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8/8/2019 Asma Acute Attack Gabungan
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HEDA MELINDA NATAPRAWIRA
RESPIROLOGY DIVISION DEPARTEMENT OF CHILD HEALTH
PADJADJARAN UNIVERSITY ± HASAN SADIKIN HOSPITAL
RESPIRATORY DISTRESS
IN CHILDHOOD ASTHMA
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Asthma is a chronic inflammation Asthma is a chronic inflammation
Asthma Asthma Respiratory distr essRespiratory distr ess
Asthma attack (acute exacerbation) Asthma attack (acute exacerbation)followed by r espiratory distr essfollowed by r espiratory distr ess
Pulmonary function tests (PEFR, FEVPulmonary function tests (PEFR, FEV11)) Asthma attack (acute exacerbation) Asthma attack (acute exacerbation) lif e lif e
savingsaving
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S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)
Tetap lebar(tidak rentan, tidak sensitif ,
tidak mudah goncang, stabil)
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S ALUR AN NAF AS ANAKS ALUR AN NAF AS ANAK
AS
M A AS
M A
S ALUR AN NAF AS ANAKS ALUR AN NAF AS ANAK
AS
M A AS
M A
Tidak timbul ser angan Timbul ser angan
Otot salur an nafas mengkerut
Salur an nafas menebal/membengka
Lendir lebih banyak dan kental/leng
Hiperreaktif :
Sangat rentan
Sangat sensitif
Mudah mengkerut
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INFLAMASIINFLAMASIDeskuamasi epitel
Mucus plug
Penebalan
membrana basalis
Infiltrasi neutrofil dan
eosinofilHipertrofi dan konstriksi
otot polos
Edema
Hiperplasi
kelenjar mukus
Barnes PJ
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Fatal asthma is combination obstructive Fatal asthma is combination obstructive
and hipertrophy airwaysand hipertrophy airways
Autopsy in adults and childr en Autopsy in adults and childr en Biopsy of sever e asthmaBiopsy of sever e asthma Fatal asthmaFatal asthma
LongLong--term tr eatmentterm tr eatment = pulmonary function= pulmonary function
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Both parent noallergies
One sibling with allergy
One parent with allergy
Both parent with allergies
10 %risk of allergy
20-30 %risk of allergy
20-40 %risk of allergy
60% - 80 %risk of allergy
Koning,1996; Bousquet,2002Sensitivity 61 %;Specificity 83%
Genetic FactorsGenetic Factors A Positive family history for allergy A Positive family history for allergy
Risk of allergyRisk of allergy
74
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Clinical findingsClinical findings
Sever e asthmaSever e asthma
attackattack
Coughwheezing
silent chest sever e obstruction
Tachypnea, Dyspnea, Retractions, Nasal flar eTachypnea, Dyspnea, Retractions, Nasal flar e
Wheezing, Sweating, ExhaustedWheezing, Sweating, Exhausted
Agitation, Cyanosis, Coma Agitation, Cyanosis, Coma
Tripod sitting positionTripod sitting position
Pulsus paradoxusPulsus paradoxus
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ComplicationsComplications
Atelectasis Atelectasis
PneumomediastinumPneumomediastinum
Tension pneumothoraxTension pneumothorax
PneumoniaPneumonia
DehydrationDehydration Abnormal secr etion of ADH Abnormal secr etion of ADH
Theophyllin overdoseTheophyllin overdose
Respiratory failur eRespiratory failur e
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Severity asthma attackSeverity asthma attack
Acute sever e asthma attack Acute sever e asthma attack
