Treatment of asthma :

1
Treatment of asthma

• Avoiding allergens.
• Hyposensitization Subcutaneous injections of
  inially very small, but gradually increasing
  doses of allergens (desensitization or
  immunotherapy ) .
• Drugs .

2
Drug treatment

• Can be divided in to 2 general categories
• 1- Quick relief medications Drugs that act as
  relaxants of tracheobronchial smooth muscle
  (bronchodilators )
• ß- adrenergic agonists, methylxonthines
  anticholinergics .
• 2- Long term control medications (Agents that
  prevent /or reverse inflammation )
• glucocorticoids, leukotriene inhibitors
  receptor antagonists , cromolyn sodium ,
  nedocromils

3
1- Adrenergic stimulants

• A- Short acting ß-adrenergic(ß2 selective)
  agonist
• Salbutamol, Terbutaline, Metaproterenol,
• Pirbuterol , bitolterol.

B- Long acting ß-adrenergic(Bselective)agents
salmeterol , fenoterol formoterol C-
Other adrenergic agonists Catecholamines
adrenaline .
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• 2-Methylxanthines(phosphodiesterase inhibitor )
• Theophylline
• 3-Anticholinergic agent
• Ipratrupium bromide and atropin.
• 4- glucocorticoids
• For treatment of asthma it is available as
  inhalation, tablets , syrup injections .
• Inhaled corticosteroid
• -Preparations available are beclomethasone,
  budesonide, flunisolide, fluticasone
  ,triamcinolone .
• Side effects of inhaled steroid
• oral candidates, glossitis , sore throat ,
  hoarseness ,dysphonia, increase systemic
  absorption with large doses of inhaled steroid
  (produce adrenal suppression, cataract, decrease
  growth in children .).

5

• 5-mast cell stabilizing agents
• Cromolyn sodium Nedocromil sodium.
• 6-Antileukotrienes
• Zafirlukast Montelukast ( leukotriene
  receptor antagonist )
• Zileuton (inhibitor of leukotriene synthesis
  ).
• 7- Antihistamines
• Astemizole Terfenadine
• 8- Ketotifen

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9-Other agents

• Steroid dependent pt. might benefit from the use
  of immunosuppressant agents (used as steroid
  sparing agents),like
• Methotrexate, Gold salt, cyclosporine .
• Methotrexate, Gold salt may produce lung toxicity
  .
• Have limited role in the manegement off asthma.
• Not used as standered therapy for asthma .

7
Omalizumab

• MECHANISM OF ACTION  Omalizumab is an IgG
  monoclonal antibody which inhibits IgE binding to
  the IgE receptor on mast cells and basophils. By
  decreasing bound IgE, the activation and release
  of mediators in the allergic response (early and
  late phase) is limited.
• Long-term treatment in patients with allergic
  asthma showed a decrease in asthma exacerbations
  and corticosteroid usage.
• USE  Treatment of moderate-to-severe, persistent
  allergic asthma not adequately controlled with
  inhaled corticosteroids
• CONTRAINDICATIONS  Hypersensitivity to
  omalizumab in status asthmaticus
• ADMINISTRATION  For SubQ injection only

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Medications to Treat Asthma Quick-Relief

• Used in acute episodes
• Generally short-acting beta2agonists

9
Medications to Treat Asthma How to Use a Spray
Inhaler

• The health-care provider should evaluate inhaler
  technique at each visit.

10
Medications to Treat Asthma Inhalers and Spacers

• Spacers can help patients who have difficulty
  with inhaler use and can reduce potential for
  adverse effects from medication.

11
Medications to Treat AsthmaNebulizer

• Machine produces a mist of the medication
• Used for small children or for severe asthma
  episodes

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Treatment of episodic asthma

• Mild infrequent episodes can be controlled
  by salbutamol inhaler . In pt. with more frequent
  episodes add sodium cromoglicate beclomethasone
  inhaler .
• Treatment of exercise induced asthma
• Common in children young adults,give 2 doses
  of salbutamol inhaler few minutes befor exercise,
  if not effective then add sodium cromoglicate
  beclomethasone inhaler .

13
Treatment of chronic persistent asthma

• Step 1 occasional use of inhaled short
  acting ß2 agonist .
• As salbutamol or terbutaline ,used by
  inhalation as required .
• If the pt. is using ß2 agonist more than once
  daily, move to step 2

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• Step 2 low dose inhaled steroid .
• Inhaled salbutamol is used as
  required regular inhaled steroid
  (beclomethasone) up to 800 microgram daily .

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• Step 3 high dose inhaled steroids or low dose
  inhaled steroids long acting inhaled ß2 agonist
  .
• Inhaled salbutamol is used as required
  inhaled steroid in dose range 800-2000 microgram
  daily.
• alternatively a long acting ß2 agonist as
  salmeterol 50 microgram 12-hourly, or a
  sustained-release theophylline may be added .

