Asthma Diagnosis, Treatment And Life Style Changes

Asthma Diagnosis, Treatment And Life Style Changes

Diagnostic test results:-

»Pulmonary function tests

»Peak expiratory flow rate (PEFR)

»Blood analysis, although not typically undertaken in asthma

»Pulse oximetry

»Arterial blood gas

»Respiratory acidosis

»Electrocardiogram (ECG)

»Chest radiograph.

Therapy:-

Treatment objectives:-

The goal of therapy is to provide symptomatic control with normalization of lifestyle and to reappearance pulmonary function as close to usual as likely.

 Reduce impairment:-

»Prevent chronic and troublesome symptoms day or night.

»Continue regular pulmonary function.

»Maintain normal activity planes, with exercise and attendance at work or school.

»Minimal use of short-acting inhaled β-2-agonist (less than two times per week) for quick relief of symptoms (not including use prior to exercise).

»Encounter patient and family expectations.





 Reduce risk:-

»Avoid repeated exacerbations and minimize need for ED hospitalizations or appointments.

»Inhibit loss of lung function.

»Provide optimal pharmacotherapy and with minimal or no adverse effects from medications.

 Management of acute asthma exacerbations:-

»Home-based treatment of an acute asthma exacerbation

»Treatment of an acute asthma exacerbation in the hospital or emergency department.

 Management of persistent asthma:-

»A stepwise approach to pharmacological therapy is suggested to gain and maintain control of asthma in together the injury and risk domains.

»At each step, patients must controller their environment to avoid or control factors, when possible, that make their asthma worse. This requires specific diagnosis and instruction.

»Inhaled steroids are considered to be first-line anti-inflammatory agents in asthma.

»Inhaled β-agonists such as albuterol and levalbuterol are used as needed for acute symptoms for all levels of severity.

»Daily or increasing use of a short-acting inhaled β-2-agonist suggests the need for additional long-term controller.

»Pretreatment with either an inhaled β-agonist, montelukast, or nedocromil may be used before exercise or allergen exposure.

»A rescue course of systemic corticosteroid (e.g., prednisone) may be needed at any time and at any step.

Prevention and treatment of exercise-induced bronchospasm (EIB):-

»Steps to prevent exercise-induced bronchospasm should be realized in all patients with asthma.

»Patients should be advised that a warm-up period might be helpful in preventing EIB.

»EIB can usually be prevented with one of the following options:

Short-acting β-agonists:- (e.g., albuterol) should be administered 15 mins before exercise. These are considered the drug of choice for EIB.

 Long-acting β-agonists: salmeterol (Serevent) and formoterol (Foradil) should be administered 30 to 60 mins before exercise of symptoms.

»Nedocromil may be used to prevent EIB and exacerbations related to exposure to other asthma symptomstriggers. Nedocromil should be administered no more than 1 hr before exercise or exposure.

»Leukotriene modifiers given daily help with EIB but should not be used on an as-needed basis just before exercise.

»Regardless of the prophylactic symptoms approach, all patients who experience EIB should have a shortacting β-agonist available for treatment of breakthrough symptoms.

Concurrent diseases:-

 Allergic rhinitis, sinusitis, and gastro esophageal reflux disease (GERD):- frequently coexist with asthma. Other notable comorbidities in asthma include vocal cord dysfunction (VCD) and obstructive sleep apnea. GERD symptoms is frequent in persons with obstructive lung disease.

Management of GERD with proton pump inhibitors (PPIs), such as pantoprazole can improve asthma symptoms and, in some patients, breathing tests. H2 antagonists, such as ranitidine are less effective than PPIs in this situation.

Therapeutic agents:-

Asthma Adults Doses        

Drug:-

Albuterol:-

Solution for nebulizer (NEB): 0.05 %( 5 μg /ml)

Asthma Acute:

Emergency for treatment (ET): 2.5-5.0 mg q20 minutes, then 2.5-10.0mg q1-4 hours or 10-15 mg/hours

Quick Response (QR): 1.25-5.00mg in 2-3 ml saline q4-8 hours

Asthma Chronic:- Not currently recommended

Metered dose inhaler (MDI): 0.09mg/puff

Asthma Acute:-

Emergency for treatment (ET): 4-8puffs q20minutes up to 4hrs ,then q1-4 hours

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT): 2puffs 5 minutes before exercise

