This document discusses the diagnosis and assessment of chronic obstructive pulmonary disease (COPD) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014 guidelines. It describes how COPD should be assessed based on symptoms, spirometry results, exacerbation risk, and comorbidities to determine a patient's category (A, B, C, or D). Spirometry is required to diagnose COPD, defined as a post-bronchodilator FEV1/FVC ratio of less than 0.7. Severity is classified according to FEV1 percentages into GOLD stages 1 to 4.

1. PENYAKIT PARU OBSTRUKTIF KRONIK
( PPOK )
SMF PARU RSUD DOK 2 JAYAPURA

2. Daftar Pustaka
 Buku PPOK PDPI
 Buku Ajar Paru
 www.goldcopd.com. G O L D

3. © 2014 Global Initiative for Chronic Obstructive Lung Disease
GLOBAL INITIATIVE FOR CHRONIC
OBSTRUCTIVE LUNG DISEASE (GOLD):
TEACHING SLIDE SET
January 2016
This slide set is restricted for academic and educational
purposes only. Use of the slide set, or of individual
slides, for commercial or promotional purposes requires
approval from GOLD.

4. lobal Initiative for Chronic
bstructive
ung
isease
G
O
L
D
© 2014 Global Initiative for Chronic Obstructive Lung Disease

5. By 2020, COPD is projected to be the third
leading cause of chronic disease mortality
worldwide1
Diarrhoeal
Disease
1990
Perinatal Disorders
Ischaemic heart
disease
Cerebrovascular
disease
Lower
Respiratory
Infections
COPD
Lower
respiratory
infections
COPD Trachea,
bronchus and
lung cancers
Road traffic
accidents
2020
1. Murray CJL et al. Lancet 1997; 349:1498-1504
Bars are used to illustrate chronic disease ranking only and do not represent
actual values

6. Burden of COPD
More than 3 million people died of COPD in 2005, which is equal to 5%
of all deaths globally that year. Almost 90% of COPD deaths occur in
low- and middle-income countries.
The primary cause of COPD is tobacco smoke (through tobacco use or
second-hand smoke).
The disease now affects men and women almost equally, due in part to
increased tobacco use among women in high-income countries.
COPD is not curable, but treatment can slow the progress of the
disease.
Total deaths from COPD are projected to increase by more than 30% in
the next 10 years without interventions to cut risks, particularly
exposure to tobacco smoke.
WHO Fact Sheet No. 315 November 2012

7. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2016: Chapters
n Definition and Overview
n Diagnosis and Assessment
n Therapeutic Options
n Manage Stable COPD
n Manage Exacerbations
n Manage Comorbidities
Updated 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease

8. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters
n Definition and Overview
Updated 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease

9. Definisi…
PPOK
GOLD 2014: PPOK yaitu Penyakit paru yang
dapat dicegah dan diobati, ditandai oleh
hambatan aliran udara persisten yang
biasanya bersifat progresif dan berhubungan
dengan respon inflamasi paru terhadap
partikel atau gas beracun/berbahaya,
eksaserbasi dan penyakit komorbid
berkontribusi terhadap berat penyakit.

10. Definisi PPOK
Penyakit yg :
 Dapat diobati dan dicegah
 Ditandai oleh persistent airflow limitation
 Yg biasanya progresif dan ada hub dg
 Peningkatan respons inflamasi kronik
 Di sal nafas dan paru thd noxious particles
atau gas
 Eksaserbasi dan komorbiditas memberi
kontribusi pd overall severity in individual
patients

11. Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations
© 2014 Global Initiative for Chronic Obstructive Lung Disease

12. Future
COPD
case
Future
asthmatic
Future COPD if
smoker
Biomass Fuel and COPD

13. Genetic factors
Respiratory infection
Other
NOXIOUS AGENT
(tobacco smoke, pollutants, occupational
agent)
COPD
Pathogenesis of COPD

14. LUNG INFLAMMATION
COPD PATHOLOGY
Oxidative
stress Proteinases
Repair
mechanisms
Anti-proteinases
Anti-oxidants
Host factors
Amplifying mechanisms
Cigarette smoke
Biomass particles
Particulates
Pathogenesis of COPD
Source: Peter J. Barnes, MD

