Download - FTT PPOK Dr. Ediyono
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Dr Ediyono Sp PSubdep Paru RSAL Dr Ramelan
Farmasi UBY Mei 2012
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NO Kelompok Penyakit Penyakit
A Infeksi 1. TBC2. Bukan TBC ( ISPA, Bronkitis, Pneumonia, Abses )
B Allergi Asma Bronkiale
C Obstruksi Saluran nafas kronis
PPOK ( Penyakit Paru Obstruksi Kronis )
D Peny. Pleura Pleuritis, Efusi Pleura, Pneumotoraks
E Tumor/ Kanker 1. Asal : PRIMER, SEKUNDER2. Pertumbuhan : JINAK, GANAS3. Tumor Paru, Tumor mediastinum
F Penyakit Paru Kerja Pneumokoniosis
Penyakit – penyakit ParuPenyakit – penyakit Paru
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GOLD
Diagnosis
Dan
Penatalaksanaan
Edisi Buku lengkap, Juli 2011Perhimpunan Okter Paru Inonesia (PDPI)
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Pokok bahasan PPOK
1. Pendahuluan.2. Definisi PPOK.3. Patogenesis & Patologi4. Faktor Risiko5. Diagnosis & Diagnosis Banding6. Klasifikasi7. Penatalaksanaan PPOK8. Komplikasi9. Keadaan Khusus10. Pencegahan
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P P O K ( P P O M )P P O K ( P P O M )1958 “ Emphysema and Chronic Bronchitis Syndrome “
1960 “ Chronic Obstructive Bronchopulmonary Disease “
1964 “ Chronic Obstructive Bronchopulmonary Disease “
1966 “ Chronic Airway Obstruction “
1967 “ Chronic Obstructive Lung Disease “
1972 “ Chronic Aspesific respiratory affection “
1977 “ Chronic Non Spesific Lung Disease “
1978 “ Chronic Obstructive Pulmonary Disease “ ( COPD )
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PendahuluanPendahuluan
PPOK (WHO 1990) : peringkat ke 6 penyebab kematian di
dunia
WHO Th 2000 : 2,74 juta kematian ok PPOK
Th 2020 : peringkat ke 5 penyakit terbanyak
didunia
SKRT DepKes 1992: penyebab kematian peringkat ke – 6
Di Indonesia : terdapat 4,8 juta pasien (prevalensi : 5,6%).
PPOK ( Penyakit paru Obstruktif Kronik). Diagnosis dan Penatalaksanaan. PDPI Juli 2011
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Pokok bahasan PPOK
1. Pendahuluan.2. Definisi PPOK.
3. Patogenesis & Patologi4. Faktor Risiko5. Diagnosis & Diagnosis Banding6. Klasifikasi7. Penatalaksanaan PPOK8. Komplikasi9. Keadaan Khusus10. Pencegahan
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PPOK ( Penyakit Paru Obstruktif Kronis )PPOK ( Penyakit Paru Obstruktif Kronis ) DEFINISI :
- Penyakit Paru yang dapat dicegah & diobati,
- ditandai dengan Hambatan aliran udara di saluran nafas,
- yang tidak sepenuhnya Reversibel
- bersifat “ Progresif “
- Berhubungan dengan respon inflamasi kronik paru
terhadap partikel / gas yg beracun / berbahaya, disertai
efek ekstraparu yang berkontribusi terhadap derajat berat
penyakit PPOK ( Penyakit paru Obstruktif Kronik). Diagnosis dan Penatalaksanaan. PDPI Juli 2011
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PPOK
1. Bronkitis Kronis 2. Emfisema
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P P O KP P O K
PPOK terdiri dari :
a. a. B R O N K I T I S K R O N I S :
Batuk kronik berdahak, minimal 3 bulan dalam setahun,
sekurang – kurangnya 2 tahun berturut-turut.
