Asma

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 1. Mild attack
episodic asthma
2. Moderate
2. Frequent
attack
episodic asthma
3. Persistent 3. Severe attack
asthma
Asthma managements
Chronic asthma Acute asthma

Long term Attack

management management

Algorithm diagnosis Algorithm attack

& treatment management
Asthma managements
Chronic asthma Acute asthma

Long term Attack

management
management
Reliever &
Controller Reliever
Asthma medication
Controller Reliever
drug to control drug to relieve
asthma ie attack asthma attack or
or symptom not symptoms
easily emerge
-agonist
Inhaled steroid Xanthine
LABA, ALTR anticholinergic
Definition
Acute asthma = asthma attack
= asthma excacerbation
Rapid progressive worsening
episode of cough, dyspnea,
wheezing, chest tightness etc
 Type of asthma attacks
in Cipto Mangunkusumo hospital
Mild

Moderate
3.9%
11.7% Severe

84.4%
 Asthma
Triggers

Inhalant
Failed of
house dustmite
long term
Smoke
management
Food

Acute attacks
Pathophysiology of acute asthma
triggers

bronchoconstriction, edema, secretion

Airway obstruction

non-uniform Lung
ventilation hyperinflation

Atelectasis Ventilation-perfusion Compliance

mismatch disturbances

surfactant Alveolar hypoventilation work of

acidosis breathing
Pulmonary PaCO2
vasoconstriction
PaO2
Michael Sly. Nelson Textbook, 1996
Respiratory track of healthy children
Triggers
(dust, animal danders, smoke, etc)
Keep on wide, opened
(not hypersensitive,
not easily constricted)

Bronchus Bronchus
Respiratory track of asthmatic children
triggers very fragile
(dust, animal danders, smoke, etc) very sensitive
constrict easily

no symptoms attack

muscle spasm
wall oedema
hyper secretions

Bronchus Bronchus
 Triggers of asthma
Respiratory infection (viral, mycoplasma)
Exercise
Allergens : - inhaled
- ingested (rare)
Irritants (cigarette smoke, air pollution)
Weather changes
Medications (ASA)
Chemical (tartrazine, sulfites, menosodium
glutamate)
Emotional stress
Gastroesophageal reflux
Symptoms of asthma attack:
Rigorous cough/without stopping
Dyspnea, difficult breathing
Wheezing
Tachypnea, fast breathing
Chest pain
Difficult to speak
Cyanosis
Asthma management principles

1.Avoidance
2.Avoidance
3.Avoidance
4.Drugs inhalation therapy
15
Goal of acute asthma management
Rapid resolution of acute symptoms
To reduce hypoxemia
Normal lung function as soon as
possible
Reevaluation to prevent asthma
attacks

Lenfant C et al, GINA 2002

 Acute asthma management
Asthma attack / symptoms present:
First line therapy
-agonist : terbutaline, salbutamol
anticholinergic: ipratropium bromida
Chronic asthma (long term management)
First line therapy
Inhaled steroid
Long-acting beta-2 agonist (LABA)

17
 Assessment of severity
Respiratory
Mild Moderate Severe arrest
imminent
Breathless Walking Talking At rest
Can lie down Infant-softer Infant stops
Shorter cry feeding
Difficult Hunched
feeding forward
Prefers
sitting

Talks in Sentences Phrases Words

Alertness Maybe Usually Usually Drowsy or

agitated agitated agitated confused

Respiratory Increased Increased Often

rate >30x/min
 Normal rates of breathing in awake children:
Age Normal rates
<2 months <60/min
2-12 months <50/min
1-5 years <40/min
6-8 years <30/min

Accessory Usually not Usually Usually Paradoxal

muscles and thoraco-
suprasternal abdominal
retractions movement
Wheeze Moderate, Loud Usually loud Absence of
often only wheeze
end
expiratory
Pulse/min <100 100-200 >120 Bradycardia