15. Patogenesis PPOK
Penyempitan-
fibrosis sal napas
Asap Rokok/Gas berbahaya
Inflamasi di Paru
Hipersekresi
mukus
Kerusakan
parenkim paru
Kerusakan
vaskuler paru
Gangguan Faal Paru
Barnes PJ, 2005, Decramer M et al, GOLD 2014

16. Patologi
Sal nafas besar
 Infiltrasi sel radang
 Kel mukus hipertrofi
 Sel goblet
Sal nafas kecil
 Penimbunan kolagen,
jar ikat
 Metaplasi sel goblet
 Otot polos >
Parenkim
 Destruksi parenkim
Vaskuler
 Perubahan struktur
tunika intima tebal
otot polos >

17. Bronchus
Wall thickening –
inflammation --
mucus gland
hypertrophy
↑ Secretions
Alveoli
Wall thinning -
inflammation -
elastolysis
Coalescence ↓
Elasticity
Bronchiole
Wall thickening –
inflammation –
repair --
remodeling
Loss of alveolar
attachments

18. COPD Pathology and Abnormal
Breathing Mechanics
 ↑Airway resistance
 ↓ Elastic recoil
 Expir. flow limitation
 Air trapping and
dynamic hyperinflation
 ↑Work of breathing
 Dyspnea, cough and
other respiratory ssx
 ↓Quality of life

19. BRONKODILATASI BRONKOKONSTRIKSI

20. airway secretions
(Bronkokonstriksi)
(Edema mukosa bronkus)
(Sumbatan
mukus)

21. AirTrapping :
inspirasi
ekspirasi

22. Mechanics of Breathing
Peripheral Lung Zone
 Airways open
and not prone
to collapse 
low resistance
 Lung recoil
strong enough
to drive tidal
expiration
(passive)
 Work of
breathing is
minimal

23. COPD: Altered Lung Mechanics
 Airway wall
thickened and
collapsing 
high resistance
 Alveoli thinned
out  poor
elastic recoil
 Expiratory flow
limitation
 Residual volume
increased

24. Time Constants
of Breathing
ΔVol
Time (seconds)
A
B C
A Wide airway, good lung recoil
B Narrowed airway, good lung recoil
Wide airway, poor lung recoil
C Narrowed airway, poor lung recoil
L
i
t
e
r
s
 Expiratory
Flow Limitation

25. Resting State
Severe obstruction, + markedly
decreased Elastic Recoil
Mild Obstruction, + mildly
decreased Elastic Recoil
COPD
Expiratory Flow Limitation and
Hyperinflation
Normal

26. Hiperinflasi alveoli
Bronkonstriksi
edema mukosa bronkus
sumbatan mukus

27. EFL and Dynamic
Hyperinflation
Initial breathing cycle
Air is trapped
During
Exercise COPD
Normal
Normal

28. EFL and Dynamic
Hyperinflation
Initial breathing cycle  Next breathing cycle
Worsening Hyperinflation
During
Exercise COPD
Normal

29. Bronkokonstriksi Edema
mukosa bronkus Sumbatan
mukus
Obstruksi jalan napas
Resistensi arus ekspirasi 
Air trapping Hiperinflasi alveoli
Kontraksi diafragma
terganggu
Otot-otot bantu pernapasan
diaktifir

30. TidalVolume
Lung
Volume
Normal
Time
Resting Exercise
Hyperventilation:
Static and Dynamic
Total Lung Capacity
COPD
INSPIRATORY
CAPACITY
END
EXPIRATORY
LUNG
VOL
FRC
FRC
IC
Airway obstruction and low
elastic recoil
Expiratory flow limitation
Hyperinflation at rest,
worsened by exercise
Limited inspiratory “space”
Dyspnea
End ExpiratoryVolume

