Asthma Treatment

Treating an Acute Attack in the Hospital.  An acute attack may require hospitalization. Laboratory tests, an electrocardiogram (ECG), and a chest x-ray are performed to determine lung function, oxygen levels, and other indications of severity or rule out other causes. Depending on the results, the following treatments may be given:

•Beta2-agonists are the standard therapy. They may be administered with a nebulizer (a device that administers the drug in a fine spray) or given hourly with an inhaler. Studies are suggesting the use of inhaler is equally or possibly more effective than a nebulizer. Intravenous delivery is not recommended in most cases.
•A corticosteroid (commonly called a steroid) given within the first hour helps reduce the need for hospitalization. Steroids are typically administered intravenously or as an injection in adults. Lower doses work as well as higher ones in these situations.
•Intravenous magnesium opens airways and is an important emergency treatment for patients with very severe asthma.
•Oxygen is usually administered, and can be life saving in severe cases.
•In life-threatening situations, the patient may require mechanical ventilation.
•Antibiotics are not useful for asthma attacks if there is no strong evidence of the presence of a bacterial infection. (Viral infections, most often colds and flus, are more likely to trigger an asthma attack. In such cases, antibiotics do not

Asthma Treatment

appear to be beneficial and may have adverse effects.)

Discharge and Relapse After Hospitalization. It typically takes 3 to 4 hours to determine if a patient can be safely sent home or if they need to stay in the hospital. Patients are generally discharged under the following circumstances:

•When symptoms are gone or are minimal, and
•The peak expiratory flow rate is 70% or more of the predicted rate
Discharged patients generally take oral corticosteroids for 5 to 7 days. Despite reasonable precautions, about 20% of patients relapse within 2 weeks, although the risk is very low if they keep taking their medication after they leave

Asthma Treatments and drugs

Treatment for asthma generally involves avoiding the things that trigger your asthma attacks and taking one or more asthma medications. Treatment varies from person to person.

■Most people with persistent asthma use a combination of long-term control medications and quick-relief medications, taken with a hand-held inhaler.
■If your asthma symptoms are triggered by airborne allergens, such as pollen or pet dander, you may also need allergy treatment.
■You may need to try a few different medications before you find what works best.
■Because asthma changes over time, you will need to work with your doctor to monitor your symptoms and learn how to make needed adjustments.
Medications used to treat asthma include long-term control medications, quick-relief (rescue) medications and medications to treat allergies. The right medication for you depends on your age and symptoms, and what seems to work best to keep your asthma under control.

Long-term control medications
In most cases, these medications need to be taken every day. Types of long-term control medications include:

■Inhaled corticosteroids such as fluticasone (Flovent Diskus), budesonide (Pulmicort), triamcinolone (Azmacort), flunisolide (Aerobid), beclomethasone (Qvar) and others. These medications reduce airway inflammation and are the most commonly used long-term asthma medication. Unlike oral corticosteroids, these medications are considered relatively low risk for long-term corticosteroid side effects. You may need to use these medications for several days to weeks before they reach their maximum benefit.
■Long-acting beta-2 agonists (LABAs) such as salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer). These inhaled medications, called long-acting bronchodilators, open the airways and reduce inflammation. They are often used to treat persistent asthma in combination with inhaled corticosteroids. Long-acting bronchodilators should not be used for quick relief of asthma symptoms.
■Leukotriene modifiers such as montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo CR). These inhaled medications work by opening airways, reducing inflammation and decreasing mucus production.
■Cromolyn and nedocromil (Tilade). These inhaled medications reduce asthma signs and symptoms by decreasing allergic reactions. They’re considered a second choice to inhaled corticosteroids, and need to be taken three or four times a day.
■Theophylline, a daily pill that opens your airways (bronchodilator). It relaxes the muscles around the airways.
Quick-relief medications
Also called rescue medications, you use quick-relief medications as needed for rapid, short-term relief of symptoms during an asthma attack, or before exercise, if your doctor recommends it. Only use these medications as often as your doctor tells you to. If you need to use these medications too often, you probably need to adjust your long-term control medication. Keep a record of how many puffs you use each day. Types of quick-relief medications include:

