CURRICULUM VITAE

N AM A
ALAMAT
PEKERJAAN

: Prof.dr.TAMSIL SYAFIUDDIN Sp.P (K)

: Jln.KARSA No F 1 KOMPLEKS EKS KOWILHAN I
Sei.Agul MEDAN 20117
: Guru Besar Tetap FK- UISU / Luar biasa FK- USU
Penasihat Perhimpunan Dokter Paru Indonesia Pusat
Anggota Kolegium Pulmonologi Indonesia
Anggota Dewan Asma Nasional
Anggota Pokja Asma dan PPOK PDPI pusat
Assesor Program Pendidikan Dokter Spesialis Paru Indonesia
Ketua Perhimpunan Dokter Paru Indonesia Sumut
Penasihat Yayasan Asma Indonesia Wilayah Sumut
Ketua Departemen Pulmonologi dan Kedokteran Respirasi
FK-UISU

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 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
WorkshopDarat
on Medical
Thoracoscopy,
American
Gatot Subroto
Jakarta,The
Jakarta
JuniCollege
1997 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 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
-Respiratory Master Class on COPD, Singapore 2011

Asthma
Prof.dr.Tamsil Syafiuddin,SpP(K)
Departemen Pulmonologi dan Ilmu Kedokteran Respirasi
Fakultas Kedokteran
Universitas Sumatera Utara
2014

DAFTAR KOMPETENSI SISTEM RESPIRASI

1.Asma
2.Bronkitis akut
3.Pneumonia,Bronkopneumonia
4.Tuberkulosis tanpa komplikasi
5.Influenza
6.Pertusis

4A
4A
4A
4A
4A
4A

SKDI 2012

DAFTAR KOMPETENSI SISTEM RESPIRASI

7. ARDS
8. SARS
9. Flu burung
10.Asma akut berat
11.Bronkiolitis akut
12.Efusi pleura masif
13.Pneumonia aspirasi
14.PPOK Eksaserbasi akut
15.Edema paru
16.Haematotoraks

3B
3B
3B
3B
3B
3B
3B
3B
3B
3B
SKDI 2012

TINGKAT KEMAPUAN:
Kemampuan 1 : Mengenali dan Menjelaskan
Kemampuan 2: Mendiagnosis dan Merujuk
Kemampuan 3: Mendiagnosis,
Penatalaksanaan awal dan Merujuk
3A: Bukan gawat darurat
3B: Gawat darurat
Kemampuan 4: Mendiagnosis,Tatalaksana
mandiri dan Tuntas
4A: Kompetensi saat lulus dokter
4B: Kompetensi intensip dan PKB
SKDI 2012

Recent issues
in asthma management
The Unmet Needs of asthma
Theme of World Asthma Day 2005-2006

You can control your asthma

Theme of World Asthma Day 2007-2014

Adherence
Self Management

UUD No 29 / 2004 : Praktik Kedokteran

Competency

Pharmacoeconomic consideration
Quality of Life

Asthma is an inflammatory diseases

GINA 2011

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.

Inflammation
(+)

Asthma

Bronchial hyperreactivity ( - )
Bronchoconstriction ( - )

Symptoms (-)
The pathogenesis of asthma

Triggers

Triggers

Normal

()

Bronchial hyperreactivity ( + )
Bronchoconstriction ( + )

Symptoms (+)

SYMPTOM,
HISTORI,
PEMERIKSAAN FISIK,
PEMERIKSAAN PENUNJANG ?

Disease Pattern
Episodic --- acute exacerbations interspersed
with 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)

Ca++ Histamin

Ag

Ig E

YY

Phospholipid

Methyl
transferase

Phosphatidyl
ethanolamine

Phosphatidyl
choline

Phospho Ca++
Arachidonic acid lipase A2
lypoxygenase
cyclooxygenase
5-HETE

Leucotrienes
LTB4
LTC4
LTD4
LTE4

Histamin
ECF, NCF

Thromboxanes Prostaglandins
TXA2
PGD
PGF2

Mediator release in asthma reactions

KURIKULUM BERBASIS KOMPETENSI

(Problem Based Learning)
MASALAH/KELUHAN/DATA
:
PEMECAHAN MASALAH/
RENCANA(Planning):

