MANAGEMENT OF

ASTHMA
ALSALMAN A. ANAM
GULLAS COLLEGE OF MEDICINE
5 ESSENTIAL FEATURES IN ASSESSING PATIENTS
WITH ASTHMA

Current degree of control based on:

Symptoms
Reliever medication use
Recent exacerbation
Clinical lung function
Risk of future adverse outcomes
LUNG FUNCTION
FEV1 and FVC
Asthmatic patients with lower FEV1 values
were at significantly higher risk of needing
acute care
FEV1 is an objective measurement of lung
action
Prebronchodilator FEV1: related to PEF measurement: standard method to
asthma control
Postbronchodilator FEV1: related to
future risk of exacerbations
Accurate measurement requires stopping
requires stopping LABAs for 12 hours and
short-acting bronchodilators for 6 hours
FEV1 is often normal or near-normal in mild
asthma. It may be poorly responsive to
bronchodilators in mild asthma
correlate physio function with asthma
severity, marker of asthma control
BIOMARKERS
Sputum eosinophilia: provides useful
information about the asthma phenotype
Low sputum eosinophil count: predicts
response to inhaled corticosteroids and
decreased risk of exacerbations
Elevated sputum eosinophils (>10%): high
risk for future exacerbations
Fractional excretion of nitric oxie (FeNO):
more advantage, less useful as an ongoing
biomarker in patients using steroid therapy
>45 parts/billion: excludes well-controlled
asthma
High FeNO suggests a severe, steroid-
responsive phenotype
Decline of >40%: sign of improved control
Low levels of FeNO: lower risk of acute
exacerbation
TREATMENT

Pharmacologic
Acute
Short-term reliever: target bronchoconstriction by relaxing ASM
-agonists,inhaled Albuterol, are the most effective reliever
Methylxanthines (theophyllines) and short-acting anticholinergics such as inhaled corticosteroids
LABAs + inhaled corticosteroid: provide additional control of sympoms
Theophylline: a bronchodilator, sustained anti-inflammatory effect at low dose
Inhaled corticosterioids (budesonide): acute treatment of asthma exacerbations
Omalizumab: specific anti-IgE antibody
Chronic controller
2-AGONISTS

2- selective agents albuterol and terbutaline receptors through down-regulation via

Improved side effects receptor endocytosis and uncoupling of
Cornerstone of asthma therapy receptor from downstream transduction
pathways
Binding to a specific G-coupled
transmemebrane receptor found in high SABA: used for rescue or emergent
abundance on ASM increased intracellular treatment (peak action: 60-90 minutes)
cyclic adenosine monophospate (AMP) and LABA: used in combination with inhaled
relaxation of ASM corticosteroids for chronic management
Chronic use: receptor desensitization Formeterol and salmeterol
decreased responsiveness of membrane
2-AGONISTS

Adverse events unwanted activation of 2 receptors on nonpulmonary tissues

Tachycardia
Arrhythmias
Tremors
Hypokalemia

Arg/Arg mutation at the B16 locus

BRONCHODILATORS

Anticholinergic agents: competition with acetylcholine at NMJ blocking transmission of

bronchoconstrictor reflexes
Ipratropium bromide: effective in COPD patients, 2nd line agent for treating asthma
Tiotropium: a long-acting anticholinergic, beneficial in COPD patients
INHALED CORTICOSTEROIDS

Suppress inflammatory responses

Bind to specific cytoplasmic receptor translocates to the nucleus modulates expression
of inflammatory genes inhibition of histone acetyltransferases and recruitment of histone
deacetylases airway inflammatory cell influx and markers of airway inflammation in asthma
are reduced
Reduce asthmatic symptoms, improve lung function, decrease airway inflammation, control
AHR
Reduce asthma exacerbations by 55%
Reduce risk of hospitalization by 50%
INHALED CORTICOSTEROIDS

Systemic side effects:

Bone dimeneralization
Cataract formation and glaucoma
HPA axis suppression, GI bleeding
Increased risk of pneumonia
Growth suppression in pediatric populations
LEUKOTRIENE MODIFIERS

Derived from arachidonic acid

LT receptors on ASM and macrophages mediate bronchoconstriction, mucus
hypersecretion, and mucosal edema
Zileuton: blocks 5-lipoxygenase, the enzyme that converts arachidonic acid to LTA4
First step in LT synthesis

Montelukast, zafirlukast, pranlukast: all inhibit LT receptors, blocking the final step in
LT synthesis
PHOSPHODIESTERASE 4 INHIBITORS
(THEOPHYLLINE)
Is a well established phosphodiesterase inhibitor, with mild anti-inflammatory properties
Has a narrow therapeutic index, not widely used in treating asthma
Currently used in low doses as adjunctive treatment for asthma that is difficult to treat
with steroids alone
SE: anorexia, palpitations, dysrhythmias, seizures
ANTI-IMMUNOGLOBULIN E

Omalizumab: a monoclonal antibody to IgE

Targets the receptor-binding portion of IgE preventing it from interacting with
immune cells to cause degranulation
Added to ICS in poorly controlled allergic asthma
rare anaphylaxis
Observe for 2 hours after each of the first 3 injections to ensure safety
NONPHARMACOLOGIC TREATMENT

Bronchial Thermoplasty
Controlled thermal energy delivered to the airway wall reduction of ASM mass
Shown to reduce airway responsiveness
Requires a series of 3 bronchoscopies