ASTHMA BRONCHIALE ASTHMA =Kelainan peradangan kronis pada pernafasan yang menyebabkan bersin, susah bernafas, sesak pada

dada, dan batuk, sering kali pada malam dan/atau pagi hari.  Status asthmaticus= keadaan dimana serangan asma tidak mereda sehingga berakibat fatal.  Belum ada klasifikasi yang seragam 1. Berdasarkan frekuensi dan keparahan gejala: mild intermittent, mild, moderate, dan severe persistent 2. Berdasarkan klinis: steroid-dependent, steroid-resistant, difficult, dan brittle 3. Umumnya: extrinsic (type I hypersensitivity) dan intrinsic (nonimmune mechanism, seperti meminum aspirin, infeksi pulmonari, virus, olahraga, dll) 4. Kategori lain: seasonal, exercise-induced, drug-induced, occupational asthma, asthmatic bronchitis pada perokok) PATHOGENESIS Etiologi pada asma: • genetic predisposition to tpe I hypersensitivity (atopy) • Acute and chronic airway inflamation • Bronchial hyperresponsiveness
IL-12 Macrophage CD4 cell IL-4 TH 2 cell TH 1 cell IFN-ɣ IL-4 Allergic inflammation; induction of antobody production by B cells Defence against intracellular organism

Atopic asthma Tipe paling sering pada asma, biasanya terjadi pada anak kecil. Patogenesis: 1. Sensitization: inhaled antigen (allergen) → stimulasi induksi TH2 cell → melepaskan mediator, seperti cytokine (IL-4, IL-5) → mendukung produksi IgE antibody oleh B cell, pertumbuhan mast cell (IL-4), pertumbuhan dan aktivasi eosinophil 2. Acute / immediate response: Mediator membuka mucosal intercellular tight junction → antigen yang masuk ke submucosal mast cell makin banyak → a. stimulasi subepithelial vagal (parasympathetic) receptor → brochoconstriction; b. Produksi mukus; c. influx leukosit lain seperti neutrophil, monosit, limfosit, basofil, dan eosinofil 3. Late-phase reaction: Leukosit yang datang karena chemotactic factor dan cytokine → mediator juga diproduksi oleh: sel inflamatori yang sebelumnya sudah ada, vascular

endothelium, dan airway epithelial cell → second wave of mediators menstimukasi late-phase reaction → epithelial damage, airway constriction Nonatopic asthma Kebanyakan dirangsang oleh respiratory tract infection. Virus (e.g. rhinovirus, parainfluenza virus) lebih sering daripada bakteri Drug-induced asthma Aspirin-sensitive asthma -> biasanya pada pasien dengan rhinitis dan nasal polyps yang berulang Occupational asthma Distimulasi oleh emisi kendaraan, organik dan debu kimia (kayu, kapas, platinum), gas (toluene), bahan kimia lainya (formaldehid, produk penicillin). SIGNS AND SYMPTOMS: Variation in pattern of symptoms, paroxysmal, constant, abnormal pulmonary function tests without symptoms •Wheezing •Nocturnal attacks •Cough •Cyanosis •Exercise-induced wheezing or cough •Tachycardia •Prolonged expiration •Accessory respiratory muscle use •Hyperresonance •Flattened diaphragms •Decreased breath sounds •Nasal polyp; seen in cystic fibrosis and aspirin sensitivity CAUSES →Allergic factors •Airborne pollens •Molds •House dust (mites) •Animal dander •Feather pillows →Other factors •Smoke and other pollutants •Infections, especially viral •Aspirin •Exercise •Sinusitis •Gastroesophageal reflux •Sleep (peak expiratory flow rate [PEFR] lowest at 4 am) →Current research focuses on inflammatory response (including abnormal release of chemical mediators, eosinophil chemotactic factor, neutrophil chemotactic factor, and leukotrienes, etc.)

DRUG(S) OF CHOICE: →Six major classes of drugs are used: •Cromoglycate and nedocromil •Steroids (budesonide, fluticasone, prednisone, etc) •Beta-agonists (albuterol, bitolterol, salmeterol, etc.) •Methylxanthines (theophylline)

•Anticholinergics (atropine, ipratropium) •Leukotriene modifiers 1. Mild intermittent asthma: brief wheezing once or twice a week: •Intermittent beta-agonist (MDI or nebulizer - albuterol, 2 puffs or 0.25-1.0 mL neb q2hr prn) •Long acting beta-agonists [e.g., salmeterol (Serevent) 2 puffs bid] •Oral beta-agonist or theophylline may be considered, but have more side effect 2. Mild persistent asthma: symptoms > 2 times a week, but < 1 time a day; affects activity. Once daily medication - choose from: •Cromolyn qid or nedocromil bid (2 puffs or 2 ml neb) •Inhaled steroids (low doses) •Consider zafirlukast or montelukast •Consider oral theophylline (10-20 mg/kg/day); not preferred Contraindications: •Sedatives, mucolytics •Antibiotics are usually not necessary •Avoid beta-adrenergic blocking drugs Precautions: Concern regarding deleterious effects of chronic use of beta agonists. Use only when symptomatic (chronic asthma may necessitate chronic use). If using beta-agonist more than twice a week, should also be on antiinflammatory. Significant possible interactions: Erythromycin and ciprofloxacin slow theophylline clearance and can increase levels 15-20%.

Sumber: 1. Kumar, Abas, Fausto: Robin and Cotran Pathologic Basis of Disease, 7th ed. 2. Dambro – Griffith’s 5 Minute Clinical Consult 2001-2002

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