Management of Asthma

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Management of Asthma

• Dr. Tara Husain

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Goals in management

• Patient education
• Assessment and monitoring of asthma severity
• control of asthma triggers
• Establishment of plans for therapy and
  management of exacerbations
• Management of comorbid conditions
• Maintain normal activity.
• Prevent sleep disturbance
• Prevent or minimize adverse effect of drugs

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Management components

• Assessment and monitoring
• Education
• Control of environmental factors and comorbid
  conditions
• Pharmacologic treatment

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Assessment and monitoring

• follow-up every 2-6 weeks is initially necessary
  (when gaining control of the disease)
• then every 1-6 months thereafter
• spirometry should be measured every 1-2 years, or
  more frequently for uncontrolled asthma

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Patient education

• Explain basic facts about asthma
• Address concerns about potential adverse effects
  of asthma medications
• Teach, demonstrate, and have patient show proper
  technique for inhaled medication and peek flow
  measurements.
• Written two-part asthma management plan dialy
  management and management of exacerbations.
• Regular follow-up visits

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Pharmacotherapy

• Drugs used for preventive therapy
• Drugs used for exacerbations

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Drugs used for preventive therapy

• Inhaled corticosteroids
• Long acting inhaled beta agonist drugs
• Luekoterine modifying agents
• Nonsteroidal anti-inflammatory agents
• Theophylin
• Systemic steroids (last choice)

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Inhaled corticosteroids

• e.g. Beclomethazon, budesonide
• extremely effective in management of
• asthma
• 1. They decrease airway hyperactivity
• 2-Decrease the need for rescue bronchodilator
  medication
• 3-Decrease emergency department visits due to
  asthma
• 4- Decrease mortality from asthma

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Side effects

• oral candidiasis.
• Dysphonia.
• Induce mucosal irritation and local
  immunosuppression.
• Doses gt 1mg/day may have some systemic side
  effects but these are significantly less than
  systemic steroids.
• Local side effects may be minimized by
• using a spacer for delivering the medication
• rinsing the oral cavity with water after use of
  these medications

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Long acting inhaled beta agonist drugs

• E.g. salmeterol, formoterole
• Used for daily controller medication not intended
  for use as rescue medication of acute asthma
  symptoms or exacerbations
• Uses
• as add-on agents in patients who are not well
  controlled on inhaled corticosteroid therapy
  alone.
• Patients with nocturnal asthma.
• Individuals who require frequent use of short
  acting beta agonist to prevent exercise induced
  asthma

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Luekoterine modifying agents

• Luekoterines are potent preinflammatory agents
  that can induce bronchospasm, mucous secretion
  and airway edema.
• There are two classes of luekoterine modifying
  agents
• 1-Inhibeters of luekoterine synthesis (zileuton)
  for childrengt12 years.
• 2- Luekoterine receptor antagonists.
  (Montelukast, Zafirlukast)

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• Actions
• - Bronchodilator.
• -Targeted anti-inflammatory properties.
• - Reduce exercise, aspirin and allergen induced
  bronchospasm
• USES
• Alternative medication for mild persistent
  asthma.
• -As add-on medication for moderate persistent
  asthma

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Nonsteroidal anti-inflammatory agents

• E.g Cromolyn and nedocromil
• Actions
• Inhibit allergen induced asthma response.
• Reduce exercise induced bronchospasm.
• These drugs are considered alternative
  anti-inflammatory drugs with mild persistent
  asthma.

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Theophylin

• Uses
• Bronchodilator.
• Anti-inflammatory affect.
• When used chronically decreased asthma symptoms
  and need for short acting beta agonist.
• Stimulates the respiratory center.
• Used as alternative monotherapy in patients with
  mild persistent asthma, its no longer used in
  small children

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• Theophylin has narrow therapeutic window so serum
  theophylin needs to be routinely measured
  specially in
• viral illness
• macrolid antibiotics
• cimitidin
• oral antifungal agents
• luekoterine synthesis inhibitors
• ciprofloxacillin

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Systemic corticosteroid

• These medications are used primarily to treat
  asthma exacerbations, and in rare cases as a
  controller medication in patients with sever
  disease who remain symptomatic despite optimal
  use of other asthma mediations. In these patients
  every attempt should be made to exclude
  co-morbid conditions and to keep oral steroid
  dose
• lt or 20mg every other day

