referat asma tegar english
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WRITTEN BY :Tegar Wibawa R
1102009281
MENTOR:Dr. Pulung M Silalahi Sp.A
DEFINISI Asthma is a chronic inflammatory disorder of the
airways involving cells and cellular elements.(Global Initiative For Asthma. Medical Communications Resources, Inc ; 2006.)
Asthma is a recurrent wheezing and / or a persistent cough with a characteristic; arise episodic, inclined at night / early morning (nocturnal), seasonal, after physical activity and there is a history of asthma or other atopic patients and / or family.(Unit Kerja Koordinasi (UKK) Respirologi IDAI pada tahun 2004)
EPIDEMIOLOGIAsthma is a chronic respiratory disease
that is most often foundThe disease usually begins since childhood30% occur in the age of 1 year80-90% of the first symptoms arise before
4-5 yearsCommon problems in Hospitalized Children IDAI. Jakarta : 8-9 mei 2011
Faktor ResikoGenetic factors
Hiperreaktivitas Atopy / allergies
bronchi Factors that
modify genetic disease
Sex Ras/Etnik
Triggers:
Alergen
irritantWeather
ISPAInfectio
n
Excercise
Comorbid Conditions
Emosional
Patofisiologi Asthma Asthma occurs due :1. Channel respiratory obstruction2. Hyperreactivity of respiratory tract3. Mucus hypersecretion
Nelson Textbook of Pediatrics : Childhood Asthma. Elsevier Science (USA);2003.
Buku Ajar Respirologi anak IDAI, tahun 2010 halaman 109
Clinically parameters, needs medication and pulmonary function
Infrequent episodic asthma (mild asthma)
Frequent episodic asthma (asthma medium)
Persistent asthma (severe asthma)
1. 1. The frequency of attacks
3-4 x / 1 year3-4 x / 1 year 1 x / month1 x / month ≥ ≥ 1x/ month1x/ month
2. 2. long attack < 1 week< 1 week ≥ ≥ 1 week1 week Almost all year round, Almost all year round, there is no remissionthere is no remission
3. 3. among attack asymptomaticasymptomatic asymptomaticasymptomatic Symptoms day and nightSymptoms day and night
4. 4. Sleep and activity Not distrubed Not distrubed <3x/week<3x/week
frequently interruptedfrequently interrupted>3x/week>3x/week
very disturbedvery disturbed
5. 5. Physical examination outside attacks
NormalNormal May be impaired (no May be impaired (no abnormality)abnormality)
Never normalNever normal
6. 6. Anti-inflammatory controller medication
no needno need Non steroid/ steroid Non steroid/ steroid inhaler low dose 100-inhaler low dose 100-200µg200µg
Steroid inhaler / oralSteroid inhaler / oral≥≥400µg/hari400µg/hari
7. 7. Lung function tests (excluding attack)
PEF / FEV 1 > 80%PEF / FEV 1 > 80% PEF / FEV 1 60-80%PEF / FEV 1 60-80% PEF / FEV1 < 60%PEF / FEV1 < 60%
8.8. Variability in pulmonary function (if there is an attack)
Variabilitas > 15%Variabilitas > 15% Variabilitas > 30%Variabilitas > 30% Variabilitas > 50%Variabilitas > 50%
Global initiative for asthma. Medical communications resources, inc: 2006
Asma intermiten : Intermittent symptoms for less than 1 time per week, short attack (hours-days) symptoms night less than two times a month outside attack without symptoms and normal pulmonary function test PEFR or PEV >80% predicted, variations of < 20%Asma persisten ringan : Symptoms > 1 time a week but less than 1 times a day attacks may disturb activity and sleep symptoms at night more than 2 times a month PEV or PEFR > 80% predicted, variations of 20-30%
Global initiative for asthma. Medical communications resources, inc: 2006
Asthma persisten Medium Symptoms every day Disrupt the activities and sleep attacks Symptoms evenings > 1 time a week Daily use of inhaled short-acting β 2 agonist PEFR or PEV > 60% - <80% predicted, variations of> 30%Asthma persisten Severe Continuous symptoms Frequent attacks Frequent night symptoms Limited physical activity due to asthma symptoms PEFR or PEV <60% predicted, variations of> 50%
Buku Ajar Respirologi anak, IDAI, tahun 2010 halaman 132
Clinical parameters, Lung
Function, laboratory
Mild Medium Severe Stop threats Breath
crowded walkBabies: loud cry
speakbabies:Short and weak crydifficulty eating
breakBabies: Stop eating
speak sentence word sentence Words
position could lay down
Rather sit Sat propped arm
awareness perhaps agitated
usually agitated
usually agitated
confusion
cyanosis Nothing Nothing Have Real
Buku Ajar Respirologi anak, IDAI, tahun 2010 halaman 132
Wheezing Moderate, often only at the end of expiration
Tinny, during expiration + inspiration
Very loud audible without stethoscope
Hard / no sound
Hard To Breathe
Minimal Medium Severe
Use of Respiratory Muscle Aids
usually not Usually yes Yes Torako abdominal paradoxical movement
Retraction Shallow, intercostal retractions
Medium, plus a retraction suprasternal
In, plus a nasal flaring
Shallow / Missing
Breathing Rate increase increase increase decrease
Guidelines for the raw value conscious respiratory rate in children: Age Laju Napas Normal< 2 month < 60 / minute1-2 month < 50 / minute1-5 month < 40 / minute6-8 month < 30 / minute
Buku Ajar Respirologi anak, IDAI, tahun 2010 halaman 132
Pulse Normal Takikardi Takikardi Bradikardi
Guidelines for the raw value pulse rate in children:Age Pulse rate Normal2-12 month < 160 / minute1-2 year < 120 / minute3-8 year < 110 / minute
Pulsus paradoxus (Examination impractical)
Nothing < 10 mmHg
Have 10-20 mmHg Have > 20 mmHg No, the sign of muscle fatigue breath
PEFR or FEV1 (alleged value /% value tebaik)pre bronchodilatorpost bronkodilator
> 60%> 80%
40-60%60-80%
<40%<60%Respon < 2 jam
SaO2 % > 95% 91-95 % ≤ 90%
PaO2 Normal (normally not need to be examined)
> 60 mmHg <60 mmHg
PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg
ANAMNESIS• Chronic cough and recurrent wheezing shortness especially at night and excessive physical activity
• Symptoms, Triggers, family history
Physical examination
Inspection:- Rapid breathing and dyspnoea- cough- Wheezing/mengi- Supraclavicular retractions, suprasternal,
epigastric and intercostal- Thoracic shape emfisematous- Hunchback forward- Intercostal space widened- AP diameter increases
Asma Kronik
Physical examinationPercussion:- Hipersonor entire thorax, especially the
bottom of the posterior
Auskultasi :- BND rugged / hardened BND became
weakened- Ekspiration lengthwise- Ronkhi dry and wet
Chronology of the diagnosis of asthma in children (continued) ...
Check peak flow meter or spirometer to assess:
• Reversibilitas (> 15%)
•Variabilitas (> 15%)
Consider:
•Foto rotgen thorak dan sinus
•Lung function tests
•Test the response to bronchodilators and systemic steroid 5 days
•Bronchial provocation test
•Sweat Test
•Imunological test
•Silia motility examination
•GE reflux examination
Give bronkodilator
Diagnosis of work: Asthma
Give anti-asthma drugs:
Not successfully reset the value of diagnosis and treatment adherence
not successful
Does not support another diagnosis
Another diagnosis support
Diagnosis and treatment of other diseases
Consideration of asthma with other diseases
Not asthma
Suspected asthma Not necessarily asthma
1. blood tests Blood and sputum eosinophilia PMN leukocytosis can occur when there is
an infection2. X-ray Thorax Increased lung markings
Hyperinflation Hiper inflasi acute attacks and chronic
Asthma Photo is repeated when there are indications
Pneumonia / pneumothoraks
Foto Toraks
Results can be normal or chest X-ray showed hyperinflation
Atelectasis picture can be obtained because of blockage by mucus and hypertrophy of smooth muscle cells.
The main bronchial wall thinning.
3. Test skin allergy and immunologyUseful to determine which allergens according
originatorIgE increased
4. Lung function testsUseful for:
Assessing the level of airway obstruction and disruption of gas exchange
Measuring the response of the airway to allergens and chemicals that are inhaled or during bronchial provocation test
Assessing the response to therapeutic agents Evaluate the long-term course of the diseas
Uji Faal ParuPerformed before and
after the administration of the aerosol bronchodilator
The increase in PFR or FEV1 at least 10% after aerosol therapy so gives the impression of asthma
Uji Faal Paru
1. Spirometri FEV1(Forced Expiratory Volume in 1 sec), FVC
(Forced Vital Capacity, rasio FEV1/FVC
www.joegoshe.com/images/spirometry.gif
2. PEF (Peak Expiratory Flow) Monitoring
www.geocities.com/.../Villa/2545/asthma.jpg
Supporting Investigation5. Bronchial provocation
testPerformed when the
diagnosis is still in doubtPurpose: indicates
bronchial hyperreactivityWhich is often done is by:
histamine, and load methacolin run
MEDIKAMENTOSANON MEDIKAMENTOSA
Treatment of asthma differ from asthma attacks :
Attacks drug / reliever short termDrug controllers / controller long term
Daftar Obat Asma yang Ada di Indonesia
Drug NameDrug Name Generic nameGeneric name trade trade namename
preparationspreparations dosedose
(’(’Releiever’)Releiever’)
Simpatomimetik (agonis-Simpatomimetik (agonis-2) :2) :
TerbutalineTerbutaline
Orciprenalin Orciprenalin (metaproterenol)(metaproterenol)Salbutamol Salbutamol (albuterol)(albuterol)HeksoprenalinHeksoprenalinFenoterolFenoterol
BricasmaBricasma
NairetNairet
ForasmaForasmaAlupentAlupent
VentolinVentolin
Berotec Berotec
Syrup, tablet, Syrup, tablet, turbuhalerturbuhalerSyrup, tablet, Syrup, tablet, ampulampulSyrup, tabletSyrup, tabletSyrup, tablet, Syrup, tablet, MDIMDISyrup, tablet, Syrup, tablet,
MDIMDIMDIMDI
0,05-0,1 mg/kgBB/hari0,05-0,1 mg/kgBB/harijamjam0,05-0,1 mg/kgBB/hari0,05-0,1 mg/kgBB/hariJamJam
0,1-0,15 mg/kgBB/kali 0,1-0,15 mg/kgBB/kali setiap 6jamsetiap 6jam
0,1 mg/kgBB/kali 0,1 mg/kgBB/kali setiap 6 jamsetiap 6 jam
Classed XantinClassed Xantin TeofilinTeofilin Syrup, tabletSyrup, tablet
(’controller’)(’controller’)
AINS :AINS : Sodium Sodium cromogylatecromogylate
IntalIntal MDIMDI NothingNothing
NedokromilNedokromil MDIMDI NothingNothing
Classes anti-inflamasi Classes anti-inflamasi steroid :steroid :
BeclomethasoneBeclomethasoneBudesonidBudesonid
FluticasonFluticason
BecotideBecotidePulmicortPulmicortInflammideInflammideFlixotideFlixotide
MDIMDIMDI, MDI, turburhalerturburhalerMDIMDI NothingNothing
Classes Classes ββ-agonis long -agonis long acting :acting :
ProkaterolProkaterolBambuterolBambuterol
SalmeterolSalmeterolKlenbuterolKlenbuterol
BambecBambec
SereventSereventSpiropentSpiropent
Sirup, Sirup, tablet, MDItablet, MDITabletTabletMDIMDISirup, tabletSirup, tablet
Classes of drugs off slow Classes of drugs off slow / controlled release / / controlled release / Slow releaseSlow release
Terbutalin Terbutalin SalbutamolSalbutamolTeofilinTeofilin
VolmaxVolmaxKapsulKapsulTabletTabletTablet salutTablet salut
Classes antileukotrien :Classes antileukotrien : ZafirlukasZafirlukasMontelukasMontelukas
AccolateAccolate TabletTablet HaveHaveNothingNothing
Classes combined Classes combined steroid +LABA :steroid +LABA :
Budesonid Budesonid +formoterol+formoterolFlutikason+salmFlutikason+salmeteroleterol
SymbicortSymbicortSeretideSeretide
TurbuhalerTurbuhalerMDIMDI
Management groove Asthma Attacks in Children
Clinic / Emergency Unit
The value of the degree of attack
Procedures beginning
Nebulized -agonis 1-3x, hose 20 minute Third Nebulized + antikolinergik
If heavy attack, nebulisasi -agonis + antikolinergik
Mild attacks(nebulized 1X, good response)•Observation 1 hour•If the effects persist, could return•If symptoms arise again, treat it as an attack medium
Attacks were (nebulized 2X, partial response)•Give oxygen•Value re-degree assault, if appropriate with moderate attack, observation at a day care room•Give oral steroids•Attach lines parenteral
Heavy attack (nebulized 3X, bad response)•Since the beginning given the current O2 / outside nebulized•Attach lines parenteral•intravenous steroids•Repeated clinical value,•if appropriate heavy attack, hospitalized in the inpatient unit•X-ray photo
Go home•Arm agonist drugs (inhaled / oral)•If there is already a controlling drugs, continue•If the viral infection as the originator, may be given oral steroids (3-5 days)•Within 20-48 hours, control clinic, outpatient for re-evaluation
Day care room / observation•Oxygen forward•Oral steroids followed•Nebulized every 2 hours•If within 12 hours of clinical improvement is stable, may return, but if the clinical remained not improved / worsened, over inpatient care to space
Inpatient unit•Oxygen forward•Overcome dehydration and acidosis if there•Steroids IV every 6-8 hours•Nebulized every 1-2 hours•Aminophilin initial IV continue maintenance•If improved in nebulized 4-6X, the interval to 4-6 hours•If clinical improvement within 20 hours of steady, go home•If the steroids and parenteral aminophilin not good, even raised the threat of stopping breathing, over care to ICU
Mild attack… Moderate attack… Severe attack…
Flow of Long-Term Management of Asthma Children
reliever : ß-agonis atau teofilin (inhaler or oral) if necessary
Add controller medications: low-dose inhaled steroid
Consider alternatives addition of one of the drugs:• ß-agonis long acting• Teofilin short acting• Antileukotriena Or doses of inhaled steroids increased (high)
Asthma Episodic Often
Asthma Persisten
4-6 week > 3x doses/ week
< 3x doses/ week
6-8 minggu respons
Asthma Episodic Rarely
Flow of Long-Term Management of Asthma Children continued
Medium-dose steroids added to one of the drugs:•ß-agonis long acting• Teofilin short acting• AntileukotrienaOr doses of inhaled steroids increased (high)
Drug Steroid Oral
6-8 minggu respons
Asthma Persisten
Non medikamentosa TheraphyPrevent children exposed to the substance /
allergen / conditions (weather) which can spur the onset of asthma attacks
Education to the families of children with asthma about the degree of illness and the degree of asthma attacks.
Prognosis
Long-term prognosis is generally good 50-80%
Most asthmatic child is diminished with age70% -80% of childhood asthma disappears at
the age of 21 years
KomplikasiEmphysema and change shapeAsthma is a chronic and severe Pigeon chestMany viscous secretions bronchial obstruction
atelektasis bronkiektasis infction bronkopneumonia
Status asmatikus respiratory failure pulse failure †
Critism and SuggestionsFor pattient
Prevent asthma attacks (environmental settings).
Giving the drug at the time, manner, and duration of the right.
Knowing the signs of the beginning of an asthma attack.
Knowing when to consult a doctor or to the hospital.
Keeping the child's general health.
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