UHT September 2012

Dr. Ediyono Sp P
EDLS Sub Dep Paru RSAL Dr Ramelan
 Pokok bahasan Asma Bronkiale
1. Pendahuluan.
2. Definisi Asma Bronkiale.
3. Patogenesis
4. Faktor Risiko
5. Diagnosis dan Klasifikasi derajat asma
6. Penatalaksanaan Asma
7. Obat Asma
8. Kondisi Khusus
9. Pencegahan
EDLS
 Klasifikasi Derajat Asma
Pedoman Diagnosis & Penatalaksanaan Asma. PDPI 2004

Intermiten Persisten Persisten Persisten

Ringan Sedang Berat
Gejala < 1 X / mg > 1 x / mg Tiap hari Terus
menerus

Serangan Singkat, Aktivitas, Aktivitas, Sering timbul

ringan tidur tidur
terganggu terganggu
Gejala < 2 x / bln > 2 x / bln > 1 x / mg Sering timbul
malam
APE > 80 % > 80% 60 – 80 % < 60 %

FEV1 > 80 % > 80 % 60 – 80 % < 60 %

APE Variabl < 20 % < 20 – 30 % > 30 % > 30 %

G lobal
INitiative for
A sthma
 GINA Classification of Asthma Severity
Symptoms/ Symptoms/ PEF or PEF
Day Night FEV1 variability
STEP 1 < 1 time a week </= 2 times a >/= 80% < 20%
Intermittent month
Asymptomatic and
normal PEF
between attacks
STEP 2 > 1 time a week but > 2 times a >/= 80% 20-30%
< 1 time a day
Mild Persistent month
Attacks may affect
activity
STEP 3 Daily > 1 time a week 60% - 80% > 30%
Moderate Attacks affect
Persistent activity
STEP 4 Continuous Frequent </= 60% > 30%
Severe Limited physical
Persistent activity
PEF, Peak Expiratory Flow; FEV1, Forced Expiratory Volume in the first second
 Pokok bahasan Asma Bronkiale
1. Pendahuluan.
2. Definisi Asma Bronkiale.
3. Patogenesis
4. Faktor Risiko
5. Diagnosis dan Klasifikasi
6. Program Penatalaksanaan Asma
7. Obat Asma
8. Kondisi Khusus
9. Pencegahan
 Bisakah ASMA
disembuhkan ???

EDLS
 Asthma Management and Prevention
Gina 2009

• Asthma has a significant impact on individuals, their

families, and society. Although there is no cure for

asthma, appropriate management that includes a

partnership between the physician and the patient/

family most often results in the achievement of control.

 Penatalaksanaan Asma

Pengaruh
Lingkungan
(mis. pajanan Pelega
Alergen) (Bronkodilator
)
Kontrol lingkungan

Genetik Inflamasi Penyempitan Batuk -batuk,

Asma ( Radang )) Saluran nafas Sesak dan mengi

Pengontrol asma
?? Oksigen,
(Anti Inflamasi ) Ekspektorans,
 Penatalaksanaan Asma

Pengaruh
Lingkungan
(mis. pajanan Bronkodilator

Alergen)
β2- agonist
( Terbutalin, salbutamol)

Genetik Inflamasi Penyempitan Batuk -batuk,

Asma ( Radang ) Saluran nafas Sesak dan mengi

Penderita asma yg sering kambuh hanya memakai B-2 aginost ,

Bisakah terkontrol ?
 TUJUAN PENATALAKSANAAN ASMA
 Menghilangkan dan mengendalikan gejala asma
 Mencegah eksaserbasi penyakit
 Meningkatkan faal paru  normal
 Mempertahankan faal paru
 Menghindari efek samping obat
 Mencegah Kecacatan paru.
 Mencegah kematian karena asma
MEMBUAT ASMA MENJADI TERKONTROL
Apa yang dimaksud
dengan
ASMA Terkontrol ???
 Penatalaksanaan Asma  Mengontrol penyakit

Asma Terkontrol bila :

1. Gejala minimal / tidak ada.
2. Tak ada keterbatasan aktivitas
3. Tidak memerlukan obat bronkodilator / minimal.
4. Varaiasi harian APE < 20 %
5. Nilai APE normal/ mendekati normal
6. Efek samping obat minimal / tak ada
7. Tak pernah ke unit gawat darurat
 Levels of Asthma Control
GINA UPDATES 2011 (Assess patient impairment)
Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)

Twice or less More than

Daytime symptoms
per week twice per week
Limitations of 3 or more
None Any
activities features of
partly
Nocturnal symptoms controlled
None Any
/ awakening asthma
present in
Need for rescue / Twice or less More than any week
“reliever” treatment per week twice per week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day
Assessment of Future Risk (risk of exacerbations, instability, rapid
decline in lung function, side effects)
 Asthma
Control Test
Skor :