31. Global Strategy for Diagnosis, Management and Prevention of COPD
Mechanisms Underlying Airflow
Limitation in COPD
Small Airways Disease
• Airway inflammation
• Airway fibrosis, luminal plugs
• Increased airway resistance
Parenchymal Destruction
• Loss of alveolar attachments
• Decrease of elastic recoil
AIRFLOW LIMITATION
© 2014 Global Initiative for Chronic Obstructive Lung Disease

32. Dampak Sistemik PPOK
PPOK - Diagnosis dan Penatalaksanaan – PDPI 2011,hal.18

33. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters
n Definition and Overview
n Diagnosis and Assessment
Updated 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease

34. Diagnosis of COPD
GOLD 2013
SYMPTOMS
chronic cough
shortness of breath
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution
SPIROMETRY: Required to establish diagnosis
sputum

35.  Spirometri
 metode pengukuran fungsi paru
 mengukur ventilasi yaitu
mengukur volume statik dan
volume dinamik paru

36. Spirometri
 Simpel
 Prinsip dasar spirometri
 mengukur volume dan flow rate
 2 tipe : - volumetric spirometer
- flow type spirometer

37. TUJUAN PEMERIKSAAN
SPIROMETRI
 Menilai status faal paru
(normal, restriksi, obstruksi,campuran)
 Menilai manfaat pengobatan
 Memantau perjalanan penyakit
 Menentukan prognosis
 Menentukan toleransi tindakan bedah

38. INDIKASI PEMERIKSAAN
 Setiap keluhan sesak
 Penderita asma stabil
 Penderita PPOK stabil
 Evaluasi penderita asma tiap tahun dan
penderita PPOK tiap 6 bulan
 Penderita yang akan dianestesi umum
 Pemeriksaan berkala pekerja yang
terpajan zat
 Pemeriksaan berkala pada perokok

40. Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Airflow Limitation:
Spirometry
 Spirometry should be performed after the
administration of an adequate dose of a short-
acting inhaled bronchodilator to minimize
variability.
 A post-bronchodilator FEV1/FVC < 0.70
confirms the presence of airflow limitation.
 Where possible, values should be compared to
age-related normal values to avoid overdiagnosis
of COPD in the elderly.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

41. 1 2 3 4 5 6
1
2
3
4
Volume,
liters
Time, sec
FVC
5
1
FEV1 = 4L
FVC = 5L
FEV1/FVC = 0.8
© 2014 Global Initiative for Chronic Obstructive Lung Disease

42. Volume,
liters
Time, seconds
5
4
3
2
1
1 2 3 4 5 6
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Normal
Obstructive
© 2014 Global Initiative for Chronic Obstructive Lung Disease

43. Determine the severity of the disease, its
impact on the patient’s health status and the
risk of future events (for example
exacerbations) to guide therapy. Consider the
following aspects of the disease separately:
 current level of patient’s symptoms
 severity of the spirometric abnormality
 frequency of exacerbations
 presence of comorbidities.
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD: Goals
© 2014 Global Initiative for Chronic Obstructive Lung Disease

44. Klasifikasi derajat Keparahan PPOK menurut
GOLD 2014
Penggolongan pasien PPOK tidak hanya dilihat
berdasarkan hasil spirometri akan tetapi dinilai
juga berdasarkan gejala atau keluhan pasien
menurut skala mMRC atau CAT dan juga
riwayat eksaserbasi.

45. Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD ( A,B,C,or D )
 Assess symptoms
 Assess degree of airflow
limitation using spirometry
 Assess risk of exacerbations
 Assess comorbidities
© 2014 Global Initiative for Chronic Obstructive Lung Disease

46. Kategori Pasien PPOK menurut GOLD 2014
Kategori Karakterisitik Klasifikasi
Spirometry
mMRC CAT Eksaserbasi
per tahun
A Risiko rendah
Gejala sedikit
GOLD 1 atau 2 0-1 < 10 ≤ 1
B Risiko rendah
Gejala banyak
GOLD 1 atau 2 ≥ 2 ≥ 10 ≤ 1
C Risiko tinggi
Gejala sedikit
GOLD 3 atau 4 0-1 < 10 ≥ 2
D Risiko tinggi
Gejala banyak
GOLD 1 atau 2 ≥ 2 ≥ 10 ≥ 2

