Referat Asma Tegar English

WRITTEN BY :Tegar Wibawa R

1102009281

MENTOR:Dr. Pulung M Silalahi Sp.A

DEFINISI Asthma is a chronic inflammatory disorder of the

airways involving cells and cellular elements.(Global Initiative For Asthma. Medical Communications Resources, Inc ; 2006.)

Asthma is a recurrent wheezing and / or a persistent cough with a characteristic; arise episodic, inclined at night / early morning (nocturnal), seasonal, after physical activity and there is a history of asthma or other atopic patients and / or family.(Unit Kerja Koordinasi (UKK) Respirologi IDAI pada tahun 2004)

EPIDEMIOLOGIAsthma is a chronic respiratory disease

that is most often foundThe disease usually begins since childhood30% occur in the age of 1 year80-90% of the first symptoms arise before

4-5 yearsCommon problems in Hospitalized Children IDAI. Jakarta : 8-9 mei 2011

Faktor ResikoGenetic factors

Hiperreaktivitas Atopy / allergies

bronchi Factors that

modify genetic disease

Sex Ras/Etnik

Triggers:

Alergen

irritantWeather

ISPAInfectio

n

Excercise

Comorbid Conditions

Emosional

Patofisiologi Asthma Asthma occurs due :1. Channel respiratory obstruction2. Hyperreactivity of respiratory tract3. Mucus hypersecretion

Nelson Textbook of Pediatrics : Childhood Asthma. Elsevier Science (USA);2003.

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Clinically parameters, needs medication and pulmonary function

Infrequent episodic asthma (mild asthma)

Frequent episodic asthma (asthma medium)

Persistent asthma (severe asthma)

1. 1. The frequency of attacks

3-4 x / 1 year3-4 x / 1 year 1 x / month1 x / month ≥ ≥ 1x/ month1x/ month

2. 2. long attack < 1 week< 1 week ≥ ≥ 1 week1 week Almost all year round, Almost all year round, there is no remissionthere is no remission

3. 3. among attack asymptomaticasymptomatic asymptomaticasymptomatic Symptoms day and nightSymptoms day and night

4. 4. Sleep and activity Not distrubed Not distrubed <3x/week<3x/week

frequently interruptedfrequently interrupted>3x/week>3x/week

very disturbedvery disturbed

5. 5. Physical examination outside attacks

NormalNormal May be impaired (no May be impaired (no abnormality)abnormality)

Never normalNever normal

6. 6. Anti-inflammatory controller medication

no needno need Non steroid/ steroid Non steroid/ steroid inhaler low dose 100-inhaler low dose 100-200µg200µg

Steroid inhaler / oralSteroid inhaler / oral≥≥400µg/hari400µg/hari

7. 7. Lung function tests (excluding attack)

PEF / FEV 1 > 80%PEF / FEV 1 > 80% PEF / FEV 1 60-80%PEF / FEV 1 60-80% PEF / FEV1 < 60%PEF / FEV1 < 60%

8.8. Variability in pulmonary function (if there is an attack)

Variabilitas > 15%Variabilitas > 15% Variabilitas > 30%Variabilitas > 30% Variabilitas > 50%Variabilitas > 50%

Global initiative for asthma. Medical communications resources, inc: 2006

Asma intermiten : Intermittent symptoms for less than 1 time per week, short attack (hours-days) symptoms night less than two times a month outside attack without symptoms and normal pulmonary function test PEFR or PEV >80% predicted, variations of < 20%Asma persisten ringan : Symptoms > 1 time a week but less than 1 times a day attacks may disturb activity and sleep symptoms at night more than 2 times a month PEV or PEFR > 80% predicted, variations of 20-30%

Global initiative for asthma. Medical communications resources, inc: 2006

Asthma persisten Medium Symptoms every day Disrupt the activities and sleep attacks Symptoms evenings > 1 time a week Daily use of inhaled short-acting β 2 agonist PEFR or PEV > 60% - <80% predicted, variations of> 30%Asthma persisten Severe Continuous symptoms Frequent attacks Frequent night symptoms Limited physical activity due to asthma symptoms PEFR or PEV <60% predicted, variations of> 50%

