2. ObjectivesObjectives
īŽ At the end of the lecture students should beAt the end of the lecture students should be
able to:able to:
īŽ ID signs and symptoms of asthmaID signs and symptoms of asthma
īŽ Differentiate the various severities of asthmaDifferentiate the various severities of asthma
īŽ Summarize an appropriate treatment regimen forSummarize an appropriate treatment regimen for
asthma of various severities.asthma of various severities.
3. Definition of AsthmaDefinition of Asthma
īŽ Chronic inflammatory disorder of the airways inChronic inflammatory disorder of the airways in
which many cells and cellular elements play awhich many cells and cellular elements play a
role.role.
īŽ In susceptible individuals, this inflammationIn susceptible individuals, this inflammation
causes recurrent episodes of wheezing,causes recurrent episodes of wheezing,
breathlessness, chest tightness, and coughing,breathlessness, chest tightness, and coughing,
particularly at night or in the early morning.particularly at night or in the early morning.
These episodes are associated with widespreadThese episodes are associated with widespread
but variable airflow obstruction that is reversiblebut variable airflow obstruction that is reversible
either spontaneously, or with treatment.either spontaneously, or with treatment.
4. AsthmaAsthma
īŽ Most common chronic condition in childrenMost common chronic condition in children
īŽ #1 cause of school absenteeism#1 cause of school absenteeism
īŽ Morbidity and mortality highly correlated withMorbidity and mortality highly correlated with
poverty, urban air quality, indoor allergens,poverty, urban air quality, indoor allergens,
lack of patient education, and inadequatelack of patient education, and inadequate
medical caremedical care
īŽ About 5000 deaths annuallyAbout 5000 deaths annually
5. AsthmaAsthma
īŽ Every day in the US, because of asthma:Every day in the US, because of asthma:
īŽ 40,000 people miss school or work40,000 people miss school or work
īŽ 30,000 people have an asthma attack30,000 people have an asthma attack
īŽ 5,000 people visit the emergency room5,000 people visit the emergency room
īŽ 1,000 people are admitted to the hospital1,000 people are admitted to the hospital
īŽ 14 people die14 people die
īŽ (Asthma and Allergy Foundation of America)(Asthma and Allergy Foundation of America)
6. AsthmaAsthma
īŽ In 2000, 11 million peoples reported havingIn 2000, 11 million peoples reported having
asthma attacksasthma attacks
īŽ In 1999, 2 million ER and 478,000In 1999, 2 million ER and 478,000
hospitalizations with asthma as the primary dxhospitalizations with asthma as the primary dx
īŽ Mortality in Black males 3X that of whiteMortality in Black males 3X that of white
īŽ Mortality in Black females 2.5X that of whiteMortality in Black females 2.5X that of white
7. AsthmaAsthma
īŽ Usually associated with airflow obstruction ofUsually associated with airflow obstruction of
variable severity.variable severity.
īŽ Airflow obstruction is usually reversible,Airflow obstruction is usually reversible,
either spontaneously, or with treatmenteither spontaneously, or with treatment
īŽ The inflammation associated with asthmaThe inflammation associated with asthma
causes an increase in the baseline bronchialcauses an increase in the baseline bronchial
hyper responsiveness to a variety of stimulihyper responsiveness to a variety of stimuli
īŽ Clinical DiagnosisClinical Diagnosis
9. Diagnostic TestingDiagnostic Testing
īŽ SpirometrySpirometry
īŽ Recommended to do spirometry pre- and post- useRecommended to do spirometry pre- and post- use
of an albuterol MDI to establish reversibility ofof an albuterol MDI to establish reversibility of
airflow obstructionairflow obstruction
īŽ >> 12% reversibility or an increase in FEV1 of12% reversibility or an increase in FEV1 of
200cc is considered significant200cc is considered significant
īŽ Obstructive pattern: reduced FEV1/FVC ratioObstructive pattern: reduced FEV1/FVC ratio
īŽ Restrictive pattern: reduced FVC with a normalRestrictive pattern: reduced FVC with a normal
FEV1/FVC ratioFEV1/FVC ratio
10. Diagnostic TestingDiagnostic Testing
īŽ SpirometrySpirometry
īŽ Can be used to identify reversible airwayCan be used to identify reversible airway
obstruction due to triggersobstruction due to triggers
īŽ Can diagnose Exercise-induced asthma (EIA) orCan diagnose Exercise-induced asthma (EIA) or
Exercise-induced bronchospasm (EIB) byExercise-induced bronchospasm (EIB) by
measuring FEV1/FVC before exercise andmeasuring FEV1/FVC before exercise and
immediately following exercise, then for 5-10immediately following exercise, then for 5-10
minute intervals over the next 20-30 minutesminute intervals over the next 20-30 minutes
looking for post-exercise bronchoconstrictionlooking for post-exercise bronchoconstriction
11. Diagnostic TestingDiagnostic Testing
īŽ SpirometrySpirometry
īŽ National Asthma Education and PreventionNational Asthma Education and Prevention
Program (NAEPP) recommends spirometry:Program (NAEPP) recommends spirometry:
īŽ For initial assessmentFor initial assessment
