2021

“Uncovering Asthma Misconceptions”

World Asthma Day (WAD) is held each May

to raise awareness of asthma world wide
DIFFICULT TO
TREAT ASTHMA IN
CHILDREN
Heda Melinda Nataprawira
OUTLINE
• The situation globally and Indonesia (prevalence)
• Definition of asthma in children (GINA 2020, NHLBI, ERS Task Force 2021 for the
diagnosis of asthma in children aged 5 to 16 years)
• Asthma diagnosis
• Misdiagnosis (under-diagnosis and over-diagnosis) (the prevalence and its
consequenses)
• Management of asthma & its challenges
• Problems & challenges of asthma management in Indonesia

No conflict of interest
 35 countries→ the
first World Asthma
Meeting on 1998

Myths and
1st World
Asthma
misconceptions
Day
concerning
asthma
Annually World Asthma
Day on May, 5th

Global Initiative for Asthma (GINA) guidelines, “World Asthma Day 2021”, 2020, available at https://ginasthma.org/wad/
 MYTHS VS TRUTHS

Asthma is a childhood Asthma can occur

disease; individuals will at any age
“grow out” of it as they age
increased
Asthma is not infectious
Asthma is infectious

When asthma is well controlled,

Asthma sufferers asthma subjects are able to exercise
should not exercise and even perform top sport

Asthma is only Asthma is most often

controllable with high controllable with low dose
dose inhaled steroids inhaled steroids
Global Initiative for Asthma (GINA) guidelines, “World Asthma Day 2021”, 2020, available at https://ginasthma.org/wad/
PREVALENCE
20-70% asthma in the community-->undiagnosed & untreated

European Union (EU): 10%

Prevalence Prevalence
in adults in 6-7 y
0.2 – 21% 2.8 – 37.6%
RISKESDAS, 2013
Indonesian children aged 0-14 yrs →
9.2%

S. D. Aaron et al. Underdiagnosis and over-diagnosis of asthma. Am J Respir Crit Care Med. 2018;198(8): 1-9..
Ikatan Dokter Anak Indonesia. Pedoman Nasional Asma Anak; 2016.
 DEFINITION OF ASTHMA
GINA 2020
A 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
www.ginaasthma.org; 2020
NHLBI ERS TASK FORCE-2021
Asthma is not one disease Asthma definition is complex
• A disease that includes the symptoms of
wheeze, cough and breathing difficulty
Asthma is a syndrome together with reversible airways obstruction,
airway inflammation and bronchial
composed of multiple hyperresponsiveness.
phenotypes • Asthma is a heterogenous and variable
condition and frequently not all the above
are present in each individual patient at the
same time
Asthma is more complex than
indicated
NEED OBJECTIVE TOOLS
Heda Melinda
GUIDELINES FOR DIAGNOSING & TREATING ASTHMA
IN CHILDREN

European Respiratory Society (ERS)

Practice Guidelines for the Diagnosis of
Asthma in Children Aged 5 to 16 Years

Heda Melinda
 Gangguan inflamasi
kronis saluran

Asthma Asthma
Definition respiratorik yang
diperankan oleh sel dan
elemen sel
Penyakit heterogen dengan kronis
Gangguan inflamasi karakteristik
pada saluran
gangguan inflamasi kronik saluran respiratori
respiratori
Hiperreaktivitas Episode saluran wheezing

respiratori
Hiperreaktivitas saluran
respiratorik
berulang, sesak napas,
rasa dada tertekan, dan
batuk, terutama pada
Airflow limitation malam hari atau dini hari

Gangguan
Airflow limitation pernafasan
Bronkokonstriksi akut
Penebalan dinding saluran respiratori
Penumpukan sekret
GINA 1993
Perubahan struktur dinding saluran GINA 2002
GINA 2014

respiratori GINA 2016

 Clinical Manifestations confirmed variable expiratory
airflow limitation

>1 Respiratory tract FEV1 is low (<80% predictive

Fluctuative value)
Cough symptoms obstruction
FEV1/ FVC ≤ 90%
Wheezing
Reversibility test Increase of FEV1 >12%
Dyspnea
Chest tightness
Worsen at Trigger Variability test Daily PEFR difference >13%
night factors
Provocation test Decrease of FEV1 >20% or
PEFR >15%
• Broad differential diagnosis
• Examination almost entirely normal
• No agreed gold standard J. Kavanagh et al. Over- and under- diagnosis in asthma, Breath,. 2020;15,:1-8.
• No objectives test available in
primary physician or hospital settings
Ikatan Dokter Anak Indonesia,.Pedoman Nasional Asma Anak; 2016.
 Classification of Asthma in Children
Asthma Exacerbation

