perioperatif pada pasien ASMA BRONKHIAL.pptx

asma bronkial perioperatif

1. PERIOPERATIF ASMA BRONKHIAL dr. Fatmi

2. Asma merupakan penyakit inflamasi kronik dari jalan napas dimana elemen dari sel serta seluler mempunyai peranan dalam proses tersebut. DEFINISI ASMA Global initiative for asthma (GINA) Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. Monitoring and Managing Perioperative Electrolyte Abnormalities, Acid-Base Disorders, and Fluid Replacement. Anesthesiology . McGraw Hill Education. Ed. 3. 2018.

3. Faktor pemicu : Asap rokok Alergen Infeksi Stimulasi pada trakea Stress emotional DEFINISI ASMA Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. Monitoring and Managing Perioperative Electrolyte Abnormalities, Acid-Base Disorders, and Fluid Replacement. Anesthesiology . McGraw Hill Education. Ed. 3. 2018. Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008.

4. Patofisiologi Serangan asma  pelepasan mediator kimia lokal pada saluran napas dan adanya aktivitas dari saraf parasimpatik yang berlebihan Pemicu dari faktor inhalasi  bronkospasme melalui mekanisme imun spesifik maupun nonspesifik dengan terjadinya degranulasi dari sel mast pada bronkial Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008.

5. Patofisiologi Penurunan aliran ekspirasi secara umum  kapasitas total paru , volume residual, kapasitas fungsional paru meningkat Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018

6. Preoperatif Asma harus diidentifikasi dan diklasifikasikan Gejala : Wheezing, nafas pendek , batuk produktif maupun nonproduktif , sesak , dada terasa tidak nyaman hingga “air hunger”, eosinofilia Sebelum melakukan induksi : Hitung RR, ritme napas, auskultasi organ paru Ro thorax : Air trapping Hiperinflasi  diafragma mendatar Smallappearing heart Area paru hiperlusen Penunjang : pemeriksaan fungsi paru Penurunan forced expiratory volume 1 second (FEV1) Peningkatan FEV1 >12% atau peningkatan FEV1 > 0.2 L setelah pemberian bronkodilator AGD PaO2 ≤60 mmHg  insufisiensi dari respirasi Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. Monitoring and Managing Perioperative Electrolyte Abnormalities, Acid-Base Disorders, and Fluid Replacement. Anesthesiology . McGraw Hill Education. Ed. 3. 2018. Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008. Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018

7. Preoperatif Mengumpulkan informasi : Aktivitas harian , ada tidaknya keterbatasan kemampuan fisik Ada tidaknya tanda infeksi Jumlah dan karakteristik sputum Ada tidaknya riwayat alergi Faktor-faktor yang memicu serangan Pengobatan yang sedang dijalankan / pengobatan efektif saat terjadi serangan Gejala yang timbul saat malam hari atau pada pagi hari Respon tubuh terhadap faktor seperti debu , obat-obatan Riw . Operasi sebelumnya Peny . Komorbid lainnya Adanya obesitas serta kejadian OSA Klasifikasi Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008.

8. Kraus, George P. 2020. Asthma, dalam Bready, LL; Noorily , SH; Hickey, R. Decision Making in Anesthesiology . 5 TH edition. London : Jaypee Brothers Medical Publisher Determine the patient’s baseline level of control and current condition Urgent or emergent procedure? Consider deferring procedure for optimization Optimize Intraoperative management Endotracheal Intubation Alternatives to intubation

9. Baseline airway function , current medication, level control of symptoms Baseline airway function Baselne airway function  Based on history and physical examination If the patient is at baseline, decide whether the baseline is satisfactory or should be optimized with more aggressive pharmacotherapy Not largely symptom-free at baseline  undertreated  noncompliant with therapy or that another process may be involved (such as emphysema or chronic bronchitis) Current medication M edication regimens should be continued perioperatively with the exception of theophylline Determine the patient’s baseline level of control and current condition A

10. Preoperatif GINA FEV1 < 80%  glukokortikoid Glukokortikoid rutin dalam 6 bulan terakhir  glukokortikoid sistemik setiap 8 jam dan dosis diturunkan dalam 24 jam setelah pembedahan dilakukan Pedoman manajemen terapi pada asma Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. Monitoring and Managing Perioperative Electrolyte Abnormalities, Acid-Base Disorders, and Fluid Replacement. Anesthesiology . McGraw Hill Education. Ed. 3. 2018. Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008.

