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Headlines:
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Back to Chest Diseases
Asthma
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Xolair reduced the rate of hospital emergency visits by 44% in
patients with inadequately controlled asthma.
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 related discussion |
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Asthma is a chronic inflammatory condition of the lung airways that is
characterized by (1) airway obstruction which is usually reversible; (2)
airway hyper-responsiveness; (3) inflammation of the bronchi with epithelial
damage, smooth muscle hypertrophy and mucus plugging. It is useful for epidemiologic
and clinical purposes to classify asthma by the principal stimuli that incite
or are associated with acute episodes. In that sense asthma can be classified
as allergic and idiosyncratic asthma (asthma that is not caused by an allergic
reaction to a allergic stimulus).
Clinical suspicion
Clinical picture is highly suggestive with episodic bouts of wheezing,
shortness of breath, cough, sense of chest tightness and choking in the
neck. The attacks usually occur at night time or on waking up but can occur
at any time of the day.
Diagnosis
Confirmation by spirometry is required and is defined as the improvement
of obstructive pattern after bronchodilator therapy. Improvement is defined
as an increase in FEV(1) by 12% or Forced expiratory flow (FEF) {flow of
expiration at midlung volumes} by 35% after 2/3 puffs of a short acting
bronchodilator.
Treatment
Stepwise approach:
Step 1 Mild Intermittent
Patients do not have daily attacks & do not awaken at night.
- Quick relief: use a beta agonist or anticholinergic bronchodilator
as required.
- No long term therapy needed.
Step 2 Mild Persistent
The administration of a disease-modifying agent is required for
patients with daily symptoms or daily use of a bronchodilator.
- Quick relief: use a beta agonist or anticholinergic bronchodilator
as required.
- Long term therapy: (disease modifying agents) use anti-inflammatory
drugs e.g. sodium cromoglycate inhalation or daily inhaled steroids. Sustained-release
theophylline to serum concentration of 5-15 ?g/mL is an alternative, but
not preferred, therapy. Leukotriene modifiers zafirlukast or zileuton
may also be considered for patients >/=12 years of age, and montelukast
for patients >/=6 years of age, although their position in therapy is
not fully established.
- Nocturnal symptoms: These symptoms may necessitate the addition at
night of either a long-acting inhaled beta-adrenergic agonist (e.g., salmeterol,
two puffs qhs) or theophylline. Also consider increasing the dose of the
disease modifying drug.
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Step 3 Severe Persistent
Patients have severe symptoms and control is inadequate despite the use
of high-dose inhaled corticosteroids (>20 puffs per day of beclomethasone,
triamcinolone, or flunisolide)
- Quick relief: use a beta agonist or anticholinergic bronchodilator
as required.
- Long term therapy: these patients may require regular use of oral
steroids to control symptoms. Fluticasone, 220 mug per puff,
is approximately four times more potent per puff than is beclomethasone,
triamcinolone, or flunisolide. In patients requiring high-dose inhaled
corticosteroids or regular use of oral corticosteroid, fluticasone is
very effective in reducing symptoms and in minimizing the effects of oral
corticosteroid use. Medications to reduce the need for oral corticosteroids
have been studied. Methotrexate or troleandomycin may be useful in some
patients. Many of these patients require regular doses of bronchodilators
and may benefit from the addition of a long-acting beta2
-adrenergic agonist (e.g., salmeterol, two puffs bid).
Modifying chronic therapy
Review treatment every 1 to 6 months; a gradual stepwise reduction in
treatment may be possible. Evaluate possible signs, symptoms of corticosteroid
withdrawal when weaning patient of inhaled steroids.
If control is not maintained, review patient medication technique, adherence,
and environmental control (avoidance of allergens or other factors that
contribute to asthma severity). May need to increase controller (anti-inflammatory)
therapy vs addition of long-acting ?agonist.
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