dr Salim S Thalib Sp.

P (K)

2018 BRONCHIALE
 What is known about asthma ?

 Asthma is a common and potentially serious chronic disease

that can be controlled but not cured.
 Asthma causes symptoms such as wheezing, shortness of
breath, chest tightness and cough that vary over time in
their occurrence, frequency and intensity.
 Symptoms are associated with variable expiratory airflow,
i.e. difficulty breathing air out of the lungs due to
▪ Bronchoconstriction (airway narrowing)
▪ Airway wall thickening
▪ Increased mucus
 Symptoms may be triggered or worsened by factors such as
viral infections, allergens, tobacco smoke, exercise and
stress.
© Global Initiative for Asthma
 What is known about asthma ?

▪ Asthma can be effectively treated.

▪ When asthma is well-controlled, patients can
▪ Avoid troublesome symptoms during the day and night.
▪ Need little or no reliever medication.
▪ Have productive, physically active lives.
▪ Have normal or near-normal lung function.
▪ Avoid serious asthma flare-ups.
(also called exacerbations, or severe attacks)

© Global Initiative for Asthma

 Definition of asthma

▪ Asthma is a heterogeneous disease, usually

characterized by chronic airway inflammation.
▪ It is defined by the history of respiratory symptoms
such as wheeze, shortness of breath, chest tightness
and cough that vary over time and in intensity,
together with variable expiratory airflow limitation.

© Global Initiative for Asthma

 Description of asthma
1

▪ Asthma is characterized by variable symptoms of

wheeze, shortness of breath, chest tightness and /or
cough, and by variable expiratory airflow limitation.

▪ Both symptoms and airway limitation characteristically

vary over time and in intensity.

▪ These variations are often triggered by factors such as

exercise, allergen or irritant exposure, change in weather,
or viral respiratory infection.
 Description of asthma
2

▪ symptoms and airway limitation may resolve

spontaneously or in response to medication, and may
sometimes be absent for weeks or months at a time. On
the other hand, patients can experience episodic flare-
ups (exacerbation) of asthma that may be life-
threatening and carry a significant burden to patients
and the community.

▪ Asthma is usually associated with airway hyper

responsiveness to direct or indirect stimuli, and with
chronic airway inflammation. these features usually
persist, even when symptoms are absent or lung
function is normal, but may normalize with treatment.
Phenotypes of asthma 1

▪ Asthma is heterogeneous disease, with different underlying

processes.
▪ Recognizable cluster of demographic, clinical and/or
pathophysiological characteristics are often called “asthma
phenotypes”.
▪ Many phenotypes have been identified. Some of the most common
include :
▪ Allergic asthma.
▪ Non-allergic asthma.
▪ Late-onset asthma.
▪ Asthma with fixed airflow limitation.
▪ Asthma with obesity.
▪ Asthma is a phenotypically heterogeneous disorder that
results from complex interactions between environmental
and genetic factors.
▪ The expression of asthma may vary according to age and
gender, association with atopic or specific provoking factors,
type of airway inflammation, or severity of the disease.
Phenotypes of asthma 1

▪ Allergic asthma.
▪ Non-allergic asthma.
▪ Late-onset asthma.
▪ Asthma with fixed airflow limitation.
▪ Asthma with obesity.
 allergic asthma

▪ allergic asthma this is most easily recognized

asthma phenotype
▪ wich often commences in childhood and is
associated with past and/or family history of
allergic disease such as eczema, allergic rhinitis,
or food or drug allergy.
▪ Examination of the induced sputum of these patients
before treatment often reveals eosinophilic airway
inflammation.
▪ Patients with this asthma phenotype usually
respond well to inhaled corticosteroid( ICS )
treatment.
allergic asthma clinical features
Allergic asthma : clinical features
 non allergic asthma

