PAFKRI

Utilizing Electrophysical
Agents and Intervention
During Pandemic COVID-19
related to Asthma;
An Evidence Based update Practice Perspective

Isnaini Herawati
PREVALENSI ASMA DI
INDONESIA
 Studi epidemiologi pertama COVID-19
PREVALENSI ASMA • di Tiongkok → Rumah Sakit Tongji, 5 dari 548 pasien
PADA COVID-19 menderita asma (0,9%).
• Rumah Sakit Zhongnan Universitas Wuhan → hanya 1
pasien dari 290 pasien rawat inap dengan COVID-19 dan
yang menderita asma (Zhang et al., 2020)
Prevalensi asma di antara pasien dengan COVID19 di
beberapa negara:
• Rusia 1,8% (Avdeev et al., 2020)
• Arab Saudi 2,7% (Shabrawishi et al., 2020), dan
• Brasil 1,5% (. Rezende et al., 2020)
• Meksiko 3,6% (Solıs et al., 2020)
• Spanyol 5,2% (Borobia et al., 2020)
• Catalonia 6,8% (Prieto-Albhambra et al., 2020)
• Irlandia 8,8% (Butler at al., 2020)
• Italy 6.0%, Spain 5.0%, and Ireland 7.0%
ASMA & COVID-19
Abrams & Szefler SJ., 2020:
- 25% orang dewasa muda yang dirawat di rumah
sakit dengan COVID-19 memiliki riwayat asma,
- anak-anak 40% memiliki beberapa bentuk penyakit
paru-paru kronis (termasuk asma).
ASTHMA
ANATOMY
PATHOGENESIS
Pengaruh mediator
terhadap manifestasi
klinis asma (Alenzi et
al., 20123)
asthmatics have a hyperactive parasympathetic nervous system
ASTHMA PROBLEM
KLASIFIKASI
DERAJAD ASMA
 MANAGEMENT ASTHMA
GOALS

• The long-term goals of asthma Management are

to achieve good symptom control,
• To minimize future risk of asthma-related
mortality, exacerbation, persistent airflow
limitation and side effects of treatment (GINA,
2019)
 MANAGEMENT of ASTHMA

• Maintain normal lung

function
• Few asthma
• Prevent exacerbations
symptoms
• Prevent asthma deaths
• No sleep disturbance • Avoid medication side-
• No exercise limitation effects

Symptom Risk
control reduction
ELECTROPHYSICAL
AGENT FOR
ASTHMA
DEFINITION OF EPA BY
ISEAPT
EPA is defined as the use of electrophysical
and biophysical energies for the purposes
of evaluation, treatment and prevention of
impairments, activity limitations, and
participation restrictions.

Electrophysical Agent adalah penggunaan

energi elektrofisika dan biofisika dengan
tujuan evaluasi, intervensi/tindakan dan
pencegahan pada gangguan
(impairments), keterbatasan aktivitas
(activity limitations) dan hambatan
partisipasi (participation restriction).
Tim Watson, 2014
Rata-rata penggunaan
modalitas elektrofisis pada
RS M bulan Oktober 2018-
Januari 2019
376 physical therapists
Brazilia

Availability of electrophysical
agents at the physical therapists’
workplaces
 NEBULIZER
- Jet Nebulizer
- Ultrasound nebulizer
- Mesh nebulizer
Advantages Disadvantages

Jet Nebulizer - Murah - Kurang efisien

- Mudah digunakan - Sulit dibersihkan
- Efektif memberikan obat yang tidak - Perlu gas terkompresi dan tabung
dapat diberikan dengan pMDIs dan DPIs tambahan
Ultrasonic Nebulizer - Mudah digunakan - Volume residu besar
- Lebih efisien dibandingkan jet nebulizer - Tidak mampu membuat aerosol larutan
kental
- Degradasi bahan peka panas
Mesh Nebulizer - fast, quiet, portable - Lebih mahal
- Sumber listrik mandiri - Sulit dibersihkan
- Mengoptimalkan ukuran partikel untuk - Dosis obat harus disesuaikan dalam
obat tertentu transisi dari JN
- Lebih efisien daripada nebulizer lain - tidak kompatibel dengan cairan kental
- Mudah digunakan atau yang mengkristal saat dikeringkan
 TERAPI NEBULISASI
- Definisi : proses pemberian obat melalui inhalasi
- Nebulizer adalah perangkat kecil yang dapat
mengubah obat dari larutan menjadi bentuk
aerosol melalui kompresor/sumber gas
terkompresi
- Memecah partikel obat menjadi aerosol
- bronkodilator adalah obat nebulisasi yang paling
umum tetapi banyak obat lain yang dapat
dinebulisasi, termasuk steroid dan antibiotik
TUJUAN
• untuk menambah kelembapan udara
• untuk menghidrasi/mengencerkan dahak
yang kental
• untuk memberikan berbagai obat ke saluran
nafas
 INDIKASI
• Bronchospasm
• Chest tightness
• Excessive and thick mucus
secretions
• Respiratory congestion
• Pneumonia
• Atelectasis
• asthma
CONTRAINDICATION

