CURRICULUM VITAE

dr.Sumardi,SpPD-KP
Tempat/Tanggal Lahir : Jakarta/ 14 Agustus 1952
PENDIDIKAN TERAKHIR :
 KONSULTAN PARU
RIWAYAT PEKERJAAN :
 Kepala Puskesmas Tk2 Kabupaten Bungotebo – Tamat 1982
 Ketua SMF Penyakit Dalam RSUD Sumbawa Besar NTB – Tamat 1996
 Ketua P2TB Komite Medik RSUP DR Sardjito Yogyakarta – 1999
 Ketua Tim Avian Influensa RSUP DR Sardjito Yogyakarta
 SMOKING Exposure to hazardous
1 pack/day in 10 years Air Pollution chemicals & Biomass
(>10 packyears) smog
 • Age >40 y.o
• Symptoms: Shortness of breath, prolonged expiration, chronic cough
or sputum production

History
• History of exposure to risk factors: smoking, occupation, indoor or
outdoor air pollution

Risk Factor
• Post-bronchodilator FEV1/FVC <0.70 confirms persistent airflow
limitation (spirometry)

Spirometry
Airflow limitation Risk
(Exacerbation history)
4

C D > 2/yr

Risk for exacerbation

3

2 1/yr
A B
1 0/yr
mMRC 0-1 mMRC > 2
CAT < 10 CAT > 10

Symptoms
Score: 35
Airflow limitation Risk
(Exacerbation history)
4

C D > 2/yr

Risk for exacerbation

3

2 1/yr
A B
1 0/yr
mMRC 0-1 mMRC > 2
CAT < 10 CAT > 10

Symptoms
 Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: Goals of Therapy

 Relieve symptoms
 Improve exercise tolerance Reduce
symptoms
 Improve health status

 Prevent disease progression

Reduce
 Prevent and treat exacerbations risk
 Reduce mortality
© 2015 Global Initiative for Chronic Obstructive Lung Disease
 Exacerbation w/
Airflow limitation hospitalization
4
C D
ICS+LABA ICS+LABA > 2/yr

Risk for exacerbation

3 or LAMA & or LAMA

2 A B LAMA or 1/yr
SABA or
SAMA prn LABA
1 0/yr
mMRC 0-1 mMRC > 2
CAT < 10 CAT > 10

Symptoms
 Manage Stable COPD: Pharmacologic Therapy

Patient Recommended Alternative choice Other Possible

First choice Treatments
LAMA
SAMA prn or
A or LABA Theophylline
SABA prn or
SABA and SAMA
LAMA
SABA and/or SAMA
B or LAMA and LABA
Theophylline
LABA
ICS + LABA LAMA and LABA or
or Formoterol LAMA and PDE4-inh. or SABA and/or SAMA
C
LAMA +Budesonid LABA and PDE4-inh. Theophylline

ICS + LABA ICS + LABA and LAMA or Carbocysteine

and/or ICS+LABA and PDE4-inh. or N-acetylcysteine
D Formoterol
LAMA LAMA and LABA or SABA and/or SAMA
+Budesonid LAMA and PDE4-inh. Theophylline
 Phenotype diagnosis

Step 2 Phenotype characterisation

Overlap COPD-asthma
phenotype

Exacerbator phenotype (C) (D)

(2 or more ex/yr)

(B)

No exacerbations (A)
< 2 ex/yr

Emphysema Chronic bronchitis

phenotype phenotype

Miravitlles et al. Arch Bronconeumol 2012; 48: 247-257

 Phenotype-guided treatment
C D
A B
Ex. with emphysema Ex. with CB
No exacerbator Overlap

Bronchodilators

ICS

Muc/NAC

Roflumilast

Antibiotics

Miravitlles et al. ERJ 2012;

 DIAGNOSE CHRONIC AIRWAYS DISEASE
STEP 1
Do symptoms suggest chronic airways disease?

