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    paru

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    5 views11 pages

    Asma Gina

    Uploaded by

    Dimas Adi Soewignyo
    paru

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF or read online from Scribd
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    of 11
    Box 1-2. Diagnostic criteria for asthma in adults, adolescents, and children 6-11 years ‘Asin |s 2 Neterogeneous disease, usually Charactenzed by chronic arway infammraticn. tS detned by the ristory ‘cf respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary overtime ard in intonsty, together wth variable expiratory airflow limitation DIAGNOSTIC FEATURE. 41. History of variable respiratory symptoms ‘CRITERIA FOR MAKING THE DIAGNOSIS OF ASTHMA, ‘Wheeze, Shortness of brea, chest ‘ighiness and cough having heavy breathing Descriptors may vary between cuitures and by aoe, ec. cnvaren may te o=scped as ‘+ Generaly more than one type of respratory simotom (in adits, sclated cough is seldom due to astima) ‘= Symptoms occur variably over imo and vary in intonsity ‘+ Symptoms ars offen worse at right oron wabing ‘+ Symotoms are often ggered by exercise laughter, allergens, col a ‘+ Symptoms ofen appear or worsen wit vl infectons 2. Confirmed variablo oxpiratory airflow limi Documented excessive vatabiliy in ing function® (one or more of the tosts boiow) AND documerted airtow tintaton™ Postve broncnodiator (80) reversiity test" (more IKely tobe postive f BD ‘medication is withheld befcre test: SABA 2d hours, LABA 15 hours) 2 weeks* ‘Sigitcant increase in ung tunction after “A weeks of ant nfammatry treatment PPostive exercise chatende test" PPostive broncnial challenge test (usually ony performed in adults) visits" (ess retable) Excessive variabilty in twice-daily PEF over Excessive variation in lung unctcn between “The greater the variations, or the more occasions #xcess variation is ‘seen, the more confident tho ciagnosis ‘Atleast once during ckagnostc process when FEV: Slow, confim that FEVFVC is reduced (normally ~0,75-0.80 in aduts, 0.50 in children) ‘Adis: increase n FEV, of >12% ard =200 mL fem baseline, 10-15 ‘minutes after 200-400 meg albutew or equivalent (greater confidence increase is ~15% and ~400 mL). (Children: nereasa in FEV, of >129% predicted Adis average daily dumal PEF variabilty -10%* (Children: average daily diumal PEF vartabity 136" ‘Adilis. increase in FEV by >12% and >200 mi (or PEF* by >20%) from, baseline after 4 weeks of treatment, ouside respiratory infections | ‘Adis Tab 9 FEY, of >10% and >200 mL from basen CCilerer: fll n FEV, of 12% predicted, or FEF =15% Fal in FEY, from baseline of 220% win standard doses of metnachoine histamine, or 215% wih standardzed hypervertilaton, hypertonic ‘saline or mannitel chalenge ‘Adis. vataton n FEV, of >12% ard >200 mL between visits, OUSide of respratory infections (Charen: variaten in FEV, of 12% In FEV, oF >18% m FEF” berwean vists (may incluoe resoretery nfectons) ED tence (shortasing SARA fpkrastng LABA) FEV, eed prany rune 1 Secor LABA loogacing bea aginst PEF peat ‘xttery Tow (ihe of twee exigs} SABA snoactegheta-aons! See Box I fr dagress mpatens aad akg conor Wearent Thasatace can reat crng eynpame arin he eary miming "Daly durel PEF vara celta or ie ly PEF 38 {ays nighet iran coyalowea] mean of days igen and wen) ane averaged’ one week For PEF betes mee each ne, 22 PEF mayvaryby upto 20% betwen fret nels ED reversibly may si during sewre saceratens oval nections." Frencedlaor ‘scrity ent reco nesipeecnnton ae! sepSepan