▪ Some adult have asthma that is not

associated with alergy.
.
▪ cellular profile of the sputum of these patients
may be neutrophilic, eosinophilic or contain
only a few inflammatory cells
(paucigranulocytic).
▪ Patients with non –allergic asthma often
respond less well to ICS.
non allergic asthma clinical features
Phenotypes of asthma
 Burden of asthma
 Asthma is one of the most common chronic diseases worldwide with
an estimated 300 million affected individuals.
 Prevalence is increasing in many countries, especially in children.
 Asthma is a major cause of school and work absence.
 Health care expenditure on asthma is very high
▪ Developed economies might expect to spend 1-2 percent of total health
care expenditures on asthma.
▪ Developing economies likely to face increased demand due to
increasing prevalence of asthma.
▪ Poorly controlled asthma is expensive.
▪ However, investment in prevention medication is likely to yield cost
savings in emergency care.

© Global Initiative for Asthma

50 tahun terakhir……..
 Patogenesa asthma
▪ Suatu inflamasi kronis di saluran napas.
▪ Banyak sel dan elemen sel yang berperan.
▪ Inflamasi kronis mengawali peningkatan
Hiperaktivitas saluran :

HIPERRESPONSIF SAL. NAPAS

HIPERSENSITIF SAL NAPAS
INFLAMMATION PROCESSING
SALURAN NAPAS
FAKTOR PENCETUS
Patogenesa asthma
INFLAMMATION PROCESSING

SYMPTOMS OF ASTHMA
INFLAMMATION PROCESSING
 INFLAMMATION PROCESSING
Acute inflammation

Chronic inflammation

Structural changes

Inflammation processing in asthma

BARNES PJ
ASTHMA IS VARIABLE DISEASE
 Faktor risiko asma bronkiale
▪ Faktor penderita
Predisposisi individual untuk pembentukan
/ perlindungan Penyakit asma.

▪ Faktor lingkungan
Berperan dalam :
▪ Pembentukan asma individu yg peka (Pemicu)
▪ Menyebabkan gejala berkelanjutan (Pemacu)
▪ Pencetus serangan asma
 Faktor risiko asma bronkiale

Faktor penderita Faktor lingkungan

▪ Genetika ▪ alergen di dalam rumah
▪ Atopi ▪ alergen di luar rumah
▪ pemicu di tempat kerja
▪ Hiperaktivitas jalan
▪ asap rokok
napas
▪ polusi udara
▪ Jenis kelamin ▪ infeksi saluran napas
▪ Ras ▪ infeksi Parasit
▪ faktor sosial ekonomi
▪ jumlah anak dalam keluarga
▪ Diet dan obat-obatan
▪ kegemukan
INFEKSI ASMA : HYGIENE HYPOTHESIS
 Diagnosis of asthma

▪ The diagnosis of asthma should be based on:

▪ A history of characteristic symptom patterns
▪ Evidence of variable airflow limitation, from bronchodilator
reversibility testing or other tests.
▪ Document evidence for the diagnosis in the patient’s notes,
preferably before starting controller treatment
▪ It is often more difficult to confirm the diagnosis after treatment has
been started
▪ Asthma is usually characterized by airway inflammation
and airway hyper responsiveness, but these are not
necessary or sufficient to make the diagnosis of asthma.

© Global Initiative for Asthma

 Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
© Global Initiative for Asthma

NO alternative diagnoses
Clinical urgency, and
YES Alternative diagnosis confirmed?
other diagnoses unlikely

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

Empiric treatment with YES NO YES

ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Treat for ASTHMA Treat for alternative diagnosis

 Diagnosis of asthma – symptoms

 Increased probability that symptoms are due to asthma if :

▪ More than one type of symptom (wheeze, shortness of breath, cough, chest
tightness)
▪ Symptoms often worse at night or in the early morning
▪ Symptoms vary over time and in intensity
▪ Symptoms are triggered by viral infections, exercise, allergen exposure,
changes in weather, laughter, irritants such as car exhaust fumes, smoke, or
strong smells

 Decreased probability that symptoms are due to asthma if:

