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Laporan Kasus

Asma Bronkial
dr. Marcella Deviana
Wahana IGD
IDENTITAS PASIEN
Nama Lengkap : Tn.M
Tempat/Tanggal Lahir : Tanjungpandan/17 Agustus 1963
Umur : 53 tahun
Jenis kelamin : Laki laki
Suku bangsa : Melayu
Agama : Islam
Alamat : Sijuk
Pendidikan : SMK
Tanggal masuk RS : 21 Februari 2017
ANAMNESIS

Keluhan Utama : Keluhan Tambahan :


Sesak 1 hari Batuk dengan dahak
SMRS yang sulit keluar
Riwayat
Penyakit
3 hari SMRS, Os batuk disertai rasa tidak
Riwayat
nyaman diPenyakit
kerongkongan tanpa sesak

2 hari smrs, batuk terasa mulai berdahak dan os


mulai merasa sesak

Os berobat ke dokter lalu diberikan terapi


nebulisasi ventolin 1x dan diberikan obat pulang
(obat batuk dan salbutamol)
1 hari SMRS, sesak makin berat dan tidak membaik
dengan perubahan posisi maupun istirahat, os ke dokter
lagi dan dirujuk ke RSUD

Os dirujuk ke RSUD H. Marsidi Judono untuk


mendapatkan penanganan lebih lanjut
Riwayat Penyakit Dahulu
Os memiliki riwayat penyakit asma
Ospernah mendapatkan terapi TB paru
selam 6 bulan tuntas
Pemeriksaan Fisik
Keadaan Umum : tampak sakit Berat badan : 60 kg
sedang
Tinggi badan : 155 cm
Kesadaran : compos mentis
BMI : 24,97
Tanda-tanda vital kg/m2
Tekanan Darah : 140/90 mmHg Status Gizi :
Nadi : 90 kali/menit overweight
Suhu : 36,5C
Laju pernapasan : 42 kali/menit
Pemeriksaan Fisik
Mata : Konjungtiva anemis -/- sklera ikterik -/-, refleks cahaya +/
+, pupil isokor
Hidung : Septum nasi di tengah, sekret -/-,
Mulut : Mukosa oral lembab, faring hiperemis
Leher : Pembesaran KGB (-), kaku kuduk (-)
Paru :
Inspeksi : tampak simetris
Palpasi : teraba simetris
Perkusi : sonor di kedua lapangan paru
Auskultasi : vesikuler -/-, Ronkhi -/-, wheezing +/+
Pemeriksaan Fisik
Jantung : Iktus cordis tidak tampak, Bunyi jantung I
dan II murni regular, murmur -, gallop -
Abdomen :
Inspeksi : tampak cembung
Palpasi : supel, nyeri tekan (-), Hepar lien tidak teraba.
Perkusi : timpani
Auskultasi : Bising usus (+)
Ekstremitas : Akral hangat, CRT <2 detik, turgor kulit
baik
Pemeriksaan Penunjang

Belum dilakukan

Planning :
Elektrokardiograf
Rontgen thorax
Pemeriksaan laboratorium
Diagnosis
Asma bronkial

Adanya sesak yang dipicu oleh batuk


Adanya riwayat Asma sejak kecil
Pada pemeriksaan fsik ditemukan RR 42x/menit, dan
wheezing pada kedua lapang paru
Penatalaksanaan
Nebulisasi Ventolin : NS sesak +, wheezing +/+
Nebulisasi ulang Ventolin +Flixotide sesak + berkurang, wheezing
+/+
Nebulisasi ulang Ventolin + Flixotide sesak + berkurang, wheezing
+/+
O2 3 lpm dengan nasal canul
Menyarankan untuk rawat inap pasien menolak

Obat pulang :
Salbutamol 3x4mg
Metil Prednisolone 3x2mg
Asma Bronkiale
Penyakit jalan nafas obstruktif kronis, intermiten dan
reversible dengan ditandai oleh inflamasi dan
peningkatan reaktivasi terhadap stimulasi tertentu.
Diagnosis
Pemeriksaan Pemeriksaan
Anamnesis Fisik Penunjang
Tanyakan sesaknya Tanda tanda vital Belum dilakukan
dari kapan, Pulmo : wheezing
Tanyakn onsetnya pada kedua lapang Planning :
bagaimana paru
Elektrokardiogram
Tanyakan keluahn
lain yang dirasakan Rontgen thorax
Tanyakan riwayat Cek Laboratorium
penyakit dahulu
Tanyakan riwayat
penyakit keluarga
Managing exacerbations in acute care
settings
INITIAL ASSESSMENT Are any of the following present?

A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE

Talks in phrases Talks in words


Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

Short-acting beta2-agonists Short-acting beta2-agonists


Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat


as
severe and re-aassess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY


MEASURE LUNG FUNCTION
in all patients one hour after initial
treatment

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or


personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently

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


INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL Consult ICU, start SABA and O2,


STATUS and prepare patient for intubation
according to worst feature

MILD or MODERATE SEVERE


Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

GINA 2015, Box 4-4 (2/4) Global Initiative for Asthma


MILD or MODERATE SEVERE
Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

Short-acting beta2-agonists Short-acting beta2-agonists


Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

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


Short-acting beta2-agonists Short-acting beta2-agonists
Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat


as
severe and re-assess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY


MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF <60% of predicted or


FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

GINA 2015, Box 4-4 (4/4) Global Initiative for Asthma


Managing exacerbations in primary care
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in words, sits hunched
LIFE-THREATENING
Talks in phrases, prefers
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) <90%
PEF >50% predicted or best PEF 50% predicted or best URGENT

START TREATMENT
SABA 410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg While waiting: give inhaled
SABA and ipratropium bromide,
Controlled oxygen (if available): target O2, systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler
best or predicted technique, adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 57 days
(3-5 days for children)
Resources at home adequate
Follow up: within 27 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

GINA 2015, Box 4-3 (1/7)


PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) <90%
PEF >50% predicted or best PEF 50% predicted or best URGENT

START TREATMENT
TRANSFER TO ACUTE
SABA 410 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING While waiting: give inhaled SABA
Prednisolone: adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

GINA 2015, Box 4-3 (4/7) Global Initiative forAsthma


Global Initiative for Asthma
START TREATMENT
SABA 410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max. While waiting: give inhaled SABA
50 mg, children 12 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 57 days
Resources at home adequate (3-5 days for children)
Follow up: within 27 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

GINA 2015, Box 4-3 (7/7) Global Initiative for Asthma


Global Initiative for Asthma

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