PENYAKIT PARU OBSTRUKTIF:

ASMA DAN
PPOK

I B NGURAH RAI
DIV. PULMONOLOGI BAG/SMF PENYAKIT
DALAM FK UNUD/RSUP SANGLAH DENPASAR

KONSEP UTAMA
RESPIRASI

VENTILASI
DIFUSI
PERFUSI

Gangguan ventilasi

Obstruktif
terhambatannya aliran udara dalam
saluran nafas, dapat terjadi oleh karena
menyempitnya saluran nafas dan atau
meningkatnya resistensi aliran udara.

Restriktif
paru tidak dapat mengembang dengan
baik sehingga volume pertukaran gas
menjadi berkurang.

Membedakan obstruksi dan

Restriksi

SPIROMETRI

SPIROMETRI
FVC (Force Vital Capacity)/
KVP (Kapasitas Vital Paksa)
FEV1 (Force Expiratory Volume 1
second)/ VEP1 (Volume Ekspirasi
Paksa detik pertama)

RESTRIKSIF

KVP<80% nilai prediksi

60-79= Ringan
30-59= Sedang
<30 = Berat

NILAI PREDIKSI: Umur, Gender,

Tinggi badan, Berat badan, Etnik

OBSTRUKTIF

VEP1/KVP <70%
Ringan= 60-69%
Sedang= 30-59%
Berat = 30%
ATAU..
VEP1/VEP1 prediksi <75%

PENYAKIT PARU
OBSTRUKTIF

Definisi

Suatu penyakit yang ditandai

dengan adanya obstruksi /
hambatan aliran udara pada
saluran nafas
Reversibel (Asma)
Ireversibel (PPOK)

Cara membedakan
reversibel dan
ireversibel
Peak flow meter
Spirometri

REVERSIBEL

Peningkatan VEP1 atau APE

>15%, lima belas menit setelah
pemberian bronkodilator inhalasi.

Penyakit Paru
Obstruktif

PPOK
Asma bronkial
Bronkiektasis
Cystic fibrosis
Post tuberkulosis
Kanker paru
Bronkiolitis obliteratif

ASMA

Asthma Prevalence and

Mortality

Source: Masoli M et al. Allergy

Definisi asma

Inflamasi kronik jalan napas, melibatkan

berbagai sel dan elemen sel.

Inflamasi kronik ini berhubungan dengan

hiperresponsif jalan napas, menyebabkan
serangan berulang wising, sesak napas, dada
berat, dan batuk.

Hambatan udara terjadi menyeluruh dan

reversibel.

Asthma Inflammation: Cells and

Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma
Inflammation

Source: Peter J. Barnes, MD

Faktor Pencetus Asma

Is it Asthma?

Recurrent episodes of wheezing

Troublesome cough at night

Cough or wheeze after exercise

Cough, wheeze or chest tightness after

exposure to airborne allergens or pollutants

Colds go to the chest or take more than

10 days to clear

Asthma Diagnosis

History and patterns of symptoms

Measurements of lung function

- Spirometry
- Peak expiratory flow

Measurement of airway responsiveness

Measurements of allergic status to identify

risk factors

Extra measures may be required to

diagnose asthma in children 5 years and
younger and the elderly

Asthma Management and Prevention

Program: Five Components
1. Develop Patient/Doctor
Partnership
2. Identify and Reduce
Exposure to Risk Factors
3. Assess, Treat and Monitor
Asthma
Updated 2009

4. Manage Asthma
Exacerbations

Asthma Management and Prevention Program

Goals of Long-term
Management

Achieve and maintain control of

symptoms

Maintain normal activity levels,

including exercise

Maintain pulmonary function as close

to normal levels as possible

Prevent asthma exacerbations

Avoid adverse effects from asthma

medications

Levels of Asthma Control

(Assess patient impairment)

Assessment of Future Risk (risk of exacerbations, instability, rapid

decline in lung function, side effects)

