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CURICULUM VITAEN A M A: Prof.Dr.TAMSIL SYAFIUDDIN Sp.P
(K)ALAMAT: Jln.KARSA No F 1 KOMPLEKS EKS KOWILHAN I SEI.AGUL MEDAN
20117PEKERJAAN : Guru Besar FK- UISU / FK- USU RIWAYAT PENDIDIKAN :
-Dokter Umum FK-USU Medan,1979 -Dokter Spesialis I Paru FK-UI
Jakarta, 1990 -Dokter Spesialis II Paru, Konsultan Asma/PPOK, 1995
Pendidikan tambahan: - Pelatihan Kanker Paru, TSUKAGUCHI Hospital,
Kobe- Japan 1989 - Pelatihan PPOK, AMAGASAKI Hospital, Kobe- Japan
1990 - Pelatihan Respiratory Physiologi, JAPAN RESPIRATORY
PHYSIOLOGIST CLUB, Kyoto- Japan 1990 - Spirometry Training Course,
Department of Respiratory Medicine, National University Hospital
Singapore, Singapore 1997
-
-Workshop of Bronchoscopy and Autofluorecent Bronchoscopy, RS
Persahabatan Jakarta, Jakarta September 2005
-Training of the new interventional technique of
bronchosfiberscopy (Optical Coherence Tommograhy) , Department of
Thoracic Surgery, Tokyo Medical University Hospital,Tokyo - Japan
2007
-Workshop new technique of Bronchoscopy, Postgradute Medical
Institute, Singapore General Hospital, Singapore 2009.- Workshop on
Medical Thoracoscopy, The American College of Chest Physicians-The
Indonesian Association of Pulmonologist, RS Persahabatan Jakarta,
Jakarta November 1997
- Workshop on Reformation of Higer Education
System,HEDS-JICA,Jakarta 1998
-Pulmonary Infections Course, Postgraduate Medical Institute,
Singapore General Hospital, Singapore 2001
- Bronchoscopy &Thoracoscopy Workshop, Postgraduate Medical
Institute, Singapore General Hospital, Singapore 2005 Workshop on
Transbronchial Lung Biopsy and Trasbronchial Needle Aspiration PDPI
Cabang Jakarta, RS Persahabatan Jakarta ,Jakarta Maret 1997 -
Workshop on Respiratory Physiology and Its Clinical Application, RS
Pusat Angkatan Darat Gatot Subroto Jakarta, Jakarta Juni 1997
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Departemen PulmonologiFakultas KedokteranUniversitas Sumatera
Utara2009Prof.Dr.Tamsil Syafiuddin,SpP(K)Dr.Bintang Sinaga, SpP
Asthma
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Tingkat kemampuan yang diharapkan dicapai pada akhir pendidikan
dokter
Tingkat Kemampuan 1Dapat mengenali dan menempatkan
gambaran-gambaran klinik sesuai penyakit ini ketika membaca
literatur. Dalam korespondensi, ia dapat mengenal gambaran klinik
ini, dan tahu bagaimana mendapatkan informasi lebih lanjut. Level
ini mengindikasikan overview level.Bila menghadapi pasien dengan
gambaran klinik ini dan menduga penyakitnya, Dokter segera
merujuk.
Tingkat Kemampuan 2Mampu membuat diagnosis klinik berdasarkan
pemeriksaan fisik dan pemeriksaanpemeriksaan tambahan yang diminta
oleh dokter (misalnya : pemeriksaan laboratorium sederhana atau
X-ray).Dokter mampu merujuk pasien secepatnya ke spesialis yang
relevandan mampu menindaklanjuti sesudahnyaStandar Kompetensi
Dokter , Konsil Kedokteran Indonesia, 2006
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Tingkat Kemampuan 33a. Mampu membuat diagnosis klinik
berdasarkan pemeriksaan fisik dan pemeriksaanpemeriksaan tambahan
yang diminta oleh dokter (misalnya : pemeriksaan laboratorium
sederhana atau X-ray). Dokter dapat memutuskan dan memberi terapi
pendahuluan, serta merujuk ke spesialis yang relevan (bukan kasus
gawat darurat).
