Klasifikasi Asma Gina 2015

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KLASIFIKASI ASMA GINA 2015

Dr. Widya Sri Hastuti, Sp.P, FCCP, FAPSR

ATLAS ID 339759/April 2016

Dr. WIDYA SRI HASTUTI, Sp.P, FCCP, FAPSR Academic Qualification: 2004 M.D, Faculty of Medicine University of Indonesia, Jakarta 2013 Pulmonologist, Faculty of Medicine University of Indonesia, Jakarta 2015 Fellow of American College of Chest Physician 2015 Fellow of Asian Pasific Society of Respirology Current Position:

Pulmonologist, Embung Fatimah Hospital, Batam Pulmonologist, Harapan Bunda Hospital, Batam Pulmonologist, Sanomedika Clinic, Batam

Global INitiative for Asthma 2006 Evolution of Asthma Control 2002 - The GINA report : “… in most patient with asthma control of the disease can, and should be achieved and maintained”

2005 – Executive Committee recommendation : “… a new report not only to incorporate updated scientific information but to implement an approach to asthma management based on asthma control, rather than asthma severity”

GINA 2006 : Assess, Treat and Maintain Asthma Control

http://www.ginasthma.com

GINA goals of treatment

GINA 2002

"The aim of asthma management should be control of the disease"

GINA goals of treatment

GINA 2006

"The goal of asthma treatment is to achieve and maintain clinical control"

Global INitiative for Asthma 2006 The Classification of Asthma 2003 2006 By Severity By Level of Control • Intermittent • Controlled • Mild Persistent • Partly Controlled • Moderate Persistent • Uncontrolled • Severe Persistent http://www.ginasthma.com

Global Strategy for Asthma Management and Prevention

Definisi Asma Asma adalah penyakit heterogen, biasanya disertai dengan inflamasi kronis pada saluran pernapasan Asma ditandai dengan adanya gejala seperti mengi, sesak napas, dada terasa berat dan batuk yang bervariasi sepanjang hari dan intensitas disertai adanya keterbatasan aliran udara yang bersifat

reversibel

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014). Available from www.ginaasthma.org. Accessed on February 07, 2015

ASTHMA PREVALENCE IN INDONESIA (RISKESDAS 2013)

Global Strategy for Asthma Management and Prevention

Diagnosis Asma 1.

Riwayat dan pola gejala

2.

Pengukuran fungsi paru 

Spirometri



Peak expiratory flow / Arus Puncak Ekspirasi

3.

Pengukuran respons saluran napas

4.

Pengukuran status alergi untuk mengindentifikasi faktor risiko

5.

Langkah tambahan mungkin diperlukan untuk mendiagnosis asma pada anak usia 5 tahun ke bawah dan orang tua

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014). Available from www.ginaasthma.org. Accessed on February 07, 2015

PATIENT HISTORY Has the patient had an attack or recurrent episodes of wheezing?  Does the patient have a troublesome cough, worse particularly at night, or on awakening?  Does the patient cough or wheeze after physical activity or exercise (eg. Playing)?  Does the patient have breathing problems during a particular season (or change of season)? 



Do the symptoms occur and worsen if presence of animal with fur, aerosol chemical, mites, pollen, smoke, strong emotional expression ?



Does the patient use any medication (e.g. bronchodilator) when symptoms occur? Is there a response?

If the patient answers “YES” to any of the above questions, suspect asthma.

Physical examination 

Because asthma symptoms are variable, the physical examination of the respiratory system maybe normal



The most usual abnormal physical finding is wheezing on auscultation

Diagnostic testing 

Measurement of lung function provide an assesment of the severity, reversibility, and variability of airflow limitation and help confirm diagnosis of asthma.  Spirometry is the preffered method of measuring airflow limitation and its reversibility to establish to diagnosis of asthma.

Diagnosis of asthma can be confirmed by demonstrating the presence of reversible airway obstruction using Spirometry or Peak flow meter.

Reversibility Spirometry

An increase FEV1 > 12 % (AND > 200 ml) after administration a bronchodilator indicate reversible airflow limitation consistent with asthma. Peakflow meter

An improvement of 60 L/min ( or > 20 % of the pre-bronchodilator PEF) after inhalation of a bronchodilator suggest a diagnosis a asthma

Daily Variability Diurnal variation in PEF more than 20% ( with twice daily reading more than 10%) suggest diagnosis asthma

Daily variability =

PEF evening - PEF morning x 100 1/2 (PEF evening + morning)

GINA 2015: Assess, Treat and Monitor Assessing Asthma Control Treating to Achieve Control Monitoring to Maintain Control Key action steps in new guidelines GINA 2006

Tujuan Manajemen Asma

OVERALL ASTHMA CONTROL Mencapai

Kontrol saat ini Didefinisikan dengan

Mengurangi

Risiko masa depan Didefinisikan dengan

Gejala

Penggunaan Obat pelega

Perburukan asma

Eksaserbasi

Aktivitas

Fungsi paru

Penurunan Fungsi paru

Efek samping pengobatan

Adapted from: Bateman E et al. J Allergy Clin Immunol 2010:125(3);600-08

Global Strategy for Asthma Management and Prevention

Kontrol Klinis Asma 1.

Tentukan tingkat atau level kontrol asma awal untuk menentukan jenis pengobatan (nilai tingkat kontrol asma pasien)

2.

