Asthma Medicines

Having a Treatment Plan

The drop in peak flow to 50 percent of the patient’s best identifies a serious attack. The patient should repeat the maneuver to determine if it is reproducible. Each patient should have a plan of treatment that has been worked out with the physician. This will typically call for immediate use of rapidly acting bronchodilator medication delivered as an aerosol. The plan should contain instructions on the use of corticosteroids and notification of the patient’s physician.

The physician’s knowledge of the patient’s history will prove invaluable at this time. Patients who have required hospitalization and especially those who have required respirator support for treatment of asthmatic attacks in the past will be advised not to delay treatment decisions. This patient group may require emergency room treatment as will patients with severe attacks who do not rapidly increase their peak flows with bronchodilator medication administered as directed (and not overused).

In treatment of bronchial asthma it is necessary to be aggressive early in treatment of severe attacks, including the possible use of an emergency room. With early recognition of a severe attack and aggressive treatment at its onset, fatal or near-fatal episodes can be avoided.

In the patient group with severe attacks who respond promptly to treatment, the patient’s treatment plan may often be continued in the home. With severe attacks this will most certainly require corticosteroids. Communication with the physician is essential and will be more accurate with serial peak flow measurements. Increasing airflows will confirm the effectiveness of treatment and can be used to adjust medication dosage and frequency of administration.

Following a severe attack that has been successfully treated it is important for the physician and patient to reassess maintenance medication and the treatment plan. The diary of peak flows will be extremely helpful since it may identify a downward trend that began before a severe attack was recognized. Emphasis on earlier recognition may prove helpful in avoiding future attacks.

With each significant attack the physician will look for a “trigger” mechanism that might be prevented in the future. An example would be raking moldy leaves or dusting without a face mask. Avoiding allergens will be stressed in sensitive patients who suffer serious attacks on exposure to these substances. Often the trigger for an asthmatic attack is the common cold. Although this infection cannot be prevented, the patient should be alerted to the possible adverse effects that might result and be prepared to institute the treatment plan.

In many instances the trigger for a severe asthmatic attack cannot be identified. If attacks are frequent, a review of the medical evaluation should be made. Additional allergy tests may be indicated and another careful examination of the home and work environment made. The patient’s administration of medication should also be examined and the maintenance medication program reviewed.

What If Avoidance Doesn’t Work?

Despite measures to avoid asthma triggers, the patient may still experience asthmatic attacks. These attacks may be frequent and severe and at times require hospitalization. In a small number of patients these attacks may prove fatal.

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A challenge test may be used by the physician to demonstrate that a patient with a normal result on pulmonary function testing may indeed have asthma. This bronchial challenge or provocation testing would only be performed if the patient’s history and physical findings suggested that the patient is asthmatic but spirometry was normal. It is not a routine part of pulmonary function testing. The substances or agents commonly used for challenge testing include histamine, methacholine, and cold air.

Histamine is stored in allergy cells such as mast cells and is released during allergic or asthmatic attacks. It is thought to be one of the mediators of asthma. For this reason it is very suitable for provoking asthma in challenge testing. Methacholine is a chemical that stimulates one part of the nervous system called the parasympathetic nervous system to fire. If inhaled into the bronchial tubes in an asthmatic subject, methacholine will trigger impulses that produce airway constriction. Cold air irritates the bronchial tubes and may also be used for challenge testing. In an asthmatic subject with hyperreactive airways, inhaling cold air will produce significant tightening of the bronchial tubes.

In the patient thought to have occupational asthma the specific offending substance may be used to confirm the direct link between the substance and the patient’s asthmatic reaction. A similar challenge test has been used in patients to confirm allergy to sulfites and aspirin. With any challenge test there is a risk of a severe asthmatic reaction and for this reason these tests are reserved for difficult diagnostic situations and are only performed under careful observation and control.

Guidelines have been developed for performing and interpreting bronchial challenge testing. It is vital to standardize this type of testing to avoid “false positive” or “false negative” results. Generally, for a provocation test to be positive, there must be at least a 15 percent fall in airflow after inhaling the challenge material.

