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dr. SAK Indriyani, SpA, MKes

Department of Child Health RSU Mataram
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Prevalence increased
Asthma: attack or not attack
Bronchoconstriction changed into chronic
inflammation remodelling
Advance in management

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F Definition of asthma has varied depending on
the purposes
F National consensus: suspected asthma if: cough
and/or wheeze that episodic, nocturnal,
reversible, activity, atopy (+)
F Asthma attacks: Episodes of rapidly
progressive increase in symptomps.

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PATHOGENESIS
1. Immunologic mechanism of respiratory tract

Antigen
Nave T lymphocyte
Th-0
Dendritic cell IL-12 (-)

IL-12 (+) (-)
Th-2 response
IL-4, IL-13 IL-9 IL-3, IL5
Th-1 response IL-4 IL- GM-CSF
(IFN-, IL-2. Lympho.)
IgE Mast cell Basophils Eosinophils

Cell mediated immunity and
Neutrophile inflammation Mediators of inflamations (eg. Histamine,
prostaglandine, leukotrines etc)

Asthma symptoms Bronchial hyperresponsiveness
Airway obstruction
Figure 1. Asthma pathogenesis (PNAA 2004)
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2. Chronic & acute inflammation
Allergen immediate allergy reaction, some of this
followed by delayed reaction

Immediate phase reaction
# Ig E specific (mast cell, macrophage, basophils)
preform mediator & newly form mediator


bronchoconstriction, sensoric nerve stimulation,
mucous hypersecretion, vasodilatation, vascular
breakage

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Delayed phase reaction

# Inflammation mechanism in asthma

# Respiratory tract cell aktivation

cytokines release to circulation

Proinflammatory leucocyte stimulation
(eosinofil & others precursor from bone marrow)

3. Remodelling process
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ENVIRONMENT
Allergens, pollutants, infections, etc


Epithelium
Dendritic cell


(Myo) T cell
Fibroblast

Matrix Cytokines


Blood vessels Nerve Smooth muscle
Macrophage
IgE Mast cell Eosinophile
Basophile
REMODELING
INFLAMATION
Mediators
ASTHMA
Figure 2. Inflammation & remodelling in asthma (PNAA 2004)
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Genetically Predisposed Population

Inducer (I)
Indoors allergens ? Avoidance
Alternaria, etc
Immune response
Th2, IgE, IgG4, IgG1

Enhancer (E)
Rhinovirus Avoidance
Ozone Anti-inflamatories
-2 agonist Immunotherapy
Inflammation
Th2, Mast cell,
Eosinophils
BHR
Triggers
Exercise/Cold air -2 agonist
Histamin/Methacoline
Wheezing

Figure 3. Factors related with asthma (PNAA 2004)

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Upper respiratory tract :
Nose
Sinus
Throat
Lower respiratory tract :
Bronchus
Bronchiolus
Alveolus
Upper & lower respiratory tract is connected

50-80% child with asthma + rhinitis
20% child with rhinitis + asthma
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Trigger
(dust, animal feather, kapok, etc)
Bronchus Bronchus
Still wide
(not susceptible, not sensitive,
stable)
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trigger
(dust, animal feather, kapok, etc)
Bronchus
No attack
attack
Respiratory tract muscle constriction
Edema mucous
Hypersecretion & sticky
Bronchus
Hyperactive:
too susceptible
too sensitive
not stable/easy to constrict
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Inhalant
Chemical
Stress
Activity (exercise)
Drugs
Foods

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Triggers
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Asthma
Triggers
Acute attacks
Inhalant
House dust mite
Smoke
Food
Failed of
long term
management
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Triggers



Airway obstruction


ununiform pulmonary
ventilation hyperinflation

atelectasis mismatch
compliance
ventilation-perfution abnormality

surfactant alv.hypoventilation Resp.rate
acidosis

pulmonary
v.constriction


b.constriction, oedema, secretion
PaCO2
PaO2
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Class. Asthma disease
Clinical parameter,
medication need,
lung function test
Infrequent episodic
asthma
Persistent asthma

