Bronchial asthma

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Guidelines for asthma management in adults

Guidelines for asthma management in adults

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  • Inflammation is the key underlying pathophysiologic mechanism
    It produces airway obstruction either directly or by causing bronchial hyperresponsiveness
  • SABA Use: Use of short acting b agonists for symptom control, not for exercise induced bronchospasm
    If parameters fall in different grades of severity, the overall level of severity is assigned to the most severe parameter.
    The recommended step to start treatment is 1 for intermittent, 2 for mild, 3 for moderate and 4 for severe
  • Medications to Treat Asthma: Inhalers and Spacers
  • Medications to Treat Asthma: Nebulizer
  • Managing Asthma: Peak Flow Chart
  • Corticosteroids: Block late-phase reaction to allergen, reduce airway hyperresponsiveness, and inhibit inflammatory cell migration and activation.
    They are the most potent and effective anti-inflammatory medication currently available (Evidence A).
    ICSs are used in the long-term control of asthma.
    Short courses of OCS are often used to gain prompt control of the disease when initiating long-term therapy.
    Long-term OCS is used for severe persistent asthma.
    Cromolyn sodium and nedocromil: Stabilize mast cells and interfere with chloride channel function.
    - Used as alternative, but not preferred, medication for the treatment of mild persistent asthma (Evidence A).
    Can be used as preventive treatment prior to exercise or unavoidable exposure to known allergens.
    Note that Cromolyn & Nedocromil will no longer be manufactured in the near future.
    Immunomodulators: Omalizumab (anti-IgE) is a monoclonal antibody that prevents binding of IgE to the high-affinity receptors on basophils and mast cells. Omalizumab is used as adjunctive therapy for patients 12 years of age who have allergies and severe persistent asthma (Evidence B). Clinicians who administer omalizumab should be prepared and equipped to identify and treat anaphylaxis that may occur.
    Leukotriene antagonists: Include LTRAs and a 5-lipoxygenase inhibitor. Two LTRAs are available—montelukast (for patients >1 year of age) and zafirlukast (for patients 7 years of age). The 5-lipoxygenase pathway inhibitor zileuton is available for patients 12 years of age; liver function monitoring is essential. LTRAs are alternative, but not preferred, therapy for the treatment of mild persistent asthma (Step 2 care) (Evidence A). LTRAs can also be used as adjunctive therapy with ICSs, but for youths 12 years of age and adults they are not the preferred adjunctive therapy compared to the addition of LABAs (Evidence A). Zileuton can be used as alternative but not preferred adjunctive therapy in adults (Evidence D).
    Methylxanthines: Sustained-release theophylline is a mild to moderate bronchodilator used as alternative, not preferred, adjunctive therapy with ICS (Evidence A). Theophylline
    may have mild anti-inflammatory effects. Monitoring of serum theophylline concentration is essential.
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  • 1. National Institute of HealthNational Institute of Health 2007 Asthma Guideline2007 Asthma Guideline Expert Panel Report (EPR) -3Expert Panel Report (EPR) -3 Bronchial AsthmaBronchial Asthma is a chronicis a chronic inflammatoryinflammatory disorder of the airways characterized bydisorder of the airways characterized by bronchial hyper-responsivenessbronchial hyper-responsiveness to a variety ofto a variety of stimuli which lead to episodes of wide spreadstimuli which lead to episodes of wide spread bronchial narrowing which is largelybronchial narrowing which is largely reversiblereversible either spontaneously or with treatment.either spontaneously or with treatment.
