Asm

KULIAH UNUSA 2016
Adyan Donastin
 Ancient Egypt – Asthma
treated by drinking incense
mixture called “Kyphi”.
 Hippocrates circa 450 B.C –
Greek word panting for this
specific respiratory problem.
 1873 – Pathophysiology of
disease known.
 1880 – Use of intravenous
doses of Pilocarpin for
treatment.
 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 2016
Asthma is a heterogeneous disease,
usually characterized by chronic airway
inflammation. It is defined by the history
of respiratory symptoms such as wheeze,
shortness of breath, chest tightness and
cough that vary over time and in intensity,
together with variable expiratory airflow
limitation
GINA 2016
AIRWAY REMODELLING
NORMAL ASTHMA
Nat Rev Immunol Jan 2015
Large airways Small airways
generation 0-8 generation 9-23

diameter > 2mm diameter < 2mm
ASTHMA :Pathophysiology of Small Airways
SMALL AIRWAY
INFLAMMATION IN
ASTHMA:
 inflammatory cells that play a
central role in asthma, i.e. Th2 cells
and eosinophils are found also in
small airways
 IL-5, a central cytokine in asthmatic
inflammation is expressed also in
small airways
 such information derives from data
obtained in studies sampling distal
airways (Tulic & Hamid, CHEST 2003;
123:348S–355S)
Barnes PJ, Nature Reviews Immunology 2008; 8: 183-192

The diagnosis of asthma should be based on :
1. History of respiratory symptoms such as

wheeze, shortness of breath, chest
tightness and cough that vary over time
and in intensity
2. Variable expiratory airflow limitation

Ad1. A history of variable respiratory symptoms
• People with asthma generally have more

than one of these symptoms
• The symptoms occur variably over time
and vary in intensity
• The symptoms often occur or are worse
at night or on waking or viral infection
• Symptoms are often triggered by
exercise, laughter, allergens or cold air
Ad2. Evidence of variable expiratory airflow
limitation.
 FEV1/FVC ratio < 0,75
 FEV1 increases by more than 12% and

200mL after inhaling a bronchodilator →
Bronchodilator reversibility .
 FEV1 increases by more than 12% and
200mL from baseline after 4 weeks of anti
inflammatory treatment.
Volume Flow
Normal
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)
Asthma
(before BD)
1 2 3 4 5 Volume
Time (seconds)
Note: Each FEV1represents the highest of
three reproducible measurements
GINA 2015 © Global Initiative for Asthma

 The primary aim of asthma
management is to provide disease
control by controlling the current Control
disease and reducing the risk of future current
exacerbations. disease
 Baseline ACQ/ ACT scores have been
shown to positively correlate with
exacerbation rates.
ASTHMA
 The level of current asthma control is CONTROL
one predictor of the future risk of
asthma instability and exacerbations.
Reduce
future risk
1. ACT merupakan alat untuk menilai kontrol asma
berdasarkan angka yang sudah divalidasi. Penilaian 5
pertanyaan dengan skala 5 poin (maksimum 25) :
19 / ↓ = Asma tidak terkontrol
20-24 = Terkontrol sebagian
25 = Terkontrol
2. Meningkatkan komunikasi pasien / dokter.

Pertanyaan yang jelas dan singkat akan menarik pasien ke
diskusi yang lebih terbuka dan terus terang.
3. ACT divalidasi dengan memakai uji spirometri dan
penilaian spesialis
Mechanism of action Bronchodilator
Large particles may
become deposited in the
oropharynx1
Smaller particles are swept

down into lungs with
laminar airflow2
Martin RJ. J Allergy Clin Immunol 2002

Newman S et al. Respir Med 2006
 How?
 Asthma severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations
 When?
 Assess asthma severity after patient has been on controller
treatment for several months
 Severity is not static – it may change over months or years,
or as different treatments become available
 Categories of asthma severity
 Mild asthma: well-controlled with Steps 1 or 2 (as-needed
SABA or low dose ICS)
 Moderate asthma: well-controlled with Step 3 (low-dose
ICS/LABA)
 Severe asthma: requires Step 4/5 (moderate or high dose
ICS/LABA ± add-on), or remains uncontrolled despite this
treatment
GINA 2015
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
Mild Mild STEP 4
STEP 3 Refer for *For children 6-11 years,

PREFERRED STEP 1 STEP 2 add-on theophylline is not
CONTROLLER treatment recommended, and preferred
e.g.
CHOICE Step 3 is medium dose ICS
Med/high Tiotropium
Omalizumab
ICS/LABA Mepolizumab **For patients prescribed
Low dose 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 2016
GINA Global Strategy for Asthma
Management and Prevention 2015
This slide set is restricted for academic and educational purposes
only. Use of the slide set, or of individual slides, for commercial or
promotional purposes requires approval from GINA.
© Global Initiative for Asthma

 A flare-up or exacerbation is an acute or
sub-acute worsening of symptoms and
lung function compared with the patient’s
usual status
GINA 2016
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
LIFE-THREATENING
Talks in words, sits hunched
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
SABA4–10 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, 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
best or predicted technique, adherence
Oxygen saturation >94% room air Prednisolone:continue, usually for 5–7 days
(3-5 days for children)
Resources at homeadequate
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?
GINA 2015, Box 4-3 (1/7)

Is it asthma?
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
systemic corticosteroid

Is it asthma?

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
TRANSFER TO ACUTE
CARE FACILITY
systemic corticosteroid

Is it asthma?

