Module 5 - Diagnosis of Asthma.pdf
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Transcript of Module 5 - Diagnosis of Asthma.pdf
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1Diagnosis of
asthma
Module 5
Training of Inhalation Therapy
& Pediatric Asthma Management
Departemen IKA FKUI-RSCM
UKK Respirologi PP IDAI
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Dr. Dr. NastitiNastiti KaswandaniKaswandani, , Sp.ASp.A
Born: Born: Surabaya, November 12, 1970Surabaya, November 12, 1970
Education:Education:
1.1. Faculty of medicine University of Indonesia, 1995Faculty of medicine University of Indonesia, 1995
2.2. Medical Post Graduate (Pediatrics), Faculty of Medical Post Graduate (Pediatrics), Faculty of
Medicine Medicine UniversitasUniversitas Indonesia, 2004 Indonesia, 2004
Recent position : Recent position :
Staf member of Division of Respirology
Lecturer on Pediatric Pulmonology and Respirology, Dept of Child Health, Faculty of Medicine University of Indonesia
Foreign affairs of Yapnas
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Definition of asthmaReversible respiratory tract obstruction spontaneously or after treatment
1950-es
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Episodic obstruction because of the increasing of bronchi response to the stimulant (bronchi hyperreactivity)
Chronic state which is indicated with repeated bronchospasm due to the narrowing of respiratory tract as a response to the stimulant, which not causing the same narrowing in other persons
PREVENTION OF BRONCHOSPASM
WHO, 1975
Chronic inflammation in respiratory tract cellular infiltrates, edema, epithelium damage, even fibrosis
ANTI-INFLAMMATION USAGE
1970-es
1960-es
1990-es
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Chronic inflammation of the respiratory tractChronic inflammation of the respiratory tract
Many cells take part (mast cell, Many cells take part (mast cell, eosinophileosinophil, ,
lymphocytelymphocyte--T)T)
In susceptible person, chronic inflammation In susceptible person, chronic inflammation
recurrent recurrent wheezingwheezing, cough, , cough, dyspneadyspnea, chest , chest
tightnesstightness
Related to the narrowing of respiratory tract Related to the narrowing of respiratory tract
partially partially irreversibleirreversible or relievedor relieved spontaneously or spontaneously or
with treatmentwith treatment
2002
The definition is very complete clinical application is difficult and not practicable, especially in babies and children
GINA, 2004GINA, 2004
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Environment Genetic susceptibility
Chronic allergic inflammation(Mast cells, T-Cells, Eosinophils)
Airway Wall Thickening(Remodeling)
Pathogenesis
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BronchoconstrictionBronchoconstriction
Chronic Chronic
inflammationinflammation
RemodelingRemodeling
ResumeResume..
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Inflammation in asthma
Barnes PJ
Chronic inflammation
Structural changes
Inflamasi akut
Steroid response
Time
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A condition with episodic wheezing and/or cough with asthma as the most possible etiology, while other infrequent causes have been excluded
Arch Dis Child 1992;67:240-8.
Recurrent wheezing and/or persistent cough with asthma as the most possible etiology, while other infrequent causes have been excluded
Warner dkk. Pediatr Pulmonol 1998;25:1-7
1989:
1992:
1998:
Operational definition
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PNAA 2004
Wheezing and/or cough with characteristics: appear episodic and/or chronic, tends at night/early morning (nocturnal), periodic, has triggers such as physical activity, reversible either spontaneously or with treatment, and has asthma history or other atopic in patient/family.
INDONESIA (RESPIROLOGY WG, IDAI)
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DiagnosisCough and/or WheezeClinical historyPhysical examinationMantoux test
Suggestive of asthma: Episodic Nocturnal Seasonal Exertional Atopic
Indeterminate features or suggestive of alternative diagnosis Neonatal onset Failure to thrive Chronic infection Vomiting/choking Focal lung or CVS signs
If possible frequent peak flowmeasurements : Reversibility (20%) Variability (20%)
Consider Chest and sinus x rays Lung function Bronchial challenge and/or Bronchodilator response
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.. Consider : Sweat test Immune function Ciliary & Reflux studies
Bronchodilator responseNo responseResponse
WD/ Asthma
Assess severity and etiology
Review diagnosis and complianceif poor response to treatment
+ ve- ve
Alternative diagnosis and treatmentChest x ray if more thanmild episodic disease
Trial of anti asthma treatment Consider asthma as an associated problem
Not asthma
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PNAA, 2004:PNAA, 2004:PNAA, 2004:PNAA, 2004:
Entry point of asthma diagnosis:
Recurrent Wheezing
and/or
Chronic Recurrent Cough
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Batasan operasional
Recurrent cough and/or wheezing with characteristics episodic, nocturnal (variability),reversible (relieve with or without treatment) plusatopic
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Reversibility (+) Variability (+)
Cough and/or wheezing
A/ + PE + SE
Not typical
EpisodicNocturnal After activity Atopic (+)
Bronchodilator
ASTHMANot Asthma
TYPICAL
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V50.FEV1
FVC
PEF V25.
