Asthma Management

based on GINA 2016

Prof. Dr. Tamsil Syafiuddin, SpP(K)

Department of Pulmonology and Respiratory Medicine,

Faculty of Medicine,
Universitas Islam Sumatera Utara / Universitas Sumatera Utara,
Medan-2017
 CURRICULUM VITAE
NAMA : Prof.Dr.TAMSIL SYAFIUDDIN Sp.P (K)
ALAMAT : Jln.KARSA No F 1 KOMPLEKS EKS KOWILHAN I SEI.AGUL MEDAN 20117
PEKERJAAN :Guru Besar Tetap FK- UISU / Luar biasa FK- USU
- Penasihat Perhimpunan Dokter Paru Indonesia Pusat
- Anggota Kolegium Pulmonologi Indonesia
- Anggota Dewan Asma Nasional
- Anggota Pokja Asma dan PPOK PDPI Pusat
- Penasihat Perhimpunan Dokter Paru Indonesia Sumut
- Penasihat Yayasan Asma Indonesia Wilayah Sumut
-Ketua Departemen Pulmonologi dan Kedokteran Respirasi FK-UISU

RIWAYAT PENDIDIKAN :
-Dokter Umum FK-USU Medan,1979
-Dokter Spesialis I Paru, FK-UI Jakarta, 1991
-Dokter Spesialis II Paru, Konsultan Asma/PPOK, 1995
Pendidikan tambahan:
- Pelatihan Kanker Paru, TSUKAGUCHI Hospital, Kobe- Japan 1989
- Pelatihan PPOK, AMAGASAKI Hospital, Kobe- Japan 1990
- Pelatihan Respiratory Physiologi, ”JAPAN RESPIRATORY PHYSIOLOGIST
CLUB”, Kyoto- Japan 1990
- Spirometry Training Course, Department of Respiratory Medicine,
National University Hospital Singapore, Singapore 1997
 - Workshop on Transbronchial Lung Biopsy and Trasbronchial Needle
Aspiration PDPI Cabang Jakarta, RS Persahabatan Jakarta ,Jakarta Maret 1997
- Workshop on Respiratory Physiology and Its Clinical Application, RS Pusat
Angkatan Darat Gatot Subroto Jakarta, Jakarta Juni 1997
- Workshop on Medical Thoracoscopy, The American College of Chest
Physicians-The Indonesian Association of Pulmonologist, RS Persahabatan
Jakarta, Jakarta November 1997
- Workshop on Reformation of Higer Education System,HEDS-JICA,Jakarta 1998
-Pulmonary Infections Course, Postgraduate Medical Institute,
Singapore General Hospital, Singapore 2001

- Bronchoscopy &Thoracoscopy Workshop, Postgraduate Medical Institute,

Singapore General Hospital, Singapore 2005
-“Workshop of Bronchoscopy and Autofluorecent Bronchoscopy,
RS Persahabatan Jakarta, Jakarta September 2005

-“Training of the new interventional technique of bronchosfiberscopy”

(Optical Coherence Tommograhy) , Department of Thoracic Surgery,
Tokyo Medical University Hospital,Tokyo - Japan 2007

-”Respiratory Master Class on COPD”, Singapore 2011

Standar Kompetensi Dokter Indonesia

Konsil Kedokteran Indonesia

Indonesian Medical Council
Jakarta 2012
 Daftar “Masalah” Sistem Respirasi
dan Sistem Kardiovaskuler:

• Batuk (kering,berdahak,darah)
• Sakit/nyeri dada
• Berdebar-berdebar
• Sesak napas atau napas pendek
• Napas berbunyi
• Sumbatan jalan napas
• Kebiruan
Lampiran 2 SKDI 2012
 Daftar Penyakit
Sistem Respirasi
(Tingkat Kompetensi)

Lampiran 3 SKDI 2012

 TINGKAT KEMAPUAN/KOMPETENSI:
• Kemampuan 1 : Mengenali dan Menjelaskan
• Kemampuan 2: Mendiagnosis dan Merujuk
• Kemampuan 3: Mendiagnosis,
Penatalaksanaan awal dan Merujuk
3A: Bukan gawat darurat
3B: Gawat darurat
• Kemampuan 4: Mendiagnosis,Tatalaksana
mandiri dan Tuntas
4A: Kompetensi saat lulus dokter
4B: Kompetensi internsip dan PKB
Lampiran 3 SKDI 2012
 DAFTAR KOMPETENSI SISTEM RESPIRASI

1.Asma 4A
2.Bronkitis akut 4A
3.Pneumonia,Bronkopneumonia 4A
4.Tuberkulosis tanpa komplikasi 4A
5.Influenza 4A
6.Pertusis 4A

Lampiran 3 SKDI 2012

 DAFTAR KOMPETENSI SISTEM RESPIRASI
7.ARDS 3B
8.SARS 3B
9.Flu burung 3B
10.Asma akut berat 3B
11.Bronkiolitis akut 3B
12.Efusi pleura masif 3B
13.Pneumonia aspirasi 3B
14.PPOK Eksaserbasi akut 3B
15.Edema paru 3B
16.Haematotoraks 3B
Lampiran 3 SKDI 2012
 G lobal
IN itiative for
A sthma

© Global Initiative for Asthma 2016

 Definition of asthma
• Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation.
• It is defined by the history of respiratory
symptoms such as wheeze, shortness of breath,
chest tightness and cough that vary over time
and in intensity, together with variable
expiratory airflow limitation.
• Heterogenous disease, phenotypes
NEW!