▪ Isolated cough with no other respiratory symptoms
▪ Chronic production of sputum
▪ Shortness of breath associated with dizziness, light-headedness or
peripheral tingling
▪ Chest pain
▪ Exercise-induced dyspnea with noisy inspiration (stridor)
▪ Diagnosis of asthma – variable airflow
limitation
▪ Confirm presence of airflow limitation
▪ Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
▪ FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
>0.90 in children
▪ Confirm variation in lung function is greater than in healthy
individuals
▪ The greater the variation, or the more times variation is seen, the
greater probability that the diagnosis is asthma
▪ Excessive bronchodilator reversibility (adults: increase in FEV1 >12%
and >200mL; children: increase >12% predicted)
▪ Excessive diurnal variability from 1-2 weeks’ twice-daily PEF
monitoring (daily amplitude x 100/daily mean, averaged)
▪ Significant increase in FEV1 or PEF after 4 weeks of controller
treatment
▪ If initial testing is negative:
▪ Repeat when patient is symptomatic, or after withholding bronchodilators
▪ Refer for additional tests (especially children ≤5 years, or the elderly)

© Global Initiative for Asthma

 Typical spirometric tracings
Volume Flow
Normal

FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)

Asthma
(before BD)

1 2 3 4 5 Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements

© Global Initiative for Asthma

 ▪ Assessment of asthma

▪ Asthma control - two domains

▪ Assess symptom control over the last 4 weeks
▪ Assess risk factors for poor outcomes.
▪ Treatment issues
▪ Check inhaler technique and adherence
▪ Ask about side-effects
▪ Does the patient have a written asthma action plan?
▪ What are the patient’s attitudes and goals for their asthma?
▪ Comorbidities
▪ Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea,
depression, anxiety
▪ These may contribute to symptoms and poor quality of life
 GINA assessment of symptom control

A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week? Yes No
• Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
• Reliever needed for symptoms* these these these
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No

B. Risk factors for poor asthma outcomes

ASSESS PATIENT’S RISKS FOR:
▪ Exacerbations
▪ Fixed airflow limitation
▪ Medication side-effects
 Assessment of risk factors for poor
asthma outcomes
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitors
 The control-based asthma management cycle

Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors

GINA 2015, Box 3-2

 Stepwise management - pharmacotherapy

Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors

STEP 5

STEP 4

STEP 3 Refer for

PREFERRED STEP 1 STEP 2
CONTROLLER
add-on
CHOICE treatment
Med/high
e.g.
ICS/LABA
Low dose anti-IgE
Low dose ICS ICS/LABA*

Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium# Add
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS tiotropium#
+ LTRA Add low
options (or + theoph*)
(or + theoph*) dose OCS

As-needed short-acting beta2-agonist (SABA) As-needed SABA or

RELIEVER
low dose ICS/formoterol**

GINA 2015, Box 3-5 (2/8) (upper part)

 Stepwise management - pharmacotherapy

STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

Mild asthma moderate asthma severe asthma

GINA 2015, Box 3-5, Step 1 (4/8)

 Reviewing response and adjusting
treatment
 How often should asthma be reviewed?
▪ 1-3 months after treatment started, then every 3-12 months
▪ During pregnancy, every 4-6 weeks
▪ After an exacerbation, within 1 week
 Stepping up asthma treatment
▪ Sustained step-up, for at least 2-3 months if asthma poorly controlled
• Important: first check for common causes (symptoms not due to asthma,
incorrect inhaler technique, poor adherence)
▪ Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
• May be initiated by patient with written asthma action plan
▪ Day-to-day adjustment
• For patients prescribed low-dose ICS/formoterol maintenance and reliever
regimen*
 Stepping down asthma treatment
▪ Consider step-down after good control maintained for 3 months
▪ Find each patient’s minimum effective dose, that controls both
symptoms and exacerbations