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Side Effects

• Immediate mainly metabolic such as
  hyperglycemia, and salt and water retention.
• Chronic side effects Growth suppression,
  hypertension, Cataract, Cushing syndrome,
  depression

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Monoclonal Antibodies

• Omalizumab is a recombinant, DNA-derived,
  humanized IgG monoclonal antibody that binds
  selectively to human IgE on surface of mast cells
  and basophils
• It reduces mediator release, which promotes
  allergic response
• is indicated for moderate-to-severe persistent
  asthma in patients who react to perennial
  allergens in whom symptoms are not controlled by
  inhaled corticosteroids

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Types

• intermittent asthma
• persistent asthma

Mild
Moderate
Sever
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Mild Intermittent asthma

• Day time symptoms lt 2days/wk
• night symptomslt 2/months.
• Normal activity
• Normal FEV1 between exacerbations
• No daily treatment is needed

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Mild Persistent Asthma

• Day symptoms gt 2day/wk
• night symptoms gt2night/ month
• Minor limitation of daily activity
• Preferred treatment
• Low dose inhaled corticosteroid.

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Moderate persistent asthma

• Symptoms are usually daily
• night symptoms gt 1 night/ wk
• Preferred treatment
• Low medium dose inhaled steroid long acting
  beta agonist

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Sever persistent asthma

• Daily symptoms are continual and night time
  symptoms are frequent
• Preferred treatment
• High dose inhaled corticosteroid long acting
  beta agonist and if
• needed
• Corticosteroid tablets or syrup long term,
  multiple attempts should be made to reduce the
  dose

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Drugs used as acute reliever medication

• 1-Short acting beta agonist.
• 2- Inhaled anticholinergics.
• 3-Short cores systemic steroids

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Short acting beta agonists

• E.g. Albuterol, Salbutamol, levabuterol,
  turbutalin.
• They have rapid onset of action, and short
  duration of action(4-6) hours,
• Beta agonists are bronchodilators by
• 1-Smooth muscle relaxation.
• 3- decrease airway edema.
• 4-Improve mucocilliary action.

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• S.E Tremor, tachycardia, Pulmonary
  vasodilatation and ventilation perfusion
  mismatch.
• Leva-albuterol an R- isomer of albuterol has less
  side effects.

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Anticholinergic agents

• Ipratropuim promide is a bronchodilator lt
  effective than beta agonists.
• It is used in acute sever asthma in combination
  with beta agonists in form of inhaler
• It improves lung function and decreases the rate
  of hospitalization in patients presented to
  emergency department

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Systemic steroids in acute reliever medication

• Prednison, Prednisolone, or Methylprednisolone.
• systemic steroid are often given orally if the
  patient can tolerate oral intake in form of
  Prednisolone 2mg/kg/24hr not more than 60mg
• intravenous steroid given in form of decadron,
  hydrocortisone or Methylprednisolone, if oral
  preparations are not tolerated.

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Status asthmaticus

• is sever exacerbation of asthma not responding to
  standard methods of treatment.
• In these cases rapid assessment of severity of
  obstruction and assessment of risk of further
  deterioration is mandatory

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Goals of our treatments are

• Correction of hypoxia.
• Rapid improvement of airway obstruction.
• Prevention of recurrence of symptoms

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Treatment 1st - Humidified oxygen. 2nd - Inhaled
short acting beta agonist every20 min. for 1
hour ( 3 times with in 1 hour). 3rd_
systemic corticosteroid given orally or
intravenously according to the severity
of the case. 4th_ Ipratropuim promide may be
added to inhaled beta agonist if the
initial improvement with the first inhaled beta
agonist is not significant. 5th-
Subcutaneous or intramuscular injection of
epinephrine or I.V injection with
salbutalmol may be needed in sever cases,
oxygen should be given for at least 20 minutes
after the last injection to compensate
for ventilation perfusion mismatch caused
by beta agonists.
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6-Hydration status assessment is particularly
important in infants and young children, who have
increase insensible losses and at the same time
have syndrome of inappropriate anti-diuretic
hormone secretion fluid at or slightly bellow
maintenance may be needed. 7- In patient not
responding to previous measures mechanical
ventilation may be needed
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Chest physiotherapy and mucolytic agents are not
recommended during the early acute period
because it may provoke bronchospasm.
Adjuvant therapy used in critically ill patients
used now are Methylxanthines, Mg salphate,
Inhaled helioix.