Asma pada Anak

Dr Rahmini Shabariah SpA

 Definisi
1950-an OBSTRUKSI
SALURAN
RESPIRATORIK
YANG REVERSIBEL
 SECARA
SPONTAN ATAU
SETELAH
PENGOBATAN
TERATASI
 DEFINISI ASMA

 Inflamasi kronik saluran respiratorik

 Banyak sel dan elemen seluler berperan (sel
mast, eosinofil, limfosit T)
 Pada orang rentan, inflamasi kronik  episodik
wheezing berulang, batuk, sesak nafas, rasa
dada tertekan
 Berhubungan dengan penyempitan saluran
respiratorik yang luas dan bervariasi 
irreversibel sebagian atau teratasi spontan /
pengobatan
GINA, 2002
 Inflamasi
Deskuamasi epitel

Hiperplasi Mucus plug

kelenjar mukus

Penebalan
membrana basalis

Edema
Infiltrasi netrofil dan
Hipertrofi dan konstriksi eosinofil
otot polos
Barnes PJ
 • sensitive
Respiratory tract of childhood asthma: • reactive
• constriction
Triggers
(dust mite, exercise, etc)

Normal Attacks

•bronchoconstriction
•oedema
•hypersecretion

bronchus bronchus
 Inflamasi pada asma
Inflamasi akut

Respons
steroid

Inflamasi kronis

Perubahan struktur

Waktu

Barnes PJ
 Transient Non-Atopic
Wheezing berulang Asma
Wheezers Wheezers
• Major :
Kejadian wheezing

• Dermatitis atopi
• Orang tua asma
• Minor
• Eosinofil darah ↑
• Wheezing
• Rinitis alergika
• Asma: jika
• 2 major atau
• 1 major +2 minor

0 3 6 11
Umur (tahun)
Fig. 6. Hypothetical peak prevalence by age for the 3 different wheezing phenotypes.
The prevalence for each age interval should be the area under the curve. This does not
imply that the groups are exclusive.
Taussig LM, et al. JACI 2003; 111:661-675
 Diagnosis

“Cough and/or wheezing that:

•episodic,
•nocturnal (variability),
•reversibility
•with atopic family”
 Klasifikasi Asma
• Derajat serangan • Klasifikasi
(Akut) penyakit (kronis)
Ringan Asma episodik jarang
Sedang Asma episodik sering
Berat Asma persisten
Ancaman henti
napas
 Klasifikasi penyakit
Parameter klinis Asma Asma
Asma persisten
dan uji fungsi paru episodik jarang episodik sering

Frekuensi < 1x /bulan > 1x /bulan Setiap hari

Lamanya < 1 minggu >1 minggu Setiap hari

Antar serangan Tanpa gejala gejala(+) Gejala malam hari

Tidur dan aktivitas Normal Mungkin terganggu terganggu

Pemeriksaan fisis Normal Mungkin abnormal Abnormal

Pengendali Tidak perlu Steroid/kombinasi Steroid/kombinasi

Fungsi paru PEF/FEV1 <60%
PEF/FEV1 >80% PEF/FEV1 60-80%
(diluar serangan) Variabilitas 20-30%
Variabilitas
>15% > 30% > 50%
(serangan)
 Tujuan tatalaksana asma
• Gejala kronik minimal (idealnya tidak ada)
• Serangan akut minimal (jarang)
• Kunjungan ke UGD tidak pernah
• Penggunaan ß2-agonis minimal
• Aktivitas tidak terhambat
• Uji fungsi paru normal (mendekati)
• Efek samping obat minimal
 Tatalaksana asma
Penghindaran
alergen

Farmako
terapi
BIAYA Imuno
terapi

Pendidikan

GINA, 2002
 A
S
Asthma attacks
Assess and
T Triggers Management 3
H 2
M 1 No asthma attacks
A (Stable asthma)

Assess of
4
classification

Infrequent Frequent episodic Persistent

5
episodic asthma asthma asthma

6 EDUCATIONS and AVOIDANCE

Reliever (+) Reliever (+) 8 Reliever (+)

7
Controller (-) Controller (+) Controller (+)
 Asthma attacks algorithms

Emergency room
Assess severity.of attacks

Early treatment
• nebulized -agonist 3x, interval 20 min
• 3rd nebulized + anticholinergic

