The Role of Budesonide Nebulization on Management of Acute Asthma in Children: 2 Non Genomic Effect of Corticosteroid as Reliever Moh Syarofil Anam Subbagian Respirologi Bagian Ilmu Kesehatan Anak FK Undip/RSUP dr. Kariadi Semarang eee KONIKA XVIMI MEDAN, 18 OKTOBER 2021POINTS OF DISCUSSION 01 Asthma as Chronic Disease 02 Role of Corticosteroid in Asthma 03 How to Choose The Right Therapy and Its Consideration? 04 Role Of Inhaled Corticosteroid (Evidence) 05 Take Home MessagesWhat do we know about Asthm *Asthma is a common and potentially serious chronic disease that can be controlled but not cured. =Symptoms are associated with variable expiratory airflow, ie. difficulty breathing air out of the lungs due to *Bronchoconstriction (airway narrowing) “Airway wall thickening due to Airway Inflamation “Increased mucus =Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stressASTHMA Pathophysiology Increased blood flow [Abnormalities of blood flow regulation Increased vascular permeability Airway From Patient with Asthma —_ "flammatory cellrecruitment ‘Angiogenesis and microvascular remodelling Normal Airway ‘an hehe immo 68 05) wae aso O2 De® transtepression __“WeeRaar! ‘Cellular Mecaniams PUR aso 22 87,001 iu ss)osns190 ce couseAction of Inhaled Corticosteroid transrepression __"Weehabhons!Vascular Effects of Inhaled Corticosteroid Inhalasi_kortikosteroid memiliki efek rapid," delayed,’ dan longterm* terhadap vaskularisasi saluran nafas pada kondisi pasien dengan asma.03 How to Choose The Right Therapy and Its Considerations on acute asthma management?Oksigen SABA Antikolinergik Corticosteroid (Inhalation/Sistemik)Rekomendasi Terapi Inhalasi pada Asma Tata laksana Asma Akut (Saat Serangan) ‘Asma serangan ringan-sedang Rekomendasi 1 ‘+ Pasien yang mengalami serangan asma ringan-sedang diberikan inhalas 2 agonist kerja pendek (shore acting 82 agonist! SABA), ukanak diatas 5 tahun, slain 2 agomisrjuga diberikan kortikoseroid nik ata kortkosteroi inhalsi dows ting saga per. xk anak bali, jika ms 1 Klinisseelah verapi dengan inhalasi SABA, kortkosteroid tidak peri diberkan, Rekomendasi 2 © Pemberian obat pereda inhalasi menggunakan pMDIvspacer sama efcktinya dengan pemberian melalui nebulisr © Kortikosteroid ampul harusdiberikan dengan nebuliser jet, tidak boleh dengan nebulise wtrasonik Cara inhaasi dengan DPI tidak sebaik nebuliser atau pMDI spacer DSTUr ees)‘Asma serangan berat Rekomendasi 3 Koti SABA dn antler dtambah dengan orton ‘Asma dengan ancaman hentnapas Rekomendasi 4 = Pasi naka yang meng Relcomendas 5S dibrcan dengan menggnaan nb Rekomendasi 6 Antilope tidak digunsan sap trai nga dalam es asannChoosing Inhalation Therapies — ERS/ISAM REPORT Pressurised Metered-Dose Inhaler dan Nebuliser dapat dipertimbangkan sebagai pilihan, pada keadaan pasien dengan koordinasi aktuasi dan inhalasi yang baik maupun buruk.Challenges of Inhalation Therapy in Pediatric Patients, and Age-appropriate Inhaler Devices and Interfaces Nebulizer & pMDI+VHC can be use in all ages compare to others.04 Role Of Inhaled Corticosteroid in acute management of asthma in children (Evidence)Respratory Medicine (2004) 98, 275-284 - Inhale Corticosteroid dose Ee ELSEVIER Corticosteroid therapy for acute asthma B.H. Rowe™”-*, M.L. Edmonds”, C.H. Spooner*, B. Diner‘, C.A. Camargo, Jr.?