G lobal

INitiative for
A sthma
 GINA Program
Objectives
 Increase appreciation of asthma as a global public
health problem
 Present key recommendations for diagnosis and
management of asthma
 Provide strategies to adapt recommendations to
varying health needs, services, and resources
 Identify areas for future investigation of particular
significance to the global community
 Global Strategy for Asthma
Management and Prevention

 Definition and Overview

 Diagnosis and
Classification
 Asthma Medications

 Asthma Management and

Prevention Program
Updated 2007
 Apa itu Asthma ?
Adalah penyakit paru paru melibatkan
radangan ( inflamasi) yang kronik pada saluran.

Apa yang berlaku pada saluran tersebut

• Radang pada saluran pernafasan
• Saluran pernafasan terlalu sensitif
• Penyempitan saluran pernafasan
(Bronchoconstriction)
Asthma Inflammation: Cells and
Mediators

Source: Peter J. Barnes, MD

 PERUBAHAN PERUBAHAN YANG
BERLAKU PADA SALURAN
PERNAFASAN
Faktor Sekitaran dan Biologi ( Penyebab )

RADANG SALURAN

Saluran pernafasan Penyempitan

terlalu sensitif saluran
pernafasan
Faktor pencetus serangan
Tanda / gejala
 hidung
tekak

farink
Trakea

bronkiol

Bronkus

alveolus
diafragm
SALURAN
PERNAFASAN
NORMAL
OTOT

KERATAN
RENTAS

The picture below shows what your lungs look like when everything is working normally. The muscles that are wrapped around the airways are very thin and loose, and the airway is
wide open. This makes it easy to move air in and out of the air sacs.

SALURAN
PERNAFASAN
ASTHMA
KERATAN
RENTAS

SEMPIT SEMPIT & SEMPIT,BENGKA

BENGKAK K & LENDIR
During an asthma attack, the muscles around the airways tighten, or "spasm" (like when you make a fist) and the lining inside the airways swell or thicken, and get clogged with lots of
thick mucous. This makes the airways much skinnier than usual so it is harder to move air in and out of the air sacs. This makes it hard to breathe! The picture below shows what
your lungs would look like during an asthma attack.
This animation shows normal breathing. As you breathe in, red air that contains lots of oxygen is pulled into the lungs. The oxygen
slowly moves out of the lungs and into the blood, and then blue air that contains carbon dioxide is pushed out of the lungs. When
things are working normally, the amount of air we breathe in is about the same as the amount of air we breathe out.
 This animation shows breathing during an asthma attack. Notice that the airways are narrowed so less air can move in and out of the lungs. When things are
working normally, the amount of air we breathe in is about the same as the amount of air we breathe out however during an asthma attack air gets trapped inside
the lungs making it harder and harder to breathe.

During an asthma attack, it is actually harder to breathe out than it is to breathe in. This means that during an asthma attack, it takes much longer to breathe out
(expire) than it does to breathe in (inspire
 Burden of Asthma

 Asthma is one of the most common chronic

diseases worldwide with an estimated 300
million affected individuals
 Prevalence increasing in many countries,
especially in children
 A major cause of school/work absence
 Risk Factors for Asthma

 Host factors: predispose individuals to,

or protect them from, developing
asthma
 Environmental factors: influence
susceptibility to development of asthma
in predisposed individuals, precipitate
asthma exacerbations, and/or cause
symptoms to persist
 Factors that Exacerbate Asthma

 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
 Factors that Influence Asthma
Development and Expression

Host Factors Environmental Factors

 Indoor allergens
 Genetic
 Outdoor allergens
- Atopy
 Occupational sensitizers
- Airway
 Tobacco smoke
hyperresponsiveness
 Air Pollution
 Gender
 Respiratory Infections
 Obesity  Diet
 Is it Asthma?

 Recurrent episodes of wheezing

 Troublesome cough at night
 Cough or wheeze after exercise
 Cough, wheeze or chest tightness
after exposure to airborne allergens
or pollutants
 Colds “go to the chest” or take more
than 10 days to clear
 Asthma Diagnosis
 History and patterns of symptoms
 Measurements of lung function
- Spirometry
- Peak expiratory flow
 Measurement of airway responsiveness
 Measurements of allergic status to identify
risk factors
 Extra measures may be required to
diagnose asthma in children 5 years and
younger and the elderly
 Clinical Control of Asthma

 No (or minimal)* daytime symptoms

 No limitations of activity
 No nocturnal symptoms
 No (or minimal) need for rescue
medication
 Normal lung function
 No exacerbations
_________
 Levels of Asthma Control
Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than
any week
“reliever” treatment week) twice / week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day

Exacerbation None One or more / year 1 in any week

Asthma Management and Prevention
Program: Five Components

1. Develop Patient/Doctor
Partnership
2. Identify and Reduce
Exposure to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma
Exacerbations
Revised
2006

5. Special Considerations
 Asthma Management and
Prevention Program: Five
Interrelated Components

1. Develop Patient/Doctor
Partnership
2. Identify and Reduce Exposure to
Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma Exacerbations
 Asthma Management and Prevention Program

Goals of Long-term
Management
 Achieve and maintain control of
symptoms
 Maintain normal activity levels,
including exercise
 Maintain pulmonary function as close
to normal levels as possible
 Prevent asthma exacerbations

 Avoid adverse effects from asthma

medications
 Prevent asthma mortality
 Asthma Management and
Prevention Program
.
 Asthma can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and related
symptoms
 Early intervention to stop exposure to the
risk factors that sensitized the airway may
help improve the control of asthma and
reduce medication needs.
 Asthma Management and
Prevention Program

 Although there is no cure for

asthma, appropriate management
that includes a partnership
between the physician and the
patient/family most often results
in the achievement of control
 Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENT

Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than________? No Yes
If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need
to step up your treatment.

