KLASIFIKASI ASMA

GINA 2015

Dr. Widya Sri Hastuti, Sp.P, FCCP, FAPSR

ATLAS ID 339759/April 2016

 Dr. WIDYA SRI HASTUTI, Sp.P, FCCP, FAPSR

Academic Qualification:
2004 M.D, Faculty of Medicine University of Indonesia,
Jakarta
2013 Pulmonologist, Faculty of Medicine University of
Indonesia, Jakarta
2015 Fellow of American College of Chest Physician
2015 Fellow of Asian Pasific Society of Respirology

Current Position:

Pulmonologist, Embung Fatimah Hospital, Batam

Pulmonologist, Harapan Bunda Hospital, Batam

Pulmonologist, Sanomedika Clinic, Batam

 Global INitiative for Asthma 2006
Evolution of Asthma Control
2002 - The GINA report :
“… in most patient with asthma control of the disease can, and should be
achieved and maintained”

2005 – Executive Committee recommendation :

“… a new report not only to incorporate updated scientific information but
to implement an approach to asthma management based on asthma
control, rather than asthma severity”

GINA 2006 :
Assess, Treat and Maintain Asthma Control

http://www.ginasthma.com
GINA goals of treatment

GINA 2002

"The aim of asthma management

should be control of the disease"
GINA goals of treatment

GINA 2006

"The goal of asthma treatment is to

achieve and maintain clinical
control"
 Global INitiative for Asthma 2006

The Classification of Asthma

2003 2006
By Severity By Level of Control
• Intermittent • Controlled
• Mild Persistent • Partly Controlled
• Moderate Persistent • Uncontrolled
• Severe Persistent
http://www.ginasthma.com
 Global Strategy for Asthma Management and Prevention

Definisi Asma

Asma adalah penyakit heterogen, biasanya disertai

dengan inflamasi kronis pada saluran pernapasan

Asma ditandai dengan adanya gejala seperti mengi,

sesak napas, dada terasa berat dan batuk yang
bervariasi sepanjang hari dan intensitas disertai
adanya keterbatasan aliran udara yang bersifat
reversibel

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014). Available from
www.ginaasthma.org. Accessed on February 07, 2015
ASTHMA PREVALENCE IN INDONESIA
(RISKESDAS 2013)
 Global Strategy for Asthma Management and Prevention

Diagnosis Asma
1. Riwayat dan pola gejala
2. Pengukuran fungsi paru
 Spirometri
 Peak expiratory flow / Arus Puncak Ekspirasi
3. Pengukuran respons saluran napas
4. Pengukuran status alergi untuk mengindentifikasi faktor
risiko
5. Langkah tambahan mungkin diperlukan untuk
mendiagnosis asma pada anak usia 5 tahun ke bawah dan
orang tua

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014). Available from
www.ginaasthma.org. Accessed on February 07, 2015
PATIENT HISTORY

 Has the patient had an attack or recurrent episodes

of wheezing?
 Does the patient have a troublesome cough, worse
particularly at night, or on awakening?
 Does the patient cough or wheeze after physical
activity or exercise (eg. Playing)?
 Does the patient have breathing problems during
a particular season (or change of season)?
 Do the symptoms occur and worsen if presence
of animal with fur, aerosol chemical, mites,
pollen, smoke, strong emotional expression ?

 Does the patient use any medication (e.g.

bronchodilator) when symptoms occur? Is there
a response?

If the patient answers “YES” to any of the

above questions, suspect asthma.
Physical examination

 Because asthma symptoms are variable,

the physical examination of the respiratory
system maybe normal

 The most usual abnormal physical finding

is wheezing on auscultation
Diagnostic testing

 Measurement of lung function provide an

assesment of the severity, reversibility, and
variability of airflow limitation and help confirm
diagnosis of asthma.
 Spirometry is the preffered method of measuring
airflow limitation and its reversibility to establish to
diagnosis of asthma.
Diagnosis of asthma can be confirmed by
demonstrating the presence of reversible
airway obstruction using Spirometry or Peak
flow meter.
Reversibility
Spirometry
An increase FEV1 > 12 % (AND > 200 ml) after
administration a bronchodilator indicate
reversible airflow limitation consistent with
asthma.

Peakflow meter
An improvement of 60 L/min ( or > 20 % of the
pre-bronchodilator PEF) after inhalation of a
bronchodilator suggest a diagnosis a asthma
 Daily Variability

Diurnal variation in PEF more than 20% ( with twice

daily reading more than 10%) suggest diagnosis
asthma

Daily variability = PEF evening - PEF morning x 100

1/2 (PEF evening + morning)
 GINA 2015: Assess, Treat and
Monitor

Assessing Asthma Control

Treating to Achieve Control

Monitoring to Maintain Control

Key action steps in

new guidelines
GINA 2006
 Tujuan Manajemen Asma

OVERALL ASTHMA CONTROL

Mencapai Mengurangi

Kontrol saat ini Risiko masa depan

Didefinisikan dengan Didefinisikan dengan

Penggunaan Perburukan
Gejala Eksaserbasi
Obat pelega asma

Penurunan Efek samping

Aktivitas Fungsi paru
Fungsi paru pengobatan

Adapted from: Bateman E et al. J Allergy Clin Immunol 2010:125(3);600-08

 Global Strategy for Asthma Management and Prevention

Kontrol Klinis Asma

1. Tentukan tingkat atau level kontrol asma

awal untuk menentukan jenis pengobatan
(nilai tingkat kontrol asma pasien)

