ASTHMA.

Principles of Clinical care

Treatment of Asthma

 Four classifications of asthma used to

develop a treatment plan.
-Mild intermittent asthma
-Mild persistent asthma
-Moderate persistent asthma
-Severe persistent asthma
Mild intermittent

 Symptoms occur on average less than

twice a week
 No symptoms and normal peak flow in
between attacks
 Night symptoms< than twice a month
 FEV1 OR PEF greater 80% of predicted
value
 PEF variability < 20%
Mild persistent asthma

 Symptoms < twice a week

 Exacerbation affect activity
 Night time symptoms occur > twice a
month
 FEV1 or PEF > than 80%
 PEF variability 20 –30%
Moderate persistent asthma

 Daily symptoms
 Daily use of short acting beta 2 agonist
 Exacerbation more than twice a week
 Night time symptoms more than twice a
week
 FEV1 or PEF > than 60% but < 80%
 PEF variability >30%
Severe persistent asthma

 Continual symptoms
 Exacerbations limit physical activity
 Frequent nighttime symptoms
 FEV1 or PEF <60% of predicted value
 PEF variability greater than 30%
Pharmacological therapy
 Goal
 Prevention of

- chronic symptoms
-recurrent exacerbation
-emergency room visits and
hospitalisation
-maintenance of normal lung function and
normal activity
-Avoidance of side effects
Classes of medication

 Mainly two classes

-Quick relief medicine
- Long term control medicine
+ Medication for allergy control
1.Quick relief medication

 Short acting bronchodilators

 Stop the symptoms of an attack
 Taken when you have symptoms eg
cough ,shortness of breath or tightness
of chest
 To prevent an attack
Short acting beta agonist

 Work within minutes

 Last for 4-6 hours
 Salbutamol
 Albuteral
Anticholinergic agents

 Ipratropium bromide- Atrovent

 Immediate relief
 Very effective at reducing the
secretions
 Children with Bronciolitis and the
elderly
Oral and IV corticosteroids

 Prednisolone and hydrocortisone

 Acute or very severe asthma
 Few hour or days to be fully effective
 Long term use have serious side
effects-cataracts, osteoporosis,
reduced resistance to infection,
hypertension oral thrush
2. Long term control
medication
 Taken every day
 Long term
 Control of persistent chronic
symptoms
Inhaled Steroids

 Anti-inflammatory drugs
 Most effective
 Reduce the inflammation in the airways-both
swelling and secretions
 Decrease the frequency of attacks and need
for other drugs
 Lower risk of side effect- direct effect+ lower
dose
 Fluticasone,budesonide, beclomethasone
Long acting beta-2 agonist

.Bronchodilators
.Last for at least 12 hours
. Control of moderate to severe symptoms
. Prevent nighttime symptoms
.Used on a regular basis with inhaled steroids
. Not to be used as main treatment
.Salmeterol (Serevent)
Leukotriene modifiers

 Block action of leukotrienes in the lungs

 Therefore reduce inflammation
 Montelukast (Singulair), zafirlukast
(Accolade)
 Used with other medication eg. Inhaled
steroids
Chromolyn and nedocromil

 Not effective in everyone

 May help prevent mild to moderate
attacks
 May be useful in exercise induced
asthma
 Inhaled cromolyn( Intal)
Theophyllines

 Daily tabs help relieve night symptoms

 Side effect major concern- palpitation,
restlessness, vomiting,diarrhea,
confusion
 Regular drug levels needed
Asthma triggered by allergies

 These focus on treating the allergy

 a) Immunotherapy-densesitization
 -determine allergen the small doses of
allergen given weekly
 b) Anti-IgE monoclonal antibodies
 -Block the action of IgE
 Omalizumab (Xolair)
Bronchial thermotherapy

 Experimental therapy for severe asthma

 Theory that there is overgrowth of
smooth muscle in the airways
 Heat is therefore applied to the muscle
using a bronchoscope
 Heat alters the contractility of the
muscle
 Step wise approach to chronic
Class
asthma treatment
Long term control Quick relief

Mild intermittent None Bronchodilator

prn/ 3-4 /day
Mild persistent Cromolyn, low dose inhaled Bronchodilator
steroid,leukotrienes prn/3-4/day

Moderate persistant Medium dose inhaled steroid Bronchodilator

alone and with cromolyn or prn/3-4.day
long acting beta 2 agonist or
theophyllines
Severe persistant High dose inhaled steroids. Broncodilators
Oral steroids or high dose prn/3-4 /day
steroids plus long acting
bronchodilator plus leukotriene
modifiers
Delivery methods

 Metered dose inhaler (MDI)

 Breath actuated MDIs
 Dry powder inhalers
 Nebulizers
Acute Asthma
 High flow oxygen
 Nebulised Salbutamol using high flow
oxygen- Can be given up to half hourly
 Steroids-iv hydrocortisone, short course
predinisolone
 Aminophylline iv start over 20 minutes then
infusion infusion
 Iv Salbutamol no advantage over nebulised
delivery but can be added in life threatening
situations
Benefit obtained by adding iv Ipratropium
bromide