  • 2. 1122 33 PathogenesisPathogenesis 1)1) Lumen:Lumen: Mucus plugsMucus plugs 2)2) Mucosa:Mucosa: SwellingSwelling 3)3) Smooth Muscles:Smooth Muscles: SpasmSpasm
  • 3. – Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma. – However, not all people with allergies have asthma, and notnot all people with allergies have asthma, and not all cases of asthma can be explained by allergic response.all cases of asthma can be explained by allergic response. – Viral respiratory infections are one of the most important causes of asthma exacerbation. – In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis (remodeling)
  • 4. OldOld && New Asthma Guidelines:New Asthma Guidelines: What hasWhat has notnot changedchanged  Initial therapyInitial therapy is determined by assessment ofis determined by assessment of asthma severityasthma severity – Ideally, before the patient is on a long-term controllerIdeally, before the patient is on a long-term controller  Stepping therapyStepping therapy up or down is based on how wellup or down is based on how well asthma controlasthma control is achieved.is achieved.  Inhaled corticosteroids (ICS)Inhaled corticosteroids (ICS) are the preferred first-line therapy forare the preferred first-line therapy for asthmaasthma  Systemic steroidsSystemic steroids can still be used to treat asthma exacerbationscan still be used to treat asthma exacerbations  Peak flows and written asthma action plans are recommended forPeak flows and written asthma action plans are recommended for asthma self managementasthma self management – Especially in moderate and severe persistent asthma, or for thoseEspecially in moderate and severe persistent asthma, or for those with a history of severe exacerbations or poorly controlled asthmawith a history of severe exacerbations or poorly controlled asthma
  • 5. 4 Components of Asthma Management4 Components of Asthma Management Component 1Component 1:: Measures of AsthmaMeasures of Asthma Diagnosis & AssessmentDiagnosis & Assessment • DiagnosisDiagnosis • Differential diagnosisDifferential diagnosis • Assessment of severityAssessment of severity (intrinsic disease intensity)(intrinsic disease intensity) • Assessment of controlAssessment of control (response to treatment)(response to treatment) • Assessment of riskAssessment of risk (probability of future morbid events)(probability of future morbid events) Component 2Component 2:: EducationEducation for a Partnership in asthma carefor a Partnership in asthma care Component 3Component 3:: Control ofControl of Environmental Factors &Environmental Factors & Comorbid ConditionsComorbid Conditions Component 4Component 4:: MedicationsMedications
  • 6. Component 1Component 1 Measures of AsthmaMeasures of Asthma Diagnosis & AssessmentDiagnosis & Assessment
  • 7. Diagnosis of AsthmaDiagnosis of Asthma To establish a diagnosisTo establish a diagnosis of asthma the clinicianof asthma the clinician should determine thatshould determine that:: – Episodic symptoms ofEpisodic symptoms of airflow obstruction orairflow obstruction or airwayairway hyperresponsivenesshyperresponsiveness are presentare present – Airflow obstruction isAirflow obstruction is at least partiallyat least partially reversiblereversible – Alternative diagnosesAlternative diagnoses are excluded.are excluded. AsthmaAsthma COPDCOPD EpisodicEpisodic Worse earlyWorse early morningmorning Mucoid sputumMucoid sputum History of otherHistory of other allergiesallergies PersistentPersistent Constant allConstant all dayday MucopurulentMucopurulent sputumsputum History ofHistory of smokingsmoking
  • 8. Methods to Establish DiagnosisMethods to Establish Diagnosis – Medical historyMedical history: Atopy, provoking factors: Atopy, provoking factors – Physical exam:Physical exam: respiratory distressrespiratory distress – Spirometry:Spirometry: Obstructive hypoventilation, BDObstructive hypoventilation, BD reversibility, bronchial provocation.reversibility, bronchial provocation. – PFM:PFM: (Peak Flow Meter)(Peak Flow Meter) – ABG.ABG.
  • 9. Key Indicators: Diagnosis of AsthmaKey Indicators: Diagnosis of Asthma Has/does the patient:Has/does the patient: – had an attack or recurrent attacks of wheezing?had an attack or recurrent attacks of wheezing? – have a troublesome cough at night?have a troublesome cough at night? – wheeze or cough after exercise?wheeze or cough after exercise? – experience wheezing, chest tightness, or coughexperience wheezing, chest tightness, or cough after exposure to airborne allergens orafter exposure to airborne allergens or pollutants?pollutants? – symptoms improved by appropriate asthmasymptoms improved by appropriate asthma treatment?treatment?