- Patients with unstable and increases

blood pressure
- Individuals with cardiac irritability (may
result to dysrhythmias)
- Persons with increased pulses
- Unconscious patients (inhalation may
be done via mask but the therapeutic
effect may be significantly low)
Optimum technique for jet nebulizers Technique for
•
•
Correctly assemble the nebulizer.
Attach the appropriate interface (mouthpiece or mask) to the nebulizer. jet, ultrasonic,
• Put medicine into the nebulizer cup. Do not exceed the volume recommended by
the manufacturer and mesh
• Sit in an upright position
•
•
Connect the nebulizer to a power source
Breathe normally with occasional deep breaths until sputter occur or until the end
nebulizers
of nebulization.
• Keep the nebulizer vertical during treatment.
• If the treatment must be interrupted, turn off the flow meter to avoid waste
• Rinse the nebulizer with sterile or distilled water and allow to air dry.

Optimum technique for ultrasonic, mesh, & smart nebulizers

• Correctly assemble the nebulizer.
• Attach the appropriate interface (mouthpiece or mask) to the nebulizer.
• If applicable, follow manufacturer’s instructions in performing functionality test prior to the first use of a new
nebulizer as well as after each disinfection to verify proper operation
• Put medicine into the nebulizer cup. Do not exceed the volume recommended by the manufacturer
• Sit in an upright position
• Follow the instructions for breathing technique that are recommended by the manufacturer
• If the treatment must be interrupted, turn off the to avoid waste. unit to avoid waste.
• At the completion of the treatment, disassemble and clean as recommended by the manufacturer. Do not
touch the mesh during cleaning in order to prevent damage.
 Norihide Murayama and Kikuno Murayama, 2018

treatment outcome
Respondent

- A mesh or jet nebulizer SpO2

N : 88 - For children < 2 years old Heart Rate
Age : < 6 years old (n:37) → 1 ml (0,1 ml Clinical symptoms with
salbutamol, 0,9 saline) Mitsui’s symptom score
Mild asthma
- Children > 2 years old (n: 51) Before and after treatment
→ 1ml (0,2 salbutamol 0,8
saline)
- Continuous inhalation via a
mask for 10 minutes
Mitsui’s symptom score [Obata et RESULT
al., 1992]:
- dyspnea (0, none; 1, chest
retractions; 2, orthopnea),
- rhonchi (0, none; 1, mild; 2, severe;
3, attenuated),
- wheezing (0, none; 1, positive; 2,
attenuated),
- cyanosis (0, absent; 1, present),
- difculty with conversation (0,
absent; 1, present), and
- clouding or loss of consciousness
(0, absent; 1, present).
The highest possible total score is 10,
- scores 1–3 → mild,
- 4–6 → moderate and
- 7–10 → severe
Rizvi DA et al. Int J Basic Clin Pharmacol. 2018 Jul;7(7):1333-1338
Respondent
- prospective eighteen months study
- N: 45 (males and 18 females)
- aged 18 years and above
- had a history of bronchial asthma for at least 6 months
- Stable asthma
treatment
First Visit (day-1): Inhaled salbutomol 200mcg
• Second visit (day-8): Budesonide (Budecort) 1mg by nebulizer
• Third visit (day 15): Budesonide (Budecort) 400mcg by metered dose inhaler
• Fourth visit (day 22): Budesonide (Budecort) 400mcg by dry powder inhaler.
output
- Pulmonary function
- Astma symptoms score
 TENS (TRANSCUTANEUS ELECTRICAL
NERVE STIMULATION)
TENS → suatu cara penggunaan energi listrik untuk merangsang saraf
melalui permukaan kulit ( Parjoto, 2006 )

