Brittle asthma 16.00

Brittle AsthmaAvissenaDuthaPratama

DivisiPulmonologi, DepartemenPenyakitDalamFK. UNDIP – RSUP. Dr. Kariadi Semarang

PertemuanIlmiahTahunan PAPDIHotel PatraJasaSemarang, 24 – 26 September 2010

Severe asthma (GINA)

• Symptoms prior to treatment are continuous and• punctuated by frequent exacerbations or frequent• nighttime symptoms; impairment of lung function is• demonstrated by FEV1 of <60% predicted, or peak• expiratory flow variability of >30%; or there is• limitation of daily physical activities by asthma• symptoms.

Severe asthma (BTS)

• Mild• Moderate• Severe

Stirling RG. Severe asthma: definition and mechanisms. Allergy 2001: 56: 825 – 40

GINA; BTS

Terminology

Refractory asthma

Brittle asthma

Irreversible asthma

Steroid dependent

asthma

Steroid resistant asthma

Difficult to control asthmaPoorly

controlled asthmaFatal or near fatal asthma

European Review for Medical and Pharmacological Sciences 2008

Definition

Fatal asthma

• Patients that have succumbed to acute asthma.

Rapidly fatal asthma

• Patients that have succumbed to acute asthma within three hours of the onset of symptoms.

Slowly fatal asthma

• Patients that succumbed to acute asthma greater than 3 hr after the onset of symptoms

Near fatal asthma

• An acute asthma attack that results with respiratory arrest or PaCO greater than 50 mmHg (6.7 pka).

European Review for Medical and Pharmacological Sciences 2008

Definition

Status asthmaticus

• Life threatening from of asthma in which progressively worsening reactive airways are unresponsive to usual appropriate therapy that leads to pulmonary insufficiency

American Academy of Allergy, Asthma and Immunology

Brittle Asthma

Warwick 1977

A sub-group of patients with severe asthma

Wide variation in peak expiratory flow (PEF) rates despite high doses of inhaled steroids

Based on daily monitoring of PEF in patients with sudden, severe and life threatening attacks

Brittle Asthma

Ayres 1998

Type I was characterized by a chaotic, unpredictable and wide peak expiratory flow (PEF) variability (> 40% diurnal variation for >50% of the time over a period of at least 150 days despite considerable medical therapy including a dose of inhaled steroids of at least 1500 μg of beclomethasone or equivalent).

Type II was characterized by sudden acute attacks occurring in less than three hours without an obvious trigger on a background of apparent normal airway function or well controlled asthma.

Epidemiology

Global prevalence of severe asthma 1 – 18%

Africa 8%

US 5%

Adeniyi BO. Acute severe asthma. African J Respi Med 2009

GINA 2009, update

Pathogenesis on chronic severe asthma

Persistent inflammation

Presence neutrophilic inflammation

Airway remodeling

Haqqee R, Arshad SH. Brittle Asthma.Current Respiratory Medicine Reviews 2007: 3: 7-13

Holgate ST, Polosa R. Lancet 2006; 368: 380 – 93

Pathology of asthma

Comparison of type I and type II Brittle asthmaCharacteri

sticType I Brittle asthma Type II Brittle asthma

Definition PEF variability (>40% diurnal variation for 50% of the time over a period of at least 150 days)

Sudden acute attack occurring in less than 3 hours without an obvious trigger on a background of apparent normal airway function

Risk factors •Atopy•Increasing susceptibility to respiratory tract infection •Psychosocial factors

•Exposure to aeroallergens such as fungal spore•Poor perception of the disease

Patients Women aged between15 – 55 years

Equally prevalent in men/women

Morbidity High -

Mortality - High

Treatment •Inhaled and/ oral CS•Inhaled bronchodilator•Control of allergens exposure•Immunotherapy•Insurance of patients compliance

•Control of allergens exposure•Identification of trigger•Self management and management of acute attacks

Toungoussova O. Monaldi Arch Chest Dis 2007; 67: 102 – 5

Diagnosis

Symptoms/history of illness

Physical examinati

on

Lung function test• Peak

expiratory flow

• Spirometry

Chest X-ray

Level of asthma control

Diagnosis

Peak expiratory flow

Reversibility; > 15%

Variability;

Daily variability :

__PEF night – PEF morning__

½ (PEF night + PEF morning)