IDENTIFIKASI
MASALAH/HIPOTESIS:

MASALAH/KELUHAN/DATA
Batuk
:

PEMECAHAN MASALAH/
RENCANA(Planning):

DATA LAIN

Sesak napas
Batuk darah
Nyeri dada
( Daftar keluhan Standar Kompetensi
Dokter Indonesia )

RENCANA
BERIKUT: PF, Ro
PFR,Spirometri

IDENTIFIKASI
MASALAH/HIPOTESIS:

OBSTRUKTIF
INFEKSI
KEGANASAN
PENYAKIT ORGAN LAIN

MASALAH/KELUHAN/DATA
PEMECAHAN MASALAH/ :
Sesak napas
RENCANA(Planning):
DATA LAIN:
1.Wheezing ?
2. Riwayat keluarga?
3. Riwayat obat terdahulu?

4.Riwayat kebiasaan ?
PEMERIKSAAN PENUNJANG:
1.Pemeriksaan fisik : Wheezing ?
2. Spirometri/PFR?
3. Radiologi?

IDENTIFIKASI
MASALAH/HIPOTESIS:
1. Kelainan OBSTRUKTIF: Asma ?
2

Appropriate
Treatment?

Inflammation
(+)

Asthma

Bronchial hyperreactivity ( - )
Bronchoconstriction ( - )

Symptoms (-)
The pathogenesis of asthma

Triggers

Triggers

Normal

()

Bronchial hyperreactivity ( + )
Bronchoconstriction ( + )

Symptoms (+)

Inflammation
Controller
Bronchial hyperreactivity

Bronchoconstriction
Reliever
Symptoms
Medicines and Pathogenesis of asthma

Anti Inflammations is
the mainstay therapy

Inhalation therapy is
the mainstay therapy

Because minimally side effect

Asthma Therapy Evolution

Large use of
short-acting
2-agonists
1975

ICS treatment
introduced
1972

Adding
LAA to ICS therapy

Kips et al, AJRCCM 2000

Pauwels et al, NEJM 1997
Greening et al, Lancet 1992

Single
inhaler
therapy
ICS+LABA

Fear of
short-acting
2-agonists

1980

1985
1990
Bronchospasm

1995
Inflammation

Remodelling

2000

Inflammation
Controller
Bronchial hyperreactivity

Bronchoconstriction
Reliever
Symptoms
Medicines and Pathogenesis of asthma

Controller:
Anti inflammation
Non steroid

Inhaled Cortico Steroid

sodium chromoglicate
budesonide
(Pulmicort)
(Intal)
(Inflamid)
ketotifen

beclomethasone
dipropionate
sodium nedocromil
(Becotide)
triamcinolone
acetonide

Reliever
Bronchodilator
2 - agonist
Xanthin
Anticholinergic

BRONCHODILATOR
Short Acting 2 AGONIST (SABA):
salbutamol/albuterol (Ventolin )
terbutaline (Bricasma)
procaterol
fenoterol
orciprenaline, etc
ANTICHOLINERGIC:
atropine sulfate
ipratropium bromide
tiotropium bromide

Long Acting 2 AGONIST:

(LABA)
salmoterol
formoterol

XANTHINE:
theophylline
aminophylline

OTHER SYMPHATOMIMETIC:

ephedrine
adrenaline, etc

Combination therapy
Symbicort
Budesonide + Formoterol

Seretide
Fluticasone + Salmoterol

ASTHMA MANAGEMENT: CLINICAL

QUICK RELIEVE MEDICATION
(EKSASERBASI)
LONG TERM TREATMENT
(STABIL)

Guidelines on Asthma Management:

