FAKULTAS KEDOKTERAN

UNIVERSITAS NUSA CENDANA KUPANG

SMF ILMU PENYAKIT DALAM
RSUD PROF. W. Z. JOHANNES KUPANG
1
2018
 INTRODUCTION
Asthma is a common and potentially serious
chronic disease that can be controlled but not
cured

Asthma is an important chronic airway disease

and is a serious public health problem in many
countries around the world.

Acute exacerbations of acute asthma is an

acute condition with symptoms and lung
function worsening than in patients with
asthma usually.
GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet]. 2018;1. Available from: http://ginasthma.org/2018-gina-report-global-
strategy-for-asthma-management-and-prevention/
Perhimpunan Dokter Paru Indonesia. Pedoman Diagnosis dan Penatalaksanaan Asma eksaserbasi akut di Indonesia. [serial online] 2003 [cited 2018
May 1]. Available from : http://www.klikpdpi.com/konsensus/asma eksaserbasi akut/asma eksaserbasi akut.html
2
 EPIDEMIOLOGY

The World Health Organization (WHO) estimates that 100 to

150 million people worldwide are suffering

In the United States an estimated 14. 7 million people visit a doctor's office for
an examination during an acute attack of asthma and doctors diagnose acute
exacerbations of asthma with varying degrees.

In Indonesia, asthma is included in the top ten causes of illness and death.
In 2005 shows that in Indonesia the prevalence of acute exacerbations of
asthma increases from 4.2% to 5.4%.

Dougherthy, RH. Acute Exacerbations of Asthma: Epidemiology, Biology and the Exacerbation-Prone Phenotype. NIH- Public Access. 2009
3
 CASE REPORT
 Name : Tn. D. T
 Age : 58 y.o.
 Sex : male
 Born : Kupang, 16/6/1960
 No. MR : 448635
 tribe : Timor
 religion : Kristen Protestan
 Marital state : Married
 Education : Senior high school
 Work : Teacher
 Healthy insurance : BPJS class II
 Address : Oepoi
4
 ANAMNESIS
 Main complaint: Shortness of breath
 Patients come to the ER of RSUD Prof. Dr. W. Z. Johannes Kupang with a
sudden shortness of breath since about a day before. The complaint
came suddenly in the afternoon when the patient had just returned
from out of town. Shortness of the longer the more burdensome. The
patient's chest feels like it is tied up and nothing can be done to ease
the symptoms. Before the shortness of complaints arise, the patient
complains of coughing and removing clear white mucus. The patient
begins to cough when the patient feels cold. Patients had used an
inhaler drug that had been used previously for 1 year if a stiff complaint
arose. Patients use inhalers up to 3 times, but the recurrence does not
subside. The use of these drugs can not eliminate the symptoms that
appear until the patient asked for help on his wife and child. Patients
also complain of dizziness, do not feel chest pain and chest pounding

5
 Past medical history :
Patients often have shortness of breath since the age of 6 years and
often recur when the grade 5 primary school, after which never relapse
again. In 2005, patients complained of frequent sneezing and runny
nose that did not improve, felt heavy in the morning, disappeared, and
sometimes still often appear until now, especially when exposed to cold
air. The patient did not go to the doctor. In the last six months,
complaints have become more frequent. Within a month, the complaint
can recur two to three times. Recurrences often occur at night when the
air gets colder, and wakes the sleep. When the patient starts relapse
always use barotec then recurrence subsides. Patients feel that their
activities remain normal despite frequent relapse, only when relapse,
the patient feels always wants to rest. Patients had been treated for
several days in 2016 due to heart disease, when the patient's chest
complaints felt very painful and pounding. Patients were then
diagnosed with CHF and HHD, had frequent control of cardiac poly and
routine consumption of amlodipine, simvastatin, and clopidogrel.

6
 Family medical history :
According to the patient's admission, the patient's niece has
the same complaint with the patient. Often shortness of
breath and when the shortness of breath like a pull.
 Medical history :
Patients to date receive therapy for asthma in the form:
Berotect inhaler is 1 year
Salbutamol tablet 2 mg
- Dexamethasone 0.5 mg
All three drugs are used by the patient when the shortness of
breath suffer relapse. There is no other medical history
consumed by the patient.