īŽ Evaluation of response to treatmentEvaluation of response to treatment
īŽ Assessment of airway function at least every 1-2 yearsAssessment of airway function at least every 1-2 years
12. Diagnostic TestingDiagnostic Testing
īŽ Methacholine challengeMethacholine challenge
īŽ Most common bronchoprovocative test in USMost common bronchoprovocative test in US
īŽ Patients breathe in increasing amounts ofPatients breathe in increasing amounts of
methacholine and perform spirometry after eachmethacholine and perform spirometry after each
dosedose
īŽ Increased airway hyperresponsiveness isIncreased airway hyperresponsiveness is
established with a 20% or more decrease in FEV1established with a 20% or more decrease in FEV1
from baseline at a concentration < 8mg/dlfrom baseline at a concentration < 8mg/dl
īŽ May miss some cases of exercise-induced asthmaMay miss some cases of exercise-induced asthma
13. Diagnostic testingDiagnostic testing
īŽ Diagnostic trial of anti-inflammatoryDiagnostic trial of anti-inflammatory
medication (preferably corticosteroids) or anmedication (preferably corticosteroids) or an
inhaled bronchodilatorinhaled bronchodilator
īŽ Especially helpful in very young children unable toEspecially helpful in very young children unable to
cooperate with other diagnostic testingcooperate with other diagnostic testing
īŽ There is no one single test or measure that canThere is no one single test or measure that can
definitively be used to diagnose asthma in everydefinitively be used to diagnose asthma in every
patientpatient
14. Goals of Asthma TreatmentGoals of Asthma Treatment
īŽ Control chronic and nocturnal symptomsControl chronic and nocturnal symptoms
īŽ Maintain normal activity, including exerciseMaintain normal activity, including exercise
īŽ Prevent acute episodes of asthmaPrevent acute episodes of asthma
īŽ Minimize ER visits and hospitalizationsMinimize ER visits and hospitalizations
īŽ Minimize need for reliever medicationsMinimize need for reliever medications
īŽ Maintain near-normal pulmonary functionMaintain near-normal pulmonary function
īŽ Avoid adverse effects of asthma medicationsAvoid adverse effects of asthma medications
15. Treatment of AsthmaTreatment of Asthma
īŽ Global Initiative for Asthma (6-point plan)Global Initiative for Asthma (6-point plan)
īŽ Educate patients to develop a partnership in asthmaEducate patients to develop a partnership in asthma
managementmanagement
īŽ Assess and monitor asthma severity with symptomAssess and monitor asthma severity with symptom
reports and measures of lung function as much asreports and measures of lung function as much as
possiblepossible
īŽ Avoid exposure to risk factorsAvoid exposure to risk factors
īŽ Establish medication plans for chronic management inEstablish medication plans for chronic management in
children and adultschildren and adults
īŽ Establish individual plans for managing exacerbationsEstablish individual plans for managing exacerbations
īŽ Provide regular follow-up careProvide regular follow-up care
16. īŽ CLASSIFICTION OF DRUGS USED INCLASSIFICTION OF DRUGS USED IN
ASTHMAASTHMA
īŽ A)Short term relievers used for relief of acuteA)Short term relievers used for relief of acute
bronchoconstriction:bronchoconstriction:
īŽ 1 Beta Adrenergic agonists1 Beta Adrenergic agonists
īŽ 2 Methylxanthines2 Methylxanthines
īŽ 3 Antimuscrinic agents3 Antimuscrinic agents
17. īŽ B)Long term controllers for reduction ofB)Long term controllers for reduction of
symptoms and prevention of attacks:symptoms and prevention of attacks:
īŽ 1 Corticosteroids1 Corticosteroids
īŽ 2Leukotriene pathway antagonist2Leukotriene pathway antagonist
īŽ 3 Inhibitor of mast cell degranulation3 Inhibitor of mast cell degranulation
18. PharmacotherapyPharmacotherapy
īŽ Beta2-receptors are the predominant receptors inBeta2-receptors are the predominant receptors in
bronchial smooth musclebronchial smooth muscle
īŽ Stimulate ATP-cAMP which leads to relaxation ofStimulate ATP-cAMP which leads to relaxation of
bronchial smooth muscle and inhibition of releasebronchial smooth muscle and inhibition of release
of mediators of immediate hypersensitivityof mediators of immediate hypersensitivity
īŽ Inhibits release of mast cell mediators such asInhibits release of mast cell mediators such as
histamine, leukotrienes, and prostaglandin-D2histamine, leukotrienes, and prostaglandin-D2
īŽ Beta1-receptors are predominant receptors in heart,Beta1-receptors are predominant receptors in heart,
but up to 10-50% can be beta2-receptorsbut up to 10-50% can be beta2-receptors
19. īŽ Beta adrenergic agonistsBeta adrenergic agonists
īŽ a) Non selective beta adrenergic agonistsa) Non selective beta adrenergic agonists
īŽ Epinephrine it stimulates alpha and beta1as wellEpinephrine it stimulates alpha and beta1as well
as beta2 receptors. It is an effective rapid actingas beta2 receptors. It is an effective rapid acting
bronchodilator when injected S/C (.4 mL ofbronchodilator when injected S/C (.4 mL of
1:1000 solution ) or inhaled as a microaerosol1:1000 solution ) or inhaled as a microaerosol
from a pressurised canister (320 mcg/ puff).from a pressurised canister (320 mcg/ puff).
