2019

Tujuan GOLD reports adalah untuk menyediakan review non-bias

GOLD dan bukti terkini untuk pendekatan assessment, cara diagnosis,
dan pengobatan pada pasien COPD yang dapat membantu klinisi.
 Chronic Obstructive Pulmonary Disease (COPD)/ Penyakit Paru
Obstruktif Kronik (PPOK)
COPD
Sering terjadi, dapat dicegah dan diobati

Di tandai dengan : abnormalitas pada saluran pernapasan dan

- Gejala pernapasan yang menetap alveolar  disebabkan oleh paparan signifikan
- Hambatan aliran udara terhadap partikel atau gas berbahaya.

Keterbatasan aliran udara kronis

Adanya campuran antara penyakit pada saluran udara kecil

(mis., bronkiolitis obstruktif) dan destruksi parenkim (emfisema)
1. Tobacco smoke

2. Indoor air pollutan Asap tungku kayu dan minyak tanah saat memasak.

3. Occuupational exposure Organic and inorganic dusts, chemical agents and fumes

4. Outdoor air pollutan

5. Genetic Factor Deficiency of alpha-1 antitrypsin (AATD) 15 ; the gene

encoding matrix metalloproteinase 12 (MMP-12) and
6. Age and Sex glutathione S-transferase

7. Lung Growth and Development

8. Socio ekonomi status

9. Asthma and airway hyper-reactivity

10. Chronic bronchitis

11. Infections
 Pathology, pathogenesis & pathophysiology
► Pathology
 Chronic inflammation
 Structural changes

► Pathogenesis
 Oxidative stress
 Protease-antiprotease imbalance
 Inflammatory cells
 Inflammatory mediators
 Peribronchiolar and interstitial fibrosis

► Pathophysiology
 Airflow limitation and gas trapping
 Gas exchange abnormalities
 Mucus hypersecretion
 Pulmonary hypertension
DIAGNOSIS AND INITIAL ASSESSMENT
 Medical History : Anamnesis
► Patient’s exposure to risk factors

► Past medical history: asthma, allergy, sinusitis, or nasal polyps; respiratory

infections in childhood; other chronic respiratory and non-respiratory
diseases
► Family history of COPD or other chronic respiratory disease.
► Pattern of symptom development
► History of exacerbations or previous hospitalizations for respiratory disorder
► Presence of comorbidities
► Impact of disease on patient’s life
► Social and family support available to the patient.
► Possibilities for reducing risk factors, especially smoking cessation.
 Symptoms of COPD
 Chronic and progressive
dyspnea
 Cough
 Sputum production
 Wheezing and chest tightness
 Others – including fatigue,
weight loss, anorexia, syncope,
rib fractures, ankle swelling,
depression, anxiety.
 Pemeriksaan fisik

Pemeriksaan penunjang: Spirometri

Penegakan diagnosis COPD Spirometry is the most reproducible and

objective measurement of airflow limitation.
Post-bronchodilator FEV1
COPD Assessment Test (CATTM)
Modified MRC dyspnea scale

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 Assessment of Exacerbation Risk
► COPD exacerbations are defined as an acute worsening of respiratory
symptoms that result in additional therapy.

► Classified as:
 Mild (treated with SABDs only)
 Moderate (treated with SABDs plus antibiotics and/or oral
corticosteroids) or
 Severe (patient requires hospitalization or visits the emergency
room). Severe exacerbations may also be associated with acute
respiratory failure.
► Blood eosinophil count may also predict exacerbation rates (in
patients treated with LABA without ICS).
© 2019 Global Initiative for Chronic Obstructive Lung Disease
 ABCD assessment tool

© 2019 Global Initiative for Chronic Obstructive Lung Disease

 ABCD Assessment Tool
Example

► Consider two patients:

 Both patients with FEV1 < 30% of predicted
 Both with CAT scores of 18
 But, one with 0 exacerbations in the past year and the other
with 3 exacerbations in the past year.