REDUCE

LEVEL OF CONTROL

TREATMENT OF ACTION
maintain and find lowest
controlling step

partly controlled

consider stepping up
to gain control
INCREASE

controlled

uncontrolled
exacerbation

REDUCE

step up until controlled

treat as exacerbation

INCREASE

TREATMENT STEPS

STEP

STEP

STEP

STEP

STEP

TO STEP 3 TREATMENT,
SELECT ONE OR MORE:

Shaded green - preferred controller options

TO STEP 4 TREATMENT,
ADD EITHER

Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled -agonists in
2
combination with inhaled
glucocorticosteroids
Systemic glucocorticosteroids
Theophylline
Cromones

Estimate Comparative Daily Dosages for

Inhaled Glucocorticosteroids by Age
Drug

Low Daily Dose (g)

>5y

Age

<5y

Medium Daily Dose (g)

>5y

Age

High Daily Dose (g)

<5y

Beclomethasone

200-500

100-200

>500-1000

>200-400

Budesonide

200-600
200

100-

600-1000

>200-400

Budesonide-Neb
Inhalation Suspension
Ciclesonide

250-

>5y

Age

>1000
>1000

500-1000

<5y
>400
>400

>1000

500
80 160

80-160

>160-320

>160-320

>320-1280

>750-1250

>2000

>1250

>200-500

>500

>500

Flunisolide

500-1000
750

500-

>1000-2000

Fluticasone

100-250
200

100-

>250-500

Mometasone furoate

200-400
200

100-

> 400-800

>200-400

>800-1200

Triamcinolone acetonide

400-1000
800

400-

>1000-2000

>800-1200

>2000

>320

>400
>1200

Reliever Medications
Rapid-acting inhaled 2agonists
Systemic
glucocorticosteroids
Anticholinergics
Theophylline

Asthma Management and Prevention Program

Component 4: Manage Asthma

Exacerbations
Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled
2-agonist
Early introduction of systemic
glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function

PPOK
(Penyakit Paru Obstruktif
Kronik)

Worldwide burden of COPD: Burden of

Obstructive Lung Disease (BOLD) initiative
Males*

Females*
Reykjavik

Cape Town

Cape Town

Manila

Bergen

Adana

Hanover

Guangzhou

Lexington

Krakow

Vancouver

Hanover

Sydney

Lexington

Krakow

Bergen

Salzburg

Reykjavik

Manila

Salzburg

Adana

Vancouver

Guangzhou

Sydney

10

15

20

25

Prevalence, %
*Ordered by descending prevalence of ever-smoking patients 40 years old

10

15

20

25

Prevalence, %
Buist et al. Lancet 2007

COPD is a major cause of death and

has increased significantly in recent
years
Proportion of the USA 1965 rate

Proportion of 1965 rate

3.0
2.5

Coronary
heart
disease

Stroke

Other
CVD

COPD

All other
causes

-59%

-64%

-35%

+163%

-7%

2.0
1.5
1.0
0.5
0

Percentage change in age-adjusted death rates in USA, from 1965 to

19981

GOLD Teaching Slide Set (Updated 2007)

Global Strategy for Diagnosis, Management and Prevention

of COPD

Definisi PPOK

PPOK, adalah penyakit yang dapat

dicegah dan diobati, ditandai oleh
hambatan aliran udara yang persisten
yang biasanya progresif, berhubungan
dengan peningkatan respon inflamasi
kronik terhadap gas atau partikel yang
berbahaya (ROKOK).

Eksaserbasi dan komorbiditas

berkontribusi pada keparahan penyakit
secara keseluruhan.

Systemic Inflammation and

Comorbidities
COPD
BODY
COMPOSITION

CARDIOVASCULAR
DISEASE

INFLAMMATIO
N
DIABETES

OSTEOPOROSIS

GASTROINTESTINAL
DISORDER
Agusti AG, et al. Eur Respir J. 2003;21:347-360.
Agusti A. Proc Am Thorac Soc. 2007;4:522-525.

36

The Downward Spiral in COPD

COPD

Lung
inflammation

Mucous
hypersecretion

Airway
obstruction

Exacerbation
Continued
smoking

Impaired
mucous clearance

Exacerbation

Submucousal gland
hypertrophy

Alveolar
destruction

Exacerbation
Hypoxaemia

DEATH
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.

