Patogenesa:

Pencetus/trigger (alergen, virus, iritan, psikis)

hiperresponsif saluran napas reaksi imunologik
dan atau gangguan keseimbangan biokimia /
neurohumoral inflamasi akut (reaksi asma tipe
cepat dan tipe lambat) bronkospasme, edema,
hipersekresi mukus inflamasi kronik & airway
remodeling
GAMBAR PARU dan SALURAN NAFAS
 Inflamasi akut:
Reaksi asma tipe cepat alergen terikat Ig E pd sel
mast degranulasi sel mast release preformed
(histamin, protease) dan newly generated mediators
(leukotrien, prostaglandin, PAF) br.spasme,
hipersekresi mukus, vasodilatasi.
Reaksi asma tipe lambat timbul 6-9 jam stl
paparan alergen aktivasi eosinofil, sel T CD4+,
netrofil & makrofag.
Inflamasi kronik & airway remodeling:
Melibatkan sel limfosit T, eosinofil, makro-
fag, sel mast, sel epitel, dan fibroblast
Menyebabkan kerusakan jaringan yg dii-kuti healing
process perubahan struk-tur (airway remodeling)
berupa:
- Hipertrofi & hiperplasia otot polos br. &
kelenjar mukus
- Penebalan membran reticular basal
- Hipervaskuler
- Perubahan struktur parenkim fibrosis
PATOFISIOLOGI
 The pathway begins with the development of TH2 cells and their production of the cytokines IL-4, IL-5 and IL-13. These cytokines stimulate
allergic and eosinophilic inflammation as well as epithelial and smooth-muscle changes that contribute to asthma pathobiology. APC, antigen-
presenting cell; CRTH2, chemoattractant receptor-homologous molecule expressed on TH2 cells; iNOS, induced nitric oxide synthase; PGD2,
prostaglandin D2; TSLP, thymic stromal lymphoprotein.

Wenzel, S. Nat Med 2012 May 4;18(5): 716-25. Used with permission.
In atopic asthma (left), eosinophilic airway inflammation and BHR are driven by adaptive TH2 cells that are stimulated by DCs to produce IL- 5,
IL-13 and IL-4, the latter driving IgE synthesis. In nonatopic or intrinsic asthma (right), which is not dependent on adaptive immunity, ILC2
cells produce IL-5 and IL-13 and thus cause eosinophilia and BHR. As there is no specific allergen involved and as ILC2 cells produce little IL-
4, there is no associated IgE response from B cells. Modified from ref. 185. MHCII, MHC class II; TSLPR, receptor for TSLP; NKT cells,
natural killer T cells.

Lambrecht, et al. Nat Immunol 2015 Jan;16(1):45-56. Used with permission.

 Gejala klinis:
Sesak napas / dada terasa penuh (chest
tightness)
Napas berbunyi (mengi/wheezing)
Batuk (terutama malam dan dini hari)
Dahak kental sulit dikeluarkan

Gejala timbul secara episodik berulang

Klasifikasi asma:
1. Asma Atopik/Ekstrinsik/Alergik
2. Asma Nonatopik/Intrinsik

Sindroma Asma:
Exercise-induced asthma
Nocturnal asthma
Occupational asthma
Aspirin-induced asthma
Fatal & near fatal asthma
Asma Atopik/Ekstrinsik/Alergik:
Anak & dewasa muda
Serangan mendadak stl terpapar alergen, dpt pulih
tanpa obat
Sering didahului influenza
Keturunan (+), eksim saat kanak2
Skin test (+), Ig E & eosinofil
Sering alergi aspirin
Respons tx baik
Asma Nonatopik/Intrinsik:
Dewasa atau usia pertengahan
Faktor imunologi (?)
Sering disebabkan infeksi, dahak purulen
Riwayat atopi ()
Skin test (-), Ig E & eosinofil normal
Respons tx kurang
Prognose lebih jelek
 Sindroma Asma:
Exercise-induced asthma (EIA):
- Pencetus latihan fisik sedang - berat
- Usia muda
- Mekanisme: ventilasi udara kering & dingin
masuk jln napas pengeringan & pendinginan
mukosa jln napas inflamamasi (sel mast melepas
mediator) br. spasme, edema, hipersekresi
mukus
- Makin kering & dingin, makin berat br.spasme
 Exercise-induced asthma
- Faktor yg dpt memperberat atau memperingan EIA:
- Asma yg tdk terkontrol baik
- Berlatih di udara kering & dingin
- Jenis & beratnya latihan fisik
- Warming-up seblm berlatih
- Terapi: 2-agonis & cromolyn inhalasi
sebelum berlatih
 Nocturnal asthma:
- Keluhan batuk / sesak terutama timbul pd
malam dini hari
- Mekanisme perubahan suhu yg ekstrim,
pe kadar hormon adreno-corticotropin pd
dini hari
- Terapi: Theophylline SR, LABA + steroid
inh.
 Occupational asthma:
- Penyebab alergen atau iritan di lingkungan
kerja
- Keluhan timbul bila px berada di lingkungan
kerja & menghilang setelah px pulang
- Terapi: masker, pindah tempat kerja, 2-
agonis & steroid inhalasi sebelum bekerja
Diagnosa:
1. Anamnesa
2. Pemeriksaan fisik
3. Pemeriksaan penunjang:
- Radiologis: foto toraks
- Test faal paru, uji provokasi bronkus
- Laboratorium: status alergi (darah tepi,
Ig E total, eosinofil count, Ig E Atopy,
skin test, sputum charcot leyden)
Anamnesa:

