You are on page 1of 43

BY MONICA HARVRIZA

Epidemiology
Prevalens in Indonesia
in 2002 6,7% 13-14 thn ( Rahajoe NN )

Lost of school days costs for asthma treatment

Definition
GINA a chronic respiratory tract inflammation involved cells such mast cell, eosinofil and lymfocyte T, characterized by wheezing, breathlessness, cough, chest tightness, usually present at night

Definition
Pedoman Nasional Asma Anak Wheezing and or cough that characterized : episodic and/ chronic, tend at night, seasonal, triggers are present, such physical activities and reversible spontaneusly or with medication and there is an asthma hystory or other atopy sign in patient or family

Etiology
Not certain Multifactorial disease
genetics Biochemistry Immunology Infection Endocrine Phsycology Environment

PATOGENESIS

Immune Mediated

Acute and chronic inflammation


IgE specific allergen in early stage mast cells and basofil mediator : histamine, proteolitic enz, glikolitic enz, heparin, adenosin, and reactive oxygen Fosfolipase A2 activated in late stage arachidonic acid activation prostaglandin, leucotrien Those mediator contraction of resp tract smooth muscle, stimulate aferen nerve, mucous hypersecretion, vasodilatation, microvascular leakage

Remodelling Respiratoric Tract


Fibroblas
TGF-

Myofibroblas

GF, chemokin and cytokin Proliferation of smooth muscle, permeability , neovaskularisation, matrix depotition

Structure change

Patofisiology
Histamin, triptase, prostaglandin, leucotrien, neuropeptide of afferen nerve, acetilcholin

Smooth muscle contraction, oedem, inflammatory cells infiltration, remodeling, hipertrophyi and hiperplation + mucous secretion

Respiratory tract obstruction

CLASIFICATION
PNAA 1. Mild Intermitten Asthma (Mild Asthma) 2. Moderate Intermitten Asthma (Moderate Asthma) 3. Persistent Asthma (Severe Asthma)

CLASIFICATION

1. 2. 3. 4.

GINA (1995)
Intermitten Asthma Mild Persistent Asthma Moderate Persistent Asthma Severe Persistent Asthma

Clasification of asthma severity


Clinical parameter, drugs usage, and pulmonary test Mild asthma Moderate asthma Severe asthma

1. Acute frequency
2. Lama serangan 3. Between acute episode 4. Sleep and activities

< 1 x / month
< 1 week No symptoms Normal

> 1 x / month
> 1 week Sometimes symptoms present Often disturbed

Often
Along year, no remition Symptoms present day and night Very disturbed

5. Physical examination during remition


6. Anti inflammation drugs as controller 7. Lung test( beyond acute episode ) 8.Lung variability (in acute episode)

Normal
Not necessary

Maybe abnormal
Low dose non steroid/steroid inhaler

Never normal
Oral steroid/inhaler PEF / FEV1 < 60% > 50%

PEF / FEV 1 > 80% PEF / FEV 1 60-80% 15% > 30%

Clinical Manifestation (1)

1. Grade I - Bronchial wall oedem - Paroksismal cough - Dry cough - Thick mucous

Clinical Manifestation (2)


2. Stadium II - Cough with clear mucous - Breathlessness - Wheezing - Work of breathing Stadium III : - Obtruction & severe bronchial spasm - Short breath and irregular - Tachypneu

3.

Anamnesis
Episodic Breathlessness Episodic Wheezing Episodic Cough Chest tightness Asthma history or other atopy sign in patient or family

Physical Examination
Tachypneu Prolonged expiration Cough Retraction : suprasternal, supraclavicula, epigastrium, and intercostae Hipersonor Rales Failure to thrive

