Underlying cause of

asthma, diagnosis &

management
Agenda
1. Burden of asthma
2. Prevalence and asthma definition
3. Pathophysiology & inappropriate treatment
4. Diagnosis of asthma
5. Goal of asthma management
6. Asthma characteristic
Burden of asthma
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million
affected individuals
Prevalence is increasing in many countries, especially in children
Asthma is a major cause of school and work absence
Health care expenditure on asthma is very high
 Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma.
 Developing economies likely to face increased demand due to increasing prevalence of asthma
 Poorly controlled asthma is expensive
 However, investment in prevention medication is likely to yield cost savings in emergency care

GINA 2015
What is known about asthma?
Asthma is a common and potentially serious chronic disease that can be controlled but not
cured
Asthma causes symptoms such as wheezing, shortness of breath, chest tightness and cough that
vary over time in their occurrence, frequency and intensity
Symptoms are associated with variable expiratory airflow, i.e. difficulty breathing air out of the
lungs due to
◦ Bronchoconstriction (airway narrowing)
◦ Airway wall thickening
◦ Increased mucus

Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco
smoke, exercise and stress

GINA 2015
What is known about asthma?
Asthma can be effectively treated
When asthma is well-controlled, patients can

Avoid troublesome symptoms during the day and night

Need little or no reliever medication
Have productive, physically active lives
Have normal or near-normal lung function
Avoid serious asthma flare-ups (also called exacerbations, or severe attacks)
Prevalence & asthma definition
Asthma prevalence & mortality

SYM/029/Okt12-Okt13/RD
Source: Masoli M et al. Allergy 2004
 Asthma prevalence in Indonesia

Indonesia: 2-3%
(1990)*

SYM/029/Okt12-Okt13/RD
Lai, C K W et al. Thorax 2009;64:476-483
* JAMA 2001;286:

Figure 1 Prevalence of current wheeze according to the written questionnaire in the 13-14 year age group. See text for definition of current wheeze. The
symbols indicate prevalence values of <5% (blue square), 5 to <10% (green circle), 10 to <20% (yellow diamond) and >20% (red star).
 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

that vary over time and in

intensity, together with
variable expiratory airflow
limitation.
GINA 2015
Pathophysiology & inappropriate treatment
 A Lot Going On
Beneath The Surface

Symptoms
Airflow
obstruction
Bronchial
hyperresponsiveness
Airway
inflammation

Warner O. Am J Resp Crit Care Med 2003; 167: 1465–1466.

Fight asthma Milwaukee allies
 Inflammation and clinical impact
• Characterized by eosinophils, mast cells and Th2 lymphocytes
• These inflammatory cells release mediators that triggers:
– Bronchoconstriction
– Mucous secretion
– Remodeling

Bergeron, airway remodelling in asthma: from benchside to clinical practice. Can Respir J Vol 17 No 4 July/August 2010
 Inappropriate treatment

Asthma is a chronic disease that can lead to permanent lung damage

Permanent changes in the airways appear to result from repeated asthmatic
events causing recurrent bouts of inflammation of the bronchi

Which in turn can lead to:

- Airway fibrosis (scarring)
- Permanent narrowing of the airwats (remodeling)

The asthma center.org

Epithelial Damage

P Jeffery, in: Asthma, Academic Press 1998

Basement Membrane
Thickening

P Jeffery, in: Asthma, Academic Press 1998

Smooth Muscle Hyperplasia

P Jeffery, in: Asthma, Academic Press 1998

 Normal Asma

Courtesy of Prof Faisal Yunus

Diagnosis of asthma
 Diagnosis of asthma
• The diagnosis of asthma should be based on:
– A history of characteristic symptom patterns
– Evidence of variable airflow limitation, from bronchodilator reversibility testing or other
tests

• Document evidence for the diagnosis in the patient’s notes, preferably before
starting controller treatment
– It is often more difficult to confirm the diagnosis after treatment has been started

• Asthma is usually characterized by airway inflammation and airway

hyperresponsiveness, but these are not necessary or sufficient to make the
diagnosis of asthma.

GINA 2015
 Making the diagnosis of asthma
• Asthma is a disease with many variation (heterogeneous),
usually characterized by chronic airway inflammation.
• Two key defining features:
– A history of respiratory symptoms such as wheeze, shortness of
breath, chest tightness and cough that vary over time and in
intensity. AND
– Variable expiratory airflow limitation

GINA 2015
 Patient with
respiratory symptoms
Are the symptoms typical of asthma?

YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?

YES

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

YES

Treat for ASTHMA

GINA 2015, Box 1-1 (1/4) © Global Initiative for©Asthma

Global Initiative for Asthma
 Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
YES Alternative diagnosis confirmed?

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

YES YES

Treat for ASTHMA Treat for alternative diagnosis

GINA 2015, Box 1-1 (2/4) © Global Initiative for©Asthma

Global Initiative for Asthma
 Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
YES Alternative diagnosis confirmed?

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

YES NO YES

Consider trial of treatment for

most likely diagnosis, or refer
for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2015, Box 1-1 (3/4) © Global Initiative for©Asthma

Global Initiative for Asthma
 Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and
YES Alternative diagnosis confirmed?
other diagnoses unlikely

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

Empiric treatment with YES NO YES

ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2015, Box 1-1 (4/4) © Global Initiative for©Asthma

Global Initiative for Asthma
Diagnosis of asthma – symptoms

 Increased probability that symptoms are due to asthma if:

 More than one type of symptom (wheeze, shortness of breath, cough, chest tightness)
 Symptoms often worse at night or in the early morning
 Symptoms vary over time and in intensity
 Symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather,
laughter, irritants such as car exhaust fumes, smoke, or strong smells
 Decreased probability that symptoms are due to asthma if:
 Isolated cough with no other respiratory symptoms
 Chronic production of sputum
 Shortness of breath associated with dizziness, light-headedness or peripheral tingling
 Chest pain
 Exercise-induced dyspnea with noisy inspiration (stridor)

GINA 2015 © Global Initiative for Asthma

 Box 3. How to assess a patient with asthma

1. Asthma control – assess both symptom control and risk factors

• Assess symptom control over the last 4 weeks (Box 4, p9)
• Identify any other risk factors for poor outcomes (Box 4)
• Measure lung function before starting treatment, 3-6 months later, and then periodically, e.g.yearly

2. Assess treatment issues

• Record the patient's treatment step (Box 7, p14), and ask about side-effects
• Watch inhaler using their inhaler, to check their technique (p18)
• Have an open empathic discussion about adherence (p18)
• Check that the patient has a written asthma action plan (p22)
• Ask the patient about their attitudes and goals for their asthma

3. Assess comorbidities

• This include rhinitis, rhinosinusitis, gastroesophageal reflux (GERD), obesity, obstructive sleep
apnea, depression and anxiety
• Comorbidities should be identified as they may contribute to respiratory symptoms and poor quality
of life. Their treatment may complicate asthma management

GINA 2015
 The control-based asthma management cycle

Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors

GINA 2015, Box 3-2 © Global Initiative for Asthma

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? Yes No
• Any activity limitation due to asthma? Yes No

*Excludes reliever taken before exercise, because many people take this routinely

This classification is the same as the GINA 2010-12

assessment 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

 Benchmarks of Good Asthma Control

• Infrequent coughing or wheezing

• No shortness of breath or difficulty breathing
• No waking up at night due to asthma
• Normal physical activities
• No childcare or school absences due to asthma
• No missed time from work for parent or caregiver

AAAAI Guide
Goal of asthma management
Asthma management: control and reduce

OVERALL ASTHMA CONTROL

To achieve Reduce

Current control Future risks

Defined by Defined by

Asthma
Symptoms Reliever use Exacerbation
worsening

Lung function Side effect of

Activity Lung function
decline treatment

Adapted from: Bateman E et al. J Allergy Clin Immunol 2010:125(3);600-08

 Stepwise management - pharmacotherapy

Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors

STEP 5
BUD/formoterol STEP 4

STEP 3 *For children 6-11 years,

Refer for theophylline is not
PREFERRED STEP 1 STEP 2
CONTROLLER
add-on recommended, and preferred
CHOICE treatment Step 3 is medium dose ICS
Med/high
e.g.
ICS/LABA **For patients prescribed
Low dose anti-IgE BDP/formoterol or BUD/
Low dose ICS ICS/LABA* formoterol maintenance and
reliever therapy
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium# Add # Tiotropium by soft-mist
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS tiotropium#
inhaler is indicated as add-on
+ LTRA Add low
options (or + theoph*)
(or + theoph*) dose OCS treatment for adults
(≥18 yrs) with a history of
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
RELIEVER exacerbations
low dose ICS/formoterol**