7
Habit history :
Patients have a habit of smoking since grade 5 of primary
school. Currently patients can smoke as much as ½ pack or
1 pack of cigarettes. Patients never feel crowded after
smoking. The patient's eating habits are two to three times
a day, according to the patient's admission, the patients eat
regularly with a fairly varied menu and in the dominance of
vegetables, occasionally meat. Triggers that can be
identified by the patient related to his shortness of breath
include: - cold air - heavy activity - dust patients rarely use
masks for daily activities.
Social and economy history :
The patient lives with a wife and three children. The patient
is a retired teacher. Patient has 3 children.

8
 REVIEW SYSTEM
Head: Dizziness (-), headache (-)
Skin: Pale (-), yellow (-)
Eyes: Blurred eyes (- / -)
Ear: Full sense in ear (- / -), fluid from ear (- / -)
Nose: Cold (-), itchy nose (-), sneezing (-)
Mouth: Swallow pain (-), cancer sores (-), white patches on the tongue (-),
Throat: Hoarseness (-), difficulty swallowing (-)
Neck: Spontaneous pain (-), tactile pain (-), tenderness (-), signs of inflammation (-),
enlargement of the neck (-)
Heart: Heart palpitations (-), chest pain (-),
Lung: Shortness of breath (+), difficulty breathing (+)
Gastrointestinal: Fast satiety (-), nausea (-), vomiting (-), epigatric pain (-), CHAPTER is felt
still normal
Kidney and urinary tract: BAK is still normal, clear yellow, no blood or sandy urine
Neurological: no decrease in consciousness, no sign of neurological deficit
Endocrine: No history of previous hormonal disorders Muskuloskeletal: No abnormalities
Extremities: No abnormalities found on the nails, warm acral

9
 PHYSICAL EXAMINATION

General situation: Seemed mild

Synonym: Compos mentis (E4V5M6)
Weight: 60 kg
Height: 162 cm
IMT: 23.43 kg / m2
Nutritional status: Normal
Vital signs
Blood pressure: 170/100 mmHg
Pulse: 110 x / min
▪ Temperature: 37.2 ° C
Respiratory: 32 x / min
Saturation: 95%
VAS: 0 (no pain)

10
 Head: normocephal, hair is not easy to fall out, black hair
color, symmetrical face.
 Skin: Cyanosis (-), jaundice (-)
 Eyes: The conjunctiva appears pale (- / -), the sclera
appears jaundiced (- / -), conjunctival bleeding (- / -), isokor
pupil, direct light reflex (+ / +)
 Ear: Deformity of ear lobes (- / -), tragus tenderness (- / -),
mastoid tenderness (- / -), otorea (- / -)
 Nose: secretions (- / -), epistaxis (- / -
 Mouth: Cyanosis (-), lips appear moist, gum bleeding (-),
pink mucosa, clean tongue
 Neck: Magnification of the thyroid gland (-), magnification of
KGB (-), spontaneous pain (-), tactile pain (-), tenderness (-),
use of breathing muscle (-)
 Thorax (shape): Thorax formation is normal, no visible
widening of the veins, not visible scar (scar)
11
 Pulmo The lungs are anterior
 I: Development of symmetrical chest when static and dynamic, no
visible use of respiratory muscle.
 Pa: Tactile left and right fremitus normal and symmetrical, no
tenderness, not palpable mass
 Pe: Sonor on both lung fields
 A: Vesikuler : + + Rhonki : Wheezing : + +
- -
+ + + +
- -
+ + + +
- -

 Pulmo The lungs are anterior

 I: Development of symmetrical chest when static and dynamic, no
visible use of respiratory muscle.
 Pa: Tactile left and right fremitus normal and symmetrical, no
tenderness, not palpable mass
 P: Sonor on both lung fields
 A: Vesikuler : + + Rhonki : - - Wheezing : + +
+ + - - + +
12
+ + - - + +
 I: Ictus cordis is not visible
 Pa: Ictus cordis is not palpable
 Pe:
 Waistline: ICS 3 linea parasternal sinistra
 Right heart limits: ICS 3 line parasternal right hand
 Left heart margin: ICS 6 line axillary anterior sinistra
 A: S1-S2 single, regular, inaudible murmur or gallop
Abdomen
 I: Symmetrical, looks flat, does not look scar or mass
 A: Bowel sounds, 12 times per minute, normal
 Pa: Top in all abdominal region, liver span 8 cm
 Pe: Tenderness (-), not palpable mass, liver and lien is not
palpable enlarged Back Normal vertebrae, no apparent
abnormality
Extremity :
 CRT <2 seconds, akral is felt warm, no edema of the legs
13
Lab. examination
21 Mei 2018