Mild-moderate
Level of Asthma Control
Severe
Degree of Asthma
Severity
Life-threatening Controlled

Intermittent
• Wide range of asthma Partially controlled
patients
Mild Persistent
Not Controlled
• Baseline Severity Classification
Moderate Persistent
during the ED visit may not as
important as ACUTE
Severe Persistent
SYMPTOMS MANAGEMENT and
RETURN VISIT PREVENTION
Global Initiative for Asthma (GINA) guidelines: Global strategy for asthma management and prevention. Available from: https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-
report_20_06_04-1-wms.pdf. 2020.
Screen Shot 2021-02-28 at 17.08.24Screen Shot 2021

Results
Study done before launching the Mexican
Asthma Guidelines (GUIMA) → detected
knowledge—gaps related to asthma
treatment
Spirometry is not routinely indicated
when asthma is very probable
 Scottish
Intercollegiate
Guidelines Network
(SIGN) British
Thoracic Society

British Guideline on
the Management of
Asthma, 2019

British Thoracic Society. British Guideline on the Management of Asthma; 2019.

 High Probability of Asthma :
1) Recurrent episode of symptoms/attacks
2) Symptoms of wheeze, cough,
breathless and chest tightness vary
over time
3) Recorded of wheeze heard by
healthcare professional
4) Personal/family history of atopic
5) No other alternatives diagnoses

Intermediate Probability of Asthma :

Typical features are doubtful

Low Probability of Asthma :

1) Do not have any of the typical features, or
2) Have symptoms suggestive of an alternative
diagnosis

BTS. British Guideline on the Management of Asthma; 2019.

 ASTHMA DIAGNOSIS
ALGORYTHM
(GINA 2020)

Global Initiative for Asthma (GINA) Guidelines. .Global Strategy for Asthma Management and
Prevention; 2020.
Diagnosis Criteria for Asthma in Adults, Adolescents, and
Children 6-11 Years
• Wheeze
Respiratory • Shortness of breath
symptoms • Chest tightness
• Cough

• Generally, more than 1 type of respiratory symptom

• Symptoms occur variably over time and vary in intensity
History • Symptoms are often worse at night or on waking
• Symptom are triggered by exercise, laughter, allergens, cold air
• Symptom often appear or worsen with viral infections

Physical • Often normal

examination • Most frequent abnormality → expiratory wheezing on auscultation

Global Initiative for Asthma (GINA) Guidelines. Global strategy for Asthma Management and Prevention; 2020.
 Diagnosis Criteria for Asthma in Adults, Adolescents, and
Children 6-11 Years

Confirmed variable expiratory

SPIROMETRY or PEAK FLOWMETER (PEF)
airflow limitation

Positive bronchodilator (BD)

Increase in FEV1 of >12% predicted after 200-400 mcg
reversibility test
salbutamol or equivalent

Excessive variation in twice daily PEF

over 2 weeks Average daily diurnal PEF variability >13%

Positive bronchial challenge test Fall in FEV1 >12% predicted, or PEF >15%

Excessive variation in lung function Variation in FEV1 of >12% in FEV1 or >15% in PEF between
between visits visits
www.ginaasthma;2020.
 Diagnosis Criteria for Asthma in Adults, Adolescents, and
Children 6-11 Years

Other tests
Fall in FEV1 from baseline of >20% with standard doses of
Bronchial Provocation test methacholine or histamine, or ≥15% with standardized
hyperventilation, hypertonic saline or mannitol challenge

Allergy test Skin prick test & serum specific IgE

Fractional concentration of
exhaled nitric oxide (FeNO)

Global Initiative for Asthma (GINA) Guidelines. Global strategy for Asthma Management and Prevention; 2020.
 Spirometry FeNO Skin Prick Test