37

Global Strategy for Diagnosis, Management and Prevention

of COPD

Mechanisms Underlying
Airflow Limitation in COPD
Small Airways Disease
Airway inflammation
Airway fibrosis, luminal
plugs
Increased airway resistance

Parenchymal
Destruction
Loss of alveolar
attachments
Decrease of elastic recoil

AIRFLOW LIMITATION

Global Strategy for Diagnosis, Management and Prevention

of COPD

Risk Factors for COPD

Genes
Infections
Socio-economic
status

Aging Populations

Global Strategy for Diagnosis, Management and Prevention of

COPD

Diagnosis of COPD
SYMPTOMS
shortness of breath
chronic cough
sputum

EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution

SPIROMETRY: Required to establish

diagnosis

Klasifikasi derajat
PPOK dng Spirometri
post
bronkodilator
Std I (Ringan)
: FEV1/FVC < 0.70

FEV1 > 80% prediksi

Std II (Sedang): FEV1/FVC < 0.70
50% < FEV1 < 80% prediksi
Std III (Berat): FEV1/FVC < 0.70
30% < FEV1 < 50% predicted
Std IV (Sangat berat): FEV1/FVC < 0.70
FEV1 < 30% predicted or FEV1 < 50%
prediksi + gagal nafas kronik

Global Strategy for Diagnosis, Management

and Prevention of COPD

Combined
Assessment of
When
assessing risk, choose the highest
COPD
risk according to GOLD grade or
exacerbation history
Spirometric
Exacerbations mMRC
Classification
per year

Patient

Characteristic

CAT

Low Risk
Less Symptoms

GOLD 1-2

0-1

< 10

Low Risk
More Symptoms

GOLD 1-2

>2

10

High Risk
Less Symptoms

GOLD 3-4

>2

0-1

< 10

High Risk
More Symptoms

GOLD 3-4

>2

>2

10

Global Strategy for Diagnosis, Management and Prevention of

COPD

Manage Stable COPD: Pharmacologic Therapy

Relieve symptoms
Improve exercise tolerance
Improve health status

Reduce
symptoms

Prevent disease progression

Prevent and treat exacerbations
Reduce mortality

Reduce
risk

GOLD Revision 2011

Global Strategy for Diagnosis, Management and Prevention

of COPD

Manage Stable COPD: Nonpharmacologic

Patient

Essential

Smoking cessation (can

include pharmacologic
treatment)

B, C, D

Smoking cessation (can

include pharmacologic
treatment)
Pulmonary rehabilitation

Recommended

Depending on local
guidelines

Physical activity

Flu vaccination
Pneumococcal
vaccination

Physical activity

Flu vaccination
Pneumococcal
vaccination

Global Strategy for Diagnosis, Management and Prevention of

COPD

Manage Stable COPD:

PharmacologicTherapy
(Medications in each box are mentioned in alphabetical order, and

Patient

therefore not necessarily in order of preference.)

First choice
Second choice
Alternative Choices

SAMA prn
or
SABA prn

LAMA
or
LABA
or
SABA and SAMA

Theophylline

LAMA
or
LABA

LAMA and LABA

SABA and/or SAMA

Theophylline

LAMA and LABA

PDE4-inh.
SABA and/or SAMA
Theophylline

ICS andLAMA or
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh.or
LAMA and LABA or
LAMA and PDE4-inh.

Carbocysteine
SABA and/or SAMA
Theophylline

ICS +LABA
or
LAMA
ICS + LABA
or
LAMA

Exacerbation
An exacerbation of COPD is:
an acute event characterized by a
worsening of the patients
respiratory symptoms that is beyond
normal day-to-day variations and
leads to a change in medication.

