Am Fam Physician. 2002;65(3):488-490
Asthma is caused by airway inflammation and bronchoconstriction. Asthma management involves decreasing inflammation and controlling the acute attack. Guidelines for asthma management are available from the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute (see accompanying table). Kalister used a MEDLINE search to identify randomized controlled studies and systematic reviews on medications used to treat children with asthma.
| Step | Long-term control | Quick relief | |
|---|---|---|---|
| Treatment of asthma in adults and children older than five years | |||
| Step 4: severe persistent | Anti-inflammatory drug: inhaled corticosteroid (high dose) and Long-acting bronchodilator: salmeterol, theophylline, or long-acting bronchodilator tablets and Oral corticosteroids, 2 mg per kg per day | Short-acting bronchodilator: inhaled β2 agonists as needed | |
| Step 3:moderate persistent | Anti-inflammatory drug: inhaled corticosteroid (medium dose) or Inhaled corticosteroid (low to medium dose) plus salmeterol, theophylline, or long-acting β2 agonist tablets | Short-acting bronchodilator: inhaled β2 agonists as needed. If using more than twice per week, consider increasing to the next step. | |
| Step 2: mild persistent | Anti-inflammatory drug: inhaled corticosteroid (low dose) or mast cell stabilizer Theophylline and leukotriene inhibitors are alternatives | Short-acting bronchodilator: inhaled β2 agonists as needed. If using more than twice per week, consider increasing to the next step. | |
| Step 1: mild intermittent | No daily medication | Short-acting bronchodilator: inhaled β2 agonists as needed If using more than twice per week, consider increasing to the next step. | |
| Treatment of asthma in adults and children five years and younger | |||
| Step 4:severe persistent | Anti-inflammatory drug: inhaled corticosteroids (high dose) Oral corticosteroids, 2 mg per kg per day, if needed | Short-acting bronchodilator: β2 agonists as needed (inhaled or oral) | |
| Step 3:moderate persistent | Anti-inflammatory drug: inhaled corticosteroid (mediumdose) with or without nedocromil sodium or theophylline | Short-acting bronchodilator: β2 agonists as needed (inhaled or oral). If using more than twice per week, consider increasing to the next step. | |
| Step 2: mild persistent | Anti-inflammatory drug: mast cell stabilizer or inhaled corticosteroids (low dose) | Short-acting bronchodilator: β2 agonists as needed (inhaled or oral). If using more than twice per week, consider increasing to the next step. | |
| Step 1: mild intermittent | No daily medications needed | Short-acting bronchodilator: β2 agonists as needed (inhaled or oral). If using more than twice per week, consider increasing to the next step. | |
Short-acting beta agonists are useful for treating acute asthma attacks. These sympathomimetic agents relax the smooth muscles of the bronchioles by stimulating β2-adrener-gic receptors. Through β1-adrenergic and alpha-adrenergic receptors, side effects, including rapid heart rate and vasoconstriction, may occur. Albuterol is the most commonly used short-acting beta agonist because of its rapid action, efficacy, and few adverse effects. Metered-dose inhalers with holding-chamber administration are at least equal to nebulized administration in the routine treatment of exacerbation, are less expensive, and can be transported easily. Oral bronchodilators are less useful because of their slower onset of action. If short-acting agents are used more than twice weekly, improved anti-inflammatory treatment is needed.
The long-acting beta agonist salmeterol has a peak action in one to four hours and is more useful for routine prevention as maintenance or before exercise. Recommended for use along with anti-inflammatory medications, salmeterol should not be used as monotherapy because of the superior efficacy of inhaled steroids. Short-acting agents may also be needed to abort acute exacerbations.
Mast cell stabilizers (cromolyn sodium and nedocromil sodium) control inflammation and exercise-induced bronchospasm by decreasing the release of inflammatory substances from mast cells. These agents are useful in the management of mild persistent asthma but less effective than mid- to high-dose inhaled steroids in patients with more moderate or severe persistent asthma.
Corticosteroids, which decrease bronchial hyperreactivity and prevent irreversible changes in lung function, offer the most effective control of inflammation. Inhaled corticosteroids are the first-line treatment for mild to severe persistent asthma. Adverse effects can be minimized by using the smallest effective dosage.
Theophylline has bronchodilatory and anti-inflammatory effects but is rarely used now because of the narrow therapeutic window and resultant high risk of side effects. Leukotriene inhibitors (montelukast, zafirlukast, and zileuton) help control inflammation and bronchoconstriction. They are well tolerated and can be used as adjunctive treatment with inhaled steroids for all degrees of persistent asthma and in patients with exercise-induced bronchospasm. Liver function should be monitored when zileuton is used because of possible impairment of liver function.
The author concludes that aggressive treatment of airway inflammation in patients with persistent asthma improves asthma control and prevents lung damage. Patients who actively participate in their care plans demonstrate improved medication adherence. Developing an asthma action plan that is based on symptoms and peak flow allows patients to manage changes in their respiratory function at home rather than in the emergency department or hospital.