Infants 2-12 months <160/min

Preschool age 1-2 years <120/min
School age 2-8 years <110/min
Pulsus Absent Maybe Often present Absence
paradoxus <10 mmHg present 20-40 mmHg suggests
10-25 mmHg
Pulsus Absent Maybe Often present Absence
suggests
paradoxus <10 mmHg present 20-40 mmHg
10-25 mmHg

PEF after Over 80% Approx. 60- <60%

initial roncho- 80% predicted or
dilator, personal best
%predicted
or response
or %personal
best
lasts <2 hrs

PaO2 (on air) Normal >60 mmHg <60 mmHg

Test not possible
and/or usually cyanosis
PaCO2 necessary <45 mmHg
<45 mmHg >45 mmHg

SaO2% >95% 91-95% <90%

 Acute asthma algorithm
Clinic/ER
Asses attack severity

1st management
nebulitation -agonis 3x, 20 min interval
3rd nebulitation + anticholinergic

Mild attack Severe attack

Moderate attack (nebulization 3x,
(nebulization 1x,
(nebulization 2-3x, no response)
complete response)
partial response) O2 from the start
persist 1-2 hr: give O2 IV line
discharge asses: Moderate asses: Severe -
symptom reappear: ODC hospitalized
Moderate attack IV line CXR
 One Day Care (ODC) Admission room
Discharge Oxygen therapy Oxygen therapy
give -agonist Oral steroid Treat dehydration and
(inhaled/oral) Nebulized / 2 hour acidosis
routine drugs Observe 8-12 hours, Steroid IV / 6-8 hours
viral infection: if stable discharge Nebulized / 1-2 hours
oral steroid Poor response in 12h, Initial aminophylline IV,
Outpatient clinic in admission then maintenance
24-48 hours Nebulized 4-6x
good response per 4-6 h
If stable in 24 hours
discharge
Poor response ICU

Notes:
In severe attack, directly use -agonist + anticholinergic
If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times
Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack
At home
Known of asthma symptoms
Nebulized 2 agonist
If not available: MDI with/without
spacer or orally
In Indonesia: not popular
Be careful with OTC
 Early management
Initial assessment of severity asthma attacks
Nebulized 2-agonist, interval 20 minute
3rd nebulization: anticholinergic agent
Severe attacks: directly with anticholinergic agent
If nebulizer not available:
MDI with Spacer
Adrenalin SC
MDI with Spacer Vs Nebulizer
2 agonist: bronchodilator
Mild-moderate attacks
MDI with spacer: as effective as nebulizer
Severe attacks:
Nebulizer is recommended
MDI with spacer vs nebulizer
Take less time
Fewer side effects
More portable
Cheaper
Easier use
2 agonist + ipratropium bromide.
Symptoms score decrease
Lung function better than alone
Hospitalized
Activity: longer
Mild attacks
Good response post nebulization
Observe: 1-2 hours
Discharge if the response is good
Treat as moderate attacks if symptoms still
remain
Use routine drugs
Out patient clinics
 Management of asthma attacks
Mild
Nebulization
Observe 1-2 hours Moderate

DISCHARGE
Routine drugs
Outpatient clinic
Moderate attacks
Partial response post nebulization
ODC admission
Oxygen therapy
Oral steroid
IV line
Repeated nebulization
Good response: discharge
Poor response: admission
Management of Asthma Attack
MILD
Nebulization
Observe: 1-2 hours MODERATE

???
DISCHARGE ODC SEVERE
Oxygen
Nebulization
IVFD
Oral steroid
Why is not response?
Dehydration
Metabolic acidosis
Atelectasis
Severe attacks
Poor response postnebulization
Oxygen therapy
IV line: rehydration and treat acidosis
Corticosteroids (IV)
Initial Aminophylline (IV), then
maintenance
Repeated nebulization
Chest X-ray
Good response : Discharge
Poor response : Intensive care
Management of asthma attack
MILD
Nebulization
Observe 1-2 hours MODERATE

