ASTMUL BRONIC

Conf. Dr. Sorin Crian, Clinica Medical V

EXAMEN. PROPUNERI SUBIECTE

Caracteristicile astmului controlat (enumerare)

Caracteristicile astmului parial controlat (enumerare)
Caracteristicile astmului necontrolat (enumerare)
Diagnosticul exacerbrii uoare (enumerare)
Diagnosticul exacerbrii moderate (enumerare)
Diagnosticul exacerbrii severe (enumerare)
Treptele terapeutice n astm

CUPRINS
Noiuni introductive

Definiie

Epidemiologie

Etiologie

Patogenez

Anatomie patologic
Diagnostic
Management

EPIDEMIOLOGIE
Prevalen
1-18%
7,7% (persoane apte de munc)
Cretere
1-4

Aspecte socioeconomice
Costuri directe
Costuri indirecte

1-4,6

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
NICE (National Institute for Health and Clinical Excellence) technology appraisal guidance 138. Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over. November 2012.
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Rod et al. Perceived stress and risk of adult-onset asthma and other atopic disorders: a longitudinal cohort study. Allergy 2012;67:1408-1414.
Henneberger et al. An Official American Thoracic Society Statement: Work-Exacerbated Asthma. Am J Respir Crit Care Med 2011;184:368-378.
Eisner et al. Severity of asthma score predicts clinical outcomes in patients with moderate to severe persistent asthma. Chest 2012;1:58-65.

ETIOLOGIE. FACTORII DE RISC

Favorizani (teren)
Genetici
Obezitate
Sex
1

2,3

Declanani (mediu)
Indoor
1

Outdoor

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Rod et al. Perceived stress and risk of adult-onset asthma and other atopic disorders: a longitudinal cohort study. Allergy 2012;67:1408-1414.
Dixon et al. An Official American Thoracic Society Workshop Report: Obesity and Asthma. Proc Am Thorac Soc 2010;7:325-335.
NICE (National Institute for Health and Clinical Excellence) technology appraisal guidance 138. Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over. November 2012.

FACTORII GENETICI
Atopie
Hiperreactivitate bronic
Mediatori ai inflamaiei
Rspuns imun
Rspunsul la medicamente
1,2

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
http://ibstreatmentcenter.com/2012/02/conventional-ige-allergies.html
http://www.mstrust.org.uk/atoz/immune.jsp

FACTORI DE MEDIU
Alergeni
Infecii
Profesionali
Fumat
Poluare
Diet
Stress cronic
1-4

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
www.sjhvaporcleaning.com
www.healthmeup.com
www.airpurifiersource.com
Baur et al. ERS (European Respiratory Society) Task Force Report. Guidelines for the management of work-related asthma. Eur Respir J 2012;39:529-545.
Rod et al. Perceived stress and risk of adult-onset asthma and other atopic disorders: a longitudinal cohort study. Allergy 2012;67:1408-1414.

PATOGENEZ
Inflamaia
Celule inflamatorii
Celule ale cilor respiratorii
Mediatori
1

Atopia

Prima expunere
Repetarea expunerii

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Kumar V, Abbas AK, Fausto N (eds). Robbins and Cotran Pathologic basis of disease, 7th Ed, Elsevier Saunders, 2005. Cap15. The Lung. Asthma
www.eczemadailycare.ca

CELULELE INFLAMATORII
Mastocite
Eozinofile
Limfocite T
Celule dendritice
Macrofage
Neutrofile
1

www.onmedica.com Mast cell showing histamine granules on the surface that have been released.
www.allergycases.blogspot.com Eosinophils
www.astrographics.com T lymphocytes
www.standardofcare.com Macrophages
www.faculty.une.edu Neutrophils

CELULELE CILOR RESPIRATORII

Celule epiteliale
Fibre musculare netede
Celule endoteliale
Fibroblati
Fibre nervoase
1,2