GINA 2016
 Inflammation
(–) (+) Asthma
Normal
 
Triggers

 


Triggers
 
 


Bronchial hyperreactivity ( - ) Bronchial hyperreactivity ( + )

Bronchoconstriction ( - ) Bronchoconstriction ( + )

Symptoms (-) Symptoms (+)

The pathogenesis of asthma
 Ca++ Histamin
Ag
Ig E YY
Methyl Phosphatidyl Phosphatidyl
Phospholipid ethanolamine choline
transferase

Phospho
lipase A2 Ca ++ Histamin
Arachidonic acid ECF, NCF
lypoxygenase cyclooxygenase

5-HETE Leucotrienes Thromboxanes Prostaglandins

LTB4 PGD
LTC4 TXA2
LTD4 PGF2
LTE4

Mediator release in asthma reactions

 Inflammation

Controller
Bronchial hyperreactivity

Bronchoconstriction
Reliever
Symptoms
Medicines and Pathogenesis of asthma
 AIRWAY REMODELLING IN ASTHMA

Eosinophil

Desquamations of epithelium

MBP, ECP
Epithelium

Thickening of basement membrane

Increase in airway smooth muscle

 Goals of asthma management
• The pharmacological treatment of asthma
categories:
-Controller medications,
-Reliever medications,
-Add-on therapies, these may be considered when
patients have persistent symptoms and/or exacerbations
despite optimized treatment with high dose controller
medications.

GINA 2016
Goals of asthma management
• Non pharmacological treatment to achieving
these goals requires a partnership between patient and
their health care providers
– Ask the patient about their own goals regarding their asthma
– Good communication strategies are essential, Adherence
– Incorrect/poor technique inhaler
– Smooking
– Co-morbid, Rhinitis
– Consider the health care system, medication availability,
cultural and personal preferences and health literacy

GINA 2016
 Asthma Therapy Evolution
ICS treatment Adding
introduced LAßA to ICS therapy
“Large use” of 1972 Kips et al, AJRCCM 2000
Pauwels et al, NEJM 1997
short-acting
Greening et al, Lancet 1992
ß2-agonists
1975 Single
inhaler therapy

1980
“Fear” of ICS+LABA
short-acting
ß2-agonists

1985
2000
1990 1995

Bronchospasm Inflammation Remodelling

 Definition of asthma
• Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation.
• It is defined by the history of respiratory
symptoms such as wheeze, shortness of breath,
chest tightness and cough that vary over time and
in intensity, together with variable expiratory
airflow limitation.
• Heterogenous disease, phenotypes

NEW!

GINA 2016
 • Symptoms
• Remodelling
• Treatment

Based on Inflammation
 Controller:
Anti inflammation

Non steroid Inhaled Cortico Steroid

• sodium chromoglicate • budesonide (Pulmicort®)
(Intal®) (Inflamid®)
• ketotifen • beclomethasone dipropionate
(Becotide®)
• sodium nedocromil
• triamcinolone acetonide
• fluticasone(Flexotide®)
 Reliever
Bronchodilator
• 2 - agonist
• Xanthin
• Anticholinergic
 BRONCHODILATOR
Short Acting 2 AGONIST (SABA): Long Acting 2 AGONIST:
•salbutamol/albuterol (Ventolin ®) (LABA)
•terbutaline (Bricasma®) •salmoterol
•procaterol
•formoterol
•fenoterol
•orciprenaline, etc

ANTICHOLINERGIC: XANTHINE:
•atropine sulfate •theophylline
•aminophylline
•ipratropium bromide
•tiotropium bromide
OTHER SYMPHATOMIMETIC:
•ephedrine
•adrenaline, etc
 Combination therapy
( ICS + LABA )

1.Symbicort®
Budesonide + Formoterol
( Rapid onset of action and Long acting of duration)

2.Seretide®
Fluticasone + Salmoterol
( Non rapid onset of action and Long acting of duration)

(BPJS Kesehatan)
 Other changes for clarification in GINA 2016 update
• Assessment of risk factors: over-usage of SABA
– High usage of SABA is a risk factor for exacerbations (Patel et al, CEA 2013)
– Very high usage (e.g. >200 doses/month) is a risk factor for asthma-
related death (Haselkom, JACI 2009)
• Beta-blockers and acute coronary events
– If cardioselective beta-blockers are indicated for acute coronary events,
asthma is not an absolute contra-indication.
– These medications should only be used under close medical supervision by a
specialist, with consideration of the risks for and against their use
• Asthma-COPD Overlap Syndrome (ACOS)
– The aims of the chapter are mainly to assist clinicians in primary care and non-
pulmonary specialties in diagnosing asthma and COPD as well as ACOS, and to
assist in choosing initial treatment for efficacy and safety
– A specific definition cannot be provided for ACOS at present, because of the
limited populations in which it has been studied
– ACOS is not considered to represent a single disease; it is expected that
further research will identify several different underlying mechanisms

