TINJAUAN PUSTAKA

Penyakit Paru Obstruksi Kronik (PPOK)

PPOK ditandai dengan adanya perlambatan aliran udara yang tidak sepenuhnya reversible. Perlambatan aliran udara umumnya bersifat progresif dan brkaitan dengan respon inflamasi yang abnormal terhadap partikel atau gas iritan.

Diagnosis

Keluhan :

- Sesak napas- Batuk-batuk kronis- Sputum yang produktif- Faktor risiko (+)

Pemeriksaan fisik :

- Pernapasan pursed lips- Takipnea- Dada emfisematous atau barrel chest- Dengan tampilan fisik pink puffer atau blue bloater- Bunyi napas vesikuler melemah- Ekspirasi memanjang- Ronki kering atau wheezing- Bunyi jantung jauh

Diagnosis pasti dengan uji spirometri :

- FEV1/FCV < 70%- Uji bronkodilator (saat diagnosis ditegakkan) : FEV1 pasca bronkodilator < 80 % prediksi

Klasifikasi PPOK menurut National Heart, Lung, and Blood Institute dan WHO

Stadium 0 Derajat berisiko PPOK- Spirometri normal- Kelainan kronik (batuk, sputum produktif)

Stadium I PPOK ringan- VEP1/KVP < 70%- VEP1 > 80% prediksi- Dengan/tanpa keluhan kronik (batuk, sputum produktif)

Stadium II PPOK sedang- VEP1/KVP < 70%- VEP1 < 80% prediksi

(II A : 50% < VEP1 < 80% prediksi)

(II B : 30% < VEP1 < 50% prediksi)- Dengan/tanpa keluhan kronik (batuk, sputum produktif)

Stadium III PPOK berat- VEP1/KVP < 70%- VEP1 < 30% prediksi atau VEP1 < 50% prediksi + gagal napas

Terapi Non-Farmakologis

- Rehabilitasi : latihan fisik, latihan endurance, latihan pernapasan, rehabilitasi psikososial- Terapi oksigen jangka panjang (> 15 jam sehari) : pada PPOK stadium III, AGD :

o PaO2 < 55 mmHg, atau SaO2 ≤ 88% dengan/tanpa hiperkapniao PaO2 55-60 mmHg, atau SaO2 ≤ 88% disertai hipertensi pulmonal, edema perifer

karena gagal jantung, polisitemia- Nutrisi- Pembedahan : pada PPOK berat (bila dapat memperbaiki fungsi paru atau gerakan mekanik

paru)

Terapi Farmakologis

- Bronkodilatoro Secara inhalasi (MDI), kecuali preparat tidak tersedia/tak terjangkauo Rutin (bila gejala menetap) atau hanya bila diperlukan (gejala intermiten)o 3 golongan :

Agonis β-2 : fenopterol, salbutamol, albuterol, terbutalin, formoterol, salmeterol

Antikolinergik : ipratropium bromid, oksitropium bromid Metilxantin : teofilin lepas lambat, bila kombinasi β-2 dan steroid belum

memuaskano Dianjurkan bronkodilator kombinasi daripada meningkatkan dosis bronkodilator

monoterapi- Steroid, pada :

o PPOK yang menunjukkan respon pada uji steroido PPOK dengan FEV1 < 50% prediksi (stadium II B dan III)o Eksaserbasi akut

- Obat-obat tambahan laino Mukolitik (mukokinetik, mukoregulator) : ambroksol, karbosistein, gliserol iodidao Antioksidan : N-asetil-sisteino Imunoregulator (imunostimulator, imunomodulator) : tidak rutino Antitusif : tidak rutino Vaksinasi : influenza, pneumokok

Hipertensi

Klasifikasi hipertensi

Kategori TD Sistolik TD DiastolikOptimal < 120 dan/atau < 80Normal 120 – 129 dan/atau 80 – 84Normal Tinggi 130 – 139 dan/atau 85 – 89Hipertensi Tingkat 1 140 – 159 dan/atau 90 – 99Hipertensi Tingkat 2 160 – 179 dan/atau 100 – 109Hipertensi Tingkat 3 >= 180 dan/atau >= 110Hipertensi Isolated Systolic

>= 140 dan/atau < 90

Tatalaksana Hipertensi

- Modifikasi gaya hidup

Modifikasi Rekomendasi Perkiraan Penurunan TDS (Skala)