14
Radiology

Chest X-ray Mr. DT 58 years old,

with AP position, taken on May 22,
2018, with enough opacity, from:
•thin soft tissue
•Bone no fracture
•trachea located in the middle
• mediastinum center location heart
looks enlarged, CTR> 0.5%
•Right tapered right costophrenicus
corner
•In the pulmonary parenchyma
there is no connectivity, infiltrates

15
Diagnose
 Asma bronchial eksaserbasi akut
 HHD
 CAD

Therapy (ER)
 Nebulisasi combivent / 8 jam
 Methylprednisolone injeksi 2 x 125 mg
 Salbutamol 3x2 mg
 For cardiac :
 Amlodipin 5mg – 0- 0
 Candesartan 0 – 0 – 10
 Clopidogrel 0 – 75 mg – 0
 Simvastatin 0- 0-20 mg

16
 THEORY
 A flare-up or exacerbation is an acute or sub-acute
worsening
of symptoms and lung function compared with the patient’s
usual status
 Terminology
 ‘Flare-up’ is the preferred term for discussion with
patients
 ‘Exacerbation’ is a difficult term for patients

 ‘Attack’ has highly variable meanings for patients and

clinicians
 ‘Episode’ does not convey clinical urgency

GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet]. 2018;1. Available
from: http://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-
prevention/
17
 PATHOPHISIOLOGY

Buddiga P, kaliner M. Asthma in Older Adults. Medscape.2015.

18
 WRITTEN ASTHMA ACTION PLANS
 All patients should have a written asthma action plan
 The aim is to show the patient how to recognize and respond to
worsening asthma
 It should be individualized for the patient’s medications, level of
asthma control and health literacy
 Based on symptoms and/or PEF (children: only symptoms)
 The action plan should include:
 The patient’s usual asthma medications
 When/how to increase reliever and controller or start OCS
 How to access medical care if symptoms fail to respond
 Why?
 When combined with self-monitoring and regular medical review,
action plans are highly effective in reducing asthma mortality and
morbidity
GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet]. 2018;1.
Available from: http://ginasthma.org/2018-gina-report-global-strategy-for-asthma-
management-and-prevention/

19
GINA 2017
 WRITTEN ASTHMA ACTION PLANS

Effective asthma self-management education requires:

• Self-monitoring of symptoms and/or lung function If PEF or FEV1

<60% best, or not
• Written asthma action plan improving after
• Regular medical review 48 hours
All patients Continue reliever

Increase reliever Continue controller

Early increase in Add prednisolone

controller as below 40–50 mg/day

Review response Contact doctor

EARLY OR MILD LATE OR SEVERE

GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet]. 2018;1.
Available from: http://ginasthma.org/2018-gina-report-global-strategy-for-asthma-
management-and-prevention/
20
GINA 2017, Box 4-2 (1/2)
WRITTEN ASTHMA ACTION PLANS –
MEDICATION OPTIONS
 Increase inhaled reliever
 Increase frequency as needed
 Adding spacer for pMDI may be helpful
 Early and rapid increase in inhaled controller
 Up to maximum ICS of 2000mcg BDP/day or equivalent
 Options depend on usual controller medication and type of LABA
 See GINA 2017 report Box 4-2 for details
 Add oral corticosteroids if needed
 Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days
 Children: 1-2mg/kg/day up to 40mg, usually 3-5 days
 Morning dosing preferred to reduce side-effects
 Tapering not needed if taken for less than 2 weeks
 Remember to advise patients about common side-effects (sleep disturbance,
increased appetite, reflux, mood changes)

• GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet].
2018;1. Available from: http://ginasthma.org/2018-gina-report-global-strategy-
for-asthma-management-and-prevention/

