Asma pada Anak

Dr Rahmini Shabariah SpA

Definisi
1950-an
OBSTRUKSI SALURAN RESPIRATORIK YANG REVERSIBEL SECARA SPONTAN ATAU SETELAH PENGOBATAN TERATASI

DEFINISI ASMA
 

Inflamasi kronik saluran respiratorik Banyak sel dan elemen seluler berperan (sel mast, eosinofil, limfosit T) Pada orang rentan, inflamasi kronik episodik wheezing berulang, batuk, sesak nafas, rasa dada tertekan Berhubungan dengan penyempitan saluran respiratorik yang luas dan bervariasi irreversibel sebagian atau teratasi spontan / pengobatan
GINA, 2002

Inflamasi
Deskuamasi epitel Hiperplasi kelenjar mukus

Mucus plug

Penebalan membrana basalis

Edema Hipertrofi dan konstriksi otot polos

Barnes PJ

Infiltrasi netrofil dan eosinofil

Respiratory tract of childhood asthma:

Triggers
(dust mite, exercise, etc)

sensitive reactive constriction

Normal

Attacks

bronchoconstriction oedema hypersecretion

bronchus

bronchus

Inflamasi pada asma

Inflamasi akut

Respons steroid

Inflamasi kronis

Perubahan struktur

Waktu

Barnes PJ

Kejadian wheezing

Transient Wheezers

Non-Atopic Wheezing berulang Wheezers Major : Dermatitis atopi Orang tua asma Minor Eosinofil darah Wheezing Rinitis alergika Asma: jika 2 major atau 1 major +2 minor

Asma

3 Umur (tahun)

11

Fig. 6. Hypothetical peak prevalence by age for the 3 different wheezing phenotypes. The prevalence for each age interval should be the area under the curve. This does not imply that the groups are exclusive.
Taussig LM, et al. JACI 2003; 111:661-675

Diagnosis
Cough

and/or wheezing that:

episodic, nocturnal (variability), reversibility

with atopic family

Klasifikasi Asma
Derajat serangan (Akut)
Ringan Sedang Berat Ancaman henti napas

Klasifikasi penyakit (kronis)

Asma episodik jarang Asma episodik sering Asma persisten

Klasifikasi penyakit
Parameter klinis dan uji fungsi paru Asma episodik jarang Asma episodik sering Asma persisten

Frekuensi Lamanya Antar serangan Tidur dan aktivitas Pemeriksaan fisis Pengendali

< 1x /bulan < 1 minggu Tanpa gejala Normal Normal Tidak perlu

> 1x /bulan >1 minggu gejala(+) Mungkin terganggu

Mungkin abnormal Steroid/kombinasi

Setiap hari
Setiap hari Gejala malam hari

terganggu Abnormal Steroid/kombinasi

Fungsi paru PEF/FEV1 <60% PEF/FEV1 >80% PEF/FEV1 60-80% (diluar serangan) Variabilitas 20-30%
Variabilitas (serangan)

>15%

> 30%

> 50%

Tujuan tatalaksana asma

Gejala kronik minimal (idealnya tidak ada) Serangan akut minimal (jarang) Kunjungan ke UGD tidak pernah Penggunaan 2-agonis minimal Aktivitas tidak terhambat Uji fungsi paru normal (mendekati) Efek samping obat minimal

Tatalaksana asma
Penghindaran alergen

Farmako terapi

BIAYA

Imuno terapi

Pendidikan

GINA, 2002

A S T Triggers H 2 M 1 A 4 Assess of classification

Asthma attacks
Assess and Management No asthma attacks (Stable asthma) 3

Infrequent episodic asthma 6 Reliever (+) Controller (-) 7

Frequent episodic asthma EDUCATIONS and AVOIDANCE Reliever (+) Controller (+) 8

Persistent asthma

Reliever (+) Controller (+)

Asthma attacks algorithms Emergency room Assess severity.of attacks Early treatment
nebulized F-agonist 3x, interval 20 min 3rd nebulized + anticholinergic Mild attacks
(nebulized 1x, good response)

Moderate attacks
(nebulized 2-3x, partial response) O2

Severe attacks
(nebulized 3x, poor response) O2 IV line reassessment p severe, p admission Chest X-ray

observe 1-2 jam, discharge symptoms (+) p moderate attack

reassessment p moderatep ODC IV line

Discharge give F-agonist

(inhaled/oral) routine drugs viral infection: oral steroid Outpatient clinic in 24-48 hours

