MONITOR RESPONSE TO TREATMENT

 Evaluate symptoms and peak flow.

 Assess oxygen saturation.
 Consider arterial blood gas measurement in the patients with suspected
hypoventilation, exhaustion, severe distress, or peak flow 30-50 percent
predicted.

BUDESONIDE: Parameters to monitor

 Signs and symptoms of acute adrenal insufficiency, particularly in
response to stress.
 Changes in nasal mucosa in patients on long-term drug therapy.
 Signs of localized infection in mouth and pharynx, (eg. red membranes
with vesicular eruptions). Treat with appropriate antifungal drug (eg.
nystatin, or discontinue treatment.)
 When switching from systemic inhalation therapy, monitor patient for
symptoms of adrenal insufficiency: hypotension, weight loss, muscular
and joint pain. If these occur, the dose of systemic steroid should be
increased followed by slower withdrawal. It may require up to 12 months
for HPA function to fully recover.

SALBUTAMOL: Parameters to monitor

 Monitor patient for possible development of tolerance with prolonged
use. Discontinue drug temporarily and effectiveness will be restored.
 Signs of paradoxical bronchospasm.
 Pulmonary function on initiation and during bronchodilator therapy.
Assess respiratory rate, sputum character (color, quantity), peak airway
flow, O2 saturation and blood gases.
 Efficacy of treatment: Improved breathing, prevention of bronchospasm,
reduction of asthmatic attacks, prevention of exercise-induced asthma. If
no relief is obtained from 3–5 aerosol inhalations within 6–12 hours, re-
evaluate effectiveness of treatment.
 FEV1 rate to determine effectiveness of the drug to reverse
bronchostriction. Efficacy is indicated by an increase in FEV1 of 10–20%.
In addition such patients, as well as those who have chronic disease,
should be given a peak flow gauge and told to determine peak expiratory
flow rate at least twice daily.

MONITORING TO MAINTAIN CONTROL

On going monitoring is essential to maintain control and establish the lowest step
and dose of treatment to minimize cost and maximize safety.

Patients should be seen one to three months after the initial visit, and every three
months thereafter. After an exacerbation, follow up should be offered within two
weeks to one month.
At each visit, ask the questions listed the table.

QUESTIONS FOR MONITORING ASTHMA CARE

IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALS
Ask the patient: Action to consider:
Has your asthma awakened you at night? Adjust medications and management
Have you needed more reliever medications plan as needed (step up or down).
than usual? But first, compliance should be
Have you needed any urgent medical care? assessed.
Has your peak flow been below your
personal best?
Are you participating in your usual physical
activities?
IS THE PATIENT USING INHALERS, SPACER, OR PEAK FLOW METERS CORRECTLY?
Ask the patient: Action to consider:
Please show me how you take your Demonstrate correct technique.
medicine. Have patient demonstrate back.
IS THE PATIENT TAKING THE MEDICATIONS AND AVOIDING RISK FACTORS
ACCORDING TO THE ASTHMA MANAGEMENT PLAN?
Ask the patient, for example: Action to consider:
So that we may plan therapy, please tell me Adjust plan to be more practical.
how often you actually take the medicine. Problem solve with the patient to
overcome barriers to following plan.
What problems have you had following the
management plan or taking your medicine?

During the last month, have you ever

stopped taking your medicine because you
were feeling better?
DOES THE PATIENT HAVE ANY CONCERN
Ask the patient: Action to consider:
What concerns might you have about your Provide additional education to
asthma, medicines, or management plan? relieve concerns and discussion to
overcome barriers.

ADJUSTING MEDICATION

 If asthma is not controlled on the current treatment regimen, STEP UP

TREATMENT. Generally, improvement should be seen within 1 month. But
first review the patient’s medication technique, compliance, and avoidance of
risk factors.
 If asthma is partly controlled, consider STEPPING UP TREATMENT,
depending on whether more effective options are available, safety and cost
of possible treatment options, and the patient’s satisfaction with the level of
control achieved.
 In control is maintained for at least 3 months, STEP DOWN with a gradual,
stepwise reduction in treatment. The goal is to decrease treatment to the
least medication necessary to maintain control.

 Monitoring is still necessary even after control is achieved, as asthma is a

variable disease; treatment has to be adjusted periodically in response to loss
of control as indicated by worsening symptoms or the development of an
exacerbation.