Lif e thr eatened asthmaLif e thr eatened asthma
WheezingWheezing
Retractions, pulse rateRetractions, pulse rate
Pulsus paradoxusPulsus paradoxus
CyanosisCyanosisPEFR, OPEFR, O22 saturationsaturation
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Acute sever e asthma attack Acute sever e asthma attack
--To tight to eat/speakTo tight to eat/speak
RetractionsRetractions
RR > 50 x/minuteRR > 50 x/minute
Pulse rate > 140 x/minutePulse rate > 140 x/minute
PEFR < 50%PEFR < 50%
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Lif e thr eatened asthmaLif e thr eatened asthma
Decr ease of consciousness/agitationDecr ease of consciousness/agitation
ExhaustedExhausted
Br eathlessnessBr eathlessness
OO22 saturation < 85%saturation < 85%Silent chestSilent chest
PEFR 33%PEFR 33%
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Table 1 Peak Expiratory Flow Rate inTable 1 Peak Expiratory Flow Rate in
Childr enChildr en
Height (cm)Height (cm) PEFR (L/minute)PEFR (L/minute)
110110
120120
130130
140140
150150
160160
170170
150150
200200
250250
300300
350350
400400
450450
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Patient with asthma who has a high risk of Patient with asthma who has a high risk of
having a heavy acute asthma attack that couldhaving a heavy acute asthma attack that couldbe lif e thr eatening ar e those with :be lif e thr eatening ar e those with :
-- A history of lif e thr eatening A history of lif e thr eatening
-- asthma attackasthma attack-- Intubation caused by acute asthma attackIntubation caused by acute asthma attack
--Pneumothorax and/or pneumomediastinumPneumothorax and/or pneumomediastinum
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-- Long periodic syndrome Long periodic syndrome
-- last one year last one year -- Low compliance of medicationLow compliance of medication
-- Misunderstanding or unknowingnessMisunderstanding or unknowingness
of the
definition of of th
ed
efinition of
-- asthmaasthma
-- A visit to the Emergency Room or A visit to the Emergency Room or being hospitalized for the being hospitalized for the
-- Psychological disorder or PsychosocialPsychological disorder or Psychosocialproblemsproblems
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Devices to assess the severity of asthma attackDevices to assess the severity of asthma attack ::
Spyrometer Spyrometer
Accurate Accurate Easy to use Easy to use
Rar ely found in the Rar ely found in the Emergency RoomEmergency Room
Peak Flow meter Peak Flow meter
SimpleSimple Resemble the caliber of the Resemble the caliber of the
r espiratory tractr espiratory tract
Used to assess the severityUsed to assess the severityof obstructionof obstruction
Assess PEFR which r elated Assess PEFR which r elatedwith FEVwith FEV1 1
PEFR is not always r elatedPEFR is not always r elatedwith the severity of with the severity of obstructionobstruction Needs a Needs a
good technique andgood technique andcooperation with patientcooperation with patient
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The newest objective assessment is by using the Pulmonal Index Scor e (PIS)The newest objective assessment is by using the Pulmonal Index Scor e (PIS)
(table below) which has a good corr elation with APE on a child with mild to(table below) which has a good corr elation with APE on a child with mild to
sever e acute asthma attack.sever e acute asthma attack.
