Asthma Management

based on GINA 2015

Prof. Dr. Tamsil Syafiuddin, SpP(K)

Department of Pulmonology and Respiratory Medicine,

Faculty of Medicine,
Universitas Islam Sumatera Utara / Universitas Sumatera Utara,
Medan-2015
 CURRICULUM VITAE
NAMA : Prof.Dr.TAMSIL SYAFIUDDIN Sp.P (K)
ALAMAT : Jln.KARSA No F 1 KOMPLEKS EKS KOWILHAN I SEI.AGUL MEDAN 20117
PEKERJAAN :Guru Besar Tetap FK- UISU / Luar biasa FK- USU
- Penasihat Perhimpunan Dokter Paru Indonesia Pusat
- Anggota Kolegium Pulmonologi Indonesia
- Anggota Dewan Asma Nasional
- Anggota Pokja Asma dan PPOK PDPI pusat
- Assesor Program Pendidikan Dokter Spesialis Paru Indonesia
- Ketua Perhimpunan Dokter Paru Indonesia Sumut
- Penasihat Yayasan Asma Indonesia Wilayah Sumut
-Ketua Departemen Pulmonologi dan Kedokteran Respirasi FK-UISU

RIWAYAT PENDIDIKAN :
-Dokter Umum FK-USU Medan,1979
-Dokter Spesialis I Paru, FK-UI Jakarta, 1991
-Dokter Spesialis II Paru, Konsultan Asma/PPOK, 1995
Pendidikan tambahan:
- Pelatihan Kanker Paru, TSUKAGUCHI Hospital, Kobe- Japan 1989
- Pelatihan PPOK, AMAGASAKI Hospital, Kobe- Japan 1990
- Pelatihan Respiratory Physiologi, JAPAN RESPIRATORY PHYSIOLOGIST
CLUB, Kyoto- Japan 1990
- Spirometry Training Course, Department of Respiratory Medicine,
National University Hospital Singapore, Singapore 1997
 - Workshop on Transbronchial Lung Biopsy and Trasbronchial Needle
Aspiration PDPI Cabang Jakarta, RS Persahabatan Jakarta ,Jakarta Maret 1997
- Workshop on Respiratory Physiology and Its Clinical Application, RS Pusat
Angkatan Darat Gatot Subroto Jakarta, Jakarta Juni 1997
- Workshop on Medical Thoracoscopy, The American College of Chest
Physicians-The Indonesian Association of Pulmonologist, RS Persahabatan
Jakarta, Jakarta November 1997
- Workshop on Reformation of Higer Education System,HEDS-JICA,Jakarta 1998
-Pulmonary Infections Course, Postgraduate Medical Institute,
Singapore General Hospital, Singapore 2001

- Bronchoscopy &Thoracoscopy Workshop, Postgraduate Medical Institute,

Singapore General Hospital, Singapore 2005
-Workshop of Bronchoscopy and Autofluorecent Bronchoscopy,
RS Persahabatan Jakarta, Jakarta September 2005

-Training of the new interventional technique of bronchosfiberscopy

(Optical Coherence Tommograhy) , Department of Thoracic Surgery,
Tokyo Medical University Hospital,Tokyo - Japan 2007

-Respiratory Master Class on COPD, Singapore 2011

Standar Kompetensi Dokter Indonesia

Konsil Kedokteran Indonesia

Indonesian Medical Council
Jakarta 2012
 Daftar Masalah Sistem Respirasi
dan Sistem Kardiovaskuler:

Batuk (kering,berdahak,darah)
Sakit/nyeri dada
Berdebar-berdebar
Sesak napas atau napas pendek
Napas berbunyi
Sumbatan jalan napas
Kebiruan
Lampiran 2 SKDI 2012
 Daftar Penyakit
Sistem Respirasi
(Tingkat Kompetensi)

Lampiran 3 SKDI 2012

 TINGKAT KEMAPUAN/KOMPETENSI:
Kemampuan 1 : Mengenali dan Menjelaskan
Kemampuan 2: Mendiagnosis dan Merujuk
Kemampuan 3: Mendiagnosis,
Penatalaksanaan awal dan Merujuk
3A: Bukan gawat darurat
3B: Gawat darurat
Kemampuan 4: Mendiagnosis,Tatalaksana
mandiri dan Tuntas
4A: Kompetensi saat lulus dokter
4B: Kompetensi internsip dan PKB
Lampiran 3 SKDI 2012
 DAFTAR KOMPETENSI SISTEM RESPIRASI

1.Asma 4A
2.Bronkitis akut 4A
3.Pneumonia,Bronkopneumonia 4A
4.Tuberkulosis tanpa komplikasi 4A
5.Influenza 4A
6.Pertusis 4A

Lampiran 3 SKDI 2012

 DAFTAR KOMPETENSI SISTEM RESPIRASI
7.ARDS 3B
8.SARS 3B
9.Flu burung 3B
10.Asma akut berat 3B
11.Bronkiolitis akut 3B
12.Efusi pleura masif 3B
13.Pneumonia aspirasi 3B
14.PPOK Eksaserbasi akut 3B
15.Edema paru 3B
16.Haematotoraks 3B
Lampiran 3 SKDI 2012
 G lobal
IN itiative for
A sthma
Global Initiative for Asthma 2015
 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.
Heterogenous disease, phenotypes
NEW!