nthe nalbiny iarist ane he uigeney oe nec orteamrert In ‘SiLston final ugenay. asda teannertmay be cnmeteec sd Gaghosic ws araged inte een mets 2 1-4, p22) GAOT ‘ondns that an mimi asta (Eo 1) shouldbe eosiered. ard the @2presis of sha comes 3s seen 2s posse Box 1.3 Differential diagnosis of asthma in adults, adolescents and children 6-11 years Age Concition ‘Symptoms, E11 [Chronic unper airway years | nnaieatoresn boay ‘ough syndrome Sneezing, ching, locked nose, throat-caring ‘Suciden onset of smptoms, unilateral wneez= [Bronchieciasis ‘Recurrent infections, productve cough [Primary citary dyskinesia ‘Recurrent infections, productive cough, siusits ‘Congenital neart disease Carciee mamurs [Bronchopulmonary cysplasia re-tem delivery, symptoms since bith \Oysti rosie Excessive cough and mucus production, gactrointestinal symptoms. 72-30_|Chronic upper airway ‘Peugh syndrome Sneezing ching, blocked nose, throat-cearing ‘years | oral cord dystunction ‘Dyspnea, inspiratory wheezing (stridor) 1 |Hyperventilaton,cysfunctcnal breathing Dizzness, paresthesia sighing ‘Bronchiectasis ‘Productve cough, recurrent infections [cystic norosis| Excessive cough and mucus production (Congenital heart disease Cardiac murmurs 'Aipharanittypsin deficiency ‘Shortness of reat, family history of early emphysema Intaled foreign body ‘Suclden onset of symptoms \Voeal cord dysfunction Dyspnea, inspirstery wheezing (stridor) |Hypervenilation, dysfunctional breathing Dizziness, paresthesia, sighing Icaro ‘Cough, sputum, dyspnea on exertion, smoking er noxious exposure ‘Bronchiectasis ‘Procuctve cough, recurrent infections ‘cardiac ralure ‘Dyspnea wih exertion, noctural symptoms (Mexicatonelated cough “Treatment wih angiotensin converting enzyme (ACE) inhibitor ‘Parenchymal lung disease Dyspnea with exertion, norrproductve cough, finger clubbing [Pumonary embolisra ‘Sudden onset of dyspnea, chest pain \Contal airway obstruction Dyspnea, unresponsive to bronchodilators “rer nere cea See Caper (RT) Any he seve cordbens nay aso cents espraoy symptoms mpatens Wn contd 3502 ‘Box 1-4. Conrirming the alagnasis of asthma ina patient already taking contratie treatment notral lang function, and no varianle aw imtaon ‘Currant status, ‘Steps to confirm ie agnosis of asthma ‘Variable esoraiey symptoms | Dagnosi of astra is confrmed, Assess the level of asthma consol (Box 22, p28) and varabe aFfow litation | and review contille vecment (Bax 3-5, p43), ‘Variable respiratory symptoms | Ropoat 8D revorsiiliy fest again afor wahholdng BD (SABA: 4 hours; LABA: 12 but no variable aifow hours) or during symptoms. If oral, consider aterativeciagnoses (x. -3, p.20) lnwtation {F FEV, 670% predicted: considera bronchial provocation tet. negative, consider ‘stepong down controle ireaiment (see Bor -5) and reassess in 2-4 weeks |FFEV, is «70% predicted: consider stepping up controler treatment for 3 months (Box 3.5), then reassess sympioms anc ung futon. ID response, resume prEVOUS. ‘teament ana ref patient for aagnes and invasteation Fewrespiratory symptoms, | Repeat 8D reversibly test agan after wihholding BD (SABA: 4 hours; LABA 12+ ‘nouts) or during sympioms. If normal, consider atemativeciaanoses (Box 1-3). ‘Consider stepping down controler treatment (see Box +5) +f eymotoms emerge and lung function fale: asthma is confrmed. Step up coniale| ‘veatment to lowest previous effective dose. ‘+ sf no change n symptoms or ung function a west control step: consicer ceasing controler, and montor patient closely for at least 12 months (Box 27). Persist shortness of breath ‘and nxed amon