GINA 2015, Box 3-5 (2/8) (upper part)

BUD/formoterol
Asthma characteristic
 Asthma characteristic
• The earlier the treatment is given, the easier to
prevent/control asthma symptoms

• The longer and heavier the asthma symptoms happen, the

more difficult to treat and cure

Courtesy of Prof Faisal Yunus

 Asthma Control and Steroid Doses After
Early or Delayed Intervention
• Patients with asthma started on budesonide were
compared based on duration of asthma at budesonide
initiation
– Asthma for <2 years
– Asthma for 2 years
• Outcomes assessed
– Lung function: FEV1, PEF
– Persistent need for inhaled corticosteroid
– Persistent symptoms
Selroos et al. Respir Med. 2004;98:254-262.
Sources: Fight asthma Milwaukee allies
 Mean ICS (budesonide) Doses and Lung Function
5 Years After Early or Delayed Intervention

Inhaled steroid
1000 FEV1 % pred 100

900 825 PEF, % pred

95
800 93.9 95

% of Predictive FEV1, PEF

Dose of Inhaled Steroid

700
600 90
87.2
500
412 84.5
400 85

300
200 80
100
0 75
Early Treatment Delayed Treatment

Selroos et al. Respir Med. 2004;98:254-262.

Sources: Fight asthma Milwaukee allies
The key for asthma control success rate
is to give early intervention

Asthma control Asthma symptoms Exacerbation

Inflammation

Smooth muscle Bronchoconstriction

 Corticosteroids for Asthma:
Benefits and Risks

Dose, drug, &

route dependent
Reduces
inflammation Generally known
and can be
Decreases monitored
morbidity / mortality
Most effective Risks
long-term control
medication for
asthma*
Benefits

Sources: Fight asthma Milwaukee allies

 ICS/LABA benefit from studies
low-dose ICS + LABA vs. “other therapy” results in:

•  Lung function
•  Symptoms
•  Albuterol use
•  Exacerbations
• Reduces need to increase ICS dose
Replicated numerous times by other investigators
Greening et al. Lancet. 1994;344:219-224.
Woolcock et al. Am J Respir Crit Care Med. 1996;153:1481-1488
Nelson et al J Allergy Clin Immunology 2000;106:1088-1095
 Penanganan Asma Eksaserbasi di Fasilitas Penanganan Akut (UGD)
Apakah gejala berikut menyertai?
PENILAIAN AWAL
A: Airway B:Breathing C:Circulation Mengantuk berat, kebingungan, silent chest

Tentukan terapi berdasarkan status klinis pasien, Konsul ke ICU, terapi dengan SABA dan O2,
Dinilai dari gejala yang paling parah dan persiapkan pasien untuk intubasi

RINGAN atau SEDANG BERAT

Bicara dalam frasa Bicara dalam kata
Memilih posisi duduk dibanding berbaring Posisi tubuh duduk membungkuk ke depan
Tidak gelisah Gelisah
Laju respirasi meningkat Laju respirasi > 30 kali per menit
Otot bantu napas tidak digunakan Otot bantu napas digunakan
Denyut jantung 100-120 denyut/menit Denyut jantung > 120 denyut/menit
Saturasi O2 (di udara) 90-95% Saturasi O2 (di udara) < 90%
APE > 50% dari angka prediksi atau nilai tertinggi APE ≤ 50% dari angka prediksi atau nilai tertinggi
 Penanganan Asma Eksaserbasi di Fasilitas Penanganan Akut (UGD)

RINGAN atau SEDANG BERAT

Beta-2-agonis kerja cepat (SABA) Beta-2-agonis kerja cepat
Kontrol O2 untuk mempertahankan saturasi hingga 93-95% (pada anak 94-98%) Pertimbangkan kortikosteroid inhalasi dosis tinggi
Kortikosteroid oral Ipratropium bromida
Pertimbangkan ipratropium bromida Kontrol O2 untuk mempertahankan saturasi hingga 93-95% (pada anak 94-98%)
Kortikosteroid oral atau IV
Pertimbangkan magnesium IV

Konsul ke ICU,
Jika pasien terus memburuk, lakukan terapi sebagai terapi dengan SABA & O2,
derajat BERAT dan nilai ulang untuk terapi di ICU dan persiapkan intubasi

