Training of Inhalation Therapy

& Pediatric Asthma Management

Module 7

Longterm Asthma
Management
Departemen IKA FKUI-RSCM
UKK Respirologi PP IDAI

Dr. Darmawan Budi Setyanto, Sp.A(K)

Born: 11 April 1961
Education:
1. Faculty of Medicine University of Indonesia, 1986
2. Medical Postgraduate (Pediatrics), Faculty of
Indonesia, 1993
3. Pediatric Pulmonology Subspecialty, Faculty of
Indonesia, 2002
Recent position :

Head of Division of Respirology, Dept of Child of
Medicine, University of Indonesia

Lecturer on Pediatric Respirology, Dept of Child
Health, Faculty of Medicine University of Indonesia2

Asthma, 2 aspects
Asthma : chronic respiratory disease that
can have acute attack (two in one
disease)

Chronic Asma

Asthma
Acute Asthma

Classification of pediatric asthma

Chronic asthma

Acute asthma

1. Infrequent
episodic asthma
2. Frequent
episodic asthma

1. Mild attack
2. Moderate
attack
3. Severe attack

3. Persistent
asthma

Asthma labelling
Chronic condition + present condition
Chronic condition: infrequent -- persistent
Present condition:
(-)
Symptom
attack (-)
(+)
attack (+)

Chronic Asthma
trigger
exposure

not optimal
medication

Acute Asthma
6

Asthma managements
Chronic asthma
Long term
management
Algorithm diagnosis
& treatment

Acute asthma
Attack
management
Algorithm attack
management

Asthma managements
Chronic asthma
Long term
management
Reliever &
Controller

Acute asthma
Attack
management
Reliever

Asthma medication
Controller
drug to control
asthma ie attack
or symptom not
easily emerge
Inhaled steroid
LABA, ALTR

Reliever
drug to relieve
asthma attack
or symptoms
-agonist
Xanthine
anticholinergic

Criteria of severity of childhood asthma

Infrequent episodic symptoms
Exacerbation 3-4 x/year, there is no sign and symptom
in between
Quality of life good

Frequent episodic symptoms

Exacerbation 1 x/month, there is no sign and symptom
in between
Quality of life good, sometimes affected

Persistent symptoms
Exacerbation > 1 x/month, there is sign and symptom
in between
Quality of life limited

Objectives of asthma management

Minimal chronic symptoms (ideally none)

Minimal acute attacks (seldom)
No visit to ER
Minimal 2-agonist using
Activity is not inhibited
Normal lung function test (mendekati)
Minimal drugs side effects

Increasing Quality
of Life

Asthma management principles

1.Avoidance
2.Avoidance
3.Avoidance
4.Drugs
inhalation therapy
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Avoidance of allergens
For all asthma: infrequent episodic,
frequent episodic, and persistent
asthma
Avoid the triggers: house dust mite
Keep away from pets
Before and during pharmacologic
treatment
GINA, 2002

Education for Patient/Family

Knowledge of asthma
Compliance
Practical management guidelines at
home
Doctor-family-patient relationship
GINA,2002

Pharmacotherapy
Reliever:
2 agonist
oral
Epinephrine
Teophyllin/aminophyllin
Anticolinergic (ipratropium br)
Steroid

: subkutan
: oral, I.V.
: inhaler
: oral, I.M.

Controller:
Steroid
LABA
Antileukotrien

: inhaler
: inhaler, oral
: oral
PNAA, 2002

: inhaler, nebulized,

Classification

Controller

Reliever

Infrequent
episodic
asthma

No

Yes

Frequent
episodic
asthma

Yes

Yes

Persistent
asthma

Yes

Yes

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Chronic asthma management

Asthma attack / symptoms present:
First line therapy
beta-2 agonist
ipratropium bromida

Chronic asthma (long term management)

First line therapy
inhaled steroid
Long-acting beta-2 agonist (LABA)
18

Medicine

Bronchodilator
Anti-inflammation
Antiremodeling
Anti IgE

Bronchodilator
Short Acting Beta-2 Agonist (SABA)
Reliever

Long Acting Beta-2 Agonist (LABA)

Controller

TREATING ASTHMA
with Bronchodilators alone

is like

Painting over rust

!!!

