9/15/2019

Curriculum Vitae
DR. Dr. Arto Yuwono Soeroto, SpPD-KP, FCCP, FINASIM
E-mail: aysoeroto@yahoo.co.id , a .y.soeroto@unpad.ac.id

Pendidikan:
S1 FK Universitas Padjadjaran
Sp1 FK Universitas Padjadjaran
Konsultan Pulmonologi KIPD
S3 FK Universitas Padjadjaran

Pekerjaan:
Kepala Departemen/KSM Ilmu Penyakit Dalam FKUP/RS Hasan Sadikin
Kepala Divisi Respirologi & Penyakit Kritis IPD FKUP/RS Hasan Sadikin
Ketua Tim TB RSUP Dr. Hasan Sadikin

Organisasi:
Ketua PB Perhimpunan Respirologi Indonesia (PERPARI)
Ketua Perhimpunan Dokter Spesialis Penyakit Dalam (PAPDI) Jabar (2009-2016)
Fellow American College of Chest Physcian (ACCP)
Fellow Indonesian Society of Internal Medicine
European Respiratory Society (ERS)

What’s New COPD Guideline

Based on GOLD 2019
Presented by : Dr. dr. Arto Yuwono Soeroto., Sp.PD-KP

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Definition and Overview

► Chronic Obstructive Pulmonary Disease (COPD) is a common,

preventable and treatable disease that is characterized by
persistent respiratory symptoms and airflow limitation that is
due to airway and/or alveolar abnormalities usually caused by
significant exposure to noxious particles or gases.

► The most common respiratory symptoms include dyspnea,

cough and/or sputum production. These symptoms may be
under-reported by patients.

► The main risk factor for COPD is tobacco smoking but other
environmental exposures such as biomass fuel exposure and air
pollution may contribute.

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Kondisi Indonesia

Prevalensi PPOK
30%
Polusi u dara di

populasi Indonesia
Indonesia
menempati posisi
Adalah 3.7% *
adalah per okok (dibandingkan asma

Riskesdas 2018
ke-11 di Du nia. 4.5%* dan TB
0.4%**)
berdasarkan setiap hari World Air Quality
merokok dan kadang Report, 2018 Riskesdas 2013
kadang merokok Berdasarkan estimasi * Berdasar gejala; **
rata-rata konsentrasi berdasar diagnosa
OM2.5 ((µg/m³) dokter

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Global Epidemic of Smoking

• More than 10 million cigarettes are smoked every

minute of every day around the world by 1:
• 1 billion men1
• 250 million women1
• China, USA, Russia, Japan and Indonesia consume
more than 50% of the world’s cigarettes1
• If current trends continue, smokers will consume 9
trillion cigarettes annually by 20251

1. The Tobacco Atlas. Second edition. Published by American Cancer Society, 2006.

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Prevalence
Prevalence of COPD

► Estimated 384 million COPD cases in 2010.

► Estimated global prevalence of 11.7% (95% CI 8.4%–

15.0%).

► Three million deaths annually.

► With increasing prevalence of smoking in developing

countries, and aging populations in high-income
countries, the prevalence of COPD is expected to rise over
the next 30 years.

► By 2030 predicted 4.5 million COPD related deaths

annually.

© 2019 Global Initiative for Chronic Obstructive Lung Disease

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Economic and Social Burden

Economic burden of COPD

► COPD is associated with significant economic burden.

► COPD exacerbations account for the greatest proportion
of the total COPD burden.

► European Union:
 Direct costs of respiratory disease ~6% of the total
healthcare budget
 COPD accounting for 56% (38.6 billion Euros) of the
cost of respiratory disease.

► USA:
 Direct costs of COPD are $32 billion
 Indirect costs $20.4 billion.

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Etiology, pathobiology & pathology of COPD leading to

airflow limitation & clinical manifestations

© 2019 Global Initiative for Chronic Obstructive Lung Disease

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FEV1 progression over time

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis and Initial Assessment

© 2019 Global Initiative for Chronic Obstructive Lung Disease

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Diagnosis and Initial Assessment

► 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.

