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Curriculum Vitae

Dr. Prayudi Santoso, SpPD-KP, M.Kes,FCCP, FINASIM


E-mail: prayudimartha@yahoo.com

Pendidikan:
S1
Sp1
Konsultan Pulmonologi
S2

FK Universitas Padjadjaran Bandung


FK Universitas Padjadjaran Bandung
KIPD
FK Universitas Padjadjaran Bandung

Pekerjaan:
Staf Divisi Respirologi & Penyakit Kritis IPD FKUP/RS Hasan Sadikin
Koordinator Tim MDR RSUP Dr. Hasan Sadikin Bandung
Organisasi:
Perhimpunan Dokter Spesialis Penyakit Dalam (PAPDI) Jabar
Perhimpunan Respirologi Indonesia (PERPARI)
Fellow American College of Chest Physcian (ACCP)
Member European Respiratory Society (ERS)

Tatalaksana Asma dalam Praktek


Sehari-hari
Prayudi Santoso
Divisi Respirologi dan Kritis Respirasi
Departemen Ilmu Penyakit Dalam
FK UNPAD/RSHS
BANDUNG 2016

Definisi Asma
Asma adalah ....
gangguan inflamasi kronik
hipersensitifitas bronkus
bronkokonstriksi yang reversibel

dengan atau tanpa pengobatan

Ref. GINA Updated 2012

Definition of asthma
Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation.
It is defined by the history of respiratory symptoms
such as wheeze, shortness of breath, chest
tightness and cough that vary over time and in
intensity, together with variable expiratory airflow
limitation.

NEW!

GINA 2015

Gejala ASMA: hanya puncak dari


gunung es1
GEJALA ASMA

Obstruksi saluran napas

Batuk
Sesak napas
Mengi (wheezing)
Dada rasa tertekan

Bronkokonstriksi
Edema bronkus
Hiper-sekresi mukus
Keterlibatan sel-sel inflamasi
eosinofil, dll

Hiper-responsif bronkus

Inflamasi saluran napas

1. Warner O. Am J Resp Crit Care Med 2003; 167: 14651466.

Inflamasi adalah masalah inti dari


asma
Paru normal
Epithelium
intact
Sparsity of
bronchial
smooth
Basement
muscle
membrane
relatively thin

Paru asma ringan


Fragile, damaged epithelium

Thickened reticular
basement membrane
beginnings of airway
remodelling

1. Jeffery P. Ped Pulm 2001; 21: 3-16.

Penatalaksanaan Asma
AKUT
Kegawat daruratan /
Emergency
Ada gejala yang dirasakan oleh
pasien.
Diperlukan obat dengan mula
kerja cepat.

KRONIS
Pasien asma yang tidak dalam
keadaan serangan eksaserbasi.
Tidak ada gejala yang
dirasakan pada periode ini.
Diperlukan obat yang
mencegah terjadinya serangan
Asma terkontrol

Asma merupakan penyakit 2 komponen:


efek saling melengkapi dari terapi kombinasi LABA / kortikosteroid

LABA

Bronkokonstriksi
Hiper-reactivitas bronkus
Hiperplasia
Pelepasan mediator inflamasi

disfungsi
otot
polos

Inflamasi
sal. napas/
remodelling

ICS

Infiltrasi / aktivasi sel inflamasi


Edema mukosa
Proliferasi selular
Kerusakan epitel
Penebalan membran basalis

Gejala \ eksaserbasi
1. Johnson M. Proc Am Thorac Soc 2004; 1: 200206.

