Presentasi DR Rina

CURRICULUM VITAE
Nama : dr. Rina Lestari,Sp.P

Tempat Lahir : Mataram
Tanggal lahir : 28 November 1979
Riwayat Pendidikan :
•Dokter Umum: Universitas Brawijaya, tahun 2005
•Spesialis Paru: Universitas Brawijaya, tahun 2013
Riwayat Pekerjaan :
•Dokter PTT Puskesmas Tanjung Lombok Utara, tahun 2005-2006
•Staf Pengajar Fakultas Kedokteran Unram, tahun 2006-sekarang
•Staf KSM Paru RSUD Prov. NTB, tahun 2013-sekarang
1
UPDATE MANAGEMENT OF
dr. Rina Lestari, Sp.P

Department of Pulmonology-Faculty of Medicine-Mataram University
West Nusa Tenggara Province General Hospital
2
OUTLINE
• Background
• Definition of asthma
• Pathogenesis and pathology of asthma
• Diagnosis of asthma
• Management of asthma
• Asthma exacerbations
• Conclusion
3
Background
Asthma is a global health concern
• Up to 334 million people worldwide are estimated to have asthma, but prevalence
varies1,2
Figure source: To T et al. 20122
4
1. Vos T, et al. Lancet. 2012;380:2163–96; 2. To T, et al. BMC Public Health. 2012;12:204
Definition of asthma
Asthma is a heterogeneous disease, usually characterized by

chronic airway inflammation.
It is defined by the history of respiratory symptoms such as

wheeze, shortness of breath, chest tightness and cough that
vary over time and in intensity, together with variable
expiratory airflow limitation.
GINA 2017
5
GINA 2017
Pathogenesis of Asthma
6
Pathology of Asthma
7
Diagnosis of Asthma
Physical
Symptoms Spirometry
examination
8
Diagnosis of asthma – symptoms
• Increased probability that symptoms are due to asthma if:

• > 1 type of symptom (wheeze, shortness of breath, cough, chest tightness)
• Symptoms often worse at night or in the early morning
• Symptoms vary over time and in intensity
• Symptoms are triggered by viral infections, exercise, allergen exposure,
changes in weather, laughter, irritants such as car exhaust fumes, smoke, or
strong smells
9
GINA 2017
Diagnosis of asthma – physical examination
 Physical examination in people with asthma

 Often normal
 The most frequent finding is wheezing on auscultation, especially on forced
expiration
 Wheezing is also found in other conditions, for example:
 Respiratory infections
 COPD
 Endobronchial obstruction
 Inhaled foreign body
 Wheezing may be absent during severe asthma exacerbations (‘silent chest’)
10
GINA 2017 © Global Initiative for Asthma
Diagnosis of asthma – variable airflow limitation
 Confirm presence of airflow limitation

 Document that FEV1/FVC is reduced (Normal: FEV1/ FVC ratio >0.75 – 0.80)
 Confirm variation in lung function is greater than in healthy individuals
 Excessive bronchodilator reversibility (adults: increase in FEV1 >12% predicted and
>200mL)
 Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring
 Significant increase in FEV1 or PEF after 4 weeks of controller treatment
11
Spirometry
Peak Expiratory Flow Rate

Typical spirometric tracings
Volume Flow
Normal
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)
Asthma
(before BD)
1 2 3 4 5 Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
13
GINA assessment of symptom control
A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week? Yes No
• Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
• Reliever needed for symptoms* these these these
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
*Excludes reliever taken before exercise, because many people take this routinely
This classification is the same as the GINA 2010-12

assessment of ‘current control’, except that lung function
now appears only in the assessment of risk factors
14
GINA 2017, Box 2-2A © Global Initiative for Asthma
GINA assessment of symptom control
A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week? Yes No
• Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
• Reliever needed for symptoms* these these these
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes

• Assess risk factors at diagnosis and periodically
• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
• Exacerbations
• Fixed airflow limitation
• Medication side-effects 15
GINA 2016 Box 2-2B (1/4) © Global Initiative for Asthma
Goals of asthma management
 The long-term goals of asthma management are

1. Symptom control: to achieve good control of symptoms and
maintain normal activity levels
2. Risk reduction: to minimize future risk of exacerbations, fixed
airflow limitation and medication side-effects
16
Stepwise approach to control asthma symptoms
and reduce risk UPDATED
2017
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Asthma medications
Side-effects
Non-pharmacological strategies
Patient satisfaction
Treat modifiable risk factors
Lung function
STEP 5
STEP 4
STEP 3 Refer for
PREFERRED STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA tiotropium,*
Low dose anti-IgE,
anti-IL5*
Low dose ICS ICS/LABA**
Other Med/high dose ICS Add tiotropium* Add low dose

