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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-