11. Preoperatif Memodifikasi jalan napas  frekuensi penyempitan jalan napas berkurang Obat inhalasi maupun kortikosteroid sistemik, teofilin, leukotriene Agen penyelamat jika terjadi bronkospasme yang akut Agonis b adrenergic dan antikolinergik Terapi Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. Monitoring and Managing Perioperative Electrolyte Abnormalities, Acid-Base Disorders, and Fluid Replacement. Anesthesiology . McGraw Hill Education. Ed. 3. 2018. Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008. Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018

12. Preoperatif Terapi Miller, R. D. Miller's anesthesia . Philadelphia. Churchill Livingstone. 7th ed. Applegate R, et al. The Perioperative Management of Asthma. Journal of allergy and Therapy . 20123

13. Preoperatif Terapi Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. Monitoring and Managing Perioperative Electrolyte Abnormalities, Acid-Base Disorders, and Fluid Replacement. Anesthesiology . McGraw Hill Education. Ed. 3. 2018. Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008. Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018 Miller, R. D. Miller's anesthesia . Philadelphia. Churchill Livingstone. 7th ed. Applegate R, et al. The Perioperative Management of Asthma. Journal of allergy and Therapy . 20123

14. Preoperatif Terapi Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. Monitoring and Managing Perioperative Electrolyte Abnormalities, Acid-Base Disorders, and Fluid Replacement. Anesthesiology . McGraw Hill Education. Ed. 3. 2018. Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008. Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018 Miller, R. D. Miller's anesthesia . Philadelphia. Churchill Livingstone. 7th ed. Applegate R, et al. The Perioperative Management of Asthma. Journal of allergy and Therapy . 20123

15. Preoperatif Terapi Pedoman tatalaksana terapi perioperatif pada pasien dengan asma Bayable SD, et al. Perioperative Management of Patients with Asthma During Elective Surgery : a Systematic Review. Annals of Medicine and Surgery. Elsevier. 2021

16. Klinis Well Controlled Not Well Controlled Poorly Controlled Gejala (wheezing, nafas pendek, chest tightness) ≤2 hari / minggu > 2 hari/minggu Setiap hari Terbangun dimalam hari karena gangguan pernapasan ≤2 kali/bulan 3-4 kali/bulan >1 kali/minggu Penggunaan agonis beta 2 sebagai reliever ≤2 kali/bulan > 2 hari/minggu Setiap hari Gangguan pada aktivitas sehari - hari Tidak terpengaruh Keterbatasan ringan Keterbatasan berat Serangan asma yang membutuhkan kortikosteroid sistemik pada pasien lebih dari 5 tahun ≤1 kali/tahun 2-3 kali/tahun >3 kali/tahun FEV1 Predicted >80% 60-80% <60% FEV1/FVC >0.8 0.75-0.80 <0.75 Level control of symptoms Applegate R, et al. The Perioperative Management of Asthma. Journal of allergy and Therapy . 20123

17. Urgent or emergent procedure? I f the surgical procedure is elective and should be postponed in favor of further evaluation and therapy. (If not urgent/emergent) Consider deferring procedure for optimization Multidisciplinary Inhaled Long term β -agonists + Inhaled corticosteroid  rapid relief of symptoms of bronchospasm S ystemic corticosteroids  severe, uncontrolled asthma Ipratropium bromide  second line for acute exacerbations, added to albuterol Leukotriene pathway modifiers, chromones, and methylxanthines are also used in the chronic treatment of asthma. If bronchial or pulmonary infection is present  antibiotics Kraus, George P. 2020. Asthma, dalam Bready, LL; Noorily , SH; Hickey, R. Decision Making in Anesthesiology . 5 TH edition. London : Jaypee Brothers Medical Publisher B C

18. N ebulized albuterol with or without ipratropium for the best chance of rapid improvement in respiratory mechanics, gas exchange, and reduced risk of reflex bronchospasm with intubation Lidocain (conflicting) S ubcutaneous epinephrine or terbutaline Start IV steroids early, as there is delayed benefit Consider other causes for wheezing and dyspnea, such as pulmonary embolism and heart failure. (If urgent / emergent) Optimize D

