Asthma Management

Aka: Asthma Management

1. See Also
   1. Asthma
   2. Asthma Evaluation
   3. Asthma Education
   4. Asthma Exacerbation
   5. Asthma Exacerbation Home Management
   6. Emergency Management of Asthma Exacerbation
   7. Asthma Inpatient Management
   8. Status Asthmaticus
2. Management: Strategy
   1. Written action plan
      1. Based on symptoms or peak expiratory flow
   2. Long term use of Inhaled Corticosteroids
      1. Decrease airway inflammation
      2. Most effective medication for long-term control
   3. Intermittent and cautious use of Inhaled Beta Agonist
      1. Avoid more than 4 times per day
   4. Treat other possible confounding factors
      1. Gastroesophageal Reflux Disease
      2. Chronic Sinusitis
      3. Allergic Rhinitis
   5. Prevent Exercise-induced and cold-induced Asthma
      1. Consider sodium cromoglycate
3. Management: Grouping (NIH recommendations)
   1. Intermittent Asthma
      1. Occasional exacerbations (Less than twice per week)
   2. Mild Persistent Asthma
      1. Frequent exacerbations (>twice weekly, but not daily)
   3. Moderate Persistent Asthma
      1. Daily symptoms with daily Beta Agonist use
   4. Severe Persistent Asthma
      1. Continuous Symptoms and frequent exacerbations
4. Management: Available Medications
   1. All aerosolized inhalers should be used with a spacer
      1. Without a spacer, medication delivery is inadequate
      2. See Spacer Devices for Asthma Inhalers
   2. Inhaled Corticosteroids
      1. Most important agents in reactive airway disease
      2. Should be first-line agent in all persistent Asthma
      3. Maximize steroid dose before adding other agents
      4. Ducharme (2002) BMJ 324:1545-8
   3. Mast Cell Stabilizers
      1. Agents
         1. Cromolyn Sodium (Intal)
         2. Nedocromil (Tilade)
      2. Indications
         1. Alternative antiinflammatory drug for age <5 years
         2. Prophylactic agent for
            1. Exercise induced Asthma
            2. Cold-air-induced Bronchial Asthma
   4. Beta Adrenergic Agonist
      1. Short acting Rescue Inhaler (e.g. Albuterol)
      2. Long acting scheduled inhaler (e.g. Serevent)
         1. Indicated for moderate to Severe Asthma
         2. Use as adjunct to Inhaled Corticosteroids
   5. Anticholinergics: Ipratropium Bromide (Atrovent)
   6. Leukotriene Receptor Antagonist (e.g. Montelukast)
      1. Indicated as adjunct for moderate to Severe Asthma
      2. Do not use as a first line agent in most cases
         1. Exception: Preschool children with Allergic Asthma
            1. Straub (2005) Chest 127:509-14
   7. Theophyllines
      1. Decreased use in current Asthma Management
   8. Anti-IgE Therapy (Omalizumab)
      1. Indicated in severe refractory (Step 5-6) Asthma with IgE levels >75
      2. Subcutaneous Injection every 2-4 weeks
5. Prevention
   1. See Asthma Education
   2. Influenza Vaccine yearly
      1. Protection lags shot by 2 weeks
   3. Consider Amantadine with Influenza Vaccine
      1. Asthma Exacerbation occurs during Influenza season
6. References
   1. Kalister (2001) West J Med 174:415-20