īŽ Adverse effects tachycardia, arrythmias andAdverse effects tachycardia, arrythmias and
worsening of angina pectoris.worsening of angina pectoris.
20. īŽ The beta2 selective adrenoceptor agonist drugsThe beta2 selective adrenoceptor agonist drugs
īŽ Short acting drugs eg albuterol,terbutaline, andShort acting drugs eg albuterol,terbutaline, and
perbuterol are available as metered-doseperbuterol are available as metered-dose
inhalers. They are potent bronchodilators.inhalers. They are potent bronchodilators.
Bronchodilation is maximal within 15-30Bronchodilation is maximal within 15-30
minutes and persists for 3-4 hours.minutes and persists for 3-4 hours.
īŽ Toxic effects are minimized when these drugsToxic effects are minimized when these drugs
are delivered by inhalation.are delivered by inhalation.
21. īŽ Albuterol and terbutaline are available in tabletAlbuterol and terbutaline are available in tablet
form ,one tablet 2or 3 times daily is the usualform ,one tablet 2or 3 times daily is the usual
regimen but this route is rarely prescribed.regimen but this route is rarely prescribed.
īŽ Terbutaline is available for S/C injection (0.25Terbutaline is available for S/C injection (0.25
mg) The indication for this route are severemg) The indication for this route are severe
asthma requiring emergency T/M whenasthma requiring emergency T/M when
aersolized therapy is not available or has beenaersolized therapy is not available or has been
ineffective.ineffective.
22. īŽ Long acting beta2 selective agonistsLong acting beta2 selective agonists
īŽ Salmeterol a potent selective beta2 agonist thatSalmeterol a potent selective beta2 agonist that
achieves its long duration of action as a resultachieves its long duration of action as a result
of high lipid solubility. This increaes theof high lipid solubility. This increaes the
affinity of the drug for the beta adrenoceptors.affinity of the drug for the beta adrenoceptors.
The drug appears to interact with inhaledThe drug appears to interact with inhaled
corticosteroids to improve asthma control.corticosteroids to improve asthma control.
They should not be used in acuteThey should not be used in acute
bronchospasmbronchospasm
23. PharmacotherapyPharmacotherapy
īŽ METHYLXANTHINESMETHYLXANTHINES
īŽ TheophyllineTheophylline
īŽ Narrow therapeutic index/Maintain 5-20 mcg/mLNarrow therapeutic index/Maintain 5-20 mcg/mL
īŽ Variability in clearance leads to a range of dosesVariability in clearance leads to a range of doses
that vary 4-fold in order to reach a therapeutic dosethat vary 4-fold in order to reach a therapeutic dose
īŽ Mechanism of actionMechanism of action
īŽ Smooth muscle relaxation (bronchodilation)Smooth muscle relaxation (bronchodilation)
īŽ Suppression of the response of the airways to stimuliSuppression of the response of the airways to stimuli
īŽ Increase force of contraction of diaphragmatic musclesIncrease force of contraction of diaphragmatic muscles
īŽ Interacts with many other drugsInteracts with many other drugs
24. īŽ The bronchodilation produced by theophyllineThe bronchodilation produced by theophylline
is the major therapeutic action in asthma.is the major therapeutic action in asthma.
īŽ Most preparations of theophylline are wellMost preparations of theophylline are well
absorbed from GIT.absorbed from GIT.
īŽ For oral therapy with prompt- releaseFor oral therapy with prompt- release
formulation the typical dose is 3-4 mg/kgformulation the typical dose is 3-4 mg/kg
every 6hours.every 6hours.
25. īŽ Adverse effectsAdverse effects
īŽ Anorexia, nausea, vomiting, abdominalAnorexia, nausea, vomiting, abdominal
discomfort, headache and anxiety may occur.discomfort, headache and anxiety may occur.
īŽ Higher levels may cause seizures orHigher levels may cause seizures or
arrythmias.arrythmias.
īŽ Toxic levels may occur in patients with liverToxic levels may occur in patients with liver
disease.disease.
īŽ Previously used to be main-stay of asthmaPreviously used to be main-stay of asthma
therapy.therapy.
26. īŽ ANTIMUSCRINIC AGENTSANTIMUSCRINIC AGENTS
īŽ MOAMOA
īŽ Muscarinic antagonists competitively inhibitMuscarinic antagonists competitively inhibit
the effect of acetylcholine at muscarinicthe effect of acetylcholine at muscarinic
receptors ie block the contraction of airwayreceptors ie block the contraction of airway
smooth muscle and the increase in thesmooth muscle and the increase in the
secretion of mucus.secretion of mucus.
27. īŽ Ipratropium bromide a quaternary ammoniumIpratropium bromide a quaternary ammonium
derivative of atropine is used .It is deliveredderivative of atropine is used .It is delivered
in high doses by inhalation route.in high doses by inhalation route.