Yes No Consider other diseases first

SYNDROMIC DIAGNOSIS IN ADULTS

STEP 2 (i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis

Features: if present suggest ASTHMA COPD

Age of onset Before age 20 years After age 40 years
Pattern of symptoms Variation over minutes, hours or days Persistent despite treatment
Worse during the night or early morning. Triggered Good and bad days but always daily
by exercise, emotions including laughter, dust or symptoms and exertional dyspnea
exposure to allergens Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Record of variable airflow limitation Record of persistent airflow limitation
Lung function
(spirometry or peak flow) (FEV1/FVC < 0.7 post-BD)
Lung function between
Normal Abnormal
symptoms
Previous doctor diagnosis of asthma Previous doctor diagnosis of COPD,
Past history or family history chronic bronchitis or emphysema
Family history of asthma, and other allergic
conditions (allergic rhinitis or eczema) Heavy exposure to risk factor: tobacco
smoke, biomass fuels

Time course No worsening of symptoms over time. Variation in

symptoms either seasonally, or from year to year
May improve spontaneously or have an immediate
response to bronchodilators or to ICS over weeks
Symptoms slowly worsening over time (progressive
course over years)
Rapid-acting bronchodilator treatment provides only
limited relief

Chest X-ray Normal Severe hyperinflation

NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or
COPD suggest that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACOS

Some features Features of both Some features

DIAGNOSIS Asthma COPD
of asthma of COPD
CONFIDENCE IN Could be Possibly
Asthma Asthma ACOS COPD
DIAGNOSIS COPD

STEP 3 Marked
reversible airflow limitation FEV1/FVC < 0.7
PERFORM post-BD
(pre-post bronchodilator) or other
SPIROMETRY proof of variable airflow limitation

STEP 4 Asthma drugs Asthma drugs ICS, and usually

INITIAL No LABA No LABA LABA COPD drugs COPD drugs
TREATMENT* monotherapy monotherapy +/or LAMA

*Consult GINA and GOLD documents for recommended treatments.

• Persistent symptoms and/or exacerbations despite treatment.

• Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases and other causes of respiratory
STEP 5 symptoms).
SPECIALISED • Suspected asthma or COPD with atypical or additional symptoms or signs (e.g. haemoptysis, weight loss, night sweats,
INVESTIGATIONS fever, signs of bronchiectasis or other structural lung disease).
or REFER IF: • Few features of either asthma or COPD.
• Comorbidities present.
• Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.

GINA 2015, Box 5-4 © Global Initiative for Asthma

 DIAGNOSE CHRONIC AIRWAYS DISEASE
STEP 1 Do symptoms suggest chronic airways disease?

Yes No Consider other diseases first

GINA 2015 © Global Initiative for Asthma

GINA 2015
GINA 2015
GINA 2015
 SYNDROMIC DIAGNOSIS IN ADULTS
STEP 2 (i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis

Features: if present suggest - ASTHMA COPD

Age of onset  Before age 20 years  After age 40 years
Pattern of symptoms  Variation over minutes, hours or days  Persistent despite treatment
 Worse during the night or early morning  Good and bad days but always daily
symptoms and exertional dyspnea
 Triggered by exercise, emotions
including laughter, dust or exposure  Chronic cough & sputum preceded
to allergens onset of dyspnea, unrelated to triggers

Lung function  Record of variable airflow limitation  Record of persistent airflow limitation
(spirometry or peak flow) (FEV1/FVC < 0.7 post-BD)
Lung function between  Normal  Abnormal
symptoms
Past history or family history  Previous doctor diagnosis of asthma  Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
 Family history of asthma, and other allergic conditions
(allergic rhinitis or eczema)  Heavy exposure to risk factor: tobacco
smoke, biomass fuels

Time course  No worsening of symptoms over time.  Symptoms slowly worsening over time
Variation in symptoms either seasonally, or from year (progressive course over years)
to year
 Rapid-acting bronchodilator treatment
 May improve spontaneously or have an immediate provides only limited relief
response to bronchodilators or to ICS over weeks

Chest X-ray  Normal  Severe hyperinflation

NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACOS

Asthma Some features Features of both Some features

DIAGNOSIS COPD
of asthma of COPD
CONFIDENCE IN Asthma Asthma Could be ACOS Possibly COPD COPD
DIAGNOSIS