b. E M F I S E M A :
Kelainan anatomis , ditandai adanya pelebaran rongga udara distal bronchioli terminal, disertai kerusakan dinding alveoli ( Permanen )
PPOK Pedoman Praktis Daignosis dan Penatalaksanaan. PDPI 2004
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1. PPOK berhubungan dengan RokokRokok
Fakta-fakta yang berhubungan PPOKFakta-fakta yang berhubungan PPOK
Riwayat Merokok Derajat Berat Merokok (∑ rokok/hari x lama/tahun)
Perokok Aktif Ringan : 0-199
Perokok Pasif Sedang : 200-599
Bekas perokok Berat : > 600
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2. Polusi udara a. Polusi di dalam ruangan : - asap rokok
- asap komporb. Polusi di luar ruangan :
- Gas buang kendaranan bermotor- Debu jalanan
c. Polusi tempat kerja ( bahan kimia, zat iritasi, gas beracun)3. Infeksi saluran nafas berulang.4. Defisiensi enzim alfa – 1 antitripsin ( Jarang )5. GENETIK
Faktor Risiko P P O KFaktor Risiko P P O K
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6 Efek nikotin pada susunan saraf pusat6 Efek nikotin pada susunan saraf pusat
a. Dopmamin
b. Norepinephrine
c. Acethylcholine
d. Vasopressin
e. Serotonin
f. β-endorphin
Pleasure
Appetite supression
Arousal,cognitive enhancement
memory
Mood mudulation
Anxiety reduction
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Definition of COPD
COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients.
Its pulmonary component is characterized by airflow limitation that is not fully reversible.
The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.
Global Initiative for Chronic Obstructive Lung Disease
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HIPERSEKRESI HIPERSEKRESI MUKUSMUKUS
BR. KRONISBR. KRONIS
Anti Anti oksidanoksidan
OksidanOksidan
Mekanisme perlindungan
Mekanisme perbaikan
Fibrosis saluran nafas
Kerusakan Parenkim Paru
Hipersekresi mukus
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Cigarette smoke
Alveolar macrophage
Neutrophil
PROTEASES
Alveolar wall destruction(Emphysema)
Mucus hypersecretion
(Chronic bronchitis)
PROTEASEINHIBITORS
Neutrophil chemotactic factors
CELLULAR MECHANISMS OF COPDCELLULAR MECHANISMS OF COPD
Neutrophil elastaseCathepsins
Matrix metalloproteinases
Cytokines (IL-8)Mediators (LTB4)4 ))
?CD8+
lymphocyte
-
MCP-1
Alveolar wall destruction( Emphysema )
Mucus Hypersecretion( Chronic Bronchitis )
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KELAINAN SALURAN NAFASKELAINAN SALURAN NAFAS
EMFISEMAEMFISEMABRONKITIS KRONISBRONKITIS KRONIS
DESTRUKSI DESTRUKSI ALVEOLIALVEOLI
Hiperplasi KelenjarHiperplasi Kelenjar
Mbr Basal menebalMbr Basal menebal
Oedem Mukosa, HipersekresiOedem Mukosa, Hipersekresi
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Gambaran Emphysema. Terjadi kerusakan alveoli
alveooli
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E M F I S E M AE M F I S E M A
EMFISEMAEMFISEMA
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Bronkitis Bronkitis KronisKronis
EMFISEMAEMFISEMA
NORMALNORMAL
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Bullae pada Emfisema
large bullae apparent on the
surface of the lungs in a patient
dying with emphysema.
Bullae are large dilated
airspaces that bulge out from
beneath the pleura.
Bullae
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Emfisema Paru
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COPD IS NOT ASTHMA !COPD IS NOT ASTHMA !
a) Beda penyebab
b) Beda sel inflamasi
c) Beda mediator inflamasi
d) Beda akibat inflamasi
e) Beda respon terapi.