īŽ Clinical usesClinical uses
īŽ Addition of Ipratropium enhances theAddition of Ipratropium enhances the
bronchodilation produced by nebulizedbronchodilation produced by nebulized
Albuterol in acute severe asthma.Albuterol in acute severe asthma.
īŽ In patients intolerant of inhaled beta agonistIn patients intolerant of inhaled beta agonist
agents.agents.
28. īŽ LONG TERM CONTROLLERSLONG TERM CONTROLLERS
īŽ CORTICOSTEROIDSCORTICOSTEROIDS
īŽ They reduce bronchial reactivity, causeThey reduce bronchial reactivity, cause
contraction of engorged vessels in bronchialcontraction of engorged vessels in bronchial
mucosa, and inhibition of the infiltration ofmucosa, and inhibition of the infiltration of
asthmatic airways by lymphocytes ,asthmatic airways by lymphocytes ,
eosinophils and mast cells.eosinophils and mast cells.
īŽ Oral and parenteral corticosteroids areOral and parenteral corticosteroids are
reserved for patients who require urgent T/M.reserved for patients who require urgent T/M.
29. īŽ Urgent T/M is often begun with an oral doseUrgent T/M is often begun with an oral dose
of 30-60 mg prednisone /day. Or an I/V doseof 30-60 mg prednisone /day. Or an I/V dose
of 1mg/kg methylprednisolone every 6 hours.of 1mg/kg methylprednisolone every 6 hours.
The daily dose is decreased after air wayThe daily dose is decreased after air way
obstruction is relieved and it is customary toobstruction is relieved and it is customary to
administer corticosteroids early in theadminister corticosteroids early in the
morning .morning .
īŽ In most patients this systemic corticosteroidIn most patients this systemic corticosteroid
therapy can be discontinued in a week or 10therapy can be discontinued in a week or 10
days.days.
30. īŽ INHALED CORTICOSTEROIDSINHALED CORTICOSTEROIDS
īŽ AerosolT/M is the most effective way toAerosolT/M is the most effective way to
avoid the systemic effects. An average dailyavoid the systemic effects. An average daily
dose of 4 puffs twice daily of Beclomethasonedose of 4 puffs twice daily of Beclomethasone
(400mcg/day) is usually given. In switching(400mcg/day) is usually given. In switching
patients from oral to inhaled corticosteroidpatients from oral to inhaled corticosteroid
therapy oral therapy is slowly tapered off.therapy oral therapy is slowly tapered off.
31. īŽ Adverse effects of inhaled coticosteroidsAdverse effects of inhaled coticosteroids
īŽ High doses of inhaled steroids may causeHigh doses of inhaled steroids may cause
adrenal suppression .adrenal suppression .
īŽ Oropharyngeal candidiasis.Oropharyngeal candidiasis.
īŽ HoarsenessHoarseness
īŽ Risks of cataracts and osteoporosis in adultsRisks of cataracts and osteoporosis in adults
over the long term use.over the long term use.
īŽ Transient slowing of rate of growth inTransient slowing of rate of growth in
children,children,
32. īŽ Clinical usesClinical uses
īŽ Chronic use of inhaled corticosteroids:Chronic use of inhaled corticosteroids:
īŽ 1.Reduces symptoms and improves1.Reduces symptoms and improves
pulmonary function in mild asthma.pulmonary function in mild asthma.
īŽ 2.Reduces or eliminates the use of oral2.Reduces or eliminates the use of oral
corticosteroids in severe asthma.corticosteroids in severe asthma.
īŽ CautionCaution
īŽ Inhaled corticosteroids are effective only soInhaled corticosteroids are effective only so
long as they are taken.long as they are taken.
34. PharmacotherapyPharmacotherapy
īŽ Mast cell stabilizers (cromolyn/nedocromil)Mast cell stabilizers (cromolyn/nedocromil)
īŽ Inhibits release of mediators from mast cellsInhibits release of mediators from mast cells
(degranulation) after exposure to specific antigens(degranulation) after exposure to specific antigens
īŽ Blocks Ca2+ ions from entering the mast cellBlocks Ca2+ ions from entering the mast cell
īŽ Safe for pediatrics (including infants)Safe for pediatrics (including infants)
īŽ Should be started 2-4 weeks before allergy seasonShould be started 2-4 weeks before allergy season
when symptoms are expected.when symptoms are expected.
īŽ Can be used before exercise (not as good as ICS)Can be used before exercise (not as good as ICS)
īŽ Alternate med for persistent asthmaAlternate med for persistent asthma
35. īŽ Mast cell stabilizersMast cell stabilizers
īŽ Cromolyn and NedocromylCromolyn and Nedocromyl
īŽ MOAMOA
īŽ An alteration in the function of delayed chlorideAn alteration in the function of delayed chloride
channels in the cell membrane results in:channels in the cell membrane results in:
īŽ Inhibition of the early response to an antigenicInhibition of the early response to an antigenic
challenge of mast cellschallenge of mast cells
īŽ Inhibition of the inflammatory response ofInhibition of the inflammatory response of
eosinophils to inhalation of allergens.eosinophils to inhalation of allergens.