GINA 2015
 General principles for stepping down
controller treatment
▪ Aim
▪ To find the lowest dose that controls symptoms and exacerbations, and
minimizes the risk of side-effects
▪ When to consider stepping down
▪ When symptoms have been well controlled and lung function stable for
≥3 months
▪ No respiratory infection, patient not travelling, not pregnant
▪ Prepare for step-down
▪ Record the level of symptom control and consider risk factors
▪ Make sure the patient has a written asthma action plan
▪ Book a follow-up visit in 1-3 months
▪ Step down through available formulations
▪ Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe
for most patients
▪ See GINA 2015 report Box 3-7 for specific step-down options
▪ Stopping ICS is not recommended in adults with asthma
▪ Diagnosis of asthma – physical examination

▪ Physical examination in people with asthma

▪ Often normal
▪ The most frequent finding is wheezing on auscultation, especially
on forced expiration
▪ Wheezing is also found in other conditions, for example:
▪ Respiratory infections
▪ COPD
▪ Upper airway dysfunction
▪ Endobronchial obstruction

FLARE UP OF ASTHMA
▪ Inhaled foreign body
▪ Wheezing may be absent during severe asthma exacerbations
(‘silent chest’)

© Global Initiative for Asthma

 Flare up of asthma
▪ A flare-up or exacerbation is an acute or sub-acute
worsening of symptoms and lung function
compared with the patient’s usual status.
▪ Terminology
▪ ‘Flare-up’ is the preferred term for discussion with
patients
▪ ‘Exacerbation’ is a difficult term for patients
▪ ‘Attack’ has highly variable meanings for patients
and clinicians
▪ ‘Episode’ does not convey clinical urgency
Common precipitating factors in flare up of asthma
Common precipitating factors in flare up of asthma
Common precipitating factors in flare up of asthma
FLARE UP OF ASTHMA
ACUTE EXACERBATION OF ASTHMA
FLARE UP OF ASTHMA
 Identify patients at risk of asthma-related death

Patients at increased risk of asthma-related death should be

identified
▪ Any history of near-fatal asthma requiring intubation
and ventilation
▪ Hospitalization/emergency care for asthma in last 12
months
▪ Not currently using ICS, or poor adherence with ICS
▪ Currently using or recently stopped using OCS
▪ Over-use of SABAs, more than 1 canister/month
▪ History of psychiatric disease or psychosocial problems
▪ Confirmed food allergy in a patient with asthma
Managing exacerbations in primary care
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE

Talks in phrases, prefers
LIFE-THREATENING
Talks in words, sits hunched
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT

START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled
SABA and ipratropium bromide,
Controlled oxygen (if available): target O2, systemic corticosteroid
saturation 93–95% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed

WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler
best or predicted technique, adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Resources at home adequate
Follow up: within 2–7 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
 ICS in asthma treatment

STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

Mild asthma moderate asthma severe asthma

GINA 2015, Box 3-5, Step 1 (4/8)

 3 INHALED IPRATROPIUM BROMIDE
ANTICHOLINERGICS OXITROPIUM BROMIDE
TIOTROPIUM BROMIDE

BRONCHODILATORS
FOR ASTHMA

4
1
BETA 2 COMBINATION
AGONIST THERAPY

IPRATOPRIUM BROMIDE
SHORT /LONG ACTING
&
INHALED
SHORT ACTING INHALED
BETA 2 AGONIST
THEOPHYLLINE BETA 2 AGONIST
2
 1
RELAX 3
2 AIRWAY SMOOTH
MUSCLE DECREASED
DECREASED INFLAMMATORY
PLASMA MEDIATOR
EXUDATION RELEASE

BRONCHODILATORS
IN ASTHMA

5 4
IMPROVE
DECREASED
RESPIRATORY
NEUROTRANSMITTER
MUSCLE RELEASE
FATIGUE
CONTROL OF THE AIRWAYS
ADRENERGIC & CHOLINERGIC ( MUSCARINIC ) RECEPTORS

ADRENERGIC CHOLINERGIC
RECEPTORS RECEPTORS
TERIMA