PENYAKIT PARU OBSTRUKTIF KRONIK

( PPOK )

Theopilus O Lay

SMF PARU RSUD DOK 2 JAYAPURA

Daftar Pustaka
 Buku PPOK PDPI
 Buku Ajar Paru
 www.goldcopd.com. G O L D
 GLOBAL INITIATIVE FOR CHRONIC
OBSTRUCTIVE LUNG DISEASE (GOLD):
TEACHING SLIDE SET
January 2016
This slide set is restricted for academic and educational
purposes only. Use of the slide set, or of individual
slides, for commercial or promotional purposes requires
approval from GOLD.

© 2014 Global Initiative for Chronic Obstructive Lung Disease

G lobal Initiative for Chronic
O bstructive
L ung
D isease
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 By 2020, COPD is projected to be the third
leading cause of chronic disease mortality
worldwide1
1990
2020

Ischaemic heart Cerebrovascular Lower

COPD Lower
Diarrhoeal Trachea,
Perinatal Disorders Road traffic
COPD
disease disease Respiratory respiratory
Disease bronchus and accidents
Infections infections lung cancers

Bars are used to illustrate chronic disease ranking only and do not represent
1. Murray CJL et al. Lancet 1997; 349:1498-1504
actual values
 Burden of COPD

More than 3 million people died of COPD in 2005, which is equal to 5%

of all deaths globally that year. Almost 90% of COPD deaths occur in
low- and middle-income countries.

The primary cause of COPD is tobacco smoke (through tobacco use or

second-hand smoke).

The disease now affects men and women almost equally, due in part to
increased tobacco use among women in high-income countries.

COPD is not curable, but treatment can slow the progress of the
disease.

Total deaths from COPD are projected to increase by more than 30% in
the next 10 years without interventions to cut risks, particularly
exposure to tobacco smoke.

WHO Fact Sheet No. 315 November 2012

Global Strategy for Diagnosis, Management and
Prevention of COPD, 2016: Chapters

 Definition and Overview

 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations
Updated 2014
 Manage Comorbidities

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters

 Definition and Overview

Updated 2014

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Definisi…

PPOK
GOLD 2014: PPOK yaitu Penyakit paru yang
dapat dicegah dan diobati, ditandai oleh
hambatan aliran udara persisten yang
biasanya bersifat progresif dan berhubungan
dengan respon inflamasi paru terhadap
partikel atau gas beracun/berbahaya,
eksaserbasi dan penyakit komorbid
berkontribusi terhadap berat penyakit.
Definisi PPOK

Penyakit yg :
 Dapat diobati dan dicegah
 Ditandai oleh persistent airflow limitation
 Yg biasanya progresif dan ada hub dg
 Peningkatan respons inflamasi kronik
 Di sal nafas dan paru thd noxious particles
atau gas
 Eksaserbasi dan komorbiditas memberi
kontribusi pd overall severity in individual
patients
Global Strategy for Diagnosis, Management and Prevention of COPD

Risk Factors for COPD

Genes

Infections

Socio-economic
status

Aging Populations
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Biomass Fuel and COPD

Future
COPD
case

Future
asthmatic

Future COPD if
smoker
 Pathogenesis of COPD
NOXIOUS AGENT
(tobacco smoke, pollutants, occupational
agent)
Genetic factors
Respiratory infection
Other

COPD
 Pathogenesis of COPD
Cigarette smoke
Biomass particles
Particulates
Host factors
Amplifying mechanisms