Consider low Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS OCS
options (or + theoph*) + LTRA
(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
technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite
ICS treatment, provided FEV1 is >70% predicted
• Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.
17
GINA 2017, Box 3-5 (1/8) © Global Initiative for©Asthma
Global Initiative for Asthma
The control-based asthma management cycle
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
18
GINA 2017, Box 3-2 © Global Initiative for Asthma
ICS +LABA
© Global Initiative for Asthma

Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)
STEP 5
STEP 4
STEP 3 Refer for

PREFERRED STEP 1 STEP 2 add-on
CONTROLLER treatment
CHOICE e.g.
Med/high tiotropium,*
anti-IgE,
ICS/LABA anti-IL5*
Low dose
Other Consider low Med/high dose ICS Add tiotropium* Add low
Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS dose OCS
Low dose theophylline*
(or + theoph*)

*Not for children <12 years

**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations 20
GINA 2017, Box 3-5, Step 1 (4/8) © Global Initiative for Asthma
Step 1 – as-needed reliever inhaler
 Preferred option: as-needed inhaled short-acting beta2-agonist

(SABA)
 SABAs are highly effective for relief of asthma symptoms
 For patients with infrequent symptoms (< 2x/month) of short
duration, and with no risk factors for exacerbations
 Other options
 Consider adding regular low dose inhaled corticosteroid (ICS) for
patients at risk of exacerbations
21

Step 2 – low-dose controller + as-needed
inhaled SABA
STEP 5
STEP 4
STEP 3 Refer for

CHOICE e.g.
anti-IgE,
ICS/LABA anti-IL5*
Low dose
(or + theoph*)


 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
22
Step 2 – Low dose controller + as-needed SABA
 Preferred option: regular low dose ICS with as-needed inhaled

SABA
 Low dose ICS:  symptoms,  risk of exacerbations and  asthma-
related hospitalization and death
 Other options
 Leukotriene receptor antagonists (LTRA) with as-needed SABA
• Less effective than low dose ICS
• May be used for some patients with both asthma and allergic rhinitis, or
if patient will not use ICS
23
Step 3 – one or two controllers + as-needed
inhaled reliever
STEP 5
STEP 4
STEP 3 Refer for

CHOICE e.g.
anti-IgE,
ICS/LABA anti-IL5*
Low dose
(or + theoph*)


GINA 2017, Box 3-5, Step 3 (6/8) © Global Initiative for©Asthma
Step 3 – one or two controllers + as-needed
inhaled reliever
 Before considering step-up

 Check inhaler technique and adherence, confirm diagnosis
 Adults/adolescents: preferred options are either combination low dose
ICS/LABA maintenance with as-needed SABA, OR combination low dose
ICS/formoterol maintenance and reliever regimen*
 Adding LABA reduces symptoms and exacerbations and increases FEV1, while
allowing lower dose of ICS
 In at-risk patients, maintenance and reliever regimen significantly reduces
exacerbations with similar level of symptom control and lower ICS doses
compared with other regimens
 Other options
 Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less
effective than ICS/LABA)
 Adults: consider adding SLIT
UPDATED
2017
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol 25
Step 4 – two or more controllers + as-needed
inhaled reliever
STEP 5
STEP 4
STEP 3 Refer for

CHOICE e.g.
anti-IgE,
ICS/LABA anti-IL5*
Low dose
(or + theoph*)


GINA 2017, Box 3-5, Step 4 (7/8) © Global Initiative for©Asthma
Step 4 – two or more controllers + as-needed
inhaled reliever
 Before considering step-up

 Check inhaler technique and adherence
 Adults or adolescents: preferred option is combination low dose
ICS/formoterol as maintenance and reliever regimen*, OR
combination medium dose ICS/LABA with as-needed SABA
 Other options (adults or adolescents)
 Tiotropium by mist inhaler may be used as add-on therapy for
patients aged ≥12 years with a history of exacerbations UPDATED
2017
 Adults: consider adding SLIT
 Add-on LTRA or low dose theophylline
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol 27
Step 5 – higher level care and/or add-on
treatment UPDATED
2017
STEP 5
STEP 4
STEP 3 Refer for

CHOICE e.g.
anti-IgE,
ICS/LABA anti-IL5*
Low dose
(or + theoph*)


