dr.

Rommy Yorinda Putra

 Introduction
*Chronic inflammatory disease.
*Increased airway responsiveness.

*Can occur spontaneously or in response to various stimuli.

*Physical exertion, allergens, medications, infection,

emotions and stress.
 Introduction
Study in RSUP Persahabatan (2006) shows that from 33 women
with Asthma during pregnancy there is 63,64% being well, 33,3%
getting worse and 3,03% nothing changed at all

In RSUD Arifin Ahmad Provinsi Riau (2018), we found 144 cases of

Asthma, and there is 14 cases of Asthma during pregnancy (9,7%)
Pathophysiology
Pathophysiology
 Asthma
c h a r a c t e r is t i c s

 Shortness of breath , wheezing and cough determine

severity
 Che st tightness

 Nocturnal awakenings

 Recurrent episodes of symptom complex

 HISTORY A N D
PHYSCIAL FINDINGS
 Exacerbations possibly provoked by nonspecific stimuli

 Personal or family history of other atopic disease (eg, hay

fever, eczema)

 Tachypnea

 Retraction (sternomastoid, abdominal, pectoralis muscles)

 Agitation, usually a sign of hypoxia or respiratory distress

 Pulsus paradoxicus (>20 mm Hg)

 PULMONARY FINDINGS

 Diffuse wheezes -Long, high-pitched sounds on

expiration and, occasionally, on inspiration)
 Diffuse rhonchi -Short, high- or low-pitched squeaks
or gurgles on inspiration and/or expiration
Bronchovesicular sounds

 Expiratory phase of respiration equal to or more

prominent than inspiratory phase
 SIGNS OF RESP FAILURE
 Alteration in the level of consciousness, such as
lethargy, which is a sign of respiratory acidosis and
fatigue
 Abdominal breathing

 Inability to speak in complete sentences

 Investigations
 CBC-anemia, thrombocytopenia or infection

 B l o o d gases ABG-to see oxygenation

 A B G values: pH = 7.4-7.45, pO2= 95-105 mm Hg, pCO2 =
28-32 mm Hg, and bicarbonate = 18-31 mEq/L.

 X R A Y Chest
 Chest x-ray
 Chest radiography is indicated
when the other coexistent
 Chest radiography
conditions, such asis indicated
when the other
pneumonia, coexistent CHF,
barotrauma,
conditions, such as pneumonia,
or chronic obstructive
barotrauma, CHF, are likely.
pulmonary disease,
or chronic obstructive
 Chest radiographs (2 views)
pulmonary disease, are likely.
with a shielded maternal
 Chest
abdomenradiographs (2 fetus
expose the views)to
with a shielded 0.00005
approximately maternalrad.
abdomen expose the fetus to
approximately 0.00005 rad.
 SPIROMETRY
• TLC • RV

• Total lung capacity: the • Residual volume: the volume of

volume in the lungs at air remaining in the lungs after a
maximal inflation, the sum maximal exhalation
of VC andRV.
• TV • ERV

• Tidal volume: that volume • Expiratory reserve volume: the

of air moved into or out of maximal volume of air that can
the lungs during quiet be exhaled from the end-
breathing
expiratory position
 Changes in Pulmonary funCtion
tests in Acute Asthma

 Decreased peak expiratory flow rate (PEFR)

and forced expiratory volume in 1 second
(FEV 1)

 Mild reduction in the forced vital capacity

(FVC)

 An increased residual volume (RV), functional

residual capacity (FRC), and total lung
capacity (TLC)

 Normal diffusing capacity

 PEFR N 380-550 L/Min

PHYSIOLOGIC CHANGES OF PREGNANCY
Structural/Hormonal changes:
↑Progesterone (respiratory
stimulant) →Hyperventilation
→ overcompensation ↓ CO2
↑Estrogen→hyperemia-rhinitis
↑Hypoxic ventilatory response
2x the normal level due to E&P
Enlarged uterus ↑abdominal
pressure ↓ chest wall
compliance 35-40% →
reduction functional residual
capacity (FRC)
Elevation of diaphragm 4cm
↑ Relaxin → ribcage ligaments
relax ↑ circumference5cm
↓ Expiratorymuscle strength
Circulatory changes:
↑ Cardiacoutput
↑ Pulmonary blood flow &
capillary bloodvolume
↑ Circulating blood volume
↓ Plasma oncoticpressure
→formation of edema in the
lungs.
Increased metabolic rate with
low oxygen levels at end of
expiration make pregnant
woman particularlysusceptible
to develop hypoxemia in the
presence of respiratory
problem
 THUS IT IS POSSIBLE TO USE NON-PREGNANT
REFERENCESVALUES TO EVALUATE LUNG
FUNCTION IN PREGNANT WOMEN.
PREGNANCY HAS NO
SIGNIFICANT EFFECT ON
FEV1 OR THE FEV1/FVC
RATIO.
PEAK EXPIRATORY FLOW RATES
REMAIN CLOSE TO THE NORMAL
RANGE AND DO NOT CHANGE
DURING PREGNANCY.

