Asthma

Treatment

By

Ph. Adnan Mustafa Ismail

DEFINITION
Asthma is defined as chronic inflammation and
constriction of Air ways.
Asthma is on two types:
1- Extrinsic asthma: commonly in children.
2- Intrinsic asthma: commonly in adults.

PATHOPHYSIOLOGY
To determine the pathology of asthma first we have to
identify factors that initiate, intensify, and modulate the
inflammatory response of the airways and to determine how
these processes produce the characteristic airway
abnormalities.

ACUTE INFLAMMATION
Inhaled allergen in allergic patients lead to an early-phase
reaction by activation of cells bearing allergen-specific IgE, it is
characterized by rapid activation of airway mast cells and
macrophages leading to rapid release of pro-inflammatory
mediators like histamine, eicosanoids and reactive oxygen that
induce contraction of airway smooth muscles, mucus secretion
and vasodilation.
For further reading please about (acute and chronic
inflammation) see pharmacotherapy a pathophysiologic
approach, 8th edition, page 441.

SIGNS AND SYMPTOMS

ACUTE SEVER ASTHMA
Signs: includes wheezing, dry cough, tachypnea, tachycardia,
and pale or cyanotic skin.
Symptoms: include SOB, chest tightness, or burning, and the
patient able to say only few words in each breath.
Symptoms are unresponsive to usual measure (SABA).

CHRONIC ASTHMA
Signs: includes wheezing, dry cough, signs of atopy (allergic
rhinitis and/or eczema).
Symptoms: includes dyspnea, chest tightness, whistling sound
when breathing.
These symptoms are associated with exercise, but may also
occur spontaneously or in association with known allergen.

TRIGGER FACTORS
Extrinsic: dust mites, allergen, and pollen.
Intrinsic: the trigger in this type of asthma is nonallergenic factors like viral infection, irritant (which cause
epithelial damage and mucosal inflammation), emotional
upset (which mediate excess sympathetic input), or
exercise which cause water and heat loss from airways,
and triggering mediators release from mast cell.

LEVEL OF CONTROL
GINA GUIDELINES FOR ASTHMA CONTROL LEVEL

Asthmatic patients can be categorized into 3 groups according

to the level of control:
1- Controlled or totally controlled ( all of the following )
Those patients must have no or less than 2 daytime
symptoms (cough, wheezing, and chest tightness), and
Asthma doesnt limit the ability of those patients to
perform their activates (go to school, work etc.), their
sleep must not disturbed by nocturnal symptoms
(awakening), they should never use rescue medication
(like Ventolin) or at least use it 2 or less in one week, the
lung function must be normal, and they should have no
Exacerbations (need for hospitalization).

2- Partly or partially controlled ( any of the following )

Those patient should have no limitation of activates or
nocturnal symptoms, have daytime symptoms of more
than 2 times in one week, use their rescue medications
more than 2 times in a week, and have one or more
exacerbations in one year.
3- Uncontrolled patient
If three or more of partially controlled patients parameters
are present, so the patient considered uncontrolled, like
have daytime symptoms of more than 2 in one week, use
their rescue medications more than 2 in one week, and
have nocturnal symptoms.

TREATMENT
GOALS OF TREATMANT OF ASTHMA
Reducing impairment:
1- Prevent chronic and troublesome symptoms
(soughing, breathlessness in daytime, night time, and
after exercise).
2- Need for rescue medication ( 2 days/week).
3- Maintain (near) normal lung function.
4- Maintain normal activity level.
Reducing risk:
1- Prevent recurrent exacerbation and visit of emergency
department.
2- Prevent loss of lung function.
3- Minimal or no adverse effect of treatment.

NOTES
The patient must be advocated to use PEF (peak
expiratory flow rate) monitoring.

You can see the device and the values of PEF in page 10.

 Advantage of the use of inhaled corticosteroids compared

to systemic corticosteroids is the targeted delivery of drug
to the lungs, which decreases the risk of systemic adverse
effects.

