ASTHMA

A. DEFINITION
A chronic inflammatory process that causes bronchial hyperactivity causing recurring
episodic symptoms of wheezing, shortness of breath, heaviness in the chest and
cough, especially at night or early morning.
These episodic symptoms are very widely and reversible (can return to normal either
with or without treatment)

B. CLASSIFICATION
a) Allergic asthma:
- appeared as a child
- associated with a family history of allergies such as eczema, allergic rhinitis,
food or drug allergies.
- usually responds well to inhaled corticosteroid treatment
- Sputum examination: increased eosinophilic
b) Non Allergic asthma
- some people with asthma have no association with allergies
- often shows short-term response to corticosteroids not good
- Sputum examination: increased neutrophils
c) Asthma in adults
- appears first in adults
- more often in women
- including non allergic
- requires a higher dose of corticosteroid
d) asthma with persistent airflow limitation
- uncontrolled and prolonged asthma patients
- not completely reversible
e) Asthma with obesity
- prominent respiratory symptoms due to obesity
- little eosinophilic inflammation

C. RISK FACTOR
 Host factors: genetics, atopy, gender
 Environmental factors:
- that affects the development of asthma in individuals: the presence of
indoor / outdoor allergens, active / passive cigarette smoke.
- that triggers an exacerbation or causes persistent symptoms of asthma:
allergens, respiratory infections, cold air, certain medications, excessive
physical activity, stress, and other irritants.
 D. PATHOPHYSIOLOGY

Triggered by a risk factor

immunological reactions
(antigen + macrophage)

formation of IgE by the body

attached to the receptors

mast cells

degranulation of mast cells and

releasing mediators (histamine,
leukotrienes, prostaglandins)

airway smooth increased capillary increased mucus

muscle contraction permeability cells from goblet
cells

bronchospasm mucosal edema increased mucus

production

airway obstruction

E. LEVEL OF ASTHMA
 Stabil, divided by four level is:

Level Symptoms Night Symptoms Pulmonary Function

Intermitten Monthly 2x / month VEP1/APE ≥ 80% prediction
symptoms 1x / week
asymptomatic beyond exacerbation
 short exacerbation
Mild Persistent Weekly >2x / month VEP1/APE ≥ 80% prediction
>1x / week but <1x / day
exacerbations can interfere with
activity and sleep
Moderate Persistent Daily >1x/week VEP1/APE 60-80% prediction
symptoms every day
exacerbations interfere with activity
and sleep
need a daily bronchodilator
Severe Persistent Continuous Often VEP1/APE ≤ 60% prediction
symptoms every day
moderate exacerbation
limited physical activity

Mild - Moderate Severe Life threatening

Speak Phrase word by word
Position Sit sitting hunched over
Respiratory rate <30x/i >30x/i
Awareness no agitation Agitation loss of consciousness
Breathing muscle - + Silent chest
Pulse frequency 100 – 120 x/i >120x/i paradoxal breathing
Saturation 90 – 95% <90%
APE >50% <50 prediction
prediction

In children with stable asthma (IDAI 2015):

 Intermitten: episodes of asthma symptoms < 6x/year or the distance between

symptoms.
 Mild Persistent: episodes of asthma symptoms >1x/month, <1x/week
 Moderate Persistent: episodes of asthma symptoms >1x/week but not
everyday.
 Severe Persistent: episodes of asthma symptoms almost everyday.

F. DIAGNOSIS
 Anamnesis
- signs and symptoms: shortness of breath, wheezing, coughing, chest
tightness
- triggered by various factors (exercise, exposure to irritants, allergens,
weather changes)
- often worse at night or early morning
- can go away on its own or require medication
- allergy history / family history
 Physical diagnostic
 -Inspection: prolonged expiration, nasal lobe breath, widening of the ribs /
convex chest (hyperinflation), use of the auxiliary muscles, tripod position
- Percussion: normal / hypersonic
- Palpation: normal
Auscultation: wheezing on expiration, silent chest (no sound of breath is
heard)
 Support diagnostic
- X-rays: usually normal / hyperinflation
-Spirometri: VEP1/KVP <70% / VEP1 <80%
- reversibility test: VEP1 > 12% AND > 200cc

G. TREATMENT
Treatment goals
- make asthma controlled
- with controlled asthma it will reduce exacerbations
- by reducing exacerbations, reducing hospitalization and mortality

 Non pharmacological
- Increase physical fitness to improve respiratory muscles by: breathing exercises,
healthy diet, weight loss, vaccination (often triggered by ISPA)
- Stop smoking
- Work environment: avoiding indoor and outdoor air pollution, avoiding
allergens outside the home
 Pharmacological
- Controllers: inhaled glucorticoids (ICS), long-acting b2 agonists (LABA),
antileukotrienes, systemic glucocorticoids.
Reliever: short acting b2 agonist (SABA), short acting anti cholinergic
(SAMA), methylxanthine, long acting b2 agonist.

Management of Acute Asthma or Exacerbation Asthma and Stabil Asthma based GINA
2020: use of SABA is reduced and as needed with using step one till step five (in adult):
 Intermitten: as needed low dose ICS Formoterol (step 1) -> if get short
breathness
 Mild Persistent: daily low single dose ICS or as needed low dose ICS
Formoterol (step 2) -> before get short breathness
 Moderate Persistent: daily low dose ICS LABA (step 3) -> everyday
Increased of short breathness after get treat with ICS LABA -> change to ICS
Formoterol up to 8x and shortness of breath did not decrease either -> go to
the emergency room
 Severe Persistent: medium dose ICS – LABA (step 4)
 Step 5: high dose ICS – LABA
Controller Medications: Inhaler Corticosteroid
 Budesonide:
- Low dose: 200 – 400 mcg
- Medium dose: > 400 – 800 mcg
- High dose: > 800 mcg
 Fluticasone:
- Low dose: 100 mcg
- Medium dose: 100 mcg
- High dose: 200 mcg

Treatment asthma in children:

 Step 1: as needed
 Step 2: daily low dose ICS
 Step 3: low dose ICS LABA or Medium dose ICS
 Step 4: medium dose ICS LABA
 Step 5: refer to phenotype assessment

Treatment monitoring to be controlled:

1. Increased treatment
 continuous improvement: at least 2-3 months, not responding adequately to initial
treatment
 short-term increase: over 1-2 weeks of increased ICS dose in respiratory infections /
seasonal allergic exposure
 day-to-day increase: adjusting the dose of ICS as a controller or reliever (for example,
if ISPA)
2. Decreased treatment
 if asthma is controlled (with ICS within 1 year) and pulmonary function has persisted
for 3 months
 step 5 -> 4 -> 3 ->dst

Levels of controlled asthma:

Controlled Partially controlled Uncontrolled
(appears one in a
particular week)
Daytime symptoms < 2x/week >2x/week ≥3 features of
Activity limitations - + partially controlled
Symptoms of - + asthma appear at
nighttime certain weeks
awakening
Need a reliever ≤2x/week >2x/week
medicine '
Pulmonary Normal <80%prediction
function
(APE/VEP1)
Treatment Exacerbation:
 Mild – Moderate
- O2 administration to maintain saturation 93-95% (children 94-98%)
- giving SABA
- SAMa considerations (Ipratorium Bromide)
- High dose ICS or OCS
 Severe:
- O2 administration to maintain saturation 93-95% (children 94-98%)
- giving SABA
- SAMA considerations (Ipratorium Bromide)
- High dose ICS or OCS
- consider intravenous magnesium (side effect: respiratory depression) ->
prepare the antidote (Ca Gluconas)
During asthma (bronchospasm): Ca + ions increase and enter to intracellularly