Transcript Slide 1

Treatment of asthma :
B.
Avoiding allergens.
Hyposensitization :Subcutaneous
C.
Drugs .
A.
injections of inially very small, but
gradually increasing doses of allergens
(desensitization or immunotherapy ) .
Drug treatment :
Can be divided in to 2 general categories :
1- Quick relief medications : Drugs that act
as relaxants of tracheobronchial smooth muscle ;
(bronchodilators ) :
β- adrenergic agonists, methylxonthines &
anticholinergics .
2- Long term control medications (Agents
that prevent &/or reverse inflammation ) :
glucocorticoids, leukotriene inhibitors & receptor
antagonists , cromolyn sodium , nedocromils
1- Adrenergic stimulants:
A- Short acting β-adrenergic(β2 selective) agonist:
Salbutamol, Terbutaline, Metaproterenol,
Pirbuterol , bitolterol.
B- Long acting β-adrenergic(Bselective)agents:
salmeterol , fenoterol & formoterol
C- Other adrenergic agonists :
Catecholamines : adrenaline .
2-Methylxanthines(phosphodiesterase inhibitor ) :
Theophylline
3-Anticholinergic agent:
Ipratrupium bromide and atropin.
4- glucocorticoids :
For treatment of asthma it is available as inhalation,
tablets , syrup & injections .
Inhaled corticosteroid :
-Preparations available are :beclomethasone, budesonide,
flunisolide, fluticasone ,triamcinolone .
Side effects of inhaled steroid :
oral candidates, glossitis , sore throat , hoarseness
,dysphonia, increase systemic absorption with large doses
of inhaled steroid (produce adrenal suppression, cataract,
decrease growth in children ….).
5-mast cell stabilizing agents:
Cromolyn sodium & Nedocromil sodium.
6-Antileukotrienes :
Zafirlukast & Montelukast ( leukotriene receptor antagonist )
Zileuton (inhibitor of leukotriene synthesis ).
7- Antihistamines :
Astemizole &Terfenadine
8- Ketotifen :
9-Other agents :

Steroid dependent pt. might benefit from the use of
immunosuppressant agents (used as steroid sparing
agents),like :
Methotrexate, Gold salt, & cyclosporine .

Methotrexate, Gold salt may produce lung toxicity .
Have limited role in the manegement off asthma.
Not used as standered therapy for asthma .


Omalizumab


MECHANISM OF ACTION — Omalizumab is an IgG monoclonal
antibody which inhibits IgE binding to the IgE receptor on mast
cells and basophils. By decreasing bound IgE, the activation and
release of mediators in the allergic response (early and late phase)
is limited.
Long-term treatment in patients with allergic asthma showed a
decrease in asthma exacerbations and corticosteroid usage.

USE — Treatment of moderate-to-severe, persistent allergic asthma
not adequately controlled with inhaled corticosteroids

CONTRAINDICATIONS — Hypersensitivity to omalizumab & in status
asthmaticus
ADMINISTRATION — For SubQ injection only

Medications to Treat Asthma:
Quick-Relief

Used in acute
episodes

Generally shortacting beta2agonists
Medications to Treat Asthma:
How to Use a Spray Inhaler
The health-care
provider should
evaluate inhaler
technique at each
visit.
Medications to Treat Asthma:
Inhalers and Spacers
Spacers can help
patients who have
difficulty with inhaler
use and can reduce
potential for adverse
effects from
medication.
Medications to Treat Asthma:
Nebulizer

Machine produces a
mist of the medication

Used for small children
or for severe asthma
episodes
Treatment of episodic asthma :
Mild & infrequent episodes can be controlled by salbutamol
inhaler . In pt. with more frequent episodes add sodium
cromoglicate & beclomethasone inhaler .
Treatment of exercise induced asthma
Common in children &young adults,give 2 doses of salbutamol
inhaler few minutes befor exercise, if not effective then add
sodium cromoglicate & beclomethasone inhaler .
Treatment of chronic persistent asthma :

Step 1 : occasional use of inhaled short
acting β2 agonist .
As salbutamol or terbutaline ,used by inhalation
as required .
If the pt. is using β2 agonist more than once
daily, move to step 2

Step 2 :low dose inhaled steroid .
Inhaled salbutamol is used as required +
regular inhaled steroid (beclomethasone) up to
800 microgram daily .

Step 3 : high dose inhaled steroids or low
dose inhaled steroids + long acting
inhaled β2 agonist .
Inhaled salbutamol is used as required +inhaled
steroid in dose range 800-2000 microgram daily.
alternatively a long acting β2 agonist as
salmeterol 50 microgram 12-hourly, or a
sustained-release theophylline may be added .