THE SHAPE OF THE FLOW- VOLUME
CURVE AND ABSOLUTE FLOW RATES
AT LOW LUNG VOLUMES ARE
NORMAL IN PREGNANT WOMAN.
“A REDUCTION IN FEV1 OR FVC SHOULD NOT
BE ATTRIBUTED TO PREGNANCY ALONE. THIS IS
IMPORTANT FOR CLINICIANS TO UNDERSTAND,
PARTICULARLY AS THEY ARE FOLLOWING
PATIENTS WITH UNDERLYING LUNG DISEASES,
SUCH ASASTHMA”.
 NORMAL RESPIRATORY PHYSIOLOGIC CHANGES IN PREGNANCY
Chest Wall Decreased FEV1 Unchanged
Compliance
Thoracic Diameter Increased FVC Unchanged
Diaphragm Elevated FEV1/FVC Unchanged
Lung Compliance Unchanged Minute ventilation Increased
Total LungCapacity Unchanged/slightly Tidal volume Increased
decreased

Vital Capacity Unchanged/slightl Respiratory rate Unchanged

y decreased

Inspiratory Capacity Slightly increased PH Normal

Functional Residual Decreased PaO2 Slightly elevated

Capacity (100-105 mmHg)
ResidualVolume Slightly decreased PaCO2 Slightly decreased
(32-34 mmHg)
Expiratory reserve Decreased Bicarbonate Slightly decreased
volume (15-20 meq/L)
 Asthma complicates 4–8% of
pregnancies.
- Prevalence of and morbidity from asthma are increasing,
although asthma mortality rates have decreased .
- Asthma symptoms peak in the late second or early third
trimester. (29-36 weeks).
- Less severe during the last month of pregnancy.
THE EFFECTS OF PREGNANCY ON ASTHMA
Asthma has been associated with considerable maternal morbidity.

In a large prospective study:

 Mild asthma had an exacerbation rate of 12.6% and hospitalization rate of

2.3%.
 Moderate asthma had an exacerbation rate of 25.7% and hospitalization rate of
6.8%.
 Severe asthmatics had exacerbation of 51.9% and hospitalization rate
26.9%.

One of the most important conclusions to be made from this study is that pregnant
asthmatic patients, even with mild or well-controlled disease, need to be monitored
 Treat airway inflammation
Management Goal

 Decrease airway responsiveness.

 Prevent asthma symptoms and exacerbations.
 Maintain adequate oxygenation to the fetus by preventing
hypoxic episodes in the mother.
Optimal management:

• Avoiding or controlling asthma triggers (Allergens (pet

dander, house dust, strong perfumes, smoking)
• 85% of asthma patients test skin positive to common
allergens.
• Allergen-impermeable pillow and mattress covers, weekly
washing bedding in hot water, air sanitizers/humidifiers, leave
when vaccuming is done, etc.
Patient Education:

*Teach early recognition of signs and symptoms.

*Improve compliance with medication.
*Seek prompt treatment when necessary.
*Prompt management of:

allergic rhinitis
sinusitis gastroesophageal reflux

*May exacerbate asthma symptom.s

COMORBIDITIES THAT MAY EXACERBATEASTHMA
o Sinusitis and Reflux are relatively common comorbidities during
pregnancy that may exacerbate asthma.

o Pregnancymay be complicated by new-onset or preexisting

rhinitis, orasthma.

o Rhinitis is avery common problem that may occur during

pregnancy. In the past, rhinitis and asthma may have been
treated as separatedisorders.

o TheUnited Airway DiseaseHypothesis proposesthat upper and

lower airway diseaseare both manifestations of asingle
inflammatory process.
Monitoring lung function:

 Spirometer
 FEV1 after a maximal inspiration is the single
best measure of pulmonary function.
PHARMACOLOGY MANAGEMENT

Reliever

Controller
Beta-2Agonists Binds to beta2 receptors leading to Human data scant, lacks Albuterol (C)
bronchial relaxation. •short acting evidence of risk of Salmeterol (C)
•long acting congenital malformation

Inhaled Counteract inflammatory response. Not contraindicated in Beclomethasone (C)

Corticosteroids Maintenance therapy. pregnancy. Budesonide (B)
Fluticasone (C)
Flunisolide (C)
Systemic Reverse inflammatory response of Not clear to what extent. Predinisone (C)
corticosteroids* asthma exacerbation/ short term Possible association (0.1- Methylprednisone (C)
therapy for severe/persistent 0.3%) facial cleft lip during Dexamethasone (C)
asthma first trimester
Anticholinergics Bind to acetylcholine, resulting in Add on therapy for beta- Ipatropium (B)
inhibition of secretions from agonist. No association to
seromucous glands increased risk of
congenital
malformation/adverse
outcome
Methylxanthines Promote smooth muscle relaxation. Add on therapy. Not used Not contraindicated during
Suppress hypersensitivity reaction in pregnancy due to pregnancy.
of the airways to stimuli multiple drug interactions, Theophylline (C)
need to monitor levels &
side effects
Cromoglycates Inhibition of airway inflammatory Not associated with Cromolyn Sodium (B)
cells. Preventive therapy for increase risk of congenital
persistent asthma malformation/adverse
maternal outcome
Leukotriene Act to antagonize leukotriene Information during Zafirlukast (B)
Inhibitors activity/inhibit bronchial smooth pregnancy is Montelukast (B)
 Relievers
Bronchodilators: short-acting inhaled β 2- adrenergic receptor
agonist used for the relief of bronchospasm.
Short-acting: rapid relief of symptoms by relaxing airways and
reducing bronchospasm.
No anti-inflammatory action.
They do not block the development of airway
hyperresponsiveness.

Ex: Albuterol (Proventil, Ventolin,

Salbutamol) Metaproterenol (Alupent)
 Controllers:

• Control inflammation and treat disease.

• Reduce the risk of Asthma attack and airway remodeling.
• Mainly anti-inflammatory.

*Inhaled corticosteroids
*LABA
*Cromolyn
*Theophylline
*Leukotrene antagonists
 Class Theraphy

Mild intermittent PRN Salbutamol

Mild persistent Inhaled corticoteroid

Moderate persistent Inhaled corticoteroid +

LABA
Inhaled corticoteroid +
Severe persistent LABA
MAJOR GOAL OF CHRONIC ASTHMA MANAGEMENT IS
THE PREVENTION OF EXACERBATION…

Pharmacologic approach:
Inhaled Beta2-agonist(Albuterol)
Inhaled Corticosteroids(Budesonide)
Alternative add-on medication (long-acting beta2-agonist, cromolyn,
leukotriene inhibitor, theophyline)

Acute management
Pharmacologic approach / step therapy
Fetal monitoring / maternal monitoring.
Supplemental O2 to maintain PO2 > 70 and O2 sat >95% by pulse
oximetry.
IV fluids at rate of 100ml/hour with glucose if pt not hyperglycemic.
RECOMMENDATIONS

Management geared towards prevention of

chronic
symptoms.

Pt should be educated how to perform accurate

peakflows

Action plan (Nelson, Gossett, &Grobman, 2010)

Monthly assessment in all asthmatic women with

evaluation of arterial sat >95% (Ivancso, Bohacs,
Eszes, Losonczy, &Tamasi, 2013)
 PULSE OXIMETER (SPO2)

Assess oxygenation by measuring the Spo2 is one patient-

arterial oxygen saturation ofHgb assessment tool and should be
interpreted alongwith other
The proper use of a pulse oximeter can patient dataincluding
ensureearlier detection ofhypoxia
Vitalsigns
A normal Spo2 range is95% to 100%
Cardiacrhythm

Breathsounds
 Conclusions

Asthma may be influenced by pregnancy, but the

outcome and prognosis of most asthmatic mothers and
their newborn infants are usually favourable,
particularly if the women's asthma is well controlled in
pregnancy.

Exacerbations should be prevented by optimal asthma

management,

Treatment should be started before pregnancy to

educate and prevent exacerbation in preg so that
asthma does not become transgeneration
THANK YOU