% of recent best

X 100%

Variabilitasaruspuncakekspirasi

Peak flow rate

Indian J Chest Dis Allied Sci 2001; 43: 33 – 8

Continuous subcutanterbutaline Continuous intravenous terbutaline

Sing Med J. 1989

GINA; 2009 Update

Asthma Control Test

Diagnosis

Spirometry

Therapy in asthma attack

Oxygen therapy BronchodilatorSystemic

corticosteroids

Oxygen therapy

High flow oxygen (60% or above)

Cannulae nasal

Simple mask

Ventury mask

O2 therapy

Bronchodilator

Click icon to add pictureClick icon to add picture

Click icon to add picture

β2 agonists

β2agonists

Bronchodilator

Corticosteroid

Click icon to add pictureClick icon to add picture

Click icon to add picture

Corticosteroid

Asthma attack

Case I

Emergency room

Male 35 yo

Chief complain : Breathlessness

History of asthma (+), wheezing (+)

BP 140/90 mmHg, RR 26 tpm, pulse rate 120 tpm

Dx ?

Severity of asthma exacerbations

GINA; 2009 Update

Clinical assessment of severity asthma attack

Asthma

attack

Emergency Room

Lugogo NL. Life-Threatening Asthma: Pathophysiology and Management. Respir Care 2008; 53: 726 – 35

Treatment case I

Oral bronchodilator ?

Oral corticosteroid ?

Inhaled bronchodilator ?

Inhaled corticosteroid ?

Inhaled mucolitic ?

Corticosteroid iv ?

Bronchodilator sc ?

Bronchodilator infusion ?

….. ?

Case I

Assessment

Medical history

Physical examination

Objective measurement

Pulse oximetry

Chest radiography

Response to therapy

Case I

10 minutes later…..

Breathlessness ( ), wheezing (+), BP 150/90 mmHg, RR 30 tpm

Planning ?

Criteria for referral to hospital

Any life threatening features

Any features of severity attack that persist or get worse after initial treatment

Peak expiratory flow < 30% best recorded or predicted value 15 – 30 minutes after nebulisation

Oxygen saturation < 92%

Indication of Mechanical Ventilation

Severe hypoxia

Depressed level of consciousness

Impending respiratory failure

Hemodynamic compromised (bradycardia)

Apnea or near apnea

Peak flows <40% of predicted

Approach to evaluation of difficult asthmaDifficult asthma :

• Frequent symptoms• Recurrent exacerbation• Persistent airflow limitation• High dose inhaled steroids ± oral steroids

Optimized treatment / compliance

Seek & treat exacerbation factors

Refractory asthmaSeverity reduced

Severity reduced

Exclude alternative diagnoses

Dx. excluded

Asthma dx.

confirmed

Confirmed asthma dx :• Consistent symptoms• Peak flow variability• Bronchial hyperresponsiveness• Bronchodilator responsiveness

Seek alternate dxWean from treatment

Probable asthmaAlternative

dx. confirmed

Stirling RG, Chung KF. Allergy 2001; 56: 825 – 40

GINA 2009 update

Asthma medication program

1. Education

2. Monitoring

3. Identification and prevent

4. Planning long treatment

5. Medication on asthma attack

6. Control

7. Life style

Asma. Pedoman diagnosis danpenatalaksanaanasmadi Indonesia. PDPI 2003

Thank You

Konsultasipenyakitparu :

Email :

www.dokterparu.com

[email protected]

[email protected]

References Restrepoa RD, Petersb J. Near-fatal asthma: recognition and management.

Current Opinion in Pulmonary Medicine 2008: 14: 13 – 23

Lugogo NL, MacIntyre NR. Life-Threatening Asthma: Pathophysiology and Management. Respir Care 2008; 53: 726 – 35.

Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adult. Chest 2004; 125: 1081 – 1102.

Urso DL, Vincenzo D, Pignataro F, Acri P, Cuccinota G. Diagnosis and treatment of refractory asthma. ERMPS 2008; 12: 315 – 20.