GOLD Revision 2011

ASMA

PPOK

Onset sering umur muda anakanak

Onset umur pertengahan

Gejala bervariasi, episodik

Gejala muncul pelan namun

progresif

Sering ada riwayat atopi / alergi

dan riwayat keluarga

Riwayat merokok jangka lama

Gejala muncul pada malam dan

dini hari

Sesak pada saat aktivitas

Hambatan aliran udara

reversibel

Hambatan aliran udara

irreversibel

Penatalaksanaan
Penyakit Paru Obstruktif

Edukasi
Obat-obatan ( Bronkodilator,
Kortikosteroid, Antibiotika,
mukolitik)
Oksigen
Nutrisi
Rehabilitasi

Edukasi pada PPOK

Pengetahuan dasar tentang PPOK,

Obat-obatan, manfaat dan efek
sampingnya
Cara pencegahan perburukan
penyakit
Menghindari pencetus (merokok)
serta penyesuaian aktifitas

Edukasi pada Asma

penderita dan keluarga agar timbul

kerjasama yang baik dalam penanganan
asma
penilaian dan pemantauan derajat
keparahan asma dengan menilai gejala dan
faal paru,
menghindari pajanan faktor risiko
menyusun rencana pengobatan jangka
panjang
menyusun rencana pengobatan untuk
tatalaksana eksaserbasi dan mengupayakan
kontrol teratur.

Obat-obatan

Bronkodilator

Beta 2 agonis
Antikolinergik
Gol Xantin (aminofilin, teofilin)

Kortikosteroid

Antibiotika

OBAT INHALASI

BRONKODILATOR

AGONIS BETA-2:
KERJA
CEPAT: terbutalin, salbutamol
KERJA PANJANG: formoterol, salmeterol,
indacaterol
Dapat diberikan secara:
Injeksi (subkutan, drip);
Inhalasi (nebulizer, inhaler)
Peroral
Diberikan untuk : eksaserbasi akut dan
terapi pemeliharaan.

2-Agonist Classification
Speed of Onset

Fast

Inhaled Terbutaline Fast Onset, Long

Inhaled Salbutamol Duration Inhaled
Formoterol

Slow

Oral Terbutaline
Oral Salbutamol
Oral Formoterol

Inhaled Salmeterol
Oral Bambuterol

Short

Long

Maintenance

As Needed Use

Duration of Effect

BRONKODILATOR

DERIVAT XANTIN:
Teofilin dan Aminofilin
Kerja cepat dan Kerja
Lambat
Injeksi: bolus dan drip,
Oral
Hati-hati EFEK
SAMPING FATAL
ANTIKOLINERGIK: Tiotropium,
Ipratropium (Inhalasi saja)

KORTIKOSTEROID

GOL. METILPREDNISOLON
Injeksi untuk serangan akut : 30-60mg
IV
Oral: serangan akut dan terapi
pemeliharaan
Inhalasi: pemeliharaan
Hati-hati efek samping penggunaan
jangka panjang

Oksigen

Pemberian dosis oksigen pada pasien asma

dapat lebih besar dibanding pada pasien
PPOK.
Pasien PPOK dengan gagal napas kronis hatihati dgn pemberian oksigen yg berlebih
Mempertahankan saturasi oksigen diatas
90%.
Pada PPOK sangat berat diperlukan terapi
oksigen jangka panjang yaitu selama 15
jam/ hari dengan dosis 1-2 liter/mnt.

Pemberian nutrisi pd
PPOK

Diberikan 5-6 x/ hari dengan porsi

lebih kecil
Dengan perbandingan

karbohidrat 50-60%,
protein 20%
lemak 25-39%.

Rehabilitasi

Tujuan rehabilitasi adalah

menurunkan gejala
memperbaiki kualitas hidup
meningkatkan partisipasi fisik dan
emosional pada setiap aktivitas

Jenis rehabilitasi

Latihan yang paling peraktis adalah jalan kaki (12

menit), bila menggunakan treadmill hendaknya
mencapai 50-70% toleransi latihan maksimal.

Latihan lain yang dianjurkan adalah latihan

pernapasan (30 menit) yaitu ekspirasi panjang
melalui pursed lip ditambah penggunaan otot
abdominal secara sadar.

Memperkuat otot napas inspiratoir juga dapat

dilakukan melalui cara bernapas dengan
menggunakan alat yang lubang masuknya dapat
diatur.