08 dr mts near fatal asthma in children
TRANSCRIPT
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NEAR-FATAL ASTHMA IN CHILDREN
~ ASMA SERANGAN BERAT PADA ANAK
mts darmawan
Blok Kegawatdaruratan, 27 Oktober 2011 [08]
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Latar Belakang
2 juta anak ke IGD/ thn
5000 - 6000 kematian/ thn di
AS
Serangan berat :
- 2-20% in ICU
- 1/3 required ET & VM
Dlm 20 thn insidensi ↑↑↑
Prevalensi dunia 7,2%
(6 % dewasa & 10 % anak)
Tata laksana : kontroversi
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Latar Belakang
Penyakit airway kronik tersering
Umum dimulai sejak masa anak
Dampak negatif :
– sering tdk sekolah → Quality of Life ↓↓↓
– batasi kegiatan OR
– aktivitas keluarga <<
– Biaya besar
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Limitations Of Activities
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Definisi
Pada anak sulit dirumuskan → Dx & Tx
sulit
→ under / overdiagnosis maupun under /
overtreatment.
Internasional :
Global Initiative for Asthma (GINA) oleh
National Lung, Heart, and Blood Institute
(NLHBI) AS ~ WHO
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Definisi
Pd anak, GINA tidak dpt diterapkan penuh
Pediatric Asthma Consensus Group :
Konsensus Internasional III Penanggulangan Asma Anak (Konsensus Internasional ) 1998
GINA & Konsensus Internasional, banyak negara memiliki konsensus nasional, mis Konsensus Australia
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Konsensus Nasional Asma Anak
KNAA: UKK Pulmonologi PP IDAI, 2004
Mjd acuan, istilah Konsensus diganti menjadi
Pedoman :
→ Pedoman Nasional Asma Anak
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Definisi
Konsep inflamasi, oleh GINA :
Ggn inflamasi kronik airway dg banyak sel yang berperan, khususnya sel mast, eosinofil, dan limfosit T.
→ episode mengi berulang, sesak nafas, rasa dada tertekan (tightness) & batuk, khususnya malam atau dini hari
Gejala : timbul akibat penyempitan luas namunbervariasi
Inflamasi berhub dg hipereaktivitas : alergi !
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Gina …
→ untuk anak tidak praktis
→ gunakan definisi lama
Mengi berulang dan/atau batuk persisten dan
asma adalah yang paling mungkin, sedangkan
sebab lain yang lebih jarang telah disingkirkan
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Pedoman Nasional Asma Anak
Batasan operasional :
Mengi berulang dan/atau batuk persisten dengan
karakteristik :
Episodik
> malam/dini hari (nokturnal)
Musiman
Pencetus/ trigger
reversibel : spontan / pengobatan
riwayat asma / atopi lain pasien/kelg
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Batuk Kronik Berulang (BKB)
Kesepakatan UKK Pulmologi
ttg BKB :
Berlangsung > 14 hari
dan/atau 3 atau lebih episode
dalam waktu 3 bulan berturut-
turut
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Etiologi
Asthma disebabkan oleh :
Inflamasi sal napas yg luas,
reversible, menyebabkan
penyempitan.
→ dasar patofisiologi
Paparan dg allergen & iritan
aktifkan sel mast pulmoner
→ bronkospasme
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Tipe Asma
Akibatnya sama –
penyempitan airways–
but kausa stimuli
bervariasi, misal
– Satu penderita mjd
wheezing karena debu
– Yang lain muncul wheezing
saat udara dingin
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THE ASTHMATIC INFLAMMATORY CASCADE
Aktivasi Sel/Pelepasan Mediator :
Eosinofil Sel Mast Makrofag
Neutrofil sel T
Sel Epitel Bronkus
Inflamasi Asmatik
Hiperesponsif Bronkial
Gejala Klinis
Stimuli Inflamasi
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Terminologi Derajat & Serangan
BERBEDA, antara :
Derajat penyakit :
1. ringan, 2. sedang, 3. berat,
dengan
Jenis serangan : 1. Ringan, 2. Sedang
3. Berat
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Tipe paling umum
Childhood Asthma
Nocturnal Asthma
Allergy Asthma
Sports Asthma / Exercise
Induced Asthma
Cardiac Asthma x
Cold and Flu Asthma x
COPD/Emphysema
Asthma x
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Triggers
- Alergen
- Infeksi virus saluran napas
- Tembakau ~ rokok
- Asap
- Exercise
- Perubahan cuaca
- Faktor emosi
- Bulu kucing : 50 %.
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Triggers
Asap rokok :
– Sgt merugikan anak
– Perokok pasif, makin buruk
gejala
– Faktor UTAMA harus dihindari
Debu rumah
Hindari SULPHUR DIOXIDE
dlm minuman dingin (soft
drink)
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Other causes of wheezing
Edema paru
Bronkiolitis
Chronic obstructive pulmonary disease (COPD)
Pneumonia
Anafilaksis
Korpus alienum
Emboli paru
Bronkektasis
Massa subglotis
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Urutan Gejala
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Klasifikasi Derajat Penyakit Asma Anak
Klinis, kebutuhan obat,
& faal paruAsma Episodik
Jarang Asma Episodik
Sering Asma Persisten
1. Freknsi serangan <1x/bulan >1x/bulan sering
2. Lama serangan <1 minggu >1 minggu Hampir sepanjang tahun,tidak ada periode bebasserangan
3.Intensitas serangan biasanya ringan biasanya sedang biasanya berat
4. Di antara serangan tanpa gejala sering ada gejala gejala siang danmalam
5. Tidur dan aktivitas tidak terganggu sering terganggu sangat terganggu
6. Pemeriksaan fisik diluar serangan
Normal (tidakditemukankelainan)
mungkin terganggu(ditemukankelainan)
tidak pernahnormal
7. Obat pengendali (antiinflamasi)
tidak perlu perlu perlu
8. Uji faal paru (di luarserangan)
PEF/FEV1>80% PEF/FEV1 60-80% PEF/FEV1<60%variabilitas 20-30%
9. Variabilitas faal paru(bila ada serangan)
variabilitas >15% variabilitas >30% variabilitas >50%
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Penilaian Serangan
Klinis, UFP, Lab Ringan Sedang Berat
Aktivitas
Berjalan
Bayi:nangis keras
Bicara
Bayi:nangis pendek
lemah, m/m <<
Istirahat
Bayi : tak mau
makan
Bicara Kalimat Penggal kalimat Kata-kata
Kesadaran Mungkin agitasi Biasanya agitasi Biasanya
teragitasi
Sianosis Tak ada Tak ada Ada
Posisi Bisa berbaring > Suka duduk Duduk brtopang
lengan
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Aspek Klinis Serangan Berat
Wheezing (+) : „biasa‟
Wheezing (-) :
obstruksi kritis, bahaya
Wheezing (+) ↑ :
tanda respon (+) thd
bronkodilator
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Tanda Serangan Berat
Bernapas sangat sulit
RR >>>, pendek, sangat dangkal, distress
Bicara : kata, pendek, terputus
Keluhan berat :
Wheezing, Batuk
dada rasa tertekan
Pucat
PFR < 50%
Retraksi berat
Bisa pe ↓ kesadaran
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Status asmatikus
Tak respon dg 2 puff β2
agonist, 30‟ after Tx
Tak respon dg 2 nebulisasi
Cemas, bernapas sangat
sulit
Tak mampu bicara (krn
sesaknya)
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Triggers
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“Modern” life damage childhood
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Anatomi Paru
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Asthma Attack
Terjadi bila airway
menyempit :
– Wheezing ekspirasi
– Napas pendek
– Dada rasa tertekan
(tightness)
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Tanda „Tripod' stance
Tanda serius :
duduk mem-bungkuk-
kan pundak pd lengan –
tiap tarikan napas
berusaha masukkan O2
→ Tanda serangan
berat
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→ Tanda „Tripod' stance
Tanda penting lain : bicara terputus-putus /
penggalan kalimat
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Makin berat → O2 ke jaringan makin ↓ :
– Koma
– Sianosis
Napas melambat ~ berhenti (agonal
gasping) - wheezing tak terdengar
→ emergency.
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Proses Difusi O2 ~ CO2
Terganggu
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Diagnosis :
Uji Fungsi Paru = Spirometri
= Pulmonary Function Test
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Patofisiologi
Meliputi 3 hal :
1. Bronkonstriksi
2. Inflamasi ~ edema
3. Mukus >>>
1 & 2 bisa diintervensi
3 :
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Patofisiologi
Khas : inflamasi
Perub ini tjd, meski secara klinis tidak bergejala
Merangsang proses perbaikan :
– perubahan struktur & fungsi :
→ airway
remodelling.
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Trapped Air
(Udara Terperangkap ~ terjebak)
Udara masuk alveolus,
tapi sulit keluar,
terperangkap →
alveolus menggembung
~ membesar ~ makin
besar ~ pecah :
pneumothoraks
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Trapped Air (Udara Terperangkap)
Paru emfisematous
~ hiperaerasi
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Hiperaerasi
Napas Cuping Hidung
Tanda keterlibatan
parenkim paru
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Treatment
Tujuan :
Dilatasi airway
secepatnya
Me ↓ hipoksemia → O2 !
Kembalikan fungsi paru
secepatnya
Mencegah kekambuhan
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Prinsip Terapi : 4 H
Hospitalised/Masuk
RS
Atasi Hipoksia
Berikan Hidrokostison
Hidrasi cukup
Metode :
Bronkodilator ~ inhalasi
Inhaled steroid
Boleh oral/ iv steroid
Drip aminofilin
1mg/kgBB/24 jam
kebutuhan cairan
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Diagnosis
Medical History
Review
Onset gejala, durasi, frekuensi &
pola
Mungkin komponen alergen
Faktor presipitasi, termasuk perub
lifestyle
Riw terapi sebelumnya
Riw keluarga
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Managing Acute Exacerbations in the Hospital
Assess severity
Initial treatment
Reassess Severe episode
Poor response
Admit to
ICU
Moderate
Episode
Good
Response
Discharge
Incomplete
Response
Improved Not
Improved
Admit to
Hospital
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Initial Stabilization
Urgent & agresif Tx simultan dg:
– O2
– Bronkodilator
– Steroid
tak respon ?
ICU
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Primary Therapy
Oksigen
Untuk semua serangan berat, meski SaO2
normal
Tetapkan SaO2 sebesar 92%
Suksesnya Tx dg β-agonists saat awal
diikuti dg perbaikan SaO2
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Types of medications 2 main types
Controller or
everyday
medications
– Intal, Singulair
– Pulmicort, Aerobid
– Azmacort, Serevent
– Seretide, symbicort
everyday basis
• Rescue or “Quick-
Relief” = “Reliever”
Albuterol, Serevent
Xopenex, Ventolin
• control broncospasms-
-release “squeezing” of
the airways
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Medikamentosa
1. Obat pereda (reliever)
2. Obat pengendali
(controller)
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Reliever
→ obat serangan
untuk redakan
serangan
Teratasi & tidak ada
gejala : stop !
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Controller
Pencegah
Atasi masalah dasar :
inflamasi kronik
Jangka lama,
tergantung derajat &
respon
Pada Asma Episodik
Sering & Persisten
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Inhaled β2-Agonists
Albuterol (or salbutamol) = Ventolin®
Cepat, tergantung dosis dg ES minimal
Kontinyu vs intermiten of nebulized
albuterol : hasil sama
MDI-spacer vs nebulizer : hasil tidak beda
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Levalbuterol
R-isomer albuterol
Baru ada di AS
(-)
Long acting agents :
Fenoterol (Meptin®) : p.o
Clenbuterol (Spiropent®) : p.o
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Serangan berat
Corticosteroids
Bukti : hanya sistemik utk serangan berat
Pemakaian awal ↓ MRS
Berikan awal pada semua px asma
Tak ada beda bermaka p.o & i.v
iv > disukai, t.u bila OS muntah ~ sulit menelan
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Adjunctive Therapies
Anticholinergics
Ipratropium bromide
(Atrovent®, Berodual®, Combivent®)
– Nebulizer dose is 0.5 mg
– slow onset (+ 20 min), peak 60-90 min
– ES sistemik (-)
– prolonged onset ~ cukup 1x
– an adjunct to albuterol.
Tiotropium : baru, longer-acting, sedang dikembangkan di AS
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Parenteral Epinephrine or Terbutaline
Epinefrin
s.c for acute severe asthma
Dose (1:1000) : 0.01 mg/kg into 3 doses of + 0.3 mg at 20-minute intervals
Side effects
↑ HR, myocardial irritability
↑ O2 demand
But its use (even in > 35 y) is well tolerated.
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Terbutaline (Bricasma®)
dose 0.25 mg sc,
repeated in 30-60‟
< familiar pd anak
> baik dari epinefrin
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Metil xantin
Aminofilin, teofilin
Obat utama selama berpuluh tahun
Mulai ditinggalkan krn ES
Aminofilin drip masih digunakan : dosis 1 mg/kgBB/kebutuhan cairan/24 jam.
Syringe pump. If tak ada :
(“ + 90 mg aminofilin dalam 500 cc infus”)
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What are NOT recommended ?
-- Tranquillisers
– Antihistamines
– Mucolitik
– Desensitisation
– Fisioterapi
– Antibiotics (only used if bacterial
infection)
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Mukolitik
Kontroversi berat
TIDAK ADA TEMPAT bagi mukolitik dalam
pengobatan BKB (batuk kronik berulang)
pada anak
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Mukolitik
Mukolitik : mengencerkan →
memperbesar volume dahak, menambah
refleks batuk.
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Carbosistein
MEMECAH dahak, BUKAN
mengencerkan
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Antitusif ?
Tambah bermasalah.
Controh : mercotin®, dekstrometorfan.
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Obat batuk pilek campuran
NOT RECOMMENDED !!!!!!!!!
Biasanya mengandung anti piretik.
Anti piretik : sendirikan !!!!
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Prinsip pengobatan
Step-up– Tx sesuai, 6-8 minggu no response → derajat
tata laksana berpindah ke yang lebih berat
Step-down– Sebaliknya : terkendali dlm 6-8 minggu
– k/p steroid hirupan stop
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Nebulisasi ~ Nebulizer
1
2 3
45 6
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Metered Dose Aerosol
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Umur Alat inhalasi
< 2 tahun Nebuliser
MDI (Metered Dose Inhaler)dengan spacer, Aerochamber, Babyhaler
5-8 tahun Nebuliser
MDI dengan spacer
DPI (Dry Powder Inhaler):Diskhaler, Turbuhaler
> 8 tahun Nebuliser
MDI dengan spacer
DPI
MDI tanpa spacer
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Inhaler + Spacer
Turbuhaler
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Metered Dose Aerosol
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Dry Powder Inhaler (DPI)
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Nebulizer
Bricasma®Ventolin®
Atrovent®,
Berodual®,
Combivent®)
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Komplikasi
Tension
pneumothorax
Atelektasis lobaris,
pneumonia, edema
paru
Cardiac causes of
death : less common
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Pencegahan
Antihistamin non sedatif (anti alergi) :
Ketotifen : 8 minggu baru ada manfaat. Mulai ditinggalkan.
Cetirizin : long acting
Obat-obat ini tidak bermanfaat sbg obat controller
Imunisasi anti influenza
Avoidance
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Terima Kasih