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It is defined as a dispersion or suspension of solid particles or liquid droplets in a gaseous medium, typically air or oxygen for medical aerosols.
Aerosol :
Particle form 1. Pure solution spherical 2. Suspension non spherical Medicinal therapeutic aerosol : heterogenous Particle size MMAD = Mass median aerodynamic diameter MMAD (dae) = d (p/p0) d : particle diameter, mm p : particle density, g/cm3
Ukuran partikel > 5 mm < 5 mm fine particle fraction 0.1-1 mm Sub micronic particle Bersifat gas Dapat menembus masuk ke dalam jaringan paru melalui epitel
DIFFUSION
1.00 SMOG
SEDIMENTATION
INERTIAL IMPACTION
FOG
POLLEN & FUNGAL SPORES
DEPOSITION FRACTION
0.80
0.60
VIRUS
BACTERIA
0.40
FUMES
DUSTS
0.20
0 0.05 0.1 0.2 0.5 1.0 2.0 5.0 10.0 20.0 50.0
PARTICLE SIZE
IMPACTION
> 10 m
Nasal cavity
SEDIMENTATION
5-10 m
Trachea
Primary bronchus
2-5 m
SEDIMENTATION + DIFFUSION
Secondary bronchus
Terminal bronchus
<2m <2m
Alveoli
Respiratory bronchiole
Alveolar Ducts & Sacs
DIFFUSION
Particles penetrate the respiratory tract to different degrees according to their size. This diagram also depicts the mechanisms that operate to clear particles from the Respiratory tract according to size Kendig 1998
Deposition
Impaction Sedimentation Diffusion Electrostatic
Tujuan tatalaksana
Anak dapat menjalani aktivitas normal termasuk olahraga sesuai dengan anak sebaya Sesedikit mungkin angka absensi sekolah Gejala tidak timbul siang ataupun malam Uji fungsi paru senormal mungkin, tidak ada variasi diurnal yang mencolok pada PEF Kebutuhan obat seminimal mungkin, kurang dari sekali dalam dua tiga hari, dan tidak ada serangan Efek samping obat dapat dicegah
Tujuan ini dicapai dengan pengendalian inflamasi dan dengan demikian diharapkan juga dapat mencegah terjadinya airway remodeling Steroid masih merupakan obat antiinflamasi yang terkuat dan terbanyak dipakai Early intervention diharapkan lebih dapat mencegah adanya airway remodeling dengan demikian faal paru menjadi lebih baik
Wheezing Prevalence
Transient Wheezing
Non-atopic Wheezers
Asthma
Age in years
11
Bronkodilator (SABA) PRN + LABA/LTRA + Low dose ICS 400 mg Budesonide / setara
Bronkodilator Bronkodilator (SABA) PRN (SABA) PRN + + LABA/LTRA LABA/LTRA + + High dose ICS Middle dose > 800 mg ICS Budesonide / 400-800 mg setara Budesonide / setara
bila perlu
4-6 minggu obat, dosis/dosis
> 3x
< 3x
1-3 bl
(-)
(+)
1-3 bl
Obat pengendali dengan steroid hirupan Dosis 200-400 mg Obat pereda: diberi bila perlu 6-8 minggu, respons
P E N G H I N D A R A N
Step up
(-)
(+)
1-3 bl
(-)
(+)
1-3 bl
Asma persisten
ICS 400-600 mg Tambahan salah satu obat : b-agonis kerja panjang b-agonis lepas terkendali Teofilin lepas lambat Antileukotrin
(-)
(+)
1-3 bl
(-)
(+)
1-3 bl
P E N G H I N D A R A N
Step down
Catatan : *) Ketotifen/cetirizin dapat ditambahkan pada pasien asma yang disertai rinitis
Reliever (pereda) pMDI / dengan spacer Nebuliser pMDI / dengan spacer Nebuliser pMDI / dengan spacer DPI Nebuliser
Controller (pengendali) pMDI / dengan spacer Nebuliser pMDI / dengan spacer Nebuliser DPI (?) pMDI / dengan spacer DPI
3-5
>5
Mechanisms of deposition within the respiratory tract. A, Impaction. B, Sedimentation. C, Diffusion Pediatric Respiratory medicine
1-degree droplets
To patient
Baffle
Feed tube
Inspiration
600 400
Flow (ml/s)
Adult
Child
Infant
Air Entrainment
Nebulizer flow rate 61 breaths/min
Time
Amount of nebulizer output inspired (Vn) Total nebulizer output in a single breath (Ttot x nebulizer flow rate)
Expiration
Figure. Effect of air entrainment on medication delivery. Aerosol concentration is greatest at low tidal volumes and is reduced by entraining air at higher tidal volumes. Ti : Inspiratory time; Ttot : time for one breath
Collis GG, et al. Lancet 1990; 336: 341-343
Driving Gas flow Rate of Drug output Volume in which drug output is distributed Aerosol concentration Volume of aerosol available for inhalation
Solution concentration
Tidal volume
Rate of drug delivery to an adult % of droplet mass in respirable range Rate of drug delivery to lower respiratory tract of an adult
Figure. Factors influencing the rate of medication delivery from jet nebulizers.
Everard ML, et al. Thorax 1995; 50:517-519
Environment
Genes
Initiation
Atopy
Epithelial Susceptibility
T-lymphocytes
Propagation
IL-4/IL-13 TGF-bhigh
IL-4/IL-13
Myofibroblast activation
Growth factors Cytokines and chemokines
Amplification
Inflammation
Atopic asthma
Steroid sensitive
CHRONIC ASTHMA
Holgate ST, et al. JACI 2003; 111(2):215