Menurunkan berat badan

Memelihara berat badan normal (IMT 18,5-24,9 kg/m2)

5-20 mmHg/10 kg penurunan berat badan

Melakukan pola diet berdasarkan DASH

Mengkonsumsi makanan yang kaya dengan buah-buahan, sayuran, produk makanan yang rendah lemak, dengan kadar lemak total dan saturasi yang rendah

8-14 mmHg

Diet rendah natrium Menurunkan asupan garam sebesar tidak lebih dari 100 mmol per hari (2.4 gr Natrium atau 6 gr garam)

2-8 mmHg

Olahraga Melakukan kegiatan aerobik fisik secara teratur, seperti jalan cepat (paling tidak 30 menit per hari, setiap hari dalam seminggu)

4-9 mmHg

Pada pasien usia ≥ 60 tahun, pengobatan dengan obat antihipertensi dapat dimulai pada TDS ≥ 150 mmHg atau TDD ≥ 90 mmHg dengan tekanan darah target (TDS) < 150 mmHg dan TDD < 90 mmHg. Pada pasien usia ≥ 60 tahun apabila pengobatan dengan antihipertensi mencapai target < 140 mmHg dan pengobatan tersebut ditoleransi dengan baik tanpa efek samping bagi kesehatan maupun kualitas hidup pasien, pengobatan tidak perlu diubah atau dimodifikasi. Semua golongan obat antihipertensi dapat dipakai pada penderita hipertensi usia lanjut, meskipun pada Isolated Systolic Hypertension lebih dipilih penggunaan diuretik atau antagonis kalsium. Hipotensi ortostatik perlu dideteksi dan diwaspadai pada pengobatan hipertensi pasien usia lanjut.

Hiperkolestrolemia

Hypercholesterolemia, or high cholesterol, occurs when there is too much cholesterol in the body. Cholesterol is a soft, waxy, fat-like substance that is a natural component of all the cells of the body. Your body makes all the cholesterol it needs. Any added cholesterol, which comes from the foods you eat, can cause harm.

Risk Factor

- Smoking. Cigarette smoking damages the walls of your blood vessels, making them likely to accumulate fatty deposits. Smoking may also lower your level of HDL, or "good," cholesterol.

- Obesity. Having a body mass index (BMI) of 30 or greater puts you at risk of high cholesterol.- Poor diet. Foods that are high in cholesterol, such as red meat and full-fat dairy products,

will increase your total cholesterol. Eating saturated fat, found in animal products, and trans fats, found in some commercially baked cookies and crackers, also can raise your cholesterol level.

- Lack of exercise. Exercise helps boost your body's HDL "good" cholesterol while lowering your LDL "bad" cholesterol. Not getting enough exercise puts you at risk of high cholesterol.

- High blood pressure. Increased pressure on your artery walls damages your arteries, which can speed the accumulation of fatty deposits.

- Diabetes. High blood sugar contributes to higher LDL cholesterol and lower HDL cholesterol. High blood sugar also damages the lining of your arteries.

- Family history of heart disease. If a parent or sibling developed heart disease before age 55, high cholesterol levels place you at a greater than average risk of developing heart disease.

Diagnosis

Most people don't have any symptoms of high cholesterol. A blood test is the only way to check levels of cholesterol in your blood. If your levels are above 200 mg/dL or your HDL is below 40, your doctor may do a fasting lipid profile (a test performed after you abstain from food for 12 hours).

Although cholesterol levels above 200 are generally considered high, what's considered safe for each person depends on whether you are at risk for, or have, heart disease.

Total cholesterol levels:

- Desirable: Below 200 mg/dL- Borderline high: 200 – 239- High: Above 240

LDL cholesterol levels:

- Optimal for people with heart disease or who are at high risk: Below 70 mg/dL- Optimal for people at risk of heart disease: Below 100- Optimal: 100 – 129

- Borderline high: 130 – 159- High: 160 - 189

HDL cholesterol levels:

- Poor: Below 40 mg/dL- Acceptable: 40 – 59

- Optimal: 60 or above

Triglyceride levels:

- Optimal: Below 150 mg/dL- Borderline high: 150 – 199

- High: Above 200

Adults with normal total and HDL cholesterol levels should have their cholesterol checked every 5 years. If you have high cholesterol, you should be checked every 2 - 6 months. You should have liver function tests as well if you are on cholesterol-lowering medication.