One Day Care (ODC)

Oxygen therapy

Admission room
Oxygen therapy Treat dehydration and acidosis Steroid IV / 6-8 hours Nebulized / 1-2 hours Initial aminophylline IV, then maintenance Nebulized 4-6x p good response per 4-6 h If stable in 24 hours p discharge Poor response p ICU

Oral steroid
Nebulized / 2 hour Observe 8-12 hours, if stablep discharge Poor response in 12 hrs,

p admission

Notes: In severe attack, directly use F-agonist + anticholinergic

If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times Oxygen therapy 2-4 l/min should be early treatment in moderate and severe attack

Tidak ada respon tata laksana

Dehydration Metabolic acidosis Atelectasis

Tatalaksana
Saat serangan asma :
F2 agonist Ephinephrin Theophyllin/aminophyllin Steroid : inhaled, nebilized, oral : subcutan : oral, I.V. : oral, I.M.

Pencegahan serangan :
Avoidance : triggers (including enhancers, inducers) especially improve indoor environment. Medicine : steroid, DSCG, antileukotrien, ketotifen, cetirizine.

LONG TERM TREATMENT

Infrequent Episodic Symptoms
F2-adrenergic or/and theophylline inhaled/oral intermittently
6-8 weeks >3 doses / week 3-6 months Evaluation

Add sodium cromoglicate

6-8 weeks response (-) 3-6 months response (+)

Frequent episodic Symptoms

Replace with low dose inhaled steroids Continue F2-adrenergic or/and theophylline inhaled/oral intermittently
6-8 weeks response (-) 3-6 months response (+)

6-8 weeks respons (-)

3-6 months respons (+)

Consider : Persistent Symptoms Long acting F2-agonists, or Slow release F2-agonists, or Slow release theophyllines
6-8 weeks respons (-) 3-6 months respons (+)

Increase dose of inhaled steroid

6-8 weeks respons (-) 3-6 months respons (+)

Add oral steroids

Kapan?
Klasifikasi Asma episodik jarang Asma episodik sering Asma persisten Pengendali (Controller) tidak Ya Ya Pelega (Reliever) Ya Ya Ya

Medikamentosa
Bronkodilator Antiinflamasi Antiremodeling Anti IgE

Anti-inflamasi
Antihistamin Disodium Cromoglycate (DSCG) Kortikosteroid Anti PDE 4 (Phosphodiesterase)

Kortikosteroid

Memperbaiki pengendalian asma pada anak Bukti-bukti penelitian:
      

meningkatkan PEF (pagi dan sore) meningkatkan FEV1 (pagi dan sore) mengurangi variasi diurnal FEV1 mengurangi gejala menurunkan frekuensi serangan asma mengurangi pengunaan obat pelega (F2 agonis) Meningkatkan kualitas hidup

FEV1, forced expiratory volume in 1 second PEF, peak expiratory flow

Keuntungan steroid inhalasi

Dosis rendah Langsung ke sal respiratorik Onset (awitan) cepat Efek samping sistemik minimal

Rasionalisasi steroid + LABA

LABA

Smooth muscle dysfunction

Airway inflammation

CS

  

Bronchoconstriction Bronchial hyperreactivity Hyperplasia Inflammatory mediator release

Inflammatory cell infiltration / activation Mucosa oedem Cellular proliferation Epithelial damage Basement membrane thickening

    

Symptoms / exacerbations

Longterm steroid

Efek samping
Suara parau Iritasi farings Kandidiasis Sakit kepala Gangguan pertumbuhan??

Tatalaksana (dalam penelitian)

Anti IgE (Omalizumab)
rhuMAb-E25 (recombinant humanized monoclonal antibody) Kalau dengan steroid dan LABA tidak baik

Anti-interleukin (IL-4, IL-5)

Proses penelitian

Imunisasi (rekayasa genetik)

Penelitian

Kesimpulan
Asma: Inflamasi kronis dan remodeling Ketotifen dan Disodium cromoglycate: kurang bermanfaat sebagai tatalaksana jangka panjang Steroid dengan/atau kombinasi: obat pilihan sebagai tatalaksana jangka panjang Indonesia: Pedoman Nasional Asma Anak (UKK Respirologi IDAI)