Asthma Bronchiale

Dewa Artika Divisi Pulmo, Bagian IP. Dalam FK. UNUD

IntroductionAsthma is a syndrome that consist of:Obstruction on reversible inhalation path way inhalation path way hyper responsiveinhalation path way inflammationasthma symptoms (wheeze, heavy feeling on the chest, difficult to breath and cough).Various incident and prevalence In UK, 8% of adult and 20% of children suffer from asthma. In The USA, Australia, 3%. In Japan, Finland 1%. While in Indonesia 2 4%.

ISAAC Steering Committee, Lancet 1998

EtiologyComplex interaction between predisposition, causal and contribution factorPredisposition factors : atopi, sex, raceCausal factors : allergen inside a room, allergen outside a room, material in work environment, medicine and food additive Contribution factors : cigarette, air pollution, infection on inhalation path way.

PathologyMucus build upMuscle hyper flationEosinofil infiltrationPem BAL :Inflammation cellEdema Extravasasiplasm

PathogenesisBronchus is keep away from inflammation by immunologic mechanismIn particular circumstances immunologic reaction upon foreign materials a disease called hyper sensitivity (allergic).Gell & Comb : divided into 4 types, and atopi asthma was included in type I reaction.On immunologic reaction, cell play an important role, mediator inflammation and triggering factor

Mechanisms Underlying the Definition of AsthmaRisk Factors(for development of asthma)

INFLAMMATIONAirwayHyperresponsivenessAirflow Obstruction Risk Factors(for exacerbations)Symptoms

Mechanism underlying definition of asthmaImmunology mechanism inhalation pathway inflammationImmune system divided into 2, that are: humeral and cellularHumeral is marked by production of specific antibody secretion by lymphocytes B cell, while cellular mainly determine by lymphocytes T.Cell lymphocytes T, controlling function of lymphocytes B and promote inflammation action via sitokain activity CD8

Pathogenesis of asthmaPrompt reaction and slow reactionExpose a patient with an allergen asthma attack which occurred for few minutes (acute phase asthma) based on reaction type 1APC (Dendrites cell or macrophage) will process allergen that was cached lymphocytes T. And then Th2 release sitokin that affects mast cell, eos, etc discharging inflammatory mediator obstruction on inhalation pathway. This reaction is call slow asthma reaction (occurred 24 48 hours after allergen exposure

Clinical FeatureSymptoms such as: wheeze, cough, difficult to breath, heavy on chest. Usually symptoms increase during night time or early morning.Previous record: generally has been having the same complaint or symptoms, often has hereditary factors and there is allergic factors

During asthma attack, often preceded by infection on upper breathing pathway, exercise, allergen, medicines as triggering factors.During physical diagnoses it is usually obtained: difficult breathing with increase breathing frequencies, sweating, sianosis, and obstruction mark such as wheezing.

Supporting DiagnosesTo diagnose asthma besides anamneses and physical diagnoses, it is also necessary to do diagnoses such as: bronchus faal test, lab diagnoses, skin test and radiology, and bronchus provocation testLung faal testUsually apply: VEP1, KVP or APEVariability APE value 20% or more between morning and night asthma also apply to value asthma severityReversibility asthma can be seen by doing broncodilator test, where increase on VEP1 or APE > 15% after bronchodilator reversible

Laboratory DiagnosesBlood edge: often found an increase of eosinofil 5 15% of total leukocyte. Total eos generally increase > 300Sputum: often found spiral from Curschmann and Charcot Leiden crystal Serum: there is an increase of total or specific IgESkin testSkin test with allergen as diagnostic tool on asthma allergic

Radiology diagnose usually normal or hyperinflationUseful for eliminate other disease or to see if there is complication such as pneumotorax or Pn. mediastinumBronchus provocation test-could show and measure bronchus hyperactivity also degree of asthma severity.

Deferential diagnosisCOPD / PPOKViral infectionHyper ventilationBronchiexthasisObstruction on main bronchusJeart failureLarynx dysfunction

Obstruction upper breath pathwayPulmonary embolismPneumothoraxEosiniphilic bronchitisPrimary pulmonary hypertension

Asthma ClassificationBased on etiologyIntrinsic asthmaExtrinsic asthmaBased on disease chronic / severityIntermittent asthmaLightly persistent asthmaMedium persistent asthmaHeavily persistent asthmaBased on severity of attack (acute)Lightly acute asthmaMedium acute asthmaHeavily acute asthmaAsthma with breathing failure

Planning and actionAimTo recover and to controlMaintain lung faalTo do everyday activityAvoid side effect of medicationInhibit irreversible obstructionInhibit fatal asthma attackAlso known as controlled asthma

Design of Planning and ActionPatient educationAssessment and monitoring of asthma severityAvoid triggering factorPlanning long term therapyDecided therapy when exacerbationAttempt to do regular control

Asthma MedicationThere are 2 kind: reliever and controllerReliever: Agonis B2 quick effect inhalation and oral, corticosteroid systemic, inhalation anticolinergik, quick effect teofilinController: kortikosteroid inhalation and systemic, sodium chromolin, sodium nedodromil, antihistamine, teofilin slow release, agonic B2 slow effect inhalation and oral, antileukotrien

Classification of SeverityCLASSIFY SEVERITYClinical Features Before TreatmentSymptomsNocturnalSymptomsFEV1 or PEFSTEP 4Severe PersistentSTEP 3Moderate PersistentSTEP 2Mild PersistentSTEP 1IntermittentContinuousLimited physical activityDailyAttacks affect activity> 1 time a week but < 1 time a day< 1 time a weekAsymptomatic and normal PEF between attacksFrequent> 1 time week> 2 times a month 2 times a month 60% predictedVariability > 30%60 - 80% predicted Variability > 30% 80% predictedVariability 20 - 30% 80% predictedVariability < 20%The presence of one feature of severity is sufficient to place patient in that category.

