Asthma is characterized by airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation with severe shortness of breath. Airway inflammation as a response to allergens and irritants plays a predominant role in the pathogenesis and pathophysiology of asthma.

 

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1. Avoid triggers like pollution, smoke, or perfumes.

Supplemental oxygen,

 

2. Bronchodilators (smooth muscle relaxants)


Bronchodilators include sympathomimetics, especially β2-selective agonists, muscarinic antagonists, methylxanthines, and leukotriene receptor blockers. (dose?)

Anti-inflammatory drugs.

intravenous glucocorticoids

Anti-inflammatory drugs used in asthma include corticosteroids, mast cell stabilizers, and an anti-IgE antibody.

Leukotriene antagonists play a dual role.

 

The four components of asthma management

 

Routine follow-up visits for patients with active asthma, at a frequency of every one to six months, depending upon the severity of asthma.

These visits should be used to assess multiple aspects of the patient's asthma and to discuss steps that patients can take to intervene early in asthma exacerbations (an asthma "action plan") [3].

The aspects of the patient's asthma that should be assessed at each visit include the following:

signs and symptoms,

pulmonary function,

quality of life,

exacerbations,

adherence with treatment,

medication side effects,

and patient satisfaction with care.

By consensus from panels of asthma experts, well-controlled asthma is characterized by daytime symptoms no more than twice per week and nighttime symptoms no more than twice per month. SABAs for relief of asthma symptoms should be needed less often than three days out of the week, and there should be no interference with normal activity (preventative use of a SABA, such as prior to exercise, is acceptable even if used in this way on a daily basis). Peak flow should remain normal or near-normal. Oral glucocorticoid courses and/or urgent care visits should be needed no more than once per year [4].

Assessment of control in patients of different ages is summarized in the tables.

Components of control Classification of asthma control (children 0-4 years of age)
Well-controlled Not-well controlled Very poorly controlled
Impairment Symptoms ≤2 days/week >2 days/week Throughout the day
Nighttime awakenings 1x/month >1x/month >1x/week
Interference with normal activity None Some limitation Extremely limited
Short-acting beta2-agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week Several times per day
Risk Exacerbations requiring oral systemic corticosteroids 0-1/year 2-3/year >3/year
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
The level of control is based on the most severe impairment or risk category. Assess impairment domain by caregiver's recall of previous 2-4 weeks. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with persistent asthma.
EIB: exercise-induced bronchospasm; ICU: intensive care unit.
Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.
Graphic 52149 Version 1.0
Assessing asthma control in children 5 to 11 years of age
Components of control Classification of asthma control (children 5 to 11 years of age)
Well controlled Not well controlled Very poorly controlled
Impairment Symptoms ≤2 days/week, but not more than once on each day >2 days/week or multiple times on ≤2 days/week Throughout the day
Nighttime awakenings ≤1 time/month ≥2 times/month ≥2 times/week
Interference with normal activity None Some limitation Extremely limited
Short-acting beta2-agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week Several times per day
Lung function
FEV1 or peak flow >80% predicted/personal best 60 to 80% predicted/personal best <60% predicted/personal best
FEV1/FVC >80% 75 to 80% <75%
Risk Exacerbations requiring oral systemic glucocorticoids 0 to 1/year ≥2/year (see footnote)
Consider severity and interval since last exacerbation
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient's/caregiver's recall of previous two to four weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic glucocorticoids in the past year may be considered the same as patients who have not well-controlled asthma, even in the absence of impairment levels consistent with not well-controlled asthma.
EIB: exercise-induced bronchospasm; FEV1: forced expiratory volume in 1 second; FVC: forced vital capacity; ICU: intensive care unit.
Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.
Graphic 73634 Version 3.0
Assessing asthma control in youths greater than or equal to 12 years of age and adults
Components of control Classification of asthma control (youths ≥12 years of age and adults)
Well controlled Not well controlled Very poorly controlled
Impairment Symptoms ≤2 days/week >2 days/week Throughout the day
Nighttime awakenings ≤2x/month 1 to 3x/week ≥4x/week
Interference with normal activity None Some limitation Extremely limited
Short-acting beta2-agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week Several times per day
FEV1 or peak flow >80 percent predicted/personal best 60 to 80 percent predicted/personal best <60 percent predicted/personal best
Validated questionnaires
ATAQ 0 1 to 2 3 to 4
ACQ ≤0.75* ≥1.5 N/A
ACT ≥20 16 to 19 ≤15
Risk Exacerbations 0 to 1/year ≥2/year (see footnote)
Consider severity and interval since last exacerbation
Progressive loss of lung function Evaluation requires long-term follow-up care
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient's recall of previous two to four weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.
EIB: exercise-induced bronchospasm; FEV1: forced expiratory volume in 1 second; ATAQ: Asthma Therapy Assessment Questionnaire (Vollmer et al. 1999); ACQ: Asthma Control Questionnaire (Juniper et al. 1999b); ACT: Asthma Control Test (Nathan et al. 2004); N/A: not applicable.
* ACQ values of 0.76 to 1.4 are indeterminate regarding well-controlled asthma.
Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.