GINA
GINA 2015, Box 5-4
2014 © Global Initiative for Asthma
 Marked
STEP 3 reversible airflow limitation FEV1/FVC < 0.7
PERFORM (pre-post bronchodilator) or other post-BD
SPIROMETRY proof of variable airflow limitation

GINA 2015 © Global Initiative for Asthma

GINA 2015, Box 5-3
 Step 3 - Spirometry

Spirometric variable Asthma COPD ACOS

Normal FEV1/FVC Compatible with asthma Not compatible with Not compatible unless
pre- or post-BD diagnosis (GOLD) other evidence of chronic
airflow limitation
Post-BD
- FEV1/FVC <0.7 Indicates airflow Required for diagnosis Usual in ACOS
limitation; may improve by GOLD criteria
FEV1 ≥80% predicted Compatible with asthma C ompatible with GOLD Compatible with mild
(good control, or interval category A or B if post- ACOS
between symptoms) BD FEV1/FVC <0.7
FEV1<80% predicted Compatible with asthma. Indicates severity of Indicates severity of
A risk factor for airflow limitation and risk airflow limitation and risk
exacerbations of exacerbations and of exacerbations and
mortality mortality
Post-BD- increase in Usual at some time in Common in COPD and Common in ACOS, and
FEV1 >12% and 200mL course of asthma; not more likely when FEV1 more likely when FEV1 is
from baseline (reversible always present is low low
airflow limitation)
Post-BD
- increase in High probability of Unusual in COPD. Compatible with
FEV1 >12% and 400mL asthma Consider ACOS diagnosis of ACOS
from baseline
GINA 2015, Box 5-3 © Global Initiative for Asthma
 STEP 4 Asthma drugs Asthma drugs ICS and
No LABA No LABA consider LABA COPD drugs COPD drugs
INITIAL
monotherapy monotherapy +/or LAMA
TREATMENT*
*Consult GINA and GOLD documents for recommended treatments.

GINA 2015 © Global Initiative for Asthma

GINA 2015
 • Persistent symptoms and/or exacerbations despite treatment.
STEP 5 • Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases and other causes of respiratory
symptoms).
SPECIALISED • Suspected asthma or COPD with atypical or additional symptoms or signs (e.g. haemoptysis,
INVESTIGATIONS • weight loss, night sweats, fever, signs of bronchiectasis or other structural lung disease).
or REFER IF: • Few features of either asthma or COPD.
• Comorbidities present.
• Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.

GINA 2015 © Global Initiative for Asthma

GINA 2015
 Step 5 – Refer for specialized investigations if needed

Investigation Asthma COPD

DLCO
Arterial blood gases
Airway hyperresponsiveness
High resolution CT scan
Tests for atopy
(sIgE and/or skin prick tests)
Normal or slightly elevated
Normal between exacerbations
Not useful on its own in distinguishing asthma and COPD.
Higher levels favor asthma
Usually normal; may show air trapping
and increased airway wall thickness
Not essential for diagnosis; increases
probability of asthma
Often reduced
In severe COPD, may be abnormal between
exacerbations
Air trapping or emphysema; may show bronchial
wall thickening and features of pulmonary
hypertension
Conforms to background prevalence; does not
rule out COPD

FENO (nitric oxide)
Blood eosinophilia
Sputum inflammatory cell
analysis
GINA 2015, Box 5-5
If high (>50ppb) supports eosinophilic Usually normal. Low in current smokers
inflammation
Supports asthma diagnosis May be found during exacerbations
Role in differential diagnosis not established in large populations
(eosinophil or neutrophil sputum)
© Global Initiative for Asthma
Long term efficacy benefits

An observational, retrospective, matched-cohort

study to map out patients with COPD and describe
COPD healthcare in real life during the first 11 years
of the 21st century
* Tanggal Indeks didefinisikan sebagai waktu
diresepkan ICS atau kombinasi ICS/LABA pertama
setelah didiagnosa PPOK
Larsson K et al. J Intern Med 2013; 273:584-94
35
Long term safety benefits

An observational, retrospective, matched-cohort study to map

out patients with COPD and describe COPD healthcare in real
life during the first 11 years of the 21st century
 Kelompok Fluticasone/Salmeterol Kelompok Budesonide/Formoterol
pneumonia pneumonia
rawat inap karena pneumonia rawat inap karena pneumonia
110
Jumlah rata – rata kejadian
pneumonia per 100 pasien