*Respratory Medicine (2004) 98, 275-284 ELSEVIE Corti B.H. Ri CA. Ci Inhale Corticosteroid dose Tbe 1 Arei-ntammatory érugs and doses common ned nthe treatment of wate asta ov at oe Spore contconeraes ‘yaocortsone 250 500m etry prearsoine 20-250 (Galunedra fn) Prednisone (en ED) 40-50 po Prechisolone (in ED) Utd evence Desmethasore (ED) Limited evidence Prednisone (at charge) 40-30 po ad fer 510 day {aperig nt equi) Innate coroners Buesenide (nD) 1-20g nebused Flaicasane (in ED) 500-1000 one Fssalie (a €) Uptozginx sn Budesenide (at charge) Say or wp to24 days Fuaicasne (at escurge) —500-1ODWg/ay for upto 21 ays Flaite (ac dcharge) Upto 200g (day forup 074 dys Spm a ry Sa Peedarc one 5-10mg/hg W (max: 2507) -2mgrigV ¢mac250m) mga tk igh po ora 50 mg) 2m po ‘Omg ior $-1mg/ ay anid bi or af fer 57 aay tapering not rer) Limited evdence: 1-2 nebulsed Umited evcence Umit evens Umit evensComparison: Outcome: Study Any steroid (po, IM, IV, inhaled) vs placebo ‘Admitted to hospital (al times) Placebo WeightComparison: Inhaled corticosteroids versus corticosteroids Outcome: Admission rate Treatment Control on Weight Study aN nn (95% Cl random) te (95% Clrandi ve a >2 019002150) vos 155 at 4 os9jos71.31 ch 2000 16st Hs —— 7.207 75acute exacerbation of asthma in children: A randomi double-blind, placebo-controlled study ALHUAN CHEN," GUANG-IA0 ZENG,* RONG-CHANG CHEN, Jig-vi ZHAN, LONG SUN, SHUN-kAI HUANG, CUI-ZHEN YANG AND NANSHAN ZHONG ‘Standar Treatment ‘Treatment group (60) | thera hour ‘Oxygen (0s Budesonide 2 mi) [ Reovaluate Fev Symptoms Nebulized inhaotion: ———| every hour > 2 saxon sero Osx sastana|s0ughg,maxsiey)_ || Control group (58) hove ception Gi2sprtropambrariae 3m) || Normal saline [2Effects of nebulized high-dose budesonide on moderate-i acute exacerbation of asthma in children: A randomi ‘Table 5 Spirometric parameters at basolina and at differant time points posttreatment in both group Parameter BUD Control # Pvalue 0.250061 03260.190 o2r2 0.348 = 0.170 0.386 0.171 0.106 Increase from baseline at 2h 0.45 +0204 040720170 0480 AaFEV: 0.096 + 0.062 0.960 + 0.082 oors ns FEV; 0.100 + 0.120 0021+ 0.128, 0001 revin Tncresse from baseline at Oh were: 1129 zag: 58 0285 Incrsese from baseline at 1h 2732+ 1338 749s 1382 0768 2162687 ae7e6at 0.000 UD group vereus control group. Se diffrence between t and Oh posttreatment ts, diflereneabetween 2 and th post-treatment: BUD, budesonie: FEV; fore‘SUMMARY AT A GLANCE Emergency Effects of nebulized) ims 9\ tsi! stsvms, “talon ON Moderate-t acute exacerba) ‘i, ‘oa! er Sole omcensien ss (2M: A randomi Tele Spirometric parameters a Stee chy pions wt | treatment in both grou Parameter incl * Paaive nw Increase from baseline at Oh 0.250 0.161 0326+0.190 o22 Increase from baseline at 1h 0.348 = 0.170 0.386 0.171 0.106 tncresse from beselin 0.485 +0204 040720170 uso aiaFEVs 0.096 + 0.062 0.060 + 0.082 oors Ans FEY; 0.100 + 0.120 0021+ 0.128, 0001 revin wes 1129 zag: 58 025 ae FEV; 2162687 ae7e6at 0.000 UD group versus control group. Se diffrence between t and Oh poet reatment ts, diflereneabetween 2 and th post-treatment: BUD, budasonise: FEV; fordThe Addition of inhaled Budesonide to Standard Therapy Shortens the Length of Stay in Hospital for