47. The characteristic symptoms of COPD are chronic and
progressive dyspnea, cough, and sputum production
that can be variable from day-to-day.
Dyspnea: Progressive, persistent and characteristically
worse with exercise.
Chronic cough: May be intermittent and may be
unproductive.
Chronic sputum production: COPD patients commonly
cough up sputum.
Global Strategy for Diagnosis, Management and Prevention of COPD
Symptoms of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease

48. Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess comorbidities
COPD AssessmentTest (CAT)
or
Clinical COPD Questionnaire (CCQ)
or
mMRCBreathlessnessscale
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease

50. Skor mMRC

51. Assess symptoms
Assess degree of airflow limitation
usingspirometry
Assess risk of exacerbations
Assess comorbidities
Use spirometry for grading severity
according to spirometry, using four
grades split at 80%, 50% and 30% of
predicted value
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease

52. Klasifikasi derajat obstruksi PPOK
( FEV1 pasca bronkodilator )
Pada pasien dengan FEV1/FVC < 0,7
GOLD 1 Ringan FEV1 ≥ 80%
predicted
GOLD 2 Sedang 50%≤ FEV1 < 80%
GOLD 3 Berat 30% ≤ FEV1 < 50%
GOLD 4 Sangat Berat FEV 1 < 30%
GOLD 2014

53. Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations
Assess comorbidities
Usehistory of exacerbations and spirometry.
Twoexacerbations or more within the last year
or an FEV1 < 50 % of predictedvalueare
indicators of highrisk. Hospitalization for a COPD
exacerbationassociated with increasedrisk of death.
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease

54. Global Strategy for Diagnosis, Management and Prevention of COPD
Assess Risk of Exacerbations
To assess risk of exacerbations use history of
exacerbations and spirometry:
 Two or more exacerbationswithinthe last
yearor an FEV1 < 50 % of
predictedvalueareindicators of highrisk.
 One or more hospitalizations for COPD
exacerbationshouldbeconsideredhighrisk.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

55. Global Strategy for Diagnosis, Management and Prevention of COPD
CombinedAssessment of COPD
 Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations
Combine these assessments for the
purpose of improving management of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease

56. Global Strategy for Diagnosis, Management and Prevention of COPD
CombinedAssessment of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Risk
(GOLD
Classification
of
Airflow
Limitation))
Risk
(Exacerbation
history)
≥ 2
or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0
Symptoms
(C) (D)
(A) (B)
CAT < 10
4
3
2
1
CAT > 10
Breathlessness
mMRC 0–1 mMRC > 2

57. Global Strategy for Diagnosis, Management and Prevention of COPD
CombinedAssessment of COPD
(C) (D)
(A) (B)
CAT < 10 CAT >10
Symptoms
If CAT < 10 ormMRC 0-1:
Less Symptoms/breathlessness (A or
C)
If CAT >10 or mMRC> 2:
More Symptoms/breathlessness (B
or D)
Assess symptoms first
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Breathlessness
mMRC 0–1 mMRC > 2

58. Global Strategy for Diagnosis, Management and Prevention of COPD
CombinedAssessment of COPD
Risk
(GOLD
Classification
of
Airflow
Limitation)
Risk
(Exacerbation
history)
(C) (D)
(A) (B)
4
3
2
1
CAT < 10 CAT >10
Symptoms
If GOLD 3 or 4 or ≥ 2
exacerbations per year or
> 1 leading to hospital
admission:
High Risk (C or D)
If GOLD 1 or 2 and only
0 or 1 exacerbations per
year (not leading to
hospital admission):
Low Risk (A or B)
Assess risk of exacerbations next
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Breathlessness
mMRC0–1 mMRC > 2
≥ 2
or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0

59. Global Strategy for Diagnosis, Management and Prevention of COPD
CombinedAssessment of COPD
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Risk
(GOLD
Classification
of
Airflow
Limitation))
Risk
(Exacerbation
history)
≥ 2
or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0
Symptoms
(C) (D)
(A) (B)
CAT < 10
4
3
2
1
CAT > 10
Breathlessness
mMRC 0–1 mMRC > 2