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Once specific allergens have been identified, the patient must attempt to avoid these substances and clear them from the home and workplace as much as possible. A natural extension of the identification of allergy is the consideration of desensitization or immunotherapy by an allergy specialist. Allergy “shots” are given after sensitivity to specific allergens has been identified. These injections contain extremely small amounts of the allergen which is slowly increased in amount. These injections produce a “blocking antibody” that interrupts the allergy reaction. Studies of immunotherapy in asthmatics have shown a reduction in symptoms and inhibition of the late asthmatic response. The administration of immunotherapy is a gradual process, often requiring weeks or months to achieve a response. In older subjects the response to treatment may not be as pronounced as in younger patients. Extremely sensitive patients may experience generalized allergic reactions to the administration of allergens.

Recent studies have focused on fatal reactions to allergy injections. The majority of these cases were patients with severe asthma who had histories of severe asthmatic attacks that required steroids and hospitalization. These patients also appeared to be highly sensitive individuals who may have had a previous reaction to allergen injection.

Who Should Be Treated?

In patients with mild or moderate asthma who are well controlled on medication, allergy injections or immunotherapy should not be necessary. Those patients who are unstable should be considered candidates for treatment. In those allergic patients whose symptoms are more severe or who require frequent or continuous administration of corticosteroids the potential benefits of immunotherapy should be weighed against the potential for severe reactions. Once a response to immunotherapy is obtained the patient may remain on maintenance therapy for several years.

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Following the careful review of the patient’s history and physical examination the physician will proceed to several commonly used laboratory tests to complete the diagnostic evaluation. There is no universal”checklist” of tests for every patient since there is great variation in each case. Physicians may also have differences in their laboratory evaluations.

Blood Tests

In the laboratory evaluation of asthma it would be common to evaluate the patient’s blood count looking for “allergy cells” called eosinophils. The physician may also obtain a level of IgE, the immunoglobulin in the blood that is often elevated in allergic patients. .

X-rays

A chest x-ray is often necessary to exclude many of the entities discussed above that can mimic asthma. It does not serve to confirm the diagnosis since the features of asthma occurring within the bronchial tubes cannot be seen on a chest x-ray.

Occasionally, the chest x-ray may show that the lungs are greatly expanded and appear larger than normal or hyperinflated. This occurs in asthma because air may enter the bronchial tubes but have difficulty being exhaled, also known as “air-trapping.” This x-ray finding cannot be used as a diagnostic tool for asthma since the same finding may occur in emphysema and in some cases of bronchitis.

Often the physician will order sinus x-rays as part of the laboratory evaluation. Evidence of sinusitis or nasal polyps would identify patients as high-risk candidates for asthma. In addition, the sinusitis may be viewed as a potential aggravating factor in asthmatic attacks and thus become a focus of treatment of individual patients. There is a recent trend toward using the more detailed CAT scan for this exam because of the increased information it provides.

Sputum Exam

Examination of swabs of nasal mucus or chest phlegm (sputum) may be helpful in diagnosing asthma. Microscopic examination may identify abundant eosinophils that would be characteristic of allergy and asthma. The presence of pus cells called neutrophils would suggest an infectious process; for example, bronchitis or sinusitis. The physician may request a culture of the coughed sputum if pus cells are seen under the microscope.

Pulmonary Function Testing

Forced Expiratory Maneuver

The most important laboratory test the physician performs in the diagnosis of asthma is pulmonary function testing. Before the testing begins the patient’s age, race, sex, height, and weight are recorded. From these statistics the expected normal values are determined. These are called the predicted normals and they are determined from statistical analysis of large groups of normal subjects.

The most common test involves a device known as a spirometer, which measures the amount of air (volume) expelled by the patient as well as its speed as the air is exhaled forcefully. In this simple but extremely important maneuver the patient is asked to take a full deep breath in, then exhale fully and forcefully this is called a maximum forced expiratory maneuver. In tracing this maneuver the physician determines the maximum amount of air the patient can expel after the deepest inhalation. This amount is called the vital capacity.

As air is expelled the airflow is measured throughout the maneuver until the patient is unable to exhale further. One extremely useful measurement is of the greatest flow that can be obtained after the patient has inhaled fully and forcefully exhaled. This is termed peak expiratory flow rate or “peak flow.” This important and easily performed. Flow rates are recorded at the beginning, middle, and end of the forced exhalation maneuver and so is the amount of air expelled each second. As air is exhaled by the lungs it is the large bronchial tubes (large airways) that empty first with the smaller passages (small airways) contributing a greater share as exhalation continues and ends. In one second a certain amount of air should normally be exhaled with an expected increase as time increases. The one-second measurement is often a good reflector of the large airways and measurements toward the middle and end of the breath usually determine the condition of smaller air passages.

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