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Date: Mon, 6 Jun 2005 18:13:54 +0700 (WIT)
Subject: naskah lengkap prof dr.adji widjaya spp
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kepada yth,
panitia konas x dpp
dengan hormatbersama ini kami kirimkan :
1.abstrak dan makalah carticosteroid in copy exacerbation (revisi akhir)
2.abstrak sleep apneta3.curiculum vitae
regards,
prof.dr adji widjayaContent-Type: application/msword; name="Steroid in COPD &
OSA,"Prof. Adji.doc"
Content-Disposition: attachment; filename="Steroid in COPD & OSA,"
Prof. Adji.doc"
CORTICOSTEROID IN COPD EXACERBATION
Prof.Dr. Adji Widjaja,Sp.P, FCCP.WIDJAJA ASTHMA CENTRE SURABAYA
ABSTRACT
In COPD it was proven pathologically by biopsy and or bronchial alveolar
lavage ( BAL ) that there is a chronic inflammation in the peripheral small airway
wall and loss of elastic recoil in alveolar structure. It consists of an increased
number of lymphocytes, macrophages and neutrophils. So it is logical that anti
inflammatory therapy can show a short-term benefit when an exacerbation is
present. Side effect of systemic corticosteroid prevent the long term use. Inhaled
corticosteroid shows less side effects, but in the treatment of COPD exacerbation
it does not show a short term beneficial effect. Until present the result of long
term therapy is conflicting long term studies is needed to answer which
parameters should be monitored in COPD patients.
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Keywords : Chronic Obstructive Pulmonary Disease, Exacerbation, Anti
inflammation, Corticosteroid Side Effects.
CORTICOSTEROID IN COPD EXACERBATION
Prof.Dr. Adji Widjaja,Sp.P, FCCP.WIDJAJA ASTHMA CENTRE SURABAYA
Penelitian efektivitas terapi terhadap Asma dan Penyakit Paru Obstruktif
Kronis telah berubah sejak satu dekade terakhir. Hasil pengobatan sebelum
1985 diukur dengan gejala. Setelah 1985 diukur dengan gejala, FEV 1 dan PC20.
Setelah 1993 diukur dengan FEV1 atau PC20, eksaserbasi, efektivitas biaya dan
kualitas hidup.
Penelitian patofisiologis PPOK ditemukan proses inflamasi kronis di
dinding saluran napas perifer dan berkurangnya elastic recoil dari struktur
alveolar, ditemukan lymfosit, neutrofil, sel mononuclear, meningkatnya jaringan
ikat dan metaplasia epitel dan ulserasi dinding saluran napas. (1)
Merokok adalah penyebab utama PPOK dimana didapat kenaikan
neutrofil dan aktivitas makrofag. Proses inflamasi saluran napas ini dipakai
sebagai pembenaran terapi anti inflamasi pada PPOK. (2)
Kortikosteroid
Kortikosteroid dikenal sebagai obat anti inflamasi paling poten, dipakai
sebagai obat obstruksi saluran napas sejak 1950, hingga kini. Setelah setengah
abad, peran steroid pada PPOK masih kontroversial, parameter akhir adalah tes
faal paru, serta ada tidaknya respon perbaikan FEV1 sebesar 15-20 %. Selain tes
faal paru, dipakai parameter eksaserbasi yang memerlukan evaluasi cukup lama,
apakah steroid inhalasi berguna pada PPOK.
Kortikosteroid Oral
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Manfaat kortikosteroid oral pada PPOK masih terjadi pertentangan. Weir
dkk.(3) menemukan masih adanya perbaikan FEV1 setelah pemberian
kortikosteroid selama 14 hari. Penelitian ini penting dalam menunjang terapi
kortikosteroid jangka panjang. Callahan dkk.(4) secara metaanalisis menyatakan
sekitar 10 % penderita PPOK menunjukkan perbaikan FEV 1 > 20 %. Penelitian
Keating dkk.(5) dengan biopsy dan Broncho Alveolar Lavage pada responder
kortikosteroid terdapat 12 % perbaikan FEV1 serta reticular basement membrane
yang lebih tebal, jumlah eosinofil lebih banyak dan adanya peningkatan
eosinophil cationic protein dalam cairan lavage maupun induce sputum.
