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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 Acute asthma
1. Infrequent 1. Mild attack
episodic asthma
2. Moderate
2. Frequent episodic
asthma attack
3. Persistent 3. Severe attack
asthma
Asthma labelling
Chronic condition + present condition
Chronic condition: infrequent -- persistent
Present condition:
(-)
Symptom attack (-)
(+)
attack (+)
 Chronic Asthma

trigger
exposure not optimal
medication

Acute Asthma
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Asthma managements
Chronic asthma Acute asthma

Long term Attack

management management

Algorithm diagnosis Algorithm attack

& treatment management
Asthma managements
Chronic asthma Acute asthma

Long term Attack

management
management
Reliever &
Controller Reliever
Asthma medication
Controller Reliever
drug to control drug to relieve
asthma ie attack or asthma attack or
symptom not symptoms
easily emerge
-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

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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 : inhaler, nebulized, oral
Epinephrine : subkutan
Teophyllin/aminophyllin : oral, I.V.
Anticolinergic (ipratropium br) : inhaler
Steroid : oral, I.M.

Controller:
Steroid : inhaler
LABA : inhaler, oral
Antileukotrien : oral
PNAA, 2002
Classification Controller Reliever

Infrequent No Yes
episodic
asthma

Frequent Yes Yes

episodic
asthma

Persistent Yes Yes

asthma

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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)

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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 )
v Reduces FEV1 diurnal variation
v Reduces symptoms
v Reduces asthma attack frequency
v 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 : inhaled, nebulized, oral
Ephinephrin : subcutan
Theophyllin/aminophyllin : oral, I.V.
Steroid : oral, I.M.

Controller (prevention of attack) :

Avoidance : triggers (including enhancers,
inducers) especially improve
indoor environment.
Medicine : inhaled steroid, antileukotrien.
Steroid efficacy in asthma

Steroid
dose
Benefit

Side-effects
Long term treatment
2-agonist or theophylline
Infrequent Episodic inhaled/oral intermittently
Symptoms
4-6 weeks 3-6 months
>3 episodes/week Evaluation

Add controller drug

Frequent episodic 6-8 weeks 3-6 months

response (-) response (+)
Symptoms
Replace with low dose inhaled steroids
Continue 2-a or/and
theophylline inhaled/oral intermittently
6-8 weeks 3-6 months
response (-) response (+)
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 6-8 weeks 3-6 months
respons (-) respons (+)

Consider :
Persistent Symptoms Long acting 2-agonists, or
Slow release 2-agonists, or
Slow release theophyllines
6-8 weeks 3-6 months
respons (-) respons (+)

Increase dose of inhaled steroid

6-8 weeks 3-6 months

respons (-) respons (+)

Add oral steroids

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 Longterm
management Low dose steroid

Medium dose Low dose Low dose Low dose

steroid steroid + LABA steroid + ALTR steroid +TSR

High dose Medium dose Medium dose Medium dose

steroid steroid + LABA steroid + ALTR steroid + TSR

ORAL
STEROID
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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
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