Oral:– 4mg Sustained release

Asthma acute:-Not currently recommended

Asthma Chronic:-4mg q12 hours

Drug:

Biolterol:-

Solution for nebulizer (NEB): 0.2% 2(mg/ml)

Asthma Acute:-

Emergency for treatment (ET):2.5-5.0 mg q20 minutes ,then 2.5-10.0mg q1-4 hours or 10-15 mg/hours

Quick Response (QR): 0.5-3.5 mg in 2-3ml saline q4-8 hours

Asthma Chronic: – Not currently recommended

Metered dose inhaler (MDI): 0.37 mg/puff

Asthma Acute:

Emergency for treatment (ET): 2.5-5.0 mg q20 minutes, then 2.5-10.0mg q1-4 hours or 10-15 mg/hours

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT): 2puffs 5minutes before exercise.

Asthma Chronic: – Not currently recommended

Drug:-

Epinephrine:

Subcutaneous (SC): 1:1000 (1 μg /ml)

Asthma Acute:

Emergency for treatment (ET): 0.3-0.5 mg/dose q20 minutes x 3doses

Asthma Chronic: – Not currently recommended.

Drug:-

Formoterol:

Dry-powder inhaler (DPI): 12mg/caps for inhalation

Asthma Acute: Not currently recommended.

Asthma Chronic: 1 capsule q12 hours.

Drug:

Pirbuterol:

Metered dose inhaler (MDI): 0.2 mg/puff

Asthma Acute:-

Emergency for treatment ET: 4-8puffs q20minutes up to 4hours, then q1-4 hours

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT): 2puffs 5 minutes before exercise

 Asthma Chronic: – Not currently recommended.

Drug:

Salmeterol:

Metered dose inhaler (MDI): 0.025 mg/puff

Asthma Acute:- Not currently recommended.

 Asthma Chronic:- 2puffs/q12hours.

Dry-powder inhaler (DPI): 0.05mg/inhalation

Asthma Acute:- Not currently recommended.

Asthma Chronic:- 1inhalation q12hours.

Drug:

Terbutaline:

Metered dose inhaler (MDI): 0.2 mg/puff

Asthma Acute:-

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT): 2puffs 5 minutes before exercise

Emergency for treatment (ET): 0.25 mg q20 minutes x 3doses

Asthma Chronic:- Not currently recommended.

Subcutaneous (SC): 0.1% (1 μg /ml)

 Asthma Acute:-

Emergency for treatment (ET): 0.25 mg q20 minutes x 3 doses

 Asthma Chronic:- Not currently recommended.

Asthma Pediatric    

Drug:-

Albuterol:-

Solution for nebulizer (NEB): 0.05 %( 5 μg /ml)

Asthma Acute:

Emergency for treatment (ET): 0.15 mg/kg q20 minutes x 3doses, then 0.15-0.30 mg/kg up to 10 mg q1-4hours or 0.05 mg/kg/hours

Quick Response (QR): 0.05mg/kg in 2-3 ml saline q4-6hours

Asthma Chronic:- Not currently recommended

Metered dose inhaler (MDI): 0.09mg/puff

Asthma Acute:-

Emergency for treatment (ET): 4-8puffs q20minutes x 3doses, then q1-4hours with spacer

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT): 1-2puffs 5 minutes before exercise

Oral:– 4mg Sustained release

Asthma acute:-Not currently recommended

Asthma Chronic:-0.3-0.6 mg/kg/day

Drug:

Biolterol:-

Solution for nebulizer (NEB): 0.2% 2(mg/ml)

Asthma Acute:-

Emergency for treatment (ET): 0.15 mg/kg q20 minutes x 3doses, then 0.15-0.30 mg/kg up to 10 mg q1-4hours or 0.05 mg/kg/hours

Quick Response (QR): 0.5-3.5 mg in 2-3ml saline q4-8 hours

Asthma Chronic: – Not currently recommended

Metered dose inhaler (MDI): 0.37 mg/puff

Asthma Acute:

Emergency for treatment (ET): 4-8puffs q20 minutes x 3doses, then q1-4 hours with spacer

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT):1-2puffs 5minutes before exercise.

Asthma Chronic: – Not currently recommended

Drug:-

Epinephrine:

Subcutaneous (SC): 1:1000 (1 μg /ml)

Asthma Acute:

Emergency for treatment (ET):0.01mg/kg/dose up to 0.3-0.5mg  q20 minutes x 3doses

Asthma Chronic: – Not currently recommended.

