Beruflich Dokumente
Kultur Dokumente
Isnu PRADJOKO
Dept.of Pulmonology and Respiratory Medicine
Medical Faculty of Airlangga University / Hospital Dr. Soetomo
Surabaya
PRELIMINARY
** PDPI 2003
DEFINITION
chronic inflammatory disease involving the respiratory
GINA 2017
tract as a result of various inflammatory cells with
airway constriction is varied, characterized by wheezing
/ wheezing, shortness of breath, tightness in the chest,
coughing especially at night / early morning. The
narrowing and asthma symptoms may be reversible
either spontaneously or with treatment
Gina 2017
Flare-up = acute deterioration / sub-acute symptoms or
lung function compared to the previous normal state.
Asthma Inflammation: Cells and mediators
1 2 3 4 5
Time (sec)
Note: Each FEV1 the curve represents the highest of three repeat measurements
Pathophysiology
Hiper
RESPONSIV
edema E Hiper
SAL. SAL.NAPAS SECRETION
BREATH mucus
AIRWAY
Bronko
remodel-
constriction LING
AIR FLOW BARRIERS
VIRUS respiration / HRV BACTERIA (M.pneumonie,
C.pneumoniae
DRUG, emotional crisis Allergens, pollutants
PDPI, 2003: Gilbert TW, Denlinger LC. Role of Infection in the development and exacerbation of asthma. NIH Public Acces.Expert Rev
Respir Med. 4. 71-83.2010
CAST bronchial mucous
CAPACITY DIFFERENCES IN DEFENSE ANTIVIRUS NORMAL CELLS WITH CELL bronchial
epithelium of asthmatic bronchial epithelium
Holgate ST, Robert G. The Role of Airway Epithellium and its interaction with the Environmental Factor in Asthma Pathogenesis. Proc Am Thorac
Soc Vol 6 pp 665-659. 2009
ASTHMA CONTROL THE UGLY Psychological dysfunction (psychosis,
anxiety, depression)
History of hospitalization due to The use of bronchodilators with
asthma increasing doses reply
Psychological dysfunction (psychosis, History of use of oral corticosteroids
anxiety, depression) as controller
Cardiovascular disease and illness
Low socio-economic
chronic lung
Hodder R, Lougheed D. Management of acute asthma in adults in the emergency department: nonventilatory
management. In the Canadian Medical Association Journal, 2010.
CLINICAL
Table 1. Common asthma symptoms and signs of acute / exacerbation
(Quoted from: Hospital Physician, 2006)
1.Young DJ, Salzman GA. Asmaticus status in adult Patients.Clinical Review Article in Hospital Physician. 2006
2.Kotaru C, McFadden ER. Acute exacerbations of asthma. In Asthma and chronic obstructive pulmonary diseases. Basic
ASSESSMENT AND EVALUATION
MANAGEMENT BEGINS WITH asthma exacerbations WEIGHT RATING
DEGREE OF ATTACKS AND EVALUATION WHICH COVERS FATAL
ASTHMA RISK FACTOR *
Oxygenation and bronchodilators
FIRST *
DIAGNOSIS asthma exacerbations **
1. Upper airway obstruction
2. Foreign body aspiration
3. The vocal cords dysfunction syndrome
4. pulmonary edema
5. Acute exacerbations of COPD
6. Conversion reaction hysterik
* Jain DG, SK Singal, Clark RK. Understanding and managing Acute Severe Asthma and Difficult. In Clinical Medicine. Journal of Indian Academy of
Clinical Medicine. Vol.7.2006
** Hodder R, Lougheed D. Management of acute asthma in adults in the emergency department: nonventilatory management. In the Canadian
Medical Association Journal, 2010.