1,3

1,4

1,5

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
www.conner.med.miami.edu Human bronchial epithelial cells
http://www.daviddarling.info/encyclopedia/E/endothelial_cell.html
http://biology-pictures.blogspot.ro/2011/10/fibroblasts-image.html
http://medical-dictionary.thefreedictionary.com/cholinergic+synapse

MEDIATORII
Chemokine
Citokine
Leucotriene C4, D4, E4
Histamin
Prostaglandin D2
Oxid nitric
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org

ATOPIA. PRIMA EXPUNERE

Alergen > Th2 > IL-3, IL-5, GM-CSF >
Eozinofile > Mediatori
Alergen > Th2 > IL-4 > Limfocite B >
IgE > Mastocite > IL-3, IL-5 >
Eozinofile > Mediatori
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Kumar V, Abbas AK, Fausto N (eds). Robbins and Cotran Pathologic basis of disease, 7th Ed, Elsevier Saunders, 2005. Cap15. The Lung. Asthma

ATOPIA. REPETAREA EXPUNERII

Reacie imediat (minute)
Alergen >
IgE >
Mastocite >
Mediatori preformai
Rspunsul ntrziat
(debut la 4-8 ore, durat 12-24 ore)
Mediat de leucocite
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Kumar V, Abbas AK, Fausto N (eds). Robbins and Cotran Pathologic basis of disease, 7th Ed, Elsevier Saunders, 2005. Cap15. The Lung. Asthma

FIZIOPATOLOGIE
Hiperreactivitatea bronic
ngustarea cilor aeriene
ngroare parietal
Contracie muscular
Ocluzia lumenului
1,2

1,2

1-4

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Kumar V, Abbas AK, Fausto N (eds). Robbins and Cotran Pathologic basis of disease, 7th Ed, Elsevier Saunders, 2005. Cap15. The Lung. Asthma
http://www.nejm.org/doi/full/10.1056/NEJM199810083391505 Papanicolaou stain, x 1000
http://www.flickr.com/photos/pulmonary_pathology/4861517242/ Bronchial mucous plugs

MODIFICRILE STRUCTURALE
Hiperinflaia
Mici arii de atelectazie
Ocluzia bronic (dopuri de mucus)
Inflamaia
1-3

2,3,5

Remodelare...............

http://www.pharmacology2000.com/Autacoids/Pulmonary/hyperinflation1.htm Post-Mortem Lung Hyperinflation: Asthma

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Kumar V, Abbas AK, Fausto N (eds). Robbins and Cotran Pathologic basis of disease, 7th Ed, Elsevier Saunders, 2005. Cap15. The Lung. Asthma
http://www.brown.edu/Courses/Digital_Path/systemic_path/pulmonary/asthma1.html Mucous plugs
http://www.healthcentral.com/asthma/c/52325/115663/updated-definition/ Bronchitis

ANAMNEZA
Antecedente familiale (atopie...)
Antecedente personale (eczem...)
Simptome recurente VARIABILITATE
Wheezing
Dispnee
Tuse
Constricie toracic
Apariie/agravare
Nocturn
Sezonier
Factori de risc din mediu
Proba terapeutic
www.prodentalcpd.com Albuterol inhaler
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk

EXAMENUL OBIECTIV
Normal
Wheezing
Sindrom de hiperinflaie
Sindrom de insuficien respiratorie
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
http://meded.ucsd.edu/clinicalmed/lung.htm

EXPLORRILE PARACLINICE
Funcia pulmonar
Spirometrie
Peak flow metrie
1,2

Reversibilitate
Variabilitate
Reactivitatea bronic
Inflamaia
Alergia
......Rx toracic

1,2

1,2

1,2

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org

British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
https://wiki.engr.illinois.edu/display/BIOE414/Spirometer+Proposal
http://www.inel.co.rs/en/products/vitalograph/mechanical_pfm.html

