FARMASI KLINIS 2 – ASMA AKUT (EKSASERBASI ASMA) – From: GINA 2017 - By: Amelia Lorensia

- 2017
Outline
Definition , description, and
diagnosis of Asthma

Assessment of asthma

Treating asthma to control

symptoms and minimize risk

Management of worsening
asthma and exacerbations

Diagnosis of asthma, COPD and

asthma-COPD overlap syndrome
(ACOS)
Asthma is a heterogeneous
disease, usually characterized
by chronic airway
inflammation. It’s defined by
the history of respiratory
symptoms such as wheeze,
shortness of breath, chest
tightness and cough that vary
over time and in intensity,
together variable expiratory
airflow limitation.1
 Asthma
Phenotypes
 Asthma Allergic asthma

Phenotypes Non-Allergic asthma

Late-onset asthma
Many phenotypes
Asthma with fixed
have been identified.
airway limitation
Some of the most
common include:1
Asthma with obesity

Asma dapat diterapi secara efektif.

Klo asma terkontrol dengan baik maka...1
Factor that may trigger or worsen asthma symptoms
include:1

• Viral infections These responses

• Domestic or occupational
allergens (e.g. House dust
are more likely
mite, pollens, cockroach), when asthma is
• Tobacco smoke
• Exercise
uncontrolled
• Stress

• Drugs 
e.g. Beta-blockers, NSAIDs
 Drug induced ASTHMA

Beta-
NSAIDs
blocker
 Beta-
blocker
NSAIDs Cyclo-oxygenase
pathway

Lipoxygenase
pathway
 EPIDEMIOLOGI
Asthma is considered the fifth caused of
death in the world, with the prevalence
range is about 5-30 %.

In Indonesia, prevalence of asthma in community

hasn't known yet, but it is predicted around 2-5%.
Riskesdas (National Health Survey) (2007)  Sample of the study is 32.262
casus. The result showed that asthma prevalence in community is 3.32 %.

Multivariate analysis shows that demographic factors (age, education, and

occupation), differential disease (TBC, acute infectious of the upper
respiratory disease, allergic dermatitis and rhinitis), life stile (smoking and
preservative), and environment (had rising livestock goat, pig, and sheep), is
the most influence in asthma disease.
Pathogenesis (Cell iInflammation in Asthma)
MAKING THE DIAGNOSIS OF ASTHMA
THE RELATIONSHIP OF LUNG FUNCTION WITH
OTHER ASTHMA CONTROL MEASURES

Lung Asthma
function symptoms
is a strong independent predictor of
FEV1 ↓ risk of exacerbations, even after
adjustment for symptom frequency.
Asthma Control Test (ACT)
1. It's simple and easy to use  only 5
questions.
2. It gives us a score,
o Perfect score is 25.
o ≤ 20  not well controlled.
3. It's validated. This ACT was validated
and showed to correlate quite well
with a specialist's assessment.
Interpreting changes in lung function (FEV1)
in clinical practice
Regular ICS FEV1 starts to Reaches after around
treatment improve 2 months

px’s highest FEV1

reading (personal best)
should be documented

variability of FEV1 (≤12% week to week

or 15% year to year in healthy individuals)

adjusting asthma treatment in clinical practice

SPIROMETRY
 PEF monitoring
ASTHMA short-term
PEF
monitoring

Personal best PEF (for 2x daily

reading) is reached on average
within 2 weeks (after starting ICS)
Average PEF continued to increase,
and diurnal PEF variability to
decrease, for about 3 months
Excessive variation in
PEF suggests suboptimal
asthma control, and
increases the risk of
exacerbations
PEAK EXPIRATORY METER

29
• The diagnosis of asthma should be
confirmed and, for future reference, the
evidence documentes in the patient’s notes.
Depending on clinical urgency and access to
resources, the should preferably be done
before starting controller treatment.
Confirming the diagnosis of asthma is more
difficult after treatment has been started.1

• Physical examination in people with asthma

is often normal, but the most frequent finding is
wheezing on auscultation, especially on forced
expiration.1
Features used in making the diagnosis of asthma:1

