Nur janah

Pulmonologist
Ratu Zalecha Hospital
Definition of Asthma...

Asthma is a disorder defined by its clinical, physiological and

pathological characteristic.

The predominant feature of the clinical history is episodic shortness of

breath, particularly at night often accompanied by cough
The main physiological feature of asthma is episodic airway obstruction
characterized by expiratory airflow limitation.
The dominant pathological feature is airway inflammation, sometimes
associated with airway structural changes.

GINA Guideline 2012

Operational description of Asthma...

Asthma is a chronic inflammatory disorder of the airways in which many

cells and cellular element play a role.

The cronic inflammation is associated with airway hyperresponsivenes

that leads to reccurent episodes of wheezing, breathlessness, chest
tightness, and coughing particulary at night or in the early morning.

These episodes are ussually associated with widespread, but variable,

airflow obstruction within the lung that is often reversible either
spontaneously or with treatment

GINA Guideline 2012

Definition Status asthmaticus ...
Is the condition of a patient in progressive respiratory failure due to
asthma, in whom conventional forms of therapy have failed.1

The exact definition differs between authors.

For practical clinical purposes, any patient not responding to initial

doses of nebulized bronchodilating agents should be considered to
have status asthmaticus.2

A review Werner HA. Chest. 2001;119(6):1913-1929

Pattern Respiratory failure in asthma

Grup 1 Acute Severe asthma Grup 2 Acute Asphyxic Asthma

 Gender : Women> men
 Baseline : Moderate to
severe airflow obstruction
 Onset : Days to week
 Pathology :1. Airway wall
edema 2. Mucus gland
hypertrophy 3. Inspissated
secretions
 Response to treatement :
Slow
 Men >Women
 Normal or mildly
decreased lung function
 Minutes to hours
 1. Acute bronchospasm 2.
neutrophilic, not
eosinophilic bronchitis
 Rapid

Medical n ventilatory management of status asthmaticus

B.D. Levy et al Intensive Care med (1998) 24: 105-117
Pathophysiology
 Pathophysiology
Host Factors
Environmental Factors

Airway Narrowing
Bronchoconstriction n spasm
Air Trap in alveoli
Relaxed
Smooth
muscle
Tightened
Smooth musle

Wall Mucous
inflammed n hypersecretion
thicken
Normal Asthmatic Asthmatic Airway
Airway Airway during attack

GINA 2012
 Penanganan Asma Eksaserbasi
di Rumah Sakit
Penilaian Awal
Anamnesis, PF (auskultasi, penggunaan otot bantu napas, denyut jantung, frekuensi napas),
APE atau VEP1 , saturasi oksigen, dan tes lain yang diperlukan

Terapi Awal
• Inhalasi 2-agonis kerja cepat secara terus menerus selama 1 jam.
• Oksigen sampai tercapai saturasi O2 > 90% (95% pada anak-anak)
• Steroid sistemik jika tidak ada respons segera, atau jika pasien sebelumnya
sudah menggunakan steroid oral atau jika derajat keparahan sudah berat
• Sedasi merupakan kontra-indikasi terapi asma eksaserbasi.

Penilaian Ulang setelah 1 jam

APE, saturasi Q2, tes lain yang diperlukan

GINA Updated 2008

lanjutan ….
Penilaian Ulang stlh 1 jam

Derajat Sedang Derajat Berat

• APE 60-80% dari yang diperkirakan
• Pem. Fisik : gejala sedang, penggunaan
otot bantu pernapasan
• Oksigen
• Inhalasi 2-agonis dan anti-kolinergik
setiap 60 menit
• Glukokortikosteroid oral
• Teruskan terapi 1-3 jam jika ada perbaikan
• APE < 60% dari yang diperkirakan
• PF: gejala berat saat istirahat, retraksi dada
• Riwayat faktor resiko mendekati asma yang
fatal
• Tidak ada perbaikan setelah terapi awal
• Inhalasi 2 -agonis dan anti-kolinergik
• Oksigen
• Glukokortikosteroid sistemik
• Teofilin IV

Penilaian Ulang stlh 1-2 jam

Respons tidak baik Respons buruk

Respons baik
selama 1-2 jam selama 1-2 jam

GINA Guideline
 Respons Baik Respons tidak lengkap Respons jelek
• Bertahan 60 menit setelah selama 1-2 jam selama 1 jam
terapi terakhir • Pasien resiko tinggi
• Pasien resiko tinggi • PF: gejala berat, kesadaran
• PF : normal
• PF: gejala ringan-sedang
• APE > 70% menurun, kebingungan
• APE < 70% • APE < 30%
• Tidak stres
• Saturasi O2 tidak membaik • PCO2 > 45mm Hg
• Saturasi O2 > 90%
(95% pada anak-anak) • PO2 < 60mm Hg

Pulangkan ke Rumah
• Lanjutkan  2-agonis inhalasi
• Pertimbangkan steroid oral
• Pertimbangkan inhaler
kombinasi
• Edukasi pasien:
Cara pakai obat yang benar
Buat rencana aksi
Follow-up teratur
Rawat Rumah Sakit
(acute care setting)
• Inh 2-agonis ± anti-kolinergik
• Steroid sistemik
• Oksigen
• Magnesium IV
• Monitor APE, saturasi O2 , nadi
Rawat di ICU
• Inh 2-agonis + anti-kolinergik
• Steroid IV
• Pertimbangkan 2 -agonis IV
• Oksigen
• Pertimbangkan teofilin IV
• Intubasi dan ventilasi mekanik
jika perlu

Perbaikan Tidak membaik

Kriteria bisa dipulangkan Rawat di ICU
Jika tidak ada perbaikan
• jika APE > 60% dari yang
setelah 6-12 jam
diperkirakan
• Kondisi tetap pada saat
terapi oral / inhalasi
 Budesonide/Formoterol SMART ™ mengurangi penggunaan
kortikosteroid dibandingkan dengan fixed kombinasi + SABA

Observations from the COMPASS study

Sal/Flu Symbicort Symbicort SMART

50/250 µg bid 320/9 µg bid 160/4.5 µg bid + prn
Level of use1 (n=1123) (n=1105) (n=1107)

Mean inhaled corticosteroid dose (µg/day)

Not adjusted (FP vs BUD) 500 640 483

BDP equivalents* 1000 1000 755

SYM/029/Okt12-Okt13/RD
Oral corticosteroid use/group

Total days with event 1132 1044 619

FP, fluticasone propionate; BUD, budesonide; prn, as needed;

*BDP (beclomethasone dipropionate) equivalents adapted from GINA guidelines 2006 .
Kuna P, et al. Int J Clin Pract 2007:61(5) :725-36
Non invasif mechanical Invasif mechanical
ventilation ventilation