3b. Mampu membuat diagnosis klinik berdasarkan pemeriksaan fisik
dan pemeriksaanpemeriksaan tambahan yang diminta oleh dokter
(misalnya : pemeriksaan laboratorium sederhana atau X-ray).Dokter
dapat memutuskan dan memberi terapi pendahuluan, serta merujuk ke
spesialis yang relevan (kasus gawat darurat)..Standar Kompetensi
Dokter , Konsil Kedokteran Indonesia, 2006
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Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006
Tingkat kemampuan4: Mampu membuat diagnosis klinik berdasarkan
pemeriksaan fisik dan pemeriksaan tambahan yang diminta oleh dokter
(misalnya: pemeriksaan laboratorum sederhana atau X-ray). Dokter
dapat memutuskan dan mampu menangani problem itu secara mandiri
hingga tuntas.
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Levels of competenceStandar Kompetensi Dokter , Konsil
Kedokteran Indonesia, 2006
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Bronchiectasis 1 2 3A 3B 4COPD 1 2 3A 3B 4SARS 1 2 3A 3B
4Pneumonia 1 2 3A 3B 4Avian influenzae 1 2 3A 3B 4Lung abscess 1 2
3A 3B 4Pulmonary embolism 1 2 3A 3B 4Lung infarction 1 2 3A 3B
4Pleurisy TBC 1 2 3A 3B 4Pleurisy Cancer 1 2 3A 3B 4Pleurisy Lupus
1 2 3A 3B 4Pneumothorax 1 2 3A 3B 4Cystic fibrosis 1 2 3A 3B
4Aspiration pneumonia 1 2 3A 3B 4Standar Kompetensi Dokter , Konsil
Kedokteran Indonesia, 2006
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Diagnosis of Asthma
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IDENTIFIKASI MASALAH/ANALISIS:MASALAH/DATA:PEMECAHAN
MASALAH/RENCANA(Planning):KURIKULUM BERBASIS KOMPETENSI (Problem
Based learning)
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IDENTIFIKASI MASALAH/ANALISIS:DATA LAINRENCANA BERIKUT PF,
Ro
BatukSesak napas Batuk darahNyeri dada
OBSTRUKTIFINFEKSI KEGANASANPENYAKIT ORGAN LAIN
MASALAH/DATA:PEMECAHAN MASALAH/RENCANA(Planning):Daftar keluhan
Standar Kompetensi Dokter Indonesia
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IDENTIFIKASI MASALAH/ANALISIS:DATA LAIN: Usia :Semua usia
Riwayat Keluarga Riwayat Mengi Riwayat Obat (BD)RENCANA BERIKUTPem
Fisik :Tanda Obtruktif: Eksirasi memanjang/MengiRO :
NormalSpirometri : Tanda obstruktifBatukSesak napasBatuk darahNyeri
dada
OBSTRUKTIF : ASMA, PPOKINFEKSIKEGANASANPENYAKIT ORGAN LAIN
MASALAH/DATA:PEMECAHAN MASALAH/RENCANA(Planning):
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Recent issues in asthma managementThe Unmet Needs of asthma
Theme of World Asthma Day 2005/2006 You can control your asthma
Theme of World Asthma Day 2007/2008Adherence Self ManagementUUD No
29 / 2004 : Praktik Kedokteran CompetencyPharmacoeconomic
consideration Quality of Life
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Definition of asthma Chronic inflammatory disease of airways
(AW) responsiveness of tracheobronchial tree Physiologic
manifestation: AW narrowing relieved spontaneously or with BD Cster
Clinical manifestations: a triad of paroxysms of cough, dyspnea and
wheezing.
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Asthma is an inflammatory diseases
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Disease Pattern Episodic --- acute exacerbations
interspersedwith symptom-free periods Chronic --- daily AW
obstruction which may be mild, moderate or severe superimposed
acute exacerbations Life-threatening--- slow-onset or
fast-onset(fatal within 2 hours)
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1. Warner O. Am J Resp Crit Care Med 2003; 167: 14651466.