LUNG INFLAMMATION
Anti-oxidants
Anti-proteinases

Oxidative
stress Proteinases

Repair
mechanisms

COPD PATHOLOGY
Source: Peter J. Barnes, MD
 Patogenesis PPOK

Asap Rokok/Gas berbahaya

Inflamasi di Paru

Penyempitan- Hipersekresi Kerusakan Kerusakan

fibrosis sal napas mukus parenkim paru vaskuler paru

Gangguan Faal Paru

Barnes PJ, 2005, Decramer M et al, GOLD 2014

Patologi
Sal nafas besar Parenkim
 Infiltrasi sel radang  Destruksi parenkim
 Kel mukus hipertrofi
 Sel goblet Vaskuler
Sal nafas kecil  Perubahan struktur
 Penimbunan kolagen, tunika intima tebal
jar ikat otot polos >
 Metaplasi sel goblet
 Otot polos >
 Wall thickening –
inflammation --
mucus gland
hypertrophy
↑ Secretions
Bronchus
Wall thickening –
inflammation –
repair --
remodeling
Loss of alveolar
Bronchiole attachments

Wall thinning -
inflammation -
elastolysis
Coalescence ↓
Elasticity
Alveoli
COPD Pathology and Abnormal
Breathing Mechanics
 ↑ Airway resistance
 ↓ Elastic recoil
 Expir. flow limitation
 Air trapping and
dynamic hyperinflation
 ↑ Work of breathing
 Dyspnea, cough and
other respiratory ssx
 ↓ Quality of life
BRONKODILATASI BRONKOKONSTRIKSI
 (Bronkokonstriksi)

(Edema mukosa bronkus)

(Sumbatan
mukus)
airway secretions
Air Trapping :

inspirasi
ekspirasi
Mechanics of Breathing
Peripheral Lung Zone
 Airways open
and not prone
to collapse 
low resistance
 Lung recoil
strong enough
to drive tidal
expiration
(passive)
 Work of
breathing is
minimal
COPD: Altered Lung Mechanics

 Airway wall
thickened and
collapsing 
high resistance
 Alveoli thinned
out  poor
elastic recoil
 Expiratory flow
limitation
 Residual volume
increased
  Expiratory
Flow Limitation
Time Constants
of Breathing
Δ Vol
A Wide airway, good lung recoil
B Narrowed airway, good lung recoil
L Wide airway, poor lung recoil
i
t C Narrowed airway, poor lung recoil
e
r A
B C
s
Time (seconds)
Expiratory Flow Limitation and
Hyperinflation
Resting State

Normal COPD

Mild Obstruction, + mildly Severe obstruction, + markedly

decreased Elastic Recoil decreased Elastic Recoil
 Hiperinflasi alveoli

Bronkonstriksi
edema mukosa bronkus
sumbatan mukus
 EFL and Dynamic
Hyperinflation
During
Normal Exercise COPD

Air is trapped

Initial breathing cycle

 EFL and Dynamic
Hyperinflation
During
Normal Exercise COPD

Worsening Hyperinflation

Initial breathing cycle  Next breathing cycle

Bronkokonstriksi Edema
mukosa bronkus Sumbatan Obstruksi jalan napas
mukus

Resistensi arus ekspirasi 

Air trapping Hiperinflasi alveoli

Kontraksi diafragma Otot-otot bantu pernapasan

terganggu diaktifir
 Airway obstruction and low
elastic recoil
Hyperventilation:
Static and Dynamic
Expiratory flow limitation

IC
Total Lung Capacity
lume
ry Vo

INSPIRATORY CAPACITY
to
Hyperinflation at rest, COPD xp ira
E

END EXPIRATORY LUNG VOL

worsened by exercise En d
Lung Volume
Tidal Volume

Limited inspiratory “space”

FRC
FRC

End Expiratory Volume

Normal
Time
Dyspnea
Resting Exercise
 Global Strategy for Diagnosis, Management and Prevention of COPD

Mechanisms Underlying Airflow

Limitation in COPD

Small Airways Disease Parenchymal Destruction

• Airway inflammation • Loss of alveolar attachments
• Airway fibrosis, luminal plugs • Decrease of elastic recoil
• Increased airway resistance

AIRFLOW LIMITATION
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Dampak Sistemik PPOK