36. īŽ Clinical usesClinical uses
īŽ They are only of value when taken Prophylactically.They are only of value when taken Prophylactically.
īŽ When used as aerosols (by nebulizer or MDI) theyWhen used as aerosols (by nebulizer or MDI) they
effectively inhibit both antigen-and exercise- inducedeffectively inhibit both antigen-and exercise- induced
asthma. Cromolyn is taken as a single T/M prior toasthma. Cromolyn is taken as a single T/M prior to
exercise or unavoidable exposure to allergen.exercise or unavoidable exposure to allergen.
īŽ
37. īŽ Cromolyn or Nedocromil when takenCromolyn or Nedocromil when taken
regularly 2-4 puffs 2-4 times daily by patientsregularly 2-4 puffs 2-4 times daily by patients
with nonseasonal asthma, reduceswith nonseasonal asthma, reduces
symptomatic severity and the need forsymptomatic severity and the need for
bronchodilator medication particularly inbronchodilator medication particularly in
young patients.young patients.
īŽ Addition of nedocromil to a standard dose ofAddition of nedocromil to a standard dose of
an inhaled corticosteroid appears to improvean inhaled corticosteroid appears to improve
asthma control.asthma control.
38. īŽ Adverse effectsAdverse effects
īŽ Minor throat irritation, cough, and mouth dryness andMinor throat irritation, cough, and mouth dryness and
rarely chest tightness and wheezing.rarely chest tightness and wheezing.
īŽ Serious adverse effects dermatitis, myositis, orSerious adverse effects dermatitis, myositis, or
gastroenteritis occurs in less than 2% of patients.gastroenteritis occurs in less than 2% of patients.
īŽ Very few cases of pulmonary infiltration andVery few cases of pulmonary infiltration and
anaphylaxis have been reported.anaphylaxis have been reported.
39. PharmacotherapyPharmacotherapy
īŽ Leukotriene receptor antagonistsLeukotriene receptor antagonists
īŽ Leukotriene-mediated effects include:Leukotriene-mediated effects include:
īŽ Airway edemaAirway edema
īŽ Smooth muscle contractionSmooth muscle contraction
īŽ Altered cellular activity associated with theAltered cellular activity associated with the
inflammatory processinflammatory process
īŽ Receptors have been found in airway smoothReceptors have been found in airway smooth
muscle cells and macrophages and on other pro-muscle cells and macrophages and on other pro-
inflammatory cells (including eosinophils andinflammatory cells (including eosinophils and
certain myeloid stem cells) and nasal mucosacertain myeloid stem cells) and nasal mucosa
40. īŽ Leukotriene pathway inhibitorsLeukotriene pathway inhibitors
īŽ Zileuton a 5- lipoxygenase inhibitorZileuton a 5- lipoxygenase inhibitor
īŽ Montelukast, Zafirlukast LTD4 â receptorMontelukast, Zafirlukast LTD4 â receptor
antagonists.antagonists.
īŽ They improve asthma control.They improve asthma control.
īŽ They are given orally can be given in patients whoThey are given orally can be given in patients who
comply poorly with inhaled therapies.comply poorly with inhaled therapies.
īŽ Montelukast can be used in children as young as 6Montelukast can be used in children as young as 6
years of age. It can be taken without regards to mealsyears of age. It can be taken without regards to meals
and only once-daily convenient dosage.and only once-daily convenient dosage.
41. īŽ ANTI âIGE MONOCLONAL ANTIBODIESANTI âIGE MONOCLONAL ANTIBODIES
īŽ Omalizumab the monoclonal humanizedantiOmalizumab the monoclonal humanizedanti
IgE antibody is reserved for patients withIgE antibody is reserved for patients with
chronic severe asthma not controlled by highchronic severe asthma not controlled by high
dose inhaled corticosteroid plus long actingdose inhaled corticosteroid plus long acting
beta agonist combination T/M.beta agonist combination T/M.
īŽ It is given by twice S/C injections.It is given by twice S/C injections.