► Both would have been labelled GOLD D in the prior classification

scheme.
► With the new proposed scheme, the subject with 3 exacerbations in
the past year would be labelled GOLD grade 4, group D.
► The other patient, who has had no exacerbations, would be
classified as GOLD grade 4, group B.
 Alpha-1 antitrypsin deficiency (AATD)
AATD screening

► The World Health Organization recommends that all patients with a

diagnosis of COPD should be screened once especially in areas with
high AATD prevalence.

► AATD patients are typically < 45 years with panlobular basal

emphysema

► Delay in diagnosis in older AATD patients presents as more typical

distribution of emphysema (centrilobular apical).

► A low concentration (< 20% normal) is highly suggestive of

homozygous deficiency.
 Terapi Pencegahan & Perawatan

► Berhenti merokok adalah kuncinya.

► Terapi farmakologis dapat mengurangi gejala COPD, mengurangi frekuensi
dan keparahan eksaserbasi, dan meningkatkan status kesehatan dan toleransi
latihan.
► Setiap rejimen pengobatan farmakologis harus individual dan dipandu oleh
keparahan gejala, risiko eksaserbasi, efek samping, komorbiditas,
ketersediaan dan biaya obat, dan tanggapan pasien, preferensi dan
kemampuan untuk menggunakan berbagai perangkat pengiriman obat.
► Teknik inhaler perlu dinilai secara teratur.
► Vaksinasi influenza menurunkan insiden infeksi saluran pernapasan bawah.
► Vaksinasi pneumokokus menurunkan infeksi saluran pernafasan bawah.
► Rehabilitasi paru meningkatkan kualitas hidup, dan partisipasi fisik dan
emosi dalam kegiatan sehari-hari. Pada pasien dengan hipoksemia kronis
berat yang beristirahat, terapi oksigen jangka panjang meningkatkan
kelangsungan hidup.
► Pada pasien dengan PPOK stabil dan istirahat atau desaturasi moderat yang
diinduksi oleh latihan, pengobatan oksigen jangka panjang tidak boleh
diresepkan secara rutin.
► Namun, faktor individu pasien harus dipertimbangkan ketika mengevaluasi
kebutuhan pasien akan oksigen tambahan.
Pharmacologic Therapy
Pharmacologi
c Therapy
Bronkodilator dalam PPOK Stabil
Terapi anti-inflamasi pada PPOK Stabil
Jalur Inhalasi
Farmakoterapi lain
Terapi Intervensional dalam
PPOK Stabil
 Manajemen PPOK Stabil

Identifikasi dan kurangi paparan terhadap faktor-faktor risik

► Identifikasi dan pengurangan paparan faktor risiko penting
dalam pengobatan dan pencegahan PPOK.
► Merokok adalah faktor risiko yang paling sering ditemui dan
mudah diidentifikasi untuk PPOK, dan berhenti merokok harus
terus didorong untuk semua orang yang merokok.
► Pengurangan paparan pribadi total terhadap debu, asap, dan
gas kerja, serta polutan udara di dalam dan luar ruangan, juga
harus ditangani.
Pengobatan PPOK Stabil

Farmakoterapi
Pengobatan PPOK Stabil
Treatment of Stable COPD
 Terapi Non-Farmakologi

► Pendidikan dan
manajemen diri ► Dukungan nutrisi
► Aktivitas fisik ► Vaksinasi
► Program rehabilitasi paru ► Terapi oksigen
Some common comorbidities occurring in patients with COPD with stable
disease include:
COPD and Comorbidities
► Cardiovascular disease (CVD)
► Heart failure
► Ischaemic heart disease (IHD)
► Arrhythmias
► Peripheral vascular disease
► Hypertension
► Osteoporosis
► Anxiety and depression
► COPD and lung cancer
► Metabolic syndrome and diabetes
► Gastroesophageal reflux (GERD)
► Bronchiectasis
► Obstructive sleep apnea