  • 10. Classification of Asthma Severity in AdultsClassification of Asthma Severity in Adults >> 12 Years12 Years Intermittent Persistent Mild Moderate Severe Before starting medications, severity assessed by impairment Symptoms < 2 d/w > 2 d/w daily continuous Nighttime Awakening < 2 x/m > 2 x/m > 1 x/w nightly Activity Limitation None Minor Moderate Extreme SABA Use < 2 d/w > 2 d/w daily daily FEV1 > 80% P > 80% P 60 – 80% P < 60% P FEV1/FVC Normal Normal Reduced < 5% Reduced>5% On medications, severity assessed by lowest level of treatment required to maintain control Step 1 Step 2 Step 3 or 4 Step 5 or 6 Risk: Expected Exacerbations requiring Systemic Steroids/Year 0 - 1 > 2 > 2 > 2 St ep 2St ep 1 Recomm ended St ep for I nit iat ing Treat m ent (See figure 4−5 for t reat ment st eps.) In 2−6 weeks, evaluate level of asthma control that is accordingly. • Normal FEV1 between exacerbations SomMinor limitationNoneInterference with normal activity not more than 1x on any day symptom control (not prevention of EIB) ≥2/year (see note) 0−1/year (see note) • FEV1 < 80 • FEV1 > 80% predicted • FEV1 > 80% predicted • FEV1 5% • FEV1/FVC normal• FEV1/FVC normal Risk Relative annual risk of exacerbations m Consider severity and interval sinc Frequency and severity may fluctuate over time fo Normal FEV1/ FVC: 8−19 yr 85% 20 −39 yr 80% 40 −59 yr 75% 60 −80 yr 70% Exacerbations requiring oral systemic corticosteroids Lung function FEV1/FVC
  • 11. Classification of Asthma Control in AdultsClassification of Asthma Control in Adults >> 12 Years12 Years Well Controlled Not Well Controlled Poorly Controlled Symptoms < 2 d/w > 2 d/w continuous Nighttime Awakening < 2 x/m 1 – 3 x/w > 4x/w Activity Limitation None Moderate Extreme SABA Use < 2 d/w > 2 d/w Several times daily FEV1 > 80% P 60 – 80% P < 60% P PFR > 80% PB 60 – 80% PB < 60% PB ATAQ 0 1 - 2 > 3 ATAQ: Asthma Therapy Assessment Questionnaire PB: Personal Best
  • 12. Asthma Therapy Assessment Questionnaire (ATAQAsthma Therapy Assessment Questionnaire (ATAQ(( 0 :0 : Well ControlledWell Controlled 1 - 2 :1 - 2 : Not Well ControlledNot Well Controlled >> 3 :3 : Poorly ControlledPoorly Controlled >5 <5
  • 13. Component 2Component 2 Education for a Partnership inEducation for a Partnership in Asthma CareAsthma Care
  • 14. Key Educational MessagesKey Educational Messages – Significance of diagnosisSignificance of diagnosis – Inflammation as the underlying causeInflammation as the underlying cause – Controllers vs. quick-relieversControllers vs. quick-relievers – How to use medication delivery devicesHow to use medication delivery devices – Triggers, including 2Triggers, including 2ndnd hand smokehand smoke – PFM (peak flow monitoring) can be helpful to:PFM (peak flow monitoring) can be helpful to: 1.1. Detect early changes in asthma control that requireDetect early changes in asthma control that require adjustments in treatmentEvaluate responses toadjustments in treatmentEvaluate responses to changes in treatmentchanges in treatment 2.2. Provide a quantitative measure of impairmentProvide a quantitative measure of impairment – Need for continuous, on-going interaction w/the clinicianNeed for continuous, on-going interaction w/the clinician to step up/down therapyto step up/down therapy – Annual influenza vaccineAnnual influenza vaccine
  • 15. How to Use Metered Dose Inhalers The health-care provider should evaluate inhaler technique at each visit.
  • 16. MDI with Spacer (Holding Chamber( Spacers can help patients who have difficulty with inhaler use. The mouth piece may be equipped with a mask or a valve Properly used MDI with VHC is as effective as nebulizer therapy.