GINA 2015
 Inflammation
() (+) Asthma
Normal

Bronchial hyperreactivity ( - ) Bronchial hyperreactivity ( + )

Bronchoconstriction ( - ) Bronchoconstriction ( + )

Symptoms (-) Symptoms (+)

The pathogenesis of asthma
 Ca++ Histamin
Ag
Ig E YY
Phosphatidyl Phosphatidyl
Phospholipid Methyl
transferase ethanolamine choline

Phospho ++
lipase A2 Ca Histamin
Arachidonic acid ECF, NCF
lypoxygenase cyclooxygenase

5-HETE Leucotrienes Thromboxanes Prostaglandins

LTB4
LTC4 TXA2 PGD
LTD4 PGF2
LTE4

Mediator release in asthma reactions

 Inflammation

Controller
Bronchial hyperreactivity

Bronchoconstriction
Reliever
Symptoms
Medicines and Pathogenesis of asthma
 Goals of asthma management
The long-term goals of asthma management are
1. Symptom control: to achieve good control of
symptoms and maintain normal activity levels
QoL
2. Risk reduction: to minimize future risk of exa
cerbations, fixed airflow limitation and medica
tion side-effects,

GINA 2015
GINA 2015
 Goals of asthma management
The pharmacological treatment of asthma
categories:
-Controller medications,
-Reliever medications,
-Add-on therapies, these may be considered when
patients have persistent symptoms and/or exacerbations
despite optimized treatment with high dose controller
medications.

GINA 2015
Goals of asthma management
Non pharmacological treatment to achieving
these goals requires a partnership between patient and
their health care providers
Ask the patient about their own goals regarding their
asthma
Good communication strategies are essential, Adherence
Incorrect/poor technique inhaler
Smooking
Co-morbid
Consider the health care system, medication availability,
cultural and personal preferences and health literacy

GINA 2015
 Asthma Therapy Evolution
ICS treatment Adding
introduced LAA to ICS therapy
Large use of 1972 Kips et al, AJRCCM 2000
Pauwels et al, NEJM 1997
short-acting
Greening et al, Lancet 1992
2-agonists
1975 Single
inhaler therapy

1980
Fear of ICS+LABA
short-acting
2-agonists

1985
2000
1990 1995

Bronchospasm Inflammation Remodelling

GINA 2015
 AIRWAY REMODELLING IN
ASTHMA
Eosinophil

Desquamations of epithelium

MBP, ECP
Epithelium

Thickening of basement membrane

Increase in airway smooth muscle

 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.
Heterogenous disease, phenotypes

NEW!

GINA 2015
 Symptoms
Remodelling
Treatment

Based on Inflammation
 Controller:
Anti inflammation

Non steroid Inhaled Cortico Steroid

sodium chromoglicate budesonide (Pulmicort)
(Intal) (Inflamid)
beclomethasone
ketotifen
dipropionate (Becotide)
sodium nedocromil
triamcinolone acetonide
fluticasone(Flexotide)
Reliever
Bronchodilator
2 - agonist
Xanthin
Anticholinergic
 BRONCHODILATOR
Short Acting 2 AGONIST (SABA): Long Acting 2 AGONIST:
salbutamol/albuterol (Ventolin ) (LABA)
terbutaline (Bricasma) salmoterol
procaterol
formoterol
fenoterol
orciprenaline, etc

ANTICHOLINERGIC: XANTHINE:
atropine sulfate theophylline
ipratropium bromide aminophylline
tiotropium bromide

OTHER SYMPHATOMIMETIC:
ephedrine
adrenaline, etc
 Combination therapy
( ICS + LABA )

1.Symbicort
Budesonide + Formoterol
( Rapid onset of action and Long acting of duration)

2.Seretide
Fluticasone + Salmoterol
( Non rapid onset of action and Long acting of duration)