TREATING ASTHMA

AntiBronchodilators
Inflammation
is like
with

alone

Antihistamine
Disodium Cromoglycate (DSCG)
Corticosteroid
Anti PDE 4 (Phosphodiesterase)

is like

Inflammation in asthma
Inflamasi akut

Steroid
response

Chronic inflammation
Structural changes

Time

Barnes PJ

Long-term placebo-controlled trial of ketotifen in the

management of preschool children with asthma
Loftus BG, Price JF
J Allergy Clin Immunol 1987; 79:350-5

The results suggest that:

Ketotifen has no place in the management

of young children with frequent asthma

Inhaled disodium cromoglycate (DSCG) as

maintenance therapy in children with asthma:
a systematic review.
Tasche MJA, Uijen JHJ, Bernsen RMD, de Jongste JC, van der Wouden JC.
Thorax 2000; 55:913-20

Insufficient evidence that DSCG has a

beneficial effect as maintenance treatment
in children with asthma

Corticosteroid

Restores asthma controlling in children

Evidences from study:


Increases PEF (morning and afternoon)

Increases FEV1 (morning and )

Reduces FEV1 diurnal variation

Reduces symptoms

Reduces asthma attack frequency

Reduces reliever using (2 agonis)

Increases quality of life

FEV1, forced expiratory volume in 1 second

PEF, peak expiratory flow

Longterm steroid

Side Effects

Hoarse voice
Pharynx irritation
Candidiasis
Headache
Growth disturbance??

Treatment
Reliever (treatment of attack) :

2 agonist
Ephinephrin
Theophyllin/aminophyllin
Steroid

: inhaled, nebulized, oral

: subcutan
: oral, I.V.
: oral, I.M.

Controller (prevention of attack) :

Avoidance

Medicine

: triggers (including enhancers,

inducers) especially improve
indoor environment.
: inhaled steroid, antileukotrien.

Steroid efficacy in asthma

Steroid
dose

Benefit

Side-effects

LABAs and ICS - complementary modes of action

LABA





Smooth muscle
dysfunction

Bronchoconstriction
Bronchial hyperreactivity
Hyperplasia
Inflammatory mediator release

Airway
inflammation

Inflammatory cell
infiltration / activation
Mucosa oedem
Cellular proliferation
Epithelial damage
Basement membrane thickening

Symptoms / exacerbations

CS







% Days
50

Wheezing
Medication
Low PEFR

40
30
20
10
0

Dust free
Bedroom

Control
Bedroom

Percentage of days (+ SE) on wich wheezing was noticed, medication was given, and
abnormally low peak expiratory flow rate (PEFR) was recorded during 4 week study period

Adding LABA to budesonide reduces rate of

severe exacerbations
Exacerbations / patient / year

1.0

Increasing Budesonide dose: p <0.001

Adding Formoterol : p = 0.014
Budesonide 800 vs. Budesonide 200 + Formoterol:
p = 0.031

0.5

0
Budesonide
100 g bid

Pauwels et al, NEJM 1997

Budesonide 100 g bid Budesonide

+ Formoterol 9 g bid 400 g bid

Budesonide 400 g bid

+ Formoterol 9 g bid

33

Adding LABA to budesonide improves FEV1

90

% predicted

85

80

75

70
-1

12

Months
Budesonide
100 g bid
Pauwels et al, NEJM 1997

Budesonide
400 g bid

Budesonide
100 g bid
+ Formoterol 9 g bid

Budesonide
400 g bid
+ Formoterol 9 g bid
34

Quality of life (CS +LABA)

207 anak, 57% menerima steroid inhaler

*p<0.01 vs baseline
p<0.05 vs placebo

Mean FSIIR
score

Status fungsional
meningkat
100

*
*

90

Placebo
Salmeterol 50 g bid

Anak sehat

*
Anak sakit kronik

80
Status fungsional
menurun

12

Waktu (minggu)

FSIIR, functional status IIR

Mahajan et al. Pediatr Asthma Allergy Immunol 1998

Long term treatment

Infrequent Episodic
Symptoms

2-agonist or theophylline
inhaled/oral intermittently
4-6 weeks
>3 episodes/week

3-6 months
Evaluation

Add controller drug

Frequent episodic
Symptoms

6-8 weeks
response (-)

3-6 months
response (+)

Replace with low dose inhaled steroids

Continue 2-a or/and
theophylline inhaled/oral intermittently
6-8 weeks
response (-)

3-6 months
response (+)
36

6-8 weeks
respons (-)

3-6 months
respons (+)

Consider :
Persistent Symptoms Long acting 2-agonists, or
Slow release 2-agonists, or
Slow release theophyllines
6-8 weeks
respons (-)

3-6 months
respons (+)

Increase dose of inhaled steroid

6-8 weeks
respons (-)

Add oral steroids

3-6 months
respons (+)


37

Longterm
management

Low dose steroid

Medium dose
steroid

Low dose
steroid + LABA

Low dose
steroid + ALTR

Low dose
steroid +TSR

High dose
steroid

Medium dose
steroid + LABA

Medium dose
steroid + ALTR

Medium dose
steroid + TSR

ORAL
STEROID
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Conclusion
Asthma prevalence: increase
Classifications of childhood asthma:
infrequent episodic asthma, frequent
episodic asthma, and persistent asthma
Longterm management: Inhalation
therapy

Thanks for
your attention
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