1Diagnosis of

asthma

Module 5

Training of Inhalation Therapy

& Pediatric Asthma Management

Departemen IKA FKUI-RSCM

UKK Respirologi PP IDAI

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

Definition of asthmaReversible respiratory tract obstruction spontaneously or after treatment

1950-es

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

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

Environment Genetic susceptibility

Chronic allergic inflammation(Mast cells, T-Cells, Eosinophils)

Airway Wall Thickening(Remodeling)

Pathogenesis

BronchoconstrictionBronchoconstriction

Chronic Chronic

inflammationinflammation

RemodelingRemodeling

ResumeResume..

Inflammation in asthma

Barnes PJ

Chronic inflammation

Structural changes

Inflamasi akut

Steroid response

Time

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

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)

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

.. 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

PNAA, 2004:PNAA, 2004:PNAA, 2004:PNAA, 2004:

Entry point of asthma diagnosis:

Recurrent Wheezing

and/or

Chronic Recurrent Cough

Batasan operasional

Recurrent cough and/or wheezing with characteristics episodic, nocturnal (variability),reversible (relieve with or without treatment) plusatopic

Reversibility (+) Variability (+)

Cough and/or wheezing

A/ + PE + SE

Not typical

EpisodicNocturnal After activity Atopic (+)

Bronchodilator

ASTHMANot Asthma

TYPICAL

V50.FEV1

FVC

PEF V25.

APAPAESAESAEJAEJLung Lung

Function Function

TestTest

Asthma : chronic respiratory disease that can have acute attack (two in one disease)

AsthmaAcute Asthma

Chronic Asma

Asthma, 2 aspects

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

Infrequent Episodic Asthma

75% of children with asthma

Episode

Frequent Episodic Asthma

20% of children with asthma

More frequent attacks

Wheezing after moderate activities

Could be prevented with 2-agonist

Symptoms

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

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%

DiagnosisDiagnosis

ASTHMAASTHMA

Asthma AttackAsthma Attack

Severe AsthmaSevere Asthma

Asthma labelling

Chronic condition + present condition

Chronic condition: infrequent -- persistent

Present condition:

(-)

Symptom attack (-)

(+)

attack (+)

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

How about preschool children???

Does every wheezing Does every wheezing

mean asthma?????mean asthma?????

3tahun

7tahun

15tahun

1tahun

6bulan

0

Alergi makanan

Dermatitis atopik

Asma

Rinitis

Allergic March

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

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

Cost ?

Availability ?

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

34

Thanks for

your attention