PPOK - Diagnosis dan Penatalaksanaan – PDPI 2011,hal.18

Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters

 Definition and Overview

 Diagnosis and Assessment

Updated 2014

© 2014 Global Initiative for Chronic Obstructive Lung Disease

 Diagnosis of COPD

EXPOSURE TO RISK
SYMPTOMS FACTORS

shortness of breath tobacco

chronic cough occupation
sputum indoor/outdoor pollution

SPIROMETRY: Required to establish diagnosis

GOLD 2013
 Spirometri
 metode pengukuran fungsi paru
 mengukur ventilasi yaitu
mengukur volume statik dan
volume dinamik paru
Spirometri

 Simpel

 Prinsip dasar spirometri

 mengukur volume dan flow rate
 2 tipe : - volumetric spirometer
- flow type spirometer
TUJUAN PEMERIKSAAN
SPIROMETRI

 Menilai status faal paru

(normal, restriksi, obstruksi,campuran)
 Menilai manfaat pengobatan
 Memantau perjalanan penyakit
 Menentukan prognosis
 Menentukan toleransi tindakan bedah
 INDIKASI PEMERIKSAAN
 Setiap keluhan sesak
 Penderita asma stabil
 Penderita PPOK stabil
 Evaluasi penderita asma tiap tahun dan
penderita PPOK tiap 6 bulan
 Penderita yang akan dianestesi umum
 Pemeriksaan berkala pekerja yang
terpajan zat
 Pemeriksaan berkala pada perokok
 Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of Airflow Limitation:

Spirometry
Spirometry should be performed after the
administration of an adequate dose of a short-acting
inhaled bronchodilator to minimize variability.
A post-bronchodilator FEV1/FVC < 0.70
confirms the presence of airflow limitation.
Where possible, values should be compared to
age-related normal values to avoid overdiagnosis
of COPD in the elderly.

© 2014 Global Initiative for Chronic Obstructive Lung Disease

 Spirometry: Normal Trace Showing
FEV1 and FVC

5 FVC
4
Volume, liters

FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1

1 2 3 4 5 6

Time, sec
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Spirometry: Obstructive Disease

5 Normal

4
Volume, liters

3
FEV1 = 1.8L
2 FVC = 3.2L Obstructive
FEV1/FVC = 0.56
1

1 2 3 4 5 6

Time, seconds

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD: Goals

Determine the severity of the disease, its
impact on the patient’s health status and the
risk of future events (for example
exacerbations) to guide therapy. Consider the
following aspects of the disease separately: 
 current level of patient’s symptoms
 severity of the spirometric abnormality
 frequency of exacerbations
 presence of comorbidities.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Klasifikasi derajat Keparahan PPOK menurut GOLD 2014

Penggolongan pasien PPOK tidak hanya dilihat

berdasarkan hasil spirometri akan tetapi dinilai
juga berdasarkan gejala atau keluhan pasien
menurut skala mMRC atau CAT dan juga
riwayat eksaserbasi.
Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD ( A,B,C,or D )

 Assess symptoms
 Assess degree of airflow
limitation using spirometry
 Assess risk of exacerbations

 Assess comorbidities
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Kategori Pasien PPOK menurut GOLD 2014
Kategori Karakterisitik Klasifikasi mMRC CAT Eksaserbasi
Spirometry per tahun

A Risiko rendah GOLD 1 atau 2 0-1 < 10 ≤1

Gejala sedikit

B Risiko rendah GOLD 1 atau 2 ≥2 ≥ 10 ≤1

Gejala banyak

C Risiko tinggi GOLD 3 atau 4 0-1 < 10 ≥2

Gejala sedikit

D Risiko tinggi GOLD 1 atau 2 ≥2 ≥ 10 ≥2

Gejala banyak
Global Strategy for Diagnosis, Management and Prevention of COPD

Symptoms of COPD
The characteristic symptoms of COPD are chronic and
progressive dyspnea, cough, and sputum production
that can be variable from day-to-day.

Dyspnea: Progressive, persistent and characteristically

worse with exercise.

Chronic cough: May be intermittent and may be

unproductive.

