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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
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
Symptoms
Airflow
obstruction
Bronchial
hyperresponsiveness
Airway
inflammation
Bergeron, airway remodelling in asthma: from benchside to clinical practice. Can Respir J Vol 17 No 4 July/August 2010
Inappropriate treatment
• 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
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
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
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
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?
• 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
*Excludes reliever taken before exercise, because many people take this routinely
AAAAI Guide
Goal of asthma management
Asthma management: control and reduce
Defined by Defined by
Asthma
Symptoms Reliever use Exacerbation
worsening
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
Inhaled steroid
1000 FEV1 % pred 100
700
600 90
87.2
500
412 84.5
400 85
300
200 80
100
0 75
Early Treatment Delayed Treatment
• 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
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
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
TINDAK LANJUT