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In the United States an estimated 14. 7 million people visit a doctor's office for
an examination during an acute attack of asthma and doctors diagnose acute
exacerbations of asthma with varying degrees.
In Indonesia, asthma is included in the top ten causes of illness and death.
In 2005 shows that in Indonesia the prevalence of acute exacerbations of
asthma increases from 4.2% to 5.4%.
Dougherthy, RH. Acute Exacerbations of Asthma: Epidemiology, Biology and the Exacerbation-Prone Phenotype. NIH- Public Access. 2009
3
CASE REPORT
Name : Tn. D. T
Age : 58 y.o.
Sex : male
Born : Kupang, 16/6/1960
No. MR : 448635
tribe : Timor
religion : Kristen Protestan
Marital state : Married
Education : Senior high school
Work : Teacher
Healthy insurance : BPJS class II
Address : Oepoi
4
ANAMNESIS
Main complaint: Shortness of breath
Patients come to the ER of RSUD Prof. Dr. W. Z. Johannes Kupang with a
sudden shortness of breath since about a day before. The complaint
came suddenly in the afternoon when the patient had just returned
from out of town. Shortness of the longer the more burdensome. The
patient's chest feels like it is tied up and nothing can be done to ease
the symptoms. Before the shortness of complaints arise, the patient
complains of coughing and removing clear white mucus. The patient
begins to cough when the patient feels cold. Patients had used an
inhaler drug that had been used previously for 1 year if a stiff complaint
arose. Patients use inhalers up to 3 times, but the recurrence does not
subside. The use of these drugs can not eliminate the symptoms that
appear until the patient asked for help on his wife and child. Patients
also complain of dizziness, do not feel chest pain and chest pounding
5
Past medical history :
Patients often have shortness of breath since the age of 6 years and
often recur when the grade 5 primary school, after which never relapse
again. In 2005, patients complained of frequent sneezing and runny
nose that did not improve, felt heavy in the morning, disappeared, and
sometimes still often appear until now, especially when exposed to cold
air. The patient did not go to the doctor. In the last six months,
complaints have become more frequent. Within a month, the complaint
can recur two to three times. Recurrences often occur at night when the
air gets colder, and wakes the sleep. When the patient starts relapse
always use barotec then recurrence subsides. Patients feel that their
activities remain normal despite frequent relapse, only when relapse,
the patient feels always wants to rest. Patients had been treated for
several days in 2016 due to heart disease, when the patient's chest
complaints felt very painful and pounding. Patients were then
diagnosed with CHF and HHD, had frequent control of cardiac poly and
routine consumption of amlodipine, simvastatin, and clopidogrel.
6
Family medical history :
According to the patient's admission, the patient's niece has
the same complaint with the patient. Often shortness of
breath and when the shortness of breath like a pull.
Medical history :
Patients to date receive therapy for asthma in the form:
Berotect inhaler is 1 year
Salbutamol tablet 2 mg
- Dexamethasone 0.5 mg
All three drugs are used by the patient when the shortness of
breath suffer relapse. There is no other medical history
consumed by the patient.
7
Habit history :
Patients have a habit of smoking since grade 5 of primary
school. Currently patients can smoke as much as ½ pack or
1 pack of cigarettes. Patients never feel crowded after
smoking. The patient's eating habits are two to three times
a day, according to the patient's admission, the patients eat
regularly with a fairly varied menu and in the dominance of
vegetables, occasionally meat. Triggers that can be
identified by the patient related to his shortness of breath
include: - cold air - heavy activity - dust patients rarely use
masks for daily activities.
Social and economy history :
The patient lives with a wife and three children. The patient
is a retired teacher. Patient has 3 children.
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REVIEW SYSTEM
Head: Dizziness (-), headache (-)
Skin: Pale (-), yellow (-)
Eyes: Blurred eyes (- / -)
Ear: Full sense in ear (- / -), fluid from ear (- / -)
Nose: Cold (-), itchy nose (-), sneezing (-)
Mouth: Swallow pain (-), cancer sores (-), white patches on the tongue (-),
Throat: Hoarseness (-), difficulty swallowing (-)
Neck: Spontaneous pain (-), tactile pain (-), tenderness (-), signs of inflammation (-),
enlargement of the neck (-)
Heart: Heart palpitations (-), chest pain (-),
Lung: Shortness of breath (+), difficulty breathing (+)
Gastrointestinal: Fast satiety (-), nausea (-), vomiting (-), epigatric pain (-), CHAPTER is felt
still normal
Kidney and urinary tract: BAK is still normal, clear yellow, no blood or sandy urine
Neurological: no decrease in consciousness, no sign of neurological deficit
Endocrine: No history of previous hormonal disorders Muskuloskeletal: No abnormalities
Extremities: No abnormalities found on the nails, warm acral
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PHYSICAL EXAMINATION
10
Head: normocephal, hair is not easy to fall out, black hair
color, symmetrical face.