  • 17. Nebulizer  Machine produces a mist of the medication  Used for small children or for severe asthma episodes  No evidence that it is more effective than an inhaler used with a spacer
  • 18. Peak Flow ChartPeak Flow Chart People withPeople with moderate ormoderate or severe asthmasevere asthma should takeshould take readings:readings: – Every morningEvery morning – Every eveningEvery evening – After anAfter an exacerbationexacerbation – Before inhalingBefore inhaling certaincertain medicationsmedications
  • 19.  Self management education isSelf management education is essential and should be integratedessential and should be integrated into all aspects of care; requiresinto all aspects of care; requires repetition and reinforcementrepetition and reinforcement  ProvideProvide allall patients with apatients with a writtenwritten asthma action plan (esp if astma isasthma action plan (esp if astma is severe or poorly controlled) thatsevere or poorly controlled) that includes 2 aspects:includes 2 aspects: – Daily managementDaily management – How to recognize &How to recognize & handle worsening asthmahandle worsening asthma symptomssymptoms  Regular review of the status ofRegular review of the status of patients asthma controlpatients asthma control  Develop an active partnership withDevelop an active partnership with the patient and family.the patient and family.  Tailor the plan to needs of eachTailor the plan to needs of each patient.patient. Asthma Action Plan
  • 20. Component 3Component 3 Control of Environmental FactorsControl of Environmental Factors && Comorbid Conditions that Affect AsthmaComorbid Conditions that Affect Asthma
  • 21. Environmental FactorsEnvironmental Factors Patients should:Patients should: – Reduce exposure to allergens & irritants.Reduce exposure to allergens & irritants. – Avoid exertion outdoors when levels of airAvoid exertion outdoors when levels of air pollution are high.pollution are high. – Avoid use of nonselective beta-blockers.Avoid use of nonselective beta-blockers. Clinicians shouldClinicians should:: – Look for other chronic co-morbid conditions,Look for other chronic co-morbid conditions, particularly when asthma control is not achieved.particularly when asthma control is not achieved. – Look for occupational exposures, particularly inLook for occupational exposures, particularly in those with new onset work related asthma.those with new onset work related asthma. – Encourage patients to receive a yearly influenzaEncourage patients to receive a yearly influenza vaccine (inactivated).vaccine (inactivated). – Consider allergen immunotherapy whenConsider allergen immunotherapy when appropriate.appropriate.
  • 22. Component 4Component 4 MedicationsMedications
  • 23.  22 general classes:general classes:  Long-term control medications:Long-term control medications: – Corticosteroids (mainly ICS, occasionally OCS).Corticosteroids (mainly ICS, occasionally OCS). – Long Acting Beta Agonists (LABA’s)Long Acting Beta Agonists (LABA’s) – Leukotriene Modifiers (LTM)Leukotriene Modifiers (LTM) – Cromolyn & NedocromilCromolyn & Nedocromil – Methylxanthines:Methylxanthines: ((Sustained-release theophylline)Sustained-release theophylline)  Quick- relief medications:Quick- relief medications: – Short acting Beta Agonists (SABA’s)Short acting Beta Agonists (SABA’s) – Systemic corticosteroidsSystemic corticosteroids – AnticholinergicsAnticholinergics
  • 24. Safety of Inhaled CorticosteroidsSafety of Inhaled Corticosteroids – ICS’s are the most effective long-term therapy available,ICS’s are the most effective long-term therapy available, – well tolerated & safe at recommended doseswell tolerated & safe at recommended doses – The potential but small risk of adverse events from the useThe potential but small risk of adverse events from the use of ICS treatment is well balanced by their efficacyof ICS treatment is well balanced by their efficacy – Local SE: hoarseness, oral candidiasis.Local SE: hoarseness, oral candidiasis. – Systemic SE: delayed linear growth in children, otherSystemic SE: delayed linear growth in children, other steroid effects.steroid effects.  Patients should rinse their mouths (rinse and spit) afterPatients should rinse their mouths (rinse and spit) after (ICS) inhalation(ICS) inhalation  Use the lowest dose of ICS that maintains asthma control:Use the lowest dose of ICS that maintains asthma control: – Evaluate patient adherence and inhaler technique as well asEvaluate patient adherence and inhaler technique as well as environmental factors before increasing the dose of ICSenvironmental factors before increasing the dose of ICS  Monitor linear growth in childrenMonitor linear growth in children
  • 25. Safety of Long-Acting BetaSafety of Long-Acting Beta22-Agonists-Agonists (LABA’s)(LABA’s) – Adding a LABA to the treatment of patients whose asthma is not wellAdding a LABA to the treatment of patients whose asthma is not well controlled on low- or medium-dose ICS improves lung function,controlled on low- or medium-dose ICS improves lung function, decreases symptoms, and reduces exacerbations and use of SABA fordecreases symptoms, and reduces exacerbations and use of SABA for quick relief.quick relief. – However, FDA analysis of studies showed anHowever, FDA analysis of studies showed an increased risk of severeincreased risk of severe exacerbationsexacerbations of asthma symptoms andof asthma symptoms and deathdeath associated with LABA use.associated with LABA use. – For patients who have asthma not sufficiently controlled with ICS alone,For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the ICS dose should be giventhe option to increase the ICS dose should be given equal weightequal weight to theto the option of the addition of a LABA to ICSoption of the addition of a LABA to ICS – It is not currently recommended that LABA be used for treatment ofIt is not currently recommended that LABA be used for treatment of acute symptoms or exacerbationsacute symptoms or exacerbations – LABAs are not to be used as monotherapy for long-term control.LABAs are not to be used as monotherapy for long-term control. Combined preparations ensure compliance for this, eg SymbicortCombined preparations ensure compliance for this, eg Symbicort (Formoterol + Budesonide).(Formoterol + Budesonide).