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• Step 4 high dose inhaled steroids regular
  bronchodilaters .
• Inhaled salbutamol is used as required
  inhaled corticosteroid (800 2000 microgram dail
  ) one or more of the following (as therapeutic
  trial )
• Inhaled long acting B2 agonist ( salmeterol ) .
• Leukotriene recepror antagonist (montelukast ).
• Inhaled ipratropium bromide .
• Long acting oral B2 agonist( sustained release
  salbutamol or terbutaline preparations ) .
• Sodium cromoglicate .

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• Step 5 addition of regular oral steroid therapy
  .
• Step 4 treatment is given regular
  prednisolone tablets prescribed in the lowest
  amount necessary to control symptoms as a single
  daily dose in the morning .

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• Occationally you can increase a step (step up) to
  control exacerbetions.
• You can decrease a step (step down) if good
  symptom control for 3 months or more .
• Only think of withdrawing anti inflammatory
  treatment if pt. well for at least 6 months .
• In general it is better to start with a treatment
  regimen which is likely to achieve disease
  control rapidly, then step down, rather than to
  start with inadequate treatment then have to
  step up .

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Management of acute sever asthma (status
asthmaticus )

• The aims of management are to prevent death to
  restore pulmonary function as quick as possible .
• We should assess the pt. for the features of
  severity .
• According to the severity we can classified sever
  asthma in to
• 1- Acute sever asthma .
• 2- Life threatening asthma .
• 3- Near fatal asthma .

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Features of acute sever asthma

1. PEFlt 50 of expected (lt200 L/min) .
2. Respiratory rate gt25 /min .
3. Heart rate gt110 beat /min .
4. Inability to complete sentences in one breath .

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Features of life threatening asthma

• Unrecordable PEF (lt100 L/min) .
• Pa O2 lt 8 kpa (especially if being treated with
  O2 ) .
• Silent chest .
• Cyanosis .
• Bradycardia or arrhythmias .
• Hypotention .
• Exhaustion .
• Confution .
• Coma.

22
Features 0f near fatal asthma

• 1- Increase PaCO2
• / or
• 2- Requirement for mechanical ventillation .

23
Immediate treatment for acute sever asthma

• 1-Oxygen should be given at the highest
  concentration available ( usually 60 ) .
• Then the concentration adjusted according to
  the arterial blood gas measurement (PaO2 should
  be maintained gt 9 kpa ) .
• 2-High dose inhaled B2 agonist
• B2 agonist should be nebulized using O2 .
• Salbutamol 2.5 5 mg. or Terbutaline 5-10 mg.
  given initially can be repeated within 30
  min.if necessary.
• 3-Systemic corticosteroid
• IV Hydrocortisone 200 mg. or oral Prednisolone
  30-60mg

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Subsequent management of acute sever asthma

• If features of severity persist you should
  continue the management as following
• 1-Close monitoring continue O2 therapy.
• 2-Continue nebulized B2 agonist every 15-30 min
• ( reduce to 4 hourly once clear clinical
  response)
• 3-Ipratropium bromide 0.5 mg. should be added to
  the nebulized B2 agonist .
• 4-Continue systemic steroid Hydrocortisone
  200mg. IV. 6 hourly .
• 5-Magnesium sulphate 25 mg /kg. IV .
• 6- Aminophylline IV .
• 7- Mechanical ventillation .

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Indications for assisted ventillation in acute
sever asthma.

• 1- Coma.
• 2-Respiratory arrest .
• 3-Exhaustion , Confution , Drowsiness.
• 4-Deterioration of arterial blood gas tention
  despite optimal therapy
• -PaO2 lt 8 kpa falling.
• -PaCO2 gt 6 kpa rising .
• -PH low falling .

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Monitoring of Treatment

• 1- PEF recording should be made every 15-30 min.
  then PEF chart 4-6 hourly during hospital stay .
• 2-Repeated measurment of arterial blood gas
  tension or using pulse oxymetry .

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Managing Asthma Peak Expiratory Flow (PEF)
Meters

• Allows patient to assess status of his/her asthma
  

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Prognosis of asthma

• -The prognosis of individual asthma attacks is
  generally good .
• Complete remission of asthma is relatively common
  in children ( episodic asthma ), as many as 25
  remain asymptomatic from adolescence onward.
• In adults ( chronic asthma ), prolonged
  remission of asthma symptoms are less common.
• Patients older than 65 years tend to have sever
  asthma that infrequently goes into remission , in
  these patients asthma is less reversible

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-

• . There is occationally a fatal outcome
  especially if treatment is inadequate or delayed.
• -Atopic asthma is usually worse in the summer(
  heavely exposed to allergens ).
• -Chronic asthma is usually worse in the winter
  (increase frequency of viral infection