Treatment and Drug

Lifestyle changes such as exercising and eating a healthy diet are the first line of defense against high cholesterol. But, if you've made these important lifestyle changes and your total cholesterol — and particularly your LDL cholesterol — remains high, your doctor may recommend medication.

The specific choice of medication or combination of medications depends on various factors, including your individual risk factors, your age, your current health and possible side effects. Common choices include:

- Statins. Statins — among the most commonly prescribed medications for lowering cholesterol — block a substance your liver needs to make cholesterol. This causes your liver to remove cholesterol from your blood. Statins may also help your body reabsorb cholesterol from built-up deposits on your artery walls, potentially reversing coronary artery disease. Choices include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev, Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor).

- Bile-acid-binding resins. Your liver uses cholesterol to make bile acids, a substance needed for digestion. The medications cholestyramine (Prevalite), colesevelam (Welchol) and colestipol (Colestid) lower cholesterol indirectly by binding to bile acids. This prompts your liver to use excess cholesterol to make more bile acids, which reduces the level of cholesterol in your blood.

- Cholesterol absorption inhibitors. Your small intestine absorbs the cholesterol from your diet and releases it into your bloodstream. The drug ezetimibe (Zetia) helps reduce blood cholesterol by limiting the absorption of dietary cholesterol. Zetia can be used in combination with any of the statin drugs.

- Combination cholesterol absorption inhibitor and statin.The combination drug ezetimibe-simvastatin (Vytorin) decreases both absorption of dietary cholesterol in your small intestine and production of cholesterol in your liver. It's unknown whether Vytorin is more effective in reducing heart disease risk than taking simvastatin by itself.

If you also have high triglycerides, your doctor may prescribe:

- Fibrates. The medications fenofibrate (TriCor) and gemfibrozil (Lopid) decrease triglycerides by reducing your liver's production of very-low-density lipoprotein (VLDL) cholesterol and by speeding up the removal of triglycerides from your blood. VLDL cholesterol contains mostly triglycerides.

- Niacin. Niacin (Niaspan) decreases triglycerides by limiting your liver's ability to produce LDL and VLDL cholesterol. Prescription and over-the-counter niacin is available, but prescription niacin is preferred as it has the least side effects. Dietary supplements containing niacin that are available over-the-counter are not effective for lowering triglycerides, and may damage your liver.

- Omega-3 fatty acid supplements. Omega-3 fatty acid supplements can help lower your cholesterol. You can take over-the-counter supplements, or your doctor may prescribe Lovaza, a prescription omega-3 fatty acid supplement, as a way to lower your triglycerides. These supplements may be taken with another cholesterol-lowering medication, such as a statin. If you choose to take over-the-counter supplements, get your doctor's OK first. Omega-3 fatty acid supplements could affect other medications you're taking.

Lifestyle

Lose extra pounds

Excess weight contributes to high cholesterol. Losing even 5 to 10 pounds can help lower total cholesterol levels. Start by taking an honest look at your eating habits and daily routine. Consider your challenges to weight loss — and ways to overcome them. Set long-term, sustainable goals.

Eat heart-healthy foods

- Cut down on saturated fats and trans fats. No more than 10% of your daily calories should come from saturated fat, and you should avoid trans fats completely. Based on data from 4 studies, it is estimated that a 2% increase in energy intake from trans fats increases the incidence of heart disease by 23%. Choose unsaturated fats, such as olive oil and canola oil, instead.

- Eat whole grains -- whole wheat bread and pasta, oatmeal, oat bran, and brown rice.- Eat more fruits and vegetables, which are high in fiber and can help lower cholesterol levels.

Studies show that plant-based diets are associated with decreases in total cholesterol and LDL cholesterol of up to 15%.

- Limit cholesterol in your diet. The highest amounts are found in egg yolks, whole milk products, and organ meats.

- Eat fatty fish. The American Heart Association (AHA) recommends that people eat at least 2 servings of fatty fish (such as salmon or herring) each week.

- Eat phytosterols and stanols found in nuts, seeds, vegetable oils, and fortified food products, such as orange juice, yogurt, and salad dressing. Studies show that eating 2 - 3 grams of phytosterols daily reduces total cholesterol by up to 11% and LDL cholesterol by up to 15%.

- Increase your intake of high fiber foods, especially oats, barley, and legumes, as well as fruits, vegetables, and other whole grains.