2. Mempertahankan kontrol asma setelah

pengobatan dilakukan
(nilai risiko asma pasien)

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014).
Available from www.ginaasthma.org. Accessed on February 07, 2015
 Levels of Asthma Control

Controlled Partly controlled

Characteristic Uncontrolled
(All of the following) (Any present in any week)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any features of
activities
partly
Nocturnal symptoms controlled
None Any
/ awakening asthma
Need for rescue / None (2 or less / More than present in any
“reliever” treatment week) twice / week week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day

Exacerbation None One or more / year 1 in any week

TOTAL CONTROL Definition
No Symptoms

No Salbutamol use

Every day 80% PEF am

No Night-time awakenings

No Exacerbations

No Emergency visits
Treatment-related adverse events
No enforcing change in therapy
TOTAL CONTROL is ALL of these sustained for at least 7 of 8 weeks

Bateman et al. ARJCCM 2004

 Asma Terkontrol

 Gejala harian : ≤2x/minggu

 Hambatan aktivitas : -
 Gejala malam : -
 Reliever : ≤2x/minggu
 Fungsi paru ( PEFR/FEV1 ) : normal
 Asma Terkontrol Parsial
 Gejala harian: >2x/minggu

 Hambatan aktivitas : ada

 Gejala malam : ada

 Perlu reliever : >2x/minggu

 Fungsi paru : <80% prediksi atau hasil terbaik

 Asma Tidak Terkontrol
 Minimal 3 atau lebih terdapat keadaan
terkontrol parsial pada tiap minggu, yaitu :

- Gejala harian : >2x/minggu

- Hambatan aktivitas : ada
- Gejala malam : ada
- Perlu reliever : >2x/minggu
- Fungsi paru : <80% prediksi atau hasil terbaik
 Tingkat Kontrol Asma
(Menilai tingkat kontrol asma)

Kontrol Gejala Level Kontrol Gejala Asma

Dalam 4 minggu terakhir, apakah pasien memiliki : Terkontrol Terkontrol Tidak

penuh sebagian terkontrol
1. Gejala asma harian lebih dari dua kali
dalam 1 minggu
2. Terbangun di malam hari karena asma Tidak Terdapat Terdapat
terdapat 1- 2 3- 4
satupun kriteria kriteria
3. Penggunaan obat pelega untuk mengatasi kriteria
gejala lebih dari dua kali dalam 1 minggu
4. Pembatasan aktivitas karena asma

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014). Available from www.ginaasthma.org. Accessed on February 07, 2015
 Global INitiative for Asthma 2006

The Classification of Asthma

2003 2006
By Severity By Level of Control
• Intermittent • Controlled
• Mild Persistent • Partly Controlled
• Moderate Persistent • Uncontrolled
• Severe Persistent
http://www.ginasthma.com
Derajat Asma berdasarkan GINA 2002
 Gejala kurang dari 1 kali/minggu
 Serangan singkat
 Gejala nokturnal ≤ 2 kali/bulan
 FEV1≥80% predicted atau PEF ≥ 80% nilai terbaik
individu
 Variabilitas PEF atau FEV1 < 20%
 Gejala lebih dari 1 kali/minggu tapi kurang dari 1
kali/hari
 Serangan dapat mengganggu aktivitas dan tisur
 Gejala nokturnal >2 kali/bulan
 FEV1≥80% predicted atau PEF ≥ 80% nilai terbaik
individu
 Variabilitas PEF atau FEV1 20-30%
 Gejala terjadi setiap hari
 Serangan dapat mengganggu aktivitas dan tidur
 Gejala nokturnal > 1 kali dalam seminggu
 Menggunakan agonis β2 kerja pendek setiap hari
 FEV1 60-80% predicted atau PEF 60-80% nilai terbaik
individu
 Variabilitas PEF atau FEV1 > 30%
 Gejala terjadi setiap hari
 Serangan sering terjadi
 Gejala asma nokturnal sering terjadi
 FEV1 ≤ predicted atau PEF ≤ 60% nilai terbaik
individu
 Variabilitas PEF atau FEV1 > 30%
 STEP 4: SEVERE PERSISTENT Step
CONTROLLER: daily multiple down
medications RELIEVER when
• Inhaled steroid
• Long-acting bronchodilator • Inhaled ß2- controlle
• Oral steroid agonist p.r.n. d
Avoid or control triggers
STEP 3: MODERATE PERSISTENT • Patient
CONTROLLER: daily education
medications RELIEVER
• Inhaled steroid and long- essential at
acting bronchodilator • Inhaled ß2- every step
• Consider anti-leukotriene agonist p.r.n. • Reduce
Avoid or control triggers therapy if
controlled
STEP 2: MILD PERSISTENT for at least
CONTROLLER: daily 3 months
medications RELIEVER • Continue
• Inhaled steroid • Inhaled ß2-
• Or possibly cromone, oral monitoring
theophylline or anti-leukotriene agonist p.r.n.
Avoid or control triggers
STEP 1: INTERMITTENT

RELIEVER Step up
CONTROLLER: none
• Inhaled ß2- if not controlled
agonist p.r.n. (after check on
inhaler technique
Avoid or control triggers and compliance)
TREATMENT
GINA Guidelines 1998
 Kesimpulan

 Asma adalah penyakit inflamasi kronis pada saluran napas.

 Overall Asthma Control dengan cara
1. Mengontrol gejala asma dan mengobati inflamasi
dalam setiap inhalasinya
2. Mengurangi eksaserbasi & mengurangi dosis
kortikosteroid
THANK YOU-WSH-