A stepwise guideline to the treatment of asthma as per needs of the patient has been recommended
CHOICE OF TREATMENT
A
stepwise guideline to the treatment of asthma as per needs of the patient has
been recommended:
(symptoms less than once daily, normal in
between attacks): Inhaled shortacting β2 agonist at onset of
each episode. No regular prophylactic therapy (Step1).
Start regular inhaled cromoglycate/low dose
inhaled steroid (200–400 μg/day) 3–4 weeks before anticipated seasonal attacks and continue
till 3–4 weeks after the season is over. Treat individual episodes with inhaled
short acting β2 agonist.
(symptoms
once daily or so) Regular inhaled lowdose steroid (Step2). Alternatively, inhaled
cromoglycate. Episode treatment with inhaled shortacting β2 agonist.
(attacks
affect activity, occur > 1 per day or mild baseline symptoms) Increasing
doses of inhaled steroid (up to 800 μg/day) + inhaled long-acting β2 agonist (Step3). Leukotriene
antagonists may be tried in patients not accepting inhaled steroids and in those
not well controlled. Theophylline may be used as alternative additional drug.
Episode treatment with inhaled shortacting β2 agonist.
(continuous
symptoms; activity limitation; frequent exacerbations/hospitalization) Regular high
dose inhaled steroid (800– 2000 μg/day) through a large volume spacer device inhaled
long-acting β2 agonist (salmeterol)
twice daily. Additional treatment with one or more of the following (Step4):
Leukotriene
antagonist/sustained release oral theophylline/oral β2 agonist/inhaled
ipratropium bromide.
Rescue
treatment with shortacting inhaled β2 agonist.
In patients not
adequately controlled or those needing frequent emergency care—institute oral
steroid therapy (Step5). Attempt withdrawing oral steroid
periodically.
Any
patient of asthma has the potential to develop acute severe asthma which may be
life-threatening. Upper respiratory tract infection is the most common precipitant.
1) Hydrocortisone
hemisuccinate 100 mg (or equivalent dose of another glucocorticoid) i.v. stat, followed by 100–200 mg 4–8 hourly
infusion; may take upto 6 hours to act.
2)
Nebulized salbutamol (2.5–5 mg) + ipratropium
bromide (0.5 mg) intermittent inhalations driven by O2.
3)
High flow humidified oxygen inhalation.
4)
Salbutamol/terbutaline 0.4 mg i.m./s.c. may be
added, since inhaled drug may not reach smaller bronchi due to severe narrowing/plugging.
5)
Intubation and mechanical ventilation, if
needed.
6)
Treat chest infection with intensive antibiotic
therapy.
7) Correct dehydration and acidosis with saline +
sod. bicarbonate/lactate infusion.
Aminophylline 250–500
mg diluted in 20–50 ml glucose (5%) solution injected i.v. over 20–30 min had
been routinely used, but recent evidence shows that it does not afford
additional benefit; may even produce more adverse effects; use is restricted to
resistant cases.
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