Last edited: 9/10/2021

1. ASTHMA TREATMENT AND PREVENTION

Asthma Treatment and Prevention Medical Editor: Dr. Sofia Suhada M. Uzir

OUTLINE (B) LOW DOSE ICS

Inhaled corticosteroids
I) COMMON DRUGS USED IN ASTHMA
II) OTHER DRUGS (1) Forms of corticosteroids
III) TYPES OF ASTHMA
Per oral (PO)
IV) ACUTE EXACERBATIONS
V) REVIEW QUESTIONS Intravenous
VI) REFERENCES Inhaled
Intranasal
(2) Drugs
Inhaled DPI
I) COMMON DRUGS USED IN ASTHMA o Fluticasone
o Budenoside
(A) SABA o Mometasone
Short acting beta 2 agonist (3) Mechanism of action
(1) Forms Very good at reversing inflammation
Decrease inflammation by inhibiting
Inhaled
o Release of cytokines
o Meter dose inhaler (MDI)
o The activation of other WBCs
 Using spacer helps the drugs to go into the with
o Chemotaxis
less medication ending up the mouth/throat
WBC release cytokines → activate other WBCs to
Dry powder inhaler (DPI)
undergo migration and chemotaxis to the inflamed area
Nebulizers
(4) Adverse drug reactions
(2) Drugs
Candidiasis
Albuterol
o Fungal infection causing oral thrush → white mucous
Levalbuterol
patches which usually appears on the tongue
o Lower dose of SABA
o Causes red inflammation if peeled off
(3) Mechanism of action Systemic side effects of corticosteroids
Bind to beta 2 adrenergic receptors in the airways → o Hypertension
epinephrine / norepinephrine causes vasodilatation o Hyperglycemia
→ bronchodilation o Sodium retention
o Depress immune system
(4) Adverse drug reactions
(5) Precautions
May affect other tissues
o Heart Always gargle and rinse off mouth with water and spit it
 Tachyarrhythmias out to avoid candidiasis
o Skeletal muscle
 Tremors Remember:
o Cerebral blood flow The best treatment and very crucial protocol for asthma is
 Dizziness CCS

(5) Contra indications

In patients with cardiac abnormalities (C) LABA
o Heart block
Long-acting beta 2 agonists
Narrow angle glaucoma Black box warning:
o Effects ciliary muscles → occlude canal of Schlemm / o Never for acute exacerbations
scleral venous sinus → increase IOP → causes the  Can make it worse
lens to protrude more forward o Never give without inhaled ccs, even if it is a low dose
of LABA
Remember: Used for treating symptoms long term
Smooth muscle has 2 types of receptors:
o Muscarinic receptors (1) Drugs
o Beta receptors Formoterol
Salmeterol
Can give in combinations of CCS +LABA

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 (D) CORTICOSTEROIDS PO/IV (B) LEUKOTRIENE RECEPTOR ANTAGONIST (LTRA)
Mainly used for short term Alternative for atopic patients
o Acute exacerbation/not properly responding to
(1) Montelukast
treatment
Bind to leukotrienes receptors → inhibit the action of
(1) Drugs
leukotrienes including inhibition of
Per Oral (PO) / intravenous (IV) forms o Vascular permeability
o Methylprednisolone (PO/IV) o Bronchospasm
o Prednisone o Mucous productions
o Prednisolone Adverse drug reaction
(2) Systemic adverse effects o Suicidal attempts

Hypertension (C) THEOPHYLLINE

Hyperglycemia Used in COPD who needs diaphragmatic arrest
Sodium retention
Depress immune system (D) OMALIZUMAB
Destruct muscle and bones Used in severe stages asthma particularly allergic
induced
II) OTHER DRUGS
It is an anti-IgE antibody → can bind on to IgE antibody
In replacement of low dose ICS/ medium dose ICS / Helps with inhibition of
LABA o bronchospasm
o Mucus productions
(A) MAST CELL STABILIZERS o Vascular permeability
Alternative for atopic patients IgE bind to mast cells and stimulate them to undergo
o Atopic dermatitis degranulation → producing mass amounts of histamines
o Allergic rhinitis associated with asthma and leukotrienes
(1) Cromolyn sodium Drawbacks
o Very extensive
Exercise or cold induced asthma o Need to visit the doctors every 2-4 weeks to get it
Mechanism of actions
o Inhibit histamine produced by mast cells
o Inhibit activation of eosinophils

