Management of asthma

exacerbations

Tutik k, dr, SpP

 Definisi asma

 Inflamasi kronis pada saluran pernafasan

 Banyak sel dan elemen seluler berperan sel mast, sel epitel,
eosinofil, limfosit T, makrofag dan neutrofil
 Peradangan kronis dikaitkan dengan hiperresponsif jalan nafas
yang menyebabkan episode berulang mengi, sesak nafas, rasa
berat di dada dan batuk
 Variasi pembatasan aliran udara
 Eksaserbasi Asma
• Episode peningkatan sesak napas, batuk,
mengi, rasa berat di dada, atau kombinasi gejala-
gejala tersebut
 History and family history
• Commencement of respiratory symptoms in
childhood
• History of allergy rhinitis or eczem
• Family history of asthma or allergy
 Factors Influencing the Development and
Expression of Asthma
• Host Factors
– Genetic
– Obesity
– Sex
• Environmental Factors
– Allergens : Indoor and Outdoor
– Infection (predominantly viral)
– Occupational sensitizers
– Tobacco smoke (passive or active smoking)
– Outdoor/Indoor air pollution
– Diet
Faktor yang Mempengaruhi Asma

SYM/029/Okt12-Okt13/RD
 Asthma triggers

• Viral respiratory infections

• Environmental allergens
• Exercise, temperature, humidity
• Occupational and recreational allergens or
irritants
• Environmental irritants (perfume, tobacco
smoke, wood-burning stoves)
• Drugs (aspirin, non-steroidal anti-inflammatory
drugs [NSAIDs], beta-blocker) and food (sulfites)
 The Underlying Mechanism
Risk Factors (for development of asthma)

INFLAMMATION

Airway Airflow
Hyperresponsiveness Limitation

Risk Factors Symptoms (shortness of

(for exacerbation) breath, cough, wheeze)
Pathological Change

Asthma
involves
inflammation
of the airways

Normal Asthma

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created
and funded by NIH/NHLBI, 1995
BRONKODILATASI BRONKOKONSTRIKSI
 (Bronkokonstriksi)

(Edema mukosa bronkus)

(Sumbatan
mukus)
airway secretions
Bronkus pada orang Bronkus pada
normal : penderita asma :
PATOFISIOLOGI
HIPER
RESPONSIF
SAL.NAPAS HIPER
EDEMA
SAL. NAPAS SEKRESI
MUKUS

AIRWAY
BRONKO
REMODEL-
KONSTRIKSI LING

HAMBATAN ALIRAN UDARA

BAKTERI
VIRUS RESPIRASI/HRV
(M.pneumonie,C.pneumoniae

OBAT, Krisis emosi Alergen,polutan

 Pemahaman Mengenai Gejala Asma

Gejala asma sangat bervariasi dari orang ke orang.

• Gejala umum termasuk:
 Nyeri di dada
 Sesak nafas
 Batuk

 Lebih dari 1 gejala: wheezing, sesak napas,

batuk, rasa berat di dada
• Gejala-gejala ini cenderung datang dan pergi dari waktu ke waktu.
• Sering lebih buruk pada malam hari atau di pagi hari dapat dipicu
oleh olahraga, infeksi virus, iritasi, serbuk sari atau alergen lainnya
Pattern of symptoms

• Perennial/seasonal
• Episodic/continual
• Diurnal
 salah satu penyebab utama kasus
kegawatdaruratan dan rawat inap

Pemahaman
EKSASERBASI/ patofisiologi,
terapi
SERANGAN meningkat
ASMA

alasan utama pasien untuk

mencari pertolongan
MANIFESTASI KLINIS

GEJALA DAN TANDA EKSASERBASI ASMA

Subyektif Obyektif
Dyspneu Takipnea ( berat, > 30x/mnt)
Batuk Takikardi ( berat, > 120x/mnt)
Wheezing Upright positioning
Rasa berat di dada ( chest Pulsus paradoksus ( berat, >
tightness) 12mmhg)
Diaphoresis Retraksi sternokleidomastoid
Produksi sputum Perubahan derajat kesadaran
Payah ( exhaustion) Telegraphic speech
• The diagnosis of asthma is based on:
– the patient's medical history,
– physical examination,
– pulmonary function tests
– laboratory test results.
• Spirometry is recommended for the diagnosis
of asthma.
• Spirometry to demonstrate airflow
obstruction and establish a diagnosis of
asthma with certainty.
• Spirometry is essential for assessing the
severity of asthma in order to make
appropriate therapeutic recommendations.
PEAKFLOW
METER
PEMBAGIAN DERAJAT BERAT SERANGAN ASMA
 Other historical components

• Emergency department visits and

hospitalization
• Medication use (especially oral steroids)
• Lung function, PEFR variability
• Associated comorbidities, e.g., rhinitis,
sinusitis, gastroesophageal reflux (GERD)
 Clinical testing

• Accurate spirometry is recommended.

