diskusi ppok

1. PPOK
(GOLD 2023)
P r e s e n t a n : d r. A n n i
P e m b i m b i n g : d r. A l i z a

2. DEFINISI
• Penyakit Paru Obstruktif Kronik (PPOK) adalah kondisi paru heterogen yang ditandai dengan gejala
pernapasan kronis (dispnea, batuk, produksi sputum eksaserbasi) akibat kelainan pada saluran
pernapasan (bronkitis, bronkiolitis) dan/atau alveoli (emfisema) yang menyebabkan obstruksi aliran udara
yang bersifat progresif.
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

3. Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2019 Report. 2019.

4. DIAGNOSIS
• Diagnosis PPOK harus dipertimbangkan pada setiap pasien yang mengalami dispnea, batuk kronis atau produksi
sputum, dan/atau riwayat pajanan terhadap faktor risiko penyakit
• Diagnosis PPOK harus dikonfirmasi dengan hasil spirometry, dengan adanya batasan aliran udara jika
FEV1/FVC<0,7.
Derajat dan tingkat keparahan obstruksi jalan napas pada
(Berdasarkan FEV1 post bronkodilator)
GOLD 1 Ringan FEV1 ≥80% prediksi
GOLD 2 Sedang 50% ≤ FEV1< 80% prediksi
GOLD 3 Berat 30% ≤ FEV1< 50% prediksi
GOLD 4 Sangat berat FEV1 < 30% prediksi
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

5. MANIFESTASI KLINIS
• Sesak napas (progressive, memberat saat olahraga,
persisten)
• Wheezing berulang
• Batuk kronis
• Infeksi saluran napas bawah yang berulang
• Riyawat faktor risiko
o Asap rokok
o Asap saat memasak dan bakan bakar
o Debu, vapor, asap, dan zat kimia lain
o Faktor host (genetik, BBLR, prematur, infeksi saluran
napas saat kcil)
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

6. ALAT PENILAIAN GOLD ABE
≥2
eksaserbasi
sedang atau
≥1
mengarah
ke rawat
inap
0 atau 1
eksaserbasi
sedang
(tidak
mengarah
ke rawat
inap
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

7. modified MRC dyspnea scale
• Saya sesak jika latihan berat
mMRC grade
0
• Sesak jika naik tangga dengan bergegas atau
berjalan ke tanjakan
mMRC grade 1
• Saya berjalan lebih lambat dibandingkan teman
sebaya karena sesak, atau saya harus behenti untuk
mengambil napas ketika berjalan di tangga
mMRC grade
2
• Setelah berjalan 100 meter atau beberapa menit di
tangga, saya harus berhenti untuk mengambil
napas
mMRC grade
3
• Saya tidak bisa keluar rumah karena sesak atau
tidak bisa mengganti baju karena sesak
mMRC grade
4
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

8. Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

9. Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

10. Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

11. TERAPI
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

12. TERAPI
2
1 Kelompok A
• Pasien diberi terapi
bronkodilator berdasarkan
efeknya terhadap sesak napas,
bisa berupa bronkodilator kerja
singkat atau kerja panjang.
• Terapi bisa dilanjutkan jika
ditemukan manfaat simtomatik.
Kelompok B
• Dimulai dengan kombinasi LABA+LAMA
• Jika kombinasi LABA+LAMA dianggap tidak efektif, tidak
terdapat bukti yang menunjukkan apakah LABA atau
LAMA lebih efektif dalam meredakan gejala. Pada kasus
seperti ini, pilihan diserahkan kepada pasien
• Pasien kelompok B kemungkinan besar memiliki
komorbid yang memperburuk gejala dan memengaruhi
prognosis, sehingga komorbid tersebut harus ditangani
berdasarkan panduan internasional
12
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

13. TERAPI
3 Kelompok E
 LABA+LAMA merupakan terapi terbaik dalam penanganan eksaserbasi
PPOK. LABA+LAMA merupakan pilihan utama pada pasien kelompok E
 Penggunaan LABA+ICS pada PPOK tidak direkomendasikan. Jika terdapat
indikasi untuk penggunaan ICS, maka LABA+LAMA+ICS lebih
direkomendasikan
 Pertimbangkan LABA + LAMA + ICS pada kelompok E jika eos > 300
sel/microliter
 Jika pasien PPOK memiliki penyakit asma konkomitan, maka ICS wajib
digunakan
13
Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

14. Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global Strategy for the Diagnosis,
Management and Prevention of COPD 2023 Report. 2023.

15. Ny. Ostofina/1006007/10-3-1972/51 yo
Chief complain : shortness of breath
Auto-anamnesis:
The patient came with complaints of shortness of breath since 2
months ago, getting worsening in last 2 days. Shortness of breath
worsening with activity not affected by weather. Cough with white
phlegm intermittently since 6 months ago, worsening last 1 week.
No coughing up blood, no history of coughing up blood. Chest
pain when cough. There is fever since 3 days ago, no history of
fever. No heartburn, nausea, and vomiting. Weakness, decrease of
appetite, weight loss of 10 kilograms in last 2 months. Both
extremities swollen since admitted to Sinar Kasih Hospital Toraja,
skin itchy and erithema all over the extremities. Defecate and
urinate within normal limits.
Tuesday | August 14, 2012
ANAMNESIS
accompanied by

