MANAGEMENT OF ASTHMA

Dr. Theja Huruggamuwa

DEFINITION Intermittent lower-airway obstruction

that is reversible either spontaneously or as the result of treatment Inflammation and edemaBronchial smooth-muscle spasmMucous plugging

Asthma exacerbation:symptoms that require a change in medication from baselineStatus asthmaticus: increasingly severe asthma that is not responsive to drugs that are usually effective

DIAGNOSING ASTHMA

Medical History Symptoms

Coughing Wheezing Shortness of breath Chest tightness

Symptom Patterns Severity Family History

DIAGNOSING ASTHMA Troublesome cough, particularly at night Awakened by coughing Coughing or wheezing after physical

activity Breathing problems during particular

seasons Coughing, wheezing, or chest tightness

after allergen exposure Colds that last more than 10 days Relief when medication is used

DIAGNOSING ASTHMA Wheezing sounds during normal

breathing

Hyperexpansion of the thorax

Increased nasal secretions or nasal polyps

Atopic dermatitis, eczema, or other allergic skin conditions

DIAGNOSING ASTHMA:

SpirometryTest lung function when diagnosing asthma

MEDICATIONS TO TREAT ASTHMA

Medications come in several forms. Inhalations Oral drugs Parenteral drugs

Two major categories of

medications are:Long-term controlQuick relief

DRUGS USED IN ASTHMA

1. Broncho dilatorsI. Adrenoreceptor agonistII. AntimuscarinicIII. TheophillineIV. compound

2. Corticosteroids3. Cromoglicate4. Leukotrine receptor antagonist5. Anti histamine

Dosage forms of drugs • Aerosol solutions• Oral tablets, capsules• Parenteral preparations

I. ADRENORECEPTOR AGONIST (sympathomemitic)

Selective beta 2-agonists - Short Acting - Salbutamol - Terbutaline - Long Acting - Salmetarol - Formetarol

Non selective drenoreceptor agonist - Adrenaline - Ephedrine

II. ANTIMUSCARINIC - Ipratropium Bromide ( MDI, Nebulizer solution)

III. THEOPHILLINE - Theophilline (Oral) - Aminophilline (IV)

IV. COMPOUND PREPARATIONS - Ipratropium with salbutamol

2. CORTICOSTEROIDS -Betamethasone dipropinate -Budesonide -Fluticasone -Mometasone -Prednisolone -Hydrocortizone

3. CROMOGLICATE -Sodium cromoglicate -Nedocromil

4. LEUKOTRINE RECEPTOR ANTAGONIST -Montelukast

5. ANTI HISTAMINE Sedative - Promathazine - Chlorpheniramine Non Sedative - Cetrizine - Leocetrizine - Loratadine - Desloratadine - Fexafenadine - Ketotifen

MEDICATIONS TO TREAT ASTHMA:LONG-TERM CONTROL

Taken daily over a long period of time Used to reduce inflammation, relax airway

muscles, and improve symptoms and lung function Inhaled corticosteroids Long-acting beta2-agonistsLeukotriene receptor antogonist

MEDICATIONS TO TREAT ASTHMA: QUICK-RELIEF

Used in acute episodes

Generally short-acting beta2agonists

MANAGEMENT ACUTE ASTHMA Moderate acute asthma Severe acute asthma Life threatening acute asthma

Moderate acute asthmaWith Oxygen + Short Acting beta 2-agonists or 4-10 puffs with spacer device + Prednisolone

Severe acute asthmaHigh flow Oxygen + Short Acting beta 2-agonists or 4-10 puffs with spacer device + Prednisolone or IV Hydracortizone + Ipratropium + Aminophilline

Life threatening acute asthmaHigh flow Oxygen + Short Acting beta 2-agonists ( only nebulization) + IV Hydracortizone + Ipratropium nebulization + Aminophilline bolus and infusion + IV MgSO4

MANAGEMENT ASTHMA - CHILDHOOD

1. Occasionally bronchodilators – short acting beta 2 agonist

2. Regular preventer (corticosteroids) + short acting beta 2 agonist

3. Regular preventer(corticosteroids) + short acting beta 2 agonist + leukotrine (2yr-5yr )

<2yr should refer to pediatrician

MANAGEMENT ASTHMA - ADULT 1. Occasionally bronchodilators – short

acting beta 2 agonist2. Regular preventer(corticosteroids) +

short acting beta 2 agonist3. Regular preventer(corticosteroids) +

short acting beta 2 agonist + long acting beta 2 agonist +(one of )leukotrine or Theophilline or oral beta 2 agonist

4. Regular preventer(corticosteroids) + short acting beta 2 agonist+ long acting beta 2 agonist +(one of )leukotrine or Theophilline or oral beta 2 agonist

5. regular oral corticosteroids + no 4

MEDICATIONS TO TREAT ASTHMA:

How to Use a Inhaler…?The health-care provider should evaluate inhaler technique at each visit.

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative for Asthma Created and funded by NIH/NHLBI

1. Take off the cap and shake well2. Stand up or keep the thorax in straight position.3. Keep vertically, hold with thumb and middle or

index finger4. Keep with teeth and seal by lips (should be tightly

closed)5. Inhale through the mouth when breathing in the

medication, not the nose6. Take a slow, deep breath at the same time you press

down on the medication canister7. If using spacer device can exhale inside to device8. Hold the breath for 10sec and then breath out9. If need to use one more puff rest for 1-2 min10.If using corticosteroids should wash the mouth and

throat11.Determine when an inhaler is empty and replace

new inhaler

Technique of using MDI inhaler

1. Remove the cap. For single use devices, load a capsule into the device as directed.

2. Breathe out slowly and completely (not into the mouthpiece).

3. Place the mouthpiece between the front teeth and seal the lips around it.

4. Breathe in through the mouth quickly and deeply over 2-3 seconds.

5. Remove the inhaler from the mouth. Hold your breath for as long as possible (4 to 10 seconds).

6. Breathe out slowly.

How to use a DPIThe instructions for using a DPI depend upon the individual type and brand.  

cleaning the mouthpiece 1. At least once per week2. Remove the medication canister and cap from the

mouthpiece. 3. Do not wash the canister or immerse it in water.4. Run warm tap water through the top and bottom of the

plastic mouthpiece for 30 to 60 seconds.5. Shake off excess water and allow the mouthpiece to dry

completely (overnight is recommended). Cleaning the spacer 6. powder particles can deposited in the chamber and should

be cleaned periodically (every 1- 2 weeks) 7. Wash the spacer with warm water and soap. Do not rub. 8. Shake off excess water and air-dry the spacer before the

next use. Cleaning the DPI 9. Most DPIs should NOT be washed with soap and water.10. The mouthpiece can be cleaned with a dry cloth.

Cleaning of inhaler and device

DRUG DELIVERY DEVICES TO TREAT ASTHMA:

Spacers can help patients who have difficulty with inhaler use

Inhalers and Spacers

Metered dose inhalers - MDI Dry powder inhalersDP haler

Inhalers

Mouth piece

Spacers devices

DRUG DELIVERY DEVICES TO TREAT ASTHMA: Machine produces a mist of

the medication

Used for small children or for severe asthma episodes

No evidence that it is more effective than an inhaler used with a spacer

Nebulizer

ASTHMA MANAGEMENT GOALS Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal

levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

• Educate patients and families about all aspects of plan of management

• Recognizing symptoms• Medication benefits and side effects