Penatalaksanaan Asma Eksaserbasi: Management Astma Exacerbations

PENATALAKSANAAN ASMA
EKSASERBASI
Management Astma Exacerbations
Uun Unaedi
RSUD 45 KUNINGAN
PIT IDI Kuningan 2018
Fact 1: WHO estimates that about 235 million people currently suffer from asthma
338 000 deaths were reported in 2015 and most deaths occur in older adults.
© Global
WHO/T. Initiative
Pietrasik for Asthma
Fact 2: Asthma deaths will increase in the next 10 years if urgent action is not
taken
Asthma cannot be cured, but proper diagnosis, treatment and patient education can
result in good asthma control and management.
© Global
WHO/T. Initiative
d. Roriguez for Asthma
Fact 3: Asthma occurs in all countries regardless of level of development
Over 80% of asthma deaths occur in low and lower-middle income countries.
For effective control, it is essential to make good-quality medications affordable
and available, especially for low-income families.
© Global
WHO Initiative for Asthma
Fact 4: Asthma is one of the major noncommunicable diseases
Asthma is a chronic disease characterized by recurrent attacks of breathlessness
and wheezing, which vary in severity and frequency from person to person.
Asthma can also present with chest tightness and cough.
© Global
WHO/ Initiative
I Brown for Asthma
Fact 5: Symptoms may occur several times in a day or week
For some people the symptoms become worse during physical activity or at night.
Failure to recognize and avoid triggers that lead to a tightened airway can be life
threatening and may result in an asthma attack, respiratory distress and even
death.
© Global
WHO/ Initiative
T. Pietrasik for Asthma
Fact 6: Failure to adhere to appropriate treatment can lead to death
Through appropriate treatment such as using inhaled corticosteroids to ease
bronchial inflammation, the number of asthma exacerbation and asthma-related
deaths can be reduced.
© Global
WHO/ Initiative
M. kokic for Asthma
Fact 7: Asthma is the most common chronic disease among children
It can be controlled through different prevention and treatment plans according
to individual symptoms, leading to increased quality of life.
© Global
WHO/ Initiative
M. kokic for Asthma
Fact 8: The fundamental causes of asthma are not completely understood
The strongest risk factors for developing asthma are exposure to indoor allergens
such as house dust mites in bedding, carpets and stuffed furniture; pollution and
pet dander; outdoor allergens such as pollens and moulds; tobacco smoke and
chemical irritants in the workplace.
© Global
WHO/ Initiative
D. Rodriguez for Asthma
Fact 8: The fundamental causes of asthma are not completely understood
The strongest risk factors for developing asthma are exposure to indoor allergens
such as house dust mites in bedding, carpets and stuffed furniture; pollution and
pet dander; outdoor allergens such as pollens and moulds; tobacco smoke and
chemical irritants in the workplace.
© Global
WHO/ Initiative
D. Rodriguez for Asthma
Fact 9: Avoiding asthma triggers can reduce the severity of asthma
Asthma triggers can include cold air, extreme emotional arousal such as anger or
fear, and physical exercise.
© Global
WHO/ Initiative
S. Volkov for Asthma
Fact 10: Asthma is often under-diagnosed and under-treated
Asthma creates a substantial burden to individuals and families and possibly
restricts individuals' activities for a lifetime.
© Global
WHO/ Initiative
T. Pietrasik for Asthma
Fakta asma
Asma merupakan penyakit yang tidak bisa disembuhkan tetapi bisa dikontrol
Asma adalah penyakit kronik yang bisa mengalami fase akut
• Asma kronik  terapi maintenance jangka panjang
• Asma akut  terapi asma eksaserbasi
© Global
PIT Initiative
IDI Uun2018 for Asthma
Fakta asma
© Global
PIT Initiative
Fakta asma
© Global
PIT Initiative
Definition and terminology
 A flare-up or exacerbation is an acute or sub-acute

worsening
of symptoms and lung function compared with the
patient’s usual status
 Terminology
 ‘Flare-up’ is the preferred term for discussion
with patients
 ‘Exacerbation’ is a difficult term for patients
 ‘Attack’ has highly variable meanings for
patients and clinicians
 ‘Episode’ does not convey clinical urgency
GINA 2018 © Global Initiative for Asthma
Identify patients at risk of asthma-related death
 Patients at increased risk of asthma-related death should be

identified
 Any history of near-fatal asthma requiring intubation and ventilation
 Hospitalization or emergency care for asthma in last 12 months
 Not currently using ICS, or poor adherence with ICS
 Currently using or recently stopped using OCS
• (indicating the severity of recent events)
 Over-use of SABAs, especially if more than 1 canister/month
 Lack of a written asthma action plan
 History of psychiatric disease or psychosocial problems
 Confirmed food allergy in a patient with asthma
GINA 2018, Box 4-1 © Global Initiative for Asthma

Managing exacerbations in primary care
PRIMARY CARE Patient presents with 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
LIFE-THREATENING
Talks in words, sits hunched
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
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled
SABA and ipratropium bromide,
Controlled oxygen (if available): target O2, 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
best or predicted technique, 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 (1/7) © Global Initiative for Asthma

PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid

PRIMARY CARE Patient presents with asthma exacerbation
Is it asthma?

