Bambang MulyawanFK-UMM

Background Asthma is a chronic lung-disease that

inflames and narrows the airways (tubes that bring air into and out of an individual’s lungs).

Asthma is the most common chronic disease among children.

Definisi (1) GINA -2002 ( Global Initiative for

Asthma) : gangguan inflamasi kronik sal. respiratorik dg banyak sel yg berperan, khususnya sel mast,eosinofil,dan limfosit T. Pada orang yg rentan inflamasi ini menyebab-kan episod wheezing berulang, sesak nafas, rasa dada tertekan, dan batuk, khususnya pd malam atau dini hari. Gejala ini biasanya ber-hubungan dg penyempitan sal.respiratorik yg luas namun bervariasi, yg paling tidak sebagi-an bersifat reversibel baik secara spontan maupun dg pengobatan. Inflamasi ini juga berhubungan dg hiperreaktivitas sal.respirato-rik thd berbagai rangsangan.

OPERATIONAL DESCRIPTION: “ Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment”

GINA: 2002,2006,2007

Definisi (2) Definisi GINA sangat lengkap,

namun dalam penerapan klinis utk anak kurang praktis.

Konsensus internasional dg definisi lama : “Wheezing berulang dan/ atau batuk persisten dalam hal ini asma adalah yg paling mungkin, sedangkan sebab lain yg lebih jarang telah disingkirkan”

Definisi (3) Pedoman Nasional Asma Anak (IDAI

– 2004) : (definisi yg praktis dalam bentuk definisi operasional) “ Wheezing dan/atau batuk dg karakteristik : timbul secara episodik dan/atau kronik, cende-rung pd malam/dini hari (nokturnal) musiman, adanya faktor pencetus diantaranya aktivitas fisik, dan bersifat reversibel baik secara spon-tan maupun dg pengobatan, serta adanya ri-wayat asma atau atopi lain pd pasien/ keluar-ganya, sedangkan sebab-sebab lain sudah disingkirkan”

Epidemiologi dan prevalensi (1) Dimulai sejak masa anak-anak Sejak 2 dekade terakhir prevalens asma

meningkat baik anak maupun dewasa Mempunyai dampak negatif : anak sering xtidak

sekolah, kegiatan olah raga/aktivitas klg terbatas Prevalens asma dunia 7,2% (anak 10%) Mortalitas asma relatif tinggi Faktor pencetus : aktivitas , alergen, infeksi,

perubahan suhu udara, asap rokok, dll.

Epidemiologi dan prevalensi (2)

Prevalensi

Mobiditas

Mortalitas

PrevalensiIndonesia 5 – 10% (Murid SD)

Australia ± 40% (Usia 12-15 thn)

Meningkat setiap tahun

Laki-laki > Perempuan

Angka Kematian cenderung meningkat

Patogenesis dan patofisiologi (1) Merupakan proses inflamasi kronik

yg khas dinding sal respiratorik,ter-batasnya aliran udara, peningkatan reaktivitas sal nafas.

Inflamasi : aktivasi eosinofil, sel mast, makrofag, sel limfosit T pd mukosa dan lumen sal respiratorik. Perubahan ini dpt terjadi meskipun scr klinis asma tidak bergejala.

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Patogenesis dan patofisiologi (2) Proses inflamasi kronik: perlukaan epitel

bronkus,merangsang proses reparasi sal respiratorik yg menghasilkan perubahan struktural dan fungsional yg menyimpang pd sal respiratorik, dikenal dg istilah remodeling.

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What Is Asthma ?

A S M A

Paradigma Lama-BHR-Bronkospasme

Paradigma Baru-Inflamasi Kronis-Remodelling

PERUBAHAN FUNDAMENTALTERAPI

BRONKODILATOR ANTI INFLAMASI

MEKANISME DASARGangguan saluran napas dengan radang kronis

Faktor genetik

Faktor lingkungan

Diagram Venn

Algoritma proses sensitisasiImunologis timbulnya radang saluran napas

FAKTOR RISIKOGenetikJenis kelamin : Laki² > PerempuanPengaruh ibu : Ibu > AyahAtopi : 2/3 - 3/4 Anak Asma menderita AlergiInfeksi saluran napas : RSV

FAKTOR PEMICUFAKTOR PEMICUAlergenAlergenIrritantIrritantPerubahan cuacaPerubahan cuacaInfeksiInfeksiExceriseExcerise

EmosiEmosiGastroesophogial refluxGastroesophogial refluxObat-obatanObat-obatanPenyakit Radang SNAPenyakit Radang SNAEndokrin Endokrin Mens Mens

PATOLOGIHiperinflasi

Hiperplasia otot polos dinding bronkus dan bronkiolus

Mucus plug

Penebalan membrana basalis

Edema mukosa

Eosinofilia sub mukosa

DERAJAT ASMA

MenetapMenetap8 jam sehari8 jam sehariCepat hilangCepat hilangLama seranganLama seranganSangat seringSangat sering> 2 x / minggu> 2 x / minggu< < 2 x / minggu2 x / mingguEksaserbasiEksaserbasi