• Additional studies done, tailored to the
specific patient.
– - Allergy testing (e.g., skin testing, blood testing, in
vitro-specific IgE antibody testing)
– - Chest radiography, to exclude alternative
diagnosis
• Bronchial provocation testing if spirometry is
normal or near normal
 The long term goals of asthma
management

• To achieve good symptom control

• To minimize future risk of exacerbation, fixed

airflow limitation and side effects of treatment
Treatment Cycle In Asthma Management

Assessing
asthma control

Treating to Monitoring to
achieve control maintain control
 Asma adalah penyakit kronis pada saluran nafas yang
ditandai oleh dua hal yaitu :
1. Inflamasi
Sehingga tetap diperlukan
dua obat yaitu :
2. Bronkokonstriksi
1. Pengontrol dan
2. Pelega

SYM/029/Okt12-Okt13/RD
Picture is Available on http:www.mydr.com.au/asthma/asthma-and-your-airways accessed on 10-Dec-2010
 Levels of Asthma Control
Characteristic Controlled (all of the Partly controlled (Any Uncontrolled
following) measure present in
any week)
Daytime < 2 / week > 2 / week
symptoms
Limitation of None Any
activities
Nocturnal None Any > 3 features of
symptoms / partly controlled
awakening asthma present in
Need for reliever < 2 / week > 2 / week any week
/ rescue
treatment
Lung function Normal < 80% predicted or
(PEF or FEV1) personal best
ACT : Asthma Control Test
 Levels of Asthma Control
Characteristic Controlled (all of the Partly controlled (Any Uncontrolled
following) measure present in
any week)
Daytime < 2 / week > 2 / week
symptoms
Limitation of None Any
activities
Nocturnal None Any > 3 features of
symptoms / partly controlled
awakening asthma present in
Need for reliever < 2 / week > 2 / week any week
/ rescue
treatment
Lung function Normal < 80% predicted or
(PEF or FEV1) personal best
 Tingkat kontrol asma berdasarkan GINA

Terkontrol
Karakteristik
Characteristics Kontrol Tidak Terkontrol
Sebagian
Tidak ada Lebih dari 2 kali
Gejala harian (2 kali atau kurang /
minggu) / minggu
Pembatasan
Tidak ada Sesekali
aktifitas
Gejala bangun
Tidak ada Sesekali
3 atau lebih
parameter pada
asma terkontrol
QoL
malam sebagian

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Kebutuhan akan Tidak ada Lebih dari 2 kali muncul dalam
obat pelega
(2 kali atau kurang /
/ minggu setiap minggu
minggu)
<80% prediksi atau angka
Fungsi paru
Normal terbaik pribadi (jika
(PEF or FEV1) diketahui) dalam setiap hari

Satu kali / lebih

Satu kali dalam
Eksaserbasi Tidak ada dalam satu
satu minggu
tahun
 REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION

maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control

INCREASE
uncontrolled step up until controlled

exacerbation treat as exacerbation

REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
Kunci keberhasilan kontrol asma adalah
mengobati inflamasi sesegera mungkin
ketika gejala muncul

Kontrol Asma Gejala Asma Eksaserbasi

Inflamasi

Otot polos Bronkokonstriksi

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Kunci mengontrol gejala
dengan meningkatkan
terapi anti-inflamasi untuk
menghindari eksaserbasi
 Controllers
Inhaled & systemic Xanthines
Glucocorticosteroid Theophylline slow released
Prednisolone, betamethasone
Beclomethasone, budesonide Anti-leukotrienes
fluticasone Montelukast, Zafirlukast
Long acting β2-agonist
Salmeterol Mast cell stabiliser
Formoterol Sodium cromoglycates

Combinations
Salmeterol/Fluticasone
Formoterol/Budesonide
Salbutamol/Beclomethasone
 Pemberian anti inflamasi akan memperbaiki kondisi asma
pasien
Saluran Nafas Penderita Asma Dengan Anti Inflamasi
(Terapi Pencegahan)

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Bronkospasme
Lumen menyempit  Lumen lebih melebar
Inflamasi  Inflamasi berkurang
Edema  Edema berkurang
Kerusakan sel epitel  Sel epitel membaik
Hipertrofi kelenjar & hipersekresi  Hipertrofi kelenjar & hipersekresi
mukus berkurang
Penebalan membran dasar  Membran dasar membaik
PRINCIPLES IN ASTHMA MANAGEMENT

RELIEVER

Source: Peter J. Barnes, MD

 What are ‘relievers’?

