All patients on inhaled drugs should have their inhalation technique evaluated

monthly initially and then every 3 to 6 months.

• After initiation of antiinflammatory therapy or increase in dosage, most patients

should experience decreased symptoms within 1 to 2 weeks and achieve maximum

improvement within 4 to 8 weeks. Improvement in baseline FEV1 or PEF should follow a similar time
course, but decrease in BHR as measured by morning PEF, PEF

variability, and exercise tolerance may take longer and improve over 1 to 3 months.

9.

NONPHARMACOLOGIC THERAPY

• Patient education is mandatory to improve medication adherence, self-management

skills, and use of healthcare services.

• Objective measurements of airflow obstruction with a home peak flow meter may not

improve patient outcomes. NAEPP advocates PEF monitoring only for patients with

severe persistent asthma who have difficulty perceiving airway obstruction.

• Avoidance of known allergenic triggers can improve symptoms, reduce medication

use, and decrease BHR. Environmental triggers (eg, animals) should be avoided in

sensitive patients, and smokers should be encouraged to quit.

• Patients with acute severe asthma should receive oxygen to maintain PaO2 greater

than 90% (>95% in pregnancy and heart disease). Dehydration should be corrected;

urine specific gravity may help guide therapy in children when assessment of hydration status is difficult.

PHARMACOTHERAPY

β2-Agonists

• Short-acting β2

-agonists (Table 77–1) are the most effective bronchodilators. Aerosol

administration enhances bronchoselectivity and provides more rapid response and

greater protection against provocations (eg, exercise, allergen challenges) than systemic administration.

• Albuterol and other inhaled short-acting selective β2

-agonists are indicated for intermittent episodes of bronchospasm and are the treatment of choice for
acute severe

asthma and EIB. Regular treatment (four times daily) does not improve symptom

control over as-needed use.

• Formoterol and salmeterol are inhaled long-acting β2

-agonists for adjunctive longterm control for patients with symptoms who are already on low to medium
doses

of inhaled corticosteroids prior to advancing to medium- or high-dose inhaled corticosteroids. Short-

acting β2

-agonists should be continued for acute exacerbations.

Long-acting agents are ineffective for acute severe asthma because it can take up to 20

minutes for onset and 1 to 4 hours for maximum bronchodilation.

• In acute severe asthma, continuous nebulization of short-acting β2

-agonists (eg, albuterol) is recommended for patients having unsatisfactory response after three doses

(every 20 min) of aerosolized β2

-agonists and potentially for patients presenting initially with PEF or FEV1 values less than 30% of
predicted normal.

 Inhaled β2

-agonists agents are the treatment of choice for EIB. Short-acting agents

provide complete protection for at least 2 hours; long-acting agents provide significant protection for 8
to 12 hours initially, but duration decreases with chronic

regular use.

• In nocturnal asthma, long-acting inhaled β2

-agonists are preferred over oral

sustained-release β2

-agonists or sustained-release theophylline. However, nocturnal

asthma may be an indicator of inadequate antiinflammatory treatment.