tmvtation | ‘Consider stepping up contol treatment for 3 montis (Box 3-5, p43), ten reassess | ‘symptoms and lung function. I no response, resume previcus teatment and refer ‘ationt for agnosis and investigation. Consider asthma-COPD ovariap eyndromo {Chapter 5, p87) 120% 1.5, Howto step down contcller aatment te help conrirm the agnosis of astama 4. ASSESS ‘= Document he patents curent statis neudng asihma con (Box 2-2 .20) and ung function. the patent nas "ek factors for astnma eracerbatons (Sor 228), donot stop down raiment winout cose supervsion. ‘+ Choose 2 sutabie me (e.g respratery nection, not gong away on vacaton, not pregnant). {+ Prove a niten asa acton plan (Bax 4-2, 175) so the pant knows howto recogtiz8 and esprit symptoms worsen. Ensure they have enough mecicafion io resume their previnus dose if heir asthma worsens, 2. ADJUST Show ine pallet how i rue Nel ICS cose by 25-50%, slop extra COnUH (eg. LABA, eukaan= receptor aniageris) being used (Box 27, p48) + Scheculea review visi for 2-4 wosks. 3._ REVIEW RESPONSE ‘Repeal assessment of asa conf and lung funcon less in 24 weeks (Bax 12, p17) + Ir Symtoms inrease and varabe afew Invaton is confimed afer Siapging down veatment, ne dagnoss of ‘asthma is confer. The controler dose shoul be retried othe lowest previnus fiectve dose +I after stepping down to aw dose controle reatment, symptoms donot worsen and theres ill no evidence. cof varable artow imtaton, coeider ceasing convo treatment ane repoatng asthma eortrol assessment and lung functon tests 2-3 weoks, but flow the patient for at ast 12 months ‘COPD: avenic cbse punenarydsese LABA acing eagENS, Box 34, Recommended oftions for mital controler reatment in adults and adcloseants resenting symptoms Preferred initial controller ‘Asthma symptoms orreed for SABA less than fice amanti;na | Ne cone (Evidence DP aking due to astra nasi mant, ane no sk tacos for eacerbators (60x 2-28, p}, inching no exacerbations in he ast vet Inequent astra Symptons, bu the patent Tas one or more sk | Low dose IC™ (Evaance Oy ‘actors for exacervalons (Bo 228),e9.low kg tuncton, of ‘eegatbationreguitng OCS n the lat year, or has ever bee a intensive cate fr aathss "Asia symptoms or peed fr SABA between twice ammonmnand_—| Low doso IGS" (Evdanco E) twee a week, or palent wakes due to astm once of more a ment Asta symtoms or need or SABA more than twee a week Low dose IGS" (Evidence A) ‘One less effective options are LIRA or theoohyline “Troublesome asthma symtoms most days. or waking due to asthma | Wediumvigh dose IOS" (Evidence A), or ‘once a week or more, especaly if any risk factors evi (Gox2-2B) | Low dose ICS/LABA (Evidence A) ‘nits ashma presentation is with severely uncontoled asa, or | Short cause of oral cacoserads AND wih an 2euteexareraton ‘Star fagularconioter eaten, optens ae + Highaose ICS (Evaence A), of + Moderate dose ICSMLABA™ Evisence 0) Before starting intial contoler treatment ‘Record evdence forthe iagress of asta, f posse ‘+ Racord he patient’ lov of sympiom onal a sk facies, elusng ung funcen (Bax 2-2, pI7) ‘Consider tacts inuening encice of eaten (Box 3-3, p27) ‘+ Ensure Dat ine patert can use the nhaler corey ‘+ Seheaule an apportmert fr afovowup vist ‘After starting intial controller treatment ‘+ Review patients response (Box 22) afer 2-3 months, or earler éepencng on cinial uroeney ‘+See Bor 35 for recommendations for ongoing treatment and other ley management sues ‘+ Step coun treatment ence good cartol has been mainainesfor3 marths (Bax 37, pa). 