1

Asthma, 2 aspects
Asthma : chronic respiratory disease that can have
acute attack (two in one disease)

Chronic Asma

Asthma

Acute Asthma

Classification of pediatric asthma

Chronic asthma
1. Infrequent
episodic asthma
2. Frequent episodic
asthma

3. Persistent

asthma

Acute asthma
1. Mild attack
2. Moderate
attack
3. Severe attack

Asthma labelling
Chronic condition + present condition
Chronic condition: infrequent -- persistent
Present condition:

(-)
Symptom

attack (-)
(+)

attack (+)

Chronic Asthma
trigger
exposure

not optimal
medication

Acute Asthma
5

Asthma managements
Chronic asthma
Long term
management
Algorithm diagnosis
& treatment

Acute asthma
Attack
management
Algorithm attack
management

Asthma managements
Chronic asthma
Long term
management
Reliever &
Controller

Acute asthma
Attack
management
Reliever

Asthma medication
Controller
drug to control
asthma ie attack or
symptom not
easily emerge

Reliever
drug to relieve
asthma attack or
symptoms
-agonist

Inhaled steroid

Xanthine

LABA, ALTR

anticholinergic

Criteria of severity of childhood asthma

Infrequent episodic symptoms
Exacerbation 3-4 x/year, there is no sign and symptom in

between
Quality of life good

Frequent episodic symptoms

Exacerbation 1 x/month, there is no sign and symptom in

between
Quality of life good, sometimes affected

Persistent symptoms
Exacerbation > 1 x/month, there is sign and symptom in

between
Quality of life limited

Objectives of asthma management

Minimal chronic symptoms (ideally none)
Minimal acute attacks (seldom)
No visit to ER

Minimal 2-agonist using

Activity is not inhibited
Normal lung function test (mendekati)

Minimal drugs side effects

Asthma management principles

1. Avoidance

2. Avoidance
3. Avoidance

4. Drugs inhalation therapy

11

Avoidance of allergens
For all asthma: infrequent episodic, frequent episodic,

and persistent asthma

Avoid the triggers: house dust mite
Keep away from pets
Before and during pharmacologic treatment

GINA, 2002

Education for Patient/Family

Knowledge of asthma
Compliance
Practical management guidelines at home

Doctor-family-patient relationship
GINA,2002

Pharmacotherapy
Reliever:
2 agonist
Epinephrine
Teophyllin/aminophyllin
Anticolinergic (ipratropium br)
Steroid

: inhaler, nebulized, oral

: subkutan
: oral, I.V.
: inhaler
: oral, I.M.

Controller:
Steroid
LABA
Antileukotrien

: inhaler
: inhaler, oral
: oral
PNAA, 2002

Classification

Controller

Reliever

Infrequent
episodic
asthma

No

Yes

Frequent
episodic
asthma

Yes

Yes

Persistent
asthma

Yes

Yes

15

Chronic asthma management

Asthma attack / symptoms present:
First line therapy

beta-2 agonist
ipratropium bromida

Chronic asthma (long term management)

First line therapy

inhaled steroid
Long-acting beta-2 agonist (LABA)

16

Medicine
Bronchodilator
Anti-inflammation
Antiremodeling

Anti IgE

TREATING ASTHMA
with Bronchodilators alone

is like

Painting over rust

!!!

Inflammation in asthma
Inflamasi akut

Steroid
response

Chronic inflammation
Structural changes

Time

Barnes PJ

Restores asthma controlling in children

Evidences from study:
v

Increases PEF (morning and afternoon)

v

Increases FEV1 (morning and )

Reduces FEV1 diurnal variation

v

Reduces symptoms

Reduces asthma attack frequency

Reduces reliever using (2 agonis)

v

Increases quality of life

FEV1, forced expiratory volume in 1 second

PEF, peak expiratory flow

Longterm steroid

Side Effects
Hoarse voice
Pharynx irritation
Candidiasis

Headache
Growth disturbance??

Treatment
Reliever (treatment of attack) :

2 agonist
Ephinephrin
Theophyllin/aminophyllin
Steroid

: inhaled, nebulized, oral

: subcutan
: oral, I.V.
: oral, I.M.

Controller (prevention of attack) :

Avoidance
Medicine

: triggers (including enhancers,

inducers) especially improve
indoor environment.
: inhaled steroid, antileukotrien.

Steroid efficacy in asthma

Steroid
dose

Benefit

Side-effects

Long term treatment

Infrequent Episodic
Symptoms

2-agonist or theophylline
inhaled/oral intermittently
4-6 weeks
>3 episodes/week

3-6 months
Evaluation

Add controller drug

Frequent episodic
Symptoms

6-8 weeks
response (-)

3-6 months
response (+)

Replace with low dose inhaled steroids

Continue 2-a or/and
theophylline inhaled/oral intermittently
6-8 weeks
response (-)

3-6 months
response (+)
25

6-8 weeks
respons (-)

3-6 months
respons (+)

Consider :
Persistent Symptoms Long acting 2-agonists, or
Slow release 2-agonists, or
Slow release theophyllines
6-8 weeks
respons (-)

3-6 months
respons (+)

Increase dose of inhaled steroid

6-8 weeks
respons (-)

Add oral steroids

3-6 months
respons (+)

26

Longterm
management

Low dose steroid

Medium dose
steroid

Low dose
steroid + LABA

Low dose
steroid + ALTR

Low dose
steroid +TSR

High dose
steroid

Medium dose
steroid + LABA

Medium dose
steroid + ALTR

Medium dose
steroid + TSR

ORAL
STEROID
27

Conclusion
Asthma prevalence: increase
Classifications of childhood asthma: infrequent

episodic asthma, frequent episodic asthma, and

persistent asthma
Longterm management: Inhalation therapy

Thanks for
your attention
29