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
START TREATMENT
TRANSFER TO ACUTE
SABA 4–10 puffs by pMDI + spacer,
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,

START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
Prednisolone:adults 1 mg/kg, max. WORSENING
CONTINUE TREATMENTwith SABA as needed

WORSENING
IMPROVING
ASSESS FOR DISCHARGE

Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air

START TREATMENT

WORSENING
IMPROVING

PEF improving, and >60-80% of personal Controller:start, or step up. Check inhaler technique,
best or predicted adherence

START TREATMENT

WORSENING
IMPROVING

PEF improving, and >60-80% of personal Controller:start, or step up. Check inhaler technique,
best or predicted adherence
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?

INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
Talks in phrases Talks in words

Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best
Short-acting beta2-agonists Short-acting beta2-agonists

Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as

severe and re-aassess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently
GINA 2015, Box 4-4 (1/4)

INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation



GINA 2015, Box 4-4 (3/4)

If continuing deterioration, treat as

severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF <60% of predicted or

FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

 Follow up all patients regularly after an exacerbation,
until symptoms and lung function return to normal
 Patients are at increased risk during recovery from an
exacerbation
 The opportunity
 Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma
management
 At follow-up visit(s), check:
 The patient’s understanding of the cause of the flare-up
 Modifiable risk factors, e.g. smoking
 Adherence with medications, and understanding of their
purpose
 Inhaler technique skills
 Written asthma action plan
GINA 2016
Inhaled corticosteroid Total daily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
 This is not a table of equivalence, but of estimated clinical comparability

 Most of the clinical benefit from ICS is seen at low doses
 High doses are arbitrary, but for most ICS are those that, with prolonged use,
are associated with increased risk of systemic side-effects
GINA 2015, Box 3-6 (1/2)

Inhaled corticosteroid Total daily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 100–200 >200–400 >400
Beclometasone dipropionate (HFA) 50–100 >100–200 >200
Budesonide (DPI) 100–200 >200–400 >400
Budesonide (nebules) 250–500 >500–1000 >1000
Ciclesonide (HFA) 80 >80–160 >160
Fluticasone propionate (DPI) 100–200 >200–400 >400
Fluticasone propionate (HFA) 100–200 >200–500 >500
Mometasone furoate 110 ≥220–<440 ≥440
Triamcinolone acetonide 400–800 >800–1200 >1200
 This is not a table of equivalence, but of estimated clinical comparability

 Most of the clinical benefit from ICS is seen at low doses
 High doses are arbitrary, but for most ICS are those that, with prolonged use, are
associated with increased risk of systemic side-effects
GINA 2015, Box 3-6 (2/2)

The term ‘difficult-to-treat’ asthma is used for patients
in whom ongoing factors such as comorbidities, poor
adherence, and allergen exposure interfere with
achieving good asthma control. ‘Treatment resistant’
or ‘refractory’ asthma refers to patients with a
confirmed diagnosis of asthma, whose symptoms or
exacerbations remain poorly controlled despite high-
dose ICS plus a second controller such as LABA
(and/or systemic corticosteroids) and management of
comorbidities, or whose asthma control deteriorates
when this treatment is stepped down. Severe asthma
includes patients with refractory asthma, and those in
whom response to treatment of comorbidities is
incomplete
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
Mild Mild STEP 4
STEP 3 Refer for *For children 6-11 years,

PREFERRED STEP 1 STEP 2 add-on theophylline is not
CONTROLLER treatment recommended, and preferred
e.g.
CHOICE Step 3 is medium dose ICS
Med/high Tiotropium
Omalizumab
ICS/LABA Mepolizumab **For patients prescribed
Low dose 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 2016
Page 18
Page 18
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KULIAH UNUSA 2016

generation 0-8 generation 9-23

Barnes PJ, Nature Reviews Immunology 2008; 8: 183-192

1. History of respiratory symptoms such as

2. Variable expiratory airflow limitation

• People with asthma generally have more

 FEV1 increases by more than 12% and

GINA 2015 © Global Initiative for Asthma

2. Meningkatkan komunikasi pasien / dokter.

Smaller particles are swept

Martin RJ. J Allergy Clin Immunol 2002

Mild Mild STEP 4

STEP 3 Refer for *For children 6-11 years,

© Global Initiative for Asthma

MILD or MODERATE SEVERE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2015, Box 4-3 (1/7)

GINA 2016 © Global Initiative for Asthma

MILD or MODERATE SEVERE

GINA 2016 © Global Initiative for Asthma

MILD or MODERATE SEVERE

GINA 2016 © Global Initiative for Asthma

CONTINUE TREATMENTwith SABA as needed

ASSESS FOR DISCHARGE

GINA 2016 © Global Initiative for Asthma

CONTINUE TREATMENTwith SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2016 © Global Initiative for Asthma

CONTINUE TREATMENTwith SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2016 © Global Initiative for Asthma

MILD or MODERATE SEVERE

Talks in phrases Talks in words

Short-acting beta2-agonists Short-acting beta2-agonists

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

GINA 2015, Box 4-4 (1/4)

MILD or MODERATE SEVERE

GINA 2016 © Global Initiative for Asthma

Short-acting beta2-agonists Short-acting beta2-agonists

GINA 2015, Box 4-4 (3/4)

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF <60% of predicted or

GINA 2016 © Global Initiative for Asthma

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

 This is not a table of equivalence, but of estimated clinical comparability

GINA 2015, Box 3-6 (1/2)

 This is not a table of equivalence, but of estimated clinical comparability

GINA 2015, Box 3-6 (2/2)

Mild Mild STEP 4

STEP 3 Refer for *For children 6-11 years,

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