Bronchoconstriction Bronchial oedema Mucous hypersecretion
Inflammatory cell recruitment eosinophilsAsthma symptoms: the tip
of the iceberg1
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Asthma Pathology and Therapy
Evolution197519801985199019952000Large use of short-acting
2-agonists Fear of short-acting 2-agonistsSingle inhaler therapy
ICS+LABAICS treatment introduced1972 Adding LAA to ICS therapy Kips
et al, AJRCCM 2000 Pauwels et al, NEJM 1997 Greening et al, Lancet
1992
BronchospasmInflammationRemodelling
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NormalAsthmaInflammation(+)() Bronchial hyperreactivity ( +
)Bronchial hyperreactivity ( - ) Symptoms (+)Symptoms
(-)TriggersBronchoconstriction ( - )Bronchoconstriction ( +
)TriggersThe pathogenesis of asthma
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Ig EAgYYMethyl
transferasePhospholipidPhosphatidylethanolaminePhosphatidyl
cholinePhospholipase A2Ca++HistaminCa++HistaminECF, NCFArachidonic
acidlypoxygenasecyclooxygenase5-HETELeucotrienesLTB4LTC4LTD4LTE4ThromboxanesTXA2ProstaglandinsPGDPGF2Mediator
release in asthma reactions
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MBP, ECPEosinophilEpitheliumAIRWAY REMODELLING IN
ASTHMADesquamations of epitheliumThickening of basement
membraneIncrease in airway smooth muscle
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Epithelial Damage P Jeffery, in: Asthma, Academic Press 1998
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Basement Membrane ThickeningP Jeffery, in: Asthma, Academic
Press 1998
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P Jeffery, in: Asthma, Academic Press 1998
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InflammationBronchial
hyperreactivitySymptomsControllerRelieverMedicines and Pathogenesis
of asthmaBronchoconstriction
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Reliever:Controler:
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Guidelines on Asthma Management: Past and Current TrendsLABA and
ICSICSLABA+ICSGINA 1998 (adapted)GINA 2006Severe persistentModerate
persistentMild persistent
Intermittent SABA / Rapid onset of action LABA
ExacerbationStable condition Total controlPartially
controlUncontrol
Old classification
New classification
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Acute severe asthma:MANAGEMENT 11.Immediate Rx: O2 40-60% mask
or cannula + SABA (salbutamol 5mg)/ nebulizer + ICS 200 mcg/
nebulizer or hydrocortisone 200mg IV. With lifethreatening features
add 0.5mg ipratropium to nebulized 2 agonist + Aminophyllin 250mg
iv over 20 min or salbutamol 250ug over 10 min.
2. Subsequent Rx: Nebulized SABA 6 hourly + ICS 200mcg or
hydrocortisone 200mg 6 hourly IV + 40-60% O2.
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MANAGEMENT 2
No improvement after 15-30 min: Nebulized 2 agonist every 15-30
min + Ipratropium.
Still no improvement: Aminophyllin infusion 750mg/24H (small
pt), 1500mg/24H (large pt), or alternatively salbutamol
infusion.
Monitor Rx: Aminophyllin blood levels + PEF after 15-30 min +
oxymetry (maintain SaO2 > 90) + repeat blood gasesafter 2 hrs if
initial PaO2 < 60, PaCO2 normal or raised andpatient
deteriorates. Deterioration: ICU, intubate, ventilate + muscle
relaxant.
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ASTHMA MANAGEMENT: CLINICAL
QUICK RELIEVE MEDICATION
LONG TERM TREATMENT
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Anti Inflammations is the mainstay therapy!
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Inhalation therapy is the mainstay therapyBecause minimally side
effect!
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Controller: Anti inflammationbudesonide (Pulmicort)
(Inflamid)beclomethasone dipropionate (Becotide) triamcinolone
acetonidefluticasone(Flexotide)sodium chromoglicate
(Intal)ketotifensodium nedocromil Inhaled Cortico SteroidNon
steroid
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Bronchodilator2 - agonist XanthinAnticholinergicReliever
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BRONCHODILATORShort Acting 2 AGONIST (SABA):salbutamol/albuterol
(Ventolin )terbutaline (Bricasma)procaterolfenoterolorciprenaline,
etcANTICHOLINERGIC:atropine sulfate ipratropium bromidetiotropium
bromideOTHER SYMPHATOMIMETIC: ephedrineadrenaline,
etcXANTHINE:theophyllineaminophyllineLong Acting 2
AGONIST:(LABA)salmoterolformoterol
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Combination therapy
SymbicortBudesonide + Formoterol
SeretideFluticasone + Salmoterol
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The Beginning of Treatment
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ExacerbationThe beginning of treatment?Stable condition x
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Asthma management* Stable condition * Long-term therapy
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Evaluations
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Inflammation can also be present during symptom-free
periodsAdapted from Woolcock A. Clin Exp Allergy Rev 2001; 1: 6264.