60. Patient Characteristic SpirometricCla
ssification
Exacerbations
per year
CAT mMRC
A
Low Risk
Less Symptoms
GOLD 1-2 ≤ 1 < 10 0-1
B
Low Risk
More Symptoms
GOLD 1-2 ≤ 1 > 10 >2
C
High Risk
Less Symptoms
GOLD 3-4 >2 < 10 0-1
D
High Risk
More Symptoms
GOLD 3-4 >2 > 10
>2
Global Strategy for Diagnosis, Management and
Prevention of COPD
CombinedAssessment of
COPD
When assessing risk, choose the highest risk
according to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)
© 2014 Global Initiative for Chronic Obstructive Lung Disease

61. Kategori Pasien PPOK menurut GOLD 2014
Kategori Karakterisitik Klasifikasi
Spirometry
mMRC CAT Eksaserbasi
per tahun
A Risiko rendah
Gejala sedikit
GOLD 1 atau
2
0-1 < 10 ≤ 1
B Risiko rendah
Gejala banyak
GOLD 1 atau
2
≥ 2 ≥ 10 ≤ 1
C Risiko tinggi
Gejala sedikit
GOLD 3 atau
4
0-1 < 10 ≥ 2
D Risiko tinggi
Gejala banyak
GOLD 1 atau
2
≥ 2 ≥ 10 ≥ 2

62. Global Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD Comorbidities
COPD patients are at increased risk for:
• Cardiovasculardiseases
• Osteoporosis
• Respiratoryinfections
• AnxietyandDepression
• Diabetes
• Lungcancer
• Bronchiectasis
These comorbid conditions may influence mortality and
hospitalizations and should be looked for routinely, and
treated appropriately.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

63. Dampak Sistemik PPOK
PPOK - Diagnosis dan Penatalaksanaan – PDPI 2011,hal.18

64. Global Strategy for Diagnosis, Management and Prevention of COPD
Differential Diagnosis:
COPD and Asthma
COPD
•Onset in mid-life
• Symptoms slowly progressive
• Long smoking history
ASTHMA
• Onset early in life (often childhood)
• Symptoms vary from day to day
• Symptoms worse at night/early morning
• Allergy, rhinitis, and/or eczema also present
• Family history of asthma
© 2014 Global Initiative for Chronic Obstructive Lung Disease

65. Diagnosis Banding
Asma bronkial
Gagal jantung kongestif
Bronkiektasis
Tuberkulosis
Bronkiolitis obliteran
Diffuse Panbronchiolitis

66. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Updated 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease

67. Penatalaksanaan
Opsi terapi:
1.Berhenti Merokok
2.Terapi Farmakologi
3.Terapi Nonfarmakologi

68. Penatalaksanaan
Berhenti merokok
Sangat penting utk pasien yg masih merokok
Intervensi dg kapasitas terbesar pd perjalanan
alamiah PPOK
Nicotine replacement theraphy meningkat long-term
smoking abstinence rates
Konseling oleh dr, tenaga kesehatan significantly
increases quit rates over self-initiated strategies
(Evidence A)

69. Penatalaksanaan: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors

70. Bronchodilator medications are central to the
symptomatic management of COPD.
 Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
 The principal bronchodilator treatments are beta2-
agonists, anticholinergics, theophylline or combination
therapy.
 The choice of treatment depends on the availability of
medications and each patient’s individual response
in terms of symptom relief and side effects..
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators
© 2014 Global Initiative for Chronic Obstructive Lung Disease

71. Influenza vaccines can reduce serious illness.
Pneumococcal polysaccharide vaccine is recommended
for COPD patients 65 years and older and for COPD
patients younger than age 65 with an FEV1< 40%
predicted.
The use of antibiotics, other than for treating infectious
exacerbations of COPD and other bacterial infections, is
currently not indicated.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other
Pharmacologic Treatments
© 2014 Global Initiative for Chronic Obstructive Lung Disease