EVALUATION exacerbations
AX • Onset, causal, severity , respons for therapy (pre emergency
room), history of diseases, and hospitalisation, and comorbid
Lab • Indicated for the detection of respiratory failure, theophylline toxicity, or a concession
that complicates the treatment of asthma (cardiovascular disease, pneumonia, or
diabetes)
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Camargo CA, Rachelefsky G. Managing Asthma exacerbations in the Emergency Department. Summary of the National
Asthma Education and Prevention Program Expert Panel. Proc Am Thorac Soc. Vol.6.357-366. 2009
WEIGHT DISTRIBUTION DEGREE OF ASTHMA ATTACK
PDPI 2003
PEAKFLOW
METER
Aim Management
exacerbations Asthma
record: increasingly fast treatment starts, increasingly easy resolve attack
medications
Pre-hospital
Inhalation β2 agonists brief 2-4 puffs every 1 hour 20 min
pd first. After the first hour, the dose of β2 agonist depending on
the severity of exacerbations. In mild exacerbations followed by 2-
4 puffs every 3 to 4 hours. Exacerbations are in need 6-10 puffs in
1 to 2 hours. Oral glucocorticoids should be given
oxygenation Handling in RS
Saturation is maintained a minimum 92%
Β2 AGONISTS SHORT
The main drug, per inhalation is highly recommended, the first 1 hour
continuous pd
Giving dg anticholinergics provide improved lung function and reduce the
number of hospitalizations
GINA 2012
FUNDAMENTAL THERAPY
PD ASTHMA ATTACK
Beta 2-agonists
RELAXATION
bronchial smooth
muscle
OTHER THERAPY
• Recommended in severe non-response to pd β2
MgSO4 agonist and systemic corticosteroids
• Consideration of efective, safe, cheap
Xantine
Inhaled Corticosteroids (Evidence B)
• MORE SECURE THAN SYSTEMIC STEROIDS
• ICS give effect that more fast (1-2jam) when be given in
dose multiple with interval time <30 minute for 90-120 minute,
Nebules
100 IV
50
0
0 20 40 60 120 180 240 300 360
Nebules 80,3 129 148 161 174 183 194 208 213
IV 71,6 111 134 147 166 174 182 185 192
Time (minute)
Sedatives = BANS *
ATTENTION
Respiratory failure intubation
* GINA 2010
**Camargo CA, Rachelefsky G. Managing Asthma exacerbations in the Emergency Department. Summary
of the National Asthma Education and Prevention Program Expert Panel. Proc Am Thorac Soc. Vol.6.357-
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?
Is this asthma?
ASSESS the PATIENT Asthma distinguished high risk of death?
The severity of exacerbations
CURRENT REPATRIATION
EVALUATION FOR REPATRIATION reliever: fill in when needed
Symptoms improved, SABA can be stopped controller: be started or the dose was increased
PEF improved, and > 60-80% of the best from the previous, Check technique using the
predictors appliance and compliance
oxygen saturation> 94% room air prednisolone: lanjjutkan, especially 5-7 day
(3-5 day for children)
Preparation for the home meet
Follow-up: for 2-7 days
NO
YES
Further Triage BY CLINICAL STATUS Consult ICU, start SABA and O2,
According to worst feature and prepare the patient for
intubation
NO
YES
principle covers
PART MANAGEMENT IN HOSPITAL
Pharmacological therapy
•bronchodilators
•corticosteroids
•Antibiotics
•additional therapy
respiratory Support
•oxygen therapy
• Mechanical ventilation: inavasif and non-invasive
• Short-acting-bronchodilator.
• Beta 2 agonists are inhaled short Work (SABA) with or
without short-acting anticholinergic is usually the
treatment of choice for exacerbations bronkodikator. SABA
given as initial therapy for acute exacerbations. Can be
administered via MDI (equivalent to 400-800 mcg
salbutamol / puff 4-8) or nebuliser (equivalent to 2.5 mg)
• Giving Phosphodiesterase inhibitors (methylxantine)
considered when not sufficiently responds to SABA.
• Oral corticosteroids can be given in most cases of moderate to severe
exacerbations.
• The dose of prednisone 40 mg per day for 5 days is an appropriate dose
• ERS / ATS Guideline instead recommends oral corticosteroids up to <14
days. (ERS / ATS)
• according to the Thorax Journal, there have been several studies
examining the administration of systemic steroids in COPD exacerbations
with dose variations of methyl prednisolone 125 mg every 6 hours to
prednisolone 30 mg daily.
• Bronchodilators and corticosteroids can also be administered by
inhalation. Each has its advantages
• Antibiotics should be given to patients with COPD
exacerbations who have 3 cardinal symptoms
• has 2 cardinal symptoms if elevation of purulent
sputum is one of 2 symptoms or sufferers
requiring mechanical ventilation.
• Recommended recommended time is 5-10 days
according to germ maps.
ANTIBIOTIC GUIDE
OXYGEN THERAPY
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THANK YOU
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