ASMA

DEFINISI
◦ Gangguan inflamasi kronis pada saluran pernapasan yang menimbulkan
bronkospasme episodik yang menyebabkan obstruksi saluran napas yang bersifat
reversibel
◦ Dikaitkan dengan adanya hiperresponsif dari saluran pernapasan terhadap
rangsangan endogen ataupun eksogen
 DEFINISI
◦ Asma merupakan penyakit pada
saluran pernapasan besar yang
ditandai dengan adanya remodeling
airway:
◦ Metaplasia mukosa
◦ Peningkatan sel goblet dan glandula
submukosa
◦ Dengan atau tanpa fibrosis lamina
retikularis
◦ Hipertropi dan hiperplasia myocyte
◦ Peningkatan jumlah kapiler
MANIFESTASI KLINIS
◦ Dyspnea
◦ Wheezing
◦ Batuk
◦ Sneezing
◦ Difficult expectoration of sputum
◦ Onset in the early morning
◦ Febrile - if infection
KLASIFIKASI (GINA 2008)
◦ Intermittent)  1-2x/weeks
◦ Mild Persistent Asthma  1x/day  Tx bronchodilator  improve
◦ Moderate Persistent Asthma  Tx bronchodilator + steroid inhaled  improved
◦ Severe Persistent Asthma  Tx bronchodilator + inhaled steroid + oral steroid 
controlled
 Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
alternative diagnoses
Clinical urgency, and NO
YES
Alternative diagnosis confirmed?
other diagnoses unlikely

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

NO
Empiric treatment with YES YES
ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Treat for ASTHMA Treat for alternative diagnosis

© Global Initiative for Asthma
◦ Kemungkinan asma meningkat jika:
◦ Lebih dari 1 tipe gejala (wheezing, napas pendek, batuk, sesak di dada)
◦ Gejala memberat pada malam hari atau subuh
◦ Gejala bervariasi dalam intensitas dan seiring waktu
◦ Gejala dipicu oleh infeksi virus, olahraga, paparan alergen, perubahan cuaca, ketawa, iritan
seperti asap knalpot mobil, asap jalanan, atau bau yang kuat.
◦ Kemungkinan asma menurun jika:
◦ Batuk tanpa gejala respiratori lainnya
◦ Produksi kronis sputum
◦ Napas pendek berhubungan dengan pusing, kepala ringan atau sensasi ringan perifer
◦ Nyeri dada
◦ Dispneu akibat olahraga dengan inspirasi yang ribut (stridor)
HASIL SPIROMETRI
Volume
Normal

FEV1
Asthma
(after BD)

Asthma
(before BD)

1 2 3 4 5 6
Time (seconds)
 approach to Diagnosis
Symptom control & risk factors

control
(including lung function)
Inhaler technique & adherence
Patient preference

asthma Symptoms
Exacerbations
Side-effects Asthma medications

symptoms
Non-pharmacological strategies
Patient satisfaction
Treat modifiable risk factors
Lung function

and reduce STEP 5

risk
STEP 4 Refer for
add-on
treatment
STEP 2 STEP 3 e.g.
tiotropium,*
Med/high anti-IgE,
anti-IL5*
ICS/LABA
PREFERRED
CONTROLLER STEP 1 Low dose ICS
Low dose
CHOICE ICS/LABA**

Med/high dose ICS Add tiotropium*

Other Consider low Leukotriene receptor antagonists (LTRA) Low dose ICS+LTRA High dose ICS Add low dose
controller dose ICS Low dose theophylline* (or + theoph*) + LTRA OCS
options (or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol#

• Provide guided self-management education (self-monitoring + written action plan + regular review)
REMEMBER • Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
TO...
• Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of sensitizers where
appropriate
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler

SLIT added as
technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided

an option
FEV1 is >70% predicted
• Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.

SLIT: sublingual immunotherapy

GINA 2017, Box 3-5 (1/8) © Global Initiative for Asthma
MANAJEMEN
◦ TREATMENT:
◦ Anti-inflamation steroid (controller):
◦ Oral: metil prednisolon, prednison, deksametason, triamsinolon
◦ Inhaled: budesonide, flutikason, beklometason
◦ Bronchodilator (reliever):
◦ Oral: salbutamol, terbutalin, aminofilin
◦ Inhalasi: salbutamol, terbutalin, ipatoprium bromid
◦ Injection: adrenalin, terbutalin, salbutamol, aminophyline
 KORTIKOSTEROID INHALASI PADA
DEWASA MUDA DAN DEWASA (>12
TAHUN)
Inhaled corticosteroid Total daily dose (mcg)
Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone furoate (DPI) 100 n.a. 200
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
ASMA EKSASERBASI
AKUT
 PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT

START TREATMENT
TRANSFER TO ACUTE
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING While waiting: give inhaled SABA
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)

© Global Initiative for Asthma

 START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed

WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Resources at home adequate
Follow up: within 2–7 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

GINA 2017, Box 4-3 (7/7) © Global Initiative for Asthma

MANAJEMEN EKSASERBASI AKUT
1. Bed rest Fowler + 02  3-4 liter/menit
2. Antiinflamasi sistemik  metilprednisolon oral 40-60 mg atau injeksi metilprednisolon
60-120 mg iv
3. Antiinflamasi inhalasi  budesonid/flutikason 1-2 mg
4. Bronchodilator inhalasi salbutamol 200-800 mcg + ipatroprium bromide 200-400
mcg
5. 1+2+3+4 berbarengan, jika perlu continuous 2-4 jam
6. Evaluasi setiap 1-2 jam
7. Jika 2 jam pertama tidak ada perbaikam, step 1+2+3+4 diulangi
8. Jika 3x evaluasi tidak ada perbaikan  ICU
REVIEW RESPON DAN PENGATURAN
DOSIS
◦ Seberapa sering pengkajian ulang terapi?
◦ 1-3 bulan setelah mulai terapi, kemudian setiap 3-12 bulan
◦ Selama kehamilan setiap 4-6 minggu
◦ Setelah eksaserbasi, dalam 1 minggu
◦ Menaikkan terapi asma
◦ Sustained step-up, minimal selama 2-3 bulan jika asma tidak terkontrol dengan baik
◦ Penting: periksa penyebab umum (gejala bukan karena asma, teknik penggunaan inhaler yang salah,
kepatuhan yang rendah)
◦ Short-term step-up, selama 1-2 minggu, misalnya karena infeksi viral atau alergen
◦ Day-to-day adjustment
◦ Pada pasien dengan ICS dosis rendah/maintenance formoterol dan reliever*

◦ Menurunkan terapi asma

◦ Pertimbangkan untuk menurunkan dosis setelah terkontrol dengan baik selama 3 bulan
◦ Tentukan batas minimum dosis efektif pasien, yang bisa mengontrol gejala dan eksaserbasi

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2017