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Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Jun 12, 2020

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Page 1: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Asthma treatment

Andrew Zaragoza

Page 2: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

What IS asthma??

● Asthma is a complex condition involving a hypersensitivity response to some

trigger, airway inflammation, obstruction, and structural changes

● The full pathogenesis, diagnosis, and classification of asthma is outside the

scope of this specific lecture

● For now, let’s talk about HOW to treat it!

Page 3: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Avoidance!

“An ounce of prevention is worth a pound of cure” -The guy on the $100 bill

Common triggers include:

● Allergens (dust, animal dander, mold, cockroaches)

● Irritants (smoke/fire/California wildfires, tobacco/inhaled drugs,

perfumes, pollution/the freeway)

● Illness (viral URIs, the flu/preventable illness, GERD)

Page 4: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Acute Exacerbation: Home & Clinic

● First line: Short acting B-agonists (SABA), such as Albuterol

○ Can be via nebulizer or MDI

○ Standard dose: 2 puffs OR 2.5mg/3 mL q2-4 hours

○ Can also do 3 treatment q20 mins to open lungs acutely

● Additive: Oral steroid

○ Pediatric: Prednisolone 2mg/kg/day div BID x 3 - 5 days

○ Can also do Dexamethasone 0.6mg/kg/day, 1-2 doses

Page 5: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Acute Exacerbation: ED

● O2 as needed!

○ NC vs oxymask vs HFNC

● Start with q20min x3 treatments of albuterol

● OR Duoneb

○ Albuterol + Atrovent (anticholinergic)

● Steroid:

○ Start with PO dexamethasone

○ If severe, skip to Methylprednisolone IV

● If that doesn’t work: Magnesium IV

● After that, they need PICU management and may need

terbutaline, continuous albuterol, PPV, or may be intubated (last resort!)

Page 6: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Long Term Management

● Step 1: All asthmatics should have a SABA on hand

● Step 2: Inhaled Corticosteroid (ICS)

○ Anti-inflammatory, also up-regulate B-agonist receptors and

prevent down-regulation

○ There are many:

○ Flovent (Fluticasone)

○ Pulmicort (Budesonide)

○ Qvar (Beclomethasone)

○ Don’t get thrush! Rinse after use

Page 7: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Long Term Management: Part 2

● Step 3: Higher dose ICS

● Step 4: ICS+Long acting beta agonist (ICS-LABA)

○ Again, many options:

○ Advair (Fluticasone+Salmeterol)

○ Dulera (Mometasone+Fomoterol)

○ Symbicort (Budesonide+Fomoterol)

● LABAs seem cool...can I use them alone?

○ NO!!! B-agonist sensitivity

○ You must use it with an ICS

Page 8: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,
Page 9: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Long Term Management: Part 3

● Can also add a leukotriene receptor antagonist (LTRA)

○ Montelukast, which is PO and not inhaled

● Consider adding less-common treatments:

○ At this point, the patient should be managed by Pulm or A&I

○ Methylxanthines, i.e. Theophylline, a phosphodiesterase

inhibitor

○ Cromoglycates, i.e. Cromolyn, a mast cell stabilizer

Page 10: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Biologics

● If the previous steps did not work:

● Xolair (Omalizumab): anti-IgE

○ Sub-Q injections q2-4 weeks

● Nucala (Mepolizumab): anti-IL5

○ Relatively new, may not be as common

Page 11: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,
Page 12: Asthma treatment - University of California, Irvine · What IS asthma?? Asthma is a complex condition involving a hypersensitivity response to some trigger, airway inflammation, obstruction,

Sources

Asthma. Shilpa J. Patel, Stephen J. Teach. Pediatrics in Review. November 2019, 40 (11) 549-567.

https://pedsinreview.aappublications.org/content/40/11/549

https://www.aap.org/en-us/Documents/medicalhome_resources_keypointsforasthma.pdf

https://www.urmc.rochester.edu/MediaLibraries/URMCMedia/childrens-hospital/pulmonology/documents/AsthmaInhaler.pdf