FEV1 (≤-0.7 z-score) ≥ 20 ppb ≥ 1 positive test:

Sensitivity: 43% (CI: 38-49%) Sensitivity: 53% (CI: 46-57%) Sensitivity: 76% (CI: 71-81%)
Specificity: 80% (CI: 73-86%) Specificity: 77% (CI: 69-84%) Specificity: 59% (CI: 50-67%)

FEV1/FVC < 80% ≥ 21 ppb ≥ 2 positive test:

Sensitivity: 36% (CI: 31-41%) Sensitivity: 50% (CI: 45-56%) Sensitivity: 58% (CI: 53-64%)
Specificity: 90% (CI: 83-94%) Specificity: 80% (CI: 72-86%) Specificity: 73% (CI: 64-81%)

FEV1/FVC < 84% ≥ 23 ppb

Sensitivity: 52% (CI: 46-57%) Sensitivity: 48% (CI: 42-53%) • Normal spirometry in an asymptomatic
Specificity: 77% (Cl: 69-84%) Specificity: 87% (Cl: 80-92%) patient does not rule out the diagnosis of
asthma.
FEV1/FVC < 90% ≥ 25 ppb • Obstructive spirometry with positive
Sensitivity: 73% (Cl: 68-71%) Sensitivity: 46% (CI: 40-52%) bronchodilator reversibility increases the
Specificity: 41% (Cl: 33-50%) Specificity: 88% (CI: 81-93%) probability asthma

FEF 50 (≤-0.3 z-score) BTS & NHS. SIGN 158 British Guideline on the Management of
Sensitivity: 58% (CI: 52-64%) Asthma; 2019.

Specificity: 75% (CI: 66-82%)

de Jong CC et al. Diagnosis of asthma in children: findings from the Swiss Paediatric Airway Cohort. Eur Respir J. 2020;1:56(5).
 Sensitivity Spesificity

Personal history of rhinitis/ 47-62% 20-75%

Family history of atopy Do not

43-44% 57-70%

Variability of
Obstructive spirometry in children (5-18 yrs)
necessarily
52% 73%
sensitivity and exclude asthma
spesificity
Bronchodilator reversibility even if
50%they are86%

Exercise challenge
normal
69–72% 90–99%

Asthma is difficult to50%

PEF charting - using variation >12.3% (95th centile) 72%

FeNO diagnose and treat 57% 87%

Blood eosinophils 55–62% 67–84%

SPT any positive test (wheal ≥3 mm) 44–79% 56–92%

BTS. British Guideline on the Management of Asthma; 2019 .1-214. Heda Melinda
J. Kavanagh et al. Over- and under- diganosis in asthma. Breath. 2020;15:1-8.
 FENO in Diagnosis of Asthma

indicator of type 2
bronchial or
eosinophilic Systematic
Aged 5 years and older for whom the
inflammation in reviews between
diagnosis of asthma is uncertain using
the airway October 2017 and
history, clinical findings, clinical course,
March 2018
and spirometry, including bronchodilator
responsiveness testing, or in whom
FeNO in diagnosis of spirometry cannot be performed----
asthma Recommendation the Expert Panel
conditionally the addition of FeNO
measurement as an adjunct to the
evaluation process.
Measured
in exhaled
breath

NAEPPCC Expert Panel Working Group, “Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group”, J
• Typical features of asthma • Respiratory symptoms • Clinical manifestation of
• Spirometry and • History asthma
ASTHMA DIAGNOSIS
• Physical examination • Spirometry, including
bronchodilator
reversibility test SHOULD NOT
• Spirometry BE BASED
/ PEF bronchodilator
• FeNO is much less •ON
FENOCLINICAL ONLY
is not routine responsiveness testing
emphatically • FeNO is recommended
recommended test in asthma when the
diagnosis is still doubtful

BTS SIGN GINA NHLBI

2019 2020 2020
Physical examination:
wheeze (+):
(sensitivity: 75-68%; specificity 64-73%)
Frequent wheeze and awakening due to dyspnoea :
(sensitivity: 84-90%; specificity 33-54%)
BTS. British Guideline on the Management of Asthma; 2019 .
 How About Asthma Diagnosis in Children ≤ 5 Years?