Frequent episodic
asthma

Attack frequency < 1x /month often > 1x /month
Attack duration < 1 week
Almost all year
No remission
1 week
Between attack No symptom
Symptom at noon & night
Frequent symptom
Sleep & activity Normal Very disturbing Frequent disturb
Physical exam. If not
in attack condition
Normal Always abnormal Maybe abnormal
Controller No need Need steroid Need steroid
Lung function test
(not attack)
PEF/FEV1 >80%
PEF/FEV1 <60%
Variability 20-30%
PEF/FEV1 60-80%
Variability in
lung function (attack)
>15% < 50% < 30%
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Class. diseases
Severity of attacks
Infrequent episodic asthma
Frequent episodic asthma
Persistent asthma
Mild
Moderate
Severe
Respiratory arrest
imminent
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The classification should be include class. disease
and severity of asthma attacks, example:
Infrequent episodic asthma without asthma attacks
Infrequent episodic asthma with mild asthma attacks
Frequent episodic asthma with severe asthma attacks
Frequent episodic asthma without asthma attacks
Persistent asthma with severe asthma attacks

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Mild Moderate Severe Respiratory
arrest imminent
Breathless Walking
Can lie down
Talking
Infant-softer
Shorter cry
Difficult feeding
Prefers sitting
At rest
Infant stops
feeding
Hunched
forward
Talks in Sentences Phrases Words
Allertness Maybe agitated Usually agitated Usually agitated Drowsy or confused
Respiratory rate Increased Increased Often >30x/min
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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
muscles and
suprasternal
retractions
Usually not Usually Usually Paradoxial
thoraco-
abdominal
movement
Wheeze Moderate, often
only end
expiratory
Loud Usually loud Absence of
wheeze
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
paradoxus
Absent
<10 mmHg
Maybe present
10-25 mmHg
Often present
20-40 mmHg
Absence
suggests
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Pulsus
paradoxus
Absent
<10 mmHg
Maybe present
10-25 mmHg
Often present
20-40 mmHg
Absence
suggests
PEF after initial
bronchodilator
%predicted or
% personal
best
Over 80% Approx. 60-80% <60% predicted or
personal best or
response lasts <2
hrs
PaO2 (on air)

and/or
PaCO2
Normal
Test not usually
necessary
<45 mmHg
>60 mmHg


<45 mmHg
<60 mmHg
possible cyanosis

>45 mmHg
SaO2% >95% 91-95% <90%
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Cost ?
Availability ?
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Minimal (ideally no) chronic symptomps
Minimal (infrequent) exacerbations
No emergency visits
Minimal (ideally no) use of as needed
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-agonist
No limitations on activities (exercise)
(Near) Normal lung function
Minimal (or no) adverse effects from medicine
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Rapid resolution of acute symptoms
To reduce hypoxemia
Normal lung function as soon as possible
Reevaluation to prevent asthma attacks
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At home
At emergency room
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Known of asthma symptoms
Nebulized
2
agonist
If not available: MDI with or without spacer or
orally



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At home
At emergency room
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Asthma attacks algorithms
Emergency room
Assess severity.of attacks
Early treatment
nebulized -agonist 3x, interval 20 min
3
rd
nebulized + anticholinergic

Moderate attacks
(nebulized 2-3x,
partial response)
O2
reassessment mode-
rate ODC
IV line


Mild attacks
(nebulized 1x,
good response)
observe 1-2 jam,
discharge
symptoms (+)
moderate attack

Severe attacks
(nebulized 3x,
poor response)
O2
IV line
reassessment severe,
admission
Chest X-ray