(BPJS Kesehatan)
 Other changes for clarification in GINA 2015 update
Assessment of risk factors: over-usage of SABA
High usage of SABA is a risk factor for exacerbations (Patel et al, CEA 2013)
Very high usage (e.g. >200 doses/month) is a risk factor for asthma-
related death (Haselkom, JACI 2009)
Beta-blockers and acute coronary events
If cardioselective beta-blockers are indicated for acute coronary events,
asthma is not an absolute contra-indication.
These medications should only be used under close medical supervision by a
specialist, with consideration of the risks for and against their use
Asthma-COPD Overlap Syndrome (ACOS)
The aims of the chapter are mainly to assist clinicians in primary care and non-
pulmonary specialties in diagnosing asthma and COPD as well as ACOS, and to
assist in choosing initial treatment for efficacy and safety
A specific definition cannot be provided for ACOS at present, because of the
limited populations in which it has been studied
ACOS is not considered to represent a single disease; it is expected that
further research will identify several different underlying mechanisms

Global
GINA 2015 Initiative for Asthma 2015
 Guidelines on Asthma Management:
Past and Current Trends

Mild Moderate Severe Old classification

Intermittent persistent persistent persistent

Exacerbation
Total control Partially control Uncontrol New classification

Inhalation SABA or Rapid onset of action LABA

GINA 1998 ICS LABA and ICS

(adapted)

GINA 2008-2015 ICS+LABA Stable condition

 SABA and Rapid onset of LABA in
treating acute severe asthma/exacerbation
Symbicort
FEV1 (% change from baseline) (Rapid onset of LABA)

Salbutamol
45
(SABA)
40
35
30
25
20
15
10
5
0
0 30 60 90 120 150 180
Time since last administration of study drug (minutes)
Balanag et al, Pulmonary Pharmacology&Therapeutics 2005
 A basis for synergy
ICS and LABA
Effects of ICS on Effects of LABA on
the glucocorticoid
the 2 receptor system
receptor system

Corticosteroids increase LABASs prime

2-receptor synthesis glucocorticoid receptor
for steroid dependent
activation

Overall biological / therapeutic

consequences
Zain-Hamid R Faculty of Medicine,
Universitas Sumatera Utara, Indonesia.
 Increasing combination therapy earlier
to prevent exacerbations
FACET exacerbation profiles
% change from
day 14
100
Reliever 2-agonist
Morning PEF
80 Window of
Night-time symptoms
opportunity to
60 prevent
exacerbations?
40

20

15 10 5 0 5 10 15
Days before and after an exacerbation
Tattersfield AE, et al. Am J Respir Crit Care Med 1999;160:594599.
The Beginning of
Treatment
 Exacerbation x

The beginning of treatment ?

Stable condition

Asthma management

* Stable condition

* Long-term therapy
 Inflammation can also be present
during symptom-free periods
Rate of response of different measures of asthma
control over 18 months of ICS treatment
% Reduction

AHR is a marker of inflammation

AHR

Night Rescue medication use

symptoms Impaired am PEF
Impaired FEV1

Start of 2 4 6 18
treatment Months

Adapted from Woolcock A. Clin Exp Allergy Rev 2001; 1: 6264.

 Treatment targets in common chronic diseases
Clear therapeutic targets exist for many
chronic diseases
Philosophy of treat to target
Hypertension BP 140/90 mmHg or less
Diabetes HbA1c 7% or less
Dyslipidaemia LDL-cholesterol <100 mg/dl

Asthma treatment is designed to meet specific

targets and achieve:
ASTHMA CONTROL
 Assessment of asthma
1. Asthma control - two domains
Assess symptom control over the last 4 weeks
Assess risk factors for poor outcomes, including low lung
function, smoking and blood eosinophilia
2. Treatment issues
Check inhaler technique and adherence
Ask about side-effects
Does the patient have a written asthma action plan?
What are the patients attitudes and goals for their asthma?
3. Comorbidities
Think of sinusitis, rhinosinusitis, GERD, obesity, obstructive
sleep apnea, depression, anxiety
These may contribute to symptoms and poor quality of life

GINA
GINA 2015, 2015
Box 2-1
 Control Level Based on GINA
Asthma PARTLY
Characteristics CONTROLLED UNCONTROLLED
Classification CONTROLLED

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of
None Any
activities 3 or more
features of partly
Nocturnal symptoms /
None Any controlled
awakening
asthma present
Need for rescue / None (2 or less / More than in any week
reliever treatment week) twice / week

Lung function < 80% predicted or personal

Normal best (if known) on any day
(PEF or FEV1)
Once/more per
Exacerbation None One in any week
year

GINA updated 2014

 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

*Excludes reliever taken before exercise, because many people take this routinely

This classification is the same as the GINA 2010-12 assessment

of current control, except that lung function now appears only
in the assessment of risk factors

GINA 2015, Box 2-2A Global Initiative for Asthma

Referency:
Global Initiative for Asthma (GINA)
Global Strategy for Asthma Management and
Prevention (updated 2015)
Sitou Timou Tumou Tou
(Sam Ratulangi , 1890 -1949)