ObnObnnnnnPeriode antar seranganPeriode antar serangan

Sering/sangat Sering/sangat seringsering

JarangJarang--Gawat Anak / MRSGawat Anak / MRS

<< 60% N 60% N60-80% N60-80% N80% N80% NFEVFEV11 /Peak Flow /Peak Flow

n / sedikit n / sedikit NNAktifitasAktifitas

Sangat seringSangat seringLebih seringLebih sering / < 2 x / bln/ < 2 x / blnSerangan malamSerangan malam

BeratBeratSedangSedangRinganRingan

DIAGNOSA1. Anamnesa

Batuk

Sesak + Napas berbunyi ( mengi )

Terutama malam dan dini hari

Hilang / berkurang siang hari

Muncul jika ada pemicu

Hilang dengan obat asma

Kumat ²an

2. Pemeriksaan FisisRetardasi pertumbuhan

Hipoksia kronisPengobatan steroid

Clubbing finger + SianosisSesakEkpirasi memanjangRetraksi + otot bantu pernapasanPemeriksaan paru

RonkhiEkspirasi memanjangWheezingHipersonorBentuk dada

Tanda alergi di saluran napas atas

DIAGNOSA

3. LaboratoriumDarah = Eosinofil, igE

Sputum & sekret hidung : Eosinofil

Ro” = Hiperinflasi, atelektasis, pneumomediastinum, pneumo thorax

Faal paru (FEV1 ) :

Test rangsang Paru : + FEV1 20%

Bronkodilator FEV1 15%

Test Alergi kulit

DIAGNOSA

DIAGNOSA BANDING

Laringotracheobronchomalasia

Fibrosis kistik

Benda asing

Bronkiolitis

TERAPIFilosofi

Mencegah ketidak bergunaan

Meminimalkan gangguan fisik & psikologis

Dapat “hidup” normal/”Berfungsi” normal

Faal paru (n)

Olah raga (n)

Gejala nokturnal (-)

Obat-obatan (-) /

Tumbuh kembang (n)

MACAM OBAT ASMA ANAK

1. RelieversShort – Acting beta – agonist

EpinephrineIsoprenalineOrciprenalineFenoterolSalbutamolTerbutaline

2.2. PreventersPreventersSodium cromoglycateSodium cromoglycateInhaled cortico steroid (ICS)Inhaled cortico steroid (ICS)

3. ControllersDitambahkan dalam terapi :Long acting beta agonists

FormoterolSalmeterolBambuterolSlow release theophylline

Leukotriene antagonistMontelukast > 2 thn : 1 x 5 mgZafirlukast > 6 thn : 2 x 10 mg

MACAM OBAT ASMA ANAK

inhaled

ALGORITMA TERAPI ASMA KRONIK ANAK

PROTOKOL SERANGAN ASMA AKUT1. SERANGAN AKUT BERAT

a. Short acting b2 agonist○ Epinephaine 1/1000 : 0.01cc/Kg BB (max 0.3 ml)

ulang sampai 3 x selang 15 – 20 mnt○ Terbutalin : 0.01 mg/kg (max 0.25 mg)/ SC / IV○ ulang sampai 3 x selang 20 menit ○ Salbutamol : 0.15 mg/kg / inhalasi○ ulang sampai 3 x selang 20 menit○ Theofilin/Aminofilin : 5 mg/kg BB / 6jam / P.O 3 – 5 hr

O2 Kortikosteroid

○ Metil prednisalon 1 mg/kg / 6 jam / IV○ Prednison○ Prednisolon 1 mg/kg / 12 jam / P.O 3 – 5 hari

2.2. STATUS ASMATIKUSSTATUS ASMATIKUS

a.a. O2O2

b.b. Infus cairan sesuai umurInfus cairan sesuai umur

c.c. AminofilinAminofilin

7 mg/kg BB / 20 menit (dosis awal)7 mg/kg BB / 20 menit (dosis awal)

0,6 – 0,80,6 – 0,8 mg/kg BB/jam (maintenance)mg/kg BB/jam (maintenance)

a.a. KortikosteroidKortikosteroid

Hidrokortison : 7 mg/kgBB awal Hidrokortison : 7 mg/kgBB awal 7 mg/kgBB/24 jam 7 mg/kgBB/24 jam

Metil Prednison : 1–2 mg/kgBB awal Metil Prednison : 1–2 mg/kgBB awal 4 mg/kgBB/24 jam 4 mg/kgBB/24 jam

Deksametason : 0.3 mg/kgBB awal Deksametason : 0.3 mg/kgBB awal 0.3 mg/kgBB/24 jam 0.3 mg/kgBB/24 jam

PROTOKOL SERANGAN ASMA AKUT

3.3. GAGAL NAPASGAGAL NAPAS

a.a. Ventilasi mekanikVentilasi mekanik

b.b. Kerjasama TeamKerjasama Team

Inhaled β2-agonists are the mainstay of therapy in acute asthma.

