___________________________________________________________ Asthma: Diagnosis and Management
ASTHMA IN ELDERLY PATIENTS The management and diagnosis of asthma in the elderly population may be difficult due to the frequency of additional medical complications or diseases, any of which may aggravate or be aggravated by asthma and/or asthma medications. Spe- cifically, the high incidence of other obstructive lung diseases makes it vital to fully explore possible causes of airway obstruc- tion. Asthma may usually be diagnosed if the obstruction is determined to be reversible. Also, due to the higher prevalence of co-existing diseases, healthcare providers should be aware of possible drug interactions. As mentioned, theophylline in particular has several possible interactions, as well as reduced clearance in the elderly, all of which should be considered. Use of the asthma classification standards and the NAEPP treat- ment plan is also approved for elderly patients, but individual condition and drug interactions should be closely monitored [9; 10]. Many medications may also trigger asthma symptoms; this may be more prevalent in the elderly population, as more medications may be prescribed. Various asthma medications can adversely affect elderly patient health. Corticosteroids have been shown to cause confusion and agitation in older patients [35]. There also appears to be a reduction in bone mineral concentrations in patients taking inhaled corticosteroids, particularly in those with pre-existing osteoporosis. However, in low-to-moderate doses, there seems to be no major adverse effect. The NAEPP recommends con- current treatment with calcium supplements and vitamin D, if appropriate [9; 10]. ASTHMA IN PREGNANCY Reliable data regarding the prevalence of asthma among pregnant women and women of childbearing age are limited, although research indicates that it is the most common chronic medical condition to be reported during pregnancy. Estimates show that approximately 8% of pregnant individuals in the United States are affected by asthma symptoms. Furthermore, asthma during pregnancy may cause complications such as high blood pressure and pre-eclampsia, preterm delivery, and low infant birth weight. For women who have experienced asthma symptoms prior to becoming pregnant, it is estimated that one-third of these women will each experience a decrease, increase, or no change in their experience of the condition. It is unclear which, if any, of the physiologic changes associated with pregnancy may cause changes in the symptomatology of asthma [9; 13; 46].
The NAEPP has established practice recommendations for the management and treatment of asthma in pregnant patients and is supported by the American Congress of Obstetricians and Gynecologists [9]. The goal for pregnant patients with asthma should be to maintain control of asthma, as it is for all patients, and to maintain normal fetal and maternal health throughout gestation. Severe asthma attacks or persistent asthma may cause fetal hypoxia. Therefore, treatment of maternal asthma should be aggressive and complete. Assessment, including PEF and FEV 1 measurements and patient history, should continue throughout the pregnancy. If a woman is found to have per- sistent asthma or if she has a severe asthma attack, additional fetal monitoring, through ultrasound and antenatal fetal test- ing, may be indicated. According to the NAEPP, all patients should be instructed to be attentive to fetal activity [9; 46]. As with asthma experienced outside of pregnancy, trigger avoidance and patient education are among the most impor- tant aspects of controlling the condition. Patient education can increase adherence to the management plan and may be used to stress the importance of controlling asthma symptoms for the benefit of the fetus. In previously untested women, allergy tests may be useful to determine if any controllable allergies are present. Immunotherapy is not generally recommended in pregnant individuals, but omalizumab therapy may be consid- ered if standard treatments are not sufficient to control severe asthma, as the benefits to the patient and fetus may outweigh the risks [9; 35; 46]. Pharmacologic treatments for asthma are generally considered more beneficial than the possible harmful side effects and are therefore recommended for the management of asthma during pregnancy. Antileukotrienes may be considered for patients whose pre-pregnancy response to the drug was favor- able. However, the drug should be considered an alternative, not a preferred, treatment option for control of mild persis- tent asthma in pregnant patients. The goal of pharmacologic treatment should be to gain and maintain control of asthma symptoms. After control is obtained and asthma symptoms stabilize for several months, less intensive treatment should be initiated. In some patients with severe or persistent asthma, the risk of a possibly harmful asthma episode may outweigh the benefits of lessening the intensity of asthma therapy. If this is the case, the step down to less intensive treatment may be deferred until after giving birth. The greatest amount of efficacy and safety data support the use of albuterol as the beta 2 agonist for use during pregnancy. Albuterol is a selective beta agonist and has a good safety record for both pregnant and nonpregnant patients. The recommended inhaled corticoste- roid for long-term management is budesonide, as more research has been conducted regarding the effects of this medication on pregnant individuals. No data regarding the unsafe or safe properties of other corticosteroids in pregnant patients have been published [9; 35; 46].
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