2. Helmi Lubis, dr, SpAK Ridwan M. Daulay, dr, SpAK Wisman Dalimunthe, dr, SpA Rini S. Daulay, dr, M.Ked(Ped), SpA

3.  Cough and/or wheezing that : Episodic Nocturnal (variability) Reversibility With atopic family”

4. 3 desquamation of epithelium Mucus plug Basal membrane thickening Netrophil and eosinophil infiltrations Smooth muscle constriction and hypertrophy Oedema Mucosal gland hyperplasia Barnes PJ

5. 4 AsthmaNormal Inflammation picture

6.  Severity of attacks (Acute)  Mild  Moderate  Severe  Respiratory arrest imminent  Class of disease (Chronic)  Infrequent episodic asthma  Frequent episodic asthma  Persistent asthma 5

7. 6 Asthma : chronic respiratory disease, that can have acute exacerbation Asthma Acute Asthma Chronic Asthma Two Aspects of Asthma

8. 7 Chronic asthma Long term management Algorithm diagnosis & treatment Acute asthma Attackmanagement Algorithm attack management

9. 8 Reliever  To relieve / reduce symptoms and/ attack  As needed use bronchodilators:  2 -agonist, xanthenes, systemic steroid oral, inhalation, injection Controller To control / prevent symptoms and/ attack Long term use Anti inflammations inhaled steroid, ALTR oral, inhalation, For FEA & PA, not for IEA

10. 9 Asthma attack / symptoms present:  First line therapy ▪  2 agonist ▪ Ipratropium bromide Chronic asthma (long term management)  First line therapy ▪ Inhaled steroid ▪ Long-acting  2 agonist (LABA)

11. 10

12. 11 Asthma Triggers Attack House dust mite (HDM) Smoke (polution) Food Infection Longterm management failure

13. 12

14. 13 Trigger Airway obstruction nonuniform hyperinflation ventilation atelectasis mismatching ofdecreased ventilation and perfution compliance decreased surfaktant alveolar hypoventilation increased work acidosis of breathing pulmonary vasoconstriction Bronchocontriction, Mucosal edema, Excessive secretion  PaCO 2  PaO 2

15. 14

16. 15 84.4% 3.9% 11.7% Mild Moderate Severe Severity of Asthma Attacks

17. 16 Estimation of severity of asthma attacks

18. 17

19. 18 Algorithms Asthma Attack Clinic/ ER Rate attack severity First management  2 -agonist nebulization (neb) 3x, 20’ interval 3 rd neb + anticholinergic Moderate attack ( neb 2-3x, partially response) give O 2 reevaluate  moderate  One day care (ODC) IV line Mild attack (neb 1x, good response hold out 1-2 hours, may go home attack reappear  moderate attack Severe attack ( neb 3x, bad/ no response) O 2 since beginning IV line chest X ray reevaluate→severe →hospitalized

20. 19 One Day Care (ODC) O2 continued give oral steroid neb every 2 hrs improve in 8-12 hrs, stable  may go home no improve within 12 hrs, hospitalized Hospital Room O2 continued overcome dehidration and acidosis IV steroid every 6-8 hrs neb every 1-2 hrs IV aminophylline, initial- maintenance improve neb every 4-6hrs stable within 24 hrs, may go home no improvement, impending resp failure - PICU May go home give  2 -agonist (inhalation / oral) patient with controller, continued Viral ARI as trigger steroid oral may given visit outpatient clinic in 24 hours Catatan: severe attack from beginning, directly neb with ipratropium neb can be replaced by adrenalin sc 0.01 ml/kgBw/x, max 0.3ml/x O 2 2-4L/mnt from the start, including during neb

21. 20  Relieve the symptoms quickly and precisely  Reduce hypocxemic  Lung function, back to normal  After attack: reevaluation

22. 21 Asthma attack Nebulization 1-2 x Good responses Discharge Bronchodilator Poor responses ODC Oxygen Nebulization Oral Steroid IVFD Good ResponsesPoor Responses Discharge Wards Oxygen Nebulization IVFD IV/oral Steroid Rehydration Amynophylline

23. 22  Dehidration  Metabolic acidosis  Atelectasis

24. 23  Must be given in severe attack  In severe attack, hypocxemic

25.  Life threatening asthma  Intubate cause asthma attack  Pneumothorax and/or pneumomediastinum  Long duration asthma attack  Use of systemic steroid (recently)  Visit to Emergency Ward or hospitalized for asthma in one last year  Psychiatry or psychology problem

26. 25  β 2 agonist and ipratropium bromide Vs β 2 agonist alone: better result:  Decreased of hospitalization rate  Decreased of symptoms scoring  Improve lung functions  Drugs duration of action, longer

27. 26  Rehydration  Drink less due to breathing difficulties  vomiting  Acid-base and electrolyte correction  Give parenteral medication

28. 27  Intravenous or oral  Antiinflamation  Controversy: the use of nebulizer

29. 28  Initial, 6-8 mg/kgBW/IV for 10-20 minutes  Maintenance, 0,5-1 mg/kgBW/hours  Need aminophylline plasma level monitoring  Be careful, narrow margin of safety

30. 29  Adrenaline, there is maximal dose, effect on  and   Salbutamol SC, have to be careful  MgSO4, no signiffican  Steroid inhaler, very high dose (1600-2000  g)  Antibiotic, not use  Mucolitic, not suggest for severe attack

31. 30  No/ bad response after nebulization  Oxygen  Parenteral, rehidration, acidosis correction  Steroid IV  lnitial Aminophylline IV, then the maintenance  Nebulization  Chest X-ray  Good: May Go Home  No/ bad response: Intensive Care

32.  Respiratory failure imminent: PaO2 45mmHg  Confuse, disorientation  Poor response of medication at ward  Worsening of vital signs  Decrease respiratory rate  Bradicardia  Mechanical ventilation (ventilator)