APAPAESAESAEJAEJLung Lung
Function Function
TestTest
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Asthma : chronic respiratory disease that can have acute attack (two in one disease)
AsthmaAcute Asthma
Chronic Asma
Asthma, 2 aspects
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Classification of pediatric asthma
Chronic asthma
1. Infrequent episodic asthma
2. Frequent episodic asthma
3. Persistent asthma
Acute asthma
1. Mild attack
2. Moderate attack
3. Severe attack
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Infrequent Episodic Asthma
75% of children with asthma
Episode
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Frequent Episodic Asthma
20% of children with asthma
More frequent attacks
Wheezing after moderate activities
Could be prevented with 2-agonist
Symptoms
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Persistent Asthma
5% of children with asma
Frequent acute episodes
Wheezing after mild activities
Needs 2-agonist between attacks, >3 times/week, either because of night arousals or heavy chest in the morning
Needs controller
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Classification of diseaseClassification of disease
Clinical parametersand lung function
Infrequent episodicasthma
Persistent asthmaFrequent episodic
asthma
Freq of attacks < 1x /month Daily> 1x /month
Duration of attacks < 1 week Daily>1 week
Between episodes No symptomsFrequent nocturnal
symptoms Symptoms (+)
Sleep and activity Normal AffectMay affect
Physical exam Normal AbnormalMay affect
Controller No need Steroid/combinationSteroid/combination
Lung function (No attacks)
PEF/FEV1 >80%PEF/FEV1 15% > 50%> 30%
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DiagnosisDiagnosis
ASTHMAASTHMA
Asthma AttackAsthma Attack
Severe AsthmaSevere Asthma
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Asthma labelling
Chronic condition + present condition
Chronic condition: infrequent -- persistent
Present condition:
(-)
Symptom attack (-)
(+)
attack (+)
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Every asthma patients The classification should be include class. disease and
severity of asthma attacks, example:
Infrequent episodic asthma without asthma attacks
Infrequent episodic asthma with mild asthma attacks
Frequent episodic asthma with severe asthma attacks
Frequent episodic asthma without asthma attacks
Persistent asthma with severe asthma attacks
Severity of disease not depends on level of attack
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How about preschool children???
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Does every wheezing Does every wheezing
mean asthma?????mean asthma?????
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3tahun
7tahun
15tahun
1tahun
6bulan
0
Alergi makanan
Dermatitis atopik
Asma
Rinitis
Allergic March
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Fig. 6. Hypothetical peak prevalence by age for the 3 different wheezing phenotypes. The prevalence for each age interval should be the area under the curve. This does not
imply that the groups are exclusive.
Asthma
Non-Atopic
Wheezers
TransientWheezers
Age (years)
W
h
e
e
z
i
n
g
p
r
e
v
a
l
e
n
c
e
0 3 6 11
Taussig LM, et al. JACI 2003; 111:661-675
Low LFT at birth
Post RSV
BHR of atopicasthma
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Recurrent wheezingRecurrent wheezingRecurrent wheezingRecurrent wheezing
Major :
Atopic dermatitis
Asthma in parent
Skin test (+) aeroallergen
Minor
Hypereosinophilia
Wheezing beyond flu
Rhinitis allergic
Skin test (+) ingestion Asthma: if
2 major and/or
1 major + 2 minor
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Cost ?
Availability ?
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Conclusion Alteration of asthma pathogenesis:
bronchospasm chronic inflammation remodeling
Diagnosis of asthma must included classification and severity of attack
It is difficult to diagnose asthma in preschool children
There is asthma prediction index in children
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34
Thanks for
your attention