TEKNIK APLIKASI TENS:

1. Conventional TENS
2. Acupunture Like TENS
3. Intense TENS
4. Pulse Burst TENS
 CONVENTIONAL
• Target: saraf
berdiameter besar
• Frekuensi sd 200 Hz
• durasi: 100-200 ms
• Sensasi parestesi, sedikit
kontraksi
AL TENS INTENSE TENS PULSE BURST TENS
• Aktivasi motoric, • Aktivasi saraf berdiameter • Frekuensi 1 – 10 Hz
serabut saraf G III da kecil • Durasi 200 μs
A alpha • Mengaktivasi nosiseptor
• Sensasi kontraksi otot • Sensasi tidak nyaman tapi
fisik yang kuat tetapi masih dapat ditoleransi
nyaman • Frekuensi 200 Hz
• Frekuensi rendah, • Durasi > 100 ms
intensitas tinggi
• Durasi: 100-200 ms
Efek stimulasi listrik terhadap jaringan tubuh
Tingkat seluler
• eksitasi saraf tepi / perifer,
• perubahan permiabilitas membran sel jaringan non
eksitatori,
• modifikasi formasi osteklas, osteoklastik, fibrolas &
fibrolastik,
• modifikasi mikrosirkulasi - arterial, venous dan limfatik
• perubahan konsentrasi protein dan sel darah,
• perubahan aktivitas enzim seperti SDH dan atau ATPase,
• perubahan sintesa protein,
• modifikasi ukuran dan konsentrasi mitokondria
Tingkat segmental
• kontraksi sekelompok otot dan pengaruhnya
terhadap gerakan sendi serta aktivitas otot sinergis,
• gaya pompa otot yang akan berpengaruh terhadap
aliran limfatik, vena dan aliran darah arteri (
makrosirkulasi ),
• perubahan aliran limfatik dan aliran darah arteri
yang bukan disebabkan oleh pengaruh gaya
pompa atot rangka
Tingkat jaringan
❖ kontraksi otot dan efeknya terhadap kekuatan otot, kecepatan
kontraksi serta daya tahan terhadap kelelahan,
❖ kontraksi otot-otot polos dan rileksasi yang berdampak pada
aliran darah di arteri maupun vena,
❖ regenerasi jaringan, termasuk tulang, ligamen, jaringan ikat dan
kulit,
❖ remodeling jaringan termasuk pelunakan, penguluran,
penurunan viskositas serta penyerapan cairan dari rongga
sendi dan rongga interstisial,
❖ perubahan suhu jaringan dan keseimbangan kimiawi
Tingkat sistemik
❖ efek analgetik yang berhubungan dengan
polipeptida endogen seperti betaendorfin,
enkhepalin, dopamin dan dimorfin,
❖ efek analgetik yang berhubungan dengan
neurotransmitter seperti serotonin dan bahan P,
❖ efek sirkulasi yang berhubungan dengan
polipeptida seperti
 Acu TENS :
- Elektroda : lateral proses VC 7 (titik
akupuntur untuk mengurangi gejala dyspnea
(Ngai et al., 2006)
- TENS portabel saluran ganda (ITO 320; ITO
Company Ltd; Tokyo, Jepang),
- frekuensi 2 Hz, pulse width 200 μs
- intensitas toleransi pasien
- Waktu: 40 menit, 3 kali/minggu selama 8
minggu berturut-turut.

- CG (16): - Serum IgEtotal

- N: 32 (12-16 y) breathing re- estimation
- Moderate – training - Pulmonary
severe asthma - IG (16) BR + function
Acu-TENS - Quality of life
RESULT

Manfaat Acu TENS pada pasien PPOK (Yu et al., Wang et al., 2018;
Ngai et al.,2017)
• memperbaiki fungsi paru,
• mengurangi sesak napas saat berolahraga, dan
• meningkatkan kualitas hidup

Acu TENS dapat meningkatkan laju aliran ekspirasi pasca latihan pada
subyek sehat (Ngai et al., 2011)
Faten & Nezar, 2019

- N: 40 male patients moderate chronic bronchial asthma

- 35 to 45 years
- All patients did not take medications
- Acu TENS group and control group (placebo TENS)

