Asthma Bronchiale

Dewa Artika
Divisi Pulmo, Bagian IP. Dalam
FK. UNUD

Introduction
Asthma is a syndrome that consist of:
Obstruction on reversible inhalation path
way
inhalation path way hyper responsive
inhalation path way inflammation
asthma symptoms (wheeze, heavy feeling
on the chest, difficult to breath and cough).
Various incident and prevalence
In UK, 8% of adult and 20% of children
suffer from asthma. In The USA, Australia,
3%. In Japan, Finland 1%. While in
Indonesia 2 4%.

> 9%
6 to < 9%
3 to 6%
< 3%
ISAAC Steering Committee, Lancet 1998

Worldwide prevalence
13-14 years

Etiology
Complex interaction between
predisposition, causal and contribution
factor
Predisposition factors : atopi, sex, race
Causal factors : allergen inside a room,
allergen outside a room, material in work
environment, medicine and food additive
Contribution factors : cigarette, air
pollution, infection on inhalation path way.

Pathology
Mucus build up
Muscle hyper
flation
Eosinofil
infiltration
Pem BAL :
Inflammation cell
Edema
Extravasasiplasm

Pathogenesis
Bronchus is keep away from inflammation
by immunologic mechanism
In particular circumstances immunologic
reaction upon foreign materials a disease
called hyper sensitivity (allergic).
Gell & Comb : divided into 4 types, and
atopi asthma was included in type I
reaction.
On immunologic reaction, cell play an
important role, mediator inflammation and
triggering factor

Mechanisms Underlying the

Definition of Asthma
Risk Factors
(for development of asthma)

INFLAMMATION
Airway
Hyperresponsiveness

Risk Factors
(for exacerbations)

Airflow Obstruction

Symptoms

Mechanism underlying definition of

asthma
Immunology mechanism inhalation
pathway inflammation

Immune system divided into 2, that are:

humeral and cellular
Humeral is marked by production of
specific antibody secretion by
lymphocytes B cell, while cellular mainly
determine by lymphocytes T.
Cell lymphocytes T, controlling function of
lymphocytes B and promote inflammation
action via sitokain activity CD8

Pathogenesis of asthma
Prompt reaction and slow
reaction
Expose a patient with an allergen asthma

attack which occurred for few minutes (acute

phase asthma) based on reaction type 1
APC (Dendrites cell or macrophage) will
process allergen that was cached
lymphocytes T. And then Th2 release sitokin
that affects mast cell, eos, etc discharging
inflammatory mediator obstruction on
inhalation pathway. This reaction is call slow
asthma reaction (occurred 24 48 hours
after allergen exposure

Clinical Feature
Symptoms such as: wheeze,
cough, difficult to breath, heavy on
chest. Usually symptoms increase
during night time or early morning.
Previous record: generally has
been having the same complaint or
symptoms, often has hereditary
factors and there is allergic factors

 During asthma attack, often

preceded by infection on upper
breathing pathway, exercise,
allergen, medicines as triggering
factors.
During physical diagnoses it is
usually obtained: difficult breathing
with increase breathing frequencies,
sweating, sianosis, and obstruction
mark such as wheezing.

Supporting Diagnoses
To diagnose asthma besides anamneses
and physical diagnoses, it is also necessary
to do diagnoses such as: bronchus faal
test, lab diagnoses, skin test and radiology,
and bronchus provocation test
Lung faal test
Usually apply: VEP1, KVP or APE
Variability APE value 20% or more between
morning and night asthma also apply to
value asthma severity
Reversibility asthma can be seen by doing
broncodilator test, where increase on VEP1 or
APE > 15% after bronchodilator reversible

 Laboratory Diagnoses
Blood edge: often found an increase of
eosinofil 5 15% of total leukocyte.
Total eos generally increase > 300
Sputum: often found spiral from
Curschmann and Charcot Leiden crystal
Serum: there is an increase of total or
specific IgE

Skin test
Skin test with allergen as diagnostic
tool on asthma allergic

 Radiology diagnose usually normal

or hyperinflation
Useful for eliminate other disease or
to see if there is complication such as
pneumotorax or Pn. mediastinum

Bronchus provocation test

-could show and measure bronchus
hyperactivity also degree of
asthma severity.

Deferential diagnosis

COPD / PPOK
Viral infection
Hyper ventilation
Bronchiexthasis
Obstruction on
main bronchus
Jeart failure
Larynx
dysfunction

Obstruction upper
breath pathway
Pulmonary
embolism
Pneumothorax
Eosiniphilic
bronchitis
Primary
pulmonary
hypertension

Asthma Classification
Based on etiology
Intrinsic asthma
Extrinsic asthma

Based on disease
chronic / severity
Intermittent
asthma
Lightly persistent
asthma
Medium persistent
asthma
Heavily persistent
asthma

Based on severity
of attack (acute)
Lightly acute
asthma
Medium acute
asthma
Heavily acute
asthma
Asthma with
breathing failure

Planning and action

Aim

To recover and to control

Maintain lung faal
To do everyday activity
Avoid side effect of medication
Inhibit irreversible obstruction
Inhibit fatal asthma attack

Also known as controlled asthma

Design of Planning and Action

Patient education
Assessment and monitoring of
asthma severity
Avoid triggering factor
Planning long term therapy
Decided therapy when
exacerbation
Attempt to do regular control