Diagnosis
BATUK DAN ATAU MENGI PATUT DIDUGA ASMA EPISODIK NOKTURNA/MORNING DIP MUSIMAN PASKA AKTIFITAS FISIK R/ ATOPIK PASIEN/KELUARGA JIKA FASILITAS ADA, PX PEAK FLOW METER ATAU SPIROMETRI UNTUK MENILAI : REVERSIBILITAS (> 15 %) VARIABILITAS (>15%) RIWAYAT PENYAKIT PEMERIKSAAN FISIS UJI TUBERKULIN TIDAK JELAS ASMA : TIMBUL MASA NEONATUS GAGAL TUMBUH INFEKSI KRONIK MUNTAH/TERSEDAK KELAINAN FOKAL PARU KELAINAN SITEM KARDIOVASKULER

BERIKAN BROKHODILATOR

TIDAK BERHASIL

PERTIMBANGKAN PX : FOTO THORAKS DAN SINUS UJI PARU-PARU RESPON THD BRONKHODILATOR UJI IMUN

BERHASIL TIDAK MENDUKUNG DIAGNOSIS LAIN MENDUKUNG DIAGNOSIS LAIN

DIAGNOSIS KERJA : ASMA

TENTUKAN DERAJAT DAN PENCETUSNYA : BILA ASMA SRG / PERSISTEN FOTO RONTGEN

DIAGNOSIS DAN PENGOBATAN SESUAI DIAGNOSIS KERJA

BERIKAN OBAT ANTI ASMA : TIDAK BERHASIL NILAI ULANG DIAGNOSIS DAN KETAATAN BEROBAT

PERTIMBANGKAN ASMA SEBAGAI PENYAKIT PENYERTA

BUKAN ASMA

Studies
Children < 3 years + respon for systemic steroid and bronchodilator for 5 days children > 6 years peak flow meter or spirometer
Variability PFR atau FEV1 > 15 % Reversibility PFR atau FEV1 > 15 % Decreasing > 20% FEV1 after provocation with metacholin or histamin

Blood test : eosinofil and IgE increase Chest radiography Provocation test

DD/

Acute Bronchiolitis Bronchitis Bronchial Stenosis Corpus Allienum Bronchiektasy Rhinitis Allergic

Complication
Emphysema Atelectasis Pneumothoraks Bronchiektasis Bronchopneumonia Heart failure Death !!!

Management

Goals
Patient can have normal activities include playing and exercise Few lost of school days The symptom doesnt present at day and night Normal or minimal abnormal lung test Less drug requirement Less or no side effect in treatment

Drugs Reliever Drug Controller Drug

Reliever Drugs
Bronchodilator Short Acting 2Agonist (SABA)
Terbutalin 0,05-0,1 mg/Kg Salbutamol 0,05-0,1 mg/Kg Oksiprenalin Heksoprenalin Fenoterol

Xantin (for acute episode)


Teofilin initial dose 10 mg/kg, max dose 300 mg/d

Controller Drugs
Anti-inflamasi non steroid Anti-inflamasi steroid
Kromoglikat (MDI) no longer exist Nedokromil (MDI) no longer exist Budesonid (MDI, terbuhaler) Beklometason (MDI)
Low dose 84-336 g/d Medium dose 336-672 g/d High dose > 672 g/d

agonist long action

Prokaterol (syrup, tablet, MDI) Bambuterol (tablet) Salmeterol (MDI)

Controller Drugs
Slow release drugs
Terbutalin (capsul) Salbutamol (tablet) Teofilin (tablet salut)

Anti leukotrien
Zafirlukas (tablet)

Combination of steroid + LABA


Budesonid + formoterol Flutikason + salmeterol

Mild Asthma
Reliever Drugs
Bronkodilator Short Acting 2-Agonist (SABA) Xantin

Moderate Asthma
Reliever Drugs Controller Drugs
Thp I : Steroid inhaler(6-8weeks)
Budesonid 100-200 g/d (50-100 g/d flutikason) for children < 12 years Budesonid 200-400 g/hr (100-200 g/hr flutikason) for children > 12 years

Evaluation after 6-8 weeks, if no respons


Increase the dosage 400 g/hr (persistent asthma management)

Persistent Asthma
Inhaler steroid 400 g/d Budesonid If no respons
Medium/low dose inhaler steroid + LABA/theophyline slow release/anti leukotrien receptor

If no respons
High dose inhaler steroid + LABA/TSR/ALTR

Final step
Oral steroid

Management of acute episode of asthma

Definition
The episode of progressive increasing symptoms (worse) from cough, breathlessness, wheezing, chest tightness or the combination of those symptoms.