■Short-acting beta-2 agonists, such as albuterol. These inhaled medications, called bronchodilators, ease breathing by temporarily relaxing airway muscles. They act within minutes, and effects last four to six hours.
■Ipratropium (Atrovent). Your doctor might prescribe this inhaled anticholinergic for the immediate relief of your symptoms. Like other bronchodilators, ipratropium relaxes the airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic bronchitis.
■Oral and intravenous corticosteroids to treat acute asthma attacks or very severe asthma. Examples include prednisone and methylprednisolone. These medications relieve airway inflammation. They may cause serious side effects when used long term, so they’re only used to treat severe asthma symptoms.
Medications for allergy-induced asthma. These decrease your body’s sensitivity to a particular allergen or prevent your immune system from reacting to allergens. Allergy treatments for asthma include:

■Immunotherapy. Allergy-desensitization shots (immunotherapy) are generally given once a week for a few months, then once a month for a period of three to five years. Over time, they gradually reduce your immune system reaction to specific allergens.
■Anti-IgE monoclonal antibodies, such as omalizumab (Xolair). This medication reduces your immune system’s reaction to allergens. Xolair is delivered by injection every two to four weeks.

Albuterol inhaler changes: Know what to expect
The Food and Drug Administration (FDA) has required that metered-dose albuterol inhalers that use chlorofluorocarbon (CFC) propellent be replaced with hydrofluoroalkane (HFA) inhalers by the end of 2008. HFA inhalers work as well as CFC inhalers and are as safe, but they don’t harm the ozone layer. If you’re used to using a CFC inhaler, talk to your doctor about making the switch to an HFA inhaler. There are a few differences you should know about:

■Your HFA inhaler may have a different taste and feel from your older CFC inhaler.
■HFA inhalers have a less forceful spray than the older CFC inhalers. Make sure you know how to use your inhaler correctly – otherwise, you may not get the full dose of medication with each spray.
■HFA inhalers are more costly than the older, generic albuterol CFC inhalers.
■HFA inhalers should be cleaned with water every week.
Treatment by severity for better control: A stepwise approach
Treatment based on asthma control can help you manage your asthma. Asthma treatment should be flexible and based on changes in symptoms, which should be assessed thoroughly each time you see your doctor. Then, treatment can be adjusted accordingly.

For example, if your asthma is well controlled, your doctor may prescribe less medicine. If your asthma is not well controlled or getting worse, your doctor may increase your medication and recommend more frequent visits.

Guidelines for Treating Asthma at Home

Avoiding allergens, following appropriate drug treatments, and home monitoring are key elements in preventing dangerous asthma attacks and hospitalization. A combination of medications is important for both treating and preventing asthma attacks. In addition, good communication between the doctor and patient is a key factor in a successful management program. Written action plans, which instruct individual patients how to properly respond to changes in their unique symptoms, are a very important element in successful self-management of asthma.

Understanding the Difference Between Treating Symptoms and Controlling the Disease

Medications for asthma fall into two categories:

•Rescue Medication. Medications that open the airways (bronchodilators, or inhalers) are used to quickly relieve any moderate or severe asthma attack. These drugs are usually short-acting beta-adrenergic agonists (beta2-agonists). Other drugs used in special cases include corticosteroids taken by mouth and anticholinergic drugs. None of these drugs have any effect on the disease process itself. They are only useful for treating symptoms.
•Maintenance Medication. Simply coping with asthma symptoms without also controlling the damaging inflammatory response is a common and serious error. For adults and children over age 5 with moderate-to-severe persistent asthma, experts now recommend inhaled corticosteroids and long-acting beta2-agonists.
Patients can greatly reduce the frequency and severity of asthma attacks by understanding the difference between coping with asthma attacks and controlling the disease over time. Unfortunately, many patients do not understand the difference between medications that provide rapid short-term relief and those that are used for long-term symptom control. Many patients with moderate or severe asthma overuse their short-term medications and underuse their corticosteroid medications. The overuse of bronchodilators can have serious consequences; not using steroids can lead to permanent lung damage.

Patients need to understand that asthma symptoms can change quickly over time and that treatment strategies may need to change. In 2005, the two leading U.S. allergy associations published joint guidelines on controlling asthma. The guidelines emphasize that asthma treatment decisions need to be made on an individual basis. It is important that patients have a close relationship with their doctor. The doctor needs to evaluate a patient’s asthma symptoms at each and every visit to determine if there should be any changes in medication.

