Dr.

Abdul Rohman SpP

RELATED TO
ACUTE ASTHMA ATTACK
GERD
TRIGGER
COMORBID
The Relationship Between GERD and Asthma
ASTHMA
COMORBI
D
Been
Discussed
Occur
Together
Unclear
The prevalence of GERD in asthmatics : 34 89 %
1892, Sir W Osler severe paroxysm of asthma may be
induced by overloading the stomach, or by taking certain
article of food.
The Expert Panel Report 3 : Guidelines for the Diagnosis and Management
of Asthma GERD as a comorbid condition of asthma and recommends
medical management of GERD in appropriate patients

GERD
CAUSE
TRIGGER
EXACERBATE
MANY PULM DISEASE

CHRONIC COUGH & ASTHMA
IPF, CYSTIC FIBROSIS, COPD & CHRONIC BRONCHITIS
GERD
ASTHMA
Esophageal Sphincter Pressure
Cough Intraabdominal pressure

INDIRECT
Reflex Theory
Foregut Smooth Muscle
Same Innervation
DIRECT
Inflammation caused by
Aspiration after reflux
Reflux Theory
PATHOPHYSIOLOGY OF THE PULMONARY MANIFESTATION OF GERD











GERD
ASTHMA
MANY POTENTIAL FACTORS THAT PROMOTE GERD IN ASTHMATICS
Microaspiration
Vagally mediated reflux
Heightened bronchial
reactivity
Local axonal reflex
Autonomic dysregulation (hypervagal state)
An increased pressure between the thorax and abdominal cavity
Asthma medication
Hiatus hernia

Hyperinflation associated with bronchospasm that alters crural diaphragma function

Neurogenic inflamation
Vagal Mediated Reflex
Hiperaktivitas Bronkus
Micro Aspiration
Neurogenic Inflammation
Local Axonal Reflex
GERD
Psikis
Lingkungan
Keturunan
Obesity Fatty meal
Pregnancy Heavy meal
Tight Fitting garment Spicy food
Rapid eating behaviour Coffee, tea, onions
Reclining after eating Cigarette smoking
Emotional stress Medication
Larynx
Middle ear
Nasal
Oral
Pharynx/Larynx

Airway
- Chronic cough
- Aspiration Pneumonia
ASMA
- AP Thorax Abdomen
- Hiperinflation
Diafragma Mendatar
- Medication
- Hiatus Hernia
- Hipervagal State


Asam Lambung
LES
Inspirasi
Infeksi
Alergen
Fisik
Gejala Klinis GERD pada Asma
Heartburn Regurgitasi Dysfagi Nyeri dada Waterbrash
Agus DS dkk 80,6 % 100 % 19,4 % 80,6 % 38,9 %
Taley dkk 40 75 8 51 -
Field dkk 77 55 24 - -
Roussos dkk 81 57 - - -
O'Connels 72 50 - - -
Nakase dkk 68,9 - 4,7 - 34,9
Esophageal 4 Gejala Utama : - Heartburn
- Regurgitasi
- Dysfagi
- waterbrash
CATATAN : - Asia (heartburn) - sedikit ~ susah pahami arti heartburn
- Agus DS dkk : heartburn 89,6 % ~ terlalu mengarahkan ?
Suspected extra-esophageal manifestation of GERD
Middle ear/eustachian tube : - Glue ear - Otitis media - Otalgia

Nasal/Sinusal : - Chronic sinusitis - Postnasal drip

Oral : - Dental erosions - Aphthous ulcers

Pharynx/Larynx : - Pharyngitis - Chronic laryngitis
- Laryngospasm - Cancer
- Globus
Airways
- Chronic cough
- Aspiration pneumonia
-
- Tracheobronhitis





- IPF
- Cystic fibrosis
- COPD
- Chronic bronchitis
- Sleep apnea
- Bronchiectasis
- Noncardiac chest pain


