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B B ronchial Asthma ronchial Asthma Therapy Therapy Bachtiar Arif N.H 20090310153

6. Bronchial Asthma

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BBronchial Asthmaronchial AsthmaTherapyTherapy 

Bachtiar Arif N.H20090310153

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DDefnisi Asthmaefnisi Asthma

BronchialBronchial 

Asthma bronchiale adalahpenyakit inamasi kronis

dari jalan nafas yangberhubungan denganhipereaktiftas bronchial

dan obstruksi jalan nafastotal atau partial yangreversible. Dimana pada

beberapa kasus hilang

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AAsthma Bronchialesthma Bronchiale

• Reversible obstruction

• Varisi simptom dalam sehari-hari

• Terdapat riwayat keluarga

• Dapat menyerang berbagai usia lebihsering pada!

 –"#-"$% anak-anak

 –  $-"#% dewasa• Tidak adak riwayat merokok

• allergy rhinitis ec&ema 'bisa

terdapat(tidak)

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EEtiopatogenesistiopatogenesis

• 

INFLAMMATININFLAMMATIN  mengaktifasimastocytes macrophages eosinophilshelper Th-lymfocytes *+ membentuk danmelepaskan mediator in,amasi! histamine

leucotriens prostaglandins bradykinin

bronchoconstriction mucus secretion plasmaeudation dan bronchial hyperreactivity

air!ay remo"elation

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T#$#anT#$#an terapi Asmaterapi Asma

BronkialBronkial• Menghilangkan "an mengen"alikan

ge$ala asma

• Mencegah eksaserbasi ak#t

• Meningkatkan "an mempertahankan%aal par# seoptimal m#ngkin

• Meng#payakan aktiviti normaltermas#k exercise

• Menghin"ari e%ek samping obat• Mencegah ter$a"i keterbatasan aliran

#"ara 'airo! limitation( ireversibel

• Mencegah kematian karena asma

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TTerapi Asma Bronkialerapi Asma Bronkial

• NonpharmacologicalNonpharmacological – /dukasi kepada pasien

 – 0enghindari faktor resiko dan pencetus asma

• )harmacological)harmacological

 – A N T I I N F L A M M A T * +• 0enghilangkan in,amasi and hipereakti1tas bronchial

• 2enggunaan secara teratur dan jangka panjang

 – B * N ,- D I L A T * + • 0enghilangkan simptom dari keterbatasan aliran saat

ekspirasi

•  Terapi pertama saat terjadi kekambuhan asma

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bat.obat Asma Bronkialbat.obat Asma BronkialA/A/ ,NT*LLE*0,NT*LLE*0

 –  3bat-obat preventive controlling inammationcontrolling inammation  –  dipakai secara terat#r1 "an $angka !akt# lamaterat#r1 "an $angka !akt# lama

untuk mengkontrol asma

   antiinammatory "r#gsantiinammatory "r#gs

   long acting inhalatory broncho"ilatorslong acting inhalatory broncho"ilatorsB/B/ *ELIE2E*0*ELIE2E*0

  menghilangkan bronchospasm

 relieving * fast acting bronchodilators

,/,/ batbat ANTIA0T-MATI,ANTIA0T-MATI, lainnyalainnya – 0onoclonal Ab against 4g/ * omali&umab '$# pat. in

5R)

 – ketotifen

 – 4munosupressives

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A/A/ ,NT*LLE*0,NT*LLE*0

• inhalatory corticoi"s ⇒ ICS

• long.acting 3.sympathomimetics

(long-acting betaagonists )⇒

 LABA,(8-15h.)

• natri#m kromoglikat1

• Natri#m ne"okromil

• antihistamin aksi lambat4

•Teoflin lepas lambat.

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B/ *ELIE2E*0

• inhalatory short.acting 3.

sympathomimetics ( short-acting

betaagonists ) ⇒

 0ABA (till 4-6 h.) 

• inhalatory anticholinergics short-

acting

•  Amino1llin

• Adrenalin

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• Peroral

• Parenteral

• Dengan inhalation ⇒ 

Efek obat ira!akan lang!"ng  Ak!i ari obat ce#at

$e%an&"ran 'ang %ak!i%al

(o)er thera#e"tic o!e! * %e%ini%alkan re!iko

keka%b"han 'g ak"t Keterbatasan dari pihak pasienKeterbatasan dari pihak pasien +tekhnik inhala!i,

ker&a!a%a "nt"k #at"h-

Resistensi dariResistensi dari inspiratoryinspiratory, har"! iata!i

*#te pemberianme"ikasi

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0acam-macam carapemberian obat inhalasi

• 4nhalasi dosis terukur'4DT)( etere!-!ose inhaler  '0D4)

• 4DT dengan alat 6antu 'spacer)• Breath-act"ate! #$I

• $r% &o'!er inhaler 'D24)

• Turbuhaler

• 7ebuliser

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nhalator'/'!te%!

No)aa'!

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  6633. 0+M)AT. 0+M)AT--MIMETIMIMETI,0,0

• Mechanism o% action * bronkodilatasimenurunkan permeabilitas kapiler danmencegahpelepasan mediator dari selmast dan baso1l salbutamol terbutalin

7474 Long.actingLong.acting 66330M0M (long-acting betaagonists ) = LABA

 – ,ontrollers  "nt" tera&i *anga &an*ang !anterat"r broncho!ilation

3434 0hort.acting0hort.acting 66330M0M (short-acting betaagonists ) = SABA

 – *elievers tera&i *anga &en!e, "nt" tera&i saat

ter*a!i eab"han

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ββ22 –sympathomimetics –sympathomimetics

(LABA and SABA)(LABA and SABA)

Fast beinnin!

short d"rationinhal. 

salb"tamol! #enoterol

Fast beinnin!

lon d"ration

inhal. #ormoterol

Slo$ beinnin!

short d"rationoral  

salb"tamol rt. c#!.