AHR is a marker of inflammationAHRRescue medication useImpaired am
PEFImpaired FEV1Start of treatment% Reduction24618Rate of response
of different measures of asthma control over 18 months of ICS
treatmentNightsymptomsMonths
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Peak flow meter600-700 0300( normal )Objective values
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Peak Flow Meter /PEFR/APEMust be avilable
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PEFR Monitoring:A Major Tool in Asthma Self-ManagementChronic
DiseasesMonitorHypertension
Diabetes
AsthmaBlood pressure
Serum glucose
PEFR
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Asthma Control Test Asthma Control Questionnaire Asthma Therapy
Assessment Questionnaire Asthma Control Scoring System
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5
-
5
-
5
-
5
-
5
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Objective use of ACTACT is a scored tool which allows numerical
targets to be set. Simple to complete 5 questions with a 5 point
rating scale (max: 25)
19 or less = Uncontrolled asthma20-24 = Well controlled25 =
Total Control
Improves patient / physician communication. Clear and concise
questions that engage patients in a more open, candid
discussionValidated using spirometry and specialist assessment
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None (2 or less / week)NoneNoneNone (2 or less /
week)NormalNoneDaytime symptomsLimitations of activitiesNocturnal
symptoms / awakeningNeed for rescue / reliever treatmentLung
function (PEF or FEV1)ExacerbationCONTROLLEDCharacteristicsMore
than twice / weekAnyAnyMore than twice / week< 80% predicted or
personal best (if known) on any dayOnce/more per yearPARTLY
CONTROLLED3 or more features of partly controlled asthma present in
any weekOne in any weekUNCONTROLLEDAsthma ClassificationGINA
updated 2008Classification of Asthma Severity by Levels of Asthma
Control(new classification)
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The goal of asthma treatment
To achieve and maintainclinical controlQ o L
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DIFFERENTIAL DIAGNOSIS
1. Upper airway obstruction glottic dysfunction.2. Acute LV
failure pulmonary oedema.3. Pulmonary embolism.4. Endobronchial
disease.5. Chronic bronchitis.6. Eosinophilic pneumonia.7.
Carsinoid syndrome.8. Vasculitis.
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DIAGNOSIS EXACERBATION : CLINICAL
Episodic asthma: Paroxysms of wheeze, dyspnoea andcough,
asymptomatic between attacks.
Acute severe asthma: upright position, use accessory resp
muscles, cant complete sentences in one breath, tachypnea >
25/min, tachycardia > 110/min, PEF 33-50% of pred or best,
pulsus paradoxus, chest hyperresonant, prolonged expiration, breath
sounds decreased, inspiratory andexpiratory rhonchi, cough.
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Life-threatening features: PEF < 33% of pred or best,silent
chest, cyanosis, bradycardia, hypotension, feeble respiratory
effort, exhaustion, confusion, coma, PaO2 < 60,PCO2 normal or
increased, acidosis (low pH or high [H+]).
Chronic asthma: Dyspnea on exertion, wheeze, chest tightness and
cough on daily basis, usually at night and early morning;
intercurrent acute severe asthma (exacerbations)and productive
cough (mucoid sputum), recurrent respiratory infection, expiratory
rhonchi throughout and accentuated on forced expiration.
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Life is not problem to be solved, but a reality to be
experienced ( Soren Kierkegaard)
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Classification of Asthma Severity byClinical Features Before
Treatment:(old classification)Intermittent:Symptoms less than once
a weekBrief exacerbationsNocturnal symptoms not more than twice a
month FEV1 or PEF 80% predicted PEF or FEV1 variability <
20%
Mild Persistent:Symptoms more than once a week but less than
once a dayExacerbations may affect activity and sleepNocturnal
symptoms more than twice a month FEV1 or PEF 80% predicted PEF or
FEV1 variability < 20 30%GINA. 2006
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Moderate Persistent:Symptoms dailyExacerbations may affect
activity and sleepNocturnal symptoms more than once a weekDaily use
of inhaled short-acting 2-agonist FEV1 or PEF 60-80% predicted PEF
or FEV1 variability > 30%
Severe Persistent:Symptoms dailyFrequent exacerbationsFrequent
nocturnal asthma symptomsLimitation of physical activities FEV1 or
PEF 60% predicted PEF or FEV1 variability > 30%GINA. 2006
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TERIMA KASIH, DOMO ARIGATOO GOZAIMASU