123 bled coven LAK isn bata TRA ine sp tage 09: alc SABA shradng Croce hese cramer vac snes ohne say nacre act nose ne ant Siiiessraatngains cameo basis patos al eae ote nce cnpng ero seme [Sedan cnesecoaione be pone SConmoun oasnng souponimes Wi romat tater cate Ott ‘Box 3-6. Low, medium and high daily doses of inhaled corticosteroids ‘Adults and adolescents (12 years and older) Drug Daily dese (meg) Low Medum High BBeciometasone dipropionate (CFC)" 7200-500 500-1000 1000 BBeclometasone dipropionate (HFA) 100-200 200-400 400 Budesonide (DPI) 200-400 800 Ciclesonide (HFA) 80-160 2300 Fluticasone furmate (DP) 10 2m Fluticasone propicnato(DP!) 100-250 600 Fluticasone propicnate (HFA) 100-250 2500 Mometasone furoate 110-20 ado ‘Trameinolone acetonide 400-1000 2000 Beclometasone dipropionate (CFO)" 100-200 $400 BBeclometasone dipropionate (HFA) 50-100 100-200, 200 Budesonide (D1) 100-200 200-400 400 Budesonide (nebuies) 250-800 500-1000 >1000 Ciclesonide 20 80-160 >160 Fluticasone furoate (DPI na, na. na Fluticasone propicnate (OP) 100-200 200-400 >400 Fluticasone propicnate (HFA) 100-200 200-800 500 Mometasone furoate 110 2220-440 M40 Trameinolone acetonide 400-800 800-1200 1200 (CFC: chibratuorocabon propel DP dryponder inhaler HFA: hyretuewalane propellant. a.notaoclcatle, "Becometazone dproponate CFC sincudesforconprsos wh oer itertre. ‘Management Evidence-based guidelines (Allergic Rhinitis n Asthma, ARIA)"* recommend intranasal coniicostercids for ueaunent of allergic thing n population-based studies, reatment of rintis wit intranasal corticosterods is associated with ss ‘need for asthmia-felated nesprialzation and errergency department vsts However, fev placebo-contolled studies have systematically evaluated the effect of oper eatmert and management of chronic chinosinusitis on asthma control [Pox 42, Seltmanagement of worsening asthma in adults and adolescents witha written asthma action plan Etfective asthma self-management education requires! + Selfmonitering ofsympioms ner lung funtion It PEF or FEV + Weitenastima action plan ieessecaict = Rogiiar medica rion improvingatter 49hours All pationts ce Cntinue roever Coninue contain ‘Add predrisobne Inorease teliover arly increase in contaler es below 40-50 mgiiay wou response | Conta’ dostor SS sss Ss EARLY OR MILD LATE OR SEVERE Evidence Mestestion 1OF-term change (1.2 wsele) for worsening aethma sn thangs (1-2 waehe) for worsening aethr iam Inorease usual releve: Sheriactna bela? agonist Increase taqiency of SARAUSE iN (SABA) Fer plot ada spacer Low dosoICStometera* Increase Yequoncy af relever use A (raximu fomoera total 72 meaicay) Increase usual controle: Narrenerce and retever — Covnimse maiterance 10S\ormoteol and inciease reeves A (eStimatot ICS emcera as nesded* (naxmam farmoterl teal 2 mcotsay) Maicerance ICS with SABA Atleast double ICS: consider increasing IOS thigh dese 5 arelever (Grasamue 2000 meoday BOP equate) Nairororce 1OSiamolerd Quaduple maitanatea \CStomatao! a va SABA rekover (Graximun: fomosera r2megday) Mainarance 1CSlaner LABA, Stapp te Agher dose femnuaton of 1CSiahor LABA. or conser wh SABA gs reaver _ecing a separate CS late (asim total 2000 mcyday Bor equate) ‘Add ord certicosteroide (OCS) and contact doctor (oC (preansone ‘Add OCS fr sovre exacerbations (e.9 PEF o FEV, <60% A peaueoone) pperanal esto redid), oF pale Nt respending to Veutnt (ver 48 nous Adults: precnaolone 1 rgalaay (maximum 50 ma) usualy fer > ST days Chldon 1-2 mgkgicay (macimum 40 mg) usualy ior 30 Gays “Tepesing isnot needed VOCS ere prescribed for <2 weeks B [BDP-becometasone dippenate: FEV ered expiratory volume in| second ICS: hale cortcsteo: PEF: peat expiratory tow SABA:shot-acing bea aponst Opions ae ited in ade of evcence. "10S tormote maintenance and reliever reginer: ow dose budesonide er beclometasone wi femeter ‘This repens not approved ior chien 12 yews inmany cours [Box3.5, Stepwise approzci to control symptoms and minimize future risk Lung tnetor svers | stera coumouen | STEPT) aires Femcror ee “ee SE | Low cose cs Be SY ons cameramen aren a, To. oases ICS hale ctccnteroic LABA engin betaragenat ‘nigh cases 0S for acu, adcescorts and chen 6-11 yeas. See Chapters Pat (pes) manager of eerasesnsiees Asteeoee srortectiy tet Imrie oma eon ranges 9 pee age rt ste pions. acetone owes ae Diagnosis ‘fata oe tao SB PP Na \ 1 un srarmesaea sao ear ext ‘Arnasded SABA or sorts (SABA) et: medion dene; OCS or cocosteciy See Bot 3. 4) tt meson th ahi is ota in ehidien Box 43. Management of asthma exacerbations in primary care (adults, adolescents, children 6-11 years) PRMARYCARE Pate ASSESS ihePATENT ——rlskiatrs or atnna-clatea deat? (oar +1) Seventy oteracerpaton? WILD or NODERITE ‘SEVERE “ansin pases pees “ans wras ts need LUPE-THREATENING iting tying, ot age tervant, agtstoa rons, contac Respraoryateienased spat ates orsienehest ule ee 120-1205 (© sanraten onan 50-95% PEF 60% precctotorvert, Pte rate>120 pn (0, satraon on) 20% ‘START TREATMENT SSABA &-10pun8 DyOUDI ¢spazer ‘TRANOFER To ACUTE repeat ever 20mnges fo hour CAREFACILITY Preanisolone 201% mama, nas WORSEHING S09, nigen'-2nghg. nas 40 m9 Cortrotedoxygen f2vasble)taet Saturation 03-95% (ren 94.985) Wnte wang gve inated SABA ane pratopum rami, ‘Sy vsems consti CONTINUE TREATMEN Twin SABA asnesied ‘AGSEB8 RESPONSE AT 4 HOUR or earier) mPREVING ph ‘ASSESS FOR DISCHARGE "ARRANGE at DISCHARGE Ssmmptems improves, mt reesig SABA Rellver coin asneedeo rer ingrovng, ana>o020% or persona Conner sa 03-4) Ftp uP o0e 3-2) Desorredeted ‘heck nksertecsnige adherence ‘oxsger satiraton 294% fon ar Precitelone: contre, silly br 57 6s Resourcesat home sceque (¢-Seaystorchiten ee ( FOLLOWUP, \ Retever:aet03s-nented CContrtier cortnu: niger cose tr shart tem (1-2weeks) orang em (Sorts), sepenaing ‘onpacigiounaioeacetanon Rls actors: choctan corectmosale rk crs tha my have Con bteco exacrbaon Ineiing mai tceigu and sdhetence(Boc2-2, Bae 2.8) ‘tion plan's ursestoat? Wasi used zoprpteW? Does Fees wodteatin? Box 4-4. Management of asthma exacerbations in acute care facility, e.g. emergency department INITIAL ASSESSMENT ‘Are any of tho following prosont? Arainway B: breathing: ckeustion Drowsiness, Confusion, Stent chest No Consult ICU, start SABA and O, Further TRIAGE BY CLINICAL STATUS. pee pececee rar yeorantie cy accoring to west feature MILD or MODERATE SEVERE Taks inprrases Tsia vores Proera siting 6 bing ts hunched forward Not agitated etm Ressratory rat increase Feepatery ate >30imin Pauls rate 100-120 bom 0, saturation (ena) 60-95% PEF >50% presicte or best Accateonyrusces being used Palse rate =120 bpm (0, satureton (on sin) < 90% PEF 580% precited or best Short.acting bela-ageniste Ipratropium bromide Controlled ©, to maintain Saturation 93-95% (chiléren 94.98%) Oral or WV corticostercids Consider IV magnesium Consider high dose ICS Short acting bta,-agoniste Consider ipratropium bromide Controle 0, to maintain ‘Saturation 93-96% (children 94-98%) ra conticosteroids Lee [ASSESS CLINICAL PROGRESS FREQUENTLY MEASURE LUNG FUNCTION nal atts one hour ater inal reament |" F—7 FEV, or PEF <60% cf precidedor SEVERE EV) o PEF 60-20% of predicted or pereonal bast ane sym improves MODERATE Consider for eenarge planning 19 whale cameos GU rns ce