FEW HAVE ASTHMA SOME HAVE ASTHMA MOST HAVE ASTHMA

• Symptoms (cough, wheeze, • Symptoms (cough, wheeze, • Symptoms (cough, wheeze,
heavy breathing) for ≤10 heavy breathing) for >10 days heavy breathing) for >10 days
days during upper during upper respiratory tract during upper respiratory tract
respiratory tract infections infections infections
•
•
2-3 episodes per year
No symptoms between
• MORE DIFFICULT
>3 episodes per year,or • >3 episodes per year,or
severe episodes and/or night severe episodes and/or night
episodes worsening worsening
• Between episodes child may • Between episodes child has
have occasional cough, wheeze, cough, wheeze, or heavy
or heavy breathing breathing during play or when
laughing
• Allergic sensitization, atopic
dermatitis, food allergy, of
family history of asthma

Global Initiative for Asthma (GINA) guidelines: Global strategy for asthma management and prevention. Available from: https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf. 2020.
MISDIAGNOSED ASTHMA: UNDER-DIAGNOSED AND
OVER-DIAGNOSED

20-70% people
with asthma in
community remain
undiagnosed and
untreated

30-35% adults and

children diagnosed
with asthma do not
have current
asthma

S. D. Aaron, L. P et al. Underdiagnosis and overdiagnosis of asthma, Am J Resp Crit Care Med,2018;198(8): 1-9.
 WHY ?
UNDER-DIAGNOSED OVER-DIAGNOSED
Patient has not communicated his/her Patient’s respiratory symptoms are mistakenly attributed
symptoms to asthma

Low socioeconomic status Patient has experienced a sustained clinical remission of

asthma
Think the patient’s respiratory symptoms
isn’t asthma Failure to use objective tests of lung function at time of
diagnosis

Poor diagnostic sensitivity of spirometry

Obesitas

S. D. Aaron, et al. Underdiagnosis and over-diagnosis of Asthma. Am J Respir Criti Care Med. 2018;198(8):1-9.
 PREVALENCE OF OVER-DIAGNOSIS

Denmark 37%

Canada 41 % Netherland up to 50 %

UK 20%

INDONESIA ?
Analyzing National Health Insurance (NHI) Claims Data
(2010-2014)
OVERDIAGNOSIS OF ASTHMA IN KOREAN CHILDREN Few patients underwent spirometry or allergy
MAKE UNECESSARY MEDICATION PRESCRIPTION AND test to TO CONFIRM THE DIAGNOSIS OF
INCREASE COST ASTHMA

OVERDIAGNOSIS OF ASTHMA IN KOREAN

CHILDREN

Outpatient prescription
Leukotrien Receptor Antagonist >>>> than ICS
Children >6 year: ICS prescribed <15% asthma
 CONSEQUENCES OF OVER-DIAGNOSED IN ASTHMA

Prescription of inappropriate
Failure to confirm variable treatment
airflow limitation at the time
of diagnosis
or
Unessesary medicinal side effects
when sustained clinical
remission of disease goes
unrecognized Increases healthcare cost
(unecessary step-up therapy →
>> cost)

OVERDIAGNOSIS Missing the real diagnosis with

persisten on-going morbidity

J. Kavanagh et al. Over- and under- diagnosis in asthma. Breath. 2020;15,:1-8.

S. D. Aaron et al. Underdiagnosis and overdiagnosis of asthma. Am J Respir Crit Care Med, 2018; 198(8):1-9.
 61 children with severe uncontrolled
asthma
re-evaluation re-evaluation of
re-evaluation of the level of the factors
of the asthma associated with a
diagnosis control lack of control

16% patient
didn’t really
have asthma

OVERDIAGNOSIS OF ASTHMA IN
BRAZIL CHILDREN

Andrade WCC et al. Phenotypes of severe asthma among children and adolescents in Brazil: a prospective study. BMC Pulm Med.
2015;15(36), 1-10.
 SOLUTION
Routine use of objective testing before
starting asthma treatment

