Treatment:

General Approach for Treating and Managing Asthma

While medications play an essential role in the management of asthma, appropriate management of asthma involves much more:

• Identifying and avoiding allergens and other asthma triggers
• Following appropriate drug treatments
• Home monitoring performed by either patient or family
• Good communication between the doctor and patient
• Needed psychosocial support
• Treatment of asthma in all environments (school, work, exercise)

The severity of asthma is classified into four groups: Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent. Six specific components of severity are used to classify patients. These components are:

• Symptom frequency, ranging from fewer than 2 days per week to throughout the day
• Nighttime awakenings, ranging from none to nightly
• Short-acting beta2-agonist use for symptom control, ranging from 2 or fewer days per week to several times per day
• Interference with normal activity, ranging from none to extremely limited
• Lung function as measured by FEV1 and FEV1/FVC, measured with pulmonary function testing at the doctor's office
• Number of exacerbations (sudden worsening) requiring oral corticosteroids, ranging from none to two or more in the last 6 months

Treating Symptoms Versus Controlling the Disease

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.

Medications for asthma fall into two categories:

• Rescue (Quick-Relief) 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. Beta2-agonists and anticholinergics do not have any effect on the disease process itself. They are only useful for treating symptoms.
• Long-Term Control (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, doctors recommend inhaled corticosteroids sometimes with 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.

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 patientâ ' s personal best
• Both the doctor and the patient consider the asthma to be well controlled

Steps for Treating Asthma

A stepwise approach is recommended for treating asthma. Medications and dosages are increased when needed, and decreased when possible. Based on severity of patients' asthma and their age, there are specific recommendations regarding whether to use long-term control medications and which ones to use. Patient education, environmental control measures, and management of any other conditions are also included. Doctors may always adjust these recommendations based on a specific patient.

In choosing therapy, doctors must also consider the risk an individual patient has for more severe exacerbations. Factors that may contribute to this include parental history of asthma, atopic dermatitis, and known sensitivity to different allergens or foods. Patients should be reevaluated within 2 - 6 weeks to assess response.

Key points regarding recommendations for adults include:

• Inhaled corticosteroids are the preferred long-term control therapy. Long-acting beta2-agonists and leukotriene antagonists are additional therapies usually used in addition to inhaled corticosteroids.
• Avoiding or managing environmental triggers is always important.

Devices Used for Administering Inhaled Drugs

Most asthma drugs are taken with inhalers. In a hospital setting, or when a patient cannot use an inhaler, a nebulizer may be used. A nebulizer is a device that administers the drug in a fine spray that the patient breathes in. The two basic inhaler devices are the metered-dose inhaler (MDI) and dry powder inhalers (DPIs).

Metered-Dose Inhaler. The standard device for administering any asthma medication is the metered-dose inhaler (MDI). This device allows precise doses to be delivered directly to the lungs. 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.

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. A spacer, which is short tube attached to the mouthpiece, can help patients make sure they are getting the right amount of medication.

Dry Powder Inhalers. Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. Some patients find that they are easier to manage than MDIs. Humidity or extreme temperatures can affect the performance of these inhalers, 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 using a DPI and to brush twice a day with a fluoride toothpaste.

Monitoring

People who self-manage their asthma with peak air flow measurements and adjust their medications as needed have fewer hospitalizations and unplanned doctors visits, and, generally, have a better quality of life than those who rely only on the occasional doctor or emergency room visit to control symptoms. Doctors recommend that patients with even mild asthma monitor their own conditions.

In general, monitoring involves the following steps:

• A peak flow meter is the standard monitoring device for measuring peak expiratory flow rate (PEFR).

• Patients with severe asthma should take PEFR readings two or three times a day. The overall goal should be to achieve less than a 20% (and ideally only 10%) variation in readings between evening and morning rates. For mild-to-moderate asthma, a single determination each morning usually suffices, but patients should check with their doctors.
• It is important to use the meter at the same times each day and to stand or sit in the same position to keep an accurate record.
• Patients should keep an ongoing record of their peak flow readings to help them detect worsening of their condition.
• They should also record attacks, exposure to any allergens or triggers, and medications taken.
• After about 2 months, patients and doctors can use the recorded data for administering medications effectively and to recognize problems before they become serious.

Treatment of Asthma during Pregnancy

Guidelines from the National Asthma Education and Prevention Program (NAEPP) emphasize that most asthma medications are safe for pregnant women. The guidelines recommend that pregnant women with asthma have albuterol available at all times. Inhaled corticosteroids should be used for persistent asthma. Patients whose persistent asthma does not respond to standard dosages of inhaled corticosteroids may need a higher dosage or the addition of a long-acting beta-agonist to their drug regimen. For severe asthma, oral corticosteroids may be necessary. The NAEPP notes that while it is not clear if oral corticosteroids are safe for pregnant women, uncontrolled asthma poses an even greater risk for a woman and her fetus.