Scor eBr eathe
<6 years
Fr equency
>6 yearsWheezing
The use of additional
r espiratory muscle
(M.sternocleidomastoideus
activity )
0 <30 <20 None No activity
1 31-45 21-35End of
expiration
Incr ease, questionable with
stethoscope
2 46-60 36-50 All expirationIncr ease, clearly with
stethoscope
3 >60 >50Inspiration +
Expiration
Max. activity without
stethoscope
Table.2 Pulmonal Index Scor e
Scor e 3 = Mild attack If ther e isn¶t any wheezing because of
4-6 = Moderate attack minimum air exchange (weak), thus
> 6 = Sever e attack scor e = 3
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Table.3 Assessment of the severity of Asthma Attack
Clinical parameter , lung function, laboratory
Mild Moderate Sever e Respiratory Arr est
Br eathless If walkingBaby : cries hard
TalkingBaby :-Short and weak
cries-Difficulty oneating/br eastf eeding
RestingBaby :Doesn¶t want to eat /
drink
Position Could lay down Pr ef er to sit Sit with handsupport
Talking Phrases Piece of phrases words
Consciousness Maybe I rritable Usually I rritable Usually I rritable Confusion
Cyanoses None None Positive Real
Wheezing Moderate, often atthe end of expiration
Loud, all the way alongexpiration + inspiration
Very loud, could be heard withoutstethoscope
Hard/difficult tohear
The use of additionalr espiratory muscle Usually no Usually yes Yes Thoracoabdominal paradox movement
Retraction Shallow, intercostalr etraction
Mild, in addition withsuprasternal r etraction
Deep, in additionwith nose br eathing
Shallow, lost
Br eathe fr equency Tachipneu Tachipneu Tachipneu Bradipneu
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Standard conscious child br eathe fr equencyStandard conscious child br eathe fr equency
Pulse Fr equency Normal Tachycardia Tachycardia Bradycardia
Age Normal br eathe fr equency
< 2 Months < 60 x/minutes
2 ±12 Months < 50 x/minutes
1 ± 5 years < 40 x/minutes
6 ± 8 years < 30 x/minutes
Standard child Pulse fr equency
Age Normal Pulse Fr equency
2 ±1
2 months <16
0x/minut
es
1 ± 2 years < 120 x/minutes
3 ± 8 years < 110 x/minutes
Pulsus Paradoksus
(the examination isnot pactical)
None
< 10 mmHg
Positive
10 ± 20 mmHg
Positive
> 20 mmHg
None, sign of tir ed
r espiratory muscle
PEFR or FEV1
-Pr ebronchodilator -Postbronchodilator
(%suspected value)
> 60%> 80%
40 ± 60%60 ± 80%
Response <2 hours
< 40%< 60%
SaO2 % > 95% 91 ± 95% 90%
PaO2 Normal (doesn¶tneed to examined)
> 60% < 60%
Pa < 45 mmHg < 45 mmHg
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Pitfalls inPitfalls in Assessment Assessment of Child Asthmaof Child Asthma
An accurate assessment of severity on An accurate assessment of severity on
child asthma could only be done if child asthma could only be done if
pitfalls pitfalls below could be avoided :below could be avoided : Unlisted anamnesis of pr eviouslyUnlisted anamnesis of pr eviously
asthma attackasthma attack
Does not understand that persistentDoes not understand that persistentcough is a sign of Bronchospasmcough is a sign of Bronchospasm
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Does not r ecognized or understand the Does not r ecognized or understand the
child normal vital signchild normal vital sign Inadequate physical diagnosisInadequate physical diagnosis
especially for the r espiratory systemespecially for the r espiratory system
Doesn¶t have the ability to do the LungDoesn¶t have the ability to do the Lungfunction testfunction test
Relying too much on laboratory dataRelying too much on laboratory data
for decision makingfor decision making
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Diagnosis on Exacerbation Asthma or Diagnosis on Exacerbation Asthma or
Asthma attack Asthma attack
Inhalation of Inhalation of 2 2 could be use ascould be use asconfirmation on diagnosis and also r educe confirmation on diagnosis and also r educe clinical symptoms (less than 15¶ ~ usually inclinical symptoms (less than 15¶ ~ usually in5¶ ther e is a r educe in bronchoconstriction )5¶ ther e is a r educe in bronchoconstriction )
Laboratory findings doesn¶t support asthmaLaboratory findings doesn¶t support asthma
diagnosisdiagnosis
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Radiologic examination does notRadiologic examination does not
needed on first attack of asthmaneeded on first attack of asthma Indication of phototoraks postIndication of phototoraks post
medication is:medication is:
TachypneaTachypneaTachycardiaTachycardia
Wheezing promoted by other cause :Wheezing promoted by other cause :
mycoplasma,viral inf ection, Tracheamycoplasma,viral inf ection, Tracheaobstruction, Mediastinum tumorsobstruction, Mediastinum tumors
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Acute Asthma Attack Guidance Acute Asthma Attack Guidance
The purpose of acute asthma attackThe purpose of acute asthma attackguidance ar e :guidance ar e :
Relieve the constriction of the r espirationRelieve the constriction of the r espiration
tract as soon as possible.tract as soon as possible. Reduce Hipoxemia.Reduce Hipoxemia.