Chronic sputum production: COPD patients commonly

cough up sputum.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD
 Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of Assessment
COPD exacerbations Test (CAT)
Assess comorbidities
or
Clinical COPD Questionnaire (CCQ)
or
mMRCBreathlessnessscale
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Skor mMRC
Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

 Assess symptoms
 Assess degree of airflow limitation
usingspirometry
Use spirometry
Assess for grading severity
risk of exacerbations
Assess comorbidities
according to spirometry, using four
grades split at 80%, 50% and 30% of
predicted value

© 2014 Global Initiative for Chronic Obstructive Lung Disease

 Klasifikasi derajat obstruksi PPOK
( FEV1 pasca bronkodilator )

Pada pasien dengan FEV1/FVC < 0,7

GOLD 1 Ringan FEV1 ≥ 80%
predicted
GOLD 2 Sedang 50%≤ FEV1 < 80%

GOLD 3 Berat 30% ≤ FEV1 < 50%

GOLD 4 Sangat Berat FEV 1 < 30%

GOLD 2014
Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

 Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations
Assess comorbidities
Usehistory of exacerbations and spirometry.
Twoexacerbations or more within the last year
or an FEV1 < 50 % of predictedvalueare
indicators of highrisk. Hospitalization for a COPD
exacerbationassociated with increasedrisk of death.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD

Assess Risk of Exacerbations

To assess risk of exacerbations use history of

exacerbations and spirometry:
 Two or more exacerbationswithinthe last
yearor an FEV1 < 50 % of
predictedvalueareindicators of highrisk.
 One or more hospitalizations for COPD
exacerbationshouldbeconsideredhighrisk.

© 2014 Global Initiative for Chronic Obstructive Lung Disease

 Global Strategy for Diagnosis, Management and Prevention of COPD

CombinedAssessment of COPD

 Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations

Combine these assessments for the

purpose of improving management of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Global Strategy for Diagnosis, Management and Prevention of COPD

CombinedAssessment of COPD
≥2
(GOLD Classification of Airflow Limitation))

4 or
> 1 leading
(C) (D) to hospital

(Exacerbation history)
admission
3

Risk
1 (not leading
Risk

to hospital
2 admission)

(A) (B)
1
0

CAT < 10 CAT > 10

Symptoms
mMRC 0–1 mMRC > 2
Breathlessness
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD

CombinedAssessment of COPD
Assess symptoms first
If CAT < 10 ormMRC 0-1:
Less Symptoms/breathlessness (A or
(C) (D) C)

If CAT >10 or mMRC> 2:

More Symptoms/breathlessness (B
or D)
(A) (B)
CAT < 10 CAT >10
Symptoms

mMRC 0–1 mMRC > 2

Breathlessness
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Global Strategy for Diagnosis, Management and Prevention of COPD

CombinedAssessment of COPD
Assess risk of exacerbations next
(GOLD Classification of Airflow Limitation)

≥2 If GOLD 3 or 4 or ≥ 2
4 or exacerbations per year or
(C) (D) > 1 leading to hospital

(Exacerbation history)
> 1 leading
3
to hospital admission:
admission High Risk (C or D)

Risk
Risk

If GOLD 1 or 2 and only

2 1 (not leading
0 or 1 exacerbations per
(A) (B) to hospital
admission) year (not leading to
1 0 hospital admission):
Low Risk (A or B)
CAT < 10 CAT >10
Symptoms
mMRC0–1 mMRC > 2
Breathlessness © 2014 Global Initiative for Chronic Obstructive Lung Disease
 Global Strategy for Diagnosis, Management and Prevention of COPD

CombinedAssessment of COPD
≥2
(GOLD Classification of Airflow Limitation))

4 or
> 1 leading
(C) (D) to hospital

(Exacerbation history)
admission
3

Risk
1 (not leading
Risk

to hospital
2 admission)

(A) (B)
1
0

CAT < 10 CAT > 10

Symptoms
mMRC 0–1 mMRC > 2
Breathlessness
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Global Strategy for Diagnosis, Management and Prevention of COPD

