ASTHMA BRONCHIALE

ASTHMA
=Kelainan peradangan kronis pada pernafasan yang menyebabkan bersin, susah
bernafas, sesak pada dada, dan batuk, sering kali pada malam dan/atau pagi hari.
 Status asthmaticus= keadaan dimana serangan asma tidak mereda sehingga
berakibat fatal.
 Belum ada klasifikasi yang seragam
1. Berdasarkan frekuensi dan keparahan gejala: mild intermittent, mild, moderate,
dan severe persistent
2. Berdasarkan klinis: steroid-dependent, steroid-resistant, difficult, dan brittle
3. Umumnya: extrinsic (type I hypersensitivity) dan intrinsic (nonimmune
mechanism, seperti meminum aspirin, infeksi pulmonari, virus, olahraga, dll)
4. Kategori lain: seasonal, exercise-induced, drug-induced, occupational asthma,
asthmatic bronchitis pada perokok)

PATHOGENESIS
Etiologi pada asma:
• genetic predisposition to tpe I hypersensitivity (atopy)
• Acute and chronic airway inflamation
• Bronchial hyperresponsiveness
Defence against
TH 1 cell intracellular organism
IL-12

IFN-ɣ
Macrophage CD4 cell
IL-4
IL-4
Allergic inflammation;
TH 2 cell induction of antobody
production by B cells

Atopic asthma
Tipe paling sering pada asma, biasanya terjadi pada anak kecil.
Patogenesis:
1. Sensitization:
inhaled antigen (allergen) → stimulasi induksi TH2 cell → melepaskan mediator,
seperti cytokine (IL-4, IL-5) → mendukung produksi IgE antibody oleh B cell,
pertumbuhan mast cell (IL-4), pertumbuhan dan aktivasi eosinophil
2. Acute / immediate response:
Mediator membuka mucosal intercellular tight junction → antigen yang masuk ke
submucosal mast cell makin banyak → a. stimulasi subepithelial vagal
(parasympathetic) receptor → brochoconstriction; b. Produksi mukus; c. influx
leukosit lain seperti neutrophil, monosit, limfosit, basofil, dan eosinofil
3. Late-phase reaction:
Leukosit yang datang karena chemotactic factor dan cytokine → mediator juga
diproduksi oleh: sel inflamatori yang sebelumnya sudah ada, vascular
 endothelium, dan airway epithelial cell → second wave of mediators menstimukasi
late-phase reaction → epithelial damage, airway constriction

Nonatopic asthma
Kebanyakan dirangsang oleh respiratory tract infection.
Virus (e.g. rhinovirus, parainfluenza virus) lebih sering daripada bakteri

Drug-induced asthma
Aspirin-sensitive asthma -> biasanya pada pasien dengan rhinitis dan nasal polyps
yang berulang

Occupational asthma
Distimulasi oleh emisi kendaraan, organik dan debu kimia (kayu, kapas, platinum),
gas (toluene), bahan kimia lainya (formaldehid, produk penicillin).

SIGNS AND SYMPTOMS:

Variation in pattern of symptoms, paroxysmal, constant, abnormal pulmonary function
tests without
symptoms

•Wheezing •Nocturnal attacks

•Cough •Cyanosis
•Exercise-induced wheezing or cough •Tachycardia
•Prolonged expiration •Accessory respiratory muscle use
•Hyperresonance •Flattened diaphragms
•Decreased breath sounds •Nasal polyp; seen in cystic fibrosis and
aspirin sensitivity

CAUSES
→Allergic factors

•Airborne pollens •Sinusitis

•Molds •Gastroesophageal reflux
•House dust (mites) •Sleep (peak expiratory flow rate
•Animal dander [PEFR] lowest at 4 am)
•Feather pillows →Current research focuses on
→Other factors inflammatory response (including
•Smoke and other pollutants abnormal release of chemical
•Infections, especially viral mediators, eosinophil chemotactic
•Aspirin factor, neutrophil chemotactic factor,
•Exercise and leukotrienes, etc.)

DRUG(S) OF CHOICE:
→Six major classes of drugs are used:
•Cromoglycate and nedocromil
•Steroids (budesonide, fluticasone, prednisone, etc)
•Beta-agonists (albuterol, bitolterol, salmeterol, etc.)
•Methylxanthines (theophylline)
 •Anticholinergics (atropine, ipratropium)
•Leukotriene modifiers
1. Mild intermittent asthma: brief wheezing once or twice a week:
•Intermittent beta-agonist (MDI or nebulizer - albuterol, 2 puffs or 0.25-1.0
mL neb q2hr prn)
•Long acting beta-agonists [e.g., salmeterol (Serevent) 2 puffs bid]
•Oral beta-agonist or theophylline may be considered, but have more side
effect
2. Mild persistent asthma: symptoms > 2 times a week, but < 1 time a day; affects
activity. Once daily medication - choose from:
•Cromolyn qid or nedocromil bid (2 puffs or 2 ml neb)
•Inhaled steroids (low doses)
•Consider zafirlukast or montelukast
•Consider oral theophylline (10-20 mg/kg/day); not preferred

Contraindications:
•Sedatives, mucolytics
•Antibiotics are usually not necessary
•Avoid beta-adrenergic blocking drugs
Precautions: Concern regarding deleterious effects of chronic use of beta
agonists. Use only when symptomatic (chronic asthma may necessitate chronic
use). If using beta-agonist more than twice a week, should also be on anti-
inflammatory.
Significant possible interactions: Erythromycin and ciprofloxacin slow
theophylline clearance and can increase levels 15-20%.

Sumber:
1. Kumar, Abas, Fausto: Robin and Cotran Pathologic Basis of Disease, 7th ed.
2. Dambro – Griffith’s 5 Minute Clinical Consult 2001-2002