SPIROMETRIA
Ziua Mondial a Spirometriei
Tehnic
Parametri
VEMS. Reversibilitate VEMS 12% i 200 mL
VEMS/CV
Avantaje
Limite
1,2

3-8

www.european-lung-fundation.org
http://www.srp.ro/Spirometrie-145.htm Ziua Mondial a Spirometriei 2012 srbtorit n Romnia
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk , www.sign.ac.uk
Miller et al. Standardisation of spirometry. Eur Respir J 2005;26:319-338.
http://www.nagelnetwork.com/pcspir.html
http://en.wikipedia.org/wiki/Spirometry
www.spirometrie.info

PEAK FLOW METRIA

Tehnic
Parametru
PEF Reversibilitate PEF 20% sau 60 L/min
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk

REACTIVITATEA BRONIC
Indicaie
Tehnic
Metacolin
Histamin
Manitol
Efort
Parametru
Concentraia/doza VEMS cu 20%
Avantaje/dezavantaje
Sensibilitate >
Specificitate <

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
http://www.sciencedirect.com/science/article/pii/S0002934303001931

INFLAMAIA
Sputa

Celule
Eozinofile
Neutrofile
Spirale Curschmann
Cristale Charcot-Leyden
Oxidul nitric n aerul expirat
Monoxidul de carbon n aerul expirat
2,3

4,5

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org http://en.wikipedia.org/wiki/Curschmann%27s_spirals
www.kmle.co.kr Curschmanns spirals
http://commons.wikimedia.org/wiki/File:Charcot-Leyden_crystals,_HE_1.jpg

http://ruby.fgcu.edu/courses/davidb/50249/web/charcot64.htm Charcot-Leyden crystals

ALERGIA
Teste cutanate
IgE serice specifice
!!!! IgE totale nu au valoare diagnostic n atopie
Teste de provocare cu alergen
1-3

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
ttp://www.kidsunder7.com/2010/08/allergy-test.html#.UT3_lTeyAwQ
http://www.myallergydr.com/services.htm

RADIOGRAFIA. INDICAII
Suspiciune pneumomediastin
Suspiciune pneumotorace
Sindrom clinic de condensare pulmonar
Astm amenintor de via
Rspuns insuficient la tratament
Ventilaie mecanic
Diagnostic incert

DIAGNOSTIC
Pozitiv

1-3

Tablou clinic
Reversibilitate
VEMS 12% i 200 mL
PEF 20% sau 60 L/minut
Diferenial
Boli cu obstrucie bronic
BPOC ....
Boli fr obstrucie bronic
IVS .........
1-3

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy ClinImmunol 2007;120(suppl 5):S94-S138 .
Tinkelman et al. Symptom-based questionnaire for differentiating COPD and asthma. Respiration 2006;3:296-305.

CLASIFICARE
Etiologie
Fenotip
Clinic
Inflamator
Severitate
Uor
Sever
Control
Clinic curent
Risc de efecte adverse
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org

ETIOLOGIE

ETI OLOGI E
Extrinsec

I ntrinsec

Debut. Copilrie

Trigger. Alergen

Antecedente familiale

Antecedente personale

Teste cutanate

I gE serice specifice

CONTROL CLINIC CURENT

CONTROL CLI NI C CURENT
Parametru

Controlat

Parial controlat

Necontrolat

Simpt diurne

sau2/ spt

> 2/ spt

> 2/ spt

Limit activitate

Simpt nocturne

Tratament

sau2/ spt

> 2/ spt

> 2/ spt

VEM, PEF

< 80%
( personal best)

< 80%
( personal best)

Exacerbare

Criteriu

Toate

Oricare sau
ExA < 1 an

3 sau
ExA < 1 spt

RISC CRESCUT DE EFECTE ADVERSE

Efecte adverse
Exacerbare
Instabilitate
Reducere rapid a funciei pulmonare
Condiii asociate cu risc crescut
Medicaie
Control
Exacerbri frecvente n ultimul an
VEMS
Fumat
National Asthma Education and Prevention Program . Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007 . J Allergy Clin Immunol . 2007 ; 120 ( suppl 5 ): S94 - S138
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org