DyspneuWheezing
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A S M AA S M A
Bahan sensitifBahan sensitif
Mediator inflamasi
CD4 + T-Limfosit
Eosinofil
Mediator inflamasi
CD4 + T-Limfosit
Eosinofil
ReversibelReversibelHambatan
Aliran udara
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ASMA PPOK SOPT
1 Usia Muda Tua +
3 Riwayat merokok +/- +++ -
4 Riwayat Alergi ++ + -
8 Reversibiliti obstruksi ++ - -
S O P T : Syndroma Obstruksi Pasca Tuberkulosa
Perbedaan Asma – PPOK – SOPT
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Gambaran Klinis P P O KGambaran Klinis P P O K
E M F I S E M A
( PINK PUFFER )
BRONKITIS KRONIS
( BLUE BOATER ) Batuk dahak - / sedikit Batuk berdahak terus menerus
Badan kurus Badan gemuk
Kulit kemerahan Tampak pucat ( sianosis )
Dada cembung ( Barrel Chest ) Dada normal
Suara nafas lemah / turun Rhonki basah / wheezing
Foto toraks : hiperaerated Foto toraks : Jantung membesar, corakan bronkus makin banyak
Foto toraks : diafragma datar Foto toraks : diafragma normal
Darah : Polisitemia ( jarang ) Darah : polisitemia sekunder ( HB ↑ )
Faal paru : Volume residu > Faal Paru : Volume residu normal
Komplikasi :Kor pulmonale jarang Komplikasi : kor pulmonale sering
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Gambaran Klinis P P O KGambaran Klinis P P O K
Emfisema( Pink Puffer )
Emfisema( Pink Puffer )
Bronkitis Kronis( Blue Boater ) Bronkitis Kronis( Blue Boater )
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Diagnosis P P O K
Diagnosis PPOK ditegakkan berdasarkan :a. Gambaran klinis
1. Anamnesa : - Keluhan - Riwayat penyakit - Faktor predisposisi
2. Pemeriksaan fisikb. Pemeriksaan penunjang
1. Pemeriksaan rutin 2. Pemeriksaan khusus
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GAMBARAN KLINIS:GAMBARAN KLINIS:
a. a. Anamnesa ( Keluhan )
- Usia tua ( > 45 th )
- Riwayat / bekas PEROKOK
- Riwayat terpajan zat iritan ( waktu lama )
- Riwayat infeksi nafas berulang, lingkungan asap rokok
- Batuk berulang dengan / tanpa dahak
- Sesak nafas bila aktivitas berat ( Dyspneu d’effort )
Diagnosis P P O K
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PEMERIKSAAN PENUNJANGPEMERIKSAAN PENUNJANG::
I.I. PEMERIKSAAN RUTINPEMERIKSAAN RUTIN
1.1. Foto Toraks ( Paru )Foto Toraks ( Paru )
II.II. PEMERIKSAN KHUSUSPEMERIKSAN KHUSUS
1.1. Spirometri ( Faal Paru )Spirometri ( Faal Paru )2.2. Analisa gas darahAnalisa gas darah3.3. EKGEKG
Diagnosis P P O K
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Tanda Fisik Kelainan ParuTanda Fisik Kelainan Paru
E M F I S E M A ( P P O M )E M F I S E M A ( P P O M )
1 Inspeksi Bentuk toraks cembung seperti Tong ( Barrel Chest ),
Iga mendatar, sela iga melebar.
Gerakan toraks terbatas, Otot bantu nafas hipertrofi
2 Palpasi Fremitus suara menurun
3 Perkusi Hipersonor seluruh hemitoraks
4 Auskultasi Suara nafas lemah, Ekspirasi lebih panjang, Krepitasi,
Wheezing.