According to the guidelines, asthma management is classified as either “well-controlled” or “not well-controlled.” Your doctor may need to change some of your medications, or increase or decrease the dosage, depending on whether your asthma is well-controlled or not well-controlled.
These are the signs of well-controlled asthma:

•Asthma symptoms occur twice a week or less
•Rescue bronchodilator medication is used twice a week or less
•Symptoms do not cause nighttime or early morning awakening
•Symptoms do not limit work, school, or exercise activities
•Peak flow meter readings are normal or the patient’s personal best
•Both the doctor and the patient consider the asthma to be well controlled
Administering Inhaled Drugs
Most asthma drugs are inhaled using various forms of inhalers or nebulizers. Inhaled drugs must be used regularly as prescribed and the patient carefully trained in their use in order for them to be effective and safe. The basic devices are the metered-dose inhaler (MDI), breath-actuated inhalers, dry powder inhalers, and nebulizers.

MDIs have used chlorofluorocarbons (CFCs) as their propellants. CFCs are damaging to the environment. Over time CFCs are being replaced with other propellants (such as hydrofluoroalkane) that are equally effective to CFCs, are environmentally safe, and do not chill the device as CFCs do. Devices that don’t use propellants at all are also now available.

Metered-Dose Inhaler. The standard device for administering any asthma medication has been the metered-dose inhaler (MDI). This device, particularly when used with a holding chamber, allows precise doses to be delivered directly to the lungs.

MDI-delivered drugs must be used regularly as prescribed, and the patient carefully trained in their use, for the drugs to be effective and safe. Some patients hold the MDI too close to their mouths, or even inside them. Others may exhale too forcefully before inhalation. The holding chamber, or spacer, allows the patient additional time to inhale the medication, improving delivery. They vary, however, in their ability to deliver medication. Often MDIs continue to deliver propellant after the drug has been used up. Patients should track their medicine and throw the device away when the last dose has been administered.

Breath-Actuated Inhalers. Breath-actuated rotary inhalers (e.g., Easi-Breathe and Autohaler) deliver the drug directly to the back of the throat as the user inhales. Their primary advantage over the MDI is their ease of use. They also do not use CFCs as propellants. In comparison studies, patients have been very successful with the breath-actuated inhalers.

Dry Powder Inhalers. Dry powder inhalers (DPIs) deliver a powdered form of beta2 agonists or corticosteroids directly into the lungs. They also do not use CFCs. Such devices include Rotahaler, Spinhaler, Turbohaler, Clickhaler, Easyhaler, Diskhaler, Discus, Twisthaler, Spiros, and others. DPIs are as effective as the older devices, and generally have a better taste and are easier to manage. They may differ among themselves, however, in their ability to deliver drugs into the airways. In one study, for example, the Turbohaler was easier to use than the Diskhaler, achieving better delivery. The Discus is another effective DPI; it has a dose counter and protects against exhalation effects.

Humidity or extreme temperatures can affect these inhalers’ performance, so they should not be stored in humid places (bathroom cabinets) or locations subject to high temperatures (glove compartments during summer months).

Dry-powder may cause tooth erosion, and children are advised to rinse their mouths out right after taking the drug and to brush twice a day with a fluoride toothpaste.

Other Hand-Held Inhalers. Respimat delivers a fine-mist spray that is created by forcing the liquid medication through nozzles. It does not use any propellant.

Nebulizers. A nebulizer is a device that administers the drug in a fine spray that the patient breathes in. They are mostly used in hospital settings or when the patient cannot use an inhaler. Nebulizers may be important for delivering newer drugs used in asthma treatment.

Asthma Treatment

Definition of Asthma Treatment
Treatment of asthma can be divided into long-term control and quick-relief medications.

Description of Asthma Treatment
Long-term control medications are taken daily to maintain control of persistent asthma. They primarily serve to control airway inflammation.

The quick-relief medications are taken to achieve prompt reversal of an acute asthma “attack” by relaxing bronchial smooth muscle.

Many asthma medications can be administered orally or by inhalation. Metered-dose inhalers (MDI’s) are the most widely used method, but dry powder inhalers are becoming popular. Metered-dose inhalers are changing from the type propelled by liquified chlorofluorocarbons (CFCs) to a new, CFC-free delivery system (see the National Heart Lung and Blood Institute review on the new MDIs at http://www.nhlbi.nih. gov/health/public/lung/asthma/mdi.htm). Nebulizer therapy is reserved for patients who are unable to use MDI’s because of difficulties with coordination.

Treatment of Asthma Treatment
Asthma cannot be cured, but it can be controlled with proper asthma management.

The first step in asthma management is environmental control. Asthmatics cannot escape the environment, but through some changes, they can control its impact on their health.