Serangan bersifat episodik/berulang /kumat-

kumatan, reversibel
Memburuk malam & dini hari
Pencetus/trigger (+)
Respons thd br.dilator (+)
Riwayat asma dlm keluarga
Riwayat alergi, sinusitis
Pemeriksaan fisik:
Dpt normal, kadang wheezing (+), eks-pirasi
memanjang
Serangan ringan wheezing akhir eks-pirasi
paksa
Serangan berat wheezing dapat tidak
terdengar, px sianosis, gelisah, taki-kardi, retraksi
ics, penggunaan otot bantu napas
Pemeriksaan penunjang:
Foto toraks normal diluar serangan, hi-perinflasi
saat serangan, adanya penyakit lain
Faal paru (spirometri / PEFR) menilai berat
obstruksi, reversibilitas, variabilitas
Uji provokasi bronkus membantu dx
Status alergi skin prick test, Ig E total, eosinofil
count, Ig E Atopy
Diagnosa Banding:
Dewasa:
PPOK, bronkitis kronis, gagal jantung kongestif,
obstruksi krn tumor, disfungsi larings, emboli paru

Anak:
Corpus alienum, laringotrakeomalasia, limfadenopati,
bronkiolitis, stenosis trakea, tumor
 Tingkat Kontrol Asma menurut GINA
2008
Klasifikasi TERKONTROL TIDAK
Characteristics
TERKONTROL
Asma SEBAGIAN TERKONTROL
2x/ > 2x/
Gejala Siang
minggu minggu
Hambatan
Tidak Ada Ada
Aktivitas KUALITAS
Gejala Malam Tidak Ada Ada HIDUP
3 atau lebih
Perlu Obat 2x/ > 2x/ keadaan
Pelega minggu minggu terkontrol
Fungsi Paru < 80% prediksi atau
Normal hasil terbaik (bila sebagian dalam
(PEF atau FEV1) ada) setiap hari setiap minggu
Satu / lebih per Satu kali pada
Eksaserbasi/kambuh Tidak Ada tahun
setiap minggu
GINA updated 2008
 Klasifikasi derajat berat asma (GINA 2004)
Derajat Gejala Gejala Faal Paru Terapi
Asma mlm
Intermitten < 1x/minggu 2x/bulan PEFR 80% SABA inhalasi saat
Asimtomatik FEV1 80% serangan
V.PEF< 20%

Mild Persisten 1x/minggu > PEFR 80% SABA inh.

< 1x/hari 2x/bulan FEV1 80% Steroid inh. dosis rendah
Aktivitas ter- V.PEF 20-30%
ganggu
Moderate Setiap hari > 1x/mgg PEFR 60-80% SABA inh.
Persisten Aktivitas & FEV1 60-80% LABA inh.
tidur tergg. V.PEF > 30% Steroid inh. dosis rendah
Br.dilator (+) sedang
Severe Kontinyu Sering PEFR < 60% LABA inh.
Persisten Aktivitas ter- FEV1 < 60% Steroid inh. dosis tinggi
batas V.PEF > 30% Theophylline SR
Oral steroid
Leukotrien
Penatalaksanaan
Tujuan:
Menghilangkan & mengendalikan gejala asma
Mencegah eksaserbasi akut
Me & mempertahankan faal paru optimal
Mengupayakan aktivitas normal (exercise)
Menghindari ESO
Mencegah airflow limitation irreversible
Mencegah kematian
 Conclusions:
what should we do?
Empower/enable the patient
Written action plan
Identify triggers and allergens and avoid
Check adherence and good inhaler technique
Rule out or treat co-morbidities
Changes in pharmacological treatment
Refer only when needed
 How to distinguish between uncontrolled
and severe asthma
Watch patient using their Compare inhaler technique with a device-
specific checklist, and correct errors;
inhaler. Discuss adherence
recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.