DISCHARGE ODC SEVERE

O2, steroid
Oxygen
Nebulization
Nebulization Hydration
Aminophylline
IVFD
R
Oral steroid ICU (?)
 Others drugs (asthma attacks)

Adrenalin: maximal dose, and b effects

Salbutamol SC: be careful
MgSO4: not significant
Inhaled steroid : high dose (1600 mg)
 Asthma attacks
Assess the
severity of attacks
Stable asthma
(No attack)
Assess class of
disease

Infrequent Frequent Persistent

episodic episodic

Educations and AVOIDANCE

Reliever (+) Reliever (+) Reliever (+)

Controller (-) Controller (+) Controller (+)
 Acute asthma attacks

Nebulization 1-2 x -Agonist

Good response Partially response

One Day Care

Oxygen
Discharge Nebulization Hospitalization
Oral steroid
IVFD Oxygen
Bronchodilator Nebulization
IVFD: rehydration
Systemic steroid
Aminophylline
Good response Poor response

Discharge
Oxygen therapy
Reduce hypoxemia
To achieve saturation > 95%
Should be titrated according to oximetry
Inhalation therapy
2 agonist and ipratropium bromide Vs
2 agonist alone:
Hospitalization
Symptoms score
Lung function
Duration of action:
Mucolytics: worsen
Schuh et al. J Pediatr 1995; 126:639-45.
IVFD
Replacement therapy for dehydration
Intake because dyspnea
Vomiting
Treat acid-base and electrolyte imbalance
Parenteral medications
Steroids
Intravenous or oral
Anti-inflammations
Inhaled steroids: controversial
Aminophylline
Initial: 6-8 mg/kgBW IV in 10-20
minute
Maintenance dose 0.5 - 1
mg/kgBW/hour
Monitoring: aminophylline serum level
Narrow safety margin

National guidelines for childhood asthma, 2004

 Other drugs
Adrenalin: maximal dose !!!, and effects
Salbutamol SC: be careful
MgSO4: not significant than salbutamol
Inhaled Steroid : high dose (1600-2000
mg)
LABA: Nocturnal asthma, EIA
Antibiotics: Not necessary except sinusitis

Lenfant C et al, GINA 2002

Inhaled steroid
Controversial (limited literature)
High dose (1600-2000 mg)
Reduced asthma attacks
Not effective in severe attacks
Alternative therapy
Management of acute asthma
MILD
Nebulization
Observe 1-2 hours MODERATE

DISCHARGE ODC SEVERE

Oxygen O2, steroid
Nebulization Nebulization
Hydration
IVFD
Aminophylline
Oral steroid R
ICU (?)
 Severe acute asthma
No response after initial serial nebulization
Oxygen
IV line: dehydration and acidosis
Systemic steroid: oral or IV
Frequent nebulization
Aminophylline IV drip: initial +
maintenance
Chest X ray
Non responsive
Dehydration:
inadequate intake, the longer the more
evaluate: clinically, laboratory;
overcome
Acidosis: correction
Atelectasis & mucus plug:
CXR mandatory; physiotherapy
Monitoring
Vital sign: consciousness, RR, HR,
temperature
Cyanosis, retraction, wheezing
Hydration state and acid base, electrolite
Complication: pneumothorax, atelectasis,
encephalopathy
Nonresponsive
Excessive use of -agonist down
regulation of -agonist receptors
tachyphylaxis, subsensitivity
Systemic steroid
reduce the edema
up regulates more -agonist
receptors sensitive again to -
agonist drugs
 Conclusion
Asthma labelling
Acute asthma: mild, moderate, and severe
Avoidance is a very important prevention
Initial management is important to prevent
mortality
Nebulisation in severe acute asthma:
agonist + ipratropium bromida
Pedoman Nasional Asma Anak