Severe Persistent Asthma

Created by :
Annisa Rosarizal
Iqbal Teguh Riady
Nanda Fitri Ayu Muningrat
Saleh Nur Azhari

Supervised by :
dr. Hotber ER Pasaribu, M.Si.Med, Sp.A(K)

PEDIATRIC DEPARTMENT
MEDICAL FACULTY UNIVERSITY OF RIAU
 Background
Based on data from the World Health
Organization (WHO) 2002 : 300 million
worldwide
The year 2025 : estimated around 400 million

United States
6 million children <18

Based on RISKESDAS
in Indonesia 2013 : 45%
ASTHMA
Heterogeneous disease with a chronic inflammatory process of the airways
with signs of wheezing, shortness of breath, chest feeling heavy, coughing that
varies in time and intensity accompanied by obstruction of expiratory air flow
due to narrowing of the bronchi that is repetitive and reversible
Etiologi
Food allergens Breathe allergens Other factors
Cow’s milk Dust Emotions
Egg Pollen Irritant
Soy - chemical
industrial
materials
Fish - Drugs
Shellfish - Ozon
Peanuts - Pollutant
Classification
• Intermittent

• Mild Persistent

• Moderate Persistent

• Severe Persistent
Risk factor
• Genetic

• Immunologist

• Infection
Pathophysiology
 Sensitization phase  Allergic phase
Antigen + ig E
Antigen + makrofag ( APC )
Mast cell
Sel T helper
Degranulasi
Proliferation
Histamin
Th 2
Sel goblet Muscle spasm
permeability
Activation ig E mucous secretion
Edema
Mast cell
ASTHMA
Diagnostic for Asthma
Anamnesis, physical examination
Patient’s history (history of
allergies)

wheezing
Distressed
chest
coughing

Breathlessness Wheezing
General
Physical
Vital sign examination

Pulmonary
functional
assessment
Asthma guidelines recommendation based on IDAI
Case Illustration
IDENTITY
Name / MR : AA / 01023169
Gender : Female
Age : 5 years old
Father/ Mother : Syamsur
Religion : Moslem
Ethnic : Melayu
Address : Perdana Sentosa Residence, Kampar
Date of admission : Saturday, Oct 5th 2019
Date of examination : Saturday, Oct 5th 2019
Date of discharge : Wednesday, Oct 9th 2019
Patient status : Alive
Case Report
Appearance
Tone : Normal PRIMARY SURVEY
Interactability : Respond low
Consolability : Irritable
Look : good ye contact Airway Clear
Speech : speak in words

Breathing Spontan, RR : 48x/I, wheezing (+/+)

Work of Breathing Circulating Pulse : 153x/i, cyanosis (-)

Wheezing (+/+) retraction (+)

Disability Composmentis, Temperature : 36.6 ’C.

Exposure Hypothermia prevention

Circulatiaon :
Cyanotic (-) pallor (-)
 Anamnesis
Chief Complain
Breathlessness since 1 hours before admission
 Current Illness
RSUD Arifin Achmad
Patient get nebulization Salbutamol sulphat,
Since 3 day
ipratropium bromide and budesonide 2 times in
The patient had white phlegm cough
range 15 minutes, after that she get
with thick consistency
methylprednisolone injection. 30 minutes later
patient get nebulization salbutamol but there is
no improvement.
Patient get several threatening conditions of
respiratory failure so that patients are taken to
the PICU room.

12 hours before admission

Breathlessness and getting heavier
during the morning, wheezing,
affected by weather and food
especially chocolate.
Patients get nebulization salbutamol and
bromhexine HCL 3 times in range 1-2 hours at
home but there is no improvement.
 History of Past Illness
Had experienced a
complaint like this
before when she’s 1
years old.

Patient complain
breathlessness 1 times in a
month

Patient have allergies of

cold weather and food
like chocolate
 Patient’s History
Family History • Grandpa, grandma and uncle has asthma

• Mother a house wife

Parents History • Father an entrepreneur

• Multigravide at 9 month gravide, never do ANC.

Pregnancy History

• BCG(1x), DPT (1x), Polio (1x), Campak (-), Hep B (-)

Vaccine History • Basic immunization is incomplete, Hep b at 6 months is not given

Growth and • Birth weight 300 gr, length 45 cm,

Development History • Present weight 14,3 kg, height 107 cm

Living Environment • Permanent house, well ventilated, bright, environmental is not good
History source of forest fire at least 1 times in a year and she has 2 cats.
Highlights of Anamnesis
•Breathlessness 1 hours before admission
• 1 hours before admission, the patient had breathlessness, coughing and wheezing
• In the house she already get nebulization 3 times but there is no improvement
• In the emergency room Arifin Achmad hospital she already get 3 times nebulization and
methylprednisolone injection but there is no improvement too and she get several
threatening conditions of respiratory failure so that patients are taken to the
PICU room.

Highlight of Physical Examination

Temperature: 36,6 ºC, RR 48x/min, HR 153x/min
Composmentis, irritable, wheezing (+/+), nasal lobe breathing (-) retractions (+)
Working Diagnosis
› SEVERE PERSISTENT ASTHMA

Prognosis
› Quo ad vitam : Bonam
› Quo ad functionam : Bonam
 Follow up
05/10/2019
• Breathlessness(+), GCS 15
• RR 100x/min, HR 153x/min 06/10/2019
• Nasal canul (+) • Breathlessness (-), GCS 15
• Wheezing (+/+) retraction (-) • Stable vital sign
• Lab : Leukosit : 27,53x103/uL • Wheezing (+/+) 07/10/2019
• Chest xray: normal • Nasal Canul (+) • Breathlessness (-), GCS 15
Treatment: Treatment: • Stable vital sign
• Ivfd Asering • Ivfd Asering • Wheezing (+/+)
• Nasal Canul 1-2 L • Bisolvon (bromhexine) • Nasal Canul (+)
• MgSO4 12cc in NaCl 0,9% 12 syrup 3x1 cth
cc
• Inj. Ceftriaxon 2x30 mg
• Inj. Methyl Prednisolone 3x5
mg
• PCT infuse 150 mg (id
neceseery)
• Nebu ipratropium bromide 4
cc/6 hour
• Inj. Omeprazol 2x10 mg
 Anamnesis
Breathlesness since 1 day before admitted to the hospital, Wheezing in all of lung field, Fever (-), Food allergy (+),
Family history of atopic(+), Vomiting (-), Nausea (-), Diarrhea (-),

Physical examination
PAT : severe disturbed of breathing and risk of respiratory failure
Due to Asthma

Laboratorium finding and chest x ray

Leucositosis , neutrophilia (H), limfositopenia (L), Normal pulmo and cardiac
 Differential diagnosis

Bronchiolitis Bronchiectasis Pneumonia

 PICU Indication
• Sever asthma exacerbation with failure of standart
therapy which is 3 times nebulization, injection of
sistemic corticosteroid, and infusion of aminofilin.

• Risk of respiratory failure

• Observation of side effect that come from

administration MgSO4 intravena
 MgSO4
• Indication of MgSO4:
MgSO4 use for alternating therapy when the
standart thearpy is failure.
THANK YOU