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD

PRINCIPLES IN ASTHMA MANAGEMENT

RELIEVER

Source: Peter J. Barnes, MD

PRINCIPLES IN ASTHMA MANAGEMENT

AVOIDANCE

Source: Peter J. Barnes, MD

PRINCIPLES IN ASTHMA MANAGEMENT

CONTROLLER

Source: Peter J. Barnes, MD

Risk Factors for Asthma

Host factors: predispose individuals to, or


protect them from, developing asthma
Environmental factors: influence
susceptibility to development of asthma in
predisposed individuals, precipitate asthma
exacerbations, and/or cause symptoms to
persist

Global Initiative for Asthma

Factors that Exacerbate Asthma

Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs

Global Initiative for Asthma

Factors that Influence Asthma


Development and Expression
Host Factors
Genetic
- Atopy
- Airway
hyperresponsiveness
Gender
Obesity

Environmental Factors
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Diet

Global Initiative for Asthma

Is it Asthma?
Recurrent episodes of wheezing
Troublesome cough at night
Cough or wheeze after exercise
Cough, wheeze or chest tightness after
exposure to airborne allergens or
pollutants
Colds go to the chest or take more than
10 days to clear

Global Initiative for Asthma

Asthma Diagnosis

History and patterns of symptoms


Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify risk
factors
Extra measures may be required to diagnose
asthma in children 5 years and younger and the
elderly
Global Initiative for Asthma

NEW!

GINA 2015 Box 1-1

Global Initiative for Asthma

GINA assessment of asthma control

GINA 2015, Box 2-2A

Global Initiative for Asthma

Assessment of risk factors for poor asthma


outcomes
Risk factors for exacerbations include:

Ever intubated for asthma


Uncontrolled asthma symptoms
Having 1 exacerbation in last 12 months
Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
Incorrect inhaler technique and/or poor adherence
Smoking
Obesity, pregnancy, blood eosinophilia

GINA 2015, Box 2-2B (2/4)

Global Initiative for Asthma

Assessment of risk factors for poor asthma


outcomes
Risk factors for exacerbations include:

Ever intubated for asthma


Uncontrolled asthma symptoms
Having 1 exacerbation in last 12 months
Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
Incorrect inhaler technique and/or poor adherence
Smoking
Obesity, pregnancy, blood eosinophilia

Risk factors for fixed airflow limitation include:


No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia

GINA 2015, Box 2-2B (3/4)

Global Initiative for Asthma

Assessment of risk factors for poor asthma


outcomes
Risk factors for exacerbations include:

Ever intubated for asthma


Uncontrolled asthma symptoms
Having 1 exacerbation in last 12 months
Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
Incorrect inhaler technique and/or poor adherence
Smoking
Obesity, pregnancy, blood eosinophilia

Risk factors for fixed airflow limitation include:


No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia

Risk factors for medication side-effects include:


Frequent oral steroids, high dose/potent ICS, P450 inhibitors
GINA 2015, Box 2-2B (4/4)

Global Initiative for Asthma

Low, medium and high dose inhaled corticosteroids


Adults and adolescents (12 years)
Inhaled corticosteroid

Total daily dose (mcg)


Low

Medium

High

Beclometasone dipropionate (CFC)

200500

>5001000

>1000

Beclometasone dipropionate (HFA)

100200

>200400

>400

Budesonide (DPI)

200400

>400800

>800

Ciclesonide (HFA)

80160

>160320

>320

Fluticasone propionate (DPI or HFA)

100250

>250500

>500

Mometasone furoate

110220

>220440

>440

4001000

>10002000

>2000

Triamcinolone acetonide

This is not a table of equivalence, but of estimated clinical comparability


Most of the clinical benefit from ICS is seen at low doses
High doses are arbitrary, but for most ICS are those that, with prolonged use,

are associated with increased risk of systemic side-effects

GINA 2015, Box 3-6 (1/2)