© 2017 Global Initiative for Chronic Obstructive Lung Disease

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis and Initial Assessment

© 2019 Global Initiative for Chronic Obstructive Lung Disease

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Spirometry

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Post-bronchodilator FEV1

© 2019 Global Initiative for Chronic Obstructive Lung Disease

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Refined ABCD Assessment Grid

Exclusively respiratory symptoms and exacerbation history to assign
catagories

Spirometrically Assessment Assessment of

confirmed of airflow symptoms/risk
diagnosis limitation of exacerbations
Exacerbation
history
FEV ≥ 2 or ≥ 1
(% predicted) leading to
Post-bronchodilator GOLD 1 ≥ 80
hospital C D
admission
FEV1/FVC < 0.7 GOLD 2 50 – 79
0 or 1 (not
GOLD 3 30 – 49 leading to
hospital A B
GOLD 4 admission)
<30

mMRC 0-1 mMRC ≥ 2

CAT < 10 CAT ≥ 10
Symptoms
@2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner

Modified MRC dyspnea scale

© 2019 Global Initiative for Chronic Obstructive Lung Disease

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COPD Assessment Test (CATTM)

© 2019 Global Initiative for Chronic Obstructive Lung Disease

Perbedaan antara PPOK dan Asma

PPOK1,2 Asma 1,2

Di awal kehidupan (seringkali masa

Onset Paruh baya
kanak-kanak)

Perlahan progresif Bervariasi dari hari ke hari

Gejala
Sesak saat berolahraga Lebih buruk di malam hari / dini hari

Keterbatasan aliran
Irreversible Reversible
udara

Faktor penyebab Riwayat merokok tembakau atau Paparan alergen, infeksi, diet, asap
utama terpapar jenis asap lainnya tembakau, sosial ekonomi

Alergi, rhinitis , dan/atau eksim

Fitur tambahan
Riwayat asma di keluarga

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Karakteristik dari radang saluran napas

berbeda pada pasien PPOK dan Asma

Wedzicha JA, Seemungal TA. Lancet 2007; Barnes PJ. Therapy 2009
Welte T, et al. Exp Toxicol Pathol 2006
Larsson K. Clin Respir J 2008

Management of Stable COPD

► Once COPD has been diagnosed, effective management should be

based on an individualized assessment to reduce both current
symptoms and future risks of exacerbations.

@2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner

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Treatment of Stable COPD

Definition of abbreviations: eos: blood eosinophil count in cells per microliter; mMRC: modified Medical
Research Council dyspnea questionnaire; CAT™: COPD Assessment Test™.

@2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner

Treatment of Stable COPD

► Following implementation of therapy, patients should be reassessed for
attainment of treatment goals and identification of any barriers for
successful treatment (Figure 4.2).
► Following review of the patient response to treatment initiation,
adjustments in pharmacological treatment may be needed.

@2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner

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Treatment of Stable COPD

Follow-up pharmacological treatment

► A separate algorithm is provided for FOLLOW-UP treatment, where the

management is still based on symptoms and exacerbations, but the
recommendations do not depend on the patient’s GOLD group at diagnosis
► These follow-up recommendations are designed to facilitate management of
patients taking maintenance treatment(s), whether early after initial
treatment or after years of follow-up.
► These recommendations incorporate recent evidence from clinical trials and
the use of peripheral blood eosinophil counts as a biomarker to guide the
use of ICS therapy for exacerbation prevention.

@2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner

@2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner

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Treatment of Stable COPD

► Figure 4.3 suggests escalation and de-escalation strategies based
on available efficacy as well as safety data.
► The response to treatment escalation should always be reviewed,
and de-escalation should be considered if there is a lack of clinical
benefit and/or side effects occur.
► De-escalation may also be considered in COPD patients receiving
treatment who return with resolution of some symptoms that
subsequently may require less therapy.
► Patients, in whom treatment modification is considered, in
particular de-escalation, should be undertaken under close medical
supervision.
► We are fully aware that treatment escalation has not been
systematically tested; trials of de-escalation are also limited and
only include ICS.

@2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner

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Terima Kasih

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