16. Tuesday | August 14, 2012
ANAMNESIS
• No history of Anti tuberculosis drugs and no history of contact with TB patient
• No history of hypertension, DM, heart disease and kidney disease.
• No confirmed history of COVID-19 and history of the COVID-19 vaccine is 1 time
• History of allergy to antibiotics (ceftriaxone)
• No history of smoking
• Job as Tailor for 30 years and domiciled in Toraja
• Hospitalized on Maret 2023 at Elim Rantepao Toraja Hospital with shortness of breath and dermatomyositis, was
given therapy with methylprednisone 4x8 mg, levofloxacine 1x750mg, loratadine 1x10mg, omeprazole 2x20 mg
• Hospitalized on April 2023 at Sinar Kasih Toraja Hospital with shortness of breath and pneumonia given therapy
with azithromycin 1x500 mg, acetyl cysteine 3x200 mg, methylprednisone 2x8mg, seretide 2x100 mcg/puff
• Hospitalized on May 2023 at Wahidin Hospital for 1 week with shortness of breath given therapy : Farbivent 1
resp/8 hours/inhalation, Pulmicort 1 prescription/12 hours/inhalation, acetylcysteine 200 mg/8 hours/oral,
Levofloxacin injection 750 mg/24 hours/intravenous, Methylprednisolone injection 62.5 mg/12
hours/intravenous, Plasbumin 25 %/12 hours/intravenous

17. PHYSICAL EXAMINATION
Moderate Illness/compos mentis/normoweight
Weight: 45 kg, Height: 150 cm, BMI: 20 kg/m2
SpO2 : 92% room air
SpO2 : 96% via 3 lpm nasal cannula
BP : 120/60 mmHg
HR : 94 beats/minute
RR : 22 breaths/minute
Temperature : 38,5 oC
Head: Normocephalic, pale conjunctiva, no
icteric sclera
Neck: no lymph node enlargement, midline
trachea
Thorax (Prone, From Anterior) :
Inspection: symmetrical both hemithorax when
static and dynamic
Palpation: tactile fremitus equal in both
hemithorax, wide intercostal
Percussion: sonor on both hemithorax
Auscultation: broncovesicular, ronchi medial both
of hemithorax and wheezing in apex left
hemithorax
Heart: Pure regular I/II heart sound, no heart
murmur
Abdomen:
Flat, peristaltic normal impression, liver and spleen
not palpable
Extremities: warm acral, no pretibial edema,
erithema on both upper and lower extremities

18. CLINIC PICTURE
07/06/2023
Wahidin Hospital

19. LABORATORY
LAB 20/5/2023
RSWS
25/5/2023
RSWS
07/6/2023
RSWS
Normal Range
WBC 22.1 12.3 21.6 4.00-10.00
HB 10.8 9.6 9.1 12.00-16.00
Platelet 317 359 323 150-400
Neutrophil 59.3 69.9 64.6 52.0-75.0
Lympochyte 30.3 26.5 3.2 20.0-40.0
EO 6.0 0.7 24.5 1-3
SGOT/SGPT 19/14 11/15 - <38/<41
Ur/Cr 17/0.54 20/0.54 - Ur 10-50/ Cr <1.3
PT/INR/APTT - 11.9/1.10/25.6 -
Albumin 2.5 2.7 - 3.5-5.00
Na/K/Cl 127/4.1/101 138/3.8/107 - 135-145/3.5-
5.1/97-111
Procalcitonin 0.14 0.07 - <0.05
CRP 67.6 31.4 - <5
D-dimer - - <0.5

20. LABORATORY
BGA 07/06/2023
RSWS
Normal Range
PH 7.404 7.35-7.45
SO2 99.9 95-98
PO2 183.3 80-100
PCO2 26.9 35-45
HCO3 17 22-26
BE -7.9 -2 s/d +2
Acid lactat 3.4 0.6-1.5
Old FiO2 0.3
New FiO2 0.1
Conclusion Fully Compensated
Alkalosis Respiratory

21. LABORATORY
Gram meter (sputum) 22-5-2023:
Quantity : positive (3+) and positive (1+)
Gram affinity: gram positive and gram negative
Shape and configuration: diplococcus and bacilli one by one
Fungi: yeast and hyphae
Culture and sensitivity: candida tropicana
AB sensitivity 22-5-2023 :
Fluconazole, voriconazole, caspofungin, micafungin, amphotericin B, flucytosine
flucytosine : sensitive
Laboratory 15-4-2023 Sinar Kasih Toraja Hospital:
RMT : MTB not detected
Lab 7-1-2023 Elim Toraja Hospital:
ANA test: <10 (negative)

22. Radiology CXR
07/06/2023
Wahidin Hospital
20/05/2023
Wahidin Hospital
14/04/2023
Sinar Kasih Hospital

23. No Assessment Planning
Diagnosis
Therapy Monitoring
1. Mild Exacerbation of COPD in COPD Group E
Subjective :
• Shortness of breath since 2 months ago, getting
worsening in last 2 days. Shortness of breath
worsening with activity not affected by weather.
Cough with white phlegm intermittently since 6
months ago, worsening the last 1 week.
• History of Hospitalized due to shortness of
breath more then 3 times in last 3 months.
• Job as Tailor for 30 years
Objective :
SpO2 : 92% room air
SpO2 : 96% via 3 lpm nasal cannula
HR : 94 beats/minute
RR : 22 breaths/minute
Thorax (Prone, From Anterior) :
Palpation: tactile fremitus equal in both
hemithorax, wide intercostal
Percussion: sonor on both hemithorax
Auscultation: broncovesicular, ronchi medial both
of hemithorax and wheezing in apex left hemithorax
EO Count : 5.292
APE Before BD : 120 L/min
APE After BD : 130 L/min
CXR 7/6/2023 :
Emfisematous Lung
Spirometry (When
Stable Condition)
- Oxygen nasal canule 3 liters per
minutes
- Farbivent 1 respul/8 hour/nebu
- Pulmicort 1 respul/12 hour/nebu
- Azitromycin 500 mg / 24 hours/
oral
- Pulmonary Rehabilition
Clinical and vital sign

24. TERIMA KASIH