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Treatment

Four classifications of asthma based on frequency and duration of symptoms are used to develop a treatment plan: (1) mild intermittent asthma, (2) mild persistent asthma, (3) moderate persistent asthma, and (4) severe persistent asthma. Patients often move from one classification to another, and the treatment is adjusted accordingly. Characteristics for classifying patients are given below:

1. Mild intermittent asthma:
   • Symptoms occur, on average, less than twice a week
   • No symptoms (asymptomatic) and normal peak expiratory flow (PEF) rate between attacks (exacerbations)
   • Brief exacerbations last from a few hours to a few days and vary in intensity
   • Nighttime symptoms occur less than twice a month
   • FEV1 or PEF greater than 80% of the predicted value
   • PEF variability of less than 20%
2. Mild persistent asthma:
   • Symptoms occur less than twice a week
   • Exacerbations affect activity
   • Nighttime symptoms occur more than twice a month
   • FEV1 or PEF greater than 80% of the predicted value
   • PEF variability of between 20% to 30%
3. Moderate persistent asthma:
   • Daily symptoms
   • Daily use of a short-acting beta2 agonist
   • Exacerbations affect activity
   • Exacerbations occur more than twice a week or persist for days
   • Nighttime symptoms occur more than once a week
   • FEV1 or PEF greater than 60% but less than 80% of the predicted value
   • PEF variability greater than 30%
4. Severe persistent asthma:
   • Continual symptoms
   • Exacerbations limit physical activity
   • Frequent exacerbations
   • Frequent nighttime symptoms
   • FEV1 or PEF less than 60% of the predicted value
   • PEF variability greater than 30%

Pharmacological Therapy
Pharmacological (drug) therapy for asthma has several goals: prevention of chronic symptoms, recurrent exacerbations, emergency room visits, and hospitalization; maintenance of normal lung function and normal activity levels; and avoidance of side effects of other medications. There are two broad classes of medications used in the treatment of asthma: quick-relief, or rescue, medications; and long-term control medications.

Quick-relief medications
Quick-relief medications include short-acting inhaled beta2 agonists, oral beta2 agonists, inhaled anticholinergics, and oral corticosteroids.

Long-term control medications
Long-term control medications include oral corticosteroids, inhaled corticosteroids, cromolyn sodium, and nedocromil, long-acting beta2 agonists, leukotriene modifiers, and theophylline.

Long term control medications are divided into two large categories based on their primary mechanism of action: anti-inflammatory drugs and prolonged bronchodilators. These are prescribed when symptoms occur more often than mildly intermittent asthma. With long term control medications, it is essential to use an antiinflammatory and the prolonged bronchodilators as supplemental medications.

Stepwise approach to chronic asthma treatment
Treatment for chronic asthma is based on a five-step approach. The initial objective is to abolish symptoms and normalize lung function, then adjust medication appropriately in response to changes. The outline below generally describes the stepwise approach, which is often modified to suit the patient.

Classification	Long-Term Control Medication	Quick-Relief Medication
Mild intermittent	None	Bronchodilator as needed, up to 3-4 times/day
Mild persistent	Cromolyn sodium, nedocromil, low-dose inhaled corticosteroid, possible leukotriene modifier	Bronchodilator as needed, up to 3-4 times/day
Moderate persistent	Medium-dose inhaled corticosteroid alone and with cromolyn sodium or nedocromil, leukotriene modifier, long-acting bronchodilator such as theophylline or long-acting beta2 agonist	Bronchodilator as needed, up to 3-4 times/day
Severe persistent	High-dose inhaled corticosteroids, oral corticosteroids; high-dose inhaled corticosteroids plus leukotriene modifier, plus long-acting bronchodilator, plus leukotriene modifier, plus long-acting bronchodilator	Bronchodilator as needed, up to 3-4 times/day
Step up or down as needed

Delivery Methods

Metered-dose inhalers
Metered-dose inhalers (MDIs) are the most common delivery systems used. They are relatively easy to use, but children under age five often have difficulty using them effectively. To use an MDI, the patient first exhales completely, then places the MDI to the lips, forms a seal around the mouthpiece, and presses on the top of the canister to deliver a measured dose of medication while slowly inhaling. After inhaling slowly, the patient holds his or her breath for 5 to 10 seconds. Typically, the patient takes at least two puffs of the medication, and it is recommended they wait 30 seconds between puffs.

An alternative method is to hold the MDI about 2 inches away from the open mouth and perform the same procedure. Although this technique is useful, it has two disadvantages: it is tricky to execute properly, and it deposits more than 80% of the medication in the mouth. Medication deposited in the mouth is especially disadvantageous with inhaled corticosteroids: deposition of inhaled corticosteroids in the mouth increases the risk for oral candidiasis (yeast infection). The mouth should be rinsed vigorously with water after administering inhaled corticosteroids.

To reduce amount of medication deposited in the mouth when using an MDI, a spacer device may be used. A spacer device is a chamber that fits on the mouthpiece of the MDI and the patient seals their lips around the opposite end. The patient exhales completely and then "puffs" the MDI, filling the spacer tube or chamber with the medication. The patient slowly inhales, drawing the medication into the lungs. As with the MDI it is important to hold the breath for 5 to 10 seconds afterward. Two advantages to using the spacer device are (1) more medication gets into the lungs and (2) the technique is often easier to master.

Breath-actuated MDIs
Breath-actuated MDIs are a variation on the standard MDI. Instead of projecting the medication into the mouth by pressing on the canister, the patient forms a good seal around the mouthpiece and inhales slowly. The inhalation and breath-hold are the same as with a standard MDI. The advantage of the breath-actuated MDI system is that it eliminates the need for hand-breath coordination. Getting the right speed of inhalation—some patients find it difficult to inhale slowly—and the fact that not all medications are available for breath-actuated MDIs are disadvantages.

Dry powder inhalers
Dry powder inhalers are used in patients under five years of age. A variety of these are available for specific medications, including beta2 agonists and corticosteroids. They work similarly to breath-actuated MDIs. The patient exhales, then forms a seal with the lips around the inhalation port. Unlike breath-actuated MDIs, however, the patient must inhale rapidly. After inhaling deeply, the patient holds his or her breath for 10 seconds. Not all medications are available in dry powder inhaler form. Another disadvantage to this system is that medication is lost if one accidentally exhales into the device.

Nebulizers
Nebulizers can be used with all classes of inhaled medications but are most commonly used with short-acting beta2 agonists and ipratropium bromide. The medication is placed in a chamber that is connected to an air compressor - powered either by standard electric house current (110 volt) or by a battery. The compressor blows air through the chamber, atomizing the medication so the patient can inhale it through a mouthpiece or facemask. The main advantage of this system is that it requires essentially no hand-breath coordination on the patient's part. It is best to take slow breaths at normal depth, with occasional deep breaths; but any manner of inhaling that the patient finds comfortable is acceptable. This method of drug delivery has obvious advantages for young children. Unfortunately, the process takes longer than MDI and the equipment is not as portable. It also is more expensive than MDIs or dry powder inhalers.

Asthma, Treatment reprinted with permission from pulmonologychannel.com
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