Confirming asthma diagnosis in patients

OVER- already on controller treatment
DIAGNOSED
Increase access to objective test in primary
care
J. Kavanagh et al. Over- and under- diganosis in asthma. Breath. 2020;15,:1-8.
S. D. Aaron et al. Underdiagnosis and overdiagnosis of asthma. Am J Respir Crit Care Med. 2018;198(8):1-9.
PREVALENCE OF UNDER-DIAGNOSIS
495 Danish school-age children (12-15
y), 71 (14.3%) asthma (airflow limitation,
bronchial hyperresponsiveness or
Denmark 37% ↑variability PF) and 26 (37%)
undiagnosed
Netherland 62%

UK 33% Georgia 65%

INDONESIA ?
 CONSEQUENCES OF UNDER-DIAGNOSED IN ASTHMA
Low quality of life

Required for OCS and Ongoing symptoms

hospitalisation
Potentially for severe
asthma exacerbations

Underreporting of Failure to prescribe

UNDER-DIAGNOSIS appropriate therapies
respiratory symptoms by
patients to physicians
Long-term airway
remodelling
Decline lung function

J. Kavanagh et al. Over- and Under- diagnosis in Asthma, Breath. 2020;15:1-8.

S. D. Aaron et al. Gershon. Underdiagnosis and overdiagnosis of asthma”, Am J Resp Criti Care Med. 2018; 198(8): 1-9,.
 SOLUTION

Increased patient reporting of

respiratory symptoms and case finding
of undiagnosed patients

UNDER- Increased use of lung function testing to

DIAGNOSED confirm a diagnosis of asthma

Screening patients with respiratory

symptoms

J. Kavanagh et al. Over- and under- diaganosis in asthma, Breath. 2020;15:1-8.

S. D. Aaron et al. Underdiagnosis and overdiagnosis of asthma. Am J Respir Crit Care Med. 2018; 198(8): 1-9.
 CHILDREN < 5 YO

BRONCHIOLITIS ASTHMA PNEUMONIA

Similar
Manifestations

90,5% asthma
patients didn’t
diagnose as asthma

UNDERDIAGNOSIS OF ASTHMA IN
UGANDA CHILDREN

Irrational used of antibiotics

due to misdiagnosis of
asthma as pneumonia
Nantanda R et al. Asthma and pneumonia among children less than five years with acute respiratory symptoms in Mulago Hospital, Uganda: Evidence of under-diagnosis of asthma, Plos One.
2013, 8(11): 1-9.
 Case 2
● 11-year-old male child
● Complaints of recurrent cough, tightness of
chest, and breathing difficulty for the last 18 months
● Chest X-ray showed right-sided hyperinflation
● He was diagnosed and treated as a case of moderate
persistent asthma
● Treatment: bronchodilators (oral salbutamol syrup;
nebulization—salbutamol, ipratropium bromide, and
budesonide)
● Symptoms appeared even on the medication
● Thorax CT scan → suggestive of mucus impaction
● Flexible bronchoscopy → a foreign body (chicken
meat) residing on right bronchus intermedius along with
soft tissue growth mobile during coughing.

Final diagnosis: Foreign body in the right bronchus

(removed by flexible bronchoscope)

Chaundhary N et al. A child with a foreign body in bronchus misdiagnosed as asthma. Clin Case Rep. 2020;8:2409-13.
Management Asthma in Children

Inhaled corticosteroid

Inhaled SABA

Leukotrien receptor antagonist

(LTRA)

LABA

Oral corticosteroid
GINA 2020, Box 3-4D Global Initiative for Asthma (GINA) guidelines,. Global strategy for asthma management and prevention.;
© Global2020.
Initiative for Asthma, www.ginasthma.org
Global Initiative for Asthma (GINA) guidelines. Global strategy for asthma management and prevention. 2020.
Global Initiative for Asthma (GINA) guidelines, “Global strategy for asthma management and prevention”, 2020.
 Recommendations for Delivery of ICSs in
Infants and Children

Murphy K et al. Nebulized inhaled corticosteroids in asthma treatment in children 5 years or younger: A Systematic review and global expert analysis. J Allergy Clin Immunol Pract. 2020;8:1815-27.
 STEP-UP TERAPI ASMA
- Harus dilakukan penyesuaian
Observasi 2-3 bulan sebelum harian oleh pasien
memutuskan step-up - Dapat diberikan as needed dosis rendah
ICS-Formoterol untuk atau sebagai
maintenance dan terapi pereda