FORME CLINICE (1)

Astm nocturn
Caugh-variant asthma
Bronhoconstricia indus de efort
Astmul indus de aspirin
Work-related asthma
1

2-5

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Tarlo SM and Malo JL. An Official ATS (American Thoracic Society) Proceedings: Asthma in the Workplace. Proc Am Thorac Soc 2009;6:339-349. DOI: 10.1513/pats.200810-119ST.
Baur et al. ERS (European Respiratory Society) Task Force Report. Guidelines for the management of work-related asthma. Eur Respir J 2012;39:529-545.
Henneberger et al. An Official American Thoracic Society Statement: Work-Exacerbated Asthma. Am J Respir Crit Care Med 2011;184:368-378. DOI:10.1164/rccm.812011ST.
Pavel A. Particularitatile diagnosticului pozitiv in astmul bronsic profesional https://www.emcb.ro/article.php?story=20051209175238186

FORME CLINICE (2)

Vrstnici
Obesity-associated asthma
Asociere cu rinit, sinuzit, polipi nazali
Difficult-to-treat asthma
Astmul fragil (brittle asthma)
1

1,2

3,4

5,6

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
Dixon et al. An Official American Thoracic Society Workshop Report: Obesity and Asthma. Proc Am Thorac Soc 2010;7:325-335. DOI:10.1513/pats.200903-013ST.
Weiler JM et al. American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. Pathogenesis, prevalence, diagnosis, and management of exerciseinduced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol 2010 Dec;105(6 Suppl):S1-47.
www.whiar.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk , www.sign.ac.uk
Ghid de management al astmului

EXACERBAREA. CLASIFICARE
EXACERBAREA. CLASI FI CARE

(1)

( 1)

Uoar

Moderat

Sever

Plimbare

Vorbire

Repaus

Wheezing

>

>>

Respiraie

25/ min

25/ min

25-30/ min

Vorbire

Fraze

Propoziii

Cuvinte

Obiectiv

Dec dorsal

eznd

Aplecare

Dispnee

EXACERBAREA. CLASIFICARE

(2)

EXACERBAREA. CLASI FI CARE

( 2)

Uoar

Moderat

Sever

Puls

< 100/ min

< 100-110

110- 120

PEF

> 80%

> 60%

< 60%

SaO2

> 95%

> 91%

< 90%

paO2

> 60 mmHg

< 60 mmHg

< 45 mmHg

< 45 mmHg

> 45 mmHg

paCO2

EXACERBAREA. CLASIFICARE (3)

Non-sever
Sever
Amenintoare de via
PEF < 33%
SaO2 < 92%
PaO2 < 60 mm Hg
PaCO2 <45 mm Hg
Cianoz
Confuzie, com
Silentium respirator
Astm aproape fatal
PaCO2 > 45 mm Hg
Necesitatea ventilaiei mecanice

British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.britthoracic.org.uk , www.sign.ac.uk

Ghid de management al astmului

CUPRINS
Noiuni introductive
Diagnostic
Management
Obiective generale
Non-farmacologic

Obiective

Mijloace
Parteneriatul pacient-medic
Identificarea i reducerea expunerii la factorii de risc
Farmacologic

PARTENERIATUL PACIENT-MEDIC
Educaia pentru sntate
Pacient
Aparintori

Consultaia iniial
Vizitele ulterioare
Aderen la tratament redus
Medicaie
Alte cauze
Planul de aciune scris

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

EDUCAIA PENTRU SNTATE

Ce este astmul bronsic?
Ce provoac astmul?
Cum se manifest astmul?
Cum se pune diagnosticul de astm?
Ce este de facut?
Tratamentul de fond al astmului
Tratamentul astmului n exacerbare
www.srp.ro/Astmul-bronic-124.htm

