WRITTEN BY :

Tegar Wibawa R
1102009281
MENTOR:
Dr. Pulung M Silalahi Sp.A

DEFINISI
Asthma is a chronic inflammatory disorder of the

airways involving cells and cellular elements. (Global

Initiative For Asthma. Medical Communications Resources, Inc ; 2006.)

Asthma is a recurrent wheezing and / or a

persistent cough with a characteristic; arise

episodic, inclined at night / early morning
(nocturnal), seasonal, after physical activity and
there is a history of asthma or other atopic patients
and / or family.
(Unit Kerja Koordinasi (UKK) Respirologi IDAI pada tahun 2004)

EPIDEMIOLOGI
Asthma is a chronic respiratory disease that

is most often found

The disease usually begins since childhood

30% occur in the age of 1 year
80-90% of the first symptoms arise before

4-5 years

Common problems in Hospitalized Children IDAI. Jakarta : 8-9 mei

2011

Faktor Resiko
Genetic factors
Hiperreaktivitas
Atopy

/ allergies
bronchi
Factors that
modify genetic
disease
Sex
Ras/Etnik

Triggers:
Alerge
n

Weathe
r

Infection

irritant

ISPA

Excercise
Comorbid
Conditions

Emosional

Patofisiologi Asthma
Asthma occurs due :
Channel respiratory obstruction
2. Hyperreactivity of respiratory tract
3. Mucus hypersecretion
1.

Nelson Textbook of Pediatrics : Childhood Asthma. Elsevier Science (USA);2003.

Clinically parameters,
needs medication and
pulmonary function

Infrequent episodic
asthma (mild
asthma)

Frequent episodic
asthma (asthma
medium)

Persistent asthma
(severe asthma)

1. The frequency of
attacks

3-4 x / 1 year

1 x / month

1x/ month

2. long attack

< 1 week

1 week

Almost all year round,

there is no remission

3. among attack

asymptomatic

asymptomatic

Symptoms day and night

4. Sleep and activity

Not distrubed
<3x/week

frequently interrupted
>3x/week

very disturbed

5. Physical examination
outside attacks

Normal

May be impaired (no

abnormality)

Never normal

6. Anti-inflammatory
controller medication

no need

Non steroid/ steroid

inhaler low dose 100200g

Steroid inhaler / oral

400g/hari

7. Lung function tests

(excluding attack)

PEF / FEV 1 > 80%

PEF / FEV 1 60-80%

PEF / FEV1 < 60%

8. Variability in
pulmonary function (if
there is an attack)

Variabilitas > 15%

Variabilitas > 30%

Variabilitas > 50%

Buku Ajar Respirologi anak IDAI, tahun 2010 halaman 109

Asma intermiten :
Intermittent symptoms for less than 1 time per week, short attack (hours-days)
symptoms night less than two times a month
outside attack without symptoms and normal pulmonary function test
PEFR or PEV >80% predicted, variations of < 20%
Asma persisten ringan :
Symptoms > 1 time a week but less than 1 times a day
attacks may disturb activity and sleep
symptoms at night more than 2 times a month
PEV or PEFR > 80% predicted, variations of 20-30%

Global initiative for asthma. Medical communications resources, inc: 2006

Asthma persisten Medium

Symptoms every day
Disrupt the activities and sleep attacks
Symptoms evenings > 1 time a week
Daily use of inhaled short-acting 2 agonist
PEFR or PEV > 60% - <80% predicted, variations of> 30%
Asthma persisten Severe
Continuous symptoms
Frequent attacks
Frequent night symptoms
Limited physical activity due to asthma symptoms
PEFR or PEV <60% predicted, variations of> 50%

Global initiative for asthma. Medical communications resources, inc: 2006

Clinical
parameters, Lung
Function,
laboratory

Mild

Medium

Severe

crowded

walk
Babies: loud
cry

speak
babies:
Short and weak
cry
difficulty eating

break
Babies: Stop
eating

speak

sentence

word sentence

Words

position

could lay down Rather sit

awareness

perhaps
agitated

usually agitated usually

agitated

cyanosis

Nothing

Nothing

Stop threats
Breath

Sat propped
arm

Have

confusion
Real

Buku Ajar Respirologi anak, IDAI, tahun 2010 halaman 132

Wheezing

Moderate, often
only at the
end of
expiration

Tinny, during
expiration +
inspiration

Very loud
audible
without
stethoscop
e

Hard To
Breathe

Minimal

Medium

Severe

Use of
Respiratory
Muscle Aids

usually not

Usually yes

Yes

Torako
abdomina
l
paradoxic
al
movemen
t

Retraction

Shallow,
intercostal
retractions

Medium, plus a
retraction
suprasternal

In, plus a
nasal flaring

Shallow /
Missing

Breathing Rate

increase

increase

increase

decrease

Guidelines for the raw value conscious respiratory rate in children:

Age
Laju Napas Normal
< 2 month
< 60 / minute
1-2 month
< 50 / minute
1-5 month
< 40 / minute
6-8 month
< 30 / minute

Hard / no
sound

Buku Ajar Respirologi anak, IDAI, tahun 2010 halaman 132

Pulse

Normal

Takikardi

Takikardi

Bradikardi

Guidelines for the raw value pulse rate in children:

Age
Pulse rate Normal
2-12 month
< 160 / minute
1-2 year
< 120 / minute
3-8 year
< 110 / minute
Pulsus
paradoxus
(Examination
impractical)

Nothing < 10
mmHg

Have 10-20 mmHg

Have > 20 mmHg No, the sign

of muscle
fatigue
breath

PEFR or FEV1
(alleged value /
% value tebaik)
pre
bronchodilator
post
bronkodilator

> 60%
> 80%

40-60%
60-80%

<40%
<60%
Respon < 2 jam

SaO2 %

> 95%

91-95 %

90%

PaO2

Normal
(normally not
need to be
examined)

> 60 mmHg

<60 mmHg

PaCO2

< 45 mmHg

< 45 mmHg

> 45 mmHg

Buku Ajar Respirologi anak, IDAI, tahun 2010 halaman 132

ANAMNESIS
Chronic cough and recurrent wheezing shortness
especially at night and excessive physical activity
Symptoms, Triggers, family history

Physical examination
Inspection:
- Rapid breathing and dyspnoea
- cough
- Wheezing/mengi
- Supraclavicular retractions, suprasternal,
epigastric and intercostal
- Thoracic shape emfisematous
- Hunchback forward
- Intercostal space widened
Asma Kronik
- AP diameter increases

Physical examination
Percussion:
- Hipersonor entire thorax, especially the
bottom of the posterior
Auskultasi :
- BND rugged / hardened BND became
weakened
- Ekspiration lengthwise
- Ronkhi dry and wet

Suspected asthma

Chronology of the diagnosis of

asthma in children (continued) ...

Not necessarily asthma

Check peak flow meter or

spirometer to assess:

Consider:

Reversibilitas (> 15%)

Lung function tests

Variabilitas (> 15%)

Test the response to bronchodilators and

systemic steroid 5 days

Foto rotgen thorak dan sinus

not successful
Give bronkodilator

Bronchial provocation test

Sweat Test
Imunological test
Silia motility examination
GE reflux examination

Diagnosis of work:
Asthma

Does not support

another diagnosis

Another
diagnosis
support

Give anti-asthma drugs:

Diagnosis and treatment of other diseases
Not successfully reset the
value of diagnosis and
treatment adherence

Consideration of asthma with

other diseases

Not asthma

1. blood tests
Blood and sputum eosinophilia
PMN leukocytosis can occur when there is an
infection
2. X-ray Thorax
Increased lung markings
Hyperinflation
Hiper inflasi
acute attacks and chronic
Asthma
Photo is repeated when there are indications
Pneumonia / pneumothoraks

Foto Toraks

Results can be normal or

chest X-ray showed

hyperinflation
Atelectasis picture can be
obtained because of
blockage by mucus and
hypertrophy of smooth
muscle cells.
The main bronchial wall
thinning.

3. Test skin allergy and immunology

Useful to determine which allergens according

originator
IgE increased

4. Lung function tests

Useful for:
Assessing the level of airway obstruction and

disruption of gas exchange

Measuring the response of the airway to
allergens and chemicals that are inhaled or
during bronchial provocation test
Assessing the response to therapeutic agents
Evaluate the long-term course of the diseas

Uji Faal Paru

Performed before and

after the administration

of the aerosol
bronchodilator
The increase in PFR or
FEV1 at least 10% after
aerosol therapy so
gives the impression of
asthma

Uji Faal Paru

1.

Spirometri
FEV1(Forced Expiratory Volume in 1 sec), FVC
(Forced Vital Capacity, rasio FEV1/FVC

www.joegoshe.com/images/spirometry.gif

2. PEF (Peak Expiratory Flow) Monitoring

www.geocities.com/.../Villa/2545/asthma.jpg

Supporting Investigation
5. Bronchial provocation
test
Performed when the
diagnosis is still in doubt
Purpose: indicates
bronchial hyperreactivity
Which is often done is by:
histamine, and load
methacolin run

MEDIKAMENTOSA
NON MEDIKAMENTOSA

Treatment of asthma differ from asthma

attacks :
Attacks drug / reliever short term
Drug controllers / controller long term

Daftar Obat Asma yang Ada di Indonesia

Drug Name

Generic name

trade
name

preparations

dose

Bricasma

0,05-0,1 mg/kgBB/hari
jam
0,05-0,1 mg/kgBB/hari
Jam

Ventolin

Syrup, tablet,
turbuhaler
Syrup, tablet,
ampul
Syrup, tablet
Syrup, tablet,
MDI
Syrup, tablet,

Berotec

MDI
MDI

(Releiever)
Simpatomimetik (agonis2)
2) :