Sebelum memutuskan step-up,

nilai terlebih dahulu:
- Teknik Penggunaan Alat Dapat dilakukan step-up
jangka pendek (1-2
- Kepatuhan Pasien minggu) pada keadaan
- Faktor risiko (merokok) infeksi virus atau terpapar
- Apakah ada komorbid lain alergen
seperti rinitis alergi atau
sinusitis

Global Initiative for Asthma (GINA) guidelines: Global strategy for asthma management and prevention. Available from: https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf. 2020.
 STEP DOWN TERAPI ASMA
Bila asma terkontrol
dilakukan observasi 3 Jika asma terkontrol
bulan untuk mencegah selanjutnya diberikan
timbulnya gejala, as needed
eksaserbasi dan efek Budesonide-
samping yang minimal Formoterol atau ICS
ditambahkan SABA

Mencatat status Jangan

baseline. menghentikan ICS
Dosis diturunkan Kontrol Teratur
25-50 % dengan
interval 2-3 bulan

Global Initiative for Asthma (GINA) guidelines: Global strategy for asthma management and prevention. Available from: https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf. 2020.
 Pemberian ICS dosis rendah
sesuai kebutuhan atau kombinasi
formoterol untuk pasien
berdasarkan GINA langkah 1, dan
ICS/formoterol dosis rendah
sesuai kebutuhan sebagai terapi
reliever dalam setiap

Cruz et al. ICS/formoterol in the management of asthma in the clinical practice of pulmonologists: an international survey on GINA strategy. Asthma Research and Practice. (2021) 7:1
 Maintenance ICS menunjukkan
perbaikan fungsi paru jangka
panjang pada pasien dengan
asma ringan sehingga
memperkuat ICS sebagai
pilihan pengobatan awal yang
direkomendasikan bahkan
untuk asma ringan

Daniel J et al. Does the use of inhaled corticosteroids in asthma benefit lung function in the long-term? A systematic review and meta-analysis. Eur Respir Rev 2021; 30: 200185
 ACUTE ASTHMA
ASTHMA EXACERBATION

Penambahan budesonide
pada kortikosteroid sistemik
(CS) untuk asma akut pada
anak yang dirawat di RS
mengurangi Length of stay
(LOS) >1 hari secara
bermakna dan terdapat
perbaikan skor keparahan
untuk pasien di ruang
emergency

Jose A, et al. Adding nebulized corticosteroids to systemic corticosteroids for acute asthma in children: A systematic review with meta‐analysis. Pediatric Pulmonology. 2020;55:2508–17.
 Nebulisasi kortikosteroid
(NebCs) efektif dan dapat
ditoleransi baik pada
pasien anak ≤5 tahun
untuk terapi asma akut
dan kronik

Murphy K et al. Nebulized inhaled corticosteroids in asthma treatment in children 5 Years or Younger: A Systematic review and global expert analysis. J Allergy Clin Immunol Pract. 2020;8:1815-27
 Rekomendasi UKK-Respirologi (2019)
Tata Laksana Asma Akut pada Anak
ICS dosis tinggi diberikan pada semua derajat asma akut

Ringan-Sedang* Berat Life threatening

SABA + CS sistemik SABA + antikolinergik + CS SABA + antikolinergik + CS
sistemik sistemik
ATAU Apabila tidak ada perbaikan + ICS dosis tinggi
SABA + dosis tinggi ICS add- on dosis tinggi ICS

✓ Penggunaan ICS menunjukkan efek samping minimal dibandingkan CS sistemik

✓ Penggunaan nebulisasi ICS dapat dicampur dengan SABA atau SABA + Ipratropium bromide dalam satu chamber
nebulizer
Keterangan:
*Rekomendasi anak diatas 5 tahun
Untuk anak balita, jika menunjukkan perbaikan klinis setelah terapi inhalasi SABA, kortikosteroid tidak perlu diberikan sebagai Pereda
SABA: short-acting ꞵ2 (beta2) agonist

IDAI. Buku Rekomendasi Terapi Inhalasi pada Anak; 2019

 CHALLENGES
• Diagnosing asthma in children remains a challenge because respiratory symptoms
such as wheeze and cough are not specific and vary over time
• Lacks an effective stand-alone diagnostic test

