1. Prevent chronic symptoms

2. Require <2 days/wk of inhaled SABA for quick refief symptoms

3. Maintain near normal pulm. funx

4. maintain normal activity levels

5. meet expectations of satisfying asthma care

1. Prevent recurrent exacerbations-minimized ED visits

2. Prevent loss of lung funx

-or reduced lung growth in childer

3. Provide optimal pharmtherapy with minimal adverse effects

1.  Coughing (pediatrics)

2. Wheezing

3. Shortness of breath

4. difficulty breathing (like through a straw)

5. Hypoxia

8-15yo = 85%

20-35 = 80%

40-59 = 75%

60-80 = 70%

Intermediate = step 1

persistent:

mild=step2

moderate=step 3 or 4

severe=step 5 or 6

1. Daily

2. Long-term control

3. Anti-inflammatory

1. As needed

2. Quick relief

3. Bronchodilators

Beclomethasone (QVAR)

Budesonide (Pulmicort)

Fluticasone (Flovent)

Mometasone (Asmanex)

Ciclesonide (Alvesco)

Prednisone (generic)

Methylprednisolone (medrol, sulumderol)

Prednisolone (Prelone)

1.Improve asthma, control more effectively than long term control meds

2.Reduce impairment and risk of exacerbations

3.Does not alter progression of underlying severity of the disease

inhaled corticosteroids

1. Response

2. Max Effects

           1. Reduce airway inflammation        

      -dec. airway hyperresponsiveness

-Dec PRN albuterol use

2. Max effect

-oral: 6-24 hrs

                    -Inhaled: days to weeks (maybe months)

-Not for rescue

0-4 yo

low: 0.25-0.5mg/d

med: >0.5-1.0mg/d

high: >1.0mg/d

5-11yo

low: 0.5mg/d

med: 1.0mg/d

High: 2.0mg/d

Reported AE:

Respiratory infections, rhinitis, otitis media, vomiting, diarrhea

1. monitor growth

2. use lowest possible dose

3. Administer with spaces or holding chambers

4. teach to "spit and rinse"

5. consider long acting beta agonist to low/med dose ICS rather than using high dose ICS

dysphonia

thrush

cough/throat

irritation

Impaired growth (High dose)

Fluid retention

muscle weakness

ulcers

malaise

Impaired wound healing

N/V, HA

osteoporosis (adults)

Cataracts (adults)

Glaucoma (adults)

Indication: daily long-term control (bronchodilate)

Mechanism: long term stimulation of beta2 receptors

Advantages:

-blunt exercise induced symptoms for longer time

-dec. nocturnal symptoms

-improve quality of life

Not for exacerbations

onset: 30 min (salmeterol)

5-10min (formoterol)

Peak: 1-2 hours (salm)

15 min-1hr (form)

Duration of effect: up to 12 hours

Not used as monotherapy

not a sub for anti-inflammatory therapy

Used in combo with ICS for long term control and prevent symptoms in mod or severe persistent asthma

1. Combination therapy (with ICS)

2. Useful for nocturnal symptoms

3. Useful for exercise-induced asthma when taken 30 min before exercise

LABA

1. Fluticasone + Salmeterol

LABA

 Budesonide + Formoterol

LABA

Mometasone + Formoterol

Zileuton 

Montelukast 

Zafirlukast

Leukotriene Modifiers

Leukotriene receptor antagonist

Zileuton - 5 lipoxygenase inhibitor

1. Improve lung funx

2. dec. need for short-acting B2 agonists

3. prevent exacerbations

Indictations:

-asthma and allergic rhinitis

-exercise induced asthma

-seasonal and perennial allergic rhinitis

**not preferred combo therapy

Theo-Dur

Slo-Bid

Slo-Phyllin

Theo-lair

1. Long term control med

2. Taken by mouth (or IV in hospital)

3. Requires serum concentration monitoring

4. MANY drug interactions

5. Adverse effects (GI, CV, CNS)

1. most effective for relief of acute bronchospasm

2. inc need for these meds= uncontrolled asthma

3. regularly scheduled use not indicated - use as needed

-may lower effect

-may inc airway hyperresponsiveness

Albuterol

levalbuterol

Pirbuterol

Terbutaline

Metaproterenol

Isoetharine

Short acting beta2-agonists

onset-

peak effect-

duration of effect-

onset: 5-10 min

peak effect: 15-30 min

Duration of effect: up to 8 hrs

-depends on underlying inflammation

-exercise induced: 2-3 hrs

Short- acting beta2 agonists side effects

tremor

inc heart rate

palpitations

Acute:

hyperglycemia

hypokalemia

hypomagnesemia

Usually 2 puffs PRN

Acute exacerbations:
up to 4-8 puffs q20min

Indications - "quick" (6-24hrs) relief of inflammation

when:

1. albuterol doesnt work- beta2 agonist

2. gradual deterioration

3. establish "control" in an existing or newly diagnosed patient

Primatene Mist

-epinephrine

Primatene tablets

-ephedrine

-guaifenesin

1. Metered-dose inhalers

2. Dry-powder inhalers

3. nebulization

4. oral medications

5. intravenous medications

1.  softer, mist-like spray

2. warmer puff

3. lower spray force

4. no priming when used more than 2 wks

5. need spacer?

6. need to clean actuator every wk

1. 10-30% actuated drugs delivered to lungs

2.  propellant is driving force

3. slow inhaltion (<30L/min)=3-5sec

4. requires priming for first dose

-Breath actuated

-require minimal hand-lung coordination

-requires a fast inhalation (>60L/min)

-delivers 10-20% of dose to airways

Formoterol (foradil)=long acting beta agonist

=need to load dose manually

Tiotropium (spiriva)

Need to load dose manually

1. allows evaporation of propellant prior to inhalation

2. good for poor hand-lung coordination

3. no clinical advantage over proper use of MDI's

4. Decreases oropharyngeal deposition

-reduce hoarseness and thrush

1. beta agonists

2. corticosteroids

3. anticholinergics

1. awakens at night with symptoms

2. Has an urgent care visit

3. Has increased need for albuterol

4. Rule of "two's"

=Step up therapy needed

1. inhaler technique

2. adherence to prescribed regimen

3. environmental changes

4. also consider alternative diagnoses

Asthma control test (25 points) scoring

>20 well-controlled

16-19 not well-controlled

<15 very poorly controlled

1. needs to be documented in chart:

a. asthma is well-controlled and indicated by Q's

b. Not at elevated risk of exacerbation

c. asthma education documented in chart

d. asthma management plan in chart

1. relief inhaler >2 times/wk

2. awake at night more than >2/mo

3.refill quick relief inhaler >2/yr

1. patient adherence to regimen

2. inhaler technique

3. freq of albuterol use

4. freq of oral corticosteroid "burst" therapy

5. side effects of meds

1. given diagnosis

2. treat acute symptoms

3. assess day and night time symptoms and pulm function

4. classify severity or control

5. select/adjust pharmacotherapy

1. Diagnosis: hx of cough, sob, chest pain or tightness, wheezing or endurance problems during exercise

2. must inform coaches and teachers

3. 15% decrease in PEFR or FEV1

1. SABA used before exercise lasts 2-3hrs

2. LABA may prevent EIB for 10-12 hrs

3. controller therapy with dec EIB

4. a lengthy warmup period before exercise may preclude medications