  • 26. – SABAs are the most effective medication for relievingSABAs are the most effective medication for relieving acute bronchospasm.acute bronchospasm. – Only selectiveOnly selective ββ22 agonists are recommended.agonists are recommended. – SABA administered by the inhaled route provide asSABA administered by the inhaled route provide as great or greater bronchodilatation with fewer SE thangreat or greater bronchodilatation with fewer SE than either the parenteral or oral routes.either the parenteral or oral routes. – Increasing use of SABA treatment or using SABA >2 daysIncreasing use of SABA treatment or using SABA >2 days a week for symptom relief (not prevention of EIB)a week for symptom relief (not prevention of EIB) indicates inadequate control of asthma.indicates inadequate control of asthma. – Regularly scheduled, daily, chronic use of SABA isRegularly scheduled, daily, chronic use of SABA is notnot recommended.recommended. Safety of Short-Acting BetaSafety of Short-Acting Beta22-Agonists-Agonists (SABA’s)(SABA’s)
  • 27. Managing Asthma Long TermManaging Asthma Long Term ““The Stepwise Approach”The Stepwise Approach” ““The goal of asthma therapy is to maintainThe goal of asthma therapy is to maintain long-term control of asthma with the leastlong-term control of asthma with the least amount of medications and hence minimalamount of medications and hence minimal risk for adverse effects”risk for adverse effects”..
  • 28. Principles of Step Therapy to Maintain ControlPrinciples of Step Therapy to Maintain Control  Step up medication dose if symptoms are notStep up medication dose if symptoms are not controlledcontrolled  If very poorly controlled, consider an increase by 2If very poorly controlled, consider an increase by 2 steps, add oral corticosteroids, or bothsteps, add oral corticosteroids, or both  Before increasing medication therapy, evaluate:Before increasing medication therapy, evaluate: – Exposure to environmental triggersExposure to environmental triggers – Adherence to therapyAdherence to therapy – Technique of device use.Technique of device use. – Co-morbiditiesCo-morbidities
  • 29. Follow-up AppointmentsFollow-up Appointments  Visits every 2-6 weeks until asthma control is achievedVisits every 2-6 weeks until asthma control is achieved  When control is achieved, follow-up every 3-6 monthsWhen control is achieved, follow-up every 3-6 months  Step-down in therapyStep-down in therapy:: – When asthma is well-controlled for at least 3 monthsWhen asthma is well-controlled for at least 3 months  Patients may relapse with total discontinuation orPatients may relapse with total discontinuation or reduction of inhaled corticosteroidsreduction of inhaled corticosteroids
  • 30. Intermittent Asthma Persistent Asthma: Daily Medication Consult asthma specialist if step 4 care or higher is required. Consider consultation at step 3 Step 1 Preferred: SABA PRN Step 2 Preferred: Low dose ICS Alternative: Cromolyn, LTRA, Nedocromil or Theophylline Step 3 Preferred: Low-dose ICS + LABA OR – Medium dose ICS Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 4 Preferred: Medium Dose ICS + LABA Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton Step 5 Preferred High Dose ICS + LABA AND Consider Omalizumab for patients who have allergies Step 6 Preferred High dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies Each Step: Patient Education and Environmental Control and management of comorbidities Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults •Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 20 minute intervals prn. Short course of o systemic corticosteroids may be needed. • Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control & the need to step up treatment. Step down if possible (and asthma is well controlled at least 3 months) Assess control Step up if needed (first check adherence, environmental control & comorbid conditions)
  • 31. Managing Exacerbations of AsthmaManaging Exacerbations of Asthma
  • 32.  ExacerbationsExacerbations are acute or subacute episodes ofare acute or subacute episodes of progressively worsening shortness of breath,progressively worsening shortness of breath, cough, and wheezing.cough, and wheezing.  Are characterized by decreases in expiratoryAre characterized by decreases in expiratory airflow that can be documented and quantified byairflow that can be documented and quantified by spirometry or peak expiratory flow.spirometry or peak expiratory flow.