Past and Current Trends

Severe
Moderate
persisten persisten
t
t

Mild
Intermittent persisten
t
Total control

Partially control

Uncontrol

Old
classification

Exacerbation
New
classification

SABA / Rapid onset of action LABA

GINA 1998
(adapted)
GINA 2011

ICS

LABA and
ICS
LABA+ICS

Stable condition

Inapropriate
Treatment

AIRWAY REMODELLING IN
ASTHMA
Eosinophil

Desquamations of epithelium
MBP, ECP
Epithelium

Thickening of basement membrane

Increase in airway smooth muscle

Epithelial Damage

P Jeffery, in: Asthma, Academic Press 1998

Basement Membrane
Thickening

P Jeffery, in: Asthma, Academic Press 1998

Smooth Muscle Hyperplasia

P Jeffery, in: Asthma, Academic Press 1998

The Beginning of
Treatment

Exacerbation

The beginning of treatment

Stable condition

Asthma management

* Stable condition
* Long-term therapy

Assessment of
treatment
Objective value
Asthma Control Test

Peak flow meter

Objective
value

600-700 (

300

normal )

Inflammation can also be present

during symptom-free periods

%
Reduction

Rate of response of different measures of asthma

control over 18 months of ICS treatment

AHR is a marker of inflammation

AHR
Rescue medication use
Night
Impaired
am
PEF
symptomsImpaired FEV
1

Start of
treatment

18

Months

Adapted from Woolcock A. Clin Exp Allergy Rev 2001; 1: 6264.

Peak Flow Meter /PEFR/APE

Must be avilable

PEFR Monitoring:
A Major Tool in Asthma Self-Management
Chronic Diseases

Monitor

Hypertension

Blood pressure

Diabetes

Serum glucose

Asthma

PEFR

Asthma Control Test

(ACT)

Target of treatment

Treatment targets in common chronic diseases

Clear

therapeutic targets exist for many

chronic diseases

Philosophy

of treat to target

Hypertension

BP 140/90 mmHg or less

Diabetes

HbA1c 7% or less

Dyslipidaemia

LDL-cholesterol <100 mg/dl

Asthma treatment is designed to meet

specific targets and achieve CONTROL

Old Classification of Asthma Severity GINA 2003

CLASSIFY SEVERITY

STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent

Clinical Features Before Treatment

Nighttime
PEF
Symptoms
Symptoms
Continuous
<60% predicted
Frequent
Limited physical
Variability >30%
activity
Daily 2-agonist
dailyAttacks affect
activity

>1 time a week

but <1 time a
day
< 1 time a week
Asymptomatic
and normal PEF
between attacks

>1 time week

>60%-<80%
predicted
Variability >30%

>2 times a
month

>80% predicted
Variability 2030%

<2 times a
month

>80% predicted
Variability <20%

Global Initiative for Asthma (GINA) WHO/NHLBI, 2003

Control Level Based on GINA 2008

New Asthma
Characteristics
Classification

CONTROLLED

PARTLY
CONTROLLED

Daytime symptoms

None (2 or
less / week)

More than
twice / week

Limitations of
activities

None

Any

Nocturnal
symptoms /
awakening

None

Any

None (2 or less /
week)

More than
twice / week

Lung function
(PEF or FEV1)

Normal

< 80% predicted or

personal best (if known)
on any day

Exacerbation

None

Once/more per
year

Need for rescue /

reliever treatment

UNCONTROLLED

3 or more
features of
partly controlled
asthma present
in any week

One in any
week
GINA updated 2011

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.

Life is not problem to be solved,

but a reality to be experienced
( Soren Kierkegaard)

Syafiuddin San : You are the Inspiring woman

Imah San
: You are the Wind beneath my wings

DIAGNOSIS EXACERBATION :
CLINICAL
Episodic asthma:
Paroxysms of wheeze, dyspnoea and
cough, 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 and
expiratory rhonchi, cough.

 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.

 Acute severe asthma:

MANAGEMENT 1
1.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.

MANAGEMENT 2
No improvement after 15-30 min:
Nebulized Short acting2 agonist every 15-30 min +
Ipratropium.
Still no improvement:
Aminophyllin infusion 750mg/24H (small pt), 1 500mg/24H
(large pt), or alternatively salbutamol infusion.
Monitor Rx:
Aminophyllin blood levels + PEF after 15-30 min +
oxymetry (maintain SaO2 > 90) + repeat blood gases
after 2 hrs if initial PaO2 < 60, PaCO2 normal or raised and
patient deteriorates.
Deterioration:
ICU, intubate, ventilate + muscle relaxant.