Hasil diatas mengesankan penderita PPOK responder terhadap
kortikosteroid oral menunjukkan kemiripan dengan asma. Pemberian dosis besar
kortikosterod tidak menjamin perbaikan FEV1.
Pada PPOK eksaserbasi akut, pemberian kortikosteroid oral 10 hari diikuti
tapering meningkatkan PaO2 , Alveolar-Oxygen gradient dan faal paru,
memperbaiki gejala dan mengurangi gagal terapi. Penelitian Postma (6)jangka
panjang selama 20 tahun dengan kortikosteroid oral pada PPOK, menunjukkan
hasil cukup baik : FEV1 tetap stabil bahkan meningkat setelah 1-2 tahun terapi,
sangat berbeda dengan asma yang menunjukkan perbaikan FEV1 segera.
Kortikosterod Sistemik
Miller dan Sayiner menyimpulkan pada penderita PPOK eksaserbasi
berat, pemberian methylprednisolone 0,5 mg/kg intravenous setiap 12 jam
selama 10 hari lebih efektip daripada pemberian selama 3 hari. Pada penelitian
ini pemberian selama 10 hari tidak menyebabkan efek samping, akan tetapi tidak
menjamin pengurangan eksaserbasi. (7)
Kortikosteroid Inhalasi
Kortikosteroid inhalasi selama 1-3 bulan tidak memperbaiki obstruksi
saluran napas PPOK yang dimonitor dengan FEV1 dan PEFR. Penelitian lain,
Renkema (8) setelah follow up selama 2 tahun dengan 1.600 g Budesonide
menghasilkan kemajuan gejala yang nyata dibandingkan dengan placebo.
Penelitian Dompeling (9) menyatakan bahwa kortikosteroid inhalasi tidak
mempengaruhi eksaserbasi pada PPOK. Perlu menunggu hasil penelitan
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Copenhagen dan ISOLDE untuk menilai kegunaan kortikosteroid bagi penderita
PPOK tingkat berat, sedang dan ringan serta penentuan respon positip pada
kortikosteroid inhalasi.
Efek Samping
Pemakaian jangka pendek efek samping hanya sedikit. Pemakaian oral
jangka panjang 10 20 tahun dosis kecil dapat timbul efek samping dan perlu
penghentian obat.(10) 40 % oleh karena osteoporosis, 20 % karena hipertensi, 20
% ulcer lambung, 10 % diabetes mellitus, 10 % lain-lain : glaucoma, gangguan
mental.
Pada pemakaian inhalasi, efek samping sistemik dapat berupa suara
serak, aphoni, nyeri tenggorokan dan infeksi candida oropharyng. Supresi
adreno cortex timbul bila dosis Beclometason atau Budesonide diatas 1.500
g./hari, bruising yaitu perdarahan dibawah kulit pada lengan, terutama pada
usia lanjut, dosis besar dan pemakaian jangka panjang.
Kesimpulan
Diperlukan lebih banyak penelitian untuk memastikan peran kortikosteroid
inhalasi pada PPOK, hal mana sudah terbukti pada Asma. Perlu ditentukan
penderita PPOK mana bereaksi baik terhadap inhalasi korticosteroid. Yang jelas
pemberian kortikosteroid oral selama ada eksaserbasi efektip memperbaikigejala klinis dan mencegah kekambuhan dini penderita PPOK.
Kepustakaan
1. OShaughnessy TC. Ansari TW. Barnes MC. Jeffry PK. Inflamation in BronchialBiopsies of Subjects with Chronic Bronchitis Iners Relationship of CD8+TLymphocyte with FEV1 . Am.J. Respir Crit Care Med 1997 ; 155 ;852-57.
2. Postma DS. Pauwels RA. Anti Inflamatory Drugs in Chronic ObstructivePulmonary Disease. Management of Chronic Obstructive Pulmonary Disease.European Respiratory Monograph. 1998
3. Weir DC. Roberson AS. Gove RI. Burge PS. Time course response to oral andinhaled corticosteroid in non asthmatic chronic airflow obstruction. Thorax 1990 ;45 : 118-21.
4. Callahan CM. Dittus RS. Katz BP. Oral corticosteroid therapy for patients withstable chronic obstructive pulmonary disease. A Meta Analysis. Ann Intern Med1991 ; 114 : 216-23.