25 : Terkontrol penuh

20-24 : Terkontrol sebagian

≤ 19 ; Tidak terkontrol
 The recommendation for asthma
management ( 5 components )
( GINA )

• 1. Develop Patient/Doctor Partnership

• 2. Identify and Reduce Exposure to Risk Factors

• 3. Assess, Treat, and Monitor Asthma

• 4. Manage Asthma Exacerbations

• 5. Special Considerations
 The recommendation for asthma
management ( 5 components )
( GINA )

• 1. Develop Patient/Doctor Partnership

• 2. Identify and Reduce Exposure to Risk Factors

- Edukasi
• 3. Assess,
- PasienTreat,
mampuandmengontrol
Monitor Asthma
penyakitnya
• 4. Manage Asthma Exacerbations

• 5. Special Considerations
 Berikan Informasi, Latihan dan Saran :

 Diagnosis
 Penggunaan “relievers” dan “controllers”
 Efek samping obat.
 Cara memakai alat inhalasi
 Mencegah gejala & serangan
 Tanda-tanda asma berat
 Monitor kontrol asma
 Kapan harus ke dokter
Gina 2009
 The recommendation for asthma
management ( 5 components )
( GINA )

• 2. Identify and Reduce Exposure to Risk Factors.

Identify and Reduce Exposure to Risk Factors
- Identifikasi faktor risiko/pencetus
• 3. Assess, Treat, and Monitor Asthma
- Preventif ( Symptom & Eksaserbasi )
• 4. Manage Asthma Exacerbations

• 5. Special Considerations
 The recommendation for asthma
management ( 5 components )
( GINA )

• 3. Assess, Treat, and Monitor Asthma. Identify and

Reduce Exposure to Risk Factors
- Derajat penyakit
• 3. Assess, Treat, and Monitor Asthma
- Cara pemakaian obat asma
• 4. Manage Asthmaasma
- Cara Monitor Exacerbations

• 5. Special Considerations
 The recommendation for asthma
management ( 5 components )
( GINA )

• 4. Manage Asthma Exacerbations

• . Identify and Reduce Exposure to Risk Factors

- Mengetahui keadaan eksaserbasi akut
• 3. Assess, Treat, and Monitor
- Cara pemakaian Asthma
obat yang tepat
• 4. Manage
- KapanAsthma Exacerbations
harus ke Gawat Darurat
- Mencegah
• 5. Special gagal nafas-kematian
Considerations
 Asma Eksaserbasi

• Exacerbations of asthma (asthma attacks or

acute asthma) are episodes of progressive
increase in shortness of breath, cough,
wheezing, or chest tightness, or some
combination of these symptoms.
• The primary therapies for exacerbations include the
repetitive administration of rapid-acting inhaled
bronchodilators, the early introduction of systemic
glucocorticosteroids, and oxygen supplementation.
•
• The aims of treatment are to relieve airflow
obstruction and hypoxemia as quickly as possible,
and to plan the prevention of future relapses
 Pokok bahasan Asma Bronkiale
1. Pendahuluan.
2. Definisi Asma Bronkiale.
3. Patogenesis
4. Faktor Risiko
5. Diagnosis dan Klasifikasi
6. Penatalaksanaan Asma
7. Obat Asma
8. Kondisi Khusus
9. Pencegahan
 Dasar Terapi Farmakologi Asma

Bronkospasme Bronkodilator

Inflamasi Kortikosteroid

Histamin, PG.
Hipersekresi Ekspektorans
Lekotrin
Mukus kental

Lekotrin Anti Lekotrin

 Obat Asma

1. Controller 2. Reliever

• Anti inflamasi untuk • Bronkodilator untuk

mengontrol penyakit & pengobatan saat
mencegah serangan serangan / mengatasi
eksaserbasi
 Component 4: Asthma Management and Prevention Program

Controller Medications

 Glucocorticosteroids ( inhaled / systemic )

 Leukotriene modifiers

 Long-acting β2-agonists ( inhaled / oral )

 Theophylline SR

 Cromones

 Anti-IgE
 Component 4: Asthma Management and Prevention Program

Reliever Medications

 Rapid-acting inhaled β2-agonists

 Systemic glucocorticosteroids

 Anticholinergics

 Theophylline

 Short-acting oral β2-agonists

 SISTEM SARAF PARA-SIMPATIS
1 OBAT ANTIKOLINERGIK
Bronkodilator
CHOLINERGIC
CHOLINERGICRECEPTOR
RECEPTOR

GUANILCYCLASE Cyclic GMP

BRONKOKONSTRIKSI
GTP 5’GMP

ATP BRONKODILATASI 5’AMP

ADENYLCYCLASE Cyclic AMP FOSFODIESTERASE

BETA-ADRENERGIC RECEPTOR
BETA ADRENERGIC RECEPTOR

3 OBAT METHYLXANTIN
2 OBAT BETA 2 AGONIS
SISTEM SARAF SIMPATIS
 Cara Pemberian
Bronkodilator

Oral Inhalasi Parenteral

(Subkutan, Intramuskuler,intravenus)