PHARMACOLOGICAL
ICS (Fluticasone) is contraindicated in patients who have
hypersensitivity to steroids and should be used cautiously in
diabetes, glaucoma, active infection and immunocompromised
patients.
Leukotriene modifier (montelukast): should be used cautiously
in patients with acute asthmatic attack, alcohol consumption, and
sever hepatic disease.
LABA (salmeterol): contraindicated as monotherapy in asthma
(i.e. should be used only in combination with ICS), sever cardiac
disease, tachycardia, and should be used cautiously in HTN,
diabetes, closed-angle glaucoma, acute asthma.
Combined ICS+LABA: see above for each component.
Theophylline: it has narrow-therapeutic index
Contraindicated in patients with tachycardia
And should be used cautiously in elderly, CHF,
hyperthyroidism, active peptic ulcer disease, and
hepatic disease.

GINA GUIDELINES FOR TREATMENT

(TREATMENT STEPS)
In the treatment of asthmatic patients we must follow the
GINA guidelines, which is a flexible strategy and give us
different alternatives in case that a drug is contraindicated or lead
to undesirable side effect.

GINA GUIDELINES FOR ASTHMA TREATMENT

STEP UP
Step one
A newly diagnosed patients we have to start from step one
(administration of SABA like Ventolin) and monitor the effect
on the symptoms.

Step two
If the patient is not "TOTALY CONTROLLED" then we have
to move to the next step in which the patient can use his rescue
medication and give him low-dose ICS if the patient not take the
medication (diabetic patients) we have to use the alternative
(LTRA).

Step three
If the patient is not "TOTALLY CONTROLLED" in the 2nd step
we have to, step up to the next step in this stage the patient can
use their rescue medication, and we give him Low-dose ICS +
LABA or alternative drugs. If they respond to LABA continue to
use it if not or the patient dont like the side effect we have to use
the alternatives.

Step four
If the patient not respond to the 3rd step treatment, we have to add
either medium or high dose ICA + LABA or LTRA or Sustained
release theophylline.

Step five
If the patient dose not respond to the step 4 treatments, we have
to add systemic glucocorticosteroid.

STEP DOWN
If the patient is "TOTALLY CONTROLLE" at any step of
treatment we have to consider several months as follow up, if he
is still "TOTALLY CONTROLLED" we have to step-down, if
he is still totally controlled we will still at that stage for several
months to evaluate his state, or if he not totally controlled (i.e his
state is not good) we have to step up to the stage at which he
was totally controlled.

ASTHMA CONTROL TEST (ACT)

It is an important issue to have a tool to determine the level
of control of asthmatic patients, one of the best tool is the figure
below.
It is contain 5 questions and for each answer there is a score, after
answering each question by the patient we will have a total score.
Note: assessment interval is after 4 weeks of starting each step of
the treatment.

Green zone (80 100%) = Controlled.

Yellow zone (50 79%) = cautionary and requires increase
bronchodilator use or beginning of prednisone if not improved.
Red zone (less than 50%) = the patient should contact with
healthcare provider.

10

EXERCISE 1
Mr. J.A is 35 years old male presented to Tikrit Teaching
Hospital with sever SOB, drowsy, and unable to speak more than
a couple of words at a time.
He complaining of flu-like symptoms and a worsening cough for
the past few days. He complain of increasing difficulty in
breathing he start to use his inhalers several times in a day for
days in a week , with no good response.
WHAT IS THE DIAGNOSIS?
CONSIDERD FOR?

AND WHAT ARE THE SYMPTOMS YOU

WHAT IS THE LEVL OF CONTROL IN THIS PATIENT?

WHICH STEP YOU SUGGEST TO STAET TREATMENT WITH? WITH
COMMENT.

REFERENCES
1234-

11

Oxford handbook of clinical medicine 7ed.

Pharmacotherapy a pathophysiologic approach 8ed.
Mosby's nursing drug reference 27ed.
Clinical pharmacy and applied therapeutics (Roger
Walker) 5ed.