Therapeutic Strategies in Asthma: Current Treatments


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Medicines & Treatment

Systemic beta-2 agonists. Subcutaneous administration is no more effective than inhalation and may have more adverse effects. Use in adults is controversial and may be contraindicated if significant cardiovascular disease is present. Short-acting beta-2 agonists. MDI is as effective as nebulized solution if patients can coordinate inhalation maneuver using spacer and holding chamber. Levalbuterol is the R -isomer of albuterol. Levalbuterol may have fewer adverse effects than albuterol. Nebulized solution: 0. Ipratropium should be added to beta-2 agonists and not used as first-line therapy.

Combination drugs. Ipratropium prolongs bronchodilator effect of albuterol. Systemic corticosteroids. August 28, Available at www. Inhaled bronchodilators beta-2 agonists and anticholinergics are the mainstay of asthma treatment in the emergency department. In adults and older children, albuterol given by a metered-dose inhaler MDI and spacer is as effective as that given by nebulizer.

Nebulized treatment is preferred for younger children because of difficulties coordinating MDIs and spacers. It should be emphasized that, contrary to popular belief, no data favor continuous beta-2 agonist nebulization over intermittent administration. Evidence suggests that bronchodilator response improves when the nebulizer is powered with a mixture of helium and oxygen heliox rather than with oxygen. Given its lower density, helium is thought to assist with delivery of bronchodilators to distal airways.

However, technical aspects of using helium for nebulization availability, calibration of helium concentration, need for custom masks to avoid dilution with room air have limited its widespread acceptance.

Current therapies and research and development in the treatment of asthma

Subcutaneous epinephrine solution or terbutaline is an alternative for children. Terbutaline may be preferable to epinephrine because of its lesser cardiovascular effects and longer duration of action, but it is no longer produced in large quantities and is expensive. Subcutaneous administration of beta-2 agonists in adults raises concerns of adverse cardiostimulatory effects. However, clinically important adverse effects are few, and subcutaneous administration may benefit patients unresponsive to maximal inhaled therapy or patients unable to receive effective nebulized treatment eg, those who cough excessively, have poor ventilation, or are uncooperative.

Nebulized ipratropium can be co-administered with nebulized albuterol for patients who do not respond optimally to albuterol alone; some evidence favors simultaneous high-dose beta-2 agonist and ipratropium as first-line treatment. Systemic corticosteroids prednisone , prednisolone , methylprednisolone should be given for all but the mildest acute exacerbation; they are unnecessary for patients whose PEF normalizes after 1 or 2 bronchodilator doses.

IV and oral routes of administration are probably equally effective. IV methylprednisolone can be given if an IV line is already in place and can be switched to oral dosing whenever necessary or convenient.

In general, higher doses prednisone 50 to 60 mg once a day are recommended for the management of more severe exacerbations requiring in-patient care while lower doses 40 mg once a day are reserved for outpatient treatment of milder exacerbations. Although evidence about optimal dose and duration is weak, a treatment duration of 3 to 5 days in children and 5 to 7 days in adults is recommended as adequate by most guidelines and should be tailored to the severity and duration of an exacerbation 1, 2.

Theophylline has very little role in treatment of an acute asthma exacerbation. Magnesium sulfate relaxes smooth muscle, but efficacy in management of asthma exacerbation in the emergency department is debated. Antibiotics are indicated only when history, examination, or chest x-ray suggests underlying bacterial infection; most infections underlying asthma exacerbations are probably viral in origin.

Implications for Asthma Treatment Strategies in Managed Care

Reassurance is the best approach when anxiety is the cause of asthma exacerbation. Anxiolytics and morphine are relatively contraindicated because they are associated with respiratory depression, and morphine may cause anaphylactoid reactions due to release of histamine by mast cells; these drugs may increase mortality, and the need for mechanical ventilation. Hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment.

Criteria for hospitalization vary, but definite indications are. A significant increase in PaCO2 indicates progression to respiratory failure. Noninvasive positive pressure ventilation NIPPV may be needed in patients whose condition continues to deteriorate despite aggressive treatment, to alleviate the work of breathing. Endotracheal intubation and invasive mechanical ventilation may be needed for respiratory failure.

NIPPV can be used to prevent intubation if used early in the course of a severe exacerbation and should be considered in patients with acute respiratory distress with a level of PaCO2 that is inappropriately high in relation to the degree of tachypnea. Mechanical ventilation should be strongly considered if there is no convincing improvement after 1 hour of NIPPV. Intubation and mechanical ventilation allow the provision of sedation to further alleviate the work of breathing, but the routine use of neuromuscular blocking agents should be avoided because of possible interactions with corticosteroids that can cause prolonged neuromuscular weakness.

Generally, volume-cycled ventilation in assist-control mode is used because it provides constant alveolar ventilation when airway resistance is high and changing. High peak airway pressures will generally be present because they result from high airway resistance and inspiratory flow rates. Subcutaneous administration of beta-2 agonists in adults raises concerns of adverse cardiostimulatory effects. However, clinically important adverse effects are few, and subcutaneous administration may benefit patients unresponsive to maximal inhaled therapy or patients unable to receive effective nebulized treatment eg, those who cough excessively, have poor ventilation, or are uncooperative.