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Clinical parameters, Lung

Function, laboratory

Mild Medium Severe Stop threats Breath

crowded walkBabies: loud cry

speakbabies:Short and weak crydifficulty eating

breakBabies: Stop eating

speak sentence word sentence Words

position could lay down

Rather sit Sat propped arm

awareness perhaps agitated

usually agitated

usually agitated

confusion

cyanosis Nothing Nothing Have Real

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Wheezing Moderate, often only at the end of expiration

Tinny, during expiration + inspiration

Very loud audible without stethoscope

Hard / no sound

Hard To Breathe

Minimal Medium Severe

Use of Respiratory Muscle Aids

usually not Usually yes Yes Torako abdominal paradoxical movement

Retraction Shallow, intercostal retractions

Medium, plus a retraction suprasternal

In, plus a nasal flaring

Shallow / Missing

Breathing Rate increase increase increase decrease

Guidelines for the raw value conscious respiratory rate in children: Age Laju Napas Normal< 2 month < 60 / minute1-2 month < 50 / minute1-5 month < 40 / minute6-8 month < 30 / minute

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Pulse Normal Takikardi Takikardi Bradikardi

Guidelines for the raw value pulse rate in children:Age Pulse rate Normal2-12 month < 160 / minute1-2 year < 120 / minute3-8 year < 110 / minute

Pulsus paradoxus (Examination impractical)

Nothing < 10 mmHg

Have 10-20 mmHg Have > 20 mmHg No, the sign of muscle fatigue breath

PEFR or FEV1 (alleged value /% value tebaik)pre bronchodilatorpost bronkodilator

> 60%> 80%

40-60%60-80%

<40%<60%Respon < 2 jam

SaO2 % > 95% 91-95 % ≤ 90%

PaO2 Normal (normally not need to be examined)

> 60 mmHg <60 mmHg

PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg

ANAMNESIS• Chronic cough and recurrent wheezing shortness especially at night and excessive physical activity

• Symptoms, Triggers, family history

Physical examination

Inspection:- Rapid breathing and dyspnoea- cough- Wheezing/mengi- Supraclavicular retractions, suprasternal,

epigastric and intercostal- Thoracic shape emfisematous- Hunchback forward- Intercostal space widened- AP diameter increases

Asma Kronik

Physical examinationPercussion:- Hipersonor entire thorax, especially the

bottom of the posterior

Auskultasi :- BND rugged / hardened BND became

weakened- Ekspiration lengthwise- Ronkhi dry and wet

Chronology of the diagnosis of asthma in children (continued) ...

Check peak flow meter or spirometer to assess:

• Reversibilitas (> 15%)

•Variabilitas (> 15%)

Consider:

•Foto rotgen thorak dan sinus

•Lung function tests

•Test the response to bronchodilators and systemic steroid 5 days

•Bronchial provocation test

•Sweat Test

•Imunological test

•Silia motility examination

•GE reflux examination

Give bronkodilator

Diagnosis of work: Asthma

Give anti-asthma drugs:

Not successfully reset the value of diagnosis and treatment adherence

not successful

Does not support another diagnosis

Another diagnosis support

Diagnosis and treatment of other diseases

Consideration of asthma with other diseases

Not asthma

Suspected asthma Not necessarily asthma

1. blood tests Blood and sputum eosinophilia PMN leukocytosis can occur when there is

an infection2. X-ray Thorax Increased lung markings

Hyperinflation Hiper inflasi acute attacks and chronic

Asthma Photo is repeated when there are indications

Pneumonia / pneumothoraks

Foto Toraks

Results can be normal or chest X-ray showed hyperinflation

Atelectasis picture can be obtained because of blockage by mucus and hypertrophy of smooth muscle cells.