• Rescue medication
• Qiuck relieve of symptoms
• Used during acute attacks
• Action lasts 4-8 hours
 Relievers
• Rapid acting inhaled β2-agonists
• Inhaled anti-cholinergic
– Ipratropium bromide
• Xanthines
– Short acting Theophyilline
• Short acting oral β2-agonists
 Prinsip Dasar Terapi
Inhalasi
● Prinsip:
Pemberian obat secara langsung ke
dalam saluran nafas melalui
penghisapan
● Onset cepat, dosis kecil, langsung ke

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target organ, efek samping minimal
 Indikasi
Meningkatkan bersihan sekret

Induksi sputum

Melembabkan gas respirasi

Mencegah atau mengobati bronkospasme

SYM/031/Okt12-Oktb13/RD
atau inflamasi saluran napas atas
 Keuntungan Terapi
Inhalasi versus Oral
Inhalasi Oral
Dosis Kecil Besar
Efek samping Sedikit Banyak
Mula kerja obat Cepat Lambat
Tempat kerja obat Langsung Tidak
Lama kerja obat Sama Sama

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Mencegah EIA Baik Tidak
Cara Pakai (koordinasi) Perlu Tidak perlu

*) EIA : Exercise Induced Asthma

 Nebuliser
● Aerosol keluar terus menerus
● Ukuran partikel 2 – 5 
● Pengendapan di paru 10% dosis
● Efek samping minimal

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Nebuliser
● Untuk Bayi

● Untuk Anak-anak

● Untuk Orang tua

● Penderita di ICU

SYM/031/Okt12-Oktb13/RD
 Severity of symptom classification

• Number of symptom episodes per week

• Number of nocturnal symptoms per month
• Objective measures of lung function (forced
expiratory volume in one second [FEV1], peak
expiratory flow rate [PEFR], PEF variability)
• At each evaluation, it is important to consider
whether or not a previous diagnosis was
correct:
– History and physical consistent with diagnosis
– Response to therapy consistent with symptoms
 Asthma severity
• Mild asthma: well controlled step 1-2 (reliever
medication alone, or with low intensity
controller treatment such as low dose ICS,
leukotriene rescetor antagonists or
chromones.
• Moderate asthma: well controlled with step 3
treatment e.g low dose ICS/LABA
• Severe asthma: high dose ICS/LABA (step 4-5)
 GAMBARAN KLINIS SEVERE ASTHMA

Feature Severe attack Life theatening

Breathless At rest Cyanosed at rest
Speech Words or phrases Too breathless to speak
Alertness Agitated Drowsy,confused
Resp rate > 25 x Tends to slowdown
Pulse >110x May progressively slow
with shock

Wheeze Loud Silent chest

PEF/FEV1 < 33%,respons thd b < 20%, sedikit/tak
dilator jelek respons thd b dilator

Paco2 < 40 mm Hg > 40 mm Hg

 Acute Exacerbation
• Transient worsening of asthma may occur
as a result of exposure to risk factors for
asthma symptoms or ‘triggers’
 Management of asthma
exacerbations in primary care

• Severe or life-threatening exacerbation:

– SABA
– Controlled oxygen and systemic corticosteroids
– Transfer to an acute care facility
 History????
• Timing of onset and cause exacerbation
• Severity of asthma symptoms any limiting
exercise? Disturbing sleep?
• Any symptoms of anaphylaxis?
• Any risk factors for asthma related death?
• Reliever and controller medications?
 Pemeriksaan fisik
• Signs of exacerbation severity and vital sign
(kesadaran, suhu, RR , TD, kemampuan
menyusun kalimat, penggunaan otot bantu
napas)
• Complicating factors (anaphylaxis;
pneumonia; pneumothorax)
• Kondisi lain? Gagal jantung? Benda asing ? Dll
• Pulse oximetry: saturasi < 90%
 Management of asthma
exacerbation in emergency dept.
• SABA
Mild or moderate: bicara • Pertimbangkan ipatropium
kalimat; tidak gelisah; • O2 saturasi 93-95% (anak2: 94-98%)
otot bantu napas (-); N • Oral steroid
100-120; O2 saturasi 90-
95%; PEF>50% predicted

• SABA
• Ipatropium Bromide
• O2 saturasi 93-95%
Severe • Oral atau IV steroid
• Pertimbangkan IV MgSO4
• Pertimbangkan High Dose ICS
 Assess clinical progress frequently measure
lung function

FEV 1 atau PEF < 60%

FEV 1 or PEF 60-80%  continue treatment as
pertimbangkan KRS above and reassess
frequently
 Management of asthma
exacerbation in primary care.
Mild or moderate: bicara • SABA 4-10 puff MDI, tiap 20 menit
kalimat; tidak gelisah; dalam 1 jam
otot bantu napas (-); N • O2 saturasi 93-95% (anak2: 94-98%)
100-120; O2 saturasi 90- • Prednisolon 1 mg/kg, max 50 mg,
95%; PEF>50% predicted anak2 1-2 mg/kg max 40 mg

• Transfer to acute care facility

• Sambil menunggu berikan SABA; O2,
Severe steroid sistemik
 Continue treatment with SABA as
needed  assess response at 1 hour
Arrange at discharge
Assess for discharge Reliever continue as
needed
Symptoms Improved: Follow up
SABA (-) Prednisolone continue
(5-7 days) Check and correct
PEF improved >60-80% modifiable risk factors
Follow up within 2-7
O2 sat > 94% days