Beruflich Dokumente
Kultur Dokumente
2016
BRONCHIALE
Definition of asthma
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.
Description of asthma
1
Description of asthma
2
Phenotypes of asthma
Phenotypes of asthma
allergic asthma
allergic asthma this is most easily recognized
asthma phenotype
wich often commences in childhood and is
associated with past and/or family history of
allergic disease such as eczema, allergic rhinitis,
or food or drug allergy.
Examination of the induced sputum of these patients
before treatment often reveals eosinophilic airway
inflammation.
Patients with this asthma phenotype usually
respond well to inhaled corticosteroid( ICS )
treatment.
Burden of asthma
50 tahun terakhir..
Patogenesa asthma
SALURAN NAPAS
FAKTOR PENCETUS
Patogenesa asthma
INFLAMMATION PROCESSING
SYMPTOMS OF ASTHMA
INFLAMMATION PROCESSING
INFLAMMATION
PROCESSING
Acute inflammation
Chronic inflammation
Structural changes
Faktor lingkungan
Berperan dalam :
Pembentukan asma individu yg peka (Pemicu)
Faktor lingkungan
Faktor penderita
Genetika
Atopi
Hiperaktivitas jalan
napas
Jenis kelamin
Ras
Diagnosis of asthma
Patient with
respiratory symptoms
Are the symptoms typical of asthma?
NO
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
NO
YES
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
NO
YES
Repeat on another
occasion or arrange
other tests
NO
YES
Review response
NO
YES
Diagnostic testing
within 1-3 months
Volume
Normal
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD)
Asthma
(after BD)
Asthma
(before BD)
Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
Assessment of asthma
Treatment issues
Comorbidities
Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea,
depression, anxiety
These may contribute to symptoms and poor quality of life
Yes No
Yes No
Yes No
Wellcontrolled
Partly
controlled
Uncontrolled
None of
these
1-2 of
these
3-4 of
these
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
GINA 2015
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
GINA 2015, Box 3-2
Asthma medications
Patient satisfaction
Non-pharmacological strategies
Lung function
STEP 5
STEP 4
STEP 3
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
Consider low
dose ICS
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
Add
tiotropium#
Add low
dose OCS
As-needed SABA or
low dose ICS/formoterol**
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
RELIEVER
Consider low
dose ICS
STEP 3
Low dose
ICS/LABA*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS
As-needed SABA or
low dose ICS/formoterol**
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
RELIEVER
Consider low
dose ICS
STEP 3
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
Add
tiotropium#
Add low
dose OCS
As-needed SABA or
low dose ICS/formoterol**
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
RELIEVER
Consider low
dose ICS
STEP 3
Low dose
ICS/LABA*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Refer for
add-on
treatment
Med/high
e.g.
ICS/LABA anti-IgE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS
As-needed SABA or
low dose ICS/formoterol**
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
RELIEVER
Consider low
dose ICS
STEP 3
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
Add
tiotropium#
Add low
dose OCS
As-needed SABA or
low dose ICS/formoterol**
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
RELIEVER
Consider low
dose ICS
STEP 3
Low dose
ICS/LABA*
Refer for
add-on
treatment
Med/high
e.g.
ICS/LABA anti-IgE
Add
tiotropium#
Add low
dose OCS
As-needed SABA or
low dose ICS/formoterol**
Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
May be initiated by patient with written asthma action plan
Day-to-day adjustment
For patients prescribed low-dose ICS/formoterol maintenance and reliever
regimen*
GINA 2015
Aim
To find the lowest dose that controls symptoms and exacerbations, and
minimizes the risk of side-effects
Respiratory infections
COPD
Upper airway dysfunction
Endobronchial obstruction
Inhaled foreign body
FLARE UP OF ASTHMA
Flare up of asthma
A flare-up or exacerbation is an acute or sub-acute
worsening of symptoms and lung function
compared with the patients 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
FLARE UP OF ASTHMA
ACUTE EXACERBATION OF ASTHMA
FLARE UP OF ASTHMA
Is it asthma?
MILD or MODERATE
SEVERE
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
START TREATMENT
SABA 410 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg
WORSENING
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled
SABA and ipratropium bromide,
O2, systemic corticosteroid
WORSENING
IMPROVING
ARRANGE at DISCHARGE
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (12 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?
INHALED
ANTICHOLINERGICS
IPRATROPIUM BROMIDE
OXITROPIUM BROMIDE
TIOTROPIUM BROMIDE
BRONCHODILATORS
FOR ASTHMA
4
COMBINATION
THERAPY
BETA 2
AGONIST
THEOPHYLLINE
IPRATOPRIUM BROMIDE
&
SHORT ACTING INHALED
BETA 2 AGONIST
2
DECREASED
PLASMA
EXUDATION
1
RELAX
AIRWAY SMOOTH
MUSCLE
3
DECREASED
INFLAMMATORY
MEDIATOR
RELEASE
BRONCHODILATORS
IN ASTHMA
5
IMPROVE
RESPIRATORY
MUSCLE
FATIGUE
4
DECREASED
NEUROTRANSMITTER
RELEASE
ADRENERGIC
RECEPTORS
CHOLINERGIC
RECEPTORS
TERIMA