CombinedAssessment of COPD

When assessing risk, choose the highest risk

according to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)
Patient Characteristic SpirometricCla Exacerbations CAT mMRC
ssification per year
Low Risk
A GOLD 1-2 ≤1 < 10 0-1
Less Symptoms
Low Risk
B GOLD 1-2 ≤1 > 10 >2
More Symptoms
High Risk
C GOLD 3-4 >2 < 10 0-1
Less Symptoms
High Risk >2
D GOLD 3-4 >2 > 10
More Symptoms
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Kategori Pasien PPOK menurut GOLD 2014
Kategori Karakterisitik Klasifikasi mMRC CAT Eksaserbasi
Spirometry per tahun

A Risiko rendah GOLD 1 atau 0-1 < 10 ≤1

Gejala sedikit 2

B Risiko rendah GOLD 1 atau ≥2 ≥ 10 ≤1

Gejala banyak 2

C Risiko tinggi GOLD 3 atau 0-1 < 10 ≥2

Gejala sedikit 4

D Risiko tinggi GOLD 1 atau ≥2 ≥ 10 ≥2

Gejala banyak 2
Global Strategy for Diagnosis, Management and Prevention of COPD

Assess COPD Comorbidities

COPD patients are at increased risk for:
 Cardiovasculardiseases
 Osteoporosis
 Respiratoryinfections
 AnxietyandDepression
 Diabetes
 Lungcancer
 Bronchiectasis
These comorbid conditions may influence mortality and
hospitalizations and should be looked for routinely, and
treated appropriately.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Dampak Sistemik PPOK

PPOK - Diagnosis dan Penatalaksanaan – PDPI 2011,hal.18

 Global Strategy for Diagnosis, Management and Prevention of COPD

Differential Diagnosis:
COPD and Asthma
COPD ASTHMA
•Onset in mid-life • Onset early in life (often childhood)
• Symptoms slowly progressive • Symptoms vary from day to day
• Long smoking history • Symptoms worse at night/early morning
• Allergy, rhinitis, and/or eczema also present
• Family history of asthma

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis Banding

Asma bronkial
Gagal jantung kongestif
Bronkiektasis
Tuberkulosis
Bronkiolitis obliteran
Diffuse Panbronchiolitis
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters

 Definition and Overview

 Diagnosis and Assessment
 Therapeutic Options

Updated 2014

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Penatalaksanaan
Opsi terapi:

1.Berhenti Merokok
2.Terapi Farmakologi
3.Terapi Nonfarmakologi
 Penatalaksanaan
Berhenti merokok

Sangat penting utk pasien yg masih merokok

Intervensi dg kapasitas terbesar pd perjalanan alamiah
PPOK
Nicotine replacement theraphy meningkat long-term
smoking abstinence rates
Konseling oleh dr, tenaga kesehatan significantly increases
quit rates over self-initiated strategies
(Evidence A)
 Penatalaksanaan: COPD Medications
Beta2-agonists

Short-acting beta2-agonists

Long-acting beta2-agonists

Anticholinergics

Short-acting anticholinergics

Long-acting anticholinergics

Combination short-acting beta2-agonists + anticholinergic in one inhaler

Methylxanthines

Inhaled corticosteroids

Combination long-acting beta2-agonists + corticosteroids in one inhaler

Systemic corticosteroids

Phosphodiesterase-4 inhibitors
 Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators

Bronchodilator medications are central to the

symptomatic management of COPD.
 Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
 The principal bronchodilator treatments are beta 2-
agonists, anticholinergics, theophylline or combination
therapy.
 The choice of treatment depends on the availability of
medications and each patient’s individual response
in terms of symptom relief and side effects..
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other
Pharmacologic Treatments

Influenza vaccines can reduce serious illness.

Pneumococcal polysaccharide vaccine is recommended
for COPD patients 65 years and older and for COPD
patients younger than age 65 with an FEV1< 40%
predicted.

The use of antibiotics, other than for treating infectious

exacerbations of COPD and other bacterial infections, is
currently not indicated.

