penyakit airway - dralf

PENYAKIT AIRWAY

Daniel Maranatha/Arief Bakhtiar/Alfian Nur RosyidDepartment of Pulmonology

Medical School Airlangga University-Dr Soetomo Hospital

© Global Initiative for Asthma

Asma bronkial

PPOK

Bronkitis Kronis

Bronkitis Akut

Bronkiektasis

Penyakit Saluran Napas


Asthma is a heterogeneous disease, usually characterized by chronic airway

inflammation.

It is defined by the history of respiratory symptoms such as wheeze, shortness

of breath, chest tightness and cough that vary over time and in intensity,

together with variable expiratory airflow limitation.

GINA 2017

Definition of asthma

Asthma Pathophysiology

• Inflammatory cell

infiltration/activation

• Mucosal edema

• Cellular proliferation

• Epithelial damage

• Basement membrane changes

• Bronchoconstriction

• Bronchial hyperreactivity

• Hyperplasia/Hypertrophy

• Inflammatory mediator

release

Symptoms/Exacerbations

Smooth

Muscle

Dysfunction

Airway

inflammation

INFLAMMATION AIRWAY

REMODELLING

EXCESS MUCOUS

SECRETION

BRONCHIAL

CONSTRICTIONHistamine, prostaglandins

and leucotrines

HYPERESPONSIVE

Tightness of chest, breathing trouble

Coughing and wheezing


Symptoms

Physical examination

Spirometry

Diagnosed based on


Increased probability that symptoms are due to asthma if:

More than one type of symptom (wheeze, shortness of breath, cough, chest tightness)

Symptoms often worse at night or in the early morning

Symptoms vary over time and in intensity

Symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather,

laughter, irritants such as car exhaust fumes, smoke, or strong smells

Decreased probability that symptoms are due to asthma if:

Isolated cough with no other respiratory symptoms

Chronic production of sputum

Shortness of breath associated with dizziness, light-headedness or peripheral tingling

Chest pain

Exercise-induced dyspnea with noisy inspiration (stridor)

Diagnosis of asthma – symptoms

GINA 2014


Physical examination in people with asthma

Often normal

The most frequent finding is wheezing on auscultation, especially on forced expiration

Wheezing is also found in other conditions, for example:

Respiratory infections

COPD

Upper airway dysfunction

Endobronchial obstruction

Inhaled foreign body

Wheezing may be absent during severe asthma exacerbations (‘silent chest’)

Diagnosis of asthma – physical examination

GINA 2016


Confirm presence of airflow limitation

Document that FEV1/FVC is reduced (at least once, when FEV1 is low)

FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and >0.90 in children

Confirm variation in lung function is greater than in healthy individuals

The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma

Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted)

Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged)

Significant increase in FEV1 or PEF after 4 weeks of controller treatment

If initial testing is negative:

• Repeat when patient is symptomatic, or after withholding bronchodilators

• Refer for additional tests (especially children ≤5 years, or the elderly)

Diagnosis of asthma – variable airflow limitation

GINA 2016, Box 1-2


Time (seconds)

Volume

Note: Each FEV1 represents the highest of

three reproducible measurements

Typical spirometric tracings

FEV1

1 2 3 4 5

Normal

Asthma

(after BD)

Asthma

(before BD)

Flow

Volume

Normal

Asthma

(after BD)

Asthma

(before BD)

GINA 2016


Patient with

respiratory symptoms

Are the symptoms typical of asthma?

Detailed history/examination

for asthma

History/examination supports

asthma diagnosis?

Perform spirometry/PEF

with reversibility test

Results support asthma diagnosis?

Empiric treatment with

ICS and prn SABA

Review response

Diagnostic testing

within 1-3 months

Repeat on another

occasion or arrange

other tests

Confirms asthma diagnosis?

Consider trial of treatment for

most likely diagnosis, or refer

for further investigations

Further history and tests for

alternative diagnoses

Alternative diagnosis confirmed?

Treat for alternative diagnosisTreat for ASTHMA

Clinical urgency, and

other diagnoses unlikely

YES

YES

YES NO

NO

NO

NO

YES

YES

NO

© Global Initiative for AsthmaGINA 2016, Box 1-1 (4/4)


GINA assessment of symptom control

A. Symptom control

In the past 4 weeks, has the patient had:Well-

controlled

Partly

controlled

Uncontrolled

• Daytime asthma symptoms more

than twice a week? Yes No

None of

these

1-2 of

these

3-4 of

these

• Any night waking due to asthma? Yes No

• Reliever needed for symptoms*

more than twice a week? Yes No

• Any activity limitation due to asthma? Yes No

Level of asthma symptom control

*Excludes reliever taken before exercise, because many people take this routinely


GINA assessment of symptom control

A. Symptom control

In the past 4 weeks, has the patient had:Well-

controlled

Partly

controlled

Uncontrolled

• Daytime asthma symptoms more

than twice a week? Yes No

None of

these

1-2 of

these

3-4 of

these

• Any night waking due to asthma? Yes No

• Reliever needed for symptoms*

more than twice a week? Yes No

• Any activity limitation due to asthma? Yes No

B. Risk factors for poor asthma outcomes

• Assess risk factors at diagnosis and periodically

• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s

personal best, then periodically for ongoing risk assessment

ASSESS PATIENT’S RISKS FOR:

• Exacerbations

• Fixed airflow limitation

• Medication side-effects

GINA 2016 Box 2-2B (1/4)

Level of asthma symptom control


The long-term goals of asthma management are

1. Symptom control: to achieve good control of symptoms and maintain normal activity levels

2. Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation and

medication side-effects

Achieving these goals requires a partnership between patient and their health care

providers

Ask the patient about their own goals regarding their asthma

Good communication strategies are essential

Consider the health care system, medication availability, cultural and personal preferences

and health literacy

Goals of asthma management

GINA 2016


Avoidance of tobacco smoke exposure

Provide advice and resources at every visit; advise against exposure of children to environmental tobacco

smoke (house, car)

Physical activity

Encouraged because of its general health benefits. Provide advice about exercise-induced

bronchoconstriction

Occupational asthma

Ask patients with adult-onset asthma about work history. Remove sensitizers as soon as possible. Refer for

expert advice, if available

Avoid medications that may worsen asthma

Always ask about asthma before prescribing NSAIDs or beta-blockers

Remediation of dampness or mold in homes

Reduces asthma symptoms and medication use in adults

(Allergen avoidance)

(Not recommended as a general strategy for asthma)

See GINA Box 3-9 and online Appendix for details

Non-pharmacological interventions

This slide shows examples of interventions with high quality evidence


Asthma exacerbations/flare-ups


A flare-up or exacerbation is an acute or sub-acute worsening

of symptoms and lung function compared with the patient’s usual status

Terminology

‘Flare-up’ is the preferred term for discussion with patients

‘Exacerbation’ is a difficult term for patients

‘Attack’ has highly variable meanings for patients and clinicians

‘Episode’ does not convey clinical urgency

Consider management of worsening asthma as a continuum

Self-management with a written asthma action plan

Management in primary care

Management in the emergency department and hospital

Follow-up after any exacerbation

Definition and terminology

GINA 2016


Managing exacerbations in primary care

PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

ASSESS the PATIENT

Is it asthma?

Risk factors for asthma-related death?

Severity of exacerbation?

MILD or MODERATE

Talks in phrases, prefers

sitting to lying, not agitated

Respiratory rate increased

Accessory muscles not used

Pulse rate 100–120 bpm

O2 saturation (on air) 90–95%

PEF >50% predicted or best

LIFE-THREATENING

Drowsy, confused

or silent chest

START TREATMENT

SABA 4–10 puffs by pMDI + spacer,

repeat every 20 minutes for 1 hour

Prednisolone: adults 1 mg/kg, max.

50 mg, children 1–2 mg/kg, max. 40 mg

Controlled oxygen (if available): target

saturation 93–95% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed

ASSESS RESPONSE AT 1 HOUR (or earlier)

TRANSFER TO ACUTE

CARE FACILITY

While waiting: give inhaled

SABA and ipratropium bromide,

O2, systemic corticosteroid

URGENT

WORSENING

ARRANGE at DISCHARGE

Reliever: continue as needed

Controller: start, or step up. Check inhaler technique, adherence

Prednisolone: continue, usually for 5–7 days (3-5 days for children)

Follow up: within 2–7 days

ASSESS FOR DISCHARGE

Symptoms improved, not needing SABA

PEF improving, and >60-80% of personal best or predicted

Oxygen saturation >94% room air

Resources at home adequate

FOLLOW UP

Reliever: reduce to as-needed

Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending on background to exacerbation

Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,

including inhaler technique and adherence

Action plan: Is it understood? Was it used appropriately? Does it need modification?

IMPROVING

WORSENING

SEVERE

Talks in words, sits hunched

forwards, agitated

Respiratory rate >30/min

Accessory muscles in use

Pulse rate >120 bpm

O2 saturation (on air) <90%

PEF ≤50% predicted or best

Asma vs COPD

onset Sejak muda >45 th

Faktor risiko athopy Noxious gas

gejala variabilitas progresif

Definisi PPOK GOLD 2019

47

GOLD 2018 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/.

►Penyakit paru obstruktif kronik (PPOK) adalah

penyakit yang umum, dapat dicegah dan diobati

ditandai dengan gejala respirasi yang persisten

dan obstruksi saluran napas (SN) disebabkan

karena kelainan pada SN dan/atau alveolar yang

biasanya akibat dari pajanan partikel atau gas

berbahaya yang signifikan

http://goldcopd.org/

Faktor yg mempengaruhi progresivitas PPOK

© 2017 Global Initiative for Chronic Obstructive Lung Disease

►Genetik

►Umur dan jenis kelamin

►Tumbuh kembang paru

►Pajanan partikel

►Status sosioekonomik

►Asma & airway hyper-reactivity

►Bronkitis kronik dan infeksi


Etiologi, patobiologi & patologi PPOK

49

Etiologi

Merokok dan polusi

Host factors

Patobiologi

• Gangguan pertumbuhan paru

• Accelerated decline• Kerusakan paru

• Inflamasi paru & sistemik

Patologi

• Gangguan atau abnormalitas saluran napas

kecil

• Emfisema

• Efek Sistemik

Hambatan aliran udara

• Hambatan aliran udara

yang persisten

Manifestasi klinis

• Gejala

• Eksaserbasi

• Komorbidities

GOLD 2017 Global Strategy for the Diagnosis,

Management and Prevention of COPD. Available online

at http://goldcopd.org/.

Patologi, patogenesis dan patofisiologi

1. Patogenesis

Inflamasi yang terjadi pada saluran napas pasien PPOK

sebagai respons peradangan terhadap iritan kronis,

seperti asap rokok. Inflamasi paru tetap bertahan setelah

berhenti merokok

Mekanisme patogenesis meliputi:- Oxidative stress

- Ketidakseimbangan Protease – antiprotease

- Inflammatory cells: di beberapa pasien terdapat peningkatan

eosinophil, Th2 atau ILC2, terutama jika terjadi bersamaan

dengan asma

- Mediator inflamasi

- Fibrosis peribronkial dan interstisial

- Perbedaan inflamasi antara PPOK dan asma

50GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/.

Alur diagnosis PPOK

51

Gejala:► Gejala respirasi yang paling sering

adalah sesak, batuk dan/atau

produksi sputum

► Faktor risiko utama adalah rokok

akan tetapi bisa bahan bakar

biomass

Spirometri:Post-bronchodilator

FEV1/FVC < 0.70


Indikator utama untuk membuat diagnosis PPOK

1. Sesak napas

• Progresif sepanjang waktu

• Diperburuk dengan olahraga

• Persisten

2. Batuk kronis

• Intermiten atau unproductive

• Mengi yang sering kambuh

3. Produksi sputum yang kronis

4. Infeksi saluran pernapasan bawah yang sering kambuh

5. Riwayat faktor risiko

Genetik, abnormalitas kongenital, asap rokok, asap dari limbah domestik atau bahan

bakar, kondisi lingkungan pekerjaan seperti debu, uap, bahan bakar, gas dan bahan

kimia lainnya

6. Riwayat keluarga dengan PPOK dan/atau faktor pada masa kecil

7. Berat badan pada saat lahir, infeksi pernapasan masa kecil, dsb

52

Pertimbangkan PPOK, dan lakukan

spirometri, jika ada dari indikator di

bawah di temukan pada pasien usia

di atas 40 tahun. Kehadiran

beberapa indikator utama

memperbesar kemungkinan

diagnosa PPOK. Spirometri

diperlukan untuk menegakkan

diagnosis PPOK

GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/. Accessed 21stNovember 2016.

Penyebab lain gejala batuk kronis (selain PPOK)

1. Asma

2. Kanker paru

3. TB

4. Bronchiectasis

5. Left heart failure

6. Interstitial lung disease

7. Fibrosis cystic

8. Batuk idiopatik

9. Rhinitis alergi kronis

10. Post nasal drip syndrome (PNDS)

11. Upper airway cough syndrome (UACS)

12. GERD

13. Pengobatan (contoh. ACE inhibitors)

53

GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/. Accessed 21stNovember 2016.

Pengelompokan pasien PPOK

54

Konfirmasi

Spirometri

Penilaian

Hambatan Udara

Sal. Napas

Penilaian Gejala/

Eksaserbasi

Post-bronchodilator

FEV1/FVC < 0.7

FEV1

(% predicted)

GOLD 1 ≥ 80

GOLD 2 50 – 79

GOLD 3 30 – 49

GOLD 4 < 30

≥ 2 atau ≥ 1

menyebabkan

hospitalisasi

0 atau 1 (tidak

menyebabkan

hospitalisasi)

C D

A B

Exacerbation

history

mMRC 0-1

CAT < 10

mMRC ≥ 2

CAT ≥ 10

Symptoms

GOLD 2018 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/

TUJUAN TERAPI PPOK

56

Menghilangkan gejala

Meningkatkan toleransi latihan

Meningkatkan status kesehatan

Mencegah perkembangan penyakit

Mencegah dan mengobati eksaserbasi

menurunkan angka kematian

Reduce

symptoms

Reduce

risk


Pengelolaan PPOK Stabil: Non - Farmakologi

57

Patient

Group

Essential Rekomendasi Tergantung pada

Pedoman Lokal

ABerhenti merokok (termasuk

pengobatan farmakologi)Aktivitas fisik

Vaksinasi flu

Vaksinasi

pneumococcal

B, C, D

Berhenti merokok (termasuk

pengobatan farmakologi),

Rehabilitasi paru

Aktivitas fisik

Vaksinasi flu

Vaksinasi

pneumococcal

GOLD 2018 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/

Terapi farmakologi

© 2019 Global Initiative for Chronic Obstructive Lung Disease

► All Group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator.

► This should be continued if benefit is documented.

AFFINITAS

RESEPTOR M3

AFFINITAS M3> M2

ATROPIN 9,68 Tidak ada

IPRATROPIUM 9,58 Tidak ada SAMA

TIOTROPIUM 11,02 Selektif Fungsional LAMA

GLYCOPYRONIUM 10,04 3x lebih selektif LAMA

ACLINIDIUM 10,74 Selektif Fungsional LAMA

RESEPTOR ANTAGONIS MUSKARINIK


1.

-

COPD Eksaserbasi

- BTS (British Thoracic Society) menyebutkan COPD

eksaserbasi sebagai perburukan dari keadaan stabil

sebelumnya.

- Gejala dari perburukan tersebut antara lain

penambahan sesak, penambahan jumlah sputum,

purulensi sputum, dada terasa berat, adanya wheezing

(Thorax 2002).

- Menurut GOLD , eksaserbasi merupakan suatu

episode akut perburukan gejala respirasi yang

memerlukan penambahan terapi. Sesak merupakan

kunci dari gejala utama eksaserbasi. (GOLD 2017)


Komponen tatalaksana di Rumah Sakit

Terapi Farmakologi

Bronkodilator

Kortikosteroid

Antibiotik

Respiratory Support

Terapi oksigen

Ventilasi mekanik: inavasif maupun non-invasif

Prinsip tatalaksana PPOK eksaserbasi : farmakoterapi dan

support respirasi


• Kondisi klinis batuk >>>

• +/- produksi sputum

• Penyebab : infeksi virus >>>

• Gejala berlangsung sedikitnya selama 5 hari

• Inflamasi yang self-limited

• Inflamasi saluran napas bagian bawah tanpa didapatkan bukti

pneumonia dan PPOK

Bronkitis Akut

(Wenzel & Fowler, 2006; Fayyaz, 2017; File, 2017)

Definisi


Patofisiologi

(Knutson, 2002; Wenzel & Fowler, 2006)

Inflamasi membran mukosa bronkial

Infeksi / noninfeksi cedera epitel bronkial respons inflamatori

hiperaktifitas jalan napas dan produksi mukus.

Deskuamasi sel epitel dan denuding jalan napas sampai membran basal menunjukkan adanya

infiltrasi limfositik seluler

Pemeriksaan mikroskopis penebalan mukosa bronkus.

PATOFISIOLOGI


Diagnosis klinis, tanpa tanda diagnostik standar & laboratorium

Bronkitis Akut

Gejala dan Tanda

• Awal gejala ISPA

• Batuk > 5 hari, durasi rata-rata 18

hari

• Demam, takipnea, mengi, ronki,

ekspirasi memanjang, produksi

sputum, dispnea, nyeri dada,

serak, malaise, rales, eritema

faring, limfadenopati, hidung

berair

• Tanda dan gejala ini mungkin

tidak ada.

Diagnosis

Fungsi Paru Pemeriksaan Penunjang

• Tes fungsi paru mungkin abnormal

FEV1 (40% kasus)

Tes provokasi bronkus hiperaktifitas

bronkial

• Tes fungsi paru tidak rutin digunakan.

Pemeriksaan bila dicurigai adanya

patologi obstruktif atau memiliki

episode bronkitis berulang

• Pulse oxymetry berperan dalam

menentukan tingkat keparahan

penyakit, namun hasilnya tidak untuk

diagnosis.

• Gambaran radiografi dada biasanya

normal namun dapat ditemukan

penebalan dinding bronkus di lobus

bawah.

• Prokalsitonin tidak rutin digunakan.

• Pewarnaan Gram dan kultur sputum

sering tidak menunjukkan adanya

pertumbuhan kuman atau hanya flora

normal.

(Knutson, 2002; File, 2017 )


Batuk produktif kronis

Tiga bulan dalam satu tahun selama dua tahun berturut-turut

Penyebab batuk kronis lainnya telah disingkirkan.

Konsekuensi klinis

fungsi paru

risiko obstruksi aliran udara

predisposisi infeksi saluran pernapasan,

frekuensi eksaserbasi

kualitas hidup

angka kematian

Bronkitis KronisDefinisi

( Kim & Criner, 2013; Han, 2017 )


Gejala & Tanda

Batuk produktif

pagi hari >>>

Mengi, dispnea, malaise, penurunan berat badan, kelelahan, rasa terbakar retrosternal, hemoptisis ringan, sianosis.

Vesikuler mengeras, ronki, mengi, jari tabuh

Pemeriksaan penunjang

Rontgen dada normal, kadang penebalan dinding bronkialBronkografi : penebalan mukosaFluororskopi : pulsasi arteri hilus pulmonalisLab : pergeseran ringan ke kiri sel netrofil, PaO2 PaCO2

Sitologi sputum: epitel terkelupas, metaplasiaKultur dahak

Fungsi Paru

Awal : normal

Obstruksi : kelainan tes fungsi paru

Bronkitis Kronis

(Kim & Criner, 2013)

Diagnosis


banding

Tuberkulosis

Karsinoma paru

Asma bronkial

Gagal jantung kongestif

Mikosis paru

Bronkitis KronisDiagnosis

(Chodos, et al., 1968

definisi kelainan kronik yang ditandai dengan dilatasi bronkus secara permanen,

disertai proses inflamasi pada dinding bronkus dan parenkim paru sekitarnya

Interactive CardioVascular and Thoracic Surgery 2011; 13: 620

BRONKIECTASIS

Pamela J, McShane I, Edward T, Naureckas I, Gregory T, Mary E. Non–Cystic Fibrosis Bronchiectasis.

American Journal Of Respiratory And Critical Care Medicine 2013; 188: 648

GAMBARAN KLINIS DAN DIAGNOSIS

Gambaran klinis

Batuk kronis dengan produksi sputum ,infeksi saluran napas

berulang. hemoptisis, nyeri dada, penurunan berat badan,

bronkospasme, sesak napas dan penurunan kemampuan fisik , jari

tabuh?

Eksaserbasi akut

•Perubahan produksi sputum

•Sesak nafas bertambah

•Batuk bertambah

•Demam (suhu badan >38,0˚C)

•Peningkatan wheezing

•Malaise, fatique, letahargie, atau penurunan toleransi aktivitas fisik

•Penurunan faal paru

•Perubahan radiologis baru yang sesuai dengan proses infiltasi

paru

•Perubahan pada suara nafas

•Barker AF. Bronchiectasis. New England Journal of Medicine 2002; 346: 1383-1393

Pemeriksaan Radiologis

Ring shadow sampai dengan cyst,

Honeycomb

Dilatasi abnormal

Bronkiektasis kistik

•Perea PL, Screaton NJ. Radiological Feature of Bronchiectasis. European Respiratory Monograph: Bronchiectasis 2011;2:44-65

Pemeriksaan Radiologis

tram track, densitas garis paralel, kurangnya

bronkial tappering penebalan dinding dan

dilatasi abnormal

Bronkiektasi silindris

•Perea PL, Screaton NJ. Radiological Feature of Bronchiectasis. European Respiratory Monograph: Bronchiectasis 2011;2:44-65

Penatalaksanaan

Identifikasi keadaan eksaserbasi akut

,,

Mengendalikan pertumbuhan

Mikrobaterapi terhadap kondisi yang mendasarinya

Mengurangi respons inflamasi yang berlebihan

peningkatan higienitas bronkial

Terapi bedah

penyakit airway - dralf

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