*Diagnosis of asthmaModule 5Training of Inhalation Therapy & Pediatric Asthma ManagementUKK Respirologi PP IDAI

Definition of asthmaReversible respiratory tract obstruction spontaneously or after treatment1950-es

Episodic obstruction because of the increasing of bronchi response to the stimulant (bronchi hyperreactivity)Chronic state which is indicated with repeated bronchospasm due to the narrowing of respiratory tract as a response to the stimulant, which not causing the same narrowing in other persons PREVENTION OF BRONCHOSPASM WHO, 1975Chronic inflammation in respiratory tract cellular infiltrates, edema, epithelium damage, even fibrosis ANTI-INFLAMMATION USAGE1970-es1960-es1990-es

Chronic inflammation of the respiratory tract Many cells take part (mast cell, eosinophil, lymphocyte-T) In susceptible person, chronic inflammation recurrent wheezing, cough, dyspnea, chest tightness Related to the narrowing of respiratory tract partially irreversible or relieved spontaneously / with treatment2002The definition is very complete clinical application is difficult and not practicable, especially in babies and childrenGINA,2004

EnvironmentGenetic susceptibilityChronic allergic inflammation(Mast cells, T-Cells, Eosinophils)Airway Wall Thickening(Remodeling)Pathogenesis

BronchoconstrictionChronic inflammationRemodelingResume.

Inflammation in asthmaBarnes PJChronic inflammationStructural changesInflamasi akutSteroid responseTime

A condition with episodic wheezing and/or cough with asthma as the most possible etiology, while other infrequent causes have been excluded

Arch Dis Child 1992;67:240-8.

Recurrent wheezing and/or persistent cough with asthma as the most possible etiology, while other infrequent causes have been excludedWarner dkk. Pediatr Pulmonol 1998;25:1-71989:1992:1998:Operational definition

PNAA 2004 Wheezing and/or cough with characteristics: appear episodic and/or chronic, tends at night/early morning (nocturnal), periodic, has triggers such as physical activity, reversible either spontaneously or with treatment, and has asthma history or other atopic in patient/family while other causes have been excluded. INDONESIA (RESPIROLOGY WG, IDAI)

DiagnosisCough and/or WheezeClinical historyPhysical examinationMantoux testSuggestive of asthma: Episodic Nocturnal Seasonal Exertional AtopicIndeterminate features or suggestive of alternative diagnosis Neonatal onset Failure to thrive Chronic infection Vomiting/choking Focal lung or CVS signsIf possible frequent peak flowmeasurements : Reversibility (20%) Variability (20%)Consider Chest and sinus x rays Lung function Bronchial challenge and/or Bronchodilator response

.. Consider : Sweat test Immune function Ciliary & Reflux studiesBronchodilator responseNo response ResponseWD/ AsthmaAssess severity and etiologyReview diagnosis and complianceif poor response to treatment+ ve- veAlternative diagnosis and treatmentChest x ray if more thanmild episodic diseaseTrial of antiasthma treatmentConsider asthma as an associated problemNot asthma

PNAA, 2004:Entry point of asthma diagnosis:Recurrent Wheezing and/or Chronic Recurrent Cough

Batasan operasionalRecurrent cough and/or wheezing with characteristics episodic, nocturnal (variability), reversible (relieve with or without treatment) plus atopic

Reversibility (+) Variability (+)

Cough and/or wheezingA/ + PE + SENot typical

Episodic Nocturnal After activity Atopic (+)

BronchodilatorASTHMANot Asthma

TYPICAL

V50.FEV1FVCPEFV25.APAESAEJLung Function Test

Classification of Asthma in Children ChronicInfrequent episodic asthmaFrequent episodic asthmaPersistent asthma AcuteMild attackModerate attackSevere attack

Infrequent Episodic Asthma75% of children with asthma Episode

Frequent Episodic Asthma20% of children with asthma More frequent attacks Wheezing after moderate activitiesCould be prevented with 2-agonistSymptoms

Persistent Asthma 5% of children with asma Frequent acute episodes Wheezing after mild activitiesNeeds 2-agonist between attacks, >3 times/week, either because of night arousals or heavy chest in the morningNeeds controller

Classification of disease

DiagnosisASTHMAAsthma AttackSevere Asthma

Every asthma patientsThe classification should be include class. disease and severity of asthma attacks, example:Infrequent episodic asthma without asthma attacksInfrequent episodic asthma with mild asthma attacksFrequent episodic asthma with severe asthma attacksFrequent episodic asthma without asthma attacks Persistent asthma with severe asthma attacksSeverity of disease not depends on level of attack

How about preschool children???

Does every wheezing mean asthma?????

3tahun7tahun15tahun1tahun6bulan0Alergi makananDermatitis atopikAsmaRinitisAllergic March

Fig. 6. Hypothetical peak prevalence by age for the 3 different wheezing phenotypes. The prevalence for each age interval should be the area under the curve. This does not imply that the groups are exclusive. AsthmaNon-AtopicWheezersTransientWheezersTaussig LM, et al. JACI 2003; 111:661-675Low LFT at birthPost RSVBHR of atopic asthma

Cost ?Availability ?

ConclusionAlteration of asthma pathogenesis: bronchospasm chronic inflammation remodelingDiagnosis of asthma must included classification and severity of attackIt is difficult to diagnose asthma in preschool children There is asthma prediction index in children

*Thanks for your attention

*Slide 14Asthma is a chronic inflammatory disease with episodic attacks, involving acute inflammationon top of persistent inflammationAcute inflammation in asthma is associated with bronchoconstriction, plasmaexudation / oedema, vasodilatation and mucus hypersecretionChronic inflammation in asthma is associated with subepithelial fibrosis, smooth musclehyperplasia / hypertrophy, mucus gland hyperplasia and new vessel formation If asthma remains uncontrolled or poorly controlled, the underlying persistent inflammationin the airways leads to structural changes (remodelling) that reduce the extent of airwayresponse to therapy