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G lobal INitiative for A sthma

GINA Program Objectives Increase appreciation of asthma as a global public health problem Present key recommendations for diagnosis and management of asthma Provide strategies to adapt recommendations to varying health needs, services, and resources Identify areas for future investigation of particular significance to the global community

Global Strategy for Asthma Management and Prevention Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention ProgramUpdated 2007

Apa itu Asthma ?Adalah penyakit paru paru melibatkan radangan ( inflamasi) yang kronik pada saluran.

Apa yang berlaku pada saluran tersebut Radang pada saluran pernafasan Saluran pernafasan terlalu sensitif Penyempitan saluran pernafasan (Bronchoconstriction)

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD



Saluran pernafasan terlalu sensitif

Penyempitan saluran pernafasan Faktor pencetus serangan Tanda / gejala

hidung tekak farink Trakea bronkiol Bronkus

alveolus diafragm


The picture below shows what your lungs look like when everything is working normally. The muscles that are wrapped around the airways are very thin and loose, and the airway is wide open. This makes it easy to move air in and out of the air sacs.





During an asthma attack, the muscles around the airways tighten, or "spasm" (like when you make a fist) and the lining inside the airways swell or thicken, and get clogged with lots of thick mucous. This makes the airways much skinnier than usual so it is harder to move air in and out of the air sacs. This makes it hard to breathe! The picture below shows what your lungs would look like during an asthma attack.

This animation shows normal breathing. As you breathe in, red air that contains lots of oxygen is pulled into the lungs. The oxygen slowly moves out of the lungs and into the blood, and then blue air that contains carbon dioxide is pushed out of the lungs. When things are working normally, the amount of air we breathe in is about the same as the amount of air we breathe out.

This animation shows breathing during an asthma attack. Notice that the airways are narrowed so less air can move in and out of the lungs. When things are working normally, the amount of air we breathe in is about the same as the amount of air we breathe out however during an asthma attack air gets trapped inside the lungs making it harder and harder to breathe. During an asthma attack, it is actually harder to breathe out than it is to breathe in. This means that during an asthma attack, it takes much longer to breathe out (expire) than it does to breathe in (inspire

Burden of Asthma

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals Prevalence increasing in many countries, especially in children A major cause of school/work absence

Risk Factors for Asthma

Host factors: predispose individuals to, or protect them from, developing asthma Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Factors that Exacerbate Asthma

Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

Factors that Influence Asthma Development and ExpressionHost Factors Genetic - Atopy - Airway hyperresponsiveness Gender Obesity Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

Is it Asthma?

Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants Colds go to the chest or take more than 10 days to clear

Asthma Diagnosis

History and patterns of symptoms Measurements of lung function - Spirometry - Peak expiratory flow Measurement of airway responsiveness Measurements of allergic status to identify risk factors Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly

Clinical Control of Asthma No (or minimal)* daytime symptoms

No limitations of activity No nocturnal symptoms No (or minimal) need for rescue medication Normal lung function No exacerbations_________

Levels of Asthma ControlCharacteristic Daytime symptoms Limitations of activities Nocturnal symptoms / awakening Need for rescue / reliever treatment Lung function (PEF or FEV1) Exacerbation Controlled(All of the following)

Partly controlled(Any present in any week)


None (2 or less / week) None None None (2 or less / week) Normal None

More than twice / week Any Any More than twice / week < 80% predicted or personal best (if known) on any day One or more / year 1 in any week 3 or more features of partly controlled asthma present in any week

Asthma Management and Prevention Program: Five Components1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor AsthmaRevised 2006

4. Manage Asthma Exacerbations 5. Special Considerations

Asthma Management and Prevention Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma 4. Manage Asthma Exacerbations

Asthma Management and Prevention Program

Goals of Long-term ManagementAchieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

Asthma Management and Prevention Program


Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.

Asthma Management and Prevention Program

Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Example Of Contents Of An Action Plan To Maintain Asthma ControlYour Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________ WHEN TO INCREASE TREATMENT Assess your level of Asthma Control In the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No Yes If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment. HOW TO INCREASE TREATMENT STEP-UP your treatment as follows and assess improvement every day: ____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number] WHEN TO CALL THE DOCTOR/CLINIC. Call your doctor/clinic: _______________ [provide phone numbers] If you dont respond in _________ days [specify number] ______________________________ [optional lines for additional instruction] EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you are having a severe attack of asthma and are frightened, If you need your reliever medication more than every 4 hours and are not improving. 1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid] 3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________ 4. Continue to use your _________[reliever medication] until you are able to get medical help.

Asthma Management and Prevention Program

Factors Involved in Non-AdherenceMedication Usage

Non-Medication Factors

Difficulties associated with inhalers Complicated regimens Fears about, or actual side effects

Misunderstanding/lack of information Fears about side-effects Inappropriate expectations Underestimation of severity Attitudes toward ill health Cultural factors Poor communication

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible. Asthma exacerbations may be caused by a variety of risk factors allergens, viral infections, pollutants and drugs. Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma development, especially in children and young infants

Asthma Man