42. Various severities of asthmaVarious severities of asthma
īŽ Step-wise pharmacotherapy treatment programStep-wise pharmacotherapy treatment program
for varying severities of asthmafor varying severities of asthma
īŽ Mild Intermittent (Step 1)Mild Intermittent (Step 1)
īŽ Mild Persistent (Step 2)Mild Persistent (Step 2)
īŽ Moderate Persistent (Step 3)Moderate Persistent (Step 3)
īŽ Severe Persistent (Step 4)Severe Persistent (Step 4)
īŽ Patient fits into the highest category that theyPatient fits into the highest category that they
meet one of the criteria formeet one of the criteria for
43. Mild Intermittent AsthmaMild Intermittent Asthma
īŽ Day time symptomsDay time symptoms << 2 times q week2 times q week
īŽ Night time symptomsNight time symptoms << 2 times q month2 times q month
īŽ PEF or FEV1PEF or FEV1 >> 80% of predicted80% of predicted
īŽ PEF variability < 20%PEF variability < 20%
īŽ PEF and FEV1 values are only for adults and forPEF and FEV1 values are only for adults and for
children over the age of 5children over the age of 5
44. Mild Persistent AsthmaMild Persistent Asthma
īŽ Day time symptoms > 2/week, but < 1/dayDay time symptoms > 2/week, but < 1/day
īŽ Night time symptoms < 1 night q weekNight time symptoms < 1 night q week
īŽ PEF or FEV1PEF or FEV1 >> 80% of predicted80% of predicted
īŽ PEF variability 20%-30%PEF variability 20%-30%
45. Moderate Persistent AsthmaModerate Persistent Asthma
īŽ Day time symptoms q dayDay time symptoms q day
īŽ Night time symptoms > 1 night q weekNight time symptoms > 1 night q week
īŽ PEF or FEV1 60%-80% of predictedPEF or FEV1 60%-80% of predicted
īŽ PEF variability >30%PEF variability >30%
46. Severe Persistent AsthmaSevere Persistent Asthma
īŽ Day time symptoms: continualDay time symptoms: continual
īŽ Night time symptoms: frequentNight time symptoms: frequent
īŽ PEF or FEV1PEF or FEV1 << 60% of predicted60% of predicted
īŽ PEF variability > 30%PEF variability > 30%
47. Pharmacotherapy for Adults andPharmacotherapy for Adults and
Children Over the Age of 5 YearsChildren Over the Age of 5 Years
īŽ Step 1 (Mild intermittent asthma)Step 1 (Mild intermittent asthma)
īŽ No daily medication neededNo daily medication needed
īŽ PRN short-acting bronchodilator (albuterol) MDIPRN short-acting bronchodilator (albuterol) MDI
īŽ Severe exacerbations may require systemicSevere exacerbations may require systemic
corticosteroidscorticosteroids
īŽ Although the overall diagnosis is âmildAlthough the overall diagnosis is âmild
intermittentâ the exacerbations themselves can stillintermittentâ the exacerbations themselves can still
be severebe severe
48. Pharmacotherapy for Adults andPharmacotherapy for Adults and
Children Over the Age of 5 YearsChildren Over the Age of 5 Years
īŽ Step 2 (Mild persistent)Step 2 (Mild persistent)
īŽ Preferred TreatmentPreferred Treatment
īŽ Low-dose inhaled corticosteroid dailyLow-dose inhaled corticosteroid daily
īŽ Alternative Treatment (no particular order)Alternative Treatment (no particular order)
īŽ CromolynCromolyn
īŽ Leukotriene receptor antagonistLeukotriene receptor antagonist
īŽ NedocromilNedocromil
īŽ Sustained release theophylline to maintain a blood levelSustained release theophylline to maintain a blood level
of 5-15 mcg/mLof 5-15 mcg/mL
49. Pharmacotherapy for Adults andPharmacotherapy for Adults and
Children Over the Age of 5 YearsChildren Over the Age of 5 Years
īŽ Step 3 (Moderate persistent)Step 3 (Moderate persistent)
īŽ Preferred TreatmentPreferred Treatment
īŽ Low-to-medium dose inhaled corticosteroidsLow-to-medium dose inhaled corticosteroids
īŽ WITH long-acting inhaled beta2-agonistWITH long-acting inhaled beta2-agonist
īŽ Alternative TreatmentAlternative Treatment
īŽ Increase inhaled corticosteroids within the medium doseIncrease inhaled corticosteroids within the medium dose
rangerange
īŽ Add leukotriene receptor antagonist or theophylline toAdd leukotriene receptor antagonist or theophylline to
the inhaled corticosteroidthe inhaled corticosteroid
50. Pharmacotherapy for Adults andPharmacotherapy for Adults and
Children Over the Age of 5 YearsChildren Over the Age of 5 Years
īŽ Step 4 (Severe persistent)Step 4 (Severe persistent)
īŽ Preferred TreatmentPreferred Treatment
īŽ High-dose inhaled corticosteroidsHigh-dose inhaled corticosteroids
īŽ AND long-acting inhaled beta2-agonistsAND long-acting inhaled beta2-agonists
īŽ AND (if needed) oral corticosteroidsAND (if needed) oral corticosteroids
51. Pharmacotherapy for Infants andPharmacotherapy for Infants and
Young Children (<5 years)Young Children (<5 years)
īŽ Step 1(mild intermittent)Step 1(mild intermittent)
īŽ No daily medication neededNo daily medication needed
52. Pharmacotherapy for Infants andPharmacotherapy for Infants and
Young Children (<5 years)Young Children (<5 years)
īŽ Step 2 (mild persistent)Step 2 (mild persistent)
