Management of Chronic Asthma

• Goal:stable, asymptomatic state with best pulmonary function possible
• Approaches:
  • patient education -- partnership with physician
  • assess/monitor disease severity; lung function tests
  • avoid known asthma triggers

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• Pharmacological interventions: use the simplest approach
  1. infrequent symptoms: sympathomimetics inhaled PRN
  2. worsening disease (nocturnal awakening/daytime symptoms): inhaled steroids and/or mast cell-stabilizers
  3. if necessary, increased dosage of inhaled steroids
  4. persistent asthma:
     • long-acting inhaled beta₂ agonists
     • sustained-released theophylline and/or parasympatholytics
  5. after control is reached and stable, therapy reduction should be initiated -- finding the minimum medication required.

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Emergency Asthma Situations

• Most effective approach for acute management: aerosolized beta₂ agonists
  • aerosolized beta₂ agonists by hand-held nebulizer, every 20 minutes for three doses, then frequency reduced to every two hours until the attack subsides
  • 3-4 times more relief compared to IV aminophylline, which may be added after the first hour
  • aerosolized beta₂ agonist intervention terminates attacks in about two-thirds of patients; another 5% -- 10% benefit by addition of a methylxanthine in combination with a sympathomimetic
  •  the remaining approximately 25% of patients have poor acute responses to interventions

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• Acute bronchial asthma: one of the most common respiratory emergencies-- important considerations:
  • identifying which episodes of airway obstruction are life-threatening and apply appropriate level of care
  • important clinical parameters in assessment:
    • expiratory flow measurements
    • gas exchange measurements
    • presence of paradoxical pulse, thorax hyperinflation/use of accessory muscles ® indicative of significant airway obstruction
      • aggressive intervention without reversal of the symptoms require objective patient monitoring using peak expired for flow rate (PEFR) or FEV₁ and arterial blood gas measurements
  •  Direct correlation between airway obstruction severity and the length of time required for resolution.
  • If FEV₁ or PEFR is equal to or less than 20% of expected on presentation and does not double within one-hour receiving aggressive treatment:
    • the patient will probably require treatment including glucocorticoids (about 20 percent of all patients fall in this category)
    • 24 hours of inpatient treatment may be required before the patient becomes asymptomatic

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Prognosis/Clinical Course

• mortality rate: small (5000 deaths/10 million patients at risk); inner city death rates arising, perhaps due to inadequate/limited availability of health-care
• generally good prognosis for 50-80% of all patients
• number of children who still have asthma 7-10 years after diagnosis, approximately 46%; the percentage with severe disease, approximately 12%
• asthma is not a progressive disease, i.e. even untreated, asthmatics do not evolve from mild to severe disease with time
• Clinical course: characterized by remission/exacerbations

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