72. Alpha-1 antitrypsin augmentation therapy: not
recommended for patients with COPD that is unrelated
to the genetic deficiency.
Mucolytics:Patients with viscous sputum may benefit from
mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators:Nitric oxide is contraindicated in stable
COPD. The use of endothelium-modulating agents for
the treatment of pulmonary hypertension associated
with COPD is not recommended.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other
Pharmacologic Treatments
© 2014 Global Initiative for Chronic Obstructive Lung Disease

73.  All COPD patients benefit from exercise training
programs with improvements in exercise tolerance
and symptoms of dyspnea and fatigue.
 Although an effective pulmonary rehabilitation
program is 6 weeks, the longer the program
continues, the more effective the results.
 If exercise training is maintained at home, the
patient's health status remains above pre-
rehabilitation levels.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation
© 2014 Global Initiative for Chronic Obstructive Lung Disease

74. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Updated 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease

75.  Relieve symptoms
 Improve exercise tolerance
 Improve health status
 Prevent disease progression
 Prevent and treat exacerbations
 Reduce mortality
Reduce
symptoms
Reduce
risk
Penatalaksanaan PPOK Stabil:
Tujuan Terapi

76. Penatalaksanaan PPOK stabil
 Identifikasi dan reduksi pajanan f risiko
 Terapi farmakologi
 Terapi nonfarmakologi
 Monitoring dan follow up

77. Penatalaksanaan PPOK stabil
Identifikasi dan reduksi pajanan f risiko
 Berhenti merokok the key intervention for all COPD
(Evidence A)
 Anjurkan pasien menghindari pajanan lebih lanjut
(Evidence D)
 Mengurangi risiko polusi udara indoor dan outdoor.
Feasible dan harus dianjurkan (Evidence B)

78. Exacerbations
per
year
> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC>2
CAT >10
GOLD 3
GOLD 2
GOLD 1
A B
D
C
Bagaimana menggunakan terapi
farmakologi ?

79. Penatalaksanaan PPOK stabil
Terapi Farmakologi
Patient First choice Second choice AlternativeChoices
A
SAMA prn
or
SABA prn
LAMA
or
LABA
or
SABA and SAMA
Theophylline
B
LAMA
or
LABA
LAMA and LABA
SABA and/or SAMA
Theophylline
C
ICS +LABA
or
LAMA
LAMA and LABA
PDE4-inh.
SABA and/or SAMA
Theophylline
D
ICS + LABA
or
LAMA
ICS andLAMA or
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh.or
LAMA and LABA or
LAMA and PDE4-inh.
Carbocysteine
SABA and/or SAMA
Theophylline

80. © 2020 Global Initiative for Chronic Obstructive Lung Disease

81. © 2020 Global Initiative for Chronic Obstructive Lung Disease

82. © 2020 Global Initiative for Chronic Obstructive Lung Disease

83. Exacerbations
per
year
> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC>2
CAT >10
GOLD 3
GOLD 2
GOLD 1
SAMA prn
or
SABA prn
LABA
or
LAMA
ICS + LABA
or
LAMA
Penatalaksanaan PPOK stabil
Terapi farmakologi
FIRST CHOICE
A B
D
C
ICS + LABA
or
LAMA

84. > 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC> 2
CAT > 10
GOLD 3
GOLD 2
GOLD 1
LAMA or
LABA or
SABA and SAMA
LAMA and LABA ICS and LAMA or
ICS + LABA and LAMA or
ICS + LABA and PDE4-inh or
LAMA and LABA or
LAMA and PDE4-inh.
LAMA and LABA
Penatalaksanaan PPOK stabil
Terapi farmakologi SECOND CHOICE
A
D
C
B
Exacerbations
per
year

85. > 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC> 2
CAT >10
GOLD 3
GOLD 2
GOLD 1
Theophylline
PDE4-inh.
SABA and/or SAMA
Theophylline
Carbocysteine
SABA and/or SAMA
Theophylline
SABA and/or
SAMA
Theophylline
Penatalaksanaan PPOK stabil : Farmako terapi
ALTERNATIVE CHOICES
A
D
C
B
Exacerbations
per
year