III) TYPES OF ASTHMA

Table 1. Classification of asthma based on symptoms

FEV1
FREQUENCY OF FRREQUENCY OF
TYPE (Between MEDICAL PROTOCOL
DAY SYMPTOMS NIGHT SYMPTOMS
exacerbations)

Intermittent <2 times per week <3 times per month > 80% SABA (PRN)

SABA (PRN)
Mild >2 times per week 3-4 times per month ≥ 80%
Low dose ICS
SABA (PRN)
+
Moderate > 7 times per week 1 or more per week 60 - 80% Medium dose ICS
Or
Low dose ICS + LABA
From level of severity (lowest → highest)

a. SABA (PRN) + Medium dose ICS

Every night
Every day + LABA
Severe throughout the < 60%
throughout the day b. SABA (PRN) + high dose ICS + LABA
night
c. SABA (PRN) + high dose ICS + LABA
+ PO corticosteroids

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 (5) Situation 5
IV) ACUTE EXACERBATIONS
Vital signs
(A) POSSIBLE TESTS o O2 <92%
o Not hyperventilating/ normal RR/ very low
(1) Peak expiratory flow rate (PEFR) o No wheezing
Normal >70% of the range based upon age, gender, Investigations
height o PEFR <25%
o ABG
(2) Arterial blood gas (ABG)
 Elevated partial pressure CO2
Measures the • Complete obstruction → respiratory acidosis
o pH
Must treat the patient immediately with supplemental
o Partial pressure of oxygen
oxygen
o Partial pressure CO2
o Bicarbonate concentration (C) EMERGENCY TREATMENT
Determines if the patient is in The measures should be taken in emergency situation
o Respiratory acidosis include:
o Respiratory alkalosis
o Metabolic acidosis (1) Non rebreather supplemental oxygen
o Metabolic alkalosis The oxygen must be > 92 %
Non rebreather pushes a lot of oxygen in as compared to
(B) POSSIBLE SITUATIONS
venturi / nasal cannula
(1) Situation 1
(2) Put on short acting drugs
Patient improve on SABA → discharge without further
investigations/treatments (i) Through nebulizer or inhaler
o Not necessary to do ABG SABA (albuterol) + Ipratropium bromide through
(2) Situation 2 Ipratropium bromide is a short acting muscarinic
antagonist
Patient doesn’t readily improve on SABA o Anticholinergic
Investigations:  Binds to muscarinic receptors preventing
o PEFR 50-70% acetylcholine from binding → inhibit smooth
o Might want to do ABG muscle contraction
 If they have underlying chronic lung disease
 Partial pressure CO2 will be lower (ii) Intravenous methylprednisolone or oral
• Breathing off CO2 (hyperventilate) prednisolone
Treat with SABA by a nebulizer If inhaled SABA + Ipratropium bromide doesn’t work
(3) Situation 3 Very short period of time to reverse the inflammation

Vital signs (iii) Intravenous magnesium sulphate

o Respiratory rate > 20-25 / min
o Hear rate >100-110 beats per min (tachycardia)
o Difficulty in completing sentences
Investigations
o PEFR 25-50% (severe asthma)
o Definitely do ABG
 Low partial pressure CO2 due to
hyperventilation
(4) Situation 4
If no adequate response to IV methylprednisolone/oral
prednisolone
Magnesium sulphate block calcium channels of the
smooth muscle → inhibit contraction → very intense
smooth muscle dilatation
(3) Positive pressure ventilation
If the above doesn’t work
CPAP