Asthma




GEJALA PERNAPASAN (BATUK, SESAK, MENGI, NAPAS
BERAT)
TIMBUL SELAMA DAN SETELAH EPISODE REFLUKS
GASTROESOFAGEAL

Harding dkk Asma + GERD (pH esofagus 24 jam)RARS: 78 %
Agus DS dkk Asma + GERD RARS = 52,8 %
- Penggunaan bronkodilator saat episode refluks : 50 %
Field dkk - Asma + GERD RARS = 41 %
- Bronkodilator inhalasi saat episode refluks : 28 %
Roussos dkk Asma RARS = 65,2 %
- Bronkodilator setelah episode refluks : 52,1 %
Erkstrom dkk Asma sedang & berat + GERD RARS = 56,25 %
Talib dkk Asma + GERD RARS = 70 %

REFLUX ASSOCIATED RESPIRATORY SYMPTOMS
(RARS)
HUBUNGAN OBAT ASMA - ESOFAGITIS
Kepustakaan : bronkodilator oral (teofilin,
agonis ) dapat me+ tekanan LES
- me | kejadian refluks asam
- me | total waktu refluks
`
Agus DS dkk : steroid oral 15,6 %, steroid inhalasi 46,9 %,
bronkodilator oral 84,4 % dan bronkodilator inhalasi 59,4 %
59,3 % esofagitis erosif e.c. pemakai bronkodilator oral

- Tidak bermakna untuk pengguna obat asma dan bukan
- Bronkodilator po resiko lebih tinggi (esofagitis erosif)

Resiko lesi



Baku emas : Endoskopi mucosal break esofagus

Klinis + sistim skoring gejala + penunjang

pH esofagus + terapi empiris

Tipikal GERD (heartburn dan regurgitasi) mulai terapi
( sensitivitas 93 % dan spesivisitas 71 % )
GERD
DIAGNOSIS
ASMA
- Gejala episodik : sesak napas, batuk, mengi, rasa berat di dada
- Timbul /memburuk terutama malam/dini hari
- Diawali faktor pencetus yang bersifat individu
- Respons thd pemberian bronkodilator
- Riwayat keluarga (atopi), alergi
+
PEMERIKSAAN JASMANI
+
spirometri

DIAGNOSIS
Diagnosing GERD in Patients with Asthma
All asthmatics asked about GERD (Eso- and Extraesophageal)
- whether frequent cough and hoarseness are presented
- whether asthma symptoms occur after meals or when lying
down
In addition, inhaler use when experiencing GERD symptoms
should be assessed
If typical GERD symptoms are present, a trial of
pharmacologic therapy is warranted.
Empiric therapy is considered successful if asthma outcomes
are improved.
Futher testing empiric therapy is unsuccessful or
have symptoms suggesting complicated GERD
Endoscopy - pH esophagus 24 jam
GERD should be considered in patients with :

Worsening asthma symptoms after meals or with reclining

Intractable nocturnal asthma
Whose disease is poorly controlled on antiasthma
medications
Those who require either systemic or high-dose inhaled
glucocorticoid therapy

Elderly patient with new-onset asthma

Lifestyle therapy :
smoking cessation, elevation of the head of the bed, avoiding large meals,
avoiding food and drink at least three hours before retiring, not lying down
within 2 hours after a meal and weight reduction.
A low-fat diet & away from foods that decrease the LES pressure : caffein,
chocolate, mint, and alcohol
Avoided medication decrease LES pressure
Medical therapy
PPIs : directly inhibit gastric secretion (the best therapy)
H2 antagonists : partially block gastric acid secretion
Antacids : symptomatic relief pH | X pepsin
Prokinetic : - improve esophageal contractility
- increase LES pressure
- incrase gastric emptying
Surgical
Nissen, Toupet, and Belsey fundoplication
Hill gastoplexy
Laparoscopy
Therapeutic Approach to GERD in Asthmatic
PENATALAKSANAAN
1. Modifikasi gaya hidup
a. Hilangkan faktor resiko : stop rokok, me + BB,

