Tjandra Yoga Aditama

Pulmonology Department Faculty of Medicine

University of Indonesia
Persahabatan General Hospital
Jakarta - Indonesia
• 1982/1983 : begin
• 1987 : 49,000 ha
• 1991 : 119,000 ha
• 1994 : 12 out of 27 provinces

• 1997 – 1998 : major fires

> 5,000 spots
> 160,000 ~ 300,000 ha
WWF: US$ 4.4 billion
• 2000 : *February – March
*> 1,000 spots
 Population exposed regional
± 75 million people
 20 million respiratory problem

Economy –
Social damage IMPACT OF Blanket many
US$ 4.4-6 billion FOREST FIRE part of ASEAN

Population exposed nationally

±20 million people
 Environmental Economy

FOREST FIRE
Transportation Social
HAZE

Tourism Agrobusiness
Health

Short Term

Long Term
 Haze 8 provinces

4 - 8 x normal values

West Sumatera : 5 - 10 x

TSP Riau : 0.8 - 8 x

South Sumatera : 3.5 - 8 x
West Kalimantan : 0.5 - 7.3 x
Central Kalimantan : 0.5 - 15 x
 JAMBI
•  51% respiratory disease
• Bronchitis asthma : 78% respiratory disease patient treated
• 70% respiratory patient worsened

SOUTH KALIMANTAN

ARI  1.8 times

SOUTH SUMATERA
ARI  3.8 times

ARI decreased parallel with decreased forest fire

Health impact during haze disaster in 8 Provinces in Indonesia
September-November 1997

Number of Number of Cases

No Province Population Death Asthma Bronchitis ARI
risk
1 Riau 1,701,000 75 41,028 7,995 199,107

2 West Sumatera 2,411,000 106 58,164 11,332 282,087

3 Jambi 1,478,000 65 35,650 6,947 172,926

4 South Sumatera 2,355,000 104 56,803 11,069 275,535

5 West Kalimantan 1,478,000 74 44,574 8,686 216,216

6 Central Kalimantan 716,000 29 17,574 3,366 83,772

7 South Kalimantan 1,733,000 69 41,800 8,145 202,716

8 East Kalimantan 118,000 5 2,846 555 13,806

Total 12,360,000 527 298,125 58,095 1,446,120

(DG CDC & EH, MOH Indonesia)

Palembang, 4 October 1997

5 Health Centre
• Dust  8 x
• NO2  : 0.06 ppm
• Respiratory diseases  51%

July October
10,875 15,561
Complain from the respondents
(Palembang)

Healthy Previously
respondents ill respondents
(n=158) (n=54)

Cough 128 (81%) 46 (83%)

Dyspnoe 38 (24%) 36 (67%)
Phlegm 30 (19%) 8 (15%)
Chest pain 14 (9%) 2 (4%)
Wheeze 16 (30%)
 Diagnose of the respondents
(Palembang)
Sore ARI Asthma Acute Suspect
throat Bronchitis Lung TB

Healthy 48 72 3 34 1
respondent (30%) (46%) (2%) (22%) (1%)
(n=158)

Previously 1 9 42 1 1
ill (2%) (17%) (78%) (2%) (2%)
respondent
(n=54)
Total 49 81 45 35 2
(n=212) (23%) (38%) (21%) (17%) (1%)
 Diagnose of the respondents
(Jambi)
Sore ARI Asthma Acute Suspect Emphysema
throat Bronchitis Lung TB

Healthy 14 33 4 15 - -
respondent (21%) (50%) (6%) (13%)
(n=66)

Previously ill 1 2 6 3 8 2
respondent (5%) (9%) (27%) 14% (36%) (9%)
(n=22)

Total 15 35 10 18 8 2
(n=88) (23%) (40%) (11%) (21%) (9%) (2%)
 Symptom of 8 Doctors After
10 - 12 hours exposed

No Symptom Number %

1. Eye irritation 8 100

2. Throat irritation 3 37,5
3. Cough 3 37,5
4. Headache 2 25
5. Cold sweat 1 12,5
Samarinda (Nox 140.30 mcg/m3, TSP 438.56 mcg/m3)
Bontang (Nox 35.52 mcg/m3, TSP 198.91 mcg/m3)
 127 high school student
No statistic different on prevalence of:
• Bronchitis
• Bronchial asthma
• FEV1
Significant difference on male for:
• FVC
• PFR
9 obstructive  7 (+) bronchial hyperactivity
(IAP)
 Conjunctivitis
Bronchial asthma
JDR Pneumonia
Team Poor respiratory function
Symptom respiratory & digestive