Return lung function to its normal state asReturn lung function to its normal state as
soon as possible.soon as possible. Planning on guidance to pr eventPlanning on guidance to pr event
r eccurr ency.r eccurr ency.
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Asthma is a chronic inflammatory Asthma is a chronic inflammatory
disorders of the airways in which manydisorders of the airways in which manycells and cellular elements play a rolecells and cellular elements play a role
The chronic inflammatory causes anThe chronic inflammatory causes an
associated incr ease in airwayassociated incr ease in airway
hyperr esponsiveness (HRBhyperr esponsiveness (HRB)) that leads tothat leads to
r ecurr ent episodes of wheezing, r ecurr ent episodes of wheezing,
br eathlessness, chest tightness, andbr eathlessness, chest tightness, and
coughing, particularly at night or in earlycoughing, particularly at night or in earlymorningmorning
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Medications that is used to r elieves asthmaMedications that is used to r elieves asthmaattacksattacks OO22, inhaled, inhaled 22--agonist, agonist,
corticosteroids, inhaled anticholinergic, corticosteroids, inhaled anticholinergic, intravenous aminophyllineintravenous aminophylline
OXYGENOXYGEN Ventilation missmatchVentilation missmatch hypoxiahypoxia
Sever e hypoxiaSever e hypoxia no r espons with oxygenno r espons with oxygentherapytherapy complications?complications?
NHLBI NAEPP: ONHLBI NAEPP: O22 11--3 L/ minutes3 L/ minutescontinuous until Pa Ocontinuous until Pa O22 > 92%> 92%
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GLUCOCORTICOIDGLUCOCORTICOID
Inflammation pr edominantlyInflammation pr edominantly onlyonly
corticosteroids r educes inflammationcorticosteroids r educes inflammation
dir ectlydir ectly
Pr ednison ( 2 mg/kg, max 80 mg) andPr ednison ( 2 mg/kg, max 80 mg) and
methylpr ednisolonemethylpr ednisolone
Mild RD: oralMild RD: oral
Sever e RD: intravenousSever e RD: intravenous
Inhaled corticosteroids: chronic asthma, Inhaled corticosteroids: chronic asthma,
acute astma attack (controversion)acute astma attack (controversion)
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BRONCHODILATORSBRONCHODILATORS
22--agonistagonist drug of choisedrug of choise
Salbutamol ( MDI / nebules)Salbutamol ( MDI / nebules) APE APE 80%80%
continuous every4
hourscontinuous every4
hours Incomplete r esponse Incomplete r esponse continuously or continuously or
intermittent nebulization (every 20 minutes, intermittent nebulization (every 20 minutes,
in 1in 1--2 hours)2 hours)
during medications : Oduring medications : O22
No r esponsesNo r esponses selective selective 22--agonistagonist
intravenousintravenous
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Ipratropium Br Ipratropium Br sever e asthma attacksever e asthma attack
NHLBINHLBI--NAEPP 1997 r ecommendation:NAEPP 1997 r ecommendation:additional therapy with albuteroladditional therapy with albuterol
(salbutamol) to r elieves acute asthma(salbutamol) to r elieves acute asthma
attackattack
THEOPHYLLINETHEOPHYLLINE
Rar ely used in acute asthma attack inRar ely used in acute asthma attack in
childr enchildr en
UsedUsed no r esponses with other therapy or no r esponses with other therapy or
sever e cases in PICU)sever e cases in PICU)
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CRITIC AL ILL P ATIENTSCRITIC AL ILL P ATIENTS
Difficult to pr edictDifficult to pr edict
IntubationIntubation rar e in acute asthma attackrar e in acute asthma attack