Slo$ beinnin!

lon d"rationinhal. salmeterol

speed o# e##ectbeinnin

FAST

SL%&

S'%RT L%d"ration o# action

resc"e treatment

  m  a

   i  n   t  a  n  a  n  c  e   t   h  e  r  a  p

  y

LABASABA

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Efek !a%#ing obat golongan agoni! beta2•gangg"an karioa!k"ler •#eningkatan tekanan arah•re%or •Pal#ita!i•takikari an !akit ke#ala

Pe%akaian agoni! beta2 !ecara reg"ler han'aiberikan #aa #enerita a!%a kronik berat 'angtiak a#at le#a! ari bronkoilator

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*2+ sympatho

,-,.T-/S

0 S,

Anti ,+cholineric 0 1sL

actiate !'%#athicN/

dilatebronchi

block#ara!'%#athic N/

dilatebronchi

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LoLoccalialisation o% sation o%  **eceptoreceptorss

cholinercholinericic (parasympat(parasympathhic)ic)

aadrenerdrenericic

(sympat(sympathhic)ic)

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  LABALABA the best fast and intense acting b-dilatans

"#ration o% "#ration o%  actionaction 8873 ho#rs73 ho#rsMMekanismeekanisme AAksiksi// 

Broncho"ilation thro#gh 93 :8 rela;ation o% smooth

m#scle

  0eningkatkan pembersihan mucociliar

  0enurunkan permeabilitas vaskular

  0engatur pelepasan mediator dari mastocytes

ba&ophils

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,ole,olecc"l"laar mechanir mechanissmm o# o#  positiepositieinterainteractionction -/S a-/S andnd LABALABA

Glucocorticoid

receptor 

ß2 -Adrenoceptor 

/orticosteroid

Anti+in#lammatory e##ect

•  .##ect o# corticosteroids on *.##ect o# corticosteroids on *22+adrenoceptors+adrenoceptors

•  .##ect o# *.##ect o# *22+aonists on l"cocorticoid receptors+aonists on l"cocorticoid receptors

*2+Aonist

Bronchodilatation

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LABA• %ormoterol• salmeterol

MonotMonothheraperapyy LABA/LABA/

•   ↓ effectivity of :A6A vs. 4;5• improving sleeping but !itho#t!itho#t e% e% % % eect toct to 

pp#lmonary#lmonary %#n%#nctionsctions 

• !itho#t!itho#t ee% % %e%ect on inam4ct on inam4 in airways

'biopsia)

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 BATBAT ANTILE5<T*IENANTILE5<T*IENEE

• controllerscontrollers untuk mengontrol simptom dalam jangka waktu lama

• antagonists o% le#kotriene 7 ',ysLT7( receptors

 – 

montel#kast1 =afrl#kast1 pranl#kast• ↓ inhibitors o% >.lipoo;ygenase 

 – &ileuton 

• 2eroral• MA/  .  additive antiin,amasi

  .  mengurangi eosinophilia jaringan

.  mild bronchodilation

  .  bronchoprotective

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  MET-+L?ANT-INE0MET-+L?ANT-INE0

• controllers untuk terapi simpom jangka panjang

• 4mprovement of clinical symptomatology 

 –  broncho"ilation - without signif. increase of </V"(

improvement of lung function parameters  through

inhibition of fosfodiesterase 4. to 4V. *+ cAM)  – antiinam4 imm#nomo"#latory e=ects

 – positive e=ect on phenomenon o% @corticoi" resist4 

• AE/ cephalea nausea vomiting tachycardiapalpitations ↑↑↑ plasm. conc. 'TD0)  arrhytmias epileptic spasms even death

• potential toicity pro1le of A/⇒

 

broncho"ilators o% the thir" choice

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  0ABA0ABA

basic relieversbasic relievers used ad hoc to relieve or to remove

symptoms

• salb#tamol (+entolin)

• %enoterol

IN-ALAT*+IN-ALAT*+

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 IN-ALAT*+IN-ALAT*+ANTI,-LINE*I, D*50ANTI,-LINE*I, D*50

 

*elievers o% the secon" choice1 at AE*elievers o% the secon" choice1 at AE  competitivecompetitive antagonistsantagonists on M71 M3 an" MCon M71 M3 an" MC 

receptors of parasympathicus ⇒

  cholinergic ton#scholinergic ton#s

  Division/Division/

• with short.lastingshort.lasting e=ect! ipratropi#m bromi"eipratropi#m bromi"e

• with long.lastinglong.lasting e=ect! tiotropi#m bromi"etiotropi#m bromi"e

',-)D(',-)D(

,, ii ii t ii

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1re+anlio3ner

1arasympatick4

anlion

1ost+anlio3

ner

A/h

'ladk3 sal

icotino3 receptor (5)

,6 receptor (5)

,2 receptor (–)

,7 receptor (5)

,"s,"sccar ar iinnicic receptoryreceptorys ins inair$aysair$ays

Barne! P4. E"r e!#ir e 1996

IN-ALAT*+

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IN-ALAT*+IN-ALAT*+

ANTI,-LINE*I, D*50ANTI,-LINE*I, D*50

• decrease n. vagus tonus• cause relaation• but no bronchoprotective action

• are in general less e=ective than @8?mimethics and have a little slowerbeginning of action

•advantageous combinations v "inhalation system!

• ipratropium• ipratropium>fenoterol

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R b t b d k

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Rencana pengobatan serangan asma berdasarkanberat serangan dan tempat pengobatan

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