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Asthma
Tamsil Syafiuddin-Bintang Sinaga
Departemen Pulmonologi Fakultas Kedokteran Universitas Sumatera Utara 2008

Levels of competence

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006

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Level of competence 4:
Dokter mampu membuat diagnosis klinik berdasarkan pemeriksaan fisik dan pemeriksaan tambahan yang diminta oleh

dokter (misalnya: pemeriksaan laboratorum sederhana atau X-ray). Dokter dapat memutuskan dan mampu menangani problem itu secara mandiri hingga tuntas.

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006

Recent issues in asthma management

The Unmet Needs of asthma
Theme of World Asthma Day 2005/2006

You can control your asthma

Theme of World Asthma Day 2007/2008

Adherence
Self Management

UUD No 29 / 2004 : Praktik Kedokteran

Competency

Pharmacoeconomic consideration
Quality of Life

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Asthma is an inflammatory diseases

Definition of asthma
Chronic inflammatory disease of airways (AW) responsiveness of tracheobronchial tree Physiologic manifestation: AW narrowing relieved spontaneously or with BD Cster Clinical manifestations: a triad of paroxysms of cough, dyspnea and wheezing.

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Disease Pattern
Episodic --- acute exacerbations interspersed with symptom-free periods Chronic --- daily AW obstruction which may be mild, moderate or severe superimposed acute exacerbations Life-threatening--- slow-onset or fast-onset (fatal within 2 hours)

Classification :
Level of asthma severity
(by Clinical Features Before Treatment)

Level of asthma control

(by Clinical Features After Treatment)
( GINA 2006 )

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Classification of Asthma Severity by Clinical Features Before Treatment:

Intermittent:
Symptoms less than once a week Brief exacerbations Nocturnal symptoms not more than twice a month FEV1 or PEF 80% predicted PEF or FEV1 variability < 20%

Mild Persistent:
Symptoms more than once a week but less than once a day Exacerbations may affect activity and sleep Nocturnal symptoms more than twice a month FEV1 or PEF 80% predicted PEF or FEV1 variability < 20 30%

Moderate Persistent:
Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short-acting 2-agonist FEV1 or PEF 60-80% predicted PEF or FEV1 variability > 30%

Severe Persistent:
Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities FEV1 or PEF 60% predicted PEF or FEV1 variability > 30%

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Levels of Asthma Control Characteristic Controlled

(All of the following) Daytime symptoms None (twice or less/week)

Partly Controlled Uncontrolled

(Any measure present in any week) More than twice/week

Three or more features of partly controlled asthma present in any week

Limitations of activities Nocturnal symptoms/awakening

None

Any

None

Any

Need for reliever/ rescue treatment Lung function (PEF or FEV1)

None (twice or less/week) Normal

More than twice/week

< 80% predicted or personal best (if known) One or more/year One in any week

Exacerbations

None

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Inflammation
Normal

()

(+)

Asthma

Bronchial hyperreactivity ( - )

Bronchial hyperreactivity ( + )

Bronchoconstriction ( - )

Bronchoconstriction ( + )

Symptoms (-) (The pathogenesis of asthma

Symptoms (+)

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Ag
Ig E

Ca++ Histamin
Methyl transferase

YY
Phosphatidyl ethanolamine Phosphatidyl choline

Phospholipid

Arachidonic acid lypoxygenase

5-HETE Leucotrienes LTB4 LTC4 LTD4 LTE4

Phospho ++ lipase A2 Ca cyclooxygenase

Histamin ECF, NCF

Thromboxanes Prostaglandins PGD TXA2 PGF2

Mediator release in asthma reactions

Inflammation
Controller Bronchial hyperreactivity

Bronchoconstriction Reliever Symptoms

Medicines and Pathogenesis of asthma

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Asthma Therapy Evolution

Large use of short-acting 2-agonists 1975 ICS treatment introduced 1972 Adding LAA to ICS therapy
Kips et al, AJRCCM 2000 Pauwels et al, NEJM 1997 Greening et al, Lancet 1992

1980

Fear of short-acting 2-agonists

Single inhaler therapy ICS+LABA

1985 1990
Bronchospasm Inflammation

2000 1995
Remodelling

DIAGNOSIS EXACERBATION : CLINICAL

Episodic asthma:
Paroxysms of wheeze, dyspnoea and cough, asymptomatic between attacks.

Acute severe asthma:

upright position, use accessory resp muscles, cant complete sentences in one breath, tachypnea > 25/min, tachycardia > 110/min, PEF 33-50% of pred or best, pulsus paradoxus, chest hyperresonant, prolonged expiration, breath sounds decreased, inspiratory and expiratory rhonchi, cough.