Vital signs (4) Intubate

o Pulse oximeter Endotracheal
 O2 saturation <92% The last resort
o Not hyperventilating/ normal RR/ very low
o No wheezing (5) Discharge

Investigations After successful treatment, discharge the patient with

o PEFR < 25 % tapering dose of oral corticosteroid
o ABG
 Normal partial pressure CO2
• Complete airways obstruction → CO2 build
up → near fatal exacerbation

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 V) REVIEW QUESTIONS 10) Which of the following statements regarding short-
acting inhaled β2-agonists is the most correct?
1) The mechanism of action of beta 2 receptor agonist a) Regular use of short-acting inhaled β2-agonists
in the bronchial asthma include all pf the following worsens asthma, increasing the morbidity from
except asthma
a) Relaxation of airway smooth muscle b) Regular use of short-acting inhaled β2-agonists
b) Inhibition of plasma exudation and airway edema increases the risk of death and near death from
c) Increased mucociliary clearance asthma
d) Increasing the release of mast cell mediator c) Short-acting inhaled β2-agonists should be used as
2) The most common side effects of beta- 2 agonists needed so that their use can be employed as an
are outcome measure
a) Dry mouth, urinary retention, and glaucoma d) Regular use of short-acting inhaled β2-agonists
b) Muscle tremor and palpitations produces tolerance so that patients will not respond
c) Nausea and vomiting, and headaches during acute exacerbations
d) Hoarseness (dysphonia) and oral candidiasis CHECK YOUR ANSWERS
3) Cromolyn sodium and nedocromil sodium are
asthma controller drugs that appear to: VI) REFERENCES
a) Act by anti-inflammatory properties ● Sabatine MS. Pocket Medicine: the Massachusetts General
b) Inhibit phosphodiesterase in airway smooth-muscle Hospital Handbook of Internal Medicine. Philadelphia: Wolters
Kluwer; 2020.
cells
● Le T. First Aid for the USMLE Step 1 2020. 30th anniversary
c) Inhibit mast cell and sensory nerve activation edition: McGraw Hill; 2020.
d) Prevent cholinergic nerve–induced ● Williams DA. Pance Prep Pearls. Middletown, DE: Kindle Direct
bronchoconstriction and mucus secretion Publishing Platform; 2020.
● Papadakis MA, McPhee SJ, Rabow MW. Current Medical
4) Acute management of bronchial asthma include all Diagnosis &amp; Treatment 2018.
● New York: McGraw-Hill Education; 2017.
the following, EXCEPT: ● Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL,
a) A high concentration of oxygen to achieve oxygen Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth
saturation of >90% Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical; 2018
● Marieb EN, Hoehn K. Anatomy & Physiology. Hoboken, NJ:
b) Short-acting inhaled beta-2-agonists
Pearson; 2020.
c) A slow infusion of aminophylline with monitoring ● Boron WF, Boulpaep EL. Medical Physiology.; 2017
blood values
d) A rapid infusion of dopamine
5) Which of the following drug is NOT available as
metered-dose inhaler (MDI?
a) Salbutamol
b) Terbutaline
c) Albuterol
d) Aminophylline
6) Beclomethasone dipropionate is commonly
administered as:
a) Intravenously
b) Subcutaneously
c) Aerosolized steroids
d) oral preparation
7) Which of the following drugs is leukotriene-
modifying drug indicated in the management of
bronchial asthma?
a) Triamcinolone acetonide
b) Budesonide
c) Zafirlukast
d) Flunisolide
8) Salbutamol is a
a) Corticosteroid
b) Alpha-adrenergic receptor agonists
c) Beta-adrenergic receptor agonist
d) Anticholinergic
9) Which of the following is the primary long-term
controller medication for a 5-year-old girl with
moderate persistent asthma?
a) Salmeterol twice daily
b) Fluticasone propionate twice daily
c) Sustained-release theophylline twice daily
d) Montelukast once daily

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