5. Keating VM,Jatakonen Y,Worsdell M,Barnes PJ,Effects of inhaled and oralglucocorticosteroids on inflammatory indices in Asthma and COPD. Am.J.Respior Crit care Med 1997 ;155: 42-48.
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6. Postma DS,Peter J,Steemhuis EJ, Sluiter HJ, Moderately severe chronic airflowobstruction : can corticosteroids slow down progression ? Eur Respir.J. 1988 I:22-6.
7. Miller KE, Sayiner A. Systemic glucocorticosteroids in severe exacerbations ofCOPD. Chest March 2001;119:726-30.
8. Renkema TEJ, Scouten JP, Koefer GH. Effects of long term treatment with
corticosteroid in COPD, Chest 1996 ; 109 : 1156-62.9. Dompeling E, Schayck Van CP, Folgeringh, Inhaled Beclomethasone improves
the course of asthma and COPD. Eur Respir J. 1992 ; 5: 945-52.10. Smith MJ, Hodson ME, Effects of long term inhaled high dose beclomethasone
diproprionate on adrenal function. Thorax 1993 ; 38 : 676-81
SLEEP APNEAProf. Dr. Adji Widjaja SpP. FCCP
WIDJAJA ASTHMA CENTRE, SURABAYA
ABSTRACTObstructive Sleep Apnea ( OSA ) is common in daily practice but
misunderstood by many medical practitioners, it needs more awareness for
Health Services regarding sleep apnea. Nutrition and Health fitness had
been studied by Researchers for many years but sleep, which take one
third ( 1/3 ) of our daily life got less attention. There is a link between OSA
and Hypertension, Stroke, Congestive Heart Failure, Depression, Chronic
Fatique Syndrome, it will decrease quality of life.
The incidence of OSA is estimated 2 4 %. The patients complained
of excessive day time sleepiness, fall as leep during work, snoring nasal
congestion, hypertension, obese. Other manifestation include impotence,
enuresis, morning head aches, loss of concentration, tired, gasping and
stop breathing. Other predisposition is over weight middle age men.
Pathologically consist of lack of pharyngeal muscle tone and gravity
resulting airway obstruction, snor or stop breathing during sleep,
especially in REM sleep, or body relax, the tongue and soft palate lose their
rigidity, gravity pulls these tissue back wards and closes the upper airway.
Polysomnography reveals repetitive obstructive apneas and
hyponeas. Apnea index less than 20 perhour is considered as mild, 20 40
as moderate and greater than 40 as severe. Temporary blocking of oxygen
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flow can lead to sudden death. Excessive daytime sleepiness which is to
blame for a car accidents and work related mishaps.
The management of OSA, the gold standard of therapy is
tracheostomy to bypass the upper airway obstruction, the result good, an
abolition of obstructive apneas and symptoms. Now Nasal Continous
Positive Airway Pressure ( CPAP ) is used, it is is effective and save as a
first line therapy. Another surgical procedure is Uvulo palato Pharyngo
Plasty, it is very effective for snoring. There are another surgical methods
to treat OSA but it is expensive.
Medical therapy include weight loss, position therapy during sleep.
Drug therapy with Tricyclic antidepressant triptyline, Serotonin inhibitors
will decrease the amount of REM sleep. Nocturnal oxygen therapy is useful
to minimize CO2 retention.
In general nasal CPAP is the treatment of choice in OSA : with this
method, a flow of pressurized room air via the nose maintains a positive
pressure in the upper airway range 5 to 20 cm H 2O.
Recently Res Meds Mask is available in Indonesia. The patient need
an adequate education about nasal CPAP before bedtime and are allowed
to become familiar with the equipment.
Keywords : Sleep apnea, Obstructive, Snooring, Daytime sleepiness,
Medical treatment and nasal CPAP.
CURICULUM VITAE
Nama : Prof. Dr. Adji Widjaja, SpP.(K).FCCP.
Tempat / tanggal lahir : Surabaya, 6 Februari 1937
Lulus Dokter : FK Unair tahun 1965
Lulus Dokter Paru : FK Unair tahun 1970
Upgrading COPD and Allergology. Ryks Universiteit Groningen Nederland
1979.
Guru Besar FK Unair 1998.
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