21
GINA 2017, Box 4-2 (2/2)
 RATIONALE FOR CHANGE IN RECOMMENDATION
ABOUT CONTROLLER THERAPY IN ASTHMA ACTION
PLANS
For the last 10 years, most guidelines recommended treating
worsening asthma with SABA alone until OCS were needed, but ...
 Most exacerbations are characterised by increased inflammation

 Most evidence for self-management involved doubling ICS dose

 Outcomes were consistently better if the action plan prescribed both increased
ICS, and OCS
 Lack of generalisability of placebo-controlled RCTs of doubling ICS

 Participants were required to be highly adherent

 Study inhalers were not started, on average, until symptoms and airflow
limitation had been worsening for 4-5 days.
 Severe exacerbations are reduced by short-term treatment with

 Quadrupled dose of ICS

 Quadrupled dose of budesonide/formoterol

 Early small increase in ICS/formoterol (maintenance & reliever regimen)

 Adherence by community patients is poor

 Patients commonly take only 25-35% of prescribed controller dose

 Patients often delay seeking care for fear of being given OCS 22
GINA 2017
 MANAGING EXACERBATIONS IN PRIMARY CARE
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
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
LIFE-THREATENING
Talks in words, sits hunched
forwards, agitated Drowsy, confused
Respiratory rate >30/min or silent chest
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best URGENT

START TREATMENT
SABA 4–10 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,
Controlled oxygen (if available): target O2, 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 home adequate
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?

23
GINA 2017, Box 4-3 (1/7)
 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?

LIFE-THREATENING
Drowsy, confused
or silent chest

URGENT

TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid

24
GINA 2017, Box 4-3 (2/7) © Global Initiative for Asthma
 PRIMARY CARE
ASSESS the PATIENT
MILD or MODERATE
Talks in phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
GINA 2017, Box 4-3 (3/7)
Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
SEVERE
Talks in words, sits hunched LIFE-THREATENING
forwards, agitated Drowsy, confused
Respiratory rate >30/min or silent chest
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best URGENT
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
25
© Global Initiative for Asthma
 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 Talks in words, sits hunched LIFE-THREATENING
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
TRANSFER TO ACUTE
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour CARE FACILITY
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,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)

26
GINA 2017, Box 4-3 (4/7) © Global Initiative for Asthma
 START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg 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

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

27
GINA 2017, Box 4-3 (5/7) © Global Initiative for Asthma
 START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen (if available): target
saturation 93–95% (children: 94-98%)
CONTINUE TREATMENT with SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
IMPROVING
ASSESS FOR DISCHARGE
Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate
GINA 2017, Box 4-3 (6/7)
TRANSFER TO ACUTE
CARE FACILITY
WORSENING
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
WORSENING
ARRANGE at DISCHARGE
Reliever: continue as needed
Controller: start, or step up. Check inhaler technique,
adherence
Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Follow up: within 2–7 days
28
© Global Initiative for Asthma
 START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg 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 technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Resources at home adequate
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?

29
GINA 2017, Box 4-3 (7/7) © Global Initiative for Asthma
 MANAGING EXACERBATIONS IN ACUTE CARE SETTINGS

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

MILD or MODERATE SEVERE

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
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

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

30
GINA 2017, 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

MILD or MODERATE SEVERE

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
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

31
GINA 2017, Box 4-4 (2/4) © Global Initiative for Asthma
 MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
GINA 2017, Box 4-4 (3/4)
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF ≤50% predicted or best
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
32
 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-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

33
GINA 2017, Box 4-4 (4/4) © Global Initiative for Asthma
 FOLLOW-UP AFTER AN EXACERBATION
 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. Global Strategy for Asthma Management and Prevention. GINA [Internet].
2018;1. Available from: http://ginasthma.org/2018-gina-report-global-strategy-
for-asthma-management-and-prevention/
34
GINA 2017, Box 4-5
 DIAGNOSE

• Persistent worsening of the cough, wheezing,

and chest pain, or some combination of
ANAMNESIS these symptoms.
• Allergic histories

• Depends on the degree of airway

obstruction. Prolonged expiration, wheezing,
EXAMINATION chest hyperinflation, rapid breathing until
cyanosis can be seen in acute exacerbation
asthma patients.