PENILAIAN ULANG ATAS KEMAJUAN KLINIS SECARA BERKALA

UKUR FUNGSI PARU pada semua pasien, satu jam setelah terapi awal

VEP1 atau APE <60% dari angka prediksi

VEP1 atau APE 60-80% dari angka prediksi
atau nilai terbaik, atau respon klinis kurang
atau nilai terbaik dan gejala membaik dari
memadai dari derajat BERAT
derajat SEDANG
Lanjutkan terapi seperti diatas dan lakukan
Pertimbangkan untuk pasien dipulangkan
Penilaian secara berkala

GINA Updated 2014

 Penanganan Asma Eksaserbasi di
pelayanan kesehatan primer

PENILAIAN Apakah asma?

Ada faktor resiko asma mengancam jiwa?
PASIEN Derajat keparahan eksaserbasi?

RINGAN atau SEDANG BERAT

Bicara dalam frasa Bicara dalam kata
Memilih posisi duduk dibanding berbaring Posisi duduk membungkuk ke depan
Tidak gelisah Gelisah MENGANCAM JIWA
Laju respirasi meningkat Laju respirasi > 30 kali per menit
Otot bantu napas tidak digunakan Otot bantu napas digunakan Mengantuk berat, bingung, atau silent
Denyut jantung 100-120 denyut/menit Denyut jantung > 120 denyut/menit chest
Saturasi O2 (di udara) 90-95% Saturasi O2 (di udara) < 90%
APE > 50% dari angka prediksi atau APE ≤ 50% dari angka prediksi atau nilai tertinggi
nilai tertinggi

TERAPI AWAL
SABA: 4-10 semprot dengan MDI + spacer, PINDAHKAN KE FASILITAS PENANGANAN
Ulangi setiap 20 menit selama 1 jam AKUT (UGD)
Prednisolon: dewasa 1mg/kg, maks. 50 mg, anak 1-2 mg/kg, maks. 40 mg MEMBURUK
Selama menunggu: berikan SABA, O2,
Oksigen (jika ada): target saturasi 93-95% (anak: 94-98%) kortikosteroid sistemik

LANJUTKAN TERAPI dengan SABA sesuai keperluan

MEMBURUK
PENILAIAN RESPON SETELAH 1 JAM (atau lebih awal)
APE: Arus Puncak Ekspirasi; SABA:Short-Acting Beta2-Agonist
 Penanganan Asma Eksaserbasi di pelayanan kesehatan primer
LANJUTKAN TERAPI dengan SABA sesuai keperluan
PENILAIAN RESPON SETELAH 1 JAM (atau lebih awal)

PENILAIAN UNTUK PASIEN DIPULANGKAN

Gejala membaik, tidak memerlukan SABA Pelega: lanjutkan sesuai kebutuhan

APE membaik dan >60-80% dari nilai terbaik atau prediksi Pengontrol: mulai atau tingkatkan dosis ICS atau
ICS/LABA*. Cek teknik penggunaan inhaler & kepatuhan.
Saturasi oksigen >94% udara ruangan Prednisolon: lanjutkan, utk 5-7 hari (3-5 hari pada anak)
Penunjang di rumah memadai Tindak Lanjut: selama 2-7 hari

TINDAK LANJUT

Pelega: dikurangi hingga sesuai kebutuhan pasien

Pengontrol: lanjutkan dosis tinggi untuk jangka pendek (1-2 minggu) atau jangka panjang (3 bulan), tergantung riwayat eksaserbasi
Faktor resiko: periksa dan koreksi pada faktor resiko termodifikasi yang dapat menyebabkan eksaserbasi, termasuk teknik penggunaan inhaler dan kepatuhan
Rencana Aksi: Apakah pasien paham? Apakah digunakan teratur? Apakah memerlukan modifikasi?

ICS: Inhaled CorticoSteroid

LABA: Long-Acting Beta2-Agonist
 Conclusion
• Asthma symptoms is just an iceberg. A lot going on beneath
the surface.
• The objective of asthma management is to achieve current
control and to reduce future risk
• GINA 2015 recommend 5 step of asthma management.
ICS/LABA should be given to patients in step 3 and above
• Study showed the earlier intervention (study with Budesonide
ICS), the better asthma controlled is achieved
Thank you