Asthma :

Prof.Dr.Tamsil Syafiuddin,SpP(K)

Departemen Pulmonologi dan Kedokteran Respirasi

Fakultas Kedokteran USU
2016
Standar Kompetensi Dokter Indonesia

Konsil Kedokteran Indonesia

Indonesian Medical Council
Jakarta 2012
 Daftar Masalah Sistem Respirasi
dan Sistem Kardiovaskuler:

Batuk (kering,berdahak,darah)
Sakit/nyeri dada
Berdebar-berdebar
Sesak napas atau napas pendek
Napas berbunyi
Sumbatan jalan napas
Kebiruan
Lampiran 2 SKDI 2012
 Daftar Penyakit
Sistem Respirasi
(Tingkat Kompetensi)

Lampiran 3 SKDI 2012

 TINGKAT KEMAPUAN/KOMPETENSI:
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 internsip dan PKB
Lampiran 3 SKDI 2012
 DAFTAR KOMPETENSI SISTEM RESPIRASI

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

Lampiran 3 SKDI 2012

 DAFTAR KOMPETENSI SISTEM RESPIRASI
7.ARDS 3B
8.SARS 3B
9.Flu burung 3B
10.Asma akut berat 3B
11.Bronkiolitis akut 3B
12.Efusi pleura masif 3B
13.Pneumonia aspirasi 3B
14.PPOK Eksaserbasi akut 3B
15.Edema paru 3B
16.Haematotoraks 3B
Lampiran 3 SKDI 2012
Penyakit-penyakit Obstruktif:

Asma
Bronkitis akut
PPOK
 Tanda-tanda obstruktif:

Pemeriksaan Fisik
Pemeriksaan penunjang
Pemeriksaan Fisik Sistem Respirasi:
Inspeksi : Gerakan pernapasan/dinding
toraks normal
Palpasi : Fremitus suara normal
Perkusi : Sonor
Auskultasi : Vesikuler
 Suara pernapasan:
Normal, Vesikuler :

Obstruktif : 1.Mengi
2.Vesikuler memanjang
 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.
Heterogenous disease, phenotypes
NEW!

GINA 2015
 Many phenotypes, some of the most common:

Allergic asthma
Non-allergic asthma
Late-onset asthma
Asthma with fixes airflow limitation
Asthma with obesity
etc
Diagnosis:
 Patern symptoms of asthma:
Symptoms: wheeze,shortness of breath,cough,
chest tightness
Worse at night or early morning
Vary over time & intensity
Have triggered
 Confirmed variable lung function:

-Positive bronchodilator reversibility test

(Medication withheld before test: SABA >4 hours,LABA >15 hours)

Adult :
increase FEV1 >12%, >200ml from baseline
average daily diurnal PEF variability >10%
Children :
increase FEV1 , 12% predicted
average daily diurnal PEF variability >13%
-Positive bronchial challenge test
PC20/PD20 : Fall in FEV1 >20% from baseline
History and family history (+)
CXR Examinations:
Normal
 Inflammation
() (+) Asthma
Normal

Triggers

Triggers

Bronchial hyperreactivity ( - ) Bronchial hyperreactivity ( + )

Bronchoconstriction ( - ) Bronchoconstriction ( + )

Symptoms (-) Symptoms (+)

The pathogenesis of asthma
 Ca++ Histamin
Ag
Ig E YY
Phosphatidyl
Phospholipid Methyl Phosphatidyl
transferase choline
ethanolamine

Phospho Ca++ Histamin

Arachidonic acid lipase A2
ECF, NCF
lypoxygenase cyclooxygenase

5-HETE
Leucotrienes Thromboxanes Prostaglandins
LTB4
LTC4 TXA2 PGD
LTD4 PGF2
LTE4

Mediator release in asthma reactions

 AIRWAY REMODELLING IN
ASTHMA
(fixed airflow limitation)
Eosinophil

Desquamations of epithelium

MBP, ECP
Epithelium

Thickening of basement membrane

Increase in airway smooth muscle

 Inflammation

Controller
Bronchial hyperreactivity

Bronchoconstriction
Reliever
Symptoms
Medicines and Pathogenesis of asthma
 Asthma Therapy Evolution
ICS treatment Adding
introduced LAA to ICS therapy
Large use of 1972 Kips et al, AJRCCM 2000
Pauwels et al, NEJM
short-acting
1997 Greening et al, Lancet
2-agonists 1992
1975 Single
inhaler therapy

1980
Fear of ICS+LABA
short-acting
2-agonists

1985
2000
1990 1995

Bronchospasm Inflammation Remodelling

GINA 2015
 Symptoms
Remodelling
Treatment
Based on Inflammation
 Goals of asthma management
The long-term goals of asthma management are
1. Symptom control: to achieve good control of
symptoms and maintain normal activity levels
QoL
2. Risk reduction: to minimize future risk of exa
cerbations, fixed airflow limitation and medica

tion side-effects,

GINA 2015
GINA 2015
 Goals of asthma management
The pharmacological treatment
of asthma categories:
-Controller medications,
-Reliever medications,
-Add-on therapies, these may be considered when
patients have persistent symptoms and/or
exacerbations despite optimized treatment with high dose
controller medications.