100 Total kejadian pneumonia

90 RR 1.73 (1.57to 1.90)
P < .001 NNT 23
80
70
60 Pneumonia karena rawat inap
50 RR 1.74 (1.56 to 1.94)
40 P < .001 NNT 34

30
20
10
0
0 1 2 3 4 5 6 7 8 9
Tahun

Jumlah rata – rata kejadian pneumonia per tahun disesuaikan

dibandingkan dengan menggunakan analisa Poisson Regression

Janson C et al. BMJ 2013; 346:f3306 doi: 10.1136/bmj.f3306

 Terjadi peningkatan 76% resiko mortalitas akibat
pneumonia pada pasien Salmeterol/Fluticasone
dibandingkan kombinasi Bud/Formoterol (P<0.003)

52 pasien meninggal akibat pnemonia pada grup pasien Budesonide/Formoterol dibandingkan dengan
97 pasien meninggal dunia akibat pneumonia pada Salmeterol/Fluticasone.

38
Dissolution time in airway

Kelarutan dalam air Waktu disolusi

(μg/mL) (human BAL fluid in vitro)

Flunisolide 140 <2 min

Triamcinolone 21 n.d.
acetonide
Budesonide 16 6 min

Beclomethasone 15.5 n.d.

17-propionate
Fluticasone 0.14 <8h
17-propionate

Beclomethasone 0.13 <5h

dipropionate
BAL : bronchoalveolar lavage
n.d.= no data

Högger and Rohdewald, Rev Contemp Pharm 1998;9: 501-522

 Meningkatnya keparahan
PPOK akan meningkatkan
resiko infeksi1
Kolonisasi bakteri
pada lumen saluran
napas meningkat(1,2)
Peningkatan resiko eksaserbasi
dan pneumonia(1,2)
FC : fluticasone; BUD : budesonide
FP memiliki kemampuan disolusi lebih
lambat dan lambat untuk menembus
jaringan(3)
Faktor FP Oleh karena itu FP tertahan
PPOK vs. dengan kontrasi yang tinggi
BUD pada mucus (4)
Meningkatkan
kerusakan
pada saluran
napas FP memiliki potensi 10 kali lipat
menekan sistem imun lokal pada
imunitas (makropage)
dibandingkan BUD5
1. Jenkins CR et al. Respir Res 2009,10: 59.
2. Crim C et al. Eur Respir J 2009, 34: 641-647
3. Högger and Rohdewald. Rev Contemp Pharm 1998;9:501-522
4. Dalby C et al. Respir Res 2009; 10:104
5. Ek A et al. Allergy 1999;54:691-699
Hypothesis of immunosuppressant event1-9

Kolonisasi bakteri di saluran

Bud/For napas lebih rendah dengan Flu/Sal
spektrum patogen yang
diamati pada pasien PPOK

ASL

Mukosa/jaringan paru

Bakteri lokal berproliferasi selama terjadinya infeksi, contoh virus

ASL : Airway Surface liquid Bacteria
Bud/For: Budesonide/Formoterol Fluticasone
Flu/Sal: Fluticasone/Salmeterol Fluticasone/GCS-
Eksaserbasi Pneumonia
receptor
(Tracheobronchitis) (Infeksi jaringan)
Budesonide 1. Wedzicha JA et al. Am J Respir Crit Care Med 2008;177:19-26.
2. Calverley PMA et al. CHEST 2011;139:505-512.
3. Patterson C et al. Respir Res 2012;13:40.
4. Ek A et al. Allergy 1999;54:691-699.
Budesonide/GCS-receptor 5. Miller-Larsson A et al. Am J Respir Crit Care Med 2000;162:1455-1461.
Eksaserbasi terus 6. Johnsson M et al. Allergy 1995;50:11-14.
7. Dalby C et al. Respi Res 2009;10:104
menerus 8. Larsson K et al. J Intern Med 2013;273:584-594.
9. Janson C et al. BMJ 2013;346:f3306. doi:10.1136/bmj.f3306