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
TRANSFER TO ACUTE
CARE FACILITY
and ipratropium bromide, O2,
systemic corticosteroid

Gejala dan Berat Serangan Akut Keadaan
Tanda Ringan Sedang Berat Mengancam jiwa
Sesak napas Berjalan Berbicara Istirahat
Posisi Dapat tidur Duduk Duduk
terlentang membungkuk
Cara berbicara Satu kalimat Beberapa kata Kata demi kata

Kesadaran Mungkin gelisah Gelisah Gelisah Mengantuk, gelisah,
kesadaran
menurun
Frekuensi napas <20/ menit 20-30/ menit > 30/menit

Nadi < 100 100 –120 > 120 Bradikardia
Pulsus paradoksus - + / - 10 – 20 + -
10 mmHg mmHg > 25 mmHg Kelelahan otot
Otot Bantu Napas dan - + + Torakoabdominal

retraksi suprasternal paradoksal
Mengi Akhir ekspirasi Akhir ekspirasi Inspirasi dan Silent Chest

paksa ekspirasi
APE > 80% 60 – 80% < 60%

PaO2 > 80 mHg 80-60 mmHg < 60 mmHg
PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg
SaO2 > 95% 91 – 95% < 90%
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
START TREATMENT
TRANSFER TO ACUTE
SABA 4–10 puffs by pMDI + spacer,
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

START TREATMENT
Prednisolone: adults 1 mg/kg, max. WORSENING

WORSENING
IMPROVING
ASSESS FOR DISCHARGE

Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air

START TREATMENT

WORSENING
IMPROVING

PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence

START TREATMENT

WORSENING
IMPROVING

PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
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?

Managing exacerbations in acute care settings
INITIAL ASSESSMENT Are any of the following present?

A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
Talks in phrases Talks in words

Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best
Short-acting beta2-agonists Short-acting beta2-agonists

Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as

severe and re-aassess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently

INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation




If continuing deterioration, treat as

severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF <60% of predicted or

FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

Follow-up after an exacerbation
 Follow up all patients regularly after an exacerbation, until

symptoms and lung function return to normal
 Patients are at increased risk during recovery from an exacerbation
 The opportunity
 Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma
management
 At follow-up visit(s), check:
 The patient’s understanding of the cause of the flare-up
 Modifiable risk factors, e.g. smoking
 Adherence with medications, and understanding of their purpose
 Inhaler technique skills
 Written asthma action plan
GINA 2017, Box 4-5 © Global Initiative for Asthma

TERIMA KASIH
© Global
PIT Initiative
IDI Kuningan for Asthma
/ Uun2018
Berdasarkan data diatas apakah diagnosis
dan tatalaksana pasien tersersebut ?
a. Asma serangan ringan
b. Asma serangan sedang
c. Asma serangan berat
d. Asma mengancam jiwa
e. Asma stabil
© Global Initiative for Asthma

Gejala dan Berat Serangan Akut Keadaan
Tanda Ringan Sedang Berat Mengancam jiwa
Sesak napas Berjalan Berbicara Istirahat
Posisi Dapat tidur Duduk Duduk
terlentang membungkuk
Cara berbicara Satu kalimat Beberapa kata Kata demi kata
Kesadaran Mungkin gelisah Gelisah Gelisah Mengantuk, gelisah,
kesadaran
menurun
Frekuensi napas <20/ menit 20-30/ menit > 30/menit
Nadi < 100 100 –120 > 120 Bradikardia
Pulsus paradoksus - + / - 10 – 20 + -
10 mmHg mmHg > 25 mmHg Kelelahan otot
Otot Bantu Napas dan - + + Torakoabdominal
retraksi paradoksal
suprasternal
Mengi Akhir ekspirasi Akhir ekspirasi Inspirasi dan Silent Chest
paksa ekspirasi
APE > 80% 60 – 80% < 60%
PaO2 > 80 mHg 80-60 mmHg < 60 mmHg
PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg
SaO2 > 95% 91 – 95% < 90%
Berdasarkan hal tersebut, maka diagnosis serangan
akut yang dialami pasien adalah?
a. Asma serangan ringan
b. Asma serangan sedang
c. Asma serangan berat
d. Asma mengancam jiwa
e. Asma stabil
© Global Initiative for Asthma

TERIMA KASIH
© Global
PIT Initiative
/ Uun2018
Written asthma action plans
 All patients should have a written asthma action plan