Skin: Cyanosis (-), jaundice (-)
Eyes: The conjunctiva appears pale (- / -), the sclera
appears jaundiced (- / -), conjunctival bleeding (- / -), isokor
pupil, direct light reflex (+ / +)
Ear: Deformity of ear lobes (- / -), tragus tenderness (- / -),
mastoid tenderness (- / -), otorea (- / -)
Nose: secretions (- / -), epistaxis (- / -
Mouth: Cyanosis (-), lips appear moist, gum bleeding (-),
pink mucosa, clean tongue
Neck: Magnification of the thyroid gland (-), magnification of
KGB (-), spontaneous pain (-), tactile pain (-), tenderness (-),
use of breathing muscle (-)
Thorax (shape): Thorax formation is normal, no visible
widening of the veins, not visible scar (scar)
11
Pulmo The lungs are anterior
I: Development of symmetrical chest when static and dynamic, no
visible use of respiratory muscle.
Pa: Tactile left and right fremitus normal and symmetrical, no
tenderness, not palpable mass
Pe: Sonor on both lung fields
A: Vesikuler : + + Rhonki : Wheezing : + +
- -
+ + + +
- -
+ + + +
- -
14
Radiology
15
Diagnose
Asma bronchial eksaserbasi akut
HHD
CAD
Therapy (ER)
Nebulisasi combivent / 8 jam
Methylprednisolone injeksi 2 x 125 mg
Salbutamol 3x2 mg
For cardiac :
Amlodipin 5mg – 0- 0
Candesartan 0 – 0 – 10
Clopidogrel 0 – 75 mg – 0
Simvastatin 0- 0-20 mg
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THEORY
A flare-up or exacerbation is an acute or sub-acute
worsening
of symptoms and lung function compared with the patient’s
usual status
Terminology
‘Flare-up’ is the preferred term for discussion with
patients
‘Exacerbation’ is a difficult term for patients
GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet]. 2018;1. Available
from: http://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-
prevention/
17
PATHOPHISIOLOGY
19
GINA 2017
WRITTEN ASTHMA ACTION PLANS
GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet]. 2018;1.
Available from: http://ginasthma.org/2018-gina-report-global-strategy-for-asthma-
management-and-prevention/
20
GINA 2017, Box 4-2 (1/2)
WRITTEN ASTHMA ACTION PLANS –
MEDICATION OPTIONS
Increase inhaled reliever
Increase frequency as needed
Adding spacer for pMDI may be helpful
Early and rapid increase in inhaled controller
Up to maximum ICS of 2000mcg BDP/day or equivalent
Options depend on usual controller medication and type of LABA
See GINA 2017 report Box 4-2 for details
Add oral corticosteroids if needed
Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days
Children: 1-2mg/kg/day up to 40mg, usually 3-5 days
Morning dosing preferred to reduce side-effects
Tapering not needed if taken for less than 2 weeks
Remember to advise patients about common side-effects (sleep disturbance,
increased appetite, reflux, mood changes)
• GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet].
2018;1. Available from: http://ginasthma.org/2018-gina-report-global-strategy-
for-asthma-management-and-prevention/
21
GINA 2017, Box 4-2 (2/2)
RATIONALE FOR CHANGE IN RECOMMENDATION
ABOUT CONTROLLER THERAPY IN ASTHMA ACTION
PLANS
For the last 10 years, most guidelines recommended treating
worsening asthma with SABA alone until OCS were needed, but ...
Most exacerbations are characterised by increased inflammation
Outcomes were consistently better if the action plan prescribed both increased
ICS, and OCS
Lack of generalisability of placebo-controlled RCTs of doubling ICS
Study inhalers were not started, on average, until symptoms and airflow
limitation had been worsening for 4-5 days.
Severe exacerbations are reduced by short-term treatment with
Patients often delay seeking care for fear of being given OCS 22
GINA 2017
MANAGING EXACERBATIONS IN PRIMARY CARE
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled
SABA and ipratropium bromide,
Controlled oxygen (if available): target O2, systemic corticosteroid
saturation 93–95% (children: 94-98%)
IMPROVING
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
23
GINA 2017, Box 4-3 (1/7)
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
24
GINA 2017, Box 4-3 (2/7) © Global Initiative for Asthma
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
25
GINA 2017, Box 4-3 (3/7) © Global Initiative for Asthma
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
START TREATMENT
TRANSFER TO ACUTE
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING While waiting: give inhaled SABA
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)
26
GINA 2017, Box 4-3 (4/7) © Global Initiative for Asthma
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)
IMPROVING
27
GINA 2017, Box 4-3 (5/7) © Global Initiative for Asthma
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)
IMPROVING
28
GINA 2017, Box 4-3 (6/7) © Global Initiative for Asthma
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)
IMPROVING
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
29
GINA 2017, Box 4-3 (7/7) © Global Initiative for Asthma
MANAGING EXACERBATIONS IN ACUTE CARE SETTINGS
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
30
GINA 2017, Box 4-4 (1/4)
INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
31
GINA 2017, Box 4-4 (2/4) © Global Initiative for Asthma
MILD or MODERATE SEVERE
Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best
32
GINA 2017, Box 4-4 (3/4)
Short-acting beta2-agonists Short-acting beta2-agonists
Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
33
GINA 2017, Box 4-4 (4/4) © Global Initiative for Asthma
FOLLOW-UP AFTER AN EXACERBATION
Follow up all patients regularly after an exacerbation, until symptoms
and lung function return to normal
Patients are at increased risk during recovery from an exacerbation
The opportunity
Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma
management
At follow-up visit(s), check:
The patient’s understanding of the cause of the flare-up
Modifiable risk factors, e.g. smoking
Adherence with medications, and understanding of their purpose
Inhaler technique skills
Written asthma action plan
GINA. Global Strategy for Asthma Management and Prevention. GINA [Internet].