Lebih lama Cepat Cepat

Target organ
Efek samping Dosis kecil Perlu bantuan
lebih banyak Efek samping sedikit
tenaga medis
 Obat asma inhaler

Steroid Anti-kolinergik Β-2 agonist

STEROID STEROID + β2 AGONIST
 Bagaimana menggunakan Turbuhaler®

1. Buka tutup 2. Putar bagian 3. Buang napas, 4. Tutup

turbuhaler bawah ke letakan kembali
kanan lalu kiri, mouthpiece di bibir tubuhaler
sampai bunyi dan tarik napas dengan
“klik” (hirup obat) penutupnya
 Jenis Inhaler

Meter dose inhaler

(MDI)
Diskhaler
Turbohaler
 Pemberian injeksi pada asma

Injeksi subkutan Injeksi intravena

( adrenalin, terbutalin, dll ) ( Aminophyllin )
Respon inflammasi dari Mast cell
Anti-IgE treatment

Omalizumab is usually
given every 2 or 4 weeks.
 Initial Assessment (severity of Astma Exacerbation)
Initial Treatment
- Oxygen
- Inhaled rapid-acting β2 agonist (continuously for one hour)
- Systemic glucocoticosteroids
Reassess after 1 hour
Moderate episode Severe episode
Treatment: Treatment:
- Oxygen -Oxygen
-Inhaled B2-agonist and inhaled anticholinergic -Inhaled B2-agonist and inhaled anticholinergic
-Oral glucocorticosteroids -Intravenous magnesium

Reassess after 1-2 hours

Good response Incomplete Poor responses
Responses Treatment:
Treatment: -Oxygen
Oxygen -Inhaled B2-agonist and inhaled anticholinergic
-Inhaled B2-agonist -Intravenous magnesium
and inhaled -Consider intravenous B2-agonist
anticholinergic -Consider intravenous theophyllin
-Intravenous Possible intubation and mechanical ventialtion
magnesium

Improved Reassess at intervals

Home Treatment
Status Asmatikus :
• Keadaan gawat darurat Paru
• Eksaserbasi Asma yg telah mendapat pengobatan Standard
• Setelah 2 jam tidak ada perbaikan
 Pokok bahasan Asma Bronkiale
1. Pendahuluan.
2. Definisi Asma Bronkiale.
3. Patogenesis
4. Faktor Risiko
5. Diagnosis dan Klasifikasi
6. Program Penatalaksanaan Asma
7. Obat Asma
8. Kondisi Khusus
9. Pencegahan
 Asma dengan beberapa keadaan

 Asma + Hipertensi
 Asma + Diabetes
 Asma + Kehamilan
 Asma + Puasa
 Asma + Tindakan Bedah
 Pokok bahasan Asma Bronkiale
1. Pendahuluan.
2. Definisi Asma Bronkiale.
3. Patogenesis
4. Faktor Risiko
5. Diagnosis dan Klasifikasi
6. Program Penatalaksanaan Asma
7. Obat Asma
8. Kondisi Khusus
9. Pencegahan
 Mengontrol Alergen di dalam & di luar rumah

1 Debu Rumah a. Cuci sarung bantal, guling, sprei dg selimut air panas
b. Ganti karpet dengan lantai kayu
c. Ganti furniture berlapis kain dengan lapis kulit
d. Gunakan pembersih vakum
e. Cuci dengan air panas selama mainan.

2 Serpihan kulit a. Pindahkan binatang peliharaan dari dalam rumah

b. Gubakan filter udara
c. Mandikan binatang peliharaan 2 X / Minggu
d. Ganti furniture berlapis kain dengan lapis kulit

3 Kecoa a. Kebersihan lingkungan yg disukai kecoak.

b. Pakai pembasmi kecoa
4 Jamur a. Bersihkan dinding basah berjamur
b. Pindahkan karpet basah berjamur
 Mengontrol Alergen di dalam & di luar rumah

5 • Polusi udara dalam a. Tidak merokok dalam rumah.

ruangan b. Hindari perokok pasif
• Asap rokok c. Ventilasi rumah harus baik.
• Asap kayu / masak d. Hindari memasak dengan kayu
• Spray pembersih rumah e. Hindari pakai spray pembersih rumah.
Obat nyamuk dll f. Hindari obat nyamuk asap

6 • Polusi udara diluar a. Hindari aktivitas fisik pada keadaan udara

ruangan dingin & kelembaban rendah
• Asap rokok b. Hindari daerah polusi
• Cuaca c. Ruang kerja dengan ventilasi baik
• Ozon d. Pemakaian masker kalau perlu
• Gas buang kendaraan
 PENUTUP
 Asma penyakit radang kronik saluran napas

 Gejala klinik bervariasi

 Berat penyakit menentukan pengobatan

 Anti inflamasi perlu pada asma persisten

EDLS
EDLS