Asthmatic Preschool Children: A Randomized, Double-Blind Pacebo-Controlied TrialThe Addition of inhaled Budesonide to Standard Therapy Shortens the Length of Stayin Hospit for Asthmatic Preschool Children: ARandomized, Double-Blind Placebo-ContolledT Total Length of Stay (LOS) pada group pasien Budesonide lebin singkat dibandingkan dengan Plasedo dengan median: 44 vs 80 h; p= G01 < 0,05 (significan).Budesonide in Hospitalization Sebuah penelitian yang dilakukan oleh Ito et.al dengan total subjek 98 orang, dengan gejala asma berat diberikan tambahan terapi inhalasi Suspensi Budesonide dibandingkan dengan tanpa Budesonide. Pemberian terapi inhalasi Budesonide mempercepat waktu recovery 2X lebih cepat dan mempersingkat waktu di rumah sakit 2 hari lebih cepat.Respiratory Meicine 2007) 101, 685-695 Inhale Corticosteroid DRUGS REVIEW Inhaled budesonide in the management of acute worsenings and exacerbations of asthma: A review of the evidence Benjamin Volovitz*Respiratory Meicine 2007) 101, 685-695 Inhale Corticosteroid DRUGS ‘Budesonide in acute asthma in children Inhaled budesonide in the mana worsenings and exacerbations 0 =: the evidence Benjamin Volovitz*“Table 1 Studies of hated budesonide in children with acute wheezing seudy Fatienssenaled Design Conmett and 22 preschoolers RDB, PC Lenmey? ath ral whezing 31 aged 3-10y with, 08, PC, CO en Svedmyr etal.” $5 aged 1-3y with RDB, PC, PG {UD 600) bd via spacer or 28 treatment pair 1600 gd 8 by 25 patients spacersmaskx 7d, Treatment. preferred BUD; 6 Continued unl ne pai of preference, Heart active and PL ler used might tie wheeze BUD TH 0.2mg gx 34, then 22 ehiteren completed 67 tid 3, thon bid 3. 2 BUD periods. Emergency room and 2PL courses gen per Wists: 3 BUD. PL All patient hospital admissions ‘sociated with PL. Morning fd evening PEFR higher with 8UD 0.015; P~ 0.02), but symptom scores sitar for BUD and PL BUD 400) oF PL id 3d, BUD reduced symptom scores then bid» 7 va (especialy cough) bit not spacersmask. Each child need Yor Hopital care followed for tye ‘Abireviationr bid twice daly BUD — budesonide; CO crogoner; D8 — double bind: PC — placebo cantralled: PEFR peak piratory flow rate R= parle ripe; P= posto; = four me ly R= randomised; TA Trbualer, ti = tree tes MS Anam’s Seren Siti mites tates ates5 ol 00 2500 9000500 4000 Dose (0) Figure 3 Comparative vasoconstrictor effacy of thee ined corticosteroids In 10 corticosteroid nave patients with asthma.“ Benjamin Yolovtzinholed budesonide in the management of cute worsenings and a ‘exacerbations of asthma: A review of the evidence, Respuatory Atedilne2007:01(4) 58535, eeeTAKE HOME IVIESSAGES *Asthma is a common and potentially serious chronic disease that can be controlled but not cured *The use of systemic corticosteroids, together with bronchodilators and oxygen therapy, has become established for the management of acute asthma, but are also associated with problems such as metabolic adverse effects “Inhaled corticosteroids (ICS) offer potential benefit in the acute setting because they are delivered directly to the airways and Non Genomic effect *The current evidence base revealed encouraging results regarding the efficacy of the ICS budesonide in patients with wheeze and acute worsening of asthmaTERIMA KASIH Yan