The accuracy of diagnostic

algorithms of asthma in
school-aged children UNDER/OVER
suspected of asthma is still
uncertain
TREATMENT

de Jong CC et al. Diagnosis of asthma in children: findings from the Swiss Paediatric Airway Cohort. Eur Respir J. 2020;1:56(5).
 CHALLENGES
Adherence to treatment in children remains as low as 50%
0-5 years
Caregivers manage nearly all of asthma control, and
interventions could focus primarily on caregiver asthma
education
Needs
5-12 years age-appropriate
approach &
Children begin to form some level of autonomy over their interventions
asthma care, but they are reliant on adults for assistance

12-18 years
Children rely more on self-management, and asthma
management could include more use of mHealth applications.
Rehman N et al. Asthma across childhood: improving adherence to asthma management from early childhood to adolescence. J Allerg Clin Immunol in Practice. 2020 Jun 1;8(6):1802-7.
 Summaries typical errors in inhaler technique for both
metered dose inhalers (MDI, with/without spacers) and
dry powder inhalers (DPI)

CHALLENGES

Often have a poor

inhaler technique→
resulting in sub-optimal
asthma control

Robert W et al. Aerosol therapy in asthma-Why we are failing our patients and how we can do better. Pediatr. 2020;8:305
 Challenges in Indonesia
Poor access to asthma
medicines
Leukotriene receptor
antagonists are not available in
government hospital or several
other hospitals AND Not covered
by national insurance (BPJS)
Spacers are often not
Inhaled bronchodilators available, resulting in the
and corticosteroids I(ICS) use of nebuliser in most
are expensive and limited private practice or
hospital settings
Asthma education and
written asthma action
Oral bronchodilator use
plans of asthma
is commonly prescribed
management are not
commonly done
Heda Melinda
 Spirometry: not always available in all primary care
or hospital
Under-diagnosed &
under-treated Bronchodilator reversibility testing: not always
OR performed
Over-diagnosed & FeNO: not available
overtreated Asthma education and written
asthma action plans of asthma
management is uncommon done

PROBLEMS IN INDONESIA

Limited access to asthma

medications and spacer
(not available/expensive
/not covered by national
insurance/BPJS)

Heda Melinda
Inhaledcorticosteroid needs to give as early as possible to treat asthma

Availability inhaled
corticosteroid-only is
limited in Indonesia

Only combined
preparation (β2-agonist
and corticosteroid)
inhaler is available in
Indonesia
Tim Op’t Holt et al. A Patient’s Guide to Aerosol Medication Delivery. American Association for Respiratory Care 2017. Heda Melinda
 SPACER

INNOVATIVE
BOTTLE SPACER
Non-valved 500 mL home-made spacers or commercial
valves spacer are equally effective as auxiliary devices
to beclomethasone pMDI in achieving disease control.
Need further studies: for children and severe asthma
 Final Remarks
• Definition of asthma is complex, asthma cannot be defined in one single sentence.
• Understanding & clinical approach to pediatric asthma remains suboptimal. Diagnosis and management
asthma is still challenging not only among general physician (GP) BUT also in pediatrician, pulmonologist,
ENT, allergist (knowledge-gaps).
• Diagnosis asthma in children are challenging and really matters to families and for the child.
• Guidelines for asthma continues to updating and revising internationally and locally.
• Asthma misdiagnosis generally occur in the private practice and in hospital setting.
• Consequences of misdiagnosis are under-diagnosis and over-diagnosis.
• Barriers to more objective testing are based on money and priorities, most children “grow out’ of their asthma,
the performing spirometry in children is difficult, international asthma guidelines do not recommend objective
tests to diagnose asthma. Spirometry has low sensitivity and moderate to good specificity.
• Have persistent airway inflammation
• GINA guideline algorithm have high specificity BUT not sensitive. The implementation of the guideline have
a limitation due to not specific asthma symptoms which vary overtime, lack of supporting instruments to use in
asthma diagnosis, limitation of availability of medications and spacers needed according to guideline.
• Error of in inhaler technique of an appropriate-asthma medication given.
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