IV arenas CRyn; FEF peak e~preonfow FEV ces ear HUME 1 SECO Box 4.5, Discharge management after hosptal or emergency department care for asthma Megications ‘Oral cotticasteroids (OCS) Fresctibe at least a 5-7 day course of OCS for adits (prechisolone or equivalent 1 mgkg/day to amaximum of SO ‘mgiéay) and 2-5 days for cicren (1-2 mekgcay to a maximum of 40 ma). For patients considered at risk of poor acherence, intramuscular coricosterccs maybe consdered= (Evidence). Reliever medication “Transfoxpationts back to as-neodod rthor than reguiar rollover modication use, basod on symptomatic and objective improvement. f ipratropium bromide was used inthe emergency department or hospital, it may be quickly ‘scontinued, as Mis unikely to provice ongoing benef Inhaled coricostoride (iCS) Initate ICS prior to discharge, i nct previously prescribed (Box 2-4, p42). Patents curently preserbed ICS-containng ‘medication Should generally have thai treatment Stepped up for 2-4 weeks (Box 4-2, p75) and shoul be reminded ‘bout tne importance of adherence wih dally use. Risk factors that contributed to the exacerbation deni faciors that may have contributed tothe exacerbation and implement stategies to reduce modfable risk factors (Box 3-8, p.50). An exacerbation severe enough to require hosptalzation may follow iritant or alergen ‘exposure, inadequate long-erm treatment, preblems with adherence, andr ack of a writen asttma action plan, a8 Wel as unavoloable factors such as vralresolatorynvectons. Self-management skills and written asthma action plan. Review inhaler technique (Box3-11, p55) Review technique with PEF meter if used. Provide a wntien asthma action plan (Box 4-2, p.7) or review the patient's existing plan either at discharge or as ‘soon as possible afterwards. Patients cischargec from the emergancy department ith an action plan and PEF ‘meter have better outcomes inan patents ischarged witnout inese resources.“ '* Evaluate the patler’s response fo the exacerbation. It it was inadequate, review the action plan and provide written guidance to assist asthma worsens again “22403 + _ Review the patient's use of controller treatment before and during the exacerbation. Was it increased promplly and ‘by how much? Were OCS added and i not, why not? Consider providing a short-course of OCS to be on hand for ‘Supsequertt exacerpatons. | Fotiow up appointment “Rolowcup apporiment wihin 2-7 cays of istharge should be made wih the palent's usual health care prowder, ‘ensure that treatment fs contrued, that asthme symptoms ae well contclled, and thatthe patients tung funcicn reaches ther persorial bes! (know). 18. nth, O08. el non PE pak wep Box §-2a, Usual features of asthma, COPD and ACOS Feature ‘Asthma cOPD Acos [Age efoncet [Usually childhood oncet [Uzualy> 40 years ofage |[Usuallyage 240 years, but may leut can commence at any. have had symotemsin laze [childhood or early adulthcod lpattern of [Symptoms may vary over |Chronic usually continuous |Respiratory symptoms including| Iespiratory time (day to day, or over symptoms, particularly |exertional dyspnea are lymptoms longer periods), often during exercise, with _|persstent but variability may limiting activity. Often ‘better’ and ‘worse’ days be prominent ‘riggered by exercise, lemetions including laughter, dust or lexposure to allergens lxung function |Current and/or istorieal |FEV, may be improved by [Airflow limitation net fully jariable aifiow limitatien,|therapy, but pest BD reversible, but often with leg. 2D reversibility, AHR |FEV,/FVC

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