
t
Total control

Partially control

Uncontrol

Old
classification

Exacerbation
New
classification

SABA / Rapid onset of action LABA

GINA 1998
(adapted)
GINA 2009

ICS

LABA and
ICS
LABA+ICS

Stable condition

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.

Evaluations
Objective values
ACT =Asthma Control Test

Peak flow meter

Objective
values

600-700 (

300

normal )

Peak Flow Meter /PEFR/APE

Must be avilable

PEFR Monitoring:
A Major Tool in Asthma Self-Management
Chronic Diseases

Monitor

Hypertension

Blood pressure

Diabetes

Serum glucose

Asthma

PEFR

Classification of Asthma Severity by


Clinical Features Before Treatment:
(old classification)
Intermittent:
Symptoms less than once a week
Brief exacerbations
Nocturnal symptoms not more than twice a month
FEV1 or PEF 80% predicted
PEF or FEV1 variability < 20%

Mild Persistent:
Symptoms more than once a week but less than once a day
Exacerbations may affect activity and sleep
Nocturnal symptoms more than twice a month
FEV1 or PEF 80% predicted
PEF or FEV1 variability < 20 30%

Moderate Persistent:
Symptoms daily
Exacerbations may affect activity and sleep
Nocturnal symptoms more than once a week
Daily use of inhaled short-acting 2-agonist
FEV1 or PEF 60-80% predicted
PEF or FEV1 variability > 30%

Severe Persistent:
Symptoms daily
Frequent exacerbations
Frequent nocturnal asthma symptoms
Limitation of physical activities
FEV1 or PEF 60% predicted
PEF or FEV1 variability > 30%

Control Level Based on GINA


(New classification)

Asthma
Characteristics
Classification

CONTROLLED

PARTLY
CONTROLLED

Daytime symptoms

None (2 or
less / week)

More than
twice / week

Limitations of
activities

None

Any

Nocturnal
symptoms /
awakening

None

Any

None (2 or less /
week)

More than
twice / week

Normal

< 80% predicted or


personal best (if known)
on any day

None

Once/more per
year

Need for rescue /


reliever treatment
Lung function
(PEF or FEV1)
Exacerbation

UNCONTROLLED

QoL

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

One in any
week
GINA updated 2009

Treatment targets in common chronic diseases


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

BP 140/90 mmHg or less

Diabetes

HbA1c 7% or less

Dyslipidaemia

LDL-cholesterol <100 mg/dl

Asthma treatment is designed to meet


specific targets and achieve CONTROL

How we can measure asthma control?

Objective use of ACT


1. ACT is a scored tool which allows numerical targets to be set.
Simple to complete 5 questions with a 5 point rating scale (max:
25)
19 or less = Uncontrolled asthma
20-24
= Well controlled
25
= Total Control

2.

Improves patient / physician communication.


Clear and concise questions that engage patients in a more
open, candid discussion

3.

Validated using spirometry and specialist assessment

SELAMAT
BELAJAR

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