GINA 2015
Goals of asthma management
Non pharmacological treatment to
achieving these goals requires a partnership between
patient and their health care providers
Ask the patient about their own goals regarding their asthma
Good communication strategies are essential, Adherence
Incorrect/poor technique inhaler
Smooking
Co-morbid
Consider the health care system, medication availability,
cultural and personal preferences and health literacy

GINA 2015
 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
sodium nedocromil dipropionate
(Becotide)
triamcinolone
acetonide
Reliever
Bronchodilator
2 - agonist
Xanthin
Anticholinergic
 BRONCHODILATOR
Short Acting 2 AGONIST (SABA): Long Acting 2 AGONIST:
salbutamol/albuterol (Ventolin ) (LABA)
terbutaline (Bricasma) salmoterol
procaterol formoterol
fenoterol
orciprenaline, etc

ANTICHOLINERGIC: XANTHINE:
atropine sulfate theophylline
aminophylline
ipratropium bromide
tiotropium bromide
OTHER SYMPHATOMIMETIC:
ephedrine
adrenaline, etc
Combination therapy
( ICS + LABA )

Symbicort
Budesonide + Formoterol

Seretide
Fluticasone + Salmoterol

(BPJS Kesehatan)
 Guidelines on Asthma Management:
Past and Current Trends

Mild Moderate Severe Old

Intermittent persisten persisten persisten classification
t t t
Exacerbation
Total control Partially control Uncontrol New
classification

SABA or Rapid onset of action LABA

?
GINA 1998 ICS LABA and
(adapted)
ICS
GINA 2008- ICS+LABA Stable condition
2015
 SABA and Rapid onset of LABA in
treating acute severe asthma/exacerbation
Symbicort
(FormoterolRapid onset
FEV1 (% change from baseline) of LABA)
45 Salbutamol
40 (SABA)

35
30
25
20
15
10
5
0
0 30 60 90 120 150 180
Time since last administration of study drug (minutes)
Balanag et al, Pulmonary Pharmacology&Therapeutics 2005
 A basis for synergy
ICS and LABA
Effects of ICS on
the 2 receptor system
Effects of LABA on
the glucocorticoid
receptor system

Corticosteroids increase LABASs prime

2-receptor synthesis glucocorticoid receptor
for steroid dependent
activation

Overall biological / therapeutic

consequences
Zain-Hamid R Faculty of Medicine,
Universitas Sumatera Utara, Indonesia.
The Beginning of
Treatment
 Exacerbation x

The beginning of treatment ?

Stable condition

Asthma management

* Stable condition

* Long-term therapy
 Inflammation can also be present during symptom-free periods

Rate of response of different measures of asthma control over 18

months of ICS treatment
% Reduction

AHR is a marker of inflammation

AHR

Night Rescue medication use

symptoms Impaired am PEF
Impaired FEV1

Start of 2 4 6 18
treatment Months

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

 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:
ASTHMA CONTROL
 Control Level Based on GINA
Asthma PARTLY
Characteristics CONTROLLED UNCONTROLLED
Classification CONTROLLED

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of
None Any
activities 3 or more
features of partly
Nocturnal symptoms /
None Any controlled
awakening
asthma present
Need for rescue / None (2 or less / More than in any week
reliever treatment week) twice / week

Lung function < 80% predicted or personal

Normal
(PEF or FEV1) best (if known) on any day

Once/more per
Exacerbation None One in any week
year

GINA updated 2015

 GINA assessment of symptom control

A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
Daytime asthma symptoms more
than twice a week?

Yes No
Any night waking due to asthma?

Yes No None of 1-2 of 3-4 of

Reliever needed for symptoms* these these these
more than twice a week?
*Excludes reliever taken before exercise, because many people take this routinely
Yes No
Any activity limitation due to asthma?
This classification is the same as the GINA 2010-12 assessment
Yes No of current control, except that lung function now appears only
in the assessment of risk factors

GINA 2015, Box 2-2A Global Initiative for Asthma

Referency:
Global Initiative for Asthma (GINA)
Global Strategy for Asthma Management and Prevention (updated 2015)
 G lobal
IN itiative for
A sthma

Global Initiative for Asthma 2015

Sitou Timou Tumou Tou
Seorang perempuan, 23 tahun sudah
mengalami sesak napas dari sejak berumur
10 tahun, datang berobat karena batuk2 dan
sesak napas, ibunya seorang penderita asma,
riwayat napas berbunyi sudah sering
dialaminya,obat yang selalu digunakannya
adalah obat sesak ibunya berupa tablet.
Seorang laki-laki mahasiswa suatu perguruan
tinggi, umur 21 tahun sudah menderta asma
dari SMP, setiap sesak napasnya kumat, selalu
berobat kedokter, oleh dokter tersebut selalu
diberikan obat semprot Ventolin yang
digunakannya kalau sesak sampai saat ini.
Seorang perempuan, 34 tahun, datang
berobat karena sesak napasnya,kadang-
kadang batuk,napas sering berbunyi
sebelumnya tidak pernah merasakan
sesak,keluarga asma juga tidak ditemukan, 3
bulan yang lalu berobat di Penang Malaysia
dan mendapat obat isap Seretide, selama ini
obat tersebut digunakan kalau sesak saja.
Seorang laki-laki umur 32 tahun, sudah
menderita asma selama 15 tahun, datang
berobat karena sesak napasnya kumat lagi, 5
bulan yang lalu berobat di Singapore dan
mendapat obat isap Symbicort, 2 bulan
pengobatan, sesak napasnya sudah jarang
sekali,karena merasa sudah sembuh obat
dihentikan, sekarang ini kumat lagi.
Seorang laki-laki umur 58 tahun, sudah
menderita asma dari umur 8 tahun tahun,
datang berobat karena sesak napasnya
kumat lagi, riwayat merokok dari sejak umur
15 tahun, selama ini batuk-batuk berdahak
sudah dialami selama 5 tahun terakhir ini, 2
hari belakangan ini sesak bertambah disertai
batuk-batuk berdahak.
Apa yang terjadi sebenarnya pada
pasien-pasien tersebut?