KOMPLIKASI1. Paru

Gagal napas akut

Atelektasis

Pneumomediastinum

Pneumotoraks

2. Diluar ParuPeningkatan vasopressin ADH release

Flaccid paralysis lengan & kaki

Gangguan metabolisme teofilin

Aritmia jantung

PENYEBAB KEMATIAN PADA ASMA1. Kesalahan dokter/penderita menilai derajad asma

Pengobatan tidak intensifPenilaian tidak obyektif

2. Pengobatan tidak tepatTerlambat diberikanTerlalu kecil (steroid)Terlalu banyak (b agonis)

3. Progressive unresponsive asthma4. Prolonged attack5. Komplikasi pulmoner

Infeksi (sering tidak terdiagnosa)PneumotoraksBarotraumaAspirasi isi lambungVentilator tidak berfungsi dengan benar

PENYEBAB KEMATIAN PADA ASMAPENYEBAB KEMATIAN PADA ASMA

6.6. Komplikasi JantungKomplikasi Jantung

AritmiaAritmia

HipotensiHipotensi

Myocardial toxicityMyocardial toxicity

Sudden cardiac arrestSudden cardiac arrest

7.7. HemodinamikHemodinamik

HipovolemikHipovolemik

ShockShock

Edema paruEdema paru

PENCEGAHAN (PROFILAKSIS) ASMA ANAK

PROFILAKSISPRIMER

Sensitisasi –Asma –

PROFILAKSISSEKUNDER

Sensitisasi +Asma –

PROFILAKSISTERSIER

Sensitisasi +Asma –

Target yang ingin dicapai dalam upaya pencegahan

Symptoms Common symptoms of asthma include:

CoughingWheezingTightness in the chestShortness of breath

Causes While the exact cause of asthma is not

known, it is thought that a variety of factors interacting with one another, early in life, result in the development of asthma.

Causes Parents with asthma Atopy Childhood respiratory infections Exposure to allergens or infections while

the immune system is developing

Diagnosis Based on:

Medical historyPhysical examinationTest results

Asthma Triggers A variety of things can cause asthma

symptoms to appear:○ Allergens○ Irritants○ Food and drinks○ Medicines○ Physical activity○ Upper respiratory infections (viral)

Asthma prevalence In the United States:

More females than males have asthma.Blacks and American Indian/Alaska natives

have higher percentages of asthma than Whites, Hispanics, and Asians.

Asthma prevalence, 2005

Lifetime asthma diagnosis, 2005

Asthma disparities Death from asthma is 3 times more

likely to occur among Blacks than Whites.

Among adults, women of all races have higher rates of illness and death from asthma than men.

Rates of hospitalization for asthma for Blacks are almost triple those for Whites.

Number of asthma deaths per 100,000 population, 2003

Increasing rates Asthma rates have been increasing in

the United States for both adults and children, males and females, and in the different races and ethnicities.

It is estimated that the number of people with asthma worldwide will increase by 25% in the next 15 years.

Child and Adult Asthma PrevalenceUnited States, 1980-2007

0

2

4

6

8

10

12

14

Year

Prev

alen

ce (%

)

12-Month

Lifetime• Child Adult

Source: National Health Interview Survey; CDC National Center for Health Statistics

Current

Asthma Prevalence by SexUnited States, 1980-2007

0

2

4

6

8

10

12

14

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006 Year

Prev

alen

ce (%

)

12-Month

Lifetime• Female Male

Source: National Health Interview Survey; CDC National Center for Health Statistics

Current

Asthma Prevalence by Race/EthnicityUnited States, 1997-2007

02468

1012141618

Year

Prev

alen

ce (%

) Lifetime

Current

▲ Black NH White NH Hispanic

Source: National Health Interview Survey; National Center for Health Statistics

Worldwide Burden of Asthma 300 million people suffer from asthma

worldwide.

255,000 asthma deaths in 2005.○ ~3,500 in the United States.

Over 80% of asthma deaths occur in low and lower-middle income countries.

Treatment While asthma cannot be cured, it can be

controlled:Medications

○ Long term○ Quick relief○ Bronchial thermoplasty

Learning to recognize one’s own triggers and taking steps to avoid them.

Treatment Medication

Long term○ Inhaled corticosteroid○ Leukotriene modifiers○ Long-acting beta agonists○ Combination inhalers

TreatmentQuick relief (rescue) medications

○ Short-acting beta agonists○ Ipratropium○ Oral and intravenous corticosteroids

Bronchial thermoplastyRecognizing, tracking, and avoiding triggers

Review Questions (Developed by the Supercourse team)

What are some of the common asthma triggers?

Which age, sex, and/or racial groups see disparities in asthma prevalence rates, as well as hospitalizations and deaths?

Describe the process of asthma diagnosis.