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Bentuk toraks penderita
Emfisema
Barrel Chest
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Pola pernafasan P P O K
Pada waktu bernafas:
Ekspirasi mulut seperti bersiul
( hampir menutup )
Pursed Lip Breathing
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Spirometri ( Faal Paru )
Manfaat :1. Mengetahui adanya hambatan aliran udara2. Beratnya penyakit3. Evaluasi hasil pengobatan
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Table 1. – Klasifikasi PPOK berdasarkan Spirometri
Severity Postbronchodilator
FEV1/FVC
FEV1 % predicted
At riskPatients who:
smoke or have exposure to pollutants
have cough, sputum or dyspnea
have family history of respiratory disease
> 0.7 ≥ 80
PPOK ringan ≤ 0.7 ≥ 80
PPOK sedang ≤ 0.7 50 – 80
PPOK berat ≤ 0.7 30 – 50
PPOK sangat berat ≤ 0.7 < 30
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PPOK dan Penyakit PenyertaPPOK dan Penyakit Penyerta
COPD patients are at increased risk for:
Myocardial infarction, angina
Osteoporosis
Respiratory infection
Depression
Diabetes
Lung cancer
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PPOK umumnya disertai gangguan kelainan diluar paru :
Berat badan turun
Gangguan nutrisi
Gangguan masa otot
PPOK dan Penyakit PenyertaPPOK dan Penyakit Penyerta
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Pokok bahasan PPOK
1. Pendahuluan.2. Definisi PPOK.3. Patogenesis & Patologi4. Faktor Risiko5. Diagnosis & Diagnosis Banding6. Klasifikasi7. Penatalaksanaan PPOK8. Komplikasi9. Keadaan Khusus10. Pencegahan
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Tujuan Penatalaksanaan P P O KTujuan Penatalaksanaan P P O K
1.1. Menghilangkan gejala Menghilangkan gejala
2.2. Mencegah progresifitas penyakitMencegah progresifitas penyakit
3.3. Meningkatkan toleransi aktivitasMeningkatkan toleransi aktivitas
4.4. Meningkatkan Status KesehatanMeningkatkan Status Kesehatan
5.5. Mencegah & mengobati KomplikasiMencegah & mengobati Komplikasi
6.6. Mencegah & mengobati EksaserbasiMencegah & mengobati Eksaserbasi
7.7. Mengurangi MortalitasMengurangi Mortalitas
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PPOK StabilPPOK
Eksaserbasi Akut
Klinis P P O KKlinis P P O K
11 22
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Management COPD Management COPD 44
PoliklinikRawat jalan
PoliklinikRawat jalan UGD UGD Ruang
rawatRuang rawat
Ruang I C U
Ruang I C U
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Penatalaksanaan PPOK
EDUKASI
OBAT - OBATAN
TERAPI OKSIGEN
VENTILASI MEKANIK
NUTRISI
REHABILITASI
KEADAANSTABIL
EKSASERBASIAKUT
1
2
3
45
6
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Managemen PPOK StabilManagemen PPOK Stabil11
EdukasiEdukasi FarmakologiFarmakologi Non FarmakologiNon Farmakologi
1. Bronkodilator2. Kortikosteroid3. Antibiotika4. Mukolitik5. Anti oksidan6. Vaksin7. Immunoregulator8. Alfa-1 antitrypsin
1. Bronkodilator2. Kortikosteroid3. Antibiotika4. Mukolitik5. Anti oksidan6. Vaksin7. Immunoregulator8. Alfa-1 antitrypsin
1. Rehabilitasi2. Terapi Oksigen3. Ventilator support4. Surgical ttherapy
1. Rehabilitasi2. Terapi Oksigen3. Ventilator support4. Surgical ttherapy
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EDUKASI
Menyesuaikan keterbatasan akitifitas
Mencegah kecepatan perburukan fungsi paru
Mengenal perjalanan penyakit & terapi
Melaksanakan pengobatan maksimal
Mencapai akitifitas optimal
Meningkatkan kualitas hidup