Mempertahankan kontrol asma setelah pengobatan dilakukan (nilai risiko asma pasien)

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014). Available from www.ginaasthma.org. Accessed on February 07, 2015

Levels of Asthma Control Characteristic

Daytime symptoms

Controlled

Partly controlled

(All of the following)

(Any present in any week)

None (2 or less / week)

More than twice / week

Limitations of activities

None

Any

Nocturnal symptoms / awakening

None

Any

Need for rescue / “reliever” treatment

None (2 or less / week)

More than twice / week

Lung function (PEF or FEV1)

Normal

< 80% predicted or personal best (if known) on any day

Exacerbation

None

One or more / year

Uncontrolled

3 or more features of partly controlled asthma present in any week

1 in any week

TOTAL CONTROL Definition No

Symptoms

No

Salbutamol use

Every day

80% PEF am

No

Night-time awakenings

No

Exacerbations

No

Emergency visits

No

Treatment-related adverse events enforcing change in therapy

TOTAL CONTROL is ALL of these sustained for at least 7 of 8 weeks Bateman et al. ARJCCM 2004

Asma Terkontrol Gejala harian : ≤2x/minggu  Hambatan aktivitas :  Gejala malam :  Reliever : ≤2x/minggu  Fungsi paru ( PEFR/FEV1 ) : normal 

Asma Terkontrol Parsial 

Gejala harian: >2x/minggu



Hambatan aktivitas : ada



Gejala malam : ada



Perlu reliever : >2x/minggu



Fungsi paru : <80% prediksi atau hasil terbaik

Asma Tidak Terkontrol 

Minimal 3 atau lebih terdapat keadaan terkontrol parsial pada tiap minggu, yaitu :

- Gejala harian : >2x/minggu - Hambatan aktivitas : ada - Gejala malam : ada - Perlu reliever : >2x/minggu - Fungsi paru : <80% prediksi atau hasil terbaik

Tingkat Kontrol Asma (Menilai tingkat kontrol asma)

Kontrol Gejala Dalam 4 minggu terakhir, apakah pasien memiliki :

Level Kontrol Gejala Asma Terkontrol penuh

Terkontrol sebagian

Tidak terkontrol

Tidak terdapat satupun kriteria

Terdapat 1- 2 kriteria

Terdapat 3- 4 kriteria

1. Gejala asma harian lebih dari dua kali dalam 1 minggu 2. Terbangun di malam hari karena asma

3. Penggunaan obat pelega untuk mengatasi gejala lebih dari dua kali dalam 1 minggu

4. Pembatasan aktivitas karena asma

Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2014). Available from www.ginaasthma.org. Accessed on February 07, 2015

Global INitiative for Asthma 2006 The Classification of Asthma 2003 2006 By Severity By Level of Control • Intermittent • Controlled • Mild Persistent • Partly Controlled • Moderate Persistent • Uncontrolled • Severe Persistent http://www.ginasthma.com

Derajat Asma berdasarkan GINA 2002

 Gejala kurang dari 1 kali/minggu 

Serangan singkat



Gejala nokturnal ≤ 2 kali/bulan



FEV1≥80% predicted atau PEF ≥ 80% nilai terbaik

individu 

Variabilitas PEF atau FEV1 < 20%

 Gejala lebih dari 1 kali/minggu tapi kurang dari 1 kali/hari 

Serangan dapat mengganggu aktivitas dan tisur



Gejala nokturnal >2 kali/bulan



FEV1≥80% predicted atau PEF ≥ 80% nilai terbaik

individu 

Variabilitas PEF atau FEV1 20-30%



Gejala terjadi setiap hari



Serangan dapat mengganggu aktivitas dan tidur



Gejala nokturnal > 1 kali dalam seminggu



Menggunakan agonis β2 kerja pendek setiap hari



FEV1 60-80% predicted atau PEF 60-80% nilai terbaik individu



Variabilitas PEF atau FEV1 > 30%



Gejala terjadi setiap hari



Serangan sering terjadi



Gejala asma nokturnal sering terjadi



FEV1 ≤ predicted atau PEF ≤ 60% nilai terbaik individu



Variabilitas PEF atau FEV1 > 30%

STEP 4: SEVERE PERSISTENT CONTROLLER: daily multiple medications • Inhaled steroid • Long-acting bronchodilator • Oral steroid

RELIEVER • Inhaled ß2agonist p.r.n.

Step down when controlle d

Avoid or control triggers STEP 3: MODERATE PERSISTENT CONTROLLER: daily medications • Inhaled steroid and longacting bronchodilator • Consider anti-leukotriene

RELIEVER • Inhaled ß2agonist p.r.n.

Avoid or control triggers STEP 2: MILD PERSISTENT CONTROLLER: daily medications • Inhaled steroid • Or possibly cromone, oral theophylline or anti-leukotriene

RELIEVER • Inhaled ß2agonist p.r.n.

• Patient education essential at every step • Reduce therapy if controlled for at least 3 months • Continue monitoring

Avoid or control triggers

STEP 1: INTERMITTENT CONTROLLER: none

RELIEVER • Inhaled ß2agonist p.r.n.

Avoid or control triggers TREATMENT GINA Guidelines 1998

Step up if not controlled (after check on inhaler technique and compliance)

Kesimpulan



 1. 2.

Asma adalah penyakit inflamasi kronis pada saluran napas.

Overall Asthma Control dengan cara Mengontrol gejala asma dan mengobati inflamasi dalam setiap inhalasinya Mengurangi eksaserbasi & mengurangi dosis kortikosteroid

THANK YOU-WSH-

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