2018;1. Available from: http://ginasthma.org/2018-gina-report-global-strategy-
for-asthma-management-and-prevention/
34
GINA 2017, Box 4-5
DIAGNOSE
35
Triggers factors for acute exacerbation :
1. Infection of respiratory virus such as influenza
2. Exposure to allergen mites, house dust, animal fur
3. Exposure to irritation of cigarette smoke, perfume
4. Activities of acute exacerbation practitioners /
sports such as running
5. Emotional expression of fear, anger, frustration
6. Aspirin medications, beta blockers, non-steroidal
anti-inflammatory
7. Work environment: chemical vapor
8. Air pollution: cigarette smoke
9. Food preservative: sulfite
10.Others: menstruation, pregnancy, sinusitis
36
Controllers are long-term acute exacerbations of acute
asthma to control acute exacerbations of asthma, given
daily to achieve and maintain controlled asthma.
Kromolin
Metilsantin
Long acting beta 2 agonis
Leukotrien modifier
37
Reliever) is principally for airway dilatation through
smooth muscle relaxation, improving and / or
inhibiting bronchostraction associated with acute
symptoms such as wheezing, chest and coughing,
not improving airway inflammation or decreasing
hypersponsif of the airway
Short acting beta 2 agonis
Antikolinergik
Systemic corticosteroid
Aminofilin
38
CASE THEORY
complaints of recurrent shortness of breath and first clinical diagnosis of asthma characterized by
felt since 1966. Complaints are felt disappeared, chronic airway inflammation and respiratory
without a fever, and appear suddenly. Patients symptoms such as wheezing, shortness of breath,
express complaints also accompanied by wheezing, chest-like bending and cough varying over time and
nasal congestion, runny nose, and sneezing sneezes intensity, along with limitation of expiratory airflow.
that have been felt since the year 2011.
patients who feel short of breath after returning triggers that are not specific but can still be marked
from out of town and after feeling very cold is the by patients such as: cold air, heavy activity, and
data that support as the cause of acute attacks in dust.
this patient.
The division of asthma degree: The presence of In 2016-2017, complaints are heavier than in the
asthma symptoms during the day more than twice a previous year and can appear two to three times in a
week The existence of symptoms of the night to month, even more often by the end of 2017, about
make the patient wake up from sleep at night Use of two to three times a week. In the last month the
over-the-counter medications more than twice a patient expresses his complaint can relapse about 2
week The existence of limited activity due to asthma times in a month accompanied by symptoms of the
complaints night. Based on this information, the patient can be
classified into a degree of partly controlled -
bronchial asthma.
39
When the attack recurred at the mild or moderate acute acute
time before the patient was rushed exacerbations according to GINA
to the hospital's ER, the patient 2018 are: speaking in phrase, more
complained of severe shortness of comfortable sitting, no agitation,
breath, preceded by cough increased respiratory rate, auxiliary
accompanied by removing white breathing muscles, pulse 100-120
mucus. The results showed that times / min, 90-95% oxygen
wheezing and respiration rates were saturation, PEF> 50%
32 times / min, still speaking in
phrases, resting in a sitting position,
110x / minute pulse, and 95%
oxygen saturation.
40
CONCLUSION
It has been reported that a 58-year-old male patient with mild or moderate acute
exacerbation asthma has been reported. The patient has been diagnosed with asthma
since 1966, has been receiving asthma therapy ever since. Patients present with
shortness of breath, preceded by cough accompanied by removing white mucus,
sound out wheeze, respiratory rate 32 times / minute. Patients administered in IGD
with Nebulisation combivent / 8 h, methylprednisolone injection 2 x 125 mg,
salbutamol 3x2 mg. The patient was then hospitalized for 3 days, from the patient's
follow-up, during the hospitalization there was no recurrence. The patient was then
discharged with symbicort inhaler, salbutamol 3 x 2 mg, and methylprednisolone 3
x 4 mg. The patient's condition is good when repatriated.
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THANK YOU
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