 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
28
Step 5 – higher level care and/or add-on
treatment
 Preferred option is referral for specialist investigation and
consideration of add-on treatment
 If symptoms uncontrolled or exacerbations persist despite Step 4
treatment, check inhaler technique and adherence before referring
 Add-on tiotropium for patients ≥12 years with history of
exacerbations
 Add-on anti-IgE (omalizumab) for patients with severe allergic
asthma
UPDATED
 Add-on anti-IL5 (mepolizumab (SC) or reslizumab (IV)) for severe 2017
eosinophilic asthma (≥12 yrs)
 Other add-on treatment options at Step 5 include:
 Sputum-guided treatment: this is available in specialized centers;
reduces exacerbations and/or corticosteroid dose
 Add-on low dose oral corticosteroids (≤7.5mg/day prednisone
equivalent): this may benefit some patients, but has significant
systemic side-effects. Assess and monitor for osteoporosis
29
Stepwise management – additional components
UPDATED
2017
• Provide guided self-management education

REMEMBER
• Treat modifiable risk factors and comorbidities
TO...
• Advise about non-pharmacological therapies and strategies
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks,
but check diagnosis, inhaler technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who
have exacerbations despite ICS treatment, provided FEV 1 is 70% predicted
• Consider stepping down if … symptoms controlled for 3 months
+ low risk for exacerbations. Ceasing ICS is not advised.
SLIT: sublingual immunotherapy HDM: House Dust Mite
30
GINA 2017, Box 3-5 (3/8) (lower part) © Global Initiative for Asthma
Non-pharmacological interventions
 Avoidance of tobacco smoke exposure

 Provide advice and resources at every visit; advise against exposure of
children to environmental tobacco smoke (house, car)
 Physical activity
 Encouraged because of its general health benefits. Provide advice about
exercise-induced bronchoconstriction
 Occupational asthma
 Ask patients with adult-onset asthma about work history. Remove sensitizers
as soon as possible. Refer for expert advice, if available
 Avoid medications that may worsen asthma
 Always ask about asthma before prescribing NSAIDs or beta-blockers UPDATED
2017
 Remediation of dampness or mold in homes
 Reduces asthma symptoms and medication use in adults
 Sublingual immunotherapy (SLIT)
 Consider as add-on therapy in adult HDM-sensitive patients with allergic rhinitis
who have exacerbations despite ICS treatment, provided FEV1 is 70%
predicted
31
GINA 2017, Box 3-9 © Global Initiative for Asthma
Asthma exacerbations/flare-ups
 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
32
Managing exacerbations in primary care
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
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?
33
GINA 2017, Box 4-3 (1/7) © Global Initiative for Asthma
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
34
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
35
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
36
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
37
START TREATMENT

WORSENING
IMPROVING

PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
38
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?
39
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
40
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

41

42
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
43
CONCLUSION
 Asthma is a heterogeneous disease, usually characterized by chronic airway

inflammation.
 Diagnosis of asma: symptoms, physical examination and spirometry
 The long-term goals of asthma management are symptom control and risk
reduce.
 Asthma exacerbation is an acute or sub-acute worsening of asthma symptoms
and lung function compared with the patient’s usual status
44
© Global Initiative for Asthma
45

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CURRICULUM VITAE

Nama : dr. Rina Lestari,Sp.P

dr. Rina Lestari, Sp.P

Figure source: To T et al. 20122

Asthma is a heterogeneous disease, usually characterized by

It is defined by the history of respiratory symptoms such as

• Increased probability that symptoms are due to asthma if:

 Physical examination in people with asthma

 Confirm presence of airflow limitation

Peak Expiratory Flow Rate

A. Symptom control Level of asthma symptom control

This classification is the same as the GINA 2010-12

A. Symptom control Level of asthma symptom control

B. Risk factors for poor asthma outcomes

 The long-term goals of asthma management are

Other Med/high dose ICS Add tiotropium* Add low dose

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

© Global Initiative for Asthma

STEP 3 Refer for

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

*Not for children <12 years

 Preferred option: as-needed inhaled short-acting beta2-agonist

GINA 2017 © Global Initiative for Asthma

STEP 3 Refer for

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

*Not for children <12 years

 Preferred option: regular low dose ICS with as-needed inhaled

STEP 3 Refer for

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

*Not for children <12 years

 Before considering step-up

STEP 3 Refer for

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

*Not for children <12 years

 Before considering step-up

STEP 3 Refer for

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

*Not for children <12 years

• Provide guided self-management education

SLIT: sublingual immunotherapy HDM: House Dust Mite

 Avoidance of tobacco smoke exposure

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

MILD or MODERATE SEVERE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

MILD or MODERATE SEVERE

MILD or MODERATE SEVERE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

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

MILD or MODERATE SEVERE

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

If continuing deterioration, treat as