  • 33. Indications of a Severe AttackIndications of a Severe Attack  Breathless at restBreathless at rest  Leaning forwardLeaning forward  Speaks in words rather than completeSpeaks in words rather than complete sentencessentences  AgitatedAgitated  Peak flow rate less than 60% of normalPeak flow rate less than 60% of normal
  • 34. Early treatment of asthma exacerbations is the best strategyEarly treatment of asthma exacerbations is the best strategy for managementfor management::  Patient education includes a written asthma action planPatient education includes a written asthma action plan (AAP) to guide patient self management of exacerbations‑(AAP) to guide patient self management of exacerbations‑ – especially for patients who have moderate or severeespecially for patients who have moderate or severe persistent asthma and any patient who has a history ofpersistent asthma and any patient who has a history of severe exacerbationssevere exacerbations  A peak flow based plan for patients who have difficulty‑ ‑A peak flow based plan for patients who have difficulty‑ ‑ perceiving airflow obstruction and worsening asthma isperceiving airflow obstruction and worsening asthma is recommendedrecommended – Recognition of early signs of worsening asthma & takingRecognition of early signs of worsening asthma & taking prompt actionprompt action – Appropriate intensification of therapy, often including aAppropriate intensification of therapy, often including a short course of oral corticosteroidsshort course of oral corticosteroids – Removal or avoidance of the environmental factorsRemoval or avoidance of the environmental factors contributing to the exacerbationcontributing to the exacerbation – Prompt communication between patient and clinician.Prompt communication between patient and clinician.
  • 35. Classifying Severity of Asthma ExacerbationsClassifying Severity of Asthma Exacerbations  SeveritySeverity Dyspnoea FEV1 %P Or PEF/PB Clinical Course Mild Exertional 2 / tachypnoea > 70  Usually cared for at home  Prompt relief with inhaled SABA Moderate Exertional 3 40 – 70  Usually requires office or Emergency Department visit  Relief from freq. inhaled SABA  Oral systemic corticosteroids Severe Exertional 4 (at rest) 25 - 40  Usually requires ED visit and likely hospitalization  Partial relief from frequent inhaled SABA  PO systemic corticosteroids; some symptoms last >3 days after treatment is begun  Adjunctive therapies are helpful Life Threatening Too dyspneic to speak < 25  Requires ED/hospitalization; possible ICU  Minimal or no relief w/ frequent inhaled SABA  Intravenous corticosteroids  Adjunctive therapies are helpful
  • 36. What the EPR -3 DoesWhat the EPR -3 Does NOTNOT RecommendRecommend – Drinking large volumes of liquids or breathing warm,Drinking large volumes of liquids or breathing warm, moist airmoist air (e.g., the mist from a hot shower)(e.g., the mist from a hot shower) – Using over-the-counter products such as antihistaminesUsing over-the-counter products such as antihistamines or cold remediesor cold remedies – Although pursed-lip and other forms of controlledAlthough pursed-lip and other forms of controlled breathing may help to maintain calm during respiratorybreathing may help to maintain calm during respiratory distress, these methods dodistress, these methods do notnot bring aboutbring about improvement in lung functionimprovement in lung function