Mild attacks Severe attacks

(nebulized 1x, Moderate attacks
(nebulized 2-3x, (nebulized 3x,
good response) poor response)
partial response)
• observe 1-2 jam, • O2 • O2
discharge • reassessment  mode- • IV line
• symptoms (+)  rate ODC • reassessment 
moderate attack • IV line severe,
 admission
• Chest X-ray
 One Day Care (ODC) Admission room
Discharge • Oxygen therapy • Oxygen therapy
• give -agonist • Oral steroid • Treat dehydration and
(inhaled/oral) • Nebulized / 2 hour acidosis
• routine drugs • Observe 8-12 hours, • Steroid IV / 6-8 hours
• viral infection: if stable discharge • Nebulized / 1-2 hours
oral steroid • Poor response in 12 hrs, • Initial aminophylline IV,
• Outpatient clinic in  admission then maintenance
24-48 hours • Nebulized 4-6x 
good response per 4-6 h
• If stable in 24 hours 
discharge
• Poor response  ICU
Notes:
• In severe attack, directly use -agonist + anticholinergic
• If nebulizers not available, use adrenalin SC 0.01 ml/kg/times
with maximal dose 0.3 ml/times
•Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack
 Tidak ada respon tata laksana
• Dehydration
• Metabolic acidosis
• Atelectasis
 Tatalaksana
Saat serangan asma :
• 2 agonist : inhaled, nebilized, oral
• Ephinephrin : subcutan
• Theophyllin/aminophyllin : oral, I.V.
• Steroid : oral, I.M.

Pencegahan serangan :
• Avoidance : triggers (including enhancers,
inducers) especially improve
indoor environment.
• Medicine : steroid, DSCG, antileukotrien,
ketotifen, cetirizine.
 LONG TERM TREATMENT
2-adrenergic or/and theophylline
Infrequent Episodic inhaled/oral intermittently
Symptoms
6-8 weeks 3-6 months
>3 doses / week Evaluation

Add sodium cromoglicate

6-8 weeks 3-6 months

response (-) response (+)

Replace with low dose inhaled steroids

Frequent episodic Continue 2-adrenergic or/and
Symptoms theophylline inhaled/oral intermittently
6-8 weeks 3-6 months
response (-) response (+)
 6-8 weeks 3-6 months
respons (-) respons (+)

Consider :
Persistent Symptoms • Long acting 2-agonists, or
• Slow release 2-agonists, or
• Slow release theophyllines
6-8 weeks 3-6 months
respons (-) respons (+)

Increase dose of inhaled steroid

6-8 weeks 3-6 months
respons (-) respons (+)

Add oral steroids

 Kapan?
Klasifikasi Pengendali Pelega
(Controller) (Reliever)
Asma episodik tidak Ya
jarang
Asma episodik Ya Ya
sering
Asma persisten Ya Ya
 Medikamentosa
• Bronkodilator
• Antiinflamasi
• Antiremodeling
• Anti IgE
 Anti-inflamasi
• Antihistamin
• Disodium Cromoglycate (DSCG)
• Kortikosteroid
• Anti PDE 4 (Phosphodiesterase)
 Kortikosteroid
• Memperbaiki pengendalian asma pada anak
• Bukti-bukti penelitian:
 meningkatkan PEF (pagi dan sore)
 meningkatkan FEV1 (pagi dan sore)
 mengurangi variasi diurnal FEV1
 mengurangi gejala
 menurunkan frekuensi serangan asma
 mengurangi pengunaan obat pelega (2 agonis)
 Meningkatkan kualitas hidup

FEV1, forced expiratory volume in 1 second

PEF, peak expiratory flow
Keuntungan steroid inhalasi
• Dosis rendah
• Langsung ke sal respiratorik
• Onset (awitan) cepat
• Efek samping sistemik minimal
 Rasionalisasi steroid + LABA

Smooth muscle Airway

LABA dysfunction inflammation CS

 • Bronchoconstriction • Inflammatory cell 

 • Bronchial hyperreactivity infiltration / activation
 • Hyperplasia • Mucosa oedem 
• Inflammatory mediator release • Cellular proliferation 
 • Epithelial damage 
• Basement membrane thickening 

Symptoms / exacerbations
 Longterm steroid……

Efek samping
• Suara parau
• Iritasi farings
• Kandidiasis
• Sakit kepala
• Gangguan pertumbuhan??
 Tatalaksana (dalam penelitian)
• Anti IgE (Omalizumab)
– rhuMAb-E25 (recombinant humanized
monoclonal antibody)
– Kalau dengan steroid dan LABA tidak baik
• Anti-interleukin (IL-4, IL-5)
– Proses penelitian
• Imunisasi (rekayasa genetik)
– Penelitian
 Kesimpulan
• Asma: Inflamasi kronis dan remodeling
• Ketotifen dan Disodium cromoglycate: kurang
bermanfaat sebagai tatalaksana jangka
panjang
• Steroid dengan/atau kombinasi: obat pilihan
sebagai tatalaksana jangka panjang
• Indonesia: Pedoman Nasional Asma Anak
(UKK Respirologi IDAI)