Management of Bronchial Asthma

Management of Bronchial Asthma

Love is not what takes you by surprise and leaves you breathless. It’s called Asthma.

For that matter, the very term ‘asthma’ originates from the Greek meaning breathlessness.

Asthma is a chronic inflammatory disorder of the airways and often associated with airway hyper-responsiveness. It is of 2 types:

  • Extrinsic asthma (Atopy, positive family history)
  • Intrinsic asthma (Non-immune mediated, negative family history)

Triggering factors

Asthmatics are completely normal in a pleasant environment, but a little alteration in the surroundings start a severe response in them. These are triggering factors, and they vary for different types of asthma. 

Intrinsic asthma is triggered by common allergens like pollen and is usually associated with allergic rhinitis. 

Extrinsic asthma is triggered by a wide range of factors like cold weather, upper respiratory tract infections, stress, smoking (active or passive), exercise, and drugs like aspirin, beta-blockers.

What do these triggering factors do? 

Asthmatics generally have a narrow airway. Exposure to triggers causes a further narrowing of this airway by inflammation, which leads to a triad of symptoms.

Diagnosing Asthma

Can we say that all patients with wheezing, cough, and dyspnoea have asthma?

No, these symptoms are not always only due to asthma. It could also result from other conditions like COPD, cardiac asthma, etc., So it's very important to differentiate between asthma and similar conditions.

For this purpose, we run the patient through the following tests:

  1. Spirometry: an FEV1/FVC ratio < 80% usually suggests obstructive causes like COPD, asthma, etc., so to further narrow down the possible cause and diagnose asthma, a short-acting bronchodilator (Salbutamol) is given to the patients, and spirometry is performed again. An improvement in the FEV1/FVC ratio is usually suggestive of asthma. 
    Wisdom: Pulmonary function test improves after salbutamol administration as narrow airways are the main problem in asthma, and this is relieved by the given bronchodilator.
  2. Broncho provocative tests: it is done in cases where the pulmonary function test comes out to be normal. In this test, methacholine - a cholinergic drug, is administered, and a pulmonary function test is performed. Being a bronchoconstrictor, this drug will reduce FEV1. In normal individuals, the reduction is not less than 12%. Whereas in asthma patients, there will be more than a 20% reduction of FEV1. 
    Warning: always perform this test in a specialized lab as the induced bronchoconstriction can pitch in an asthma episode in the patient.
  3. Chest X-ray of asthmatics shows hyperinflation of the lung and flattening of the diaphragm.

Medications for Asthma

Before learning about the management, let us take a quick view of the various drugs used for treating asthma. They are of wide range as,

  1. Reliever drugs: these relieve the symptoms of an acute asthmatic attack. Drugs used for this purpose are short-acting beta-2 agonists(salbutamol, terbutaline)
  2. Controller drugs: these are given to patients with persistent asthma to achieve and maintain the control of symptoms. Drugs used under this category are
  • Long-acting beta-2 agonists (formoterol, salmeterol)
  • Corticosteroids
    • Systemic: Hydrocortisone, Prednisolone
    • Inhaled:  Budesonide, Beclomethasone dipropionate, Fluticasone.

Other drugs used in the management of bronchial asthma are:

  1. Mast cell stabilizers (Sod. cromoglycate, Ketotifen)
  2. Methylxanthines(Theophylline, Aminophylline)
  3. Leukotriene antagonists (Montelukast, Zafirlukast)
  4. Monoclonal antibodies against Ig E such as Omalizumab (in case of extrinsic asthma)
  5. Muscarinic receptor antagonists(Ipratropium bromide, Tiotropium bromide)

Managing Bronchial Asthma

Asthmatics are managed in a personalized way based on the severity of the disease they have. Thus, it is important thing to categorize the patients accordingly before planning the management. 

Based on the (GINA) guideline, they are clinically classified as intermittent, mild persistent, moderate persistent, and severe persistent.

For this, five variables are considered, namely: 

  1. Daytime symptoms
  2. Nighttime symptoms
  3. Frequency of medications used.
  4. Limitation of activities
  5. Lung function

Stepwise Approach In Asthma Patients

After classifying the patient, treatment is started with reliever and controller drugs as follows:

Reliever drug

Low dose Inