| Written by Dr.Md.Redwanul Huq (Masum) |
| Monday, 20 June 2011 15:33 |
[HINTS: Contd-To be continued, M- Month, ±M- Before or After Meal, AM- After Meal, ½HBM- ½ Hour Before Meal,W- Week, D-Day.2HAM- 2 Hour After Meal,bid-Twice daily, tid-Three times daily,qid-Four times daily.]
Treatment of paroxysmal asthma:
1. Short-acting beta 2-adrenoreceptor agonist bronchodilators (e.g. salbutamol, terbutaline) is the first choice which is used only during episode. These drugs are available in inhaler and oral form between which the former is better.
Inhaler: 2 Puffs-when required.
Oral: 2mg or 4mg tab bid or tid.
2. If symptoms are not relieved even after use of the above drug steroid inhaler, e.g. Beclomithasone should be used- 2 puffs-bid.
Treatment for Chronic asthma:
Stepwise treatment of chronic bronchial asthma-
| Steps | Asthma status/ symptoms | Treatment |
| STEP 1 | Mild intermittent asthma (Symptoms appear less than once in a week for 3 months and less than two nocturnal attacks per month) | For more than 5 years to adults: Short-acting beta2 -agonist bronchodilator (e.g. salbutamol, terbutaline) inhaler- 200 mcg (2 puffs) at a time when required, up to 4-6 times per day. Additional 2 puffs before exercise or heavy work.For 5 years or less: Short-acting beta2 -agonist bronchodilator inhaler- 100-200 mcg (1-2 puffs) at a time when required, up to 4-6 times per day. Additional 1-2 puffs before exercise or sports. |
| STEP 2 | Mild persistent asthma ( When patient has one or more of the followings-1.Symptoms appear three times or more in a week2.Has developed an exacerbation of bronchial asthma in last 2 years3.Wake up in one night for asthmatic attack per week 4.Used beta 2 -agonist inhalers three times or more in a week) | STEP 1 +For more than 5 years to adults: ICS (Inhaled corticosteroids, e.g. Beclomethasone or Budesonide) Low dose-For 5-12 years: 200-400 mcg per day preferably in two divided doses.For more than 12 years to adults: 400-800 mcg per day preferably in two divided doses.
For 5 years or less: ICS (Inhaled corticosteroids, e.g. Beclomethasone or Budesonide) Low dose- 100-250 mcg per day preferably in two divided doses. [Fluticasone and Mometasone exert similar efficacy at half the dosage of Beclomethasone or Budesonide] |
| STEP 3 | Moderate persistent asthma(Symptoms are not well controlled even after use of ICS low dose) | STEP 2 +LABA(Long-acting beta2 -agonists, e.g. Salmeterol,Bambuterol or Formoterol) bronchodilator inhaler Or, Leukotriene antagonists (e.g. Montelukast 5-10 mg daily) Or, SR(Sustained release) Theophylline Or, Ipratropium bromide inhaler
ALTERNATIVE TREATMENT: STEP 1+ For more than 5 years to adults: ICS (Inhaled corticosteroids, e.g. Beclomethasone or Budesonide) High dose-For 5-12 years: up to 800 mcg per day preferably in two divided doses. For more than 12 years to adults: up to 2000 mcg per day preferably in two divided doses. For 5 years or less: ICS (Inhaled corticosteroids, e.g. Beclomethasone or Budesonide) Medium dose- 250-500 mcg per day preferably in two divided doses. [Fluticasone and Mometasone exert similar efficacy at half the dosage of Beclomethasone or Budesonide] |
| STEP 4 | Severe persistent asthma(Symptoms are not well controlled even after getting treatment of STEP 3) | STEP 1 +For more than 5 years to adults: ICS (Inhaled corticosteroids, e.g. Beclomethasone or Budesonide) High dose-For 5-12 years: up to 800 mcg per day preferably in two divided doses.For more than 12 years to adults: up to 2000 mcg per day preferably in two divided doses.