Drug:-

Formoterol:

Dry-powder inhaler (DPI): 12mg/caps for inhalation

Asthma Acute: Not currently recommended.

Asthma Chronic: ≥ years 1 capsule q12 hours.



Drug:

Pirbuterol:

Metered dose inhaler (MDI): 0.2 mg/puff

Asthma Acute:-

Emergency for treatment ET: 4-8puffs q20minutes x 3doses,then q1-4 hours with spacer

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT): 1-2puffs 5 minutes before exercise

 Asthma Chronic: – Not currently recommended.

Drug:

Salmeterol:

Metered dose inhaler (MDI): 0.025 mg/puff

Asthma Acute:- Not currently recommended.

 Asthma Chronic:- >4years 12puffs/q12hours.

Dry-powder inhaler (DPI): 0.05mg/inhalation

Asthma Acute:- Not currently recommended.

Asthma Chronic:- >4 years 1inhalation q12hours.

Drug:

Terbutaline:

Metered dose inhaler (MDI): 0.2 mg/puff

 Asthma Acute:-

Quick Response (QR): 2puffs 3times/4times

Prophylactic treatment (PT): 1-2puffs 5 minutes before exercise

Asthma Chronic:- Not currently recommended.

 Subcutaneous (SC): 0.1% (1 μg /ml)

 Asthma Acute:-

Emergency for treatment (ET): 0.01 mg/kg q20 minutes x 3 doses then q2-6 hours.

 Asthma Chronic:- Not currently recommended.

β-Agonists:- albuterol, formoterol, arformoterol, levalbuterol, metaproterenol , pirbuterol, salmeterol

Therapeutic effects:- These sympathomimetic intermediaries release bronchoconstriction symptoms through severe asthma exacerbations as well as during chronic treatment and prevent exacerbations from occurring during exercise.

 Mechanism of action:-

»β2- Agonists stimulate β2-receptors, activating adenyl cyclase, which increases intracellular production of returning adenosine monophosphate (cAMP).

»Increased intracellular cAMP and activation of cAMP results in bronchodilation, improved mucociliary clearance, and reduced inflammatory cell mediator release.

»Stimulation of β2-receptors in symptoms of skeletal muscle accounts for tremor.

 Precautions and monitoring effects:-

»Common adverse effects of β-agonists include tremor, palpitation, tachycardia, nervousness, and headache. Leg cramps may occur with high doses owing to hypokalemia.

Corticosteroids:-

 Therapeutic effects:- Corticosteroids suppress the inflammatory response and lowering airway hyper responsiveness.

 Mechanism of action:- Corticosteroids bind to glucocorticoid receptors on the cytoplasm of cells. The activated receptor regulates transcription of target genes.

»Corticosteroids reduce inflammation via symptoms.

»increased transcription of anti-inflammatory genes that produce proteins that participate in or suppress the inflammatory process

»reduced production of inflammatory mediators

»decreased mucus production

»prevention, symptoms of endothelial and vascular leakage

»partial reversal of tissue-remodeling

 Precautions and monitoring effects:-

Systemic corticosteroids:-

»Careful monitoring is necessary in patients with diabetes, hypertension , adrenal suppression, congestive heart failure symptoms, peptic ulcer disease, candidiasis, immunosuppression, osteoporosis, chronic infections, cataracts, glaucoma, myasthenia gravis, and psychiatric diseases. Some of these side effects begin shortly after beginning systemic steroids (e.g., hyperglycemia), whereas others (e.g., osteoporosis) only occur with long-term use.

»If a prolonged course of systemic therapy is necessary to maintain asthma control, interference with the hypothalamic symptoms-pituitary-adrenal axis is lessened by a single morning dose. For alternate-day therapy, the dose is twice that of the single morning dose.

»Patients on regular systemic therapy should be closely monitored and should receive regular ophthalmological evaluations and osteoporosis screening, and preventative therapy (e.g., calcium, vitamin D, bisphosphonates) if indicated.

Cromolyn:-

 Therapeutic effects:- Cromolyn is currently only available as a nebulized solution for the treatment of asthma symptoms. Nedocromil and cromolyn MDIs have been removed from the market.

Cromolyn is less effective in its anti-inflammatory properties than the inhaled steroids, however, because of its excellent safety profile is sometimes still used in children.

