asthma treatment - university of california, irvine · what is asthma?? asthma is a complex...
TRANSCRIPT
Asthma treatment
Andrew Zaragoza
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!
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)
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
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!)
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
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
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
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
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