 The aim is to show the patient how to recognize and respond to
worsening asthma
 It should be individualized for the patient’s medications, level of
asthma control and health literacy
 Based on symptoms and/or PEF (children: only symptoms)
 The action plan should include:
 The patient’s usual asthma medications
 When/how to increase reliever and controller or start OCS
 How to access medical care if symptoms fail to respond
 Why?
 When combined with self-monitoring and regular medical review,
action plans are highly effective in reducing asthma mortality and
morbidity

Written asthma action plans
Effective asthma self-management education requires:
• Self-monitoring of symptoms and/or lung function If PEF or FEV1

<60% best, or not
• Written asthma action plan improving after
• Regular medical review 48 hours
All patients Continue reliever
Increase reliever Continue controller
Early increase in Add prednisolone

controller as below 40–50 mg/day
Review response Contact doctor
EARLY OR MILD LATE OR SEVERE

Written asthma action plans – medication options
 Increase inhaled reliever

 Increase frequency as needed
 Adding spacer for pMDI may be helpful
 Early and rapid increase in inhaled controller
 Up to maximum ICS of 2000mcg BDP/day or equivalent
 Options depend on usual controller medication and type of LABA
 See GINA 2017 report Box 4-2 for details
 Add oral corticosteroids if needed
 Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days
 Children: 1-2mg/kg/day up to 40mg, usually 3-5 days
 Morning dosing preferred to reduce side-effects UPDATED
2017
 Tapering not needed if taken for less than 2 weeks
 Remember to advise patients about common side-effects (sleep
disturbance, increased appetite, reflux, mood changes)

Rationale for change in recommendation about
controller therapy in asthma action plans
For the last 10 years, most guidelines recommended treating
worsening asthma with SABA alone until OCS were needed, but ...
 Most exacerbations are characterised by increased inflammation
 Most evidence for self-management involved doubling ICS dose
 Outcomes were consistently better if the action plan prescribed both
increased ICS, and OCS
 Lack of generalisability of placebo-controlled RCTs of doubling ICS
 Participants were required to be highly adherent
 Study inhalers were not started, on average, until symptoms and airflow
limitation had been worsening for 4-5 days.
 Severe exacerbations are reduced by short-term treatment with
 Quadrupled dose of ICS
 Quadrupled dose of budesonide/formoterol
 Early small increase in ICS/formoterol (maintenance & reliever regimen)
 Adherence by community patients is poor
 Patients commonly take only 25-35% of prescribed controller dose
 Patients often delay seeking care for fear of being given OCS
TERIMA KASIH
© Global
PIT Initiative
/ Uun2018

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PENATALAKSANAAN ASMA

 A flare-up or exacerbation is an acute or sub-acute

 Patients at increased risk of asthma-related death should be

GINA 2018, Box 4-1 © Global Initiative for Asthma

MILD or MODERATE SEVERE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2017, Box 4-3 (1/7) © Global Initiative for Asthma

GINA 2017, Box 4-3 (2/7) © Global Initiative for Asthma

MILD or MODERATE SEVERE

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

Cara berbicara Satu kalimat Beberapa kata Kata demi kata

Frekuensi napas <20/ menit 20-30/ menit > 30/menit

Otot Bantu Napas dan - + + Torakoabdominal

Mengi Akhir ekspirasi Akhir ekspirasi Inspirasi dan Silent Chest

APE > 80% 60 – 80% < 60%

MILD or MODERATE SEVERE

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

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE

GINA 2017, Box 4-3 (5/7) © Global Initiative for Asthma

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2017, Box 4-3 (6/7) © Global Initiative for Asthma

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

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

INITIAL ASSESSMENT Are any of the following present?

MILD or MODERATE SEVERE

Talks in phrases Talks in words

Short-acting beta2-agonists Short-acting beta2-agonists

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

GINA 2017, Box 4-4 (1/4) © Global Initiative for Asthma

MILD or MODERATE SEVERE

GINA 2017, Box 4-4 (2/4) © Global Initiative for Asthma

Short-acting beta2-agonists Short-acting beta2-agonists

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

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF <60% of predicted or

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

 Follow up all patients regularly after an exacerbation, until

GINA 2017, Box 4-5 © Global Initiative for Asthma

© Global Initiative for Asthma

© Global Initiative for Asthma

 All patients should have a written asthma action plan

GINA 2017 © Global Initiative for Asthma

Effective asthma self-management education requires:

• Self-monitoring of symptoms and/or lung function If PEF or FEV1

Increase reliever Continue controller

Early increase in Add prednisolone

Review response Contact doctor

EARLY OR MILD LATE OR SEVERE

GINA 2017, Box 4-2 (1/2) © Global Initiative for Asthma

 Increase inhaled reliever

GINA 2017, Box 4-2 (2/2) © Global Initiative for Asthma

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