REDUCE

LEVEL OF CONTROL
controlled

TREATMENT OF ACTION
maintain and find lowest controlling step

uncontrolled

step up until controlled

INCREASE

partly controlled

consider stepping up to gain


control

exacerbation

treat as exacerbation

REDUCE
STEP

INCREASE
STEP

TREATMENT STEPS
STEP

Global Initiative for Asthma

STEP

STEP

Classification of Severity
CLASSIFY SEVERITY

Clinical Features Before Treatment


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

Continuous

Nocturnal
Symptoms

Limited physical activity

Frequent

Daily
Attacks affect activity

> 1 time week

> 1 time a week


but < 1 time a day

> 2 times a month

< 1 time a week


Asymptomatic and
normal PEF between
attacks

2 times a month

FEV1 or PEF
60% predicted
Variability > 30%
60 - 80% predicted
Variability > 30%
80% predicted

Variability 20 - 30%

80% predicted
Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma Therapy


- Adults
Outcome: Best Possible
Results

Outcome: Asthma Control

Controller:

Controller:
None

Reliever:
STEP 1:
Intermittent

Controller:
Daily inhaled
corticosteroid

Controller:

Daily inhaled

corticosteroid plus
Daily long-acting
inhaled 2-agonist -Theophylline-SR

Rapid-acting inhaled 2-agonist prn


STEP 2:
Mild Persistent

Daily inhaled
corticosteroid plus
Daily long acting
inhaled 2-agonist
plus (if needed)

STEP 3:
Moderate
Persistent

When asthma is
controlled,
reduce therapy
Monitor

-Leukotriene
-Long-acting inhaled
2- agonist
-Oral corticosteroid

STEP 4:
Severe Persistent

Alternative controller and reliever medications may be considered (see text).

STEP Down

Recommended Asthma Medications Step 1:


Adults

Severity

Daily Controller
Medications

Step 1:
None
Intermittent

Other Options (in order


of cost)
None

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a
day. Once control is achieved and maintained for at least 3 months, gradual reduction of
therapy should be tried.

Recommended Asthma Medications Step 2:


Adults

Severity
Step 2:
Mild
Persistent

Daily Controller
Medications

Other Options (in order


of cost)

Low-dose inhaled Sustained-release


glucocorticosteroid theophylline, or
Cromone, or
Leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a
day. Once control is achieved and maintained for at least 3 months, gradual reduction of
therapy should be tried.

Recommended Asthma Medications Step 3:


Adults
Severity
Step 3:
Moderate
persistent

Daily Controller
Medications
Low- to medium-dose
inhaled glucocorticosteroid plus long-acting
inhaled 2- agonist

Other Options (in order of cost)


Medium-dose inhaled glucocorticosteroid
plus sustained- release theophylline, or
Medium-dose inhaled glucocorticosteroid
plus long-acting inhaled 2- agonist, or
High-dose inhaled glucocorticosteroid, or
Medium-dose inhaled glucocorticosteroid
plus leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a
day. Once control is achieved and maintained for at least 3 months, gradual reduction of
therapy should be tried.

Recommended Asthma Medications Step 4:


Adults
Severity

Daily Controller Medications

Step 4
Severe
persistent

High-dose inhaled glucocorticosteroid


plus long-acting inhaled 2- agonist
plus one or more of the following, if
needed:
- Sustained-release theophylline
- Leukotriene modifier
- Long-acting inhaled 2- agonist
- Oral glucocorticosteroid

Other Options

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a
day. Once control is achieved and maintained for at least 3 months, gradual reduction of
therapy should be tried.

Stepwise approach to control asthma symptoms


and reduce risk

NEW!

Global Initiative for Asthma

Step 1 as-needed inhaled short-acting


beta2-agonist (SABA)
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE

STEP 2

STEP 1

Low dose ICS


Other
controller
options
RELIEVER

Consider low
dose ICS

Leukotriene receptor antagonists (LTRA)


Low dose theophylline*

As-needed short-acting beta2-agonist (SABA)

STEP 3

Low dose
ICS/LABA*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)

Med/high
ICS/LABA

Refer for
add-on
treatment
e.g.
anti-IgE

Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)

Add
tiotropium#
Add low
dose OCS

As-needed SABA or
low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of exacerbations; it is not indicated
in children <18 years.