Planning and Action for Chronic AsthmaIntermittent AsthmaController: no needReliever: inhalation B2 agonis short action if necessaryLightly persistent AsthmaController: inhalation steroid 500 m.grAlternative: slow release teofilin or chromolin or anti leucotrienReliever: inhalation B2 agonis short action if necessary

Medium persistent AsthmaController: corticosteroid is increased until 800 mgr, B2 agonist slow action inhalation or oral or slow release teofilin, anti leucotrienAlternative: slow release teofilin or chromolin or anti leucotrienReliever: inhalation B2 agonis short action if necessary (not more than 3 4 times)

Heavily persistent AsthmaController: inhalation steroid >1000 mgr, plus B2 agonis slow action, plus one or more from this medicine (slow release teofilin, anti leucotrien, B2 agonist slow action, corticosteroid oral)Reliever: inhalation B2 agonis short action if necessary

Part 4: Long-term Asthma ManagementStepwise Approach to Asthma Therapy - AdultsReliever:Rapid-acting inhaled 2-agonist prnController:Daily inhaledcorticosteroid Controller:Daily inhaled corticosteroid plus Daily long-acting inhaled 2-agonistController:Daily inhaled corticosteroid plusDaily long acting inhaled 2-agonistplus (if needed)

When asthma is controlled, reduce therapy

MonitorSTEP 1:IntermittentSTEP 2:Mild PersistentSTEP 3: Moderate PersistentSTEP 4:Severe PersistentSTEP DownOutcome: Asthma ControlOutcome: Best Possible ResultsAlternative controller and reliever medications may be considered (see text). Controller:None -Theophylline-SR -Leukotriene -Long-acting inhaled 2- agonist -Oral corticosteroid

Planning and Action for Acute AsthmaAimTo avoid fatal /deadTo eliminate obstruction promptlyTo overcome hypoxemiaTo recover lung faal quicklyPrevent asthma attack again

Given inhalation B2 agonist short actionInhalation anti colinergikB2 short action subcutan agonistic injectionAdrenalin subcutan injectionFor acute asthma medium and heavy, corticosteroid systemic are given because it canspeed up recoveryPrevent from asthma attack againShorten hospitalizationDeath prevention

ALGORITMAPenilaian awalPengobatan awalPenilaian ulangEpisode sedangEpisode beratRespon baikRespon tidak lengkapRespon burukPemulangan pasienRawat di RSRawat di ICUPerbaikanTidak membaikPerawatan di ICUPemulangan pasien

Asthma on special conditionAsthma during pregnancyPregnancy can affect asthma that is 1/3 asthma patient are deterioratingMedication principle are the same, only put on priority to give minimal oral medicationOn acute attack, should be given optimal medication. Systemic corticosteroid should be given if necessary. During inpartu, it is better not to five terbutalin, Ok can cause post partum bleeding

Asthma during operation Asthma can increase complication intra and after an operationIn principal, same with acute asthmaCorticosteroid systemic is given if:Asthma with medium heavy degreeEarly inhalation agonist B2 did not make any improvementWhile on oral steroid medicationExarbation before taking steroid

Exercise Induce Asthma (EIA)Ok can occur on EIA, hyperventilation occurred and there for breathing pathway become dry mast cell broken inflammation mediator discharged such as histamine, etc asthma occurred. Medication same as acute asthma.Can recover after good restTo prevent inhalation B2 short action can be given before exercise.

Occupational AsthmaAsthma with ok occurred get substance exposure in their work environment / workplace.Same medicationThe most important thing is to avoid triggering factor in the workplace.

Aspirin Induce Asthma (AIA)Asthma that occurred after taking aspirinSymptoms, coughing, difficult to breath, heavy feeling on chest, red face, runny noseOccurred due to cycloxygenase formation inhibition by certain substance, therefore prostaglandin and tromboxan came out causing bronco constrictionSame medication with acute asthmaThe most important thing is to avoid aspirin as triggering factor.

SummaryDiagnoses based on anamnesa, physical diagnoses, lung faal diagnoses, laboratory, skin test, radiology, bronco provocation test.Asthma classification based on etiology, disease severity and pattern of attack timing.

Planning and action objective is to make asthma controllableAsthma is a chronic inflammation on inhalation pathwayMedication principal: give reliever medicine, controller and avoid causing factor or triggering factor.

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The estimated world population prevalence of asthma among adults is about 6% At least 180,000 deaths per year worldwide can probably be attributed to asthma Prevalence rate estimates vary in different regions of the world, and even in different parts of each country In general, asthma is more common in urban than in rural areas Prevalence rates may also be affected by genetic factors, climatic conditions and increased reporting due to improvements in diagnosis and better public awareness about asthma This map illustrates the results of a recent survey of just under 500,000 children, aged 13-14 years, in 56 countries using a one-page questionnaire to identify those with symptoms of asthma The highest 12 month prevalence rates for asthma symptoms were located in the UK, Australia and New Zealand followed by most centres in North, Central and South America