19. Favored induction agents : IV propofol, IV or IM ketamine, and inhalational sevoflurane Thiopental dapat menginduksi terjadinya bronkospasme akibat keluarnya histamin Etomidate  Vasodilatasi Sevoflurane, isoflurane, and halothane are potent bronchodilators, decrease airway responsiveness, and can attenuate bronchospasm D esflurane  pungency and airway irritant Nitrous oxide may be used in patients, but it does not have bronchodilatory effects. If muscle relaxants are needed, consider the use of agents that will not require antagonism with anticholinesterase agents, because the muscarinic properties of these antagonist drugs can promote bronchospasm Dexmedetomidine has been effectively used in asthmatics. Synthetic opioids, with the exception of meperidine, offer pain relief with minimal risk of histamine release.5 Intraoperative management E

20. Kontraksi dan relaksasi dari jalan napas dipengaruhi oleh sistem saraf otonom Yamakage M, Iwasaki S, Namini A. Guideline-oriented Perioperative Management of Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Journal of Anesthesia . 2008. Endotracheal Intubation F

21. Intraoperatif Refleks bronkospasme dapat ditumpulkan dengan beberapa cara : Mendalamkan anestesi dengan cara memberikan ventilasi selama 5 menit dengan 2-3 MAC Pemberian lidokain intravena atau intratrakeal 1-2 mg/kg. perlu menjadi perhatian bahwa lidokain intratrakea dapat menginisiasi bronkospasme apabila dosis induksi tidak adekuat . Dalam sumber lain IV lidocaine (1–1.5 mg/kg) Inhalational albuterol (2–4 puffs via metered-dose inhaler) 15 minutes sebelum induksi Pemberian agen antikolinergik dapat menghambat refleks bronkospasme namun memiliki efek samping takikardi Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018.

22. Intraoperatif Terjadi bronkospasme intraoperatif  pastikan penyebabnya bukan dari obstruksi mekanik pada breathing circuit, jalan napas, atau pada selang endotrakeal Obstruksi mekanik dari tube endotrakeal Kinking Sekresi Overinflasi dari cuff tube trakeal Kedalaman anestesi yang tidak adekuat Penurunan kapasitas fungsional paru Usaha napas Intubasi endobronkial   Aspirasi pulmoner   Edema pulmoner   Emboli pulmoner   Serangan asma akut   Jika sudah dipastikan penyebabnya merupakan asma , maka dengan mendalamkan anestesi akan menghilangkan bronkospasme Diagnosis banding dari bronkospasme Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018. Stoelting RK, Hines RL., & Marschall KE. Stoelting's anesthesia and co-existing disease. Chapter 9: Respiratory Disease . Elsevier. Ed. 5. 2018.

23. Intraoperatif Tanda terjadinya bronkospasme saat periode intraoperatif : meningkatkan peak inspiratory pressure dan penurunan volum tidal, serta wheezing, peningkatan gelombang pada kapnografi Gambaran gelombang kapnograf pada obstruksi jalan napas saat ekspirasi Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018.

24. Intraoperatif Pembiusan regional masih menjadi pilihan dibandingkan pembiusan umum Ventilasi dan oksigenasi arteri dipertahankan dengan penggunaan ventilator mekanik Pada pasien asma, laju inspirasi perlahan akan mengoptimalkan ventilasi dan perfusi Pemanjangan waktu ekshalasi dapat mencegah air trapping Pemberian cairan adekuat selama perioperatif  membantu hidrasi dan menurunkan viskositas sekresi lendir Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018.

25. Alternatives to intubation Avoid tracheal instrumentation by administering general anesthesia by mask or by laryngeal mask airway (LMA), local anesthesia , and regional anesthesia . Sedation is safe in asthmatic patients, as is the appropriate use of IV and neuraxial narcotic agents to treat pain. G

26. Postoperatif Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patient With Respiratory Disease. Morgan & Mikhails’s : Clinical Anesthesiology . McGraw-Hill Education. Ed 6. 2018. Applegate R, et al. The Perioperative Management of Asthma. Journal of allergy and Therapy . 20123 Shaikh SI, Nilangekar MT. Perioperative Anaesthetic management in Asthma. International Journal of Biomedical Research. Pg 144-150. 2015

27. Terima kasih.