A history of variable
respiratory symptoms

Evidence of variable
expiratory airflow FEV1 / FVC
limitation >0,75 – 0,80
 Features used in making the diagnosis of asthma:1

 >1 symptoms
A history of variable  Worse at night or in the early
morning
respiratory symptoms
 Vary over time and intensity
 Symptoms are triggered

Confirmed variable  Isolated cough

expiratory airflow  Chronic production of
sputum
limitation
 Shortness of breath
 Chest pain
 Exercise-induced dyspnea
 Features used in making the diagnosis of asthma:1

A history of variable Confirmed variable expiratory airflow

respiratory symptoms
.............
limitation
- ............
- Document that variation in lung
function is grater than in healthy people.
- ............

 FEV1 increases by >12% and 200 mL (in children: >12% of the predicted value)
after inhaling a bronchodilator. This is called “bronchodilator” reversibility.
 Average daily diurnal PEF variability is >10% (in children: >13%)
Calculated from 2x daily readings (best of 3 each times), as ([the day ‘s
highest PEF minus the day’s lowest PEF]) divided by the mean of the day’s
highest and lowest PEF, and averaged over 1-2 weeks.
If using PEF at home or in the office, use the same PEF meter each time.
 FEV1 increases by >12% and 200 mL from baseline (in children by >12% of the
predictes value) after 4 weeks of antiinflammatory treatment (outside
respiratory infections).
 Features used in making the diagnosis of asthma:1

Lung Function Testing to document variable

expiratory airflow limitation

Asthma is characterized by variable expiratory airflow limitation.

In asthma, lung function may vary between completely normal and
severely obstructed in the same px.
Poorly controlled asthma is associated with greater variability in lung
function than well-controlled asthma.

FEV1 more reliable than PEF FEV1/FVC ratio is

normally greater
than 0,75 to 0,80
If PEF is used, the same meter should be
used each time, as measurements may
differ from meter to meter by up to 20%.
 Features used in making the diagnosis of asthma:1
Lung Function Testing to document variable expiratory airflow limitation
(cont’d)

In clinical practice, once an obstructive defect has been confirmed, variation

in airflow limitation is generally assessed from variation in FEV1 or PEF.

Variability refers to improvement and/or deterioration

in symptoms and lung function.
Excessive variability may be identified over the course of
one day (diurnal variability), from day to day, from visit
to visit, or seasonall, or from a reversibility test.

Reversibility generally refers to rapid

improvements in FEV1 (or PEF), measured within
minutes after inhalation of a rapid-acting
bronchodilator (such as 200-400 mcg Salbutamol) or
more sustained improvement over days or weeks after the
introduction of effective controller treatment such as ICS.
Are there any comorbidities? 1

These include:
– Rhinitis
– Rhinosinusitis
– GERD
– Obesity
– Onstructive sleep Comorbidities should be
apnea identified as they contribute
– Depression to respiratory symptoms and
– Anxiety poor quality of life. Their
treatment may complicate
asthma management.
 Exacerbation asthma /
Asthma attacks (Asthma flare-ups) 1
Is an acute or sub-acute
worsening in symptoms and
lung function from the px’s
usual status; occasionally it
may be the initial
presentation of asthma. P.58
TERMINOLOGY ABOUT
EXACERBATION
 In hospital-based studies
 acute severe asthma.
 In clinical practice 
exacerbation is not
suitable.
 = Flare-up
 = attack
 EKSASERBASI ASMA
Exacerbation asthma / Asthma
attacks (Asthma flare-ups) 1

• May occur, even in people

taking asthma treatment.
• When asthma is uncontrolled,
or in some high-risk patients,
these episodes are more
frequent and more severe,
and may be fatal.1
These px should be identified, and flagged for more frequent review.

