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Treatment of bronchial asthma ,step-wise approach

This is an an approach to treatment of bronchial asthma , both during and in-between attacks and finally the ttt. and management of Status Asthmaticus ( Acute severe asthma ).

Goals of therapy :

(1) Maintain near-normal pulmonary function.
(2) Maintain normal activity levels.
(3) Prevent recurrent exacerbations.
(4) Avoid adverse effects of the used medications.

A-  treatment of bronchospasm during attack

Treatment of bronchial asthma

B- Step-wise approach to treatment of Bronchial Asthma in between attacks 

Some patients display only occasional attacks of exertional dyspnea and wheezing which respond to inhaled bronchodilators alone.
 Other patients have chronic symptoms requiring continuous use of inhaled or oral medications.
Pharmacology , Doses and full details of drugs used in ttt. of B.A are discussed Here 

Step I ---> (Occasional symptoms less frequent than daily with PEFR i.e. peak expiratory flow rate 1000/0).

Occasional use of inhaled short acting B2 agonist bronchodilators e.g. salbutamol (used as required).
 If it is needed more often than once daily or three times/week, shift to step II.

Step II  ---> (Daily symptoms with PEFR < 80).

Regular inhaled steroid (beclomethasone) 800 mcg/day plus inhaled short acting B2 agonist as required.
 If there is unsatisfactory response, shift to step III.

Step III  ---> (Severe symptoms with PEFR 50-80 %).

High dose inhaled steroid 800-2000 mcg/day plus inhaled short acting B2 agonist as required.
If no satisfactory response, shift to step IV.

Step IV  ---> (Severe symptoms uncontrolled with high dose inhaled steroid with PEFR 50-80 %).

As step III plus one or more of the following :
• Inhaled ipratropium bromide.
• Inhaled long acting 82 agonist e.g. salmeterol 50 ug/12hr or formoterol 12 ug/12hr.
• Sustained release theophylline.
• Oral 82 agonists.
• Leukotriene receptor antagonist (Montelukast sodium).

Step V  ---> (Severe symptoms with deterioration with PEFR < 50%) .
As step IV plus regular prednisolone oral in the lowest dose necessary to control symptoms in a single daily dose in the morning.

Severe symptoms with deterioration inspite of prednisolone therapy with PEFR < 30%, hospital admission is required ( step VI ).

Treatment of Status Asthmaticus

(1) Hospitalization with full assessment including:

• Signs of severity of asthmatic attack, see later.
• Peak expiratory flow rate PEFR.
• Arterial blood gases.

(2) Initial treatment :

• O2 with high concentration (60%), thereafter the O2 concentration can be adjusted according to the arterial blood gases.
• Hydrocortisone 200 mg IV/4-6 hours for 24 hours then prednisolone 60 mg/day orally for 2 weeks then gradual tapering.
• Salbutamol by nebulizer (2.5-5 mg/4 hours) it can be repeated every 30 minutes as necessary, then 2.5 mg/4 hours once there is clinical response.
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Tamer Mobarak

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