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Manage Stable COPDManage Stable COPD11
EdukasiEdukasi FarmakologiFarmakologi Non FarmakologiNon Farmakologi
1. Bronkodilator2. Kortikosteroid3. Antibiotika4. Mukolitik5. Anti oksidan6. Vaksin7. Immunoregulator8. Alfa-1 antitrypsin
1. Bronkodilator2. Kortikosteroid3. Antibiotika4. Mukolitik5. Anti oksidan6. Vaksin7. Immunoregulator8. Alfa-1 antitrypsin
1. Rehabilitasi2. Terapi Oksigen3. Nutrisi support4. Ventilator support5. Surgical ttherapy
1. Rehabilitasi2. Terapi Oksigen3. Nutrisi support4. Ventilator support5. Surgical ttherapy
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OBAT-OBATAN
BRONKODILATOR
ANTI INFLAMASI
ANTIBIOTIKA
ANTIOKSIDAN
MUKOLITIK ANTITUSIF
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BRONKODILATOR
PEMILIHAN INHALASI
GOLONGAN XANTIN
DIUTAMAKANOBAT
SLOW RELEASELONG ACTING
GOLONGAN BETA-2 AGONIS
GOLONGAN ANTIKOLINERGIK
KOMBINASI
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Ccommonly Used Formulations of Drugs in COPD
Ccommonly Used Formulations of Drugs in COPD
1 Beta-2 agonist Short acting ( SABA ) Fenoterol, albuterol, terbutalin
Long acting ( LABA ) Formoterol, Salmeterol
2 Anticholinergic Short acting Ipratropium bromide
Long Acting Tiotropium
3 Methylxanthine Aminophyllin, Theophylin SR
4 Combination SABA + anticholinergic
Fenoterol/Ipratropium, Salbutamol/Ipratropium
5 Combination LABA + Glucocorticoid
Formoterol/BudesonidSalmeterol/Fluticasone
6 Systemic Glucocortikoid
Prednison, Methylprednisolon
( GOLD 2006 )
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ANTIBIOTIKA
LINI 1Amoksisilin
makrolid
BILA ADA INFEKSI
LINI 2Amoksisilin-asam klavulanat
SefalosporinKuinolon & makrolid baru
PERAWATAN RUMAH SAKIT
Amoksilin-klavulanatSefalosporin II & III
Kuinolon oral
DITAMBAHAnti Pseudomonas
AminoglikosideKuinolon
Sefalosporin gen. IV
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ANTI INFLAMASI
MENEKAN INFLAMASI
PADA EKSASERBASI AKUT
METILPREDNISOLONPREDNISON
BENTUK INHALASI TERAPI JANGKA PANJANG
UJI KORTIKOSTEROIDPOSITIF
VEP1 meningkat > 20 %Paska bronkodilator
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MUKOLITIK
TERUTAMAPADA
EKSASERBASIAKUT
KARENAMEMPERCEPAT
PERBAIKANEKSASERBASI
PADABRONKITIS KRONIS
DENGANSPUTUM
YANG VISCOUS
TIDAK DIANJURKANSEBAGAI
PEMBERIANRUTIN
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ANTIOKSIDAN
Mengurangieksaserbasi
N-ASETILSISTEIN
MemperbaikiKualitas hidup
PADA PPOKSERING
EKSASERBASI
TIDAKDIANJURKANPEMBERIAN
RUTIN
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HIPERSEKRESI HIPERSEKRESI MUKUSMUKUS
BR. KRONISBR. KRONIS
Anti Anti oksidanoksidan
OksidanOksidan
Mekanisme perlindungan
Mekanisme Mekanisme perbaikanperbaikan
Mekanisme Mekanisme perbaikanperbaikan
Fibrosis saluran nafas
Destruksi Parenkim Paru
Hipersekresi mukus
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Managemen PPOK StabilManagemen PPOK Stabil11
EdukasiEdukasi FarmakologiFarmakologi Non FarmakologiNon Farmakologi
1. Bronkodilator2. Kortikosteroid3. Antibiotika4. Mukolitik5. Anti oksidan6. Vaksin7. Immunoregulator8. Alfa-1 antitrypsin
1. Bronkodilator2. Kortikosteroid3. Antibiotika4. Mukolitik5. Anti oksidan6. Vaksin7. Immunoregulator8. Alfa-1 antitrypsin
1. Rehabilitasi2. Terapi Oksigen3. Ventilator support4. Surgical therapy
1. Rehabilitasi2. Terapi Oksigen3. Ventilator support4. Surgical therapy
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REHABILITASIMEDIK Simptom pernapasan berat