Increasing hospital visit

Increased admission
Might be increasing severity
 Respiratory function test for persons
with respiratory symptoms
%VC
100%
10.2% (9) 21.6% (19)
80%

17.0% (15) 51.1% (45)

FEV1 0%
0 70% 100%
• 17,000 islands
5 major : Sumatera, Kalimantan, Java, Sulawesi &
Irian Jaya
• 200 million people
• Area: 1.9 million Km2
• Largest archipelago in the world
• National resources

Agriculture
Forestry
Fisheries, Mining etc
 Flow Chart Approach to Patients with CAP
( American Thoracic Society)
CAP IS PRESENT

OUTPATIENT THERAPY INPATIENT THERAPY

NO HISTORY OF
CARDIOPULMON CARDIOPULMO
ARY NARY MILD- SEVERE
DISEASE DIEASE, +/OR MODERATE CAP
NO MODIFIERS MODIFIERS ILLNESS
GROUP 1 GROUP II

CARDIOPULMONARY NO CARDIOPULMONARY
NO RISK FOR RISK FOR
DISEASE DISEASE
P. AERUGINOSA P. AERUGINOSA
+/OR MODIFIERS NO MODIFIERS

GROUP III A GROUP III B GROUP IV A GROUP IV B

Ref : American Thoracic Society, Guidelines for the

Management of Adults with CAP; 2001; 1737
 Group I: Outpatients,
No Cardiopulmonary Disease,
No Modifying Factors
Organisms Therapy
• Streptococcus pneumoniae Advanced generation macrolide
• Mycoplasma pneumoniae • Clarithromycin or
• Chlamydia pneumoniae • Azithromycin or
• Haemophilus influenzae • Doxycycline
• Respiratory viruses
• Legionella sp
• Mycobacterium tuberculosis
• Endemic fungi
Ref : American Thoracic Society; Guidelines for the Management of
Adults with Community-Acquired Pneumonia, 2001; 1730 - 1753
 Group II: Outpatients, With
Cardiopulmonary Disease,
and/or Other Modifying Factors
Organisms Therapy
• Streptococcus pneumoniae -lactam
• Mycoplasma pneumoniae
• Chlamydia pneumoniae +
• Mixed infection Macrolide or Doxycycline
• Haemophilus influenzae
or
• Enteric Gram (-)
• Respiratory viruses Antipneumococcal
• Legionella sp fluoroquinolone
• Mycobacterium tuberculosis
• Endemic fungi
Ref : American Thoracic Society; Guidelines for the Management of
Adults with Community-Acquired Pneumonia, 2001; 1730 - 1753
 Group III: Inpatients, Not in ICU
A. Cardiopulmonary Disease and/or
Modifying Factors
Organisms Therapy
• Streptococcus pneumoniae -lactam (i.v)
• Haemophilus influenzae
+
• Mycoplasma pneumoniae
• Chlamydia pneumoniae Macrolide or Doxycycline
• Mixed infection (i.v & p.o)
• Enteric Gram (-) or
• Anaerobes
Antipneumococcal
• Viruses
• Legionella sp
fluoroquinolone (i.v)
• Mycobacterium tuberculosis,
Endemic fungi, Pneumocystis carinii
Ref : American Thoracic Society; Guidelines for the Management of
Adults with Community-Acquired Pneumonia, 2001; 1730 - 1753
 Group III: Inpatients, Not in ICU
B. No Cardiopulmonary Disease,
No Modifying Factors

Organisms Therapy
• Streptococcus pneumoniae Azithromycin (i.v) alone or
• Haemophilus influenzae
• Mycoplasma pneumoniae Doxycycline & -lactam
• Chlamydia pneumoniae or
• Mixed infection
Monotherapy with an
• Viruses
• Legionella sp
Antipneumococcal
• Mycobacterium tuberculosis, fluoroquinolone
Endemic fungi, Pneumocystis
carinii
Ref : American Thoracic Society; Guidelines for the Management of
Adults with Community-Acquired Pneumonia, 2001; 1730 - 1753
 Group IV: ICU Admitted Patients
A. No Risks for Pseudomonas aeruginosa
Organisms Therapy
• Streptococcus pneumoniae Antipseudomonal -lactam (i.v)
• Staphylococcus aureus +
• Haemophilus influenzae
Antipseudomonal quinolone (i.v)
• Enteric gram (-) bacilli
• Mycoplasma pneumoniae or
• Respiratory viruses Selected antipseudomonal
• Chlamydia pneumoniae -lactam (i.v)
• Mixed infection
+
• Viruses
• Legionella sp Aminoglycoside + Macrolide (i.v)
• Mycobacterium tuberculosis, or
Endemic fungi Nonpseudomonal fluoroquinolone
Ref : American Thoracic Society; Guidelines for the Management of
Adults with Community-Acquired Pneumonia, 2001; 1730 - 1753
 Group IV: ICU Admitted Patients
B. No Risks for Pseudomonas aeruginosa