Asthma Medication
There are 2 kind: reliever and controller
Reliever: Agonis B2 quick effect
inhalation and oral, corticosteroid
systemic, inhalation anticolinergik,
quick effect teofilin
Controller: kortikosteroid inhalation and
systemic, sodium chromolin, sodium
nedodromil, antihistamine, teofilin slow
release, agonic B2 slow effect inhalation
and oral, antileukotrien

Classification of Severity
CLASSIFY SEVERITY

Clinical Features Before Treatment

Symptoms
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent

Continuous
Limited physical
activity
Daily
Attacks affect activity
> 1 time a week
but < 1 time a day

Nocturnal
Symptoms
Frequent

> 1 time week

> 2 times a month

FEV1 or PEF
60% predicted
Variability > 30%
60 - 80% predicted
Variability > 30%
80% predicted

Variability 20 - 30%

< 1 time a week

STEP 1
Intermittent

Asymptomatic
and normal PEF
between attacks

2 times a month

80% predicted
Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.

Planning and Action for Chronic

Asthma
Intermittent Asthma
Controller: no need
Reliever: inhalation B2 agonis short action if
necessary

Lightly persistent Asthma

Controller: inhalation steroid 500 m.gr

Alternative: slow release teofilin or

chromolin or anti leucotrien
Reliever: inhalation B2 agonis short action if
necessary

 Medium persistent Asthma

Controller: corticosteroid is increased
until 800 mgr, B2 agonist slow action
inhalation or oral or slow release teofilin,
anti leucotrien

Alternative: slow release teofilin or

chromolin or anti leucotrien
Reliever: inhalation B2 agonis short
action if necessary (not more than 3 4
times)

 Heavily persistent Asthma

Controller: inhalation steroid >1000
mgr, plus B2 agonis slow action, plus
one or more from this medicine (slow
release teofilin, anti leucotrien, B2
agonist slow action, corticosteroid
oral)
Reliever: inhalation B2 agonis short
action if necessary

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma

Therapy - Adults
Outcome: Best
Possible Results

Outcome: Asthma Control

Controller:

Controller:
Controller:
None

Controller:
Daily inhaled
corticosteroid

Daily inhaled
corticosteroid
plus
Daily longacting inhaled
2-agonist

Daily inhaled
corticosteroid
plus
Daily long
acting inhaled
2-agonist
plus (if needed)

-Theophylline-SR
-Leukotriene
-Long-acting inhaled
2- agonist
-Oral corticosteroid

When
asthma is
controlled,
reduce
therapy

Monitor

Reliever: Rapid-acting inhaled 2-agonist prn

STEP 1:
Intermittent

STEP 2:
Mild Persistent

STEP 3:
Moderate
Persistent

STEP 4:
Severe
Persistent

STEP Down

Alternative controller and reliever medications may be considered (see text).

Planning and Action for Acute

Asthma
Aim

To avoid fatal /dead

To eliminate obstruction promptly
To overcome hypoxemia
To recover lung faal quickly
Prevent asthma attack again

Given inhalation B2 agonist short action

Inhalation anti colinergik
B2 short action subcutan agonistic injection
Adrenalin subcutan injection
For acute asthma medium and heavy,
corticosteroid systemic are given because it
can

speed up recovery
Prevent from asthma attack again
Shorten hospitalization
Death prevention

ALGORITMA

Penilaian awal

Pengobatan awal

Penilaian ulang

Episode berat

Episode sedang
Respon tidak lengkap
Respon baik

Rawat di RS

Pemulangan pasien
Perbaikan
Pemulangan pasien

Respon buruk

Rawat di ICU

Tidak membaik
Perawatan di ICU

Asthma on special condition

Asthma during pregnancy
Pregnancy can affect asthma that is 1/3
asthma patient are deteriorating
Medication principle are the same, only
put on priority to give minimal oral
medication
On acute attack, should be given optimal
medication. Systemic corticosteroid
should be given if necessary. During
inpartu, it is better not to five terbutalin,
Ok can cause post partum bleeding

 Asthma during operation

Asthma can increase complication intra
and after an operation
In principal, same with acute asthma
Corticosteroid systemic is given if:
Asthma with medium heavy degree
Early inhalation agonist B2 did not make any
improvement
While on oral steroid medication
Exarbation before taking steroid

 Exercise Induce Asthma (EIA)

Ok can occur on EIA, hyperventilation
occurred and there for breathing
pathway become dry mast cell broken
inflammation mediator discharged
such as histamine, etc asthma
occurred.
Medication same as acute asthma.
Can recover after good rest
To prevent inhalation B2 short action
can be given before exercise.

 Occupational Asthma
Asthma with ok occurred get substance
exposure in their work environment /
workplace.
Same medication
The most important thing is to avoid
triggering factor in the workplace.

 Aspirin Induce Asthma (AIA)

Asthma that occurred after taking aspirin
Symptoms, coughing, difficult to breath,
heavy feeling on chest, red face, runny nose
Occurred due to cycloxygenase formation
inhibition by certain substance, therefore
prostaglandin and tromboxan came out
causing bronco constriction
Same medication with acute asthma
The most important thing is to avoid aspirin
as triggering factor.

Summary
Diagnoses based on anamnesa,
physical diagnoses, lung faal
diagnoses, laboratory, skin test,
radiology, bronco provocation test.
Asthma classification based on
etiology, disease severity and
pattern of attack timing.

 Planning and action objective is to

make asthma controllable
Asthma is a chronic inflammation on
inhalation pathway
Medication principal: give reliever
medicine, controller and avoid
causing factor or triggering factor.

THANK YOU