Nebulized ipratropium can be co-administered with nebulized albuterol for patients who do not respond optimally to albuterol alone; some evidence favors simultaneous high-dose beta-2 agonist and ipratropium as first-line treatment. Systemic corticosteroids prednisone , prednisolone , methylprednisolone should be given for all but the mildest acute exacerbation; they are unnecessary for patients whose PEF normalizes after 1 or 2 bronchodilator doses.

IV and oral routes of administration are probably equally effective. IV methylprednisolone can be given if an IV line is already in place and can be switched to oral dosing whenever necessary or convenient. In general, higher doses prednisone 50 to 60 mg once a day are recommended for the management of more severe exacerbations requiring in-patient care while lower doses 40 mg once a day are reserved for outpatient treatment of milder exacerbations.

Although evidence about optimal dose and duration is weak, a treatment duration of 3 to 5 days in children and 5 to 7 days in adults is recommended as adequate by most guidelines and should be tailored to the severity and duration of an exacerbation 1, 2. Theophylline has very little role in treatment of an acute asthma exacerbation. Magnesium sulfate relaxes smooth muscle, but efficacy in management of asthma exacerbation in the emergency department is debated.

Antibiotics are indicated only when history, examination, or chest x-ray suggests underlying bacterial infection; most infections underlying asthma exacerbations are probably viral in origin. Reassurance is the best approach when anxiety is the cause of asthma exacerbation. Anxiolytics and morphine are relatively contraindicated because they are associated with respiratory depression, and morphine may cause anaphylactoid reactions due to release of histamine by mast cells; these drugs may increase mortality, and the need for mechanical ventilation.

Hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment. Criteria for hospitalization vary, but definite indications are. A significant increase in PaCO2 indicates progression to respiratory failure. Noninvasive positive pressure ventilation NIPPV may be needed in patients whose condition continues to deteriorate despite aggressive treatment, to alleviate the work of breathing. Endotracheal intubation and invasive mechanical ventilation may be needed for respiratory failure. NIPPV can be used to prevent intubation if used early in the course of a severe exacerbation and should be considered in patients with acute respiratory distress with a level of PaCO2 that is inappropriately high in relation to the degree of tachypnea.

Mechanical ventilation should be strongly considered if there is no convincing improvement after 1 hour of NIPPV. Intubation and mechanical ventilation allow the provision of sedation to further alleviate the work of breathing, but the routine use of neuromuscular blocking agents should be avoided because of possible interactions with corticosteroids that can cause prolonged neuromuscular weakness.

Generally, volume-cycled ventilation in assist-control mode is used because it provides constant alveolar ventilation when airway resistance is high and changing.

NEWS & VIDEOS

High peak airway pressures will generally be present because they result from high airway resistance and inspiratory flow rates. In these patients, peak airway pressure does not reflect the degree of lung distention caused by alveolar pressure. However, if plateau pressures exceed 30 to 35 cm water, then tidal volume should be reduced to limit the risk of pneumothorax.

When reduced tidal volumes are necessary, a moderate degree of hypercapnia is acceptable, but if arterial pH falls below 7. Once airflow obstruction is relieved and PaCO2 and arterial pH normalize, patients can usually be quickly weaned from the ventilator. For further details, see Respiratory Failure and Mechanical Ventilation.

Other therapies are reportedly effective for asthma exacerbation, but none have been thoroughly studied. A mixture of helium and oxygen heliox is used to decrease the work of breathing and improve ventilation through a decrease in turbulent flow attributable to helium, a gas less dense than oxygen. However, heliox could be beneficial for the management of patients with vocal cord dysfunction. General anesthesia in patients with status asthmaticus causes bronchodilation by an unclear mechanism, perhaps by a direct relaxant effect on airway smooth muscle or attenuation of cholinergic tone.

British Thoracic Society Asthma Guidelines From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. The Merck Manual was first published in as a service to the community.

Learn more about our commitment to Global Medical Knowledge. Common Health Topics. Videos Figures Images Quizzes. Commonly Searched Drugs. Emergency department care. Other therapy. General references. Test your knowledge.


  1. Introduction?
  2. Passion on the Vine: A Memoir of Food, Wine, and Family in the Heart of Italy?
  3. New Strategies in the Medical Management of Asthma - American Family Physician.
  4. Asthma guidelines.
  5. Asthma - Treatment - NHS;
  6. Absorption and Drug Development: Solubility, Permeability and Charge State.
  7. Strong at the Broken Places: Voices of Illness, a Chorus of Hope.

Add to Any Platform. Click here for Patient Education. It may be mixed in same nebulizer as albuterol.

Therapeutic Strategies in Asthma: Current Treatments Therapeutic Strategies in Asthma: Current Treatments
Therapeutic Strategies in Asthma: Current Treatments Therapeutic Strategies in Asthma: Current Treatments
Therapeutic Strategies in Asthma: Current Treatments Therapeutic Strategies in Asthma: Current Treatments
Therapeutic Strategies in Asthma: Current Treatments Therapeutic Strategies in Asthma: Current Treatments
Therapeutic Strategies in Asthma: Current Treatments Therapeutic Strategies in Asthma: Current Treatments

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