b. Hindari makanan potensi refluks : coklat, mint,
alkohol, onions, kopi, cola, citrus fruits
c.
d. Hindari makan/minum sebelum tidur at least three
hours before retiring
e. Hindari high-fat meals that delay gastric emptying and
foods that lower LES pressure
Meninggikan kepala dan tempat tidur
menghindari pakaian ketat
Stop Rokok & Menurunkan BB
Avoid Tight Clothing
Avoid Foods
Do Not Lie Down for 2 hours After Eating
PENATALAKSANAAN
2. Farmakologi : PPI, H2 antagonis, antacid dan prokinetik

3. Bedah antirefluks : medikamentosa gagal, hiatus hernia

4. Terapi endoskopi : radiofrekuensi, endoscopic suturing

5. Follow up
Farmakologi
PENATALAKSANAAN
1. Edukasi
2. Menilai dan monitor berat asma secara
berkala
3. Identifikasi dan mengendalikan faktor
pencetus
4. Merencanakan dan memberikan pengobatan
jangka panjang
5. Menetapkan pengobatan pada serangan akut
6. Kontrol secara teratur
7. Pola hidup sehat

STRATEGI PENGELOLAAN GERD
PPI (Dosis Standar)
H2RA (Dosis Standar)
H2RA (Dosis Anti Refluks)
Pendekatan Step-Up Pendekatan Step-Down
Heartburn : rasa tidak nyaman, sensasi panas atau perasaan
terbakar dibawah/belakang dada (sternum), kadang-kadang
menjalar ke arah leher atau punggung (belakang).
It is commonly postpandrial and exacerbated by lying flat or
bending over
Regurgitation : pergerakan kembali isi lambung (material refluks)
sampai esofagus atau faring yang menimbulkan keluhan sering
sendawa dan/atau mulut rasa asam atau pahit
This occurs in the absence of retching, which distinguishes
it from vomiting
Waterbrush : refleks sekresi saliva di mulut yang distimulasi oleh
asam di esofagus
lacks the bitter taste of acid and accumulates in the mouth,
rather coming from below up to the mouth
Dysphagia . This often manifest itself to the patient as a
sensation of food sticking in the retrosternal area. Difficulties with
swallowing related to reflux disease are often intermittent, when
they are probably related to reflux-related esophageal
spasm/disordered peristalsis. When less intermittent or
progressive, they may be related to more structural reflux-related
damage, such as peptic stricture or cancer
Odynophagia. This is a sensation of painful swallowing . The
patient will often describe being uncomfortably aware of the
passage of food boluses or hot liquids from the upper sternum
down to the epigastrium.
Chest Pain


INHALASI
PEMBERIAN MEDIKASI LANGSUNG KE JALAN NAPAS
KELEBIHAN
1. Lebih efektif untuk mencapai konsentrasi tinggi di
jalan napas
2. Efek sistemik minimal atau dihindarkan
3. Beberapa obat hanya dapat diberikan melalui
inhalasi, tidak terabsopsi peroral (antikolinergik)
KEKURANGAN
1. Sulit koordinasikan 2 kegiatan (menekan inhaler dan
menarik napas) dalam satu waktu
2. Perlu latihan berulang-ulang penderita trampil
Possible Approach to GERD in
Asthmatics with Reflux Symptoms
Three month trial omeprazole 20 mg BID
Monitor PEF, asthma symptoms

Improved Not improved
Not GERD related
Maintenance Therapy
Consider Surgical Evaluation
o Proton Pump Inhibitor - Confirm presence of GERD
o H2 Blockers (pH monitor, EGD)
o Prokinetic Agents - Absence of long stricture
(barium swallow, EGD)
- Hypotonic LESP (manometry)
- Normal esophageal motility
(manometry, barium swallow)