 Mechanism of action:-Cromolyn is believed to act locally by stabilizing mast cells and thereby inhibiting mast cell degranulation.

Precautions and monitoring effects:-

Cromolyn is not effective during an acute asthma exacerbation. It should be used only for maintenance therapy of persistent asthma symptoms or for prevention of EIB.

»It is well tolerated, although paradoxical bronchospasm, wheezing, coughing, nasal congestion, and irritation or dryness of the throat may occur.

Drug delivery options:-

Metered Dose Inhalers (MDIs):-

Inhaler

Image Source: Inhaler

»When administered with good technique and a spacer, the efficacy of MDIs is similar to that of nebulizers, despite the lower doses administered with an MDI and spacer. The only MDI that comes with a built-in spacer is the Azmacort inhaler.

»For small children to be able to use an MDI, a spacer with a face mask must be used.

»MDIs can be difficult to use. Steps for properly using an MDI are outlined in.

»MDIs can be administered to patients on mechanical ventilation with the use of an attachment device designed for the mechanical ventilator circuit. Higher doses of the β2-agonist are oft en used in this setting.

»Breath-actuated MDIs require the patient to use a closed-mouth technique. When inhalation has begun, the medication is released automatically.

»This type of inhaler is useful for a patient who is having problems coordinating actuation and inhalation asthma symptoms .

 Spacers and holding chambers:- (e.g., Aero Chamber, Aero Vent, Ellipse, inspires, Optichamber)

»Spacers and holding chambers reduce the amount of drug deposited in the oral cavity.

»The use of spacers and holding chambers may minimize local and systemic adverse reactions.

»Addition of a spacer in a patient with poor MDI technique may improve pulmonary delivery of the agent.

»Spacers should be considered in all patients who are receiving medium-to-high doses of inhaled corticosteroids.

»They are especially beneficial for patients with poor hand–lung coordination, such as very young and old.

»Devices vary in construction and efficacy. The presence of a one-way mouthpiece valve, inhalation rate whistle, size, and durability are all factors that should be considered when selecting a particular spacer for a patient.

»Some new spacers have antistatic interiors to minimize adherence of aerosol particles to the interior of the spacer.

Nebulizers:-

»Compared to MDI and space administration, nebulizers require less patient coordination during administration of multiple inhalations.

»Disadvantages of nebulizers include cost, preparation and administration time, size of the device, and drug delivery inconsistencies among devices.

»Despite the disadvantages, nebulization is recommended for delivery of high-dose β-agonists and anticholinergic in severe exacerbations.

 Dry-powder inhalers:-

»Dry-powder inhalers (DPIs) are coming to the market as a result of the international move to avoid the use of chlorofluorocarbon (CFC) propellants. They are also being used more frequently because many patients find them easier to use than an MDI.

»Dry-powder inhalers require the user to

»first load the dose into the delivery chamber

»exhale fully

»inhale rapidly or slowly, depending on the device (versus only slow inhalation required for MDI administration)

»use the closed-mouth technique

»avoid exhaling into the mouthpiece before inhalation

»Spacers are not used with DPIs.

»Patients should be advised to keep these devices away from moisture.

 Non-pharmacological treatment:-

 Humidified oxygen:- is administered to all patients with severe, acute asthma to reverse hypoxemia. Although the fraction of inspired oxygen (Fio2) administered is based on the patient’s arterial

blood gas status, 1 to 3 L/min is generally given via face mask or nasal cannula. The goal is to keep the Sao2 >90% (>95% if the patient is pregnant or has heart disease.)

 Heliox:- is a mixture of helium and oxygen that has a lower density than air. Because of its decreased airflow resistance, heliox may increase ventilation during acute asthma exacerbations.

Because conflicting information has been published in studies using heliox, its role in asthma is unclear.

 Intravenous fluids:- and electrolytes may be required if the patient is volume depleted.

 Environmental control:- and allergen avoidance are important in the management of a patient with asthma symptoms.

»Available data suggest that avoidance of known allergens can improve asthma control.

»Some measures include use of allergen-resistant mattress and pillow encasements, use of high filtration vacuum cleaners, removal of carpets and draperies, and avoidance of furry pets.

 Inoculations:- (e.g., influenza virus, polyvalent pneumococcal) are recommended to prevent infection,  which may precipitate an exacerbation.



Conclusion:-

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