īŽ Preferred treatmentPreferred treatment
īŽ Low-dose inhaled corticosteroidsLow-dose inhaled corticosteroids
īŽ Alternative treatmentAlternative treatment
īŽ Cromolyn (nebulizer preferred)Cromolyn (nebulizer preferred)
īŽ OR leukotriene receptor antagonistOR leukotriene receptor antagonist
53. Pharmacotherapy for Infants andPharmacotherapy for Infants and
Young Children (<5 years)Young Children (<5 years)
īŽ Step 3 (moderate persistent)Step 3 (moderate persistent)
īŽ Preferred treatmentPreferred treatment
īŽ Low-dose inhaled corticosteroids and long-acting beta2-Low-dose inhaled corticosteroids and long-acting beta2-
agonistagonist
īŽ OR Medium-dose inhaled corticosteroidsOR Medium-dose inhaled corticosteroids
īŽ Alternative treatmentAlternative treatment
īŽ Low-dose inhaled corticosteroids with either:Low-dose inhaled corticosteroids with either:
īŽ Leukotriene receptor antagonistLeukotriene receptor antagonist
īŽ OR theophyllineOR theophylline
54. Pharmacotherapy for Infants andPharmacotherapy for Infants and
Young Children (<5 years)Young Children (<5 years)
īŽ Step 4 (severe persistent)Step 4 (severe persistent)
īŽ Preferred treatmentPreferred treatment
īŽ High-dose inhaled corticosteroidsHigh-dose inhaled corticosteroids
īŽ AND long-acting inhaled beta2-agonistAND long-acting inhaled beta2-agonist
īŽ AND (if needed) Oral corticosteroidsAND (if needed) Oral corticosteroids
īŽ For young children, inhaled medications should beFor young children, inhaled medications should be
given by nebulizer, dry powder inhaler (DPI), orgiven by nebulizer, dry powder inhaler (DPI), or
MDI with a chamber/spacerMDI with a chamber/spacer
55. Acute ExacerbationsAcute Exacerbations
īŽ Inhaled albuterol is the treatment of choice inInhaled albuterol is the treatment of choice in
absence of impending respiratory failureabsence of impending respiratory failure
īŽ MDI with spacer as effective as nebulizer withMDI with spacer as effective as nebulizer with
equivalent dosesequivalent doses
īŽ Adding an antibiotic during an acuteAdding an antibiotic during an acute
exacerbation is not recommended in theexacerbation is not recommended in the
absence of evidence of an acute bacterialabsence of evidence of an acute bacterial
infectioninfection
56. Acute ExacerbationsAcute Exacerbations
īŽ BeneficialBeneficial
īŽ Inhaled atrovent added to beta2-agonistsInhaled atrovent added to beta2-agonists
īŽ High-dose inhaled corticosteroidsHigh-dose inhaled corticosteroids
īŽ MDI with spacer as effective as nebulizerMDI with spacer as effective as nebulizer
īŽ OxygenOxygen
īŽ Systemic steroidsSystemic steroids
īŽ Likely to be beneficialLikely to be beneficial
īŽ IV theophyllineIV theophylline
57. Exercise-induced BronchospasmExercise-induced Bronchospasm
īŽ Evaluate for underlying asthma and treatEvaluate for underlying asthma and treat
īŽ SABA are best pre-treatmentSABA are best pre-treatment
īŽ Mast cell stabilizers less effective than SABAMast cell stabilizers less effective than SABA
īŽ Anticholinergics less effective than mast cellAnticholinergics less effective than mast cell
stabilizersstabilizers
īŽ SABA + mast cell stabilizer not better thanSABA + mast cell stabilizer not better than
SABA aloneSABA alone
58. īŽ TREATMENT OF CHRONICTREATMENT OF CHRONIC
OBSTRUCTIVE PULMONARY DISEASEOBSTRUCTIVE PULMONARY DISEASE
īŽ Acute stage inhalation of a short acting betaAcute stage inhalation of a short acting beta
agonist eg albuterol,or an anticholinergic drugagonist eg albuterol,or an anticholinergic drug
eg ipratropium bromide or the two ineg ipratropium bromide or the two in
combination is usually effective.combination is usually effective.
īŽ Persistent symptoms of exertional dyspnea andPersistent symptoms of exertional dyspnea and
limitation of activities requires a long actinglimitation of activities requires a long acting
beta agonist or long acting anticholinergic.beta agonist or long acting anticholinergic.
59. īŽ Severe airflow obstruction or a H/OSevere airflow obstruction or a H/O
exacerbations: regular use of an inhaledexacerbations: regular use of an inhaled
corticosteroid reduces the incidence of futurecorticosteroid reduces the incidence of future
exacerbations.exacerbations.
60. īŽ Theophylline may be used to increaseTheophylline may be used to increase
ventilatory capacity.ventilatory capacity.
īŽ Antibiotics are used in exacerbations ofAntibiotics are used in exacerbations of
COPD.COPD.
61. īŽ ANTI TUSSIVE AGENTSANTI TUSSIVE AGENTS
īŽ DEXTROMETHORPHAN AsyntheticDEXTROMETHORPHAN Asynthetic
derivative of morphine , suppresses thederivative of morphine , suppresses the
response of the cough centre.response of the cough centre.
īŽ CODEINE decreases the sensitivity of coughCODEINE decreases the sensitivity of cough
centres to peripheral stimuli and decreasescentres to peripheral stimuli and decreases
mucosal secretions.mucosal secretions.
