Management of Asthma and Prevention

Management of Asthma and Prevention

Raj B Singh, Chennai

Treatment

1.  Most patients with asthma well managed with regular ICS + LABA

2.  Difficult Asthma

a.  Steroid resistant, fixed

i.  Reduce steroids

ii.  Bronchodilators

iii.  Omalizumab

iv.  Macrolides

v.  Thermoplasty

b.  Steroid dependent

c.  Poor perceiver

d.  Comorbid conditions

i.  COPD

ii.  Obesity

iii.  Restrictive lung disease

iv.  Pregnancy

Prevention

1.  Regular treatment

2.  Allergen avoidance

3.  Immunotherapy

Case No 1

A 45 year old lady has a 6 year h/o asthma. She is currently on Fluticasone 1000 mcg/ day, Salemeterol 100 mcg/ day, oral steroids several courses a year and nebulisations almost daily. On examination, she is cushingoid, breathless with an audible wheeze at rest; PEFR 180, FEV1 34% improving to 36.2% with neb salbutamol.

Case No 2

A 7 year old boy is brought to the emergency, acutely breathless, with a temperature of 39.10 with a faint wheeze on expiration. Oxygen saturation 92% on RA, inflamed throat, TLC 15230, N87, L12, E1. CXR – Left basal opacity.

Case No 3

A 62 year old smoker with a 24 pack year history presents to the OP clinic with a history of intermittent wheezy breathlessness and cough for more than 30 years. He had been treated with intermittent bronchodilators and steroids, oral and inhaled. He had been hospitalized the year before for a week and treated with NIV for 3 days. His FEV1 is 52% (61% post neb) FVC 56% (65%). CXR – overinflated lungs.

Case No 4

A 29 year ols pregnant lady presents with acute wheeze. She had miscarried 2 years ago after an admission for acute asthma. She was on intermittent oral theophylline and inhaled salbutamol. Temp 38.2, throat congested, rhonchi ++. PEFR 180, FEV1 48% (61%)

References:

1.  Optimal Management of severe/Refractory Asthma. Pakhale S, Mulpuru S and Boyd M

Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine 2011:5 37–47

2.  Nonpharmacological and pharmacological interventions to prevent or reduce airway remodeling. E.H. Walters, D.W. Reid, D.P. Johns and C. Ward

Eur Respir J 2007; 30: 574–588

3.  Meta-analysis of the Efficacy and Safety of Bronchial Thermoplasty in Patients with Moderate-to-severe Persistent Asthma. Q Wu, Y Xing, X Zhou and D Wang

The Journal of International Medical Research 2011; 39: 10 – 22 [first published online as 39(1) 3]

4.  Efficacy and Safety of Subcutaneous Omalizumab vs Placebo as Add-on Therapy to Corticosteroids for Children and Adults With Asthma. A Systematic Review. Gustavo J. Rodrigo, MD; Hugo Neffen, MD; and José A. Castro-Rodriguez, MD, PhD

Chest 2011; 139(1):28–35

5.  Scientific rationale for inhaled combination therapy with long-acting b2-agonists and corticosteroids. P.J. Barnes

Eur Respir J 2002; 19: 182–191

6.  New therapies and management strategies in the treatment of asthma: patient-focused developments. Agbetile J and Green R

Journal of Asthma and Allergy 2011:4 1–12

7.  Recommendation for optimal management of severe refractory asthma

Morjaria JB and Polosa Ri

Journal of Asthma and Allergy 2010:3 43–56