Sering masuk rawat darurat
Kualitas hidup menurun
1. LATIHAN FISIS
2. PSIKOSOSIAL
3. LATIHAN PERNAPASAN
TUJUAN
PROGRAM
INDIKASI
Meningkatkan toleransi latihan
Memperbaiki kualitas hidup
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TerapiOksigenTerapi
Oksigen
Mengurangi sesakMengurangi sesak
MemperbaikiFungsi neurupsikiatri
MemperbaikiFungsi neurupsikiatri
Memperbaikiaktivitas
Memperbaikiaktivitas
MeningkatkanKualitas hidupMeningkatkanKualitas hidup
Mencegah komplikasi jantung
Mencegah komplikasi jantung
Mengurangi VasokonstriksiMengurangi
Vasokonstriksi
TERAPI OKSIGEN
PPOK hipoksemia kerusakan jaringanPPOK hipoksemia kerusakan jaringan
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Cara pemberian Oksigen :
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NUTRISIHIPOFOSFATEMI
HIPOKALSEMI
HIPOMAGNESEMI
Komposisi nutrisi seimbang
Nutrisi terus-menerus ( Nocturnal feeding )
KONDISIMALNUTRISI
TERAPI
Gangguan KeseimbanganElektrolit
Kebutuhan energi meningkatKerja otot respirasi meningkat
HIPERKALEMI
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Nutrisi
Cara mengatasi malnutrisi :
1. Nutrisi diberikan secara terus menerus
2. Seimbang kalori yang masuk dengan yg dibutuhkan
3. Komposisi nutrisi yang seimbang : tinggi lemak – rendah
karbohidrat
4. Pada PPOK + gagal nafas : protein ber > an timbul
kelelahan
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IV: Very Severe III: Severe II: Moderate I: Mild
Therapy at Each Stage of COPD
FEV1/FVC < 70%
FEV1 > 80% predicted
FEV1/FVC < 70%
50% < FEV1 < 80% predicted
FEV1/FVC < 70%
30% < FEV1 < 50% predicted
FEV1/FVC < 70%
FEV1 < 30% predicted
or FEV1 < 50% predicted plus chronic respiratory failure
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long term oxygen if chronic respiratory failure. Consider surgical treatments
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PPOK EKSASERBASI AKUT
Timbul perburukan dibandingkan kondisi sebelumnya .
GEJALA EKSASERBASI :
a. Sesak bertambah
b. Sputum meningkat
c. Sputum ( menjadi purulent )
PPOK Eksaserbasi dibagi 3 :
• TIPE I ( berat ) :
ada 3 gejala diatas.
• TIPE II ( sedang ) :
ada 2 gejala diatas.
• TIPE III ( ringan ) :
ada 1 gejala diatas + ispa
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Komplikasi P P O KKomplikasi P P O K
KOMPLIKASI :KOMPLIKASI :
1)1) Infeksi berulang ( Pneumonia )Infeksi berulang ( Pneumonia )
2)2) PneumotoraksPneumotoraks
3)3) Kor Pulmonale Kronikum ( CPC ) Kor Pulmonale Kronikum ( CPC )
Kompensata / DekompensataKompensata / Dekompensata
4)4) Gagal NafasGagal Nafas
5)5) MeninggalMeninggal
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Komplikasi PPOK
Penyakit jantung akibat PPOK
Pelebaran vena di leher
Pembesaran ( hipertrofi & dilatasi ) jantung kanan
Hepar membesar
( hepatomegali )
Edema pada tungkai
Kor Pulmonale
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Manajemen PPOK
a. Oksigen
b. Bronkodilator
c. Clearance` mukus
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Managemen PPOK
a. Hindari iritan
b. Exercise
c. Pencegahan infeksi
d. Minum cukup
e. Nutrisi adekuat
f. Latihan nafas
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PPOK obstruksi saluran nafas, irreversible Umumnya usia tua Faktor risiko : ROKOK Patogenesis : reaksi inflamasi ( macrofag, neutrofil ) PPOK terdiri : EMFISEMA & BRONKITIS KRONIS Gejala “ Sesak bila aktivitas“ Klinis : PPOK STABIL & EKSASERBASI AKUT Penyakit progresif
Ringkasan P P O KRingkasan P P O K