A history of near-fatal asthma requiring intubation &

ventilation.
Hospitalization or emergency care for asthma in last 12
months
Not currenly using ICS, or poor adherence with ICS
Currently using or recently stopped using OCS (this
indicates the severity of recent events)
Over-use of SABAs, especially >1 canister/month
Lack of written asthma action plan (poor adherence)
History of psychiatric disease or psychosocial problems
Food allergy in a patient with asthma
DIAGNOSIS OF EXACERBATIONS

Change in symptoms

decrease in expiratory airflow

can be quantified by lung function
measurement such as PEF or FEV1
Assess MANAGING
EXACERBATIONS IN
PRIMARY OR ACUTE CARE
ASSESS exacerbaton severe
while starting SABA and
oxygen.
Assess dyspnea (e.g. Is the px
ablw to speak sentence, or
only word), respiratory rate,
pulse rate, oxygen saturation
and lung function (e.g. PEF)
Check for anaphylaxis.
Assess MANAGING
EXACERBATIONS IN
PRIMARY OR ACUTE CARE

Consider Alternative causes

of acute breathlessness
(e.g. Heart failure, upper
airway dysfungtion, inhaled
foreign body or pulmonary
embolism).
Assess MANAGING
EXACERBATIONS IN
PRIMARY OR ACUTE CARE
Arrenge immediate transfer to an
acute care facility if there are signs
of severe exacerbation, or to
intensive care if the px is drowsy,
confused, or has a silent chest.
For the px, immediately givw inhaled
SABA, inahled ipratropium bromide,
oxygen and systemic corticosteroid.
Assess MANAGING
EXACERBATIONS IN
PRIMARY OR ACUTE CARE
Start treatment with repeated dose of
SABA (usually by pMDI and spacer),
early OCS, and controlled flow
oxygen if available.
Check response of symptoms and
saturation frequently, and measure
lung function after 1 hour.
Titrate oxygen to maintain saturation
of 93-95% in adults and adolescents
(94-98% in children 6-12 years).
Assess MANAGING
EXACERBATIONS IN
PRIMARY OR ACUTE CARE
For severe exacerbations, add
ipratropium bromide, and consider
giving SABA by nebulizer.
In acute care facilities, intravenous
MgSO4 may be considered if px isn’t
responding to intensive intial
treatment.
 MANAGEMENT OF ASTHMA EXACERBATIONS IN PRIMARY CARE

PRIMARY CARE  Px presents with acute of sub-acute asthma exaserbation

ASSESS the PX  Is it asthma?

Risk factors for asthma-related death?
Severe of exacerbation?

MILD or MODERATE SEVERE LIFE-

• Talks in phases, prefers sitting
to lying, not agitated
• Respiratory rate increased
• Acceccory muscles not used
• Pulse rate 100-120 bpm
• O2 saturation (on air) 90-95%
• PEF >50% predicted or best
• Talk in words, sits hunched THREATENING
forwards, agitated
• Respiratory rate >30/min
• Acceccory muscle in use • Drowsy,
• Pulse rate >120 bpm confused or
• O2 saturation (on air) <90% silent chest
• PEF ≤50% predicted or best

urgent
START TREATMENT TRANSFER TO ACUTE CARE FACILITY
 START TREATMENT
SABA
4-10 puff pMDI + spacer, repeat
every 20 minutes for 1 hour.
Prednisolone
Adult 1 mg/kg, max 50 mg.
Controlled oxygen
(if available): target saturation
93-95%.
ASSESS for DISCHARGE
Symptoms improved, not needing
SABA
PEF improving, and >60-80% of
personal best or predicted
Oxygen saturation >94% room air
Resources at home adequat
TRANSFER TO ACUTE CARE FACILITY
While waiting: give SABA, O2, systemic
corticosteroid.
CONTINUE TREATMENT
with SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
ARRANGE at DISCHARGE
Reliever: continue as needed
Controller: start, or step up. Check
inhaler technique, adherence
Prednisolone: continue, usually for 5-
7 days
Follow up: within 2-7 days
FOLLOW UP
 FOLLOW UP

Reliever: reduce to as-needed

Controller: continue higher dose for short term (1-2 weeks) or long term (3
months), depending on backgound to exacerbation
Risk factors: check and correct modifible risk factors that may have
constributed to exacerbation, including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriated? Does it need
modification?

...until symtoms and lung function return to normal.

Take the opportunity to review:
- The px’s understanding of the cause of the
exacerbation
- Modifiable risk factors for exacerbations, e.g. Smoking
- Understanding of purposes of medications, and inhaler
technique skills
- Review and revise written asthma action plan