Asthma Management

It is well accepted that certain diseases exacerbate asthma. In my practice allergic rhinitis, chronic sinusitis, and gastroesophageal reflux disease are common among asthmatic patients. I therefore find it useful to ask about postnasal drip, purulent rhinorrhea, and heartburn.

Montelukast (marketed as Singulair) is rapidly and nearly completely absorbed following oral administration. Peak plasma concentrations are reached in 2 to 3 hours for the 5- and 10-mg formulations.

How do I know whether I have allergies or asthma? If I have no family history of allergies or asthma, is it true that I won’t get them? How old does a child have to be before getting tested for allergies or asthma?

The medications used for quick relief of bronchoconstriction and immediate reversal of airflow obstruction include short-acting beta2-agonists, anticholinergic agents, and systemic corticosteroids. TABLE 2 itemizes the advantages and disadvantages of the quick-relief medications that are used for the treatment of asthma symptoms. Short-acting beta2-agonists typically take effect within 5 to 15 minutes, causing a relaxation in airway smooth muscles and an improvement in airflow.

Medications used in children to control asthma symptoms and to prevent exacerbations include inhaled corticosteroids (ICSs), leukotriene receptor antagonists (LTRAs) (or leukotriene modifiers in the older children), long-acting beta2-agonists (LABAs), theophylline, and cromolyn. No daily medications are needed for mild intermittent asthma, whereas mild to severe persistent asthma requires one or more controller medications. A low-dose ICS via a nebulizer or MDI with a holding chamber and with or without a face mask or dry powdered inhaler (DPI) for mild persistent asthma is preferred.

In sensitized patients, inhalation of a specific allergen results in acute bronchoconstriction that usually subsides spontaneously within 2 hours; this phenomenon is known as the early asthmatic response. In many asthma patients, the early response resolves only to be followed by a second episode of airway narrowing that begins 3 to 4 hours after allergen challenge. This late response can last as long as 24 hours.

Sometimes children or their caregivers are intolerant of albuterol’s side effects, namely palpitations, tremors, hyperactivity, insomnia, and tachycardia. Levalbuterol (Xopenex), the (r)-enantiomer of racemic albuterol, was first introduced in 1999 and was subsequently FDA approved in 2002 for use in children ages 6 to 11 at a dose of 0.31 mg three times a day via nebulization.

Although millions of prescriptions are filled each year for asthma medications, Lozano et al demonstrated that the insured population who are prescribed controller medications exhibit inadequate control. Thus, pharmacists should intervene proactively and offer education as appropriate. Pharmacists in all types of practices, including community, hospital, or ambulatory settings, have many opportunities to contribute to the management of asthma.

Although 50% to 80% of people with asthma develop symptoms before age 5, many children are misdiagnosed with reactive airway disease, allergic bronchitis, wheezy bronchitis, asthmatic bronchitis, recurrent pneumonia, or recurrent bronchiolitis. Asthma is diagnosed after a young child has had multiple admissions for the same condition and when other respiratory illnesses, such as cystic fibrosis, bronchopulmonary dysplasia, tracheoesophageal fistula, gastroesophageal reflux, and vocal cord dysfunction, have been ruled out. Caregivers who do not understand that asthma can be controlled may react strongly to the diagnosis.

No appointment for managing chronic asthma is complete without booking a follow-up appointment. For well controlled asthma treated with regular preventive medications, I tend to book appointments every 3 months.

In a class of thirty students there will be on average four to five with asthma. One or two of these will have obvious asthma for which they may be taking treatment, but the others may not be recognized or treated. Many students may not be aware that their shortness of breath and chest tightness are abnormal.

It seems obvious that we can have the best asthma medications in the world but treat asthma successfully only if these medications are delivered in sufficient quantities to the airways. Nevertheless published studies reveal that only 45% to 55% of asthma patients use their metered dose inhalers (MDI) correctly and that 50% to 65% of non-respiratory specialist physicians do not know how to use MDIs. It is, therefore, imperative for family physicians not only to teach and to reinforce the correct use of inhalation devices, but to be familiar with their use themselves.

During follow-up visits I spend the least amount of time on the physical examination, and on occasion I omit it entirely. However, I do have the nurse measure peak expiratory flow rate, height and weight, and blood pressure for all asthmatic patients. I find it particularly useful to assess growth in patients who receive inhaled glucocorticoids to reassure them that their medication has not altered their growth pattern.

Despite advances in the understanding of asthma and availability of improved medications, the morbidity and mortality of the disease are increasing. In the United States, asthma affects 14 to 15 million persons.

Asthma severity in children, as in adults, is classified as mild intermittent (step 1), mild persistent (step 2), moderate persistent (step 3), and severe persistent (step 4), based on the child’s daytime and nighttime clinical features before treatment or adequate control. Infants and young children require long-term treatment if they have had more than three episodes of wheezing in the past 12 months that lasted more than one day and affect sleep, and if they have a high risk of developing persistent asthma as indicated by physician diagnosis of atopic dermatitis or parental history of asthma.

Asthma is a chronic disease characterized by inflammation of the airways and reversible bronchoconstriction resulting in wheezing, coughing, shortness of breath, and exercise intolerance. It affects 26 million people worldwide at some time in their lives.

You’ve just been told that your child has asthma. The doctor has explained that with good medical control your child can live a normal life.

The student should use pre-exercise medication if exercise regularly causes asthma. An inhaled bronchodilator should be taken10-30 minutes before significant exercise. If cromoglycate or nedocromil is used, this should be taken at this time also.

If patients have no nocturnal symptoms, have normal activity levels, and have not been absent from work or school, I consider them well controlled. If I find that patients are not well controlled, I then take the time to review their understanding of asthma and the medications they are receiving.

Can leukotriene-receptor antagonists (LTRAs) be first-line maintenance therapy for persistent asthma? Many studies have tested LTRAs in this role, most commonly comparing them with placebo. Clearly, leukotriene-receptor antagonists are superior to placebo.

Children and their caregivers should be educated about self-monitoring and self-management of exacerbations, especially for moderate and severe persistent asthma or history of severe asthma exacerbations. A written action plan with patient-specific instructions based on clinical indicators using peak flow readings, symptoms, or both to identify the need for prompt medical care should be developed, reviewed periodically, and revised for home and school settings. peak flow meters (PFMs) should be used every morning upon awakening before medication administration.

To manage your asthma, you need to keep track of your symptoms, your use of medicine, and your peak expiratory flow (PEF). GREEN means Go: You’re feeling OK.

The principal goals of asthma management are: 1) To prevent the occurrence of symptoms that are chronic or troublesome (such as coughing or breathlessness after exercise) in the nighttime or in the early morning; 2) To maintain near normal pulmonary function; 3) To sustain normal levels of physical activity, including exercise; 4) To prevent the recurrence of asthma exacerbations and to reduce visits to the ER or hospital; 5) To provide optimal pharmacotherapy with minimal adverse effects; and 6) To provide asthma care that meets the needs and expectations of patients and their families. Care of these patients by clinicians well versed in the underlying pathophysiology of asthma as well as currently available comprehensive pharmacotherapeutic agents, can achieve these goals.

Asthma severity is classified into one of the following four categories: 1) mild intermittent, 2) mild persistent, 3) moderate persistent, and 4) severe persistent. TABLE 1 outlines this classification.