© 2014 Global Initiative for Chronic Obstructive Lung Disease

 Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other
Pharmacologic Treatments
Alpha-1 antitrypsin augmentation therapy: not
recommended for patients with COPD that is unrelated
to the genetic deficiency.
Mucolytics:Patients with viscous sputum may benefit from
mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators:Nitric oxide is contraindicated in stable
COPD. The use of endothelium-modulating agents for
the treatment of pulmonary hypertension associated
with COPD is not recommended.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation

 All COPD patients benefit from exercise training

programs with improvements in exercise tolerance
and symptoms of dyspnea and fatigue.
 Although an effective pulmonary rehabilitation
program is 6 weeks, the longer the program
continues, the more effective the results.
 If exercise training is maintained at home, the
patient's health status remains above pre-
rehabilitation levels.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters

 Definition and Overview

 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD

Updated 2014

© 2014 Global Initiative for Chronic Obstructive Lung Disease

 Penatalaksanaan PPOK Stabil:
Tujuan Terapi
 Relieve symptoms
 Improve exercise tolerance Reduce
 Improve health status symptoms

 Prevent disease progression

 Prevent and treat exacerbations Reduce
 Reduce mortality risk
 Penatalaksanaan PPOK stabil

 Identifikasi dan reduksi pajanan f risiko

 Terapi farmakologi

 Terapi nonfarmakologi

 Monitoring dan follow up

 Penatalaksanaan PPOK stabil
Identifikasi dan reduksi pajanan f risiko

 Berhenti merokok the key intervention for all COPD

(Evidence A)
 Anjurkan pasien menghindari pajanan lebih lanjut
(Evidence D)
 Mengurangi risiko polusi udara indoor dan outdoor.
Feasible dan harus dianjurkan (Evidence B)
 Bagaimana menggunakan terapi
farmakologi ?

GOLD 4
C D >2

Exacerbations per year

GOLD 3

GOLD 2
1
A B
GOLD 1
0

mMRC 0-1 mMRC>2

CAT < 10 CAT >10
 Penatalaksanaan PPOK stabil
Terapi Farmakologi
Patient First choice Second choice AlternativeChoices

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 PDE4-inh.
C or LAMA and LABA SABA and/or SAMA
LAMA
Theophylline

ICS + LABA ICS andLAMA or

or ICS + LABA and LAMA or Carbocysteine
D ICS+LABA and PDE4-inh.or SABA and/or SAMA
LAMA LAMA and LABA or Theophylline
LAMA and PDE4-inh.
 Penatalaksanaan PPOK stabil
Terapi farmakologi
FIRST CHOICE

C D
GOLD 4
ICS + LABA ICS + LABA
>2

Exacerbations per year

or or
GOLD 3 LAMA LAMA

A B
GOLD 2
SAMA prn LABA 1
or or
GOLD 1 SABA prn LAMA
0

mMRC 0-1 mMRC>2

CAT < 10 CAT >10
 Penatalaksanaan PPOK stabil
Terapi farmakologi SECOND CHOICE

C D
GOLD 4 LAMA and LABA ICS and LAMA or
ICS + LABA and LAMA or >2

Exacerbations per year

ICS + LABA and PDE4-inh or
GOLD 3 LAMA and LABA or
LAMA and PDE4-inh.
A B
GOLD 2
LAMA or LAMA and LABA 1
LABA or
GOLD 1 SABA and SAMA
0

mMRC 0-1 mMRC> 2

CAT < 10 CAT > 10
Penatalaksanaan PPOK stabil : Farmako terapi
ALTERNATIVE CHOICES

C D

GOLD 4 PDE4-inh. Carbocysteine

SABA and/or SAMA SABA and/or SAMA >2

Exacerbations per year

Theophylline Theophylline
GOLD 3

A SABA and/or B
GOLD 2 Theophylline
SAMA 1
Theophylline
GOLD 1
0

mMRC 0-1 mMRC> 2

CAT < 10 CAT >10
 Penatalaksanaan PPOK stabil
Bronkodilator- Rekomendasi

 Agonis β2 dan antikolinergik: Long acting lebih

dipilih dp short acting (Evidence A)
 Bronkodilator inhalasi lebih dipilih dp oral
berdasar efikasi dan ESO (Evidence A)