Fundoplication

Table-Medical Trials of GERD-Related Asthma
Source No.of
Patients
No. of Control
Subjects
Treatment Asthma Outcome
Kjellen et al 31 31 Antacids/alginic acid 54 % improved
Goodall et al 18 Placebo crossover Cimet 200 mg qid for 6 wk
Increased PEFR &
decreased asthma
symptoms in 75 %
Harper et al 15 - Ranit 150 mg bid for 8 wk
Decreased symptoms &
improved PFT results over
entire group
Nagel et al 15 Placebo crossover Ranit 450 mg/d for 1 wk No difference
Ekstrom et al 24 Placebo crossover Ranit 150 mg bid for 4 wk
Mild decrease nocturnal
symptoms and decreased
MDI use
Depla et al 1 - OMZ 20 mg/d for 3 mo Complete relief of
symptoms
Ford et al 11 Placebo crossover OMZ 20 mg/d for 4 wk No difference
Meier et al 15 Placebo crossover OMZ 20 mg bid for 6 wk
29 % increased FEV1
by 20 %
Harding et al 30 - OMZ 20-60 mg/d;
documented acid suppression
73 % increased PEFR or
decreased symptoms by
20 %
UPPER GI SYMPTOMS
GERD-like symptoms
Heartburn
Regurgitation
Dysphagia
Odynophagia
Waterbrush
Ulcer-like symptoms
Epigastric paint/discomfort
Dysmotility-like symptoms
Bloating
Nausea and vomiting
Early satiety
Excessive flatus
FAKTOR RESIKO UNTUK PERTIMBANGAN
MENEGAKKAN DIAGNOSA GERD
Fatty meals
Heavy meals
Spicy food, onions
Chocolate, mints
Coffee, tea,
Rapid eating behavior
Reclining after eating

Cigarette smoking
Medication
Tight fitting garments
Obesity
Pregnancy
Emotional stress


Cause Direct
Mucosal Injury
Alendronate
Nonsteroidal anti-
inflammatory drugs
Potassium chloride
tablets
Quinidine
Tetracycline
Decrease LES Pressure

|-adrenergic agonists
o-adrenergic antagonist

Anticholinergic

Calcium channel
blockers
Diazepam
Estrogens
Narcotics
Progesterone
Theophylline
Tricyclic antidepressants
Table 11-1 Medication that can cause GERD or esophagitis
Table 11-2. Factors that can precipitate or exacerbate GERD symptoms
Medications (See table 11-1)
Foods
Caffeine
Chocolate
Peppermint
Alcohol (red wine pH = 3,25)
Carbonated beverages (cola pH = 2,75)
Citrus fruits (orange juice pH = 3,25)
Tomato-based produts (tomato juice pH = 3,25)
Vinegar (pH = 3,00)
Lifestyle factors
Weight gain
Smoking
Eating prior to recumbency


Table 11-3. Alarm signs that necessitate further evaluation of
GERD
Dysphagia
Odynophagia
Weight loss
Gastrointestinal (GI) bleeding
Family history of upper GI tract cancer
Anemia
Advanced age
Does asthma cause GERD ?
There is little controversy about the association between GER and asthma, but the
exact nature of the relationship is unclear
It the present study, asthma patients had a higher prevalence of GER symptoms and
greater need for antireflux medication than two otherwise similar control groups.
The proportions of asthmatics, with and without GER symptoms, taking |-agonists,
theophylline, ipratropium, and oral and inhaled corticosteroids were similar
suggesting that asthma medication is not an important determinant of GER
symptoms

Does Asthma Predispose Patients to Get GERD ?
Physiologic alterations associated with asthma and bronchodilator medications may
promote GERD
Hubert et al administered oral theophylline or placebo to asthmatics finding no difference in the number
of reflux episodes or total acid exposure time while pulmonary function improved
Sontag et al Asthmatic had significantly more reflux than normal control subjects. However, the
74 asthmatic taking theophylline, |-agonists, and/or prednisone had no more esophageal reflux
than the 30 asthmatics not receiving these medications

