Documenti di Didattica
Documenti di Professioni
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Childhood Asthma
Helmi Lubis
Ridwan M. Daulay
Wisman Dalimunthe
Rini S. Daulay 1
Definition of cough
a sudden explosive expiratory maneuver
that tends to clear materials from the
airways and prevent aspiration of food or
fluid
2
Physiologic or pathologic?
Cough
Physiologic Pathologic
3
Cough Model Reflex
Cerebral cortex
Voluntary control Placebo effect
of cough
Sensation of
irritation
Vagus nerve
Larynx
Vagal nerve
Muscle,
branch
Trachea Larynx, trachea,
and bronchus
Bronchus Vagal nerve
Distributed evenly
Ear in medulla near by
the respiratory
Gastric center:
Under the higher
control center Diaphragm;
Nerve Phrenicus,
Nose Intercostal,
Trigeminal nerve Intercostal &
Abdominal & lumbal
Sinus paranasal lumbaris
muscles
Pericardium
Nerve phrenicus
diaphragm
5
Chang AB. Cough 2003;7:1-15.
How do we cough ?
Inspiratory Compressive Expiratory
cmH2O
4.0 40
L/s
8
Diagnosis of Asthma
Basement
Membrane
thickening
Oedema
Neutrophil and
Smooth muscle eosinophil infiltration
Hypertrophy and contraction 10
Barnes PJ
Getting to asthmatic inflammation
– what does it take ???
Normal Asthma
11
Inflammation in asthma
Acute
inflammation
Steroid
response
Chronic inflammation
Structural changes
Time
12
Barnes PJ
Pathogenesis
Environment Genetic susceptibility
14
2 aspect of asthma
Asthma : chronic respiratory disease, that can
have acute exacerbation
Chronic Asthma
Asthma
Acute Asthma
Asthma management
19
Why happened ??
Asthma
Triggers
Attack
Pathophysiology
Trigger
Nonuniform Hyperinflation
ventilation
Decreased
surfaktant Alveolar hypoventilation Increased work
Acidosis of breathing
Pulmonary
vasoconstriction PaCO2
PaO2
Severity of asthma attack
Mild
Moderate
3.9%
11.7% Severe
84.4%
Estimation of severity of asthma attack
Sign/ Mild Moderate Severe Imminent
Symptom respiratory
arrest
Activities Walking Talking Rest
(infant) (loudly cried) (weak cried) (stop eating)
First management
• 2-agonist nebulization (neb) 3x, 20’ interval
• 3rd neb + anticholinergic
Nebulization 1-2 x
ODC
Discharge Oxygen
Nebulization Wards
Oral Steroid Oxygen
Bronchodilator
IVFD Nebulization
IVFD
IV/oral Steroid
Good Response Poor Response Rehydration
Amynophylline
Discharge
Why no response ???
• Dehidration
• Metabolic acidosis
• Atelectasis
Severe Attack
• No/ bad response after nebulization
• Oxygen
• Parenteral, rehidration, acidosis
correction
• Steroid IV
• lnitial Aminophylline IV,
then the maintenance
• Nebulization
• Chest X-ray
• Good: May Go Home
• No/ bad response: Intensive Care
Oxygen
• Must be given in severe attack
41
Classification of disease
Clinical parameter , Infrequent episodic Frequent episodic
Persistent asthma
And lung function asthma asthma
Frequent nocturnal
Between episodes No symptoms Symptoms (+) symptoms
Sleep and activity Normal May affect Affect
“Fear” of
1980 short-acting
ß2-agonists
1985
2000
1990 1995
Pharmaco- Immuno-
therapy COSTS therapy
Education
45
GINA, 2002
Cost ?
Availability ?
46
Avoidance
• Avoidance of triggers : House dust
mite
• Pre and during pharmacotherapy
GINA, 2002
47
Family Education
• Aim to:
– Increase understanding
– Increse skill
– Increse satisfaction
– Increse confidence
– Increse compliance and self management
– Patient-family-doctor relationships
GINA,2002
48
Immunotherapy
• Desensitisation
• Controversial
• Multifactorial triggers
• Not populair
49
Pharmacotherapy
Reliever:
• 2 agonist : inhaler, nebulized, oral
• Epinephrine : subcutan
• Theophylline : oral, I.V.
• Anticholinergic (ipratropium br) : inhaler
• Steroid : oral, I.M.
Controller:
• Steroid : inhaler
• LABA : inhaler, oral
• Leukotrien : oral
PNAA, 2002
50
When??
Classifications Controller Reliever
Infrequent No Yes
episodic asthma
Frequent Yes Yes
episodic asthma
Persistent Yes Yes
asthma
51
Medications
• Bronchodilators
• Antiinflammations
• Anti-remodelling
• Anti IgE
• Immunizations: ??
52
TREATING ASTHMA
is like
Painting over rust !!!
53
Infrequent episodic asthma
• No daily medication
• Treatment of exacerbations depend on
severity of attacks
• -2 agonist as needed
54
Frequent episodic and persistent
asthma
• Controller medications: every day
• Corticosteroid with or without any drugs
• Combination with LABA, TSR, ALT
• Gradual reduction if stable in 6-8 weeks
55
Anti-inflammations
• Antihistamine
• Disodium Cromoglycate (DSCG)
• Corticosteroids
56
Long-term placebo-controlled trial of ketotifen in the
management of preschool children with asthma
Loftus BG, Price JF
J Allergy Clin Immunol 1987; 79:350-5
57
Inhaled disodium cromoglycate (DSCG) as
maintenance therapy in children with asthma:
a systematic review.
Tasche MJA, Uijen JHJ, Bernsen RMD, de Jongste JC, van der Wouden JC.
Thorax 2000; 55:913-20
ORAL
STEROID
59
Corticosteroids
• The most effective anti-inflammatory
medications
• Improving lung function
• Airway hiperresponsiveness:
• Reducing symptoms
• Frequency and severity of
exacerbations:
• Improving quality of life
60
Epithelial Repair Following Steroid Treatment
Before After
P Howarth, 1999
61
Steroid efficacy in asthma
Steroid
Benefit dose
Side-effects
62
Type of inhalation therapy
• Metered dose inhaler (MDI)
– With spacer
– Without spacer
• Dry powder inhaler (DPI)
– Turbuhaler, cyclohaler
• Nebulizer
– Jet
– Ultrasonic
63
Benefit of steroid inhalation
• Low dose
• Directly to respiratory tract
• Fast onset
• Minimal systemic side effects
64
LABA’s and ICS - complementary modes of action
Symptoms / exacerbations
65
CS + LABA Vs CS double dose
85
% predicted
80
75
70
-1 0 1 2 3 6 9 12
Months
Placebo
*p<0.01 vs baseline Salmeterol 50 µg bid
Increased †p<0.05 vs placebo
functional status 100
*† *† Well children
*
Mean FSIIR
* *
score
90
Chronically
ill children
80
0
Decreased 0 4 12
8
functional status
Time (weeks)
68
FSIIR, functional status IIR
Mahajan et al. Pediatr Asthma Allergy Immunol 1998
Longterm steroid……
Adverse event
• Hoarseness
• Throat irritations
• Candidiasis
• Headaches
• Growth??
69
Positive impact of inhalation therapy
INHALATION
Family Financial
ORAL
• Quality of life
Patient • Quality of therapy
• To another doctor
• Go abroad
- Stable asthma
(Low performance
of Indonesian Patient Get Patient
70
pediatricians )
71