62. QuestionQuestion
īŽ Which one of the following is true concerningWhich one of the following is true concerning
control of mild persistent asthma in thecontrol of mild persistent asthma in the
pediatric population?pediatric population?
īŽ Cromolyn should not be used under age 5Cromolyn should not be used under age 5
īŽ Atrovent should be added if beta-agonists do notAtrovent should be added if beta-agonists do not
maintain control of asthmamaintain control of asthma
īŽ LABA should be added if SABA is ineffectiveLABA should be added if SABA is ineffective
īŽ SABA may be used q2h to maintain controlSABA may be used q2h to maintain control
īŽ Initial treatment should be an inhaled anti-Initial treatment should be an inhaled anti-
inflammatory such as ICS or cromolyninflammatory such as ICS or cromolyn
63. Answer EAnswer E
īŽ Initial medications for chronic asthma shouldInitial medications for chronic asthma should
include an anti-inflammatory such as ICS orinclude an anti-inflammatory such as ICS or
cromolyn. Cromolyn is safe for all pediatriccromolyn. Cromolyn is safe for all pediatric
age groups. Atrovent is useful in COPD, butage groups. Atrovent is useful in COPD, but
very limited use in asthma. Albuterol shouldvery limited use in asthma. Albuterol should
be used up to every 4 hours prn. Overuse ofbe used up to every 4 hours prn. Overuse of
inhaled beta-agonists has been associated withinhaled beta-agonists has been associated with
an increased mortality rate.an increased mortality rate.
64. QuestionQuestion
īŽ It is estimated allergic rhinitis affects how mayIt is estimated allergic rhinitis affects how may
people in the US?people in the US?
īŽ 20 million20 million
īŽ 40 million40 million
īŽ 50 million50 million
īŽ 100 million100 million
īŽ Answer: B 40 millionAnswer: B 40 million
65. QuestionQuestion
īŽ Which one of the following statements concerningWhich one of the following statements concerning
the association between allergic rhinitis and asthma isthe association between allergic rhinitis and asthma is
false?false?
īŽ Almost all patients with allergic asthma also haveAlmost all patients with allergic asthma also have
symptoms of rhinitissymptoms of rhinitis
īŽ About 1/3 of patients with allergic rhinitis also have asthmaAbout 1/3 of patients with allergic rhinitis also have asthma
īŽ Pharmacologic treatment for allergic rhinitis will notPharmacologic treatment for allergic rhinitis will not
improve the symptoms of asthmaimprove the symptoms of asthma
īŽ Patients with allergic rhinitis and patients with asthmaPatients with allergic rhinitis and patients with asthma
exhibit peripheral eosinophilia and basophilia.exhibit peripheral eosinophilia and basophilia.
66. Answer: CAnswer: C
īŽ Patients with asthma should have their allergicPatients with asthma should have their allergic
rhinitis treatedrhinitis treated
īŽ People with asthma and allergic rhinitis whoPeople with asthma and allergic rhinitis who
are treated for their allergic rhinitis have aare treated for their allergic rhinitis have a
significantly lower risk of subsequent asthma-significantly lower risk of subsequent asthma-
related events than those not treated forrelated events than those not treated for
allergic rhinitis.allergic rhinitis.
67. QuestionQuestion
īŽ Which one of the following findings on a nasalWhich one of the following findings on a nasal
smear suggests a diagnosis of allergic rhinitis?smear suggests a diagnosis of allergic rhinitis?
īŽ > 10% neutrophils> 10% neutrophils
īŽ > 10% eosinophils> 10% eosinophils
īŽ < 10% neutrophils< 10% neutrophils
īŽ > 10% erythrocytes> 10% erythrocytes
īŽ Answer: B >10% eosinophilsAnswer: B >10% eosinophils
68. QuestionQuestion
īŽ Which of the following statements is true?Which of the following statements is true?
īŽ An acceptable strategy for eliminating sedatingAn acceptable strategy for eliminating sedating
effects of 1effects of 1stst
-generation antihistamines and-generation antihistamines and
containing the cost of 2containing the cost of 2ndnd
-generation is to use 2nd--generation is to use 2nd-
generation in the AM and 1generation in the AM and 1stst
-generation in the PM-generation in the PM
īŽ In most states, patients taking 1In most states, patients taking 1stst
-generation are-generation are
considered âunder the influence of drugs.âconsidered âunder the influence of drugs.â
īŽ Mast cell stabilizers are becoming an excellentMast cell stabilizers are becoming an excellent
choice for children because of their ability to treatchoice for children because of their ability to treat
symptoms after they have started and their safetysymptoms after they have started and their safety
69. Answer: BAnswer: B
īŽ Patients taking 1Patients taking 1stst
-generation antihistamines-generation antihistamines
are considered âunder the influence of drugs.âare considered âunder the influence of drugs.â
The sedating effects have been shown to carryThe sedating effects have been shown to carry
over to the next day even when taken only atover to the next day even when taken only at
night and this type of chronic use is notnight and this type of chronic use is not
recommended.recommended.
īŽ Mast cell stabilizers should be started beforeMast cell stabilizers should be started before
symptoms develop, not after.symptoms develop, not after.