Acu TENS
- TENS machine (Myo 200 electrotherapy device;
GymnaUniphy, Bilzen, Belgium
- Elektrode : Lateral proc spinosus VC7
- Frekuensi 4 Hz, 200 μs pulse width, intensitas
tertinggi yang dapat ditoleransi oleh pasien dengan
nyaman
- Waktu 45 menit 3 kali seminggu selama 4 minggu .
- Outcome: FVC, FEV1, Dyspnea Scale (MRC)
Faten & Nezar, 2019
RESULT

Peningkatan FEV1 15,08% (IG)

dan 2,15% (CG)

Peningkatan FVC 13,18% (IG)

dan 0,69% (CG)

MRC no significant different

Saif Eldeen Ahmed ragab et al., 2017

- Cross sectional study

- N : 31 patients “acute axacerbation”
- Age: 21 – 70 years old
- 2 group: VNS (n: 21) and sham VNS (n: 10)
- Low intensity current stimulus : intensitas: between 0.1
and 10mA with a stimulation frequency of 25 Hz.
- Stimulation was active for 30 s, followed by a break of
180 s
 Saif Eldeen Ahmed ragab et al., 2017
RESULT
Comparison of relative
between both VNS group
(I)and sham VNS group (II):
Methods of
Treatment in
Asthma Studies
EA, electroacupuncture; V, volts; min,
minutes; d, day(s); Ig, immunoglobulin; mV,
millivolt; wk(s), week(s); Th, T-helper; NO,
nitric oxide; MA, manual acupuncture; ms,
millisecond(s); Treg, T-regulator; mo, month;
IL, interleukin; NF-jB, nuclear factor kappa–B;
HPA, hypothalamic– pituitary-adrenal.
 - RCT
- N: 20 (IG : 11; CG: 9)
- All patients received respiratory physical therapy
- Outcome:
- quality of life questionnaire
- Pulmonary function tests
- incremental exercise test
- TNF-α, ꞵ-endorphin level
- EMG

- NMES bilateral quadriceps

- Multicurrent Device, EndoMed 686, Enraf-Nonius B.V., Rotterdam,
Netherlands, GB 3004
• symmetrical biphasic square pulsed current at 50 Hz
• 2 s on and 18 s off (10%) pada minggu pertama
• 5 s on and 25 s off (20%) pada minggu kedua
• 10 s on and 30 s off (33%) > minggu kedua
• pulses of 300 - 400 ms, amplitudo 15 - 20 mA pada awal terapi dan
ditingkatkan sampai 100 mA.
• Intensitas ditingkatkan sampai terlihat kontraksi otot yg kuat/toleransi
maksimum
• 5 kali seminggu, 2 kali sehari selama 8 minggu . 60 min per sessi
RESULT
TNF-a (A) and b-endorphin (B) levels in two groups before and after the
intervention period, (NMES, black bar, and Control, gray bar). * Two-way
repeated-measures ANOVA (P < 0.001) for group, training and interaction
effects.
Abbreviations: FFM, fat-free mass; MM, muscle mass; thigh circumference at 14 cm (C14), 21 cm (C21) and 28 cm (C28);
_V O2 Z oxygen uptake; _VCO2 Z carbon dioxide output; RER Z ratio exchange ratio; _V E Z minute ventilation; Tlim,
exercise tolerance; SpO2, pulse oximetry (oxyhemoglobin saturation); BLES, Borg leg effort; BDS, Borg dyspnea sensation;
Gross ME, mechanical efficiency; 6-MWT, 6- min walk test. P value represents the overall comparison between the
groups. Data presented as mean SD. *P < 0.01 from before within a given treatment; yP < 0.01 between-treatment
comparison
 application NMES for diaphragma (Nohama, 2012;Geddes,
1991)
- synchronized impulse
- frequency of 30 Hz, 1 s pulse increase period, 1 s “on” (muscle
contraction) period, 1 s pulse decrease period, and 20 s “off”
(disconnection) period;
- Each session was performed for 45 min at intensities that
produced visible contractions.
application NMES for quadriceps
- synchronized impulse
- frequency of 50 Hz, 8 s pulse increase period, 1 s “on” (muscle
contraction) period, 1 s pulse decrease period, and 30 s “off”
(disconnection) period;
- Each session was performed for 45 min at intensities that
produced visible contractions.

- DG (n:17) - Peripheral
- RCT - QG (n:24) muscle strength
N: 67 - CG (n:26) - Respiratory
- ICU patients conventional PT muscle strength
2x/d - ADL
Marcela Aparecida Leite, et al., 2018
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PAFKRI