Helmi Lubis, dr, SpAK Ridwan M. Daulay, dr, SpAK Wisman Dalimunthe, dr, SpA Rini S. Daulay, dr, M.Ked(Ped), SpA

 Cough and/or wheezing that : Episodic Nocturnal (variability) Reversibility With atopic family”

3 desquamation of epithelium Mucus plug Basal membrane thickening Netrophil and eosinophil infiltrations Smooth muscle constriction and hypertrophy Oedema Mucosal gland hyperplasia Barnes PJ

4 AsthmaNormal Inflammation picture

 Severity of attacks (Acute)  Mild  Moderate  Severe  Respiratory arrest imminent  Class of disease (Chronic)  Infrequent episodic asthma  Frequent episodic asthma  Persistent asthma 5

6 Asthma : chronic respiratory disease, that can have acute exacerbation Asthma Acute Asthma Chronic Asthma Two Aspects of Asthma

7 Chronic asthma Long term management Algorithm diagnosis & treatment Acute asthma Attackmanagement Algorithm attack management

8 Reliever  To relieve / reduce symptoms and/ attack  As needed use bronchodilators:  2 -agonist, xanthenes, systemic steroid oral, inhalation, injection Controller To control / prevent symptoms and/ attack Long term use Anti inflammations inhaled steroid, ALTR oral, inhalation, For FEA & PA, not for IEA

9 Asthma attack / symptoms present:  First line therapy ▪  2 agonist ▪ Ipratropium bromide Chronic asthma (long term management)  First line therapy ▪ Inhaled steroid ▪ Long-acting  2 agonist (LABA)

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11 Asthma Triggers Attack House dust mite (HDM) Smoke (polution) Food Infection Longterm management failure

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13 Trigger Airway obstruction nonuniform hyperinflation ventilation atelectasis mismatching ofdecreased ventilation and perfution compliance decreased surfaktant alveolar hypoventilation increased work acidosis of breathing pulmonary vasoconstriction Bronchocontriction, Mucosal edema, Excessive secretion  PaCO 2  PaO 2

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% 3.9% 11.7% Mild Moderate Severe Severity of Asthma Attacks

16 Estimation of severity of asthma attacks

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18 Algorithms Asthma Attack Clinic/ ER Rate attack severity First management  2 -agonist nebulization (neb) 3x, 20’ interval 3 rd neb + anticholinergic Moderate attack ( neb 2-3x, partially response) give O 2 reevaluate  moderate  One day care (ODC) IV line Mild attack (neb 1x, good response hold out 1-2 hours, may go home attack reappear  moderate attack Severe attack ( neb 3x, bad/ no response) O 2 since beginning IV line chest X ray reevaluate→severe →hospitalized

19 One Day Care (ODC) O2 continued give oral steroid neb every 2 hrs improve in 8-12 hrs, stable  may go home no improve within 12 hrs, hospitalized Hospital Room O2 continued overcome dehidration and acidosis IV steroid every 6-8 hrs neb every 1-2 hrs IV aminophylline, initial- maintenance improve neb every 4-6hrs stable within 24 hrs, may go home no improvement, impending resp failure - PICU May go home give  2 -agonist (inhalation / oral) patient with controller, continued Viral ARI as trigger steroid oral may given visit outpatient clinic in 24 hours Catatan: severe attack from beginning, directly neb with ipratropium neb can be replaced by adrenalin sc 0.01 ml/kgBw/x, max 0.3ml/x O 2 2-4L/mnt from the start, including during neb

20  Relieve the symptoms quickly and precisely  Reduce hypocxemic  Lung function, back to normal  After attack: reevaluation

21 Asthma attack Nebulization 1-2 x Good responses Discharge Bronchodilator Poor responses ODC Oxygen Nebulization Oral Steroid IVFD Good ResponsesPoor Responses Discharge Wards Oxygen Nebulization IVFD IV/oral Steroid Rehydration Amynophylline

22  Dehidration  Metabolic acidosis  Atelectasis

23  Must be given in severe attack  In severe attack, hypocxemic

 Life threatening asthma  Intubate cause asthma attack  Pneumothorax and/or pneumomediastinum  Long duration asthma attack  Use of systemic steroid (recently)  Visit to Emergency Ward or hospitalized for asthma in one last year  Psychiatry or psychology problem

25  β 2 agonist and ipratropium bromide Vs β 2 agonist alone: better result:  Decreased of hospitalization rate  Decreased of symptoms scoring  Improve lung functions  Drugs duration of action, longer

26  Rehydration  Drink less due to breathing difficulties  vomiting  Acid-base and electrolyte correction  Give parenteral medication

27  Intravenous or oral  Antiinflamation  Controversy: the use of nebulizer

28  Initial, 6-8 mg/kgBW/IV for minutes  Maintenance, 0,5-1 mg/kgBW/hours  Need aminophylline plasma level monitoring  Be careful, narrow margin of safety

29  Adrenaline, there is maximal dose, effect on  and   Salbutamol SC, have to be careful  MgSO4, no signiffican  Steroid inhaler, very high dose (  g)  Antibiotic, not use  Mucolitic, not suggest for severe attack

30  No/ bad response after nebulization  Oxygen  Parenteral, rehidration, acidosis correction  Steroid IV  lnitial Aminophylline IV, then the maintenance  Nebulization  Chest X-ray  Good: May Go Home  No/ bad response: Intensive Care

 Respiratory failure imminent: PaO2 45mmHg  Confuse, disorientation  Poor response of medication at ward  Worsening of vital signs  Decrease respiratory rate  Bradicardia  Mechanical ventilation (ventilator)