SUPPORTING • The effects of severe acute exacerbations

on spirometry results were reduced by FEV1
EXAMINATION ≥20% and ≥500mL.

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Triggers factors for acute exacerbation :
1. Infection of respiratory virus such as influenza
2. Exposure to allergen mites, house dust, animal fur
3. Exposure to irritation of cigarette smoke, perfume
4. Activities of acute exacerbation practitioners /
sports such as running
5. Emotional expression of fear, anger, frustration
6. Aspirin medications, beta blockers, non-steroidal
anti-inflammatory
7. Work environment: chemical vapor
8. Air pollution: cigarette smoke
9. Food preservative: sulfite
10.Others: menstruation, pregnancy, sinusitis

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 Controllers are long-term acute exacerbations of acute
asthma to control acute exacerbations of asthma, given
daily to achieve and maintain controlled asthma.

 Kromolin
 Metilsantin
 Long acting beta 2 agonis
 Leukotrien modifier

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 Reliever) is principally for airway dilatation through
smooth muscle relaxation, improving and / or
inhibiting bronchostraction associated with acute
symptoms such as wheezing, chest and coughing,
not improving airway inflammation or decreasing
hypersponsif of the airway
 Short acting beta 2 agonis
 Antikolinergik
 Systemic corticosteroid
 Aminofilin

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 CASE
complaints of recurrent shortness of breath and first
felt since 1966. Complaints are felt disappeared,
without a fever, and appear suddenly. Patients
express complaints also accompanied by wheezing,
nasal congestion, runny nose, and sneezing sneezes
that have been felt since the year 2011.
patients who feel short of breath after returning
from out of town and after feeling very cold is the
data that support as the cause of acute attacks in
this patient.
The division of asthma degree: The presence of
asthma symptoms during the day more than twice a
week The existence of symptoms of the night to
make the patient wake up from sleep at night Use of
over-the-counter medications more than twice a
week The existence of limited activity due to asthma
complaints
THEORY
clinical diagnosis of asthma characterized by
chronic airway inflammation and respiratory
symptoms such as wheezing, shortness of breath,
chest-like bending and cough varying over time and
intensity, along with limitation of expiratory airflow.
triggers that are not specific but can still be marked
by patients such as: cold air, heavy activity, and
dust.
In 2016-2017, complaints are heavier than in the
previous year and can appear two to three times in a
month, even more often by the end of 2017, about
two to three times a week. In the last month the
patient expresses his complaint can relapse about 2
times in a month accompanied by symptoms of the
night. Based on this information, the patient can be
classified into a degree of partly controlled -
bronchial asthma.
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When the attack recurred at the
time before the patient was rushed
to the hospital's ER, the patient
complained of severe shortness of
breath, preceded by cough
accompanied by removing white
mucus. The results showed that
wheezing and respiration rates were
32 times / min, still speaking in
phrases, resting in a sitting position,
110x / minute pulse, and 95%
oxygen saturation.
The management provided in the ER
in this patient includes:
Nebulisasi combivent/8hours
Methylprednisolone injection 2 x
125 mg Salbutamol 3x2 mg
mild or moderate acute acute
exacerbations according to GINA
2018 are: speaking in phrase, more
comfortable sitting, no agitation,
increased respiratory rate, auxiliary
breathing muscles, pulse 100-120
times / min, 90-95% oxygen
saturation, PEF> 50%
patients with mild or moderate
acute exacerbations are inhaled
with SABA and ipratropium bromide,
oral corticosteroids, and oxygen
administration.
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 CONCLUSION
 It has been reported that a 58-year-old male patient with mild or moderate acute
exacerbation asthma has been reported. The patient has been diagnosed with asthma
since 1966, has been receiving asthma therapy ever since. Patients present with
shortness of breath, preceded by cough accompanied by removing white mucus,
sound out wheeze, respiratory rate 32 times / minute. Patients administered in IGD
with Nebulisation combivent / 8 h, methylprednisolone injection 2 x 125 mg,
salbutamol 3x2 mg. The patient was then hospitalized for 3 days, from the patient's
follow-up, during the hospitalization there was no recurrence. The patient was then
discharged with symbicort inhaler, salbutamol 3 x 2 mg, and methylprednisolone 3
x 4 mg. The patient's condition is good when repatriated.

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THANK YOU

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