Toungoussova O, Barbaro MP, Esposito LM, Carpagnano GE, Salerno FG, Dal Negro RW, et al. Brittle asthma. Monaldi Arch Chest Dis 2007; 67: 102 – 5

Bumroongkit C, Charoenpan P. Serum magnesium levels in acute severe asthma. Chiang Mai Med Bull 2001; 40: 1 – 5

Barnes PJ. Difficult asthma. EurRespir J 1998; 12: 1209 – 18

Haqqee R, Arshad SH. Brittle Asthma.Current Respiratory Medicine Reviews 2007: 3: 7-13

GINA 2006

Reassess: pem fisik, PEF, sat O2, dan tes lain yang diperlukan

Penilaian awal :anamnesis, pemeriksaan fisik, pem penunjang: saturasi oksigen, FEV1 dan PEFTerapi awal:1. Oksigen hingga saturasi mencapai 95%2. Β2 agonist rapid acting inhalasi terus menerus hingga 1

jam3. Glukokortiokosteroid sistemik jika tdk ada respon

segera/jika pasien sebelumnya mendapat glukokortikosteroid oral

4. Sedasi merupakan KI

Kriteria : Episode sedang:1. PEF 60-80% nilai prediksi2. pem fisik: gejala moderate, pemakaian otot bantu

napasTerapi :OksigenΒ2 agonist inhalasi dan antikolinergik inhalasi setiap 60 menitGlukokortikosteroid oralLanj terapi hingga 1 – 3 jam, hingga tercapai perbaikan

Kriteria : Episode Berat:1. PEF < 60 % nilai prediksi2. pem fisik: gejala berat, retraksi dinding dada3. Tidak ada perbaikan setelah terapi awal

Terapi :OksigenΒ2 agonist inhalasi dan antikolinergik inhalasiGlukokortikosteroid sistemikMg intravena

Good Respon/ respon baik:1. Respon bertahan minimal 60 menit setelah terapi terakhir2. Pem fifik: normal, tidak ada distress3. PEF > 70%4. Saturasi O2 > 90%

Incomplete Respon/ sebagian:

1. Faktor risiko2. Pem fisik: tanda ringan -

sedang3. PEF > 60%4. Saturasi O2 tidak membaik

Incomplete Respon/ buruk:1. Faktor risiko2. Pem fisik: tanda berat, konfusio, drowsiness• PEF < 30%• PCO2 > 45%• PO2 < 60%

Terapi:1. Oksigen2. Β2 agonist inhalasi dan antikolinergik

inhalasi3. Glukokortikosteroid sistemik4. Pertimbangkan: Β2 agonist iv5. Pertimbangkan: teofiline iv6. Intubasi/ pemasangan ET, ventilator

mekanik.

Terapi:OksigenΒ2 agonist inhalasi dan antikolinergik

inhalasiGlukokortikosteroid sistemik (iv)MG ivMonitor PEF, sat O2, pulse

Kriteria dipulangkan:- PEF > 60% prediks- Terapi obat secara oral dan inhalasi diteruskan

Terapi di rumah:1. Teruskan Β2 agonist inhalasi 2. Pertimbangkan: glukokortikosteroid oral3. Edukasi pasien:

- pakai obat secara benar- review action plan

STEROID INHALASI

Jenis Sediaan obat Dosis dewasa

Fluticasone propionat MDI 50,125 mcg/semprot 125 – 500 mcg/hari

Budesonide MDI, turbuhaler 100, 200, 400 mcg 100 – 800 mcg/hari

Beclometason dipropionat MDI, rotacap, rotahaler, rotadisk 100 – 800 mcg/hari

STEROID SISTEMIK


metilprednisolonTablet 4, 8 ,16 mg 4 – 40 mg/hari, dosis

tunggal / terbagi

prednison

Tablet 5 mg Short course:20-40 mg/hari dosis tunggal atau terbafi selama 3-10 hari

Agonis β2 kerja singkat


TerbutalinMDI 0,25 mg/semprot 0,25 – 0,5 mg. 3 – 4

kali/hari

Salbutamol

MDI 100 mcg/semprotNebules/solutio2,5 mg/2ml, 5 mg/mlTablet 2 mg, 4 mgSirup 1 mg, 2 mg/5 ml

Inhalasi 200 mcg 3-4x/hari

Oral: 1-2 mg, 3-4 x/hari

Fenoterol MDI 100, 200 mcg/semprot 200 mcg 3-4x/hari

Prokaterol

MDI 10 mcg/semprotTablet 25,50 mcgSirup 5 mcg/ml

2 -4x/hari2 x 50 mcg/hari2 x 2,5 ml/hari

Agonis β2 kerja lama


salmeterolMDI 25 mcg/semprotRotadisk 50 mcg

2 – 4 semprot2 x hari

Bambuterol Tablet 10 mg 1 x 10 mg/hari

Prokaterol Tablet 25,50 mcg 2 x 25 mcg

Formoterol

MDI 4,5;9 mcg/semprot 2 -4x/hari2 x 50 mcg/hari2 x 2,5 ml/hari

Brittle asthma 16.00

Documents

Transcript of Brittle asthma 16.00