Patophysiology
Triggers

Bronchoconstriction, mucosal oedem, over secretion


Obstruction of resp. tract

Ventilation unpair

Lung hyperinflation
Compliance disorder Work of breathing

Atelectasis

Ventilation-perfution failure Alveolar hipoventilation ascidosis PaCO2

Surfactant

Pulmonal vasoconstriction

PaCO2

Clasification of acute episode asthma


Clinical parameter, lung test, and labo breathlessnes s

Mild
Walk Baby : loud cry Can lay

Moderate Severe
Talk Baby :short cry and weak hard to eat Prever to sit Rest Baby :daoest want to drink or eat Sit with hand at the back

Threat of respiratory arrest

Position

Speech
Conciousness cyanosis wheezing

Sentences
Maybe irritable Not present Moderate, present only at the end of expiration

Cut of sentence
Usually irritable Not present High pitch, along expiration, inspiration

Words
Usually irritable Present Very high pitch, heard without stethoscope Confuse Real Difficult to hear

Usage of additional resp muscle retraction

No

Usually yes

yes

Paradoks movement torako-abd

Short, inatercostal retraction tachypneu normal Not present < 10 mmHg

Moderate, plus suprasternal retraction tachypneu takikardi Present 1020 mmHg

Deep, plus ala Short/disappe nasi breath ar

Respiratory frequency Pulse frequency Pulsus paradoksus

tachypneu takikardi Present >20 mmHg

bradypneu bradikardi Not present, sign of reaspiratory weekness

SaO2
PaCO2

>95%
<45 mmHg

91-95%
<45 mmHg

<90%
> 45 mmHg

Management acute episode of asthma in clinic/emergency


Mild acute asthma episode
Nebulation with agonis + NaCl 0,9% Observe 1 hour if good respons, the patient can go home Give agonis ( inhaler/oral) every 4-6 hours

Moderate acute asthma episode


Sistemic steroid metilprednisolon 0,5-1 mg/Kg/d for 3-5 days Observe in one day care room

Management acute episode of asthma in clinic/emergency


Severe acute asthma episode
Nebulate agonis + anticholinergic O2 2-4 LPM IV line + chest radiography If there is threat of respiratory arrest hospitalized

Management in one day care


Nebulate agonis + anticholinergic every 2 hours Oral steroid metilprednisolon/prednison for 3-5 days O2 continue Observe for12 hours good respons home + drugs If no respons management of severe acute asthma episode

Management in one day care


O2 continue Correct dehidration and ascidosis if present Steroid iv (bolus), every 6-8 hours 0,5-1 mg/Kg/day Nebulate agonis + anticholinergic every 1-2 hours if good respons after given 4-6 times give every 4-6 hours Aminofilin iv
If havent have it, 6-8 mg/kg in dekstrose/ NaCl 0,9% 20 ml If already have it (< 8 jam) , give the half dose Aminofilin for maintenance 0,5-1 mg/Kg/hour

Management in one day care


If clinically well, nebulation every 6 hours, steroid and aminofilin orally If within 24 hours the patient stabile, patient can go home with agonis inhaler/oral every 4-6 hours for 2448 hours Steroid continue for 24-48 hours

Indication for ICU


No respons for emergency treatment or worse confused, disorientation, other sign that threat respiratory arrest, lost of conciousness There is no better respons for management in one day care Hipoksemia present although has been given the oxygen (PaO2 <60 mmHg and/ PaCO2 > 45 mmHg)

KIE
KNOWLEDGE OF ASTHMA MEDIC PARENT TEACHERS SOCIALS SOCIAL ORGANIZATION MEDIA

ASTHMA CONTROLL

MORTALITY & MORBIDITY