HOW TO INCREASE TREATMENT

STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.

Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROL

If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical help.
 Asthma Management and Prevention Program
Factors Involved in Non-Adherence

Medication Usage Non-Medication Factors

 Difficulties associated
with inhalers
 Complicated regimens
 Fears about, or actual
side effects
 Misunderstanding/lack of
information
 Fears about side-effects
 Inappropriate expectations
 Underestimation of severity
 Attitudes toward ill health
 Cultural factors
 Poor communication
 Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors

 Measures to prevent the development of asthma,

and asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
 Asthma exacerbations may be caused by a variety
of risk factors – allergens, viral infections,
pollutants and drugs.
 Reducing exposure to some categories of risk
factors improves the control of asthma and
reduces medications needs.
 Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors

 Reduce exposure to indoor allergens

 Avoid tobacco smoke
 Avoid vehicle emission
 Identify irritants in the workplace
 Explore role of infections on asthma
development, especially in children and
young infants
 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma

The goal of asthma treatment, to

achieve and maintain clinical
control, can be achieved in a
majority of patients with a
pharmacologic intervention strategy
developed in partnership between
the patient/family and the health
care professional
 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma
 Depending on level of asthma control,
the patient is assigned to one of five
treatment steps
 Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
 Levels of Asthma Control

Characteristic Controlled Partly controlled Uncontrolled

(Any present in any week)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than
any week
“reliever” treatment week) twice / week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day

Exacerbation None One or more / year 1 in any week

 Component 4: Asthma Management and Prevention Program

Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Theophylline
 Long-acting oral β2-agonists
 Anti-IgE
 Systemic glucocorticosteroids
 Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (µg) Medium Daily Dose (µg) High Daily Dose (µg)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100- 600-1000 >200-400 >1000 >400

200

Budesonide-Neb 250- >500- >1000

Inhalation Suspension 500 1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500- >1000-2000 >750-1250 >2000 >1250

750
Fluticasone 100-250 100- >250-500 >200-500 >500 >500
200
Mometasone furoate 200-400 100- > 400-800 >200-400 >800-1200 >400
200

Triamcinolone acetonide 400-1000 400- >1000-2000 >800-1200 >2000 >1200

800
 Component 4: Asthma Management and Prevention Program

Reliever Medications

 Rapid-acting inhaled β2-agonists

 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
 REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION

maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control

INCREASE
uncontrolled step up until controlled

exacerbation treat as exacerbation

REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
 Treating to Maintain Asthma
Control

 When control as been achieved,

ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient
 Treating to Maintain Asthma
Control
Stepping down treatment when asthma is controlled

 When controlled on medium- to high-

dose inhaled glucocorticosteroids: 50%
dose reduction at 3 month intervals
(Evidence B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
 Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations

 Exacerbations of asthma are episodes of

progressive increase in shortness of breath,
cough, wheezing, or chest tightness
 Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
 Severe exacerbations are potentially life-
threatening and treatment requires close
supervision
 Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations

Primary therapies for exacerbations:

• Repetitive administration of rapid-acting inhaled
β2-agonist
• Early introduction of systemic
glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function
 Asthma Management and
Prevention Program: Summary

 Asthma can be effectively controlled in most

patients by intervening to suppress and reverse
inflammation as well as treating
bronchoconstriction and related symptoms
 Although there is no cure for asthma,
appropriate management that includes a
partnership between the physician and
the patient/family most often results in
the achievement of control
 Asthma Management and
Prevention Program: Summary

 A stepwise approach to pharmacologic

therapy is recommended. The aim is to
accomplish the goals of therapy with the
least possible medication

 The availability of varying forms of

treatment, cultural preferences, and
differing health care systems need to be
considered
 A. PERSEDIAAN PERALATAN
• Kad pesakit asthma
• Buku pendaftaran pesakit luar
• Peralatan ukur timbang/ tinggi
• Blood Pressure set
• Peak flow meter (adult/ paediatric)
• Pulse oxymeter
• Nebuliser and face mask
• Inhaler placebo - ( untuk tujuan pendidikan kesihatan)
• Ubatan reliever- Salbutamol MDI/ Bricanyl MDI
• Ubatan controller – Budesonide/ Beclomethasone MDI, Budesonide
Turbohaler
• Ubatan bronchodilator – untuk acute case ( Salbutamol, Bricanyl, Combivent,
Atrovent)
• Oxygen supply
• Oral steroids prednisolone, Intravenous Steroids ( hydrocortisone)
• Flow chart untuk management of acute asthma
• Flow chart untuk asthma assessment
• Carta pengkelasan asthma control
• Bahan pendidikan kesihatan asthma
• Written asthma plan
•
Alternate Slides for
Asthma Treatment
 Levels of Asthma Control
Characteristic Controlled Partly Controlled Uncontrolled
(All of the (Any measure
following) present in any
week)
Daytime symptoms None (twice or More than twice/week
less/week)
Limitations of None Any
activities Three or more
features of
Nocturnal None Any partly
symptoms/awakeni controlled
ng asthma
Need for reliever/ None (twice or More than twice/week
less/week) present in any
rescue treatment
week
Lung function (PEF Normal < 80% predicted or
or FEV1) personal best (if known)

Exacerbations None One or more/year* One in any week†

* Any exacerbation should prompt review of maintenance treatment to ensure that it

is adequate.
† By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Asthma Control: Treatment Steps
Children Older than Five Years, Adolescents, Adults
 Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENT

Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than________? No Yes
If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need
to step up your treatment.

HOW TO INCREASE TREATMENT

STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.

Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROL

If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical help.