REFERAT

ASMA BRONKHIAL

SABRINA AZIMA
201820401011157

PEMBIMBING:
DR. AFAN FATKHUR SP.P

SMF ILMU KESEHATAN PARU RSU HAJI SURABAYA

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH MALANG
PENDAHULUAN

 Asma bronkial merupakan kelainan saluran napas kronik yang

merupakan salah satu masalah kesehatan masyarakat di
dunia. Penyakit ini dapat terjadi pada berbagai usia, baik laki-
laki maupun perempuan.
 Dalam dekade terakhir ini prevalensi asma bronkial cenderung
meningkat, sehingga masalahpenanggulangan asma menjadi
masalah yang menarik
DEFINISI

Menurut GINA  penyakit heterogen,

biasanya ditandai dengan peradangan
saluran napas kronis.

Didefinisikan dengan riwayat

gejala pernapasan seperti:
- Mengi -sedak dada
- Sesak napas -batuk
Epidemiologi

 World Health Organization (WHO) tahun 2017 memperkirakan

235 juta penduduk dunia saat ini menderita penyakit asma.
 Setengah dari seluruh kasus diawali sebelum berumur 10 tahun
dan sepertiga bagian lainnya terjadi sebelum umur 40 tahun.
 Pada usia anak-anak, terdapat perbandingan 2:1 untuk lakki-
laki dibandingkan wanita, namun perbandingan ini menjadi
sama pada umur 30 tahun.
Faktor Resiko (GINA)

1. Pasien dengan minimal 1 5. Permasalahan psikologis

faktor resiko eksaserbasi besar
2. Minimal 1 periode 6. Permasalahan sosioekonomi
eksaserbasi berat di tahun besar
terakhir
7. Alergi makanan terkonfirmasi
3. Paparan tembakau dan
rokok 8. Paparan allergen jika
tersensitisasi
4. Penurunan 𝐹𝐸𝑉1 , terutama
<60% prediksi 9. Eosinofilia pada sputum
Patofisiologi

Asma

Inflamasi akut Inflamasi Kronik

Reaksi asma fase Reaksi asma Tipe

lambat Cepat
 Pembentukan
Diolah
Alergen Sel Th IgE dan sel
APC
radang lain

Pembentukan
Mediator
inflamasi

Infiltrasi Peningkatan
Sekresi Fibrosis sub
sel Edema permeabilitas
mukus epitel
radang kapiler

Hiperreaktivitas
saluran napas
 Diagnosis
- Riwayat pengulangan
batuk mengi
Diagnosis asma ditegakkan - Riwayat asma
berdasarkan (Gina,2018): sebelumnya
Anamnesis
- Riwayat keluarga
(atopik)
- Riwayat alergi/atopik
- Keluhan berkurang
dengan pemberian
Pemeriksaan obat asma
Fisik

Pemeriksaan
Penunjang
Klasifikasi
Diagnosis Banding

Kategori Kriteria
Penyakit penyebab sesak PPOK, penyakit jantung
berulang coroner, GERD, gagal jantung
kongestif, emboli paru

Penyakit yang Rhinitis, sinusitis, otitis,

menimbulkan batuk bronkiektasis

Penyakit yang sering PPOK, cystic fibrosis

menimbulkan obstruksi
saluran nafas
Penggolonan obat asma

Controller
 Kotrikosteroid (inhalasi, sistemik)
 Leukotriene modifeier
 Long acting b2 agonist (LABA) :
inhalasi, oral
 Chromolin: Sodium cromoglycate
dan Nedocromil
 Teofilin lepas lambat
 Anti IgE
 Antikolinergik: Tiotropium
Reliever
 Short acting b2 agonist
(SABA) : inhalasi, oral
 Kortikosteroid sistemik
 Antikolinergik : Ipratropium
br, oxitropium
 Teofilin
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
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

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**
 Step 1 – as-needed inhaled
short-acting
beta2-agonist (SABA)
STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
 Step 2 – low-dose controller +
as-needed
inhaled SABA
STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS
tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
 Step 3 – one or two
controllers + as-needed
inhaled reliever
STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
© Global Initiative for Asthma
 Step 4 – two or more
controllers + as-needed
UPDATED!

inhaled reliever
STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS
tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
© Global Initiative for Asthma
 Step 5 – higher level care UPDATED!