Organisms
• Streptococcus pneumoniae
• Staphylococcus aureus
• Haemophilus influenzae
• Enteric gram (-) bacilli
• Mycoplasma pneumoniae
• Respiratory viruses
• Chlamydia pneumoniae
• Mixed infection
• Viruses
• Legionella sp
• Mycobacterium tuberculosis,
Endemic fungi
Ref : American Thoracic Society; Guidelines for the Management of
Therapy
Antipseudomonal -lactam (i.v)
+
Antipseudomonal quinolone (i.v)
or
Selected antipseudomonal -lactam
(i.v)
+
Aminoglycoside + Macrolide (i.v) or
Nonpseudomonal fluoroquinolone
Adults with Community-Acquired Pneumonia, 2001; 1730 - 1753
 History, physical examination ,CXR

Infiltrate + compatible clinical features of CAP

Evaluate for admission using clinical prediction rule

Manage as outpatient Hospitalize the patient

Empirical therapy
Appropriate Lab.tests
with ? antibiotic 1
Severity Grading

General medical ward Intensive Care Unit

Pathogen defined
4
No pathogen isolated or No pathogen isolated or tests
tests pendings: Specific pendings: Rx.empirically?
2
Rx.empirically ? antibiotic therapy antibiotic 3
Asma
adalah penyakit inflamasi kronik
saluran napas yang melibatkan
banyak sel. Inflamasi kronik
disebabkan hipereaktiviti bronkus
ditandai sesak dan wheezing yang
berulang terutama pada malam
menjelang pagi
Diagnosis Asma
Terdiri dari:
 Riwayat keluhan

 Pemeriksaan fisik

 Pemeriksaan penunjang

 Uji provokasi bronkus

 Derajat : PERSISTEN BERAT

Gejala Kontinu
• Gejala terus menerus
APE < 60
• Aktiviti fisik terbatas • VEP1 < 60% normal
• Sering kambuh • APE variabiliti > 30%
• Gejala malam sering

Derajat: PERSISTEN SEDANG

Gejala Harian
• Menggunakan obat setiap hari APE 60 - 80%
• Serangan mengganggu aktiviti • VEP1 > 60% tetapi < 80% normal
• Serangan > 2x / minggu,
• APE variabiliti > 30%
bisa berhari-hari
• Gejala malam sekali seminggu

Derajat: PERSISTEN RINGAN

Gejala Mingguan APE > 80%

• Gejala >1x / minggu • VEP1 > 80% normal
• Serangan dapat mengganggu aktiviti
• APE variabiliti < 20 -30%
• Gejala malam > 2 kali sebulan

Derajat: INTERMITEN

Gejala Bulanan
• Gejala < 1x / minggu APE > 80%
• Di luar serangan tak ada gejala • VEP1 > 80% normal
• Serangan singkat, ringan • APE variabiliti < 20%
• Gejala malam < 2 kali sebulan

Perhimpunan Dokter Paru Indonesia

Obat Asma
 Pengendali
– Kortikosteroid inhalasi
– Agonist 2 kerja lama
– Steroid oral
– Sodium kromoglikat, nedokromil, anti leukotrien
 Pelega
– Agonist 2 singkat
– Teofilin
– Steroid leukotrien
– Antileukotrien
 Obat oral, injeksi, inhalasi
 KENALI
PENYAKIT

KENALI
PENCETUS GEJALA

POLA HIDUP ASMA OBAT

DR- PATIENT
KELUARGA RELATIONSHIP
 KOMITMEN
POLITIK

DIAGNOSTIK OBAT

DOTS

DOT R.R
 PENGOBATAN
Harus beberapa obat sekaligus

Harus setidaknya 6 bulan

Setelah 2-3 bulan gejala hilang – pasien berhenti

Bila berhenti – kambuh, obat tidak mempan

Kepatuhan amat penting

 Air Surveillance

Evacuation Monitoring

Mask etc

Resource DURING
mobilization Protection
HAZE
Information

Diagnosis and
Research
treatment
Protection Effectiveness
Limited
Treatment Resources

Elimination the sources

• Regulation
• Public information
• Coordination
• Socio economic approach