 

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●Patient education to create a partnership between clinician and patient

●Controlling environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity

●Pharmacologic therapy

GOALS OF ASTHMA TREATMENT — The goals of chronic asthma management may be divided into two domains: reduction in impairment and reduction of risk [1].

Reduce impairment — Impairment refers to the intensity and frequency of asthma symptoms and the degree to which the patient is limited by these symptoms. Specific goals for reducing impairment include:

●Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath)

●Minimal need (≤2 days per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms

●Few night-time awakenings (≤2 nights per month) due to asthma

●Optimization of lung function

●Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise

●Satisfaction with asthma care on the part of patients and families

Reduce risk — The 2007 NAEPP guidelines introduced the concept of risk to encompass the various adverse outcomes associated with asthma and its treatment [1]. These include asthma exacerbations, suboptimal lung development (children), loss of lung function over time (adults), and adverse effects from asthma medications. Proper asthma management attempts to minimize the patient's likelihood of experiencing these outcomes. Specific goals for reducing risk include:

●Prevention of recurrent exacerbations and need for emergency department or hospital care

●Prevention of reduced lung growth in children, and loss of lung function in adults

●Optimization of pharmacotherapy with minimal or no adverse effects

 

 

 

 

Management of Asthma Exacerbations1

An asthma exacerbation is an episode of progressively increasing dyspnea, cough, wheezing, and/or chest tightness associated with a significant reduction in airflow parameters by spirometry or peak flow measurement.

Increase in the dose and/or frequency of short-acting bronchodilator therapy, combined with oral or IV corticosteroids at a dose equivalent to 0.5-1 mg of prednisone/kg/day (usually not exceeding 60-80 mg/day).

Severe exacerbations not responding to initial therapy, or status asthmaticus, require in-hospital therapy.

IV aminophylline and/or magnesium sulfate have been employed as adjunctive bronchodilators in severe exacerbations.

 Heliox (helium-enriched air) increases laminar airflow and reduces airway turbulence by its reduced density and viscosity, and thus may help ameliorate dyspnea and decrease the work of breathing in patients with status asthmaticus.

Non-invasive ventilation can be attempted in patients experiencing respiratory distress and impending respiratory failure; it may obviate the need for intubation and mechanical ventilation in status asthmaticus.

For patients requiring invasive mechanical ventilation, permissive hypercapnia can be used to maintain adequate Sao2 and low peak PAW at the expense of a mild respiratory acidosis with elevated Paco2 values. This particular approach has been associated with a decrease in asthma mortality compared to historical controls.

