Asthma treatment can be different depending on what stage the asthma is in.
Stage I (= mild intermittent asthma ): With mild asthma the patient may only need an inhaler (=beta-2- agonist , Albuteranol etc. or for exercise induced asthma a cromolyn or nedocromil inhaler may be all that is necessary.
Stage II (= mild persistent asthma): In this patient group the inflammatory reaction of the airways is more of a problem. A low dose corticosteroid inhaler needs to be added and usually will provide stability to the stage II asthma. It is combined with the beta-2-inhalers. A new class of anti-inflammatories (leukotriene receptor antagonists) are useful for some patients with allergies.Two common drugs in that group are montelukast (Singulair) and zafirlukast (Accolate). Your physician may combine these pills with the inhalers.
What to do in case of an acute asthma attack
In case of an acute asthma attack it is best to call for an ambulance and treat this in the hospital setting as asthma can acutely deteriorate into a life threatening situation, called “status asthmaticus”. In the hospital the physician will assess the patient quickly and depending on the condition likely treat with inhalation of a beta-2-agonist by nebulizer inhalation device. In addition, depending on the severity of the blood gases or oxymeter reading prior to treatment, oral or intravenous corticosteroids may be administered. In some cases, particularly in children, adrenaline as subcutaneous injections may be given, but in older patients with heart disease this would not be advisable for fear of causing serious heart rhythm problems. However, in children adrenaline can stop allergic reactions rapidly, such as peanut induced asthma or other IgE antibody induced asthma. In cases where the patient becomes unconscious the ER physician will likely very quickly intubate the patient in order to have rapid access to the airways and to be able to quickly regain control. In milder such emergencies intubation and 100% oxygen administration may get the patient conscious quickly, in more serious cases the patient may have to be paralyzed like in an Operative Room setting. The anesthetist can often make the difference between life and death in this type of patient. This latter case is called “status asthmaticus” (thanks to emedicine.medscape.com for this link) and is fortunately fairly rare. Patients will have to reach at least 70% or more of their prior best FEV1 or PEF value (or of the expected values) before they could be discharged from the Emergency Room. However, each situation must be judged on its own merits and the Emergency Room doctor is in the best situation to give sound advice.
Stage III (= moderate persistent asthma): At this stage there are even more problems with inflammation and hyperirritability of the airways. More emphasis is put on longterm treatment of anti-inflammatory modalities such as corticosteroid inhalation in the low to mid dose range (500 to 1000 micrograms per day) in combination with theophylline tablets at bedtime to control nighttime asthma. These patients should be seen by a specialist as the asthma likely will be an ongoing problem and complications need to be prevented. Specialists such as a respirologist (the medical term for “lung specialist”, other name “pulmonologist”) and an allergist would be recommendable. The respirologist is very knowledgeable on spirometry findings and the combination of the optimal medication regime. The allergist in this asthma stage will often find a hidden allergen such as an inhalant allergen (dust, molds, tree or grass pollen) or even food allergies that have been unknown or were overlooked in earlier testing. I have seen many patients in this stage stabilize with their asthma on allergy avoidance schemes and allergy injections for inhalants. Often they were able to reduce their asthma severity to a stage II or even stage I on such an allergy regime.
Theophylline (such as the long-acting Theo-Dur) has been very useful for stabilizing patients who have nighttime asthma problems. However, there are possible side-effects and your physician may want to send you for blood theophylline levels to ensure that the level stays within the “therapeutic window” (which according to Ref. 3, page 758, is now accepted as therapeutic when in the 5 to 15 µg/mL range). Theophylline has been shown to have an anti-inflammatory as well as bronchodilator function. In older patients who are more heart sensitive, there is a danger of irregular heart beats with this drug and the doctor may not want to use it or order blood levels more often. However, for children and teenagers there is still room for this type of medication to stabilize asthma.
Stage IV (= severe persistent asthma): These patients with severe asthma need the attention of the lung specialist (=pulmonologist). They need a combination therapy in higher doses all the time. They will usually need oral corticosteroids (prednisone or others) on an ongoing basis. As this is an essential hormone, which is produced by the adrenal glands, this medication suppresses the body’s own production within 2 weeks of therapy. One way around this is to use alternate day corticosteroid therapy, if possible. However, not every patient tolerates the “off-day”. FEV1 and/or PEF must be closely monitored. Not infrequently other lung diseases are present that could complicate the asthma such as bronchiectasis, pneumonia, COPD or emphysema. The respirologist will monitor for other causes that are treatable and optimize the asthma therapy by finding the best combination therapy. Often home oxygen and chest phsyiotherapy treatments are also part of the overall management of these severe asthmatics.
Supplements for Asthmatics
As mentioned before in the introduction to asthma there is a strong correlation between chronic inflammation and asthma. As Ref. 10 shows, asthmatics benefit from fish oil (omega-3-fatty acids), magnesium, selenium and vitamin D3, which control the inflammatory process and make asthma more manageable. This is true for all stages of asthma.
1. Noble: Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc.
2. National Asthma Education and Prevention Program. Expert Panel Report II. National Heart, Lung and Blood Institute, 1997.
3. Rakel: Conn’s Current Therapy 2002, 54th ed., Copyright © 2002 W. B. Saunders Company
4. Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed., Copyright © 2000 W. B. Saunders Company
5. Behrman: Nelson Textbook of Pediatrics, 16th ed., Copyright © 2000 W. B. Saunders Company
6. Merck Manual: Asthma (thanks to http://www.merckmanuals.com for this link)
7. Goldman: Cecil Textbook of Medicine, 21st ed., Copyright © 2000 W. B. Saunders Company
8. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
9. Rakel: Conn’s Current Therapy 2004, 56th ed., Copyright © 2004 Elsevier