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H
TA
C
OWO ACHIEVE
STHMA
ONTROL?
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APA YANG DIKETAHUI
TENTANG ASMA
Asma adalah salah satu penyakit kronis yangtersering,ada 300 juta orang penderita diseluruh dunia,prevalensinya cenderungmeningkat terutama anak anak
Asma secara efektif dapat diobati dansebagian besar dapat mencapai TOTAL
CONTROL.
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Clinical Control of Asthma
No (or minimal)* daytime symptoms
No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue medication
Normal lung function
No exacerbations_________
* Minimal = twice or less per week
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Levels of Asthma Control
CharacteristicControlled
(All of the following)
Partly controlled(Any present in any week)
Uncontrolled
Daytime symptomsNone (2 or less /
week)
More than
twice / week
3 or morefeatures of
partly
controlled
asthma
present in
any 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 1 in any week
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Pasien yang mencapai kontrol
Partly dan Uncontrolled
Controlled
Hanya 5% pasien
yang mencapai
kontrol asma
Rabe et al. Eur Respir J, 2000
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Hanya 5 % pasien yang mencapai kontrol
asma. Hal ini dikarenakan:
Ekspektasi yang rendah tentang kontrol
asma baik dari dokter maupun pasien.
Komunikasi dokter / pasien yang kurang
tentang tingkatan asma kontrol
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pre-study post-study
Bateman et al,Amer J Respir Crit Care Med2004; 170: 836-844
%p
asien
100%
Tidak Terkontrol
100%
100%
Membaik
71%
Terkontrol Baik
41%
Terkontrol Penuh
GOAL Study: Dengan Seretide 70% pasien asma yang tidak terkontrol
dapat mencapai dan mempertahankan kontrol asma
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1.Membangun Hubungan pasien -dokter
2. Mengidentifikasi dan mengurangipaparan terhadap faktor resiko
3. Menilai,mengobati dan memonitorgejala Asma(Assess, Treat and Monitor
Asthma)
4. Pengelolaan Eksaserbasi Asma
4 Komponen Penatalaksanaan Asma
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PERLU ALAT SEDERHANA UNTUK MENILAI
KONTROL ASMA
NILAI STATUS KONTROL ASMA
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ACTTM(Asthma Control Test):
Direkomendasikan oleh GINA & DAI (Dewan AsmaIndonesia)
Tervalidasi dengan pemeriksaan paru lainnya; spirometri,peak flow meter.
Mudah (5 pertanyaan) & tanpa biaya(www.asthmacontroltest.com).
www.asthmacontroltest.com, GINA 2008
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Asthma Control TestTM
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CONTROLLED
PARTLY CONTROLLED
UNCONTROLLED
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Levels of Asthma Control
CharacteristicControlled
(All of the following)
Partly controlled(Any present in any week)
Uncontrolled
Daytime symptomsNone (2 or less /
week)
More than
twice / week
3 or morefeatures of
partly
controlled
asthma
present in
any 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 1 in any week
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Ada 5 level pengobatan asma,tergantung status asma kontrol
Pengobatan disesuaikan dalam suatusiklus kontinyu dengan berpedomanpada status asma kontrol.Siklustersebut meliputi:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
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Levels of Asthma Control
Characteristic Controlled Partly controlled(Any present in any week)
Uncontrolled
Daytime symptomsNone (2 or less /
week)
More than
twice / week
3 or morefeatures of
partly
controlled
asthma
present in
any 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 1 in any week
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Component 4: Asthma Management and Prevention Program
Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled
2-agonists Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral 2-agonists
Anti-IgE
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Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400
Budesonide-Neb
Inhalation Suspension
250-500 >500-1000 >1000
Ciclesonide 80 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200
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Component 4: Asthma Management and Prevention Program
Reliever Medications
Rapid-acting inhaled 2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral 2-agonists
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controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTION
TREATMENT STEPSREDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCE
INCREASE
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Step 1 Obat pelega sesuai kebutuhan
Pasien dengan gejala yang jarang dan
dengan durasi serangan pendek.