EXPUNEREA LA FACTORII DE RISC

Alergeni
Pneumoalergeni
Alimentari i digestivi
Insecte (venin)
Medicamente
Chimici (profesionali sau nu)
Ali factori de risc
Emoii
Reflux gastroesofagian
Efort fizic
Alte condiii
Menstruaia
Sarcina
Imunoterapia specific cu vaccinuri alergenice
Ghid de management al astmului

MANAGEMENTUL. MIJLOACE
Medicaie de control (controllers)
Medicaie de salvare (relievers)
Medicina complementar/alternativ
Termoplastia
Suplimentele alimentare
Gimnastica respiratorie
http://sleepapneadisorder.info/2010/07/05/redwood-city-ca-residents-find-freedom-from-asthma-snoring-sleep-apnea-and-allergies-with-buteyko-breathing-from-buteykolearning-com

MEDICAIA DE CONTROL
10

Corticosteroizi inhalatori (CSI)

Antileucotriene (AL)
Beta 2 agoniti cu durat lung de aciune (BADLA)
Teofilin retard (Tf)
Corticosteroizi orali (CSO)
Anticolinergice inhalatorii. Tiotropium
Cromone
Anti IgE
1-4

1,2

1,2

1,2

1,2

1,2

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
NICE (National Institute for Health and Clinical Excellence) technology appraisal guidance 138. Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over. November 2012.
www.nice.org.uk/TA138
http://es.usermeds.com/medicamentos/pulmicort
Kerstjens et al. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med 2012;367:1198-1207.
NICE (National Institute for Health and Clinical Excellence) technology appraisal guidance 133. Omalizumab for severe persistent allergic asthma. August 2010. www.nice.org.uk/TA133

CORTICOSTEROIZII INHALATORI
CORTI COSTEROI ZI I I NHALATORI
Molecula

Doz mic
( g/ zi)

Doz medie
( g/ zi)

Doz mare
( g/ zi)

Budesonid

200-400

> 400-800

> 800- 1600

Beclometazon

100-250

> 250-500

> 500- 1000

Fluticazon

100-250

> 250-500

> 500- 1000

Ciclesonid

80-160

> 160-320

> 320- 1280

Mometazon

200

400

800

MEDICAIA DE SALVARE
Beta 2 agoniti inhalatori cu durat scurt de aciune (BADSA)
Anticolinergice inhalatorii. Ipratropium
Corticosteroizi
Beta 2 agoniti pe cale oral (durat scurt)
Sulfat de magneziu iv
Aminofilin iv
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

http://inhalerdosage.com/atrovent-inhaler-dosage/

TREPTELE TERAPEUTICE. STEPPING

11

TREPTELE TERAPEUTI CE. STEPPI NG

Ghid de management al astmului

MONITORIZAREA
Cine?
Medic de familie
Medic specialist
Cum?
Chestionare
Controlul astmului
Calitatea vieii
Spirometrie
Peak flow metrie
Oxid nitric n aerul expirat

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk

CHESTIONARELE
Royal College of Physicians (RCP) 3 Questions
Asthma Control Test (ACT)
Asthma Control Questionnaire (ACQ)
Asthma Therapy Assessment Questionnaire (ATAQ)
Asthma Control Scoring System (ACSS)
Work productivity and impairment index-asthma (WPAI-A)
The severity of asthma (SOA) score
Asthma Impact Survey (AIS-6)
Asthma Quality of Life Questionnaire (AQLQ)
Mini Asthma Quality of Life Questionnaire (mAQLQ)
1