Risk factors : passive smokers, RTI, Risk factors : passive smokers, RTI, steroid dependence, hospitalized, steroid dependence, hospitalized,
psychological & psychosocial problemspsychological & psychosocial problems
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Another tr eatment as adjuvant medication Another tr eatment as adjuvant medication
Epinef r inIt was drugs of choice f or acute
Asthma attack
At patient with mild ± severe respir atory distressSubcutan epinef r in has no excess than
2-agonist inhalation
Epinef r in 0,01 mg /kgBW ± 0,3-0,5 mg scconsider f or severe respir atory distress, worse
aer ation, fall to decompensated stage, no respons to
Another medication
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Another tr eatment as adjuvant medication Another tr eatment as adjuvant medication
Ter butalin
Initiated with bolus (10 mcg /kgBW)continue with
dr ip 0,2 mcg /kgBW /minute
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Another tr eatment as adjuvant medication Another tr eatment as adjuvant medication
Magnesium sulfat Calcium channel modulation
Decrease acetyl choline
bronchodilation
Delayed histamin and mast cell
release
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Another treatment as adjuvant medicationAnother treatment as adjuvant medication
Heliox Another inhalation
anestesi
Halotan
Enflur an
Isoflur an
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Intubation
Absolut Indication
Apnea
Respir atory failure (PaCO2 > 60 mmHg)Coma
Another reason
Severe hypoxia
Increase hypercapnia with respir ator ic acidosis,
Difficulty conversation, decrease of consciousness,
tired
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Mechanic VentilationMechanic Ventilation
PURPOSE
Completely oxygenation
and ventilation to decrease
wor k of breathing
Child with asthma
Permissive Hypercapnia
Methods of mechanic
ventilation
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ALGORITMA SERANGANALGORITMA SERANGAN
ASMAASMAKlinik / IGDKlinik / IGDNilai der ajat ser angan
Tatalaksana awal nebulisasi F2-agonis 1-3x, selang 20 menit
nebulisasi ketiga + antikolinergik
jika ser angan ber at, nebulisasi F2-agonis +antikolinergik)
Ser angan sedang
(nebulisasi 2-3x,respons parsial )
ber ikan O2
nilai ulang p sedangp Ruang Rawat
Sehar i pasang inf us
Ser angan r ingan
(nebulisasi 1xrespons
baik) observasi 1-2 jam
ef ek ber tahan boleh
pulang
jika ge jala timbul lagi,
per lakukan seper ti
ser angan sedang
Ser angan ber at( nebulisasi 3x,
respons buruk) O2 se jak awal
steroid iv
nilai ulang p ber at,
r awat inap
f oto Ro tor aks
pasang inf us
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Rng. Rawat Sehar i Oksigen teruskan
steroid or al nebulisasi tiap 2 jam
8-12 jam klinis sta-
bilp boleh pulang
12 jam tetap belumbaikp r awat inap
Ruang Rawat Inap Oksigen teruskan
atasi dehidr asi &
asidosis jika ada
steroid IV tiap
6-8 jam
nebulisasi tiap1-2 jam aminofilin IV awal,
lan jutkan rumatan
nebulisasi 4-6x p
baik, interval 4-6 jam
24 jam stabil p
boleh pulang dengan steroid &
aminofilin IV tetap
tidak baik p ICU
Boleh pulang
bekali F2-agonis(hirupan /or al)
jika ada obat
pengendali, te-
ruskan
inf .virus (+),
steroid or al 24-48 jam kon-
trol proevaluasi
Catatan:
Jika penilaianserangan berat, nebulisasi pertamalangsung F-agonis +antikolinergik
Jika ada ancaman henti nafas segera ke ICU
Bila belum ada alat nebulisasi, dapat diganti
dengan adr enalin sk. 0,01 ml/kgbb/kali, maksimal
0,3 ml/kali.
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