If lung function normal during symptoms,

Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Remove potential Check for risk factors or inducers such as

smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider step up to next treatment level.

Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.

If asthma still uncontrolled after 36 months

Refer to a specialist or on Step 4 treatment, refer for expert advice.
severe asthma clinic Refer earlier if asthma symptoms severe,
or doubts about diagnosis.

GINA 2016, Box 2-4 (5/5) Global Initiative for Asthma

 Stepwise management - UPDATED!

pharmacotherapy Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors

STEP 5

STEP 4

STEP 3 Refer for *Not for children <12 years

PREFERRED STEP 1 STEP 2 add-on **For children 6-11 years, the
CONTROLLER treatment
e.g.
preferred Step 3 treatment is
CHOICE Med/high tiotropium,* medium dose ICS
ICS/LABA omalizumab,
#For patients prescribed
Low dose mepolizumab*
Low dose ICS BDP/formoterol or BUD/
ICS/LABA**
formoterol maintenance and
reliever therapy
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium* Add low
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS dose OCS Tiotropium by mist inhaler is
+ LTRA
options (or + theoph*)
(or + theoph*)
an add-on treatment for
patients 12 years with a
As-needed short-acting beta2-agonist (SABA) As-needed SABA or history of exacerbations
RELIEVER low dose ICS/formoterol#

GINA 2016, Box 3-5 (2/8) (upper part)

Kunci dari keberhasilan kontrol asma adalah
mengobati inflamasi sesegera mungkin pada
saat gejala timbul

Kontrol Asma Gejala Asma Eksaserbasi

Inflammasi

Otot halus Bronkokonstriksi

Kunci mengontrol gejala

adalah dengan mening-
katkan terapi anti-infla-
masi untuk menghindari
eksaserbasi
Penatalaksanaan.
1. Saat Serangan:
Reliever/Pelega:
Gol. Adrenergik:
- Adrenalin/epinephrine 1 : 1000 0,3 cc/sc
- Ephedrine: oral
- Short Acting 2-agonis (SABA)
- Salbutamol (Ventolin): oral, inj., inh.
- Terbutaline (Bricasma): oral, inj., inh.
- Fenoterol (Berotec): inh.
- Procaterol (Meptin): oral, inh.
- Orciprenaline (Alupent): oral, inh.
Penatalaksanaan
Gol. Methylxantine:
- Aminophylline: oral, inj.
- Theophylline: oral
Gol. Antikolinergik:
- Atropin: inj
- Ipratropium bromide: inh.
Gol. Steroid:
- Methylprednisolone: oral, inj.
- Dexamethasone: oral, inj.
- Beclomethasone (Beclomet): inh.
- Budesonide (Pulmicort): inh.
- Fluticasone (Flixotide): inh.
Penatalaksanaan
Controller/Pengontrol:
Gol. Adrenergik:
- Long-acting 2-agonis (LABA):
- Salmeterol & Formoterol: inh.
Gol. Methylxantine:
- Theophylline Slow Release
Gol. Steroid: inh., oral, inj.
Leukotriene Modifiers: Zafirlukast
Cromolyne sodium: inh.
Kombinasi LABA & Steroid: inh.
Bila perlu dpt diberikan Antibiotik
Penatalaksanaan.
2. Diluar serangan:
Menjauhi alergen, bila perlu desensitisasi
Menghindari kelelahan
Menghindari stress psikis
Mencegah/mengobati ISPA sedini mungkin
Olahraga (renang, senam asma)
Vaksinasi influenza
 OBAT HISAP

Metered Dose Inhaler Turbuhaler

Aerosol Dry Powder
 NEBULISER

Nebulisasi dengan Micromist Nebulisasi dengan

Masker
 Beda Asma Br. dan PPOK
BEDA ASMA BRONKIALE PPOK
Usia Anak, remaja, dewasa Dewasa > 40 tahun
Merokok +/- ++
Reversibiliti Reversibel Non-reversibel
Progresifiti Non-progresif Progresif
Riwayat Alergi ++ +/-
Batuk Malam dini hari Sewaktu-waktu
Dyspneu on effort Bila serangan ++
Sputum Kental, sulit dikeluarkan +/-
Faal paru Me bila serangan FEV1/FVC < 70%
Variabiliti PF ++ -
Darah Lengkap Normal Polisitemia
Analisa Gas Darah PaO2 N/ PaCO2 , PaO2 N/
Foto Toraks Normal, hiperinflasi saat Hiperinflasi
serangan
Sel-sel inflamasi Eosinofil, CD4+ Netrofil, CD8+