© Global
GINA 2015 Initiative for Asthma 2016
 Guidelines on Asthma Management:
Past and Current Trends

Mild Moderate Severe Old classification

Intermittent persistent persistent persistent

Exacerbation
Total control Partially control Uncontrol New classification

Inhalation SABA or Rapid onset of action LABA

GINA 1998 ICS LABA and ICS

(adapted)

GINA 2008-2016 ICS+LABA Stable condition

 SABA and Rapid onset of LABA in
treating acute severe asthma/exacerbation
Symbicort
(Formoterol
FEV1 (% change from baseline) Rapid onset of LABA)

45 Salbutamol
(SABA)
40
35
30
25
20
15
10
5
0
0 30 60 90 120 150 180
Time since last administration of study drug (minutes)
Balanag et al, Pulmonary Pharmacology&Therapeutics 2005
 A basis for synergy
ICS and LABA
Effects of ICS on
the ß2 receptor system
Corticosteroids increase
ß2-receptor synthesis
Overall biological / therapeutic
consequences
Effects of LABA on
the glucocorticoid
receptor system
LABASs prime
glucocorticoid receptor
for steroid dependent
activation
Zain-Hamid R – Faculty of Medicine,
Universitas Sumatera Utara, Indonesia.
 Increasing combination therapy earlier
to prevent exacerbations
FACET exacerbation profiles
% change from
day –14
100
Reliever β2-agonist
Morning PEF
80 Window of
Night-time symptoms
opportunity to
60 prevent
exacerbations?
40

20

–15 –10 –5 0 5 10 15
Days before and after an exacerbation
Tattersfield AE, et al. Am J Respir Crit Care Med 1999;160:594–599.
The Beginning of
Treatment
 Exacerbation x

The beginning of treatment ?

Stable condition

Asthma management

* Stable condition

* Long-term therapy
 Inflammation can also be present during symptom-free periods

Rate of response of different measures of asthma

control over 18 months of ICS treatment
% Reduction

AHR is a marker of inflammation

AHR

Night Rescue medication use

symptoms Impaired am PEF
Impaired FEV1

Start of 2 4 6 18
treatment Months

Adapted from Woolcock A. Clin Exp Allergy Rev 2001; 1: 62–64.

 Treatment targets in common chronic diseases
• Clear therapeutic targets exist for many
chronic diseases
• Philosophy of ‘treat to target’
– Hypertension BP 140/90 mmHg or less
– Diabetes HbA1c 7% or less
– Dyslipidaemia LDL-cholesterol <100 mg/dl

Asthma treatment is designed to meet specific

targets and achieve:
‘ASTHMA CONTROL’
 Assessment of asthma
1. Asthma control - two domains
– Assess symptom control over the last 4 weeks
– Assess risk factors for poor outcomes, including low lung
function, smoking and blood eosinophilia
2. Treatment issues
– Check inhaler technique and adherence
– Ask about side-effects
– Does the patient have a written asthma action plan?
– What are the patient’s attitudes and goals for their asthma?
3. Comorbidities
– Think of sinusitis, rhinosinusitis, GERD, obesity, obstructive
sleep apnea, depression, anxiety
– These may contribute to symptoms and poor quality of life

GINA
GINA 2015, 2016
Box 2-1
 Control Level Based on GINA
Asthma PARTLY
Characteristics CONTROLLED UNCONTROLLED
Classification CONTROLLED

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of
None Any
activities 3 or more
features of partly
Nocturnal symptoms /
None Any controlled
awakening
asthma present
Need for rescue / None (2 or less / More than in any week
“reliever” treatment week) twice / week

Lung function < 80% predicted or personal

Normal best (if known) on any day
(PEF or FEV1)
Once/more per
Exacerbation None One in any week
year

GINA updated 2014

 GINA assessment of symptom control

A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week?

Yes No
• Any night waking due to asthma?

Yes No None of 1-2 of 3-4 of

• Reliever needed for symptoms* these these these
more than twice a week?
*Excludes reliever taken before exercise, because many people take this routinely
Yes  No
• Any activity limitation due to asthma?
This classification is the same as the GINA 2010-12 assessment
Yes No of ‘current control’, except that lung function now appears only
in the assessment of risk factors

GINA 2016, Box 2-2A © Global Initiative for Asthma

Referency:
Global Initiative for Asthma (GINA)
Global Strategy for Asthma Management and Prevention (updated 2016)
Sitou Timou Tumou Tou
(Sam Ratulangi , 1890 -1949)