GLOBAL INITIATIVE FOR ASTHMA

Pembimbing:dr. Retno, Sp. P

Anggota Kelompok:Muflikha Sofiana Putri, S. KedNovita Dwiswara Putri, S. Ked

Rizky Bayu Ajie, S. Ked

KEPANITERAAN KLINIK BAGIAN ILMU PENYAKIT DALAMRUMAH SAKIT UMUM DAERAH DR. H. ABDUL MOELOEK

FAKULTAS KEDOKTERAN UNIVERSITAS LAMPUNGBANDAR LAMPUNG

2015 

G INA

G INA

lobal

itiative for

sthma

lobal

itiative for

sthma

Pendahuluan

Diagnosis Asma - Gejala

Diagnosis Asma – pemeriksaan fisik

Diagnosis Asma – variasi keterbatasan jalan napas

Alur Diagnosis Asma Patient with

respiratory symptoms

Are the symptoms typical of asthma?

Detailed history/examination for asthma

History/examinationsupports asthma diagnosis?

Perform spirometry/PEF with reversibility test

Results support asthma diagnosis?

Empiric treatment with ICS and prn SABA

Review response

Diagnostic testing within 1-3 months

Repeat on another occasion or arrange

other tests

Confirms asthma diagnosis?

Consider trial of treatment for most likely diagnosis, or refer

for further investigations

Further history and tests for alternative diagnoses

Alternative diagnosis confirmed?

Treat for alternative diagnosisTreat for ASTHMA

Clinical urgency, and other diagnoses unlikely

YES

YES

YES

NO

NO

NO

YES

YES

NO

Diagnosis Banding

Penilaian Asma

Penilaian keparahan asma

GINA assessment of symptom controlA. Symptom control

In the past 4 weeks, has the patient had:Well-

controlledPartly

controlledUncontrolled

• Daytime asthma symptoms more than twice a week?

Yes No

None of these

1-2 of these

3-4 of these

• Any night waking due to asthma?

Yes No• Reliever needed for symptoms*

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 assessmentASSESS PATIENT’S RISKS FOR:• Exacerbations• Fixed airflow limitation• Medication side-effects

Level of asthma symptom control

Penilaian faktor resiko pada asma dengan respon yang buruk

Penatalaksanaan Asma

Siklus dasar management asma

GINA 2015, Box 3-2

Diagnosis

Symptom control & risk factors(including lung function)

Inhaler technique & adherence

Patient preference

Asthma medications

Non-pharmacological strategies

Treat modifiable risk factors

Symptoms

Exacerbations

Side-effects

Patient satisfaction

Lung function

Farmakoterapi

GINA 2015, Box 3-5, Step 1 (4/8)

PREFERRED CONTROLLER

CHOICE

Other controller

options

RELIEVER

STEP 1 STEP 2 STEP 3

STEP 4

STEP 5

Low dose ICS

Consider low dose ICS

Leukotriene receptor antagonists (LTRA)Low dose theophylline*

Med/high dose ICSLow dose ICS+LTRA

(or + theoph*)

As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol**

Low dose ICS/LABA*

Med/high ICS/LABA

Refer for add-on

treatment e.g.

anti-IgE

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of exacerbations; it is not indicated in children <18 years.

Add tiotropium#High dose ICS + LTRA (or + theoph*)

Add tiotropium#Add low dose OCS

Kortikosteroid inhalasi

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400

Budesonide (DPI) 200–400 >400–800 >800

Ciclesonide (HFA) 80–160 >160–320 >320

Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500

Mometasone furoate 110–220 >220–440 >440

Triamcinolone acetonide 400–1000 >1000–2000 >2000

GINA 2015, Box 3-6 (1/2)

Lanjutan....