 Berdasar bukti relatif low efficacy dan lebih

banyak efek samping, theofilin tidak
direkomendai kecuali other long-term treatment
bronkodilator tidak ada (Evidence B)
 Penatalaksanaan PPOK stabil
Kortikosteroid-PDE-4 Inhibitor Rekomendasi
 Tx jangka panjang dg kortikosteroid inhalasi direkomendasi
utk PPOK berat dan sangat berat dan sering eksaserbasi yg
tidak terkontrol dg LABA (Evidence A)
 Long-term monotheraphy oral steroid tidak diarekomendasi
(Evidence A)
 Long-term monotheraphy inhaled steroid tidak
direkomendasi ok kurang efektif dibanding LABAC
(Evidence A)
 PDE-4 Inhibitor mungkin digunakan utk mengurangi
eksaserbasi pasien Bronkitis Kronis, PPOK berat, sangat
berat dan sering eksaserbasi (Evidence B)
Penatalaksanaan PPOK stabil
Terapi nonfarmakolgi

Kelomp Essential Rekomendasi Local guideline

ok

A Berhenti Physical Flu vaccination

merokok activity Pneumococcal
vaccination
B-D Berhenti Physical Flu vaccination
merokok activity Pneumococcal
Pulmonary vaccination
rehabilitation
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters

 Definition and Overview

 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations

Updated 2014

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Penatalaksanaan Eksaserbasi

An exacerbation of COPD is:

“an acute event characterized by a
worsening of the patient’s
respiratory symptoms that is
beyond normal day-to-day
variations and leads to a change in
medication.”
 Consequences Of COPD Exacerbations

Negative Impact on
impact on symptoms
quality of life and lung
function

EXACERBATIONS
Accelerated Increased
lung function economic
decline costs

Increased
Mortality
 Penatalaksanaan eksaserbasi
Opsi Terapi

Oxygen: titrate to improve the patient’s hypoxemia with a target

saturation of 88-92%.
 
Bronchodilators:Short-acting inhaled beta2-agonists with or
without short-acting anticholinergics are preferred.
 
Systemic Corticosteroids:Shorten recovery time, improve lung
function (FEV1) and arterial hypoxemia (PaO2), and reduce the
risk of early relapse, treatment failure, and length of hospital
stay. A dose of 30-40 mg prednisolone per day for 10-14 days is
recommended.
 Penatalaksanaan Eksaserbasi
Opsi terapi

Antibiotics should be given to patients with:

 Three cardinal symptoms: increased

dyspnea, increased sputum volume, and
increased sputum purulence.
 Who require mechanical ventilation.
 Penatalaksanaan Eksaserbasi
Opsi Terapi
Noninvasive ventilation (NIV):
 Improves respiratory acidosis, reduces
respiratory rate, severity of dyspnea,
complications and length of hospital stay.
 decreases mortality and needs for intubation.
 Penatalaksanaan Eksaserbasi
Indications for Hospital Admission

 Marked increase in intensity of symptoms

 Severe underlying COPD
 Onset of new physical signs
 Failure of an exacerbation to respond to
initial medical management
 Presence of serious comorbidities
 Frequent exacerbations
 Older age
 Insufficient home support
Monitoring dan Follow up

 Monitoring disease progression and

development of complications
 Monitori Pharmacotheraphy and Other
medical treatment
 Monitor exacerbation history
 Monitor Comorbidities
Penyulit

 Gagal napas

 Infeksi berulang

 Cor pulmonale
Prognosis

Buruk pada:
 FEV1 rendah
 Masih merokok
 Nutrisi jelek
 Korpulmonale
 Komorbid
TERIMA KASIH