GINA 2015, Box 3-5, Step 1 (4/8)

Step 4 two or more controllers + asneeded inhaled reliever


UPDATED
!

STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE

STEP 1

STEP 2

Low dose ICS


Other
controller
options
RELIEVER

Consider low
dose ICS

Leukotriene receptor antagonists (LTRA)


Low dose theophylline*

As-needed short-acting beta2-agonist (SABA)

STEP 3

Low dose
ICS/LABA*

Med/high
ICS/LABA

Med/high dose ICS Add tiotropium#


Low dose ICS+LTRA High dose ICS
+ LTRA
(or + theoph*)
(or + theoph*)

Refer for
add-on
treatment
e.g.
anti-IgE

Add
tiotropium#
Add low
dose OCS

As-needed SABA or
low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of exacerbations; it is not indicated
in children <18 years.

GINA 2015 Box 3-5, Step 4 (7/8)

Global Initiative for Asthma

Step 4 two or more controllers + asneeded inhaled reliever

UPDATED
!

Before considering step-up


Check inhaler technique and adherence

Adults or adolescents: preferred option is combination low dose

ICS/formoterol as maintenance and reliever regimen*, OR


combination medium dose ICS/LABA with as-needed SABA

Other options (adults or adolescents)


Tiotropium by soft-mist inhaler may be used as add-on therapy for

adult patients (18 years) with a history of exacerbations


Increase dosing frequency (for budesonide-containing inhalers)
Add-on LTRA or low dose theophylline
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2015

Step 5 higher level care and/or add-on


treatment

UPDATED!

STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE

STEP 1

STEP 2

Low dose ICS


Other
controller
options
RELIEVER

Consider low
dose ICS

Leukotriene receptor antagonists (LTRA)


Low dose theophylline*

As-needed short-acting beta2-agonist (SABA)

STEP 3

Low dose
ICS/LABA*

Refer for
add-on
treatment
Med/high
e.g.
ICS/LABA anti-IgE

Med/high dose ICS Add tiotropium#


Low dose ICS+LTRA High dose ICS
+ LTRA
(or + theoph*)
(or + theoph*)

As-needed SABA or
low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of exacerbations; it is not indicated
in children <18 years.

GINA 2015, Box 3-5, Step 5 (8/8)

Add
tiotropium#
Add low
dose OCS

Step 5 higher level care and/or addon treatment

UPDATED!

Preferred option is referral for specialist investigation and

consideration of add-on treatment

Add-on omalizumab (anti-IgE) is suggested for patients with moderate

or severe allergic asthma that is uncontrolled on Step 4 treatment

Other add-on treatment options at Step 5 include:


Tiotropium: for adults (18 years) with a history of exacerbations

despite Step 4 treatment; reduces exacerbations


Add-on low dose oral corticosteroids (7.5mg/day prednisone
equivalent): this may benefit some patients, but has significant systemic
side-effects. Assess and monitor for osteoporosis

GINA 2015

Reviewing response and adjusting


treatment
How often should asthma be reviewed?
1-3 months after treatment started, then every 3-12 months
During pregnancy, every 4-6 weeks
After an exacerbation, within 1 week

Stepping up asthma treatment


Sustained step-up, for at least 2-3 months if asthma poorly controlled
,)
Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
Day-to-day adjustment
For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen*

Stepping down asthma treatment


Consider step-down after good control maintained for 3 months
Find each patients minimum effective dose, that controls both symptoms and

exacerbations

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2015

Managing exacerbations in primary care

NEW!

GINA 2015, Box 4-3 (1/3)

Global Initiative for Asthma

GINA 2015 Box 4-3 (2/3)

Global Initiative for Asthma

GINA 2015, Box 4-3 (3/3)

Global Initiative for Asthma

Global Initiative for Asthma

HASAN SADIKIN GENERAL HOSPITAL