Step 4 : high dose inhaled steroids &
regular bronchodilaters .
Inhaled salbutamol is used as required + inhaled
corticosteroid (800 – 2000 microgram dail ) + one or
more of the following (as therapeutic trial ) :
•
•
•
•
•
Inhaled long acting B2 agonist ( salmeterol ) .
Leukotriene recepror antagonist (montelukast ).
Inhaled ipratropium bromide .
Long acting oral B2 agonist( sustained release
salbutamol or terbutaline preparations ) .
Sodium cromoglicate .

Step 5 : addition of regular oral steroid
therapy .
Step 4 treatment is given +regular prednisolone
tablets prescribed in the lowest amount
necessary to control symptoms as a single daily
dose in the morning .

Occationally you can increase a step (step up) to control
exacerbetions.

You can decrease a step (step down) if good symptom
control for 3 months or more .

Only think of withdrawing anti inflammatory treatment if
pt. well for at least 6 months .

In general it is better to start with a treatment regimen
which is likely to achieve disease control rapidly,& then
step down, rather than to start with inadequate
treatment & then have to step up .
Management of acute sever asthma
(status asthmaticus ):

The aims of management are to prevent death & to
restore pulmonary function as quick as possible .

We should assess the pt. for the features of severity .
According to the severity we can classified sever asthma
in to :
1- Acute sever asthma .
2- Life threatening asthma .

3- Near fatal asthma .
Features of acute sever asthma :
1.
PEF< 50% of expected (<200 L/min) .
2.
Respiratory rate >25 /min .
3.
Heart rate >110 beat /min .
4.
Inability to complete sentences in one breath .
Features of life threatening asthma :
1.
2.
3.
4.
5.
6.
7.
8.
9.
Unrecordable PEF (<100 L/min) .
Pa O2 < 8 kpa (especially if being treated with
O2 ) .
Silent chest .
Cyanosis .
Bradycardia or arrhythmias .
Hypotention .
Exhaustion .
Confution .
Coma.
Features 0f near fatal asthma :
1- Increase PaCO2
& / or
2- Requirement for mechanical ventillation .
Immediate treatment for acute sever
asthma :
1-Oxygen: should be given at the highest concentration
available ( usually 60 % ) .
Then the concentration adjusted according to the arterial
blood gas measurement (PaO2 should be maintained >
9 kpa ) .
2-High dose inhaled B2 agonist :
B2 agonist should be nebulized using O2 .
Salbutamol 2.5 – 5 mg. or Terbutaline 5-10 mg. given
initially & can be repeated within 30 min.if necessary.
3-Systemic corticosteroid:
IV Hydrocortisone 200 mg. or oral Prednisolone 30-60mg
Subsequent management of acute
sever asthma
If features of severity persist you should continue the
management as following:
1-Close monitoring & continue O2 therapy.
2-Continue nebulized B2 agonist : every 15-30 min
( reduce to 4 hourly once clear clinical response)
3-Ipratropium bromide 0.5 mg. should be added to the
nebulized B2 agonist .
4-Continue systemic steroid : Hydrocortisone 200mg. IV. 6
hourly .
5-Magnesium sulphate : 25 mg /kg. IV .
6- Aminophylline IV .
7- Mechanical ventillation .
Indications for assisted ventillation
in acute sever asthma.
1- Coma.
2-Respiratory arrest .
3-Exhaustion , Confution , Drowsiness.
4-Deterioration of arterial blood gas tention despite optimal
therapy :
-PaO2 < 8 kpa & falling.
-PaCO2 > 6 kpa &rising .
-PH low & falling
.
Monitoring of Treatment
1- PEF recording should be made every 15-30 min. then
PEF chart 4-6 hourly during hospital stay .
2-Repeated measurment of arterial blood gas tension or
using pulse oxymetry .
Managing Asthma:
Peak Expiratory Flow (PEF) Meters

Allows patient to assess status of his/her asthma
Prognosis of asthma
 -The prognosis of individual asthma attacks is generally

good .
Complete remission of asthma is relatively common in
children ( episodic asthma ), as many as 25%
remain asymptomatic from adolescence onward.

In adults ( chronic asthma ), prolonged remission of
asthma symptoms are less common.

Patients older than 65 years tend to have sever
asthma that infrequently goes into remission , in these
patients asthma is less reversible

. There is occationally a fatal outcome especially if

-Atopic asthma is usually worse in the summer( heavely
exposed to allergens ).

-Chronic asthma is usually worse in the winter (increase
frequency of viral infection
treatment is inadequate or delayed.