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 100–200 >200–400 >400

Beclometasone dipropionate (HFA) 50–100 >100–200 >200

Budesonide (DPI) 100–200 >200–400 >400

Budesonide (nebules) 250–500 >500–1000 >1000

Ciclesonide (HFA) 80 >80–160 >160

Fluticasone propionate (DPI) 100–200 >200–400 >400

Fluticasone propionate (HFA) 100–200 >200–500 >500

Mometasone furoate 110 ≥220–<440 ≥440

Triamcinolone acetonide 400–800 >800–1200 >1200

GINA 2015, Box 3-6 (2/2)

Intervensi Non-farmakologi

Kapan Dimulainya Terapi Kontrol Pada Asma??

Catatan

Penilaian Respon Terapi

Asma eksaserbasi

Asma Eksaserbasi

© Global Initiative for AsthmaGINA 2015, Box 6-8 (2/3)

PRIMARY CARE Child presents with acute or sub-acute asthma exacerbation or acute wheezing episode

ASSESS the CHILDConsider other diagnoses

Risk factors for hospitalization

Severity of exacerbation?

MILD or MODERATEBreathless, agitated

Pulse rate ≤200 bpm (0-3 yrs) or ≤180 bpm (4-5 yrs)

Oxygen saturation ≥92%

MONITOR CLOSELY for 1-2 hoursTransfer to high level care if any of:

• Lack of response to salbutamol over 1-2 hrs

• Any signs of severe exacerbation

• Increasing respiratory rate

• Decreasing oxygen saturation

START TREATMENTSalbutamol 100 mcg two puffs by pMDI + spacer or 2.5mg by nebulizer

Repeat every 20 min for the first hour if needed

Controlled oxygen (if needed and available): target saturation 94-98%

URGENT

SEVERE OR LIFE THREATENINGany of:

Unable to speak or drink

Central cyanosis

Confusion or drowsiness

Marked subcostal and/or sub-glottic retractions

Oxygen saturation <92%

Silent chest on auscultation

Pulse rate > 200 bpm (0-3 yrs)or >180 bpm (4-5 yrs)

TRANSFER TO HIGH LEVEL CARE (e.g. ICU)

While waiting give:

Salbutamol 100 mcg 6 puffs by pMDI+spacer (or 2.5mg nebulizer). Repeat every 20 min as needed.

Oxygen (if available) to keep saturation 94-98%

Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max. 30 mg for 2–5 yrs) as a starting dose

Consider 160 mcg ipratropium bromide (or 250 mcg by nebulizer). Repeat every 20 min for 1 hour if needed.

© Global Initiative for AsthmaGINA 2015, Box 6-8 (3/3)

MONITOR CLOSELY for 1-2 hours

Transfer to high level care if any of:

• Lack of response to salbutamol over 1-2 hrs

• Any signs of severe exacerbation

• Increasing respiratory rate

• Decreasing oxygen saturation

TRANSFER TO HIGH LEVEL CARE (e.g. ICU)

While waiting give:

Salbutamol 100 mcg 6 puffs by pMDI+spacer (or 2.5mg nebulizer). Repeat every 20 min as needed.

Oxygen (if available) to keep saturation 94-98%

Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max. 30 mg for 2–5 yrs) as a starting dose

Consider 160 mcg ipratropium bromide (or 250 mcg by nebulizer). Repeat every 20 min for 1 hour if needed.

Worsening, or failure to respond to

10 puffs salbutamol over 3-4 hrs

FOLLOW UP VISIT Reliever: Reduce to as-needed

Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol

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?

Schedule next follow up visit

DISCHARGE/FOLLOW-UP PLANNING

Ensure that resources at home are adequate.

Reliever: continue as needed

Controller: consider need for, or adjustment of, regular controller

Check inhaler technique and adherence

Follow up:within 1-7 days

Provide and explain action plan

CONTINUE TREATMENT IF NEEDED

Monitor closely as above

If symptoms recur within 3-4 hrs

• Give extra salbutamol 2-3 puffs per hour

• Give prednisolone 2mg/kg (max. 20mg for <2 yrs; max. 30mg for 2-5 yrs) orally

IMPROVING

IMPROVING