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Life-threatening features:
PEF < 33% of pred or best,silent chest, cyanosis, bradycardia, hypotension, feeble respiratory effort, exhaustion, confusion, coma, PaO2 < 60, PCO2 normal or increased, acidosis (low pH or high [H+]).

Chronic asthma:
Dyspnea on exertion, wheeze, chest tightness and cough on daily basis, usually at night and early morning; intercurrent acute severe asthma (exacerbations) and productive cough (mucoid sputum), recurrent respiratory infection, expiratory rhonchi throughout and accentuated on forced expiration.

Acute severe asthma:

MANAGEMENT 1 1.Immediate Rx:
O2 40-60% mask or cannula + SABA (salbutamol 5mg)/ nebulizer + ICS 200 mcg/ nebulizer or hydrocortisone 200mg IV. With lifethreatening features add 0.5mg ipratropium to nebulized 2 agonist + Aminophyllin 250mg iv over 20 min or salbutamol 250ug over 10 min. 2. Subsequent Rx: Nebulized SABA 6 hourly + ICS 200mcg or hydrocortisone 200mg 6 hourly IV + 40-60% O2.

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MANAGEMENT 2
No improvement after 15-30 min: Nebulized 2 agonist every 15-30 min + Ipratropium. Still no improvement: Aminophyllin infusion 750mg/24H (small pt), 1 500mg/24H (large pt), or alternatively salbutamol infusion. Monitor Rx: Aminophyllin blood levels + PEF after 15-30 min + oxymetry (maintain SaO2 > 90) + repeat blood gases after 2 hrs if initial PaO2 < 60, PaCO2 normal or raised and patient deteriorates. Deterioration: ICU, intubate, ventilate + muscle relaxant.

ASTHMA MANAGEMENT: CLINICAL

QUICK RELIEVE MEDICATION LONG TERM TREATMENT

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Total control

Guidelines on Asthma Management: Past and Current Trends

Partially control

Uncontrol

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Exacerbation

SABA /

Anti Inflammations is the mainstay therapy

ABAL noitca fo tesno dipaR

ICS

LABA+ICS

LABA and ICS

Stable condition

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Inhalation therapy is the mainstay therapy

Because minimally side effect

AIRWAY REMODELLING IN ASTHMA

Eosinophil

Desquamations of epithelium MBP, ECP

Epithelium

Thickening of basement membrane Increase in airway smooth muscle

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Basement Membrane Thickening

Epithelial Damage

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Smooth Muscle Hyperplasia

Controller: Anti inflammation Inhaled Cortico Steroid

Non steroid

sodium chromoglicate budesonide (Pulmicort) (Inflamid) (Intal) beclomethasone ketotifen dipropionate (Becotide) sodium nedocromil triamcinolone acetonide fluticasone(Flexotide)

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Reliever
Bronchodilator
2 - agonist Xanthin Anticholinergic

BRONCHODILATOR
Short Acting 2 AGONIST (SABA): salbutamol/albuterol (Ventolin ) terbutaline (Bricasma) (Bricasma procaterol fenoterol orciprenaline, etc ANTICHOLINERGIC: atropine sulfate ipratropium bromide tiotropium bromide ephedrine adrenaline, etc Long Acting 2 AGONIST: (LABA) salmoterol formoterol

XANTHINE: theophylline aminophylline

OTHER SYMPHATOMIMETIC:

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Combination therapy

Symbicort Symbicort
Budesonide + Formoterol

Seretide Seretide
Fluticasone + Salmoterol

The Beginning of Treatment

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Exacerbation

x ?

The beginning of treatment

Stable condition

Asthma management

* Stable condition * Long-term therapy

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Evaluations

Peak flow meter

Objective values

600-700 (

normal )

300

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Peak Flow Meter /PEFR/APE

Must be avilable

PEFR Monitoring: SelfA Major Tool in Asthma Self-Management

Chronic Diseases Hypertension Monitor Blood pressure

Diabetes

Serum glucose

Asthma

PEFR

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DIFFERENTIAL DIAGNOSIS
1. Upper airway obstruction glottic dysfunction. 2. Acute LV failure pulmonary oedema. 3. Pulmonary embolism. 4. Endobronchial disease. 5. Chronic bronchitis. 6. Eosinophilic pneumonia. 7. Carsinoid syndrome. 8. Vasculitis.

Life is not problem to be solved, but a reality to be experienced

( Soren Kierkegaard)

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