 

Lifestyle and home remedies

Taking steps to reduce your child's exposure to his or her asthma triggers will lessen the possibility of asthma attacks. Steps to help avoid triggers vary depending on what triggers your child's asthma. Here are some things that may help:

  • Maintain low humidity at home. If you live in a damp climate, talk to your child's doctor about using a device to keep the air drier (dehumidifier).
  • Keep indoor air clean. Have a heating and air conditioning professional check your air conditioning system every year. Change the filters in your furnace and air conditioner according to the manufacturer's instructions. Also consider installing a small-particle filter in your ventilation system.
  • Reduce pet dander. If your child is allergic to dander, it's best to avoid pets with fur or feathers. Regularly bathing or grooming your pets also may reduce the amount of dander in your surroundings.
  • Use your air conditioner. Air conditioning helps reduce the amount of airborne pollen from trees, grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your child's exposure to dust mites. If you don't have air conditioning, try to keep your windows closed during pollen season.
  • Keep dust to a minimum. Reduce dust that may aggravate nighttime symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dust-proof covers. Consider removing carpeting and installing hard flooring, particularly in your child's bedroom. Use washable curtains and blinds.
  • Clean regularly. Clean your home at least once a week to remove dust and allergens.
  • Reduce your child's exposure to cold air. If your child's asthma is worsened by cold, dry air, wearing a face mask outside can help.

Alternative medicine

While some alternative remedies are used for asthma, in most cases more research is needed to see how well they work and to measure the extent of possible side effects. Alternative treatments that may help with asthma include:

  • Breathing techniques. These include structured breathing programs, such as the Buteyko breathing technique, the Papworth method and yoga breathing exercises (pranayama).
  • Acupuncture. This technique has roots in traditional Chinese medicine. It involves placing very thin needles at strategic points on your child's body. Acupuncture requires holding still for up to a few minutes, which can be hard for young children. It's safe and generally painless.
  • Relaxation techniques. Techniques such as meditation, biofeedback, hypnosis and progressive muscle relaxation may help with asthma by reducing tension and stress.
  • Homeopathy. Homeopathy aims to stimulate the body's self-healing response by using very small doses of substances that cause symptoms. In the case of asthma, homeopathic remedies are made from substances that trigger an asthmatic reaction, such as pollen or weeds. There's still not enough evidence to determine whether homeopathy helps treat asthma caused by allergies.
  • Herbal remedies and supplements. A few herbal remedies have shown some evidence that they may help in treating asthma, including beta-carotene, black seed, fish oil and magnesium. However, further studies need to be made to confirm their benefit.

    Herbs and supplements can have side effects and some may interact with other medications your child is taking. Talk to your child's doctor before trying any herbs or supplements.

Coping and support

 

  • Make treatment a regular part of life. If your child has to take daily medication, don't make a big deal out of it — it should be as routine as eating breakfast or brushing teeth.

Severe Asthma

 In a patient with an acute asthma attack, a normal or high PaCO2 indicates that the patient can no longer maintain the work of breathing and is often a sign of impending respiratory failure. A pulsus paradoxus and electrocardiographic signs of right ventricular strain (ST-segment changes, right axis deviation, and right bundle-branch block) are also indicative of severe airway obstruction.

 

 

 

Environmental Measures

Preventive measures that involve environmental modifications to reduce exposure to indoor and outdoor aeroallergens may help improve asthma symptoms and reduce its potentially serious exacerbations.

Measures that reduce indoor dust mite burden include encasing the mattress and pillows in mite-impermeable materials, removing bedroom carpets and upholstered furniture as well as furry toys, washing the beddings weekly in hot water, and using dehumidifiers. Dehumidifiers and proper ventilation systems also prevent the growth of mold in damp areas such as basements and bathrooms. Mold damage in homes and work areas should be rectified. Removal or distancing of pets from the living areas or at least the bedroom can improve asthma symptoms in a pet-sensitized asthmatic. Keeping doors and windows closed year-round can prevent outdoor aeroallergens from entering the home. Public health policies should be promoted that prohibit smoking in public areas and improve indoor and outdoor air quality.

 

Immunization

Yearly influenza vaccination is recommended by the Centers for Disease Control and Prevention (CDC) for asthma patients to reduce their frequency of exacerbations associated with the flu, although strong proof of this efficacy in asthmatics is lacking. Immunization of all asthmatics with the 23-valent pneumococcal vaccine has also been recommended by the CDC, again despite the lack of robust evidence of its clinical efficacy in preventing pneumococcal pneumonia in this cohort.1

 

 

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