Direkomendasikan inhalasi 2-agonist kerja
cepat (Evidence A)
Bila gejala memberat dan lebih sering dan
atau memburuk secara periodik,pasien butuh
obat kontroler (step 2atau di atasnya)
Treating to Achieve Asthma Control
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Step 2
Obat Pelega dan kontroler tunggal
Direkomendasikan inhalasi
glucocorticosteroid dosis rendah sebagaiawal pengobatan kontroler semua tingkat
usia (Evidence A)
Sebagai alternatif bisa diberikan leukotriene(Evidence A)
Treating to Achieve Asthma Control
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Step 3
Obat pelega ditambah 1 atau 2 kontroler
Pada dewasa diberi kombinasi inhalasi
kortikosteroid dosis rendah dengan 2-agonist
kerja panjang, dengan inhalasi kombinasi atauterpisah (Evidence A)
2-agonist kerja panjang jangan sebagai
monoterapi
Pada anak berikan inhalasi kortikosteroid dosis
medium (Evidence A)
Treating to Achieve Asthma Control
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pre-study post-study
Bateman et al,Amer J Respir Crit Care Med2004; 170: 836-844
%p
asien
2. Treat (Obati Untuk Mencapai Kontrol)
100%
Tidak Terkontrol
100%
100%
Membaik
71%
Terkontrol Baik
41%
Terkontrol Penuh
GOAL Study: Dengan Seretide 70% pasien asma yang tidak terkontrol
dapat mencapai dan mempertahankan kontrol asma
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Step 3 tambahan pilihan obat untuk dewasa
Naikkan inhalasi kortikosteroid ke dosis
medium (Evidence A) inhalasi kortikosteroid dosis rendah
kombinasi dengan leukotriene modifiers
(Evidence A) inhalasi kortikosteroid dosis rendah
sustained-release theophylline (Evidence B)
dosis rendah
Treating to Achieve Asthma Control
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Step 4
Reliever medication plus two or morecontrollers
Pilihan obat pada step 4 tergantung pilihan
obat pada step 2 atau 3
Sebaiknya pada pasien yang tidak dapat
mencapai kontrol asma pada step 3 dirujuk
Treating to Achieve Asthma Control
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Step 4
Obat Pelega ditambah 2 atau lebih kontroler
Kombinasi inhalasi kortikosteroid dosis medium
atau tinggi dengan inhalasi 2-agonist kerja
panjang (Evidence A)
inhalasi kortikosteroid dosis medium atau tinggi
kombinasi dengan leukotriene modifier(Evidence
A) Sustained-release theophylline dosis rendah
tambahkan Inhalasi kortikosteroid dosis medium-
atau inhalasi kortikosteroid dosis tinggi
kombinasi den an -a onist ker a
Treating to Achieve Asthma Control
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Treating to Achieve Asthma Control
Step 5
Reliever medication plus additional controller options
Penambahan kortikosteroid oral dosis rendah
mungkin efektif (Evidence D) tetapi banyak
efek samping(Evidence A)
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MONITORING
Bila kontrol asma sudah tercapai,monitoring berkesinambungan mutlakdilakukan untuk:
- pemeliharaan kontrol asma
- Menentukan penurunan step ataudosis pengobatan
Kontrol asma harus dimonitor olehpasien dan dokter
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Check Status Kontrol/nilai ACT
Membaik
Pertahankan dosis :3 bulan
Memburuk
Naikkan dosis dan cekrespon:
3 bulan
Membaik / memburuk?
3. Monitor to Maintain (pantau untukmempertahankan kontrol)
GINA 2008
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MONITORING
Stepping down treatment when asthma is controlled
Bila kontrol asma tercapai pada Inhalasi
kortikosteroid dosis medium sampaitinggi: pengurangan dosis 50% pada
interval 3 bulan.(Evidence B)
Bila kontrol asma tercapai pada inhalasi
kortikosteroid dosis rendah : ubah ke
dosis sehari (Evidence A)
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MONITORING
Stepping down treatment when asthma is controlled
Bila kontrol asma tercapai pada kombinasiinhalasi kortikosteroid inhalasi
2-agonist
kerja panjang , kurangi dosis inhalasi KS50% 2-agonist kerja panjang tetapdiberikan (Evidence B)
Bila kontrol asma tetap terjaga, kurangidosis inhalasi KS ke dosis rendah danstop 2-agonist kerja panjang(Evidence D)
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KASUS I
Anak 5 tahun
Batuk setiap malam selama >1bulan,kadang
ada suara mengi
Riwayat atopi dalam keluarga
Bacaan X Foto torak proses spesifik
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Characteristic ControlledPartly controlled
(Any present in any week)Uncontrolled
Daytime symptomsNone (2 or less /
week)
More than
twice / week
3 or more
features of
partly
controlledasthma
present in
any week
Limitations of
activitiesNone 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 (ifknown) on any day
Exacerbation None One or more / year 1 in any week
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Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400
Budesonide-Neb
Inhalation Suspension
250-500 >500-1000 >1000
Ciclesonide 80 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200
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Batuk dan sesak hilang
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Asthma Control TestTM
5
5
5
5
5
25
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Check Status Kontrol/nilai ACT
Membaik
Pertahankan dosis :3 bulan
Memburuk
Naikkan dosis dan cekrespon:
3 bulan
Membaik / memburuk?
3. Monitor to Maintain (pantau untukmempertahankan kontrol)
GINA 2008
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Wanita 35 tahun Riwayat asma sejak umur 18 tahun Dalam 1 bulan ini hampir seminggu
sekali menggunakan pelega Setiap malam selalu terbangunkarena batuk atau sesak
Dalam 1tahun ini 2 kali ke UGD
karena asma
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Characteristic ControlledPartly controlled
(Any present in any week)Uncontrolled
Daytime symptomsNone (2 or less /
week)
More than
twice / week
3 or more
features of
partly
controlled
asthma
present in
any week
Limitations of
activitiesNone 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 1 in any week
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Keluhan tetap sama,hampirseminggu sekali menggunakan
obat semprot pelega
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Asthma Control TestTM
2
3
2
2
1
10
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