+ LABA (Long-acting beta2 -agonists, e.g. Salmeterol,Bambuterol or Formoterol) bronchodilator inhaler &/Or, Leukotriene antagonists (e.g. Montelukast 5-10 mg daily) &/Or, SR(Sustained release) Theophylline &/Or, Ipratropium bromide inhaler For 5 years or less: ICS (Inhaled corticosteroids, e.g. Beclomethasone or Budesonide) High dose- 500-800 mcg per day preferably in two divided doses. OR, ICS High dose +LABA(Long-acting beta2 -agonists, e.g. Salmeterol,Bambuterol or Formoterol) bronchodilator inhaler Or, Leukotriene antagonists (e.g. Montelukast 5 mg daily) Or, SR(Sustained release) Theophylline Or, Ipratropium bromide inhaler. [Fluticasone and Mometasone exert similar efficacy at half the dosage of Beclomethasone or Budesonide] |
| STEP 5 | Very severe persistent asthma (Symptoms are poorly controlled with all above measures) | STEP 4 +Oral corticosteroids (usually prednisolone or prednisone) 30 – 45 mg od in the morning for 5-10 days, then the lowest dose required to control symptoms(usually 7.5-10 mg od in the morning) should be continued if necessary. |
Step Down Therapy: When the symptoms of asthma are under control, the therapy should be decreased slowly to the lowest dose at which effective control of symptoms of asthma is maintained.
Treatment of acute severe asthma attack-
Immediate treatment:
1.Position: Propped up position of the patient
2.Oxygen: High concentrations of oxygen (4-6 liters/min) should be given by face mask to maintain the oxygen saturation more than 92% in adults
3.Nebulization: Respiratory solution ofshort-acting beta2-agonist bronchodilator (e.g. salbutamol, terbutaline etc) with(if needed) or withoutIpratropium bromide are given stat by nebulizer
4. Intravenous (IV) beta2- agonist: In patients with impending respiratory failure- IV beta 2-agonist can be given
5.Parenteral or Oral Steroids: Inj. Hydrocortisone 200 mg IV or Oral Prednisolone 30-60 mg stat
6. Intravenous fluids: Dehydrated patients should be given Intravenous fluids
Subsequent treatment:
If patient improves:
1. High concentrations of oxygen should be continued until cyanosis persists or blood gas analysis shows normal levels
2.Nebulization should be reduced- 4 hourly, 6 hourly, 8 hourly, 12 hourly and then inhalers should be started
3. Inj. Hydrocortisone 200 mg IV should be reduced- 6 hourly, 8 hourly, 12 hourly and then oral prednisolone should be started at a dose of 30 – 45 mg od in the morning for 5 – 10 days, then the lowest dose required to control symptoms (usually 7.5-10 mg od in the morning) should be continued if necessary.
If patient does not improve:
1. High concentrations of oxygen should be continued
2. Nebulization should be repeated after 30 minutes and continued hourly until patient improves
3. Magnesium sulfate may be given IV or by inhaler in patients with PEF < 30% predicted
4. Slow infusion of Aminophylline can be administered as following-
Inj. Aminophylline 125 mg/5ml amp- 2 amp in 500 ml Normal Saline IV @ 10-15 drops/min
5.Antibiotic(s) should be used when there are signs of Pneumonia
6.Assisted Ventilation is needed in following conditions-
i) Exhaustion,
ii) Drowsiness,
iii) Confusion,
iv) Coma,
v) Respiratory arrest
vi) PaCO2 is more than 6 kPa (45 mmHg) and increasing
vii) PaO2 is less than 8 kPa (60 mmHg) and decreasing
viii) pH is low and decreasing i.e. H+ concentration is high and increasing.
Treatment monitoring:
1. PEF of the patient should be monitored every 15-30 minutes and then 4-6 hourly
2. Oxygen saturation should be monitored by pulse oximetry and maintained more than 92% in adults
3.Arterial blood gas analysis should be repeated if there are indications of assisted ventilation.
