A S T H M A

Dr. Bayu Sukresno, Sp. PD

 Episodic or chronic symptoms of airflow

obstruction : breathlessness, chest tightness, wheezing, and cough. Complete or partial reversibility of airflow obstruction, either spontaneously or following bronchodilator therapy. Symptoms frequently worse at night or in the early morning. Prolonged expiration and diffuse wheezes on physical examination. Limitation of airflow on pulmonary function testing or positive bronchoprovocation challenge.

 Asthma is a chronic inflammatory disorder of the airways. The strongest identifiable predisposing factor is atopy, but obesity is increasingly recognized as a risk factor. Exposure of sensitive patients to inhaled allergens increases airway inflammation, airway hyper-responsiveness, and symptoms. Symptoms may develop immediately or 4-6 hours after allergen exposure.

 Common allergens include house dust mites (often found in pillows, mattresses, upholstered furniture, carpets, and drapes), cockroaches,

cat dander, and seasonal pollens.

Nonspesific precipitants of asthma include

exercise, URI, rhinitis, sinusitis, postnasal drip, aspiration, gastroesophageal reflux, changes in the weather, and stress.

Others : air pollutants, certain medications, occupational asthma, catamenial asthma.

SYMPTOMS AND SIGNS

Episodic wheezing, difficulty in breathing, chest tightness, and cough. Excess sputum production is common. The frequency of asthma symptoms is highly variable. Asthma symptoms are frequently worse at night. Chest examination may be normal between exacerbations in patients with mild asthma.

Severity of asthma exacerbations

Mild : dyspnea only with activity; talks in

sentences Moderate : dyspnea interferes with limits of usual activity; talks in phrases Severe : dyspnea at rest; interferes with conversation; talks in words
- Life threatening : too dyspneic to speak; perspiring

Classification of asthma severity

INTERMITTENT :
Symptoms < 2 days/week Nighttime awakenings < 2x/month SABA use for symptom control < 2 days/week Interference with normal activity : none

 MILD PERSISTENT : Symptoms > 2 days/week but not daily Nighttime awakenings 3-4x/month SABA > 2 days/week but not daily Interference with normal activity : minor limitation MODERATE PERSISTENT : Symptoms daily Nighttime awakenings > 1x/week SABA daily Interference with normal activity : some limitation

 SEVERE PERSISTENT :
Symptoms throughout the day Nighttime awakenings often 7x/week SABA several times per day Interference with normal activity : extremely limited

Pulmonary Function Testing

Spirometry Peak expiratory flow meter Bronchial provocation testing Arterial blood gas measurements Additional testing :
Routine chest radiographs are usually normal; indicated when pneumonia or pneumothorax is suspected

Complications
Exhaustion, dehydration, airway infection, and tussive syncope. Pneumothorax occurs but is rare. Acute hypercapnic and hypoxic respiratory failure occurs in severe disease.

COMPONENTS OF ASTHMA DIAGNOSIS AND MANAGEMENT

1. Assessing and monitoring asthma severity and asthma control. 2. Patient education designed to foster a partnership for care. 3. Control of environmental factors and comorbid conditions that affect asthma. 4. Pharmacologic agents of asthma.

Pharmacologic agents for asthma

1. RELIEVER (Quick-relief medications)

Act principally by direct relaxation of bronchial smooth muscle SABA (short-acting beta-adrenergic agonists), anticholinergics, phosphodiesterase inhibitors, corticosteroids
act primarily to attenuate airway inflammation Corticosteroids, long acting bronchodilator (LABA = long-acting beta-adrenergic agonists), leukotrien modifiers

2. CONTROLLER (Long-term medications)

RELIEVER
Albuterol (SABA)
MDI (90mcg/puff) : 2 puffs every 4-6 hours as needed Nebulizer solution (2,5mg/3mL) : 1,25 5 mg in 3 mL of saline every 4-8 hours as needed MDI (17mcg/puff) : 2-3 puffs every 6 hours Nebulizer solution (0,25mg/mL) : 0,25 mg every 6 hours Nebulizer solution (0,5 mg/3mL ipratropium bromide and 2,5 mg/3 mL albuterol) : 3 mL every 4-6 hours

Ipratropium (anticholinergic)

Ipratropium with albuterol

CONTROLLER
Inhaled corticosteroid
Fluticasone Budesonide

Inhaled LABA
Salmeterol Formoterol

Combined medication Fluticasone/salmeterol Budesonide/formoterol