In conclusion, these data suggest that asthma should be treated aggresively with
bronchodilator and anti-inflammatory agents; however, theophylline should be
used carefully in asthmatics with GERD
STRATEGI PENGELOLAAN GERD
PPI (Dosis Standar)
H2RA (Dosis Standar)
H2RA (Dosis Anti Refluks)
Pendekatan Step-Up Pendekatan Step-Down
Heartburn : rasa tidak nyaman, sensasi panas atau perasaan
terbakar dibawah/belakang dada (sternum), kadang-kadang
menjalar ke arah leher atau punggung (belakang).
It is commonly postpandrial and exacerbated by lying flat or
bending over
Regurgitation : pergerakan kembali isi lambung (material refluks)
sampai esofagus atau faring yang menimbulkan keluhan sering
sendawa dan/atau mulut rasa asam atau pahit
This occurs in the absence of retching, which distinguishes
it from vomiting
Waterbrush : refleks sekresi saliva di mulut yang distimulasi oleh
asam di esofagus
lacks the bitter taste of acid and accumulates in the mouth,
rather coming from below up to the mouth
Dysphagia . This often manifest itself to the patient as a
sensation of food sticking in the retrosternal area. Difficulties with
swallowing related to reflux disease are often intermittent, when
they are probably related to reflux-related esophageal
spasm/disordered peristalsis. When less intermittent or
progressive, they may be related to more structural reflux-related
damage, such as peptic stricture or cancer
Odynophagia. This is a sensation of painful swallowing . The
patient will often describe being uncomfortably aware of the
passage of food boluses or hot liquids from the upper sternum
down to the epigastrium.
Chest Pain


Vagal Mediated Reflex
Hiperaktivitas Bronkus
Micro Aspiration
Neurogenic Inflammation
Local Axonal Reflex
Infeksi
Alergen
Fisik
GERD
Psikis
Lingkungan
Keturunan
Obesity Fatty meal
Pregnancy Heavy meal
Tight Fitting garment Spicy food
Rapid eating behaviour Coffee, tea, onions
Reclining after eating Cigarette smoking
Emotional stress Medication
Larynx
Middle ear
Nasal
Oral
Pharynx/Larynx