2,3

4,5

6,7

10

11

11

Pearson MB (ed). Measuring clinical outcomes in asthma: a patient focused approach. London: Royal College of Physicians; 1999.
http://www.asthmacontroltest.com/
Schatz M, Sorkness CA, Li JT, Marcus P, Murray JJ, Nathan RA, et al. Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol
2006;117(3):549-56.
http://www.qoltech.co.uk/acq.html www.qoltech.co.uk/Asthma1.htm
Juniper EF, Bousquet J, Abetz L, Bateman ED. Identifying wellcontrolled and not well-controlled asthma using the Asthma Control Questionnaire. Respir Med 2006;100(4):616-21.
http://www.asthmacontrolcheck.com/asthma_control/asthmacontrolcheck/consumer/questionnaire_adults.jsp
Juniper EF, OByrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999;14(4):902-907.
Boulet et al. How should we quantify asthma control? A proposal. Chest 2002;122:2217-2223.
Eisner et al. Severity of asthma score predicts clinical outcomes in patients with moderate to severe persistent asthma. Chest 2012;1:58-65.
Schatz et al. The relationship of asthma impairment determined by psychometric tools to future asthma exacerbations. Chest 2012;1:66-72.
Juniper EF, OByrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999;14(4):902-7.

12

MANAGEMENTUL EXACERBRILOR
Managementul n ambulator
Managementul n UPU
Criterii de internare n spital
Criterii de externare din UPU
Criterii de externare din spital
Monitorizare dup externare
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

MANAGEMENTUL N AMBULATOR
MANAGEMENTUL N AMBULATOR

Preluare

ExA non-sever

ExA sever

ExA
amenintoare
de via

MANAGEMENTUL N UPU

13

MANAGEMENTUL N UPU
Preluare

ExA
non- sever
sever

ExA
amenintoare
de via

Externare

I nternare

CRITERII DE INTERNARE
ExA non-sever ce nu rspunde la tratamentul iniial (n ambulator)
ExA sever ce nu rspunde la tratamentul iniial (n ambulator, UPU)
ExA sever dac nu sunt condiii de supraveghere i tratament (n UPU)
ExA amenintoare de via sau aproape fatal (n UPU)
Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

LUAREA N CONSIDERARE A INTERNRII

Prezentare dup amiaza/seara (n ambulator)
Simptome nocturne recente (n ambulator)
Antecedente de ExA severe/spitalizri pentru astm (n ambulator)
Condiii socioeconomice precare (n ambulator)
ExA sever care a rspuns la tratamentul iniial (n UPU), (PEF > 75% din personal best sau
prezis dup 1 h de tratament intensiv) dar care prezint una din urmtoarele caracteristici:
Simptome semnificative restante
Noncomplian, probleme psihologice
Lips de ajutor la domiciliu
Dificulti de nvare
Dizabilitate fizic
Antecedente de EXA aproape fatal sau de astm fragil
Prezentare n cursul nopii (n UPU)
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

CRITERII DE EXTERNARE
ExA non-sever care devine stabil clinic + PEF > 75% dup BADSA nebulizare generat
de oxigen
ExA non-sever care devine stabil clinic + PEF > 75% dup BADSA nebulizare generat
de oxigen, repetat la 15-20 min + Prednison 40-50 mg/zi

14

ExA sever care devine stabil clinic + PEF > 75% dup BADSA nebulizare generat de
oxigen, repetat la 15-20 min + Prednison 40-50 mg/zi
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

MONITORIZARE DUP EXTERNARE

n primele 1-2 zile
Identificarea factorilor de risc
Revizuirea tehnicii inhalatorii, PEF
Revizuirea planului de aciune
Tratament
CSO 7 zile
CSI iniiere sau continuare
BADSA pn la ritmul de dinainte de exacerbare
Anticolinergicul ntrerupt ct mai repede
BADLA

Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

MANAGEMENT. SITUAII SPECIALE

Sarcin
Alptare
Operaii
Anafilaxie
Global Strategy for Asthma Management and Prevention. Update 2012. www.ginasthma.org
British Thoracic Society, Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. www.brit-thoracic.org.uk ,
www.sign.ac.uk
Ghid de management al astmului

15