The main bronchial wall thinning.

3. Test skin allergy and immunologyUseful to determine which allergens according

originatorIgE increased

4. Lung function testsUseful for:

Assessing the level of airway obstruction and disruption of gas exchange

Measuring the response of the airway to allergens and chemicals that are inhaled or during bronchial provocation test

Assessing the response to therapeutic agents Evaluate the long-term course of the diseas

Uji Faal ParuPerformed before and

after the administration of the aerosol bronchodilator

The increase in PFR or FEV1 at least 10% after aerosol therapy so gives the impression of asthma

Uji Faal Paru

1. Spirometri FEV1(Forced Expiratory Volume in 1 sec), FVC

(Forced Vital Capacity, rasio FEV1/FVC

www.joegoshe.com/images/spirometry.gif

2. PEF (Peak Expiratory Flow) Monitoring

www.geocities.com/.../Villa/2545/asthma.jpg

Supporting Investigation5. Bronchial provocation

testPerformed when the

diagnosis is still in doubtPurpose: indicates

bronchial hyperreactivityWhich is often done is by:

histamine, and load methacolin run

MEDIKAMENTOSANON MEDIKAMENTOSA

Treatment of asthma differ from asthma attacks :

Attacks drug / reliever short termDrug controllers / controller long term

Daftar Obat Asma yang Ada di Indonesia

Drug NameDrug Name Generic nameGeneric name trade trade namename

preparationspreparations dosedose

(’(’Releiever’)Releiever’)

Simpatomimetik (agonis-Simpatomimetik (agonis-2) :2) :

TerbutalineTerbutaline

Orciprenalin Orciprenalin (metaproterenol)(metaproterenol)Salbutamol Salbutamol (albuterol)(albuterol)HeksoprenalinHeksoprenalinFenoterolFenoterol

BricasmaBricasma

NairetNairet

ForasmaForasmaAlupentAlupent

VentolinVentolin

Berotec Berotec

Syrup, tablet, Syrup, tablet, turbuhalerturbuhalerSyrup, tablet, Syrup, tablet, ampulampulSyrup, tabletSyrup, tabletSyrup, tablet, Syrup, tablet, MDIMDISyrup, tablet, Syrup, tablet,

MDIMDIMDIMDI

0,05-0,1 mg/kgBB/hari0,05-0,1 mg/kgBB/harijamjam0,05-0,1 mg/kgBB/hari0,05-0,1 mg/kgBB/hariJamJam

0,1-0,15 mg/kgBB/kali 0,1-0,15 mg/kgBB/kali setiap 6jamsetiap 6jam

0,1 mg/kgBB/kali 0,1 mg/kgBB/kali setiap 6 jamsetiap 6 jam

Classed XantinClassed Xantin TeofilinTeofilin Syrup, tabletSyrup, tablet

(’controller’)(’controller’)

AINS :AINS : Sodium Sodium cromogylatecromogylate

IntalIntal MDIMDI NothingNothing

NedokromilNedokromil MDIMDI NothingNothing

Classes anti-inflamasi Classes anti-inflamasi steroid :steroid :

BeclomethasoneBeclomethasoneBudesonidBudesonid

FluticasonFluticason

BecotideBecotidePulmicortPulmicortInflammideInflammideFlixotideFlixotide

MDIMDIMDI, MDI, turburhalerturburhalerMDIMDI NothingNothing

Classes Classes ββ-agonis long -agonis long acting :acting :

ProkaterolProkaterolBambuterolBambuterol

SalmeterolSalmeterolKlenbuterolKlenbuterol

BambecBambec

SereventSereventSpiropentSpiropent

Sirup, Sirup, tablet, MDItablet, MDITabletTabletMDIMDISirup, tabletSirup, tablet

Classes of drugs off slow Classes of drugs off slow / controlled release / / controlled release / Slow releaseSlow release