Terbutaline

Nairet
Orciprenalin
(metaproterenol)
Salbutamol
(albuterol)
Heksoprenalin
Fenoterol

Classed Xantin

Teofilin

Forasma
Alupent

Syrup, tablet

0,1-0,15 mg/kgBB/kali
setiap 6jam
0,1 mg/kgBB/kali
setiap 6 jam

(controller)
AINS :

Sodium
cromogylate

Intal

MDI

Nothing

MDI

Nothing

Fluticason

Becotide
Pulmicort
Inflammide
Flixotide

MDI
MDI,
turburhaler
MDI

Nothing

Prokaterol
Bambuterol

Bambec

Salmeterol
Klenbuterol

Serevent
Spiropent

Sirup,
tablet, MDI
Tablet
MDI
Sirup, tablet

Nedokromil
Classes anti-inflamasi
steroid :

Classes -agonis long

acting :

Beclomethasone
Budesonid

Classes of drugs off slow Terbutalin

/ controlled release /
Salbutamol
Slow release
Teofilin

Volmax

Kapsul
Tablet
Tablet salut

Classes antileukotrien :

Zafirlukas
Montelukas

Accolate

Tablet

Classes combined
steroid +LABA :

Budesonid
+formoterol
Flutikason+salm
eterol

Symbicort
Seretide

Turbuhaler
MDI

Have
Nothing

Management groove Asthma Attacks in Children

Clinic / Emergency Unit
The value of the degree of attack
Procedures beginning
Nebulized -agonis 1-3x, hose 20 minute
Third Nebulized + antikolinergik
If heavy attack, nebulisasi -agonis + antikolinergik
Mild attacks
(nebulized 1X, good
response)
Observation 1 hour
If the effects persist,
could return
If symptoms arise again,
treat it as an attack
medium

Attacks were (nebulized 2X,

partial response)
Give oxygen
Value re-degree assault, if
appropriate with moderate
attack, observation at a day
care room
Give oral steroids
Attach lines parenteral

Heavy attack
(nebulized 3X, bad
response)
Since the beginning
given the current O2 /
outside nebulized
Attach lines parenteral
intravenous steroids
Repeated clinical value,
if appropriate heavy
attack, hospitalized in the
inpatient unit
X-ray photo

Mild attack

Go home
Arm agonist drugs
(inhaled / oral)
If there is already a
controlling drugs,
continue
If the viral infection as
the originator, may be
given oral steroids (3-5
days)
Within 20-48 hours,
control clinic, outpatient
for re-evaluation

Moderate attack

Day care room /

observation
Oxygen forward
Oral steroids followed
Nebulized every 2
hours
If within 12 hours of
clinical improvement is
stable, may return, but
if the clinical remained
not improved /
worsened, over
inpatient care to space

Severe attack

Inpatient unit
Oxygen forward
Overcome dehydration and
acidosis if there
Steroids IV every 6-8 hours
Nebulized every 1-2 hours
Aminophilin initial IV
continue maintenance
If improved in nebulized 46X, the interval to 4-6 hours
If clinical improvement
within 20 hours of steady,
go home
If the steroids and
parenteral aminophilin not
good, even raised the threat
of stopping breathing, over
care to ICU

Flow of Long-Term Management of Asthma

Children
reliever : -agonis atau teofilin (inhaler or
Asthma Episodic
oral) if necessary
Rarely

4-6 week
Asthma Episodic
Often
6-8 minggu
respons

Asthma
Persisten

> 3x
< 3x
doses/
doses/
week
week
Add controller medications: low-dose
inhaled steroid

Consider alternatives addition of one of the

drugs:
-agonis long acting
Teofilin short acting
Antileukotriena
Or doses of inhaled steroids increased
(high)

Flow of Long-Term Management of Asthma Children continued

Asthma
Persisten

Medium-dose steroids added to one of

the drugs:
-agonis long acting
Teofilin short acting
Antileukotriena
Or doses of inhaled steroids increased
(high)

6-8 minggu respons

Drug Steroid Oral

Non medikamentosa
Theraphy
Prevent children exposed to the substance /
allergen / conditions (weather) which can spur
the onset of asthma attacks
Education to the families of children with

asthma about the degree of illness and the

degree of asthma attacks.

Prognosis
Long-term prognosis is generally good 50-80%
Most asthmatic child is diminished with age
70% -80% of childhood asthma disappears at

the age of 21 years

Komplikasi
Emphysema and change shape
Asthma is a chronic and severe Pigeon chest
Many viscous secretions bronchial obstruction

atelektasis bronkiektasis infction

bronkopneumonia
Status asmatikus respiratory failure pulse failure

Critism and Suggestions

For pattient
Prevent asthma attacks (environmental

settings).
Giving the drug at the time, manner, and
duration of the right.
Knowing the signs of the beginning of an
asthma attack.
Knowing when to consult a doctor or to the
hospital.
Keeping the child's general health.