Listed below are some ways to change the environment in order to lessen the chance of an asthma attack:

Clean the house at least once a week and wear a mask while doing it

Avoid pets with fur or feathers

Wash the bedding (sheets, pillow cases, mattress pads) weekly in hot water

Encase the mattress, pillows and box springs in dust-proof covers

Replace bedding made of down, kapok or foam rubber with synthetic materials

Consider replacing upholstered furniture with leather or vinyl

Consider replacing carpeting with hardwood floors or tile

Use the air conditioner

Keep the humidity in the house low

The second step is to monitor lung function. Asthmatics use a peak flow meter to gauge their lung function. Lung function decreases before symptoms of an asthma attack – usually about two to three days prior. If the meter indicates the peak flow is down by 20 percent or more from your usual best effort, an asthma attack is on its way.

The third step in managing asthma involves the use of medications. There are two major groups of medications used in controlling asthma – anti-inflammatories (corticosteroids) and bronchodilators.

Anti-inflammatories reduce the number of inflammatory cells in the airways and prevent blood vessels from leaking fluid into the airway tissues. By reducing inflammation, they reduce the spontaneous spasm of the airway muscle. Anti-inflammatories are used as a preventive measure to lessen the risk of acute asthma attacks. The corticosteroids are given in two ways – inhaled via a metered dose inhaler (MDI) or orally via pill/tablet or liquid form. The inhaled corticosteroids are flunisolide (AeroBid), triamcinolone (Azmacort) and beclomethasone (Beclovent and Vaceril). The oral corticosteroids (pill/tablet form) are prednisone (Deltasone, Meticorten or Paracort), methylprednisolone (Medrol) and prednisolone (Delta Cortef and Sterane). The oral corticosteroids (liquid form) are Pedipred and Prelone. These liquid forms are used for asthmatic children.

Three drugs, zafirlukast (Accolate), montelukast (Singulair) and zileuton (Zyflo), are part of a newer class of anti-inflammatories called leukotriene modifiers. Taken orally, these drugs work by inhibiting leukotrienes (fatty acids that mediate inflammation) from binding to smooth muscle cells lining the airways. They also reduce the recruitment of inflammatory cells to the airways. These drugs both prevent and reduce symptoms, and are intended for long-term use.

Other inhaled anti-inflammatory drugs include cromolyn sodium (Intal) and nedrocromil (Tilade).

Bronchodilators work by increasing the diameter of the air passages and easing the flow of gases to and from the lungs. They come in two basic forms – short-acting and long-acting. The short-acting bronchodilators are metaproterenol (Alupent, Metaprel), ephedrine, terbutaline (Brethaire) and albuterol (Proventil, Ventolin). These drugs are inhaled and are used to relieve symptoms during acute asthma attacks. The long-acting bronchodilators are salmeterol (Serevent), metaproterenol (Alupent), and theophylline (Aerolate, Bronkodyl, Slo-phyllin, and Theo-Dur to name a few). Serevent and Alupent are inhaled and theophylline is taken orally. These drugs are sometimes used to control symptoms in special circumstances, such as during sleep or when intensive exposure to a particular irritant can be predicted (i.e. pollen season). Atrophine sulfate (Atrovent) is another highly effective bronchodilator. This drug opens the airways by blocking reflexes through nerves that control the bronchial muscles.

Some people cannot control the symptoms by avoiding the triggers or using medication. For these people, immunotherapy (allergy shots) may help. Immunotherapy involves the injection of allergen extracts to “desensitize” the person. The treatment begins with injections of a solution of allergen given one to five times a week, with the strength gradually increasing.

Note: Asthmatics vary considerably in their responses to different types, combinations and amounts of medicines so therapy must be carefully tailored to the individual. Even medication that may work well with some asthmatics may not be effective for others. Please discuss your individual situation with your doctor and both of you will determine a course of management that is best for you.

Prevention of Asthma Treatment
Periodic assessments and ongoing monitoring of asthma are essential to determine if therapy is adequate. Patients need to understand how to use a peak flow meter and understand the symptoms and signs of an asthma exacerbation.

Regular follow-up visits (at least every six months) are important to maintain asthma control and to reassess medication requirements.

Patients with persistent asthma should be given an annual influenza vaccine.

Questions To Ask Your Doctor About Asthma Treatment
Is there any further testing that can be done?

What further treatment do you recommend?

Will you be prescribing something new?

What are the side effects?

What is an MDI (inhaler)?

What is a spacer?

Am I using my MDI (inhaler) correctly?

What is a peak flow meter?

How do I use it?

How often?

I have heard that some medications are ‘second-line’ treatments. What does that mean?