and/or add-on treatment

STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS
tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
 Non-pharmacological
interventions
 Avoidance of tobacco smoke exposure
 Provide advice and resources at every visit; advise against
exposure of children to environmental tobacco smoke (house,
car)
 Physical activity
 Encouraged because of its general health benefits. Provide
advice about exercise-induced bronchoconstriction
 Occupational asthma
 Ask patients with adult-onset asthma about work history. Remove
sensitizers as soon as possible. Refer for expert advice, if available
 Avoid medications that may worsen asthma
 Always ask about asthma before prescribing
 (Allergen avoidance)
 (Not recommended as a general strategy for asthma)

This slide shows examples of interventions with high quality evidence

GINA 2015, Box 3-9
 Evaluasi pengobatan
Asma
Step up terapi asma
Diperlukan jika dalam keadaan asma tidak terkontrol, faktor resiko tinggi dan eksaserbasi
 Sustained step up (untuk < 2 – 3 bulan) ; perbaiki cara dan ketaatan pemakaian
inhaler serta faktor resiko modifikasi seperti merokok untuk dieliminasi kemudian
evaluasi 2 – 3 bulan jika tidak ada respon lanjutkan untuk step berikutnya,
pengobatan alternatif dan pertimbangkan rujukan
 Short term step up ( untuk 1 – 2 minggu ) ; sesekali menaikkan dosis maintenance
ICS selama 1-2 minggu misalnya pada saat terjadi infeksi, alergi atau penyakit
comorbid lainnya
 Day to day adjustment ; untuk pasien yang diberikan resep obat
budesonide/formoterol, beclometason/formoterol sebagai maintenance dan terapi
relivier. Memerlukan tambahan dosis pada ICS/formoterol dalam hari ke hari
menurut gejalanya.
Step down terapi ketika asma sudah terkontrol
 Ketika kontrol asma yang baik telah dicapai dan dipertahankan selama 3 bulan dan fungsi
paru – paru telah mencapai plateu serta faktor resiko yang rendah. pengobatan biasanya telah
berhasil untuk dikurangi tanpa kehilangan kontrol asma. Tujuan step down adalah :
 Untuk menemukan efek terapi minimal yang bermanfaat untuk mempertahankan
kontrol asma yag baik dari gejala dan eksaserbasi serta meminimalkan biaya
pengobatan dan potensi efek samping
 Mendorong pasien untuk melanjutkan perawatan kontrol secara teratur 21
Asthma flare-ups
(exacerbations)

GINA Global Strategy for Asthma

Management and Prevention

© Global Initiative for Asthma

Definisi

 Suatu episode asma (sesak nafas, batuk,

mengi, rasa tertekan) yang terjadi
secara progresif dan cepat (akut).
Assessment of risk factors for poor asthma
outcomes
Risk factors for exacerbations include:
• Uncontrolled asthma symptoms
Additional risk factors, even if the patient has few symptoms:
• High SABA use (≥3 canisters/year)
• Having ≥1 exacerbation in last 12 months
• Low FEV1; higher bronchodilator reversibility
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Obesity, chronic rhinosinusitis, pregnancy, blood eosinophilia
• Elevated FeNO in adults with allergic asthma taking ICS
• Ever intubated for asthma
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia; pre-term birth, low birth weight
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitors
© 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 phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
LIFE-THREATENING
Talks in words, sits hunched
forwards, agitated Drowsy, confused
Respiratory rate >30/min or silent chest
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best URGENT

START TREATMENT
SABA 4–10 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 1–2 mg/kg, max. 40 mg While waiting: give inhaled
SABA and ipratropium bromide,
Controlled oxygen (if available): target O2, systemic corticosteroid
saturation 93–95% (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
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate
Reliever: continue as needed
Controller: start, or step up. Check inhaler
technique, adherence
Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Follow up: within 2–7 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 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?
 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 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT

START TREATMENT
TRANSFER TO ACUTE
SABA 4–10 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 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)

© Global Initiative for Asthma

START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (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 5–7 days
(3-5 days for children)
Resources at home adequate
Follow up: within 2–7 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 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?

© Global Initiative for Asthma

Prognosis

 Dalam kasus-kasus ringan sampai sedang, asma dapat

meningkatkan dari waktu ke waktu, dan banyak orang
dewasa bahkan bebas dari gejala.
 Pada sekitar 10 % kasus persisten berat, perubahan dalam
struktur dinding saluran nafas menyebabkan masalah progresif
dan ireversibel dalam fungsi paru-paru, bahkan pada pasien
yang diobati secara agresif .