86. Penatalaksanaan PPOK stabil
Bronkodilator- Rekomendasi
 Agonis β2 dan antikolinergik: Long acting lebih
dipilih dp short acting (Evidence A)
 Bronkodilator inhalasi lebih dipilih dp oral
berdasar efikasi dan ESO (Evidence A)
 Berdasar bukti relatif low efficacy dan lebih
banyak efek samping, theofilin tidak
direkomendai kecuali other long-term treatment
bronkodilator tidak ada (Evidence B)

87. Penatalaksanaan PPOK stabil
Kortikosteroid-PDE-4 Inhibitor Rekomendasi
 Tx jangka panjang dg kortikosteroid inhalasi direkomendasi
utk PPOK berat dan sangat berat dan sering eksaserbasi yg
tidak terkontrol dg LABA (Evidence A)
 Long-term monotheraphy oral steroid tidak diarekomendasi
(Evidence A)
 Long-term monotheraphy inhaled steroid tidak
direkomendasi ok kurang efektif dibanding LABAC
(Evidence A)
 PDE-4 Inhibitor mungkin digunakan utk mengurangi
eksaserbasi pasien Bronkitis Kronis, PPOK berat, sangat
berat dan sering eksaserbasi (Evidence B)

88. Penatalaksanaan PPOK stabil
Terapi nonfarmakolgi
Kelomp
ok
Essential Rekomendasi Local guideline
A Berhenti
merokok
Physical
activity
Flu vaccination
Pneumococcal
vaccination
B-D Berhenti
merokok
Pulmonary
rehabilitation
Physical
activity
Flu vaccination
Pneumococcal
vaccination

89. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Updated 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease

90. Penatalaksanaan Eksaserbasi
An exacerbation of COPD is:
“an acute event characterized by a
worsening of the patient’s
respiratory symptoms that is
beyond normal day-to-day
variations and leads to a change in
medication.”

91. Impact on
symptoms
and lung
function
Negative
impact on
quality of life
Consequences Of COPD Exacerbations
Increased
economic
costs
Accelerated
lung function
decline
Increased
Mortality
EXACERBATIONS

92. Oxygen: titrate to improve the patient’s hypoxemia with a target
saturation of 88-92%.
Bronchodilators:Short-acting inhaled beta2-agonists with or
without short-acting anticholinergics are preferred.
Systemic Corticosteroids:Shorten recovery time, improve lung
function (FEV1) and arterial hypoxemia (PaO2), and reduce the
risk of early relapse, treatment failure, and length of hospital
stay. A dose of 30-40 mg prednisolone per day for 10-14 days is
recommended.
Penatalaksanaan eksaserbasi
Opsi Terapi

93. Antibiotics should be given to patients with:
 Three cardinal symptoms: increased
dyspnea, increased sputum volume, and
increased sputum purulence.
 Who require mechanical ventilation.
Penatalaksanaan Eksaserbasi
Opsi terapi

94. Noninvasive ventilation (NIV):
 Improves respiratory acidosis, reduces
respiratory rate, severity of dyspnea,
complications and length of hospital stay.
 decreases mortality and needs for intubation.
Penatalaksanaan Eksaserbasi
Opsi Terapi

95.  Marked increase in intensity of symptoms
 Severe underlying COPD
 Onset of new physical signs
 Failure of an exacerbation to respond to initial
medical management
 Presence of serious comorbidities
 Frequent exacerbations
 Older age
 Insufficient home support
Penatalaksanaan Eksaserbasi
Indications for Hospital Admission

96. Monitoring dan Follow up
 Monitoring disease progression and
development of complications
 Monitori Pharmacotheraphy and Other
medical treatment
 Monitor exacerbation history
 Monitor Comorbidities

97. Penyulit
 Gagal napas
 Infeksi berulang
 Cor pulmonale

98. Prognosis
Buruk pada:
 FEV1 rendah
 Masih merokok
 Nutrisi jelek
 Korpulmonale
 Komorbid

99. TERIMA KASIH