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One Day Care (ODC)
Oxygen therapy
Oral steroid
Nebulized / 2 hour
Observe 8-12 hours,
if stable discharge
Poor response in 12 hrs,
admission
Admission room
Oxygen therapy
Treat dehydration and
acidosis
Steroid IV / 6-8 hours
Nebulized / 1-2 hours
Initial aminophylline IV,
then maintenance
Nebulized 4-6x
good response per 4-6 h
If stable in 24 hours
discharge
Poor response ICU
Discharge
give -agonist
(inhaled/oral)
routine drugs
viral infection:
oral steroid
Outpatient clinic in
24-48 hours
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
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Initial assessment of severity asthma attacks
Nebulized
2
-agonist, interval 20 minute
3
rd
nebulization: anticholinergic agent
Severe attacks: directly with anticholinergic agent
If nebulizer not available:
MDI with Spacer
Adrenalin SC
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Good response post nebulization
Observe: 1-2 hours
Discharge if good response
Treat as moderate attacks if symptoms still remain
Use routine drugs
Out patient clinics
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Management of asthma attacks
Mild
Nebulization
Observe 1-2 hours
DISCHARGE
Moderate
Routine drugs
Outpatient clinic
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Partial response post nebulization
ODC admission
Oxygen therapy
Oral steroid
IV line
Repeated nebulization
Good response: discharge
Poor response: admission
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MANAGEMENT OF ASTHMA ATTACKS
MILD
Nebulization
Observe: 1-2 hours
DISCHARGE
MODERATE

Oxygen
Nebulization
IVFD
Oral steroid
ODC SEVERE
???
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Dehydration
Metabolic acidosis
Atelectasis
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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
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MANAGEMENT OF ASTHMA ATTACKS
MILD
Nebulization
Observe 1-2 hours
DISCHARGE
MODERATE

Oxygen
Nebulization
IVFD
Oral steroid
ODC SEVERE
O
2
, steroid
Nebulization
Hydration
Aminophylline
R
ICU (?)

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Adrenalin: maximal dose, and effects
Salbutamol SC: be careful
MgSO4: not significant
Inhaled steroid : high dose (1600 mg)
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Asthma attacks
Stable asthma
(No attack)
Infrequent
episodic
Frequent
episodic
Persistent
Reliever (+)
Controller (-)
Reliever (+)
Controller (+)
Reliever (+)
Controller (+)
Assess the
severity of attacks
Assess class
of disease
AVOIDANCE
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-agonis (short acting) Steroid anti inflammation
Terbutalin Budesonid
Salbutamol Fluticason
Orsiprenalin Beclometason
Heksoprenalin Non steroid anti inflammation
Fenoterol Chromoglikat
Xantin Nedokromil
Teofilin -agonis (long acting)
Procaterol
Bambuterol
Salmeterol
Klenbuterol
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Low dose steroid
Flix 2 x 50 mcg or Bud/BDP 2 x 100 mcg
Normal dose steroid
Flix 2 x 100 mcg or Bud/BDP 2 x 200 mcg
Increase steroid
(high dose)
Normal Steroid + LABA (long
acting agonist)
Steroid + ALR
(Antileucotriene)
Oral Steroid
Longterm management
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Allergen
avoidance
Immuno
therapy
Pharmaco
therapy
EDUCATION
Asthma management
COSTS


GINA, 2002
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Trigger avoidance: dust house mite
Stay away from pet
Before & during pharmacotherapy

GINA, 2002
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Pharmacotherapy
Reliever :

2
agonis : inhaler, nebulized, oral
Epinefrin : subcutan
Teofilin/aminofilin : oral, I.V.
Anticholinergic(ipratropium br) : inhaler
Steroid : oral, I.M.
Controller :
Steroid : inhaler
LABA : inhaler, oral
Antileukotrien : oral

PNAA, 2002
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About asthma
Compliance
Practical guideline in home
Patient-family-doctor relationship

GINA,2002
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Known as desensitization
Still controversial
Multifactorial trigger


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Asthma prevalence in childhood:
Classification of asthma: infrequent episodic
asthma, frequent episodic asthma, persistent
asthma
Acute asthma attacks: mild, moderate, severe
attack
Asthma management in childhood: controversial
In Indonesia: National Consensus for asthma
management in childhood
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