Airway
- Chronic cough
- Aspiration Pneumonia
ASMA
Medication
Hiatus Hernia
Hipervagal State
P Thorax Abdomen
Hiperinflation
Diafragma Mendatar
Asam Lambung
LES
Inspirasi
Penatalaksanaan serangan Asma di Rumah
Penilaian Berat Serangan
Klinis: gejala (batuk, sesak, mengi, dada terasa berat) yang bertambah
APE<80% nilai terbaik/ prediksi
Terapi awal
Inhalasi agonis beta-2 kerja singkat (setiap 20 menit, 3kali dalam 1jam), atau Bronkodilator oral
Respon baik
Gejala (batuk/ berdahak/ sesak/
mengi) membaik
Perbaikan dengan agonis beta-2 &
bertahan selama 4 jam. APE>80%
prediksi/ nilai terbaik
-Lanjutkan agonis beta-2 inhalasi setiap 3 - 4 jam
untuk 24 48 jam
Alternatif: bronkodilator oral setiap 6 8 jam
-Steroid inhalasi diteruskan dengan dosis tinggi
(bila sedang menggunakan steroid inhalasi)
selama 2minggu, kmd kembali ke dosis
sebelumnya
Hubungi dokter
untuk instruksi
selanjutnya
Respon buruk
Gejala menetap atau bertambah
berat
APE<60% prediksi/ nilai terbaik
-tambahkan kortikosteroid
oral
-Agonis beta-2 diulang
Segera ke dokter/ IGD/ RS
Klasifikasi berat serangan asma akut
Gejala dan Tanda Berat Serangan Akut Keadaan Mengancam
Jiwa
Ringan Sedang Berat
Sesak Napas Berjalan Berbicara Istirahat
Posisi Dapat tidur tenang Duduk Duduk membungkuk
Cara berbicara Satu kalimat Beberapa kata Kata demi kata
Kesadaran Mungkin gelisah Gelisah Gelisah Mengantuk, gelisah,
kesadaran menurun
Frekuensi napas <20x/menit 20-30x/menit >30x/menit
Nadi <100 100-120 >120 Bradikardia
Pulsus paradoksus -
10mmHg
+/-
10-20mmHg
+
> 25mmHg
-
Kelelahan otot
Otot Bantu Napas dan
retraksi suprasternal
Mengi
-
Akhir ekspirasi paksa
+
Akhir ekspirasi
+
Inspirasi dan ekspirasi
Torakoabdominal
paradoksal
Silent chest
APE > 80% 60-80% < 60%
PaO > 80mmHg 60-80mmHg < 60mmHg
PaCO < 45mmHg < 45mmHg > 45mmHg
SaCO > 95% 91-95% < 90%
The Relationship Between GERD and Asthma
Many trigger and comorbid conditions asthma
Been discussed for many years
Two disorders often occur together unclear
The prevalence of GERD in asthmatics : 34 89 %
The Expert Panel Report 3 : Guidelines for the
Diagnosis and Management of Asthma GERD
as a comorbid condition of asthma and
recommends medical management of GERD in
appropriate patients
1892, Sir W Osler : severe paroxysm of asthma
may be induced by overloading the stomach, or
by taking certain article of food.
Algoritme Penatalaksanaan GERD
Pelayanan Kesehatan Lini Pertama
Gejala Khas GERD
*Heartburn
*Regurgitasi
Gejala peringatan
Umur > 40 thn
Tanpa gejala peringatan
Umur >40 thn
Gejala menetap / berulang
Kekambuhan
Terapi empirik (PPI test)
Respons baik
Terapi minimal 4 minggu
On-demand therapy
Endoskopi
Typical GERD symptoms
Alarn sign present Alarm signs absent
Lifestyle changes,
OTC,antacids, H2RA prn
Lifestyle changes,
OTC,antacids, H2RA prn

STEROID EFFECTS in ASTHMA with GERD
Sebagian besar GERD mempunyai tonus LES yang normal
transient LES relaxation (TLESR) : relaksasi LES bersifat spontan
dan berlangsung lebih kurang 5 detik tanpa didahului proses
menelan.
Ada hubungannya dgn : - pengosongan lambung lambat dan
- dilatasi lambung

1. Refluks spontan pd saat relaksasi LES yang tidak adekuat
2. Aliran retrogad yang mendahului kembalinya tonus LES
setelah menelan
3. Meningkatnya tekanan intra abdomen


Mekanisme refluks gastroesofageal pada GERD
Faktor-faktor dapat menurunkan tonus LES
1. Adanya hiatus hernia.
2. Panjang LES (makin pendek LES, makin rendah tonusnya)
3. Obat-obatan (antikolinergik, |-adrenergik, teofilin, opiat dll)
4. Faktor hormonal. Selama kehamilan kadar progesteron me |
Alarm sign : BB menurun +, anemia,
hematemesis/melena, disfagia, odinofagia, Rx.
Keluarga Ca esofagus/lambung & umur 40 th
MODIFIKASI GAYA HIDUP
1) Meninggikan posisi kepala pada saat tidur dan menghindari
makan sebelum tidur- menigkatkan bersihan asam selama
tidur dan mencegah refluks asam lambung
2) Stop merokok dan alkohol menurunkan LES
3) Me + konsumsi lemak dan mengurangi jumlah makanan
menimbulkan distensi lambung
4) Me + BB dan hindari pakaian ketat me + tekanan abdomen
5) Makanan/minuman merangsang sekresi asam lambung :
coklat, teh, kopi, mint & minuman bersoda
6) Jika mungkin hindari obat me + tonus LES : anti kolinergik,
teofilin, diazepam, opiat, antagonis kalsium, agonist beta
adrenergik, progesteron