Terbutalin Terbutalin SalbutamolSalbutamolTeofilinTeofilin

VolmaxVolmaxKapsulKapsulTabletTabletTablet salutTablet salut

Classes antileukotrien :Classes antileukotrien : ZafirlukasZafirlukasMontelukasMontelukas

AccolateAccolate TabletTablet HaveHaveNothingNothing

Classes combined Classes combined steroid +LABA :steroid +LABA :

Budesonid Budesonid +formoterol+formoterolFlutikason+salmFlutikason+salmeteroleterol

SymbicortSymbicortSeretideSeretide

TurbuhalerTurbuhalerMDIMDI

Management groove Asthma Attacks in Children

Clinic / Emergency Unit

The value of the degree of attack

Procedures beginning

Nebulized -agonis 1-3x, hose 20 minute Third Nebulized + antikolinergik

If heavy attack, nebulisasi -agonis + antikolinergik

Mild attacks(nebulized 1X, good response)•Observation 1 hour•If the effects persist, could return•If symptoms arise again, treat it as an attack medium

Attacks were (nebulized 2X, partial response)•Give oxygen•Value re-degree assault, if appropriate with moderate attack, observation at a day care room•Give oral steroids•Attach lines parenteral

Heavy attack (nebulized 3X, bad response)•Since the beginning given the current O2 / outside nebulized•Attach lines parenteral•intravenous steroids•Repeated clinical value,•if appropriate heavy attack, hospitalized in the inpatient unit•X-ray photo

Go home•Arm agonist drugs (inhaled / oral)•If there is already a controlling drugs, continue•If the viral infection as the originator, may be given oral steroids (3-5 days)•Within 20-48 hours, control clinic, outpatient for re-evaluation

Day care room / observation•Oxygen forward•Oral steroids followed•Nebulized every 2 hours•If within 12 hours of clinical improvement is stable, may return, but if the clinical remained not improved / worsened, over inpatient care to space

Inpatient unit•Oxygen forward•Overcome dehydration and acidosis if there•Steroids IV every 6-8 hours•Nebulized every 1-2 hours•Aminophilin initial IV continue maintenance•If improved in nebulized 4-6X, the interval to 4-6 hours•If clinical improvement within 20 hours of steady, go home•If the steroids and parenteral aminophilin not good, even raised the threat of stopping breathing, over care to ICU

Mild attack… Moderate attack… Severe attack…

Flow of Long-Term Management of Asthma Children

reliever : ß-agonis atau teofilin (inhaler or oral) if necessary

Add controller medications: low-dose inhaled steroid

Consider alternatives addition of one of the drugs:• ß-agonis long acting• Teofilin short acting• Antileukotriena Or doses of inhaled steroids increased (high)

Asthma Episodic Often

Asthma Persisten

4-6 week > 3x doses/ week

< 3x doses/ week

6-8 minggu respons

Asthma Episodic Rarely

Flow of Long-Term Management of Asthma Children continued

Medium-dose steroids added to one of the drugs:•ß-agonis long acting• Teofilin short acting• AntileukotrienaOr doses of inhaled steroids increased (high)

Drug Steroid Oral

6-8 minggu respons

Asthma Persisten

Non medikamentosa TheraphyPrevent children exposed to the substance /

allergen / conditions (weather) which can spur the onset of asthma attacks

Education to the families of children with asthma about the degree of illness and the degree of asthma attacks.

Prognosis

Long-term prognosis is generally good 50-80%

Most asthmatic child is diminished with age70% -80% of childhood asthma disappears at

the age of 21 years

KomplikasiEmphysema and change shapeAsthma is a chronic and severe Pigeon chestMany viscous secretions bronchial obstruction

atelektasis bronkiektasis infction bronkopneumonia

Status asmatikus respiratory failure pulse failure †

Critism and SuggestionsFor pattient

Prevent asthma attacks (environmental settings).

Giving the drug at the time, manner, and duration of the right.

Knowing the signs of the beginning of an asthma attack.

Knowing when to consult a doctor or to the hospital.

Keeping the child's general health.