ASTHMA

Setya Puspa Dewi Aprilyani

ASTHMA
▪ Asthma is a complex disorder
characterized by variable and
recurring symptoms, airflow
obstruction, bronchial
hyperresponsiveness, and an
underlying inflammation
▪ The changes are:
▪ Bronchoconstriction
▪ Airway hyperresponsiveness
▪ Airway Edema

British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the
management of asthma. Thorax. 2019.
DIAGNOSIS OF
ASTHMA
▪ Asthma has two key defining
features:
A. History of respiratory
symptoms (wheezing, shortness
of breath, chest tightness, and
cough) that vary over time and in
intensity
AND
B. Variable expiratory airflow
limiation

Global Initiative for Asthma, POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION A Pocket Guide for Health
Professionals Updated 2019 (for Adults and Children Older than 5 Years): GINA MAIN REPORT. 2019
 DIAGNOSIS CRITERIA OF ASTHMA
Respiratory Symptoms Expiratory Airflow Limitation

▪ Wheeze, shortness of breath, chest ▪ FEV1/FVC ratio is below normal

tightness, cough ▪ For children, the normal ratio is >0,85
▪ People usually has more than onse
symptoms ▪ Variation in lung function is greater
than healthy people, for example:
▪ Symptoms occur variably over time and
intensity ▪ FEV increases by >12% (in children)
after inhaling bronchodilator
▪ Worsened at night
▪ Average daily diurnal PEF variabilitay is
▪ Often triggered by exercise, laughter, >13% (in children)
allergen, cold air
▪ FEV1 increases by >12% after 4 weeks
▪ Often worsen with viral infections of anti-inflammatory treatment

Global Initiative for Asthma, POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION A Pocket Guide for Health
Professionals Updated 2019 (for Adults and Children Older than 5 Years): GINA MAIN REPORT. 2019
 RECENT ADVANCES IN DIAGNOSTIC TESTING
Diagnostic Testing Study results
Lipoxins and Lipoxin A4 and Leukotriene B4 is higher in EBC of asthmatic patients
proinflammatory Leukotriene
in EBC (Exhaled breath
condensate)

Broncoprovocation test Use is limited, diagnostic sensitivity is reduced on patient taking ICS
Sputum eosinophil and Potential biomarker, There are significant association between eosinophil
neutrophil percentages and neutrophil percentages with FEV1.
However, the diagnostic test is still not predictive

Serum periostin Potential biomarker, Higher serum periostin is associated with lower FEC

Advances in adult asthma diagnosis and treatment in 2013 Apter, Andrea J. Journal of Allergy and Clinical
Immunology, Volume 133, Issue 1, 49 - 56
National Institute for healthcare and Excellence. Asthma: diagnosis, monitoring and chronic asthma
management. NICE Guideline. 2017
 ASTHMA SEVERITY
ASSESMENT

National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007
[published correction appears in J Allergy Clin Immunol. 2008 Jun;121(6):1330]. J Allergy Clin Immunol. 2007;120(5 Suppl):S94–S138. doi:10.1016/j.jaci.2007.09.043
 ASSESMENT OF
ASTHMA
CONTROL

National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007
[published correction appears in J Allergy Clin Immunol. 2008 Jun;121(6):1330]. J Allergy Clin Immunol. 2007;120(5 Suppl):S94–S138. doi:10.1016/j.jaci.2007.09.043
 ASTHMA MANAGEMENT
▪ The principle of treatment are risk
reduction and symptom control
▪ The aim is to reduce burden to patient
and minimizing risk of asthma-related
death, exacerbation, airway damage,
and medication side effects
▪ The treatment includes:
▪ Medications: ICS controller medication to
reduce risk of serieous exacerbation
▪ Treating modifiable risk factor
▪ Use of non-pharmacological therapies
▪ Training essential skills for patient:
▪ Asthma information
▪ Inhaler skills
▪ Adherence
▪ Written action plan
▪ Self-monitoring of symptoms and peak flow
▪ Regular medical review

Global Initiative for Asthma, POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION A Pocket Guide for Health
Professionals Updated 2019 (for Adults and Children Older than 5 Years): GINA MAIN REPORT. 2019
 ASTHMA STEPWISE TREATMENT (GINA)

Global Initiative for Asthma, POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION A Pocket Guide for Health
Professionals Updated 2019 (for Adults and Children Older than 5 Years): GINA MAIN REPORT. 2019
 ASTHMA STEPWISE
TREATMENT
(CPG)

National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007
[published correction appears in J Allergy Clin Immunol. 2008 Jun;121(6):1330]. J Allergy Clin Immunol. 2007;120(5 Suppl):S94–S138. doi:10.1016/j.jaci.2007.09.043
British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline
on the management of asthma. Thorax. 2019.
MAGNESIUM SULFATE USES BY DIFFERENT GUIDELINES

Song, Woo Jung and Yoon-Seok Chang. “Magnesium sulfate for acute asthma in adults: a
systematic literature review.” Asia Pacific allergy (2012).
 MAGNESIUM SULFATE EVIDENCE

Subjects/Intervention Result

25-40 mg/kg Iv MgSo4 in 143 children • Significant decrease in mechanical ventilation requirement

20-75 mg/kg + Continous infusion 40 mg/kg/h • Found to be safe and Mg levels are maintained
for 4 hour in 19 children

MgSO4 + B2 agonist • Conflicting data

508 Children, MgSO4 vs placebo • Asthma score is significantly lower by MgSo 4 in 60 and
240 mins. Not serious adverse event observed

Nebulized MgSO4 (3 ml) • There is bronchodilator effect

• FEV1 and PEF rise was not superior than salbutamol

Indinnimeo L, Chiappini E, Miraglia Del Giudice M; Italian Panel for the management of acute asthma attack in
children Roberto Bernardini. Guideline on management of the acute asthma attack in children by Italian
Society of Pediatrics. Ital J Pediatr. 2018;44(1):46. Published 2018 Apr 6. doi:10.1186/s13052-018-0481-1
 MECHANISM OF MAGNESIUM SULFATE ON
ASTHMA

▪ MgSO4 has a secondary spasmolytic ▪ MG2+ also has several effects:

property ▪ Inhibiting release of acetylcholine from
motor nerve terminals
▪ There are also inflammatory
modulation effect by attenuating ▪ Inhibiting hitamine release
neutrophil respiratory burst ▪ Decreasing production of mucus in
secretory gland

Block NMDA-
Unbound serum Muscle
receptor Bronchodilation
magnesium relaxation
calcium channel

Jose Enrique Irazuzta, Nicolas Chiriboga, Magnesium sulfate infusion for acute asthma in the emergency department, Jornal de Pediatria,
Volume 93, Supplement 1, 2017, Pages 19-25,
 MANAGEMENT OF
EXACERBATIONS

Global Initiative for Asthma, POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION A Pocket Guide for Health
Professionals Updated 2019 (for Adults and Children Older than 5 Years): GINA MAIN REPORT. 2019
 EXAMPLE OF ASTHMA ACTION PLAN

National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report
3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug
 FOLLOW-UP AFTER AN EXACERBATION
▪ All patients must be followed up regularly by a health care provider until
symptoms and lung function return to normal
▪ The review at follow up includes:
▪ Patient’s understanding the cause of exacerbation
▪ Modifiable risk factors for exacerbation
▪ Understanding the purpose of medications and inhaler technique
▪ Review written asthma action plan

Global Initiative for Asthma, POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION A Pocket Guide for Health
Professionals Updated 2019 (for Adults and Children Older than 5 Years): GINA MAIN REPORT. 2019
 TERIMA KASIH
MOHON ASUPAN