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A S T H M A

Dr. Bayu Sukresno, Sp. PD

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Episodic or chronic symptoms of airflowobstruction : breathlessness, chest tightness,wheezing, and cough.

Complete or partial reversibility of airflowobstruction, either spontaneously or followingbronchodilator therapy.

Symptoms frequently worse at night or in theearly morning.

Prolonged expiration and diffuse wheezes on

physical examination. Limitation of airflow on pulmonary function

testing or positive bronchoprovocationchallenge.

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Asthma is a chronic inflammatory disorder of theairways.

The strongest identifiable predisposing factor isatopy, but obesity is increasingly recognized as

a risk factor. Exposure of sensitive patients to inhaled

allergens increases airway inflammation, airwayhyper-responsiveness, and symptoms.

Symptoms may develop immediately or 4-6hours after allergen exposure.

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Common allergens include house dust mites(often found in pillows, mattresses, upholsteredfurniture, carpets, and drapes), cockroaches,cat dander, and seasonal pollens.

Nonspesific precipitants of asthma includeexercise, URI, rhinitis, sinusitis, postnasal drip,aspiration, gastroesophageal reflux, changes inthe weather, and stress.

Others : air pollutants, certain medications,occupational asthma, catamenial asthma.

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SYMPTOMS AND SIGNS

Episodic wheezing, difficulty in breathing, chesttightness, and cough.

Excess sputum production is common.

The frequency of asthma symptoms is highlyvariable.

Asthma symptoms are frequently worse at night.

Chest examination may be normal betweenexacerbations in patients with mild asthma.

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Severity of asthma exacerbations

Mild: dyspnea only with activity; talks insentences

Moderate: dyspnea interferes with limitsof usual activity; talks in phrases

Severe: dyspnea at rest; interferes with

conversation; talks in words- Life threatening : too dyspneic to speak;

perspiring

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Classification of asthma severity

INTERMITTENT :

Symptoms < 2 days/week Nighttime awakenings < 2x/month

SABA use for symptom control < 2

days/week Interference with normal activity : none

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MILD PERSISTENT :

Symptoms > 2 days/week but not daily

Nighttime awakenings 3-4x/month

SABA > 2 days/week but not daily

Interference with normal activity : minor

limitation MODERATE PERSISTENT :

Symptoms daily

Nighttime awakenings > 1x/week

SABA daily

Interference with normal activity : somelimitation

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SEVERE PERSISTENT :

Symptoms throughout the day

Nighttime awakenings often 7x/week

SABA several times per day

Interference with normal activity : extremelylimited

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Pulmonary Function Testing

Spirometry

Peak expiratory flow meter

Bronchial provocation testingArterial blood gas measurements

Additional testing :

Routine chest radiographs are usually normal;indicated when pneumonia or pneumothoraxis suspected

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Complications

Exhaustion, dehydration, airway infection,and tussive syncope.

Pneumothorax occurs but is rare.

Acute hypercapnic and hypoxic respiratory

failure occurs in severe disease.

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COMPONENTS OF ASTHMA

DIAGNOSIS AND MANAGEMENT

1. Assessing and monitoring asthmaseverity and asthma control.

2. Patient education designed to foster apartnership for care.

3. Control of environmental factors andcomorbid conditions that affect asthma.

4. Pharmacologic agents of asthma.

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Pharmacologic agents for asthma

1. RELIEVER (Quick-relief medications) Act principally by direct relaxation of bronchial

smooth muscle

SABA (short-acting beta-adrenergic agonists),anticholinergics, phosphodiesterase inhibitors,corticosteroids

2. CONTROLLER(Long-term medications) act primarily to attenuate airway inflammation

Corticosteroids, long acting bronchodilator (LABA =long-acting beta-adrenergic agonists), leukotrienmodifiers

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RELIEVER

Albuterol (SABA) MDI (90mcg/puff) : 2 puffs every 4-6 hours as

needed

Nebulizer solution (2,5mg/3mL) : 1,25

5 mg in 3 mLof saline every 4-8 hours as needed

Ipratropium (anticholinergic) MDI (17mcg/puff) : 2-3 puffs every 6 hours Nebulizer solution (0,25mg/mL) : 0,25 mg every 6

hours Ipratropium with albuterol

Nebulizer solution (0,5 mg/3mL ipratropium bromideand 2,5 mg/3 mL albuterol) : 3 mL every 4-6 hours

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CONTROLLER

Inhaled corticosteroid

Fluticasone

Budesonide

Inhaled LABA

Salmeterol

Formoterol

Combined medication Fluticasone/salmeterol

Budesonide/formoterol