___________________________________________________________ Asthma: Diagnosis and Management
STEPWISE APPROACH FOR MANAGING ASTHMA IN PATIENTS 12 YEARS OF AGE AND OLDER Treatment Step Preferred Treatment Alternative Treatment Considerations Steps 1–6 In each step, assess environmental factors, provide patient education, and manage comorbidities, then: Step up if needed; reassess in 2 to 6 weeks Step down if possible (if asthma is well controlled for at least 3 consecutive months) ICS=inhaled corticosteroid; LABA=long-acting beta2-agonist; LAMA=long-acting muscarinic antagonist; LTRA=leukotriene receptor antagonist; SABA=inhaled short-acting beta2-agonist Note: Medications linked with a slash (/) indicate combination formulations in a single inhaler. a Cromolyn, nedocromil, theophylline, and LTRAs including zileuton and montelukast were not considered in the 2022 update of the NAEPP guidelines, have limited availability for use in the United States, and/or have an increased risk of adverse consequences and need for monitoring that make their use less desirable. The FDA issued a boxed warning for montelukast in March 2020 due to the risk for serious neuropsychiatric events, including suicide. Source: [9; 10] Table 2
PHARMACOLOGIC INTERVENTIONS When considering pharmacologic treatment of asthma, the dosage, timing, and type of medication should be tailored to individual needs. Optimal treatment should include methods to reverse airflow barriers, stop symptoms from occurring, prevent serious attacks and need for emergency care and hospitalization, keep asthma from interfering with activities of daily living, minimize side effects, and control symptoms with the least amount of medication. As with the approach to management, medication therapy generally adheres to two possible uses: to relieve symptoms quickly with the use of bronchodilators or to reduce chronic airway inflammation with anti-inflammatory medications, preventing asthma from recurring in the future [9; 10]. Medication Administration Asthma medications may be inhaled, taken orally in pill, granule, or liquid form, or in emergency situations, injected intravenously. Inhalers There are several types of inhalers available including aerosol, dry powder, and nebulizers. Metered-dose inhalers (MDIs) rely on a mixture of medication, preservatives, and liquid propel- lant gas to deliver medicine into the lungs in aerosol form. As of 2008, inhalers that contain chlorofluorocarbon propellants are no longer permitted to be sold [34]. Some short-acting inhaled medications begin to reverse airway constriction within five minutes; however, long-acting medica- tions have been developed in inhalant form as well. Inhaled medications have advantages over oral administration because the medication is able to enter directly into the lungs rather than through the circulatory system. Some MDIs discharge medication after a trigger is pressed, but newer versions are breath activated. For patients with poor coordination or impaired hand function, such as those with arthritis or with a history of stroke, breath-activated devices may improve medica-
tion delivery. The drawback of the breath-activated inhalers is that, during a severe attack, a lack of air may make device triggering difficult [9; 11]. Some patients require the assistance of a spacer when using an inhaler. A spacer is a plastic tube that attaches to an MDI; its function is to momentarily trap medication as it exits the inhaler, allowing the medication to be inhaled more easily and preventing it from being lost. Spacers may benefit patients who find it difficult to squeeze the trigger and inhale at the same moment, such as young children or older adults. As medicine deposited in the mouth area can produce side effects, spacers can help limit this and ensure that more medication reaches the lungs instead of the tongue or back of the throat [9; 11]. A major problem with MDIs is knowing when they are empty. Usually, a patient cannot see, hear, or taste when a canister is empty or delivering less medication than intended; in fact, at times, inhalers may feel heavy enough to hold medication but only contain propellant and preservatives. In some cases, empty inhalers may leave a strange taste or heavier spray in the patient’s mouth [9; 11]. Each inhaler should have a label that indicates how many mea- sured metered doses the canister holds. For regularly scheduled medications, it is best to calculate the number of usable doses before a new inhaler is needed. Patients may mark calendars or the canister to remind themselves when to reorder another inhaler. In the past, some patients have used the so-called “float test” to determine the amount of medication remaining in the canister. This has been proven to be inaccurate and should not be recommended. Some canisters may require cleaning to prevent the accumulation of bacteria [9; 11]. Breath-activated dry powder inhalers incorporate the same ben- efits as other breath-activated inhalers; patients are not required to coordinate inhaling with releasing medication. Some dry powder inhalers have a different delivery system involving the insertion of a capsule with medicated, fine powder into the canister. In general, each capsule contains a single dose that
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