Exercise regularly

Regular exercise can help improve your cholesterol levels. With your doctor's OK, work up to 30 to 60 minutes of exercise a day. Take a brisk daily walk. Ride your bike. Swim laps. To maintain your motivation, keep it fun. Find an exercise buddy or join an exercise group. And, you don't need to get all 30 to 60 minutes in one exercise session. If you can squeeze in three to six 10-minute intervals of exercise, you'll still get some cholesterol-lowering benefits.

Hiperurisemia

A high uric acid level, or hyperuricemia, is an excess of uric acid in your blood. Uric acid is produced during the breakdown of purine, a substance found in many foods. Once produced, uric acid is carried in your blood and passes through your kidneys, where most of it leaves your body when you urinate.

A high uric acid level may result in attacks of gout, but not everyone who has high uric acid gets gout, and not everyone with gout has high uric acid.

Factors that may cause a high uric acid level in your blood include :

- Diuretic medications (water pills)- Drinking too much alcohol- Genetics (inherited tendencies)- Hypothyroidism (a thyroid disorder)- Immune-suppressing drugs- Niacin, or vitamin B-3- Obesity - Psoriasis - Purine-rich diet — organ meat, game meat, anchovies, herring, gravy, dried beans, dried

peas, mushrooms and other foods- Renal insufficiency — inability of the kidneys to filter waste- Tumor lysis syndrome — a rapid release of cells into the blood caused by certain cancers or

by chemotherapy for those cancers

Also, you may be monitored for high uric acid levels when undergoing chemotherapy or radiation treatment for cancer.

Treatment

- Allopurinol is the most widely used antihyperuricemic agent. The major metabolite of allopurinol is oxypurinol, and both allopurinol and oxypurinol are competitive inhibitors of the enzyme xanthine oxidase.

- The ideal candidates for allopurinol treatment are uric acid overproducers (24-h urinary uric acid excretion >800 mg on general diet or >600 mg on a purine-restricted diet); patients with renal insufficiency, nephrolithiasis, or tophaceous gout; or patients at risk for developing uric acid nephropathy. Although allopurinol can be used in almost any hyperuricemic state, the above-mentioned conditions are more specific indications for allopurinol use. The usual maintenance dose for adults is 200-300 mg/d. The long half-life of oxypurinol makes once-daily dosing possible. Very importantly, adjust the dose in persons with chronic renal insufficiency because a higher incidence of adverse effects is observed if the dose is not adjusted.

- Allopurinol is well tolerated by most patients, but hypersensitivity reactions may develop, which can be severe or fatal. Because a skin rash may progress to a severe hypersensitivity reaction, patients who develop a skin rash should discontinue allopurinol. Hepatotoxicity, bone marrow depression, and interstitial nephritis are rare but serious adverse effects of allopurinol.

Diet

The use of a low-purine diet may significantly lower serum uric acid levels.

- This diet principally consists of sugars, starches, and fats, with protein supplied by eggs and cheese.

- Meats, poultry, fish, seafood, organ meats, alcohol, beans, and peas should be avoided.

Gangguan Pendengaran Pada Geriatri

Tuli konduktif pada geriatriPada telinga luar dan telinga tengah proses degenerasi dapat menyebabkan perubahan atau kelainan berupa:

1. Berkurangnya elastisitas dan bertambahnya ukuran pinna daun telinga2. Atrofi dan bertambah kakunya liang telinga3. Penumpukan serumen4. Membrane timpani bertambah tebal dan kaku5. Kekakuan sendi tulang- tulang pendengaran

Pada usila kelenjar seruman mengalami atrofi, produksi kelenjar serumen berkurang, dan serumen lebih kering, mudah terjadi serumen prop yang mengakibatkan tuli konduktif. Membrane timpani yang bertambah kaku dan tebal juga menyebabkan gangguan konduksi, demikian pula halnya dengan kekakuan yang terjadi pada persendian tulang – tulang pendengaran.

Tuli saraf pada geriatric ( Presbikusis)Presbikusis adalah tuli sensorineural frekuensi tinggi, umumnya terjadi mulai usia 65 tahun, simetris pada telinga kiri dan kanan. Presbikusis dapat mulai pada frekuensi 1000 Hz/ lebih.

EtiologiAkibat proses degenerasi.Diduga mempunyai hubungan dengan faktor herediter, pola makan, metabolism, arteriosklerosis, infeksi, bising, gaya hidup atau bersifat multifactor.Progesifitas dipengaruhi oleh usia dan jenis kelamin, laki- laki lebih cepat dari perempuan.

PatologiProses degenerasi menyebabkan perubahan struktur koklea dan N. VIII.Pada koklea proses perubahan yang mencolok adalah atrofi dan degenerasi sel- sel rambut penunjang pada organ corti. Proses atrofi disertai dnegan perubahan vascular juga terjadi pada stria vaskularis. Terdapat pula perubahan berupa berkurangnya jumlah dan ukuran sel- sel ganglion dan saraf. Hal yang sama juga terjadi pada myelin akson saraf.

Klasifikasi

Gejala klinikKeluhan utama presbikusis berupa berkurangnya pendengaran secara perlahan- lahan dan progresif, simetris pada kedua telinga.Keluhan lainnya adalah telinga berdenging ( tinnitus nada tinggi). Pasien dapat mendengar suara percakapan, tetapi sulit untuk memahaminya, terutama bila diucapkan dengan cepat di tempat dengan latar belakang yang bising ( cocktail party deafness). Bila intensitas suara ditinggikan akan timbul rasa nyeri di telinga, hal ini disebabkan oleh faktor kelelahan saraf ( recruitment).DiagnosisDengan pemeriksaan otoskopik, tampak membrane timpani suram, mobilitas berkurang. Pada tes penala didapatkan tuli sensorineural. Pemeriksaan audiometric nada murni menunjukkan suatu tuli saraf nada tinggi, bilateral dan simetris.Pada tahap awal terdapat penurunan yang tajam ( sloping) setelah frekuensi 2000Hz.Garis ambang dengar pada metabolic dan mekanik lebnih mendatar kemudian pada tahap berikutnya berangsur- angsur terjadi penurunan.Pemeriksaan audiometric turut menunjukkan gangguan diskriminasi wicara. Keadaan ini jelas terlihat pada presbikusis neural dan koklear.Penatalaksanaan Rehabilitasi sebagai upaya mengembalikan fungsi pendengaran dilakukan dengan pemasangan alat bantu dengar ( hearing aid). Perlu dikombinasikan dengan latihan membaca, ujaran dan mendengar bersama dengan ahli terapi wicara.

Presbycusis

The term presbycusis refers to sensorineural hearing impairment in elderly individuals. Characteristically, presbycusis involves bilateral high-frequency hearing loss associated with difficulty in speech discrimination and central auditory processing of information.

In patients with presbycusis, no abnormalities are found on physical examination.

- Presbycusis is a diagnosis of exclusion that should not be made until all other possible etiologies of hearing loss in elderly individuals have been evaluated and excluded.

- Etiologies as simple as cerumen impaction and as complex as otosclerosis or cholesteatoma must not be overlooked in the elderly patient with hearing loss because these are amenable to treatment.

Imaging Studies

Evaluation may entail a variety of tests, including CT scanning or MRI to exclude anatomic abnormalities or mass lesions that may cause hearing loss.

Other Tests

- Audiometric testing with pure-tone average and speech discrimination forms the cornerstone of diagnostic testing for presbycusis.

- The need for additional testing can usually be determined from the audiometric test results. For example, individuals with asymmetric hearing loss (ie, more than 10 dB difference at any 2 consecutive frequencies) and individuals with a conductive component require further evaluation.

- Evaluation may entail a variety of tests, including tests of central auditory processing to exclude abnormal processing of auditory information in the central nervous system.

Medical Care

Presbycusis is not curable, but the effects of the disease on patients’ lives can be mitigated.

- Amplification devices: Properly fitted hearing aids may contribute to the rehabilitation of a patient with presbycusis. Older patients with arthritis in their fingers and visual difficulties need extra help in learning to use hearing aids. Patients using hearing aids may still experience difficulties with speech discrimination in noisy situations.

- Lip reading: Lip reading may help patients with diminished speech discrimination and may help hearing aid users who have difficulty in noisy environments.

- Assistive listening devices: These range from a simple amplification of the telephone signal to a device on the television that sends a signal across the room to a headset worn by a patient with hearing loss. The patient can amplify the sound without disturbing other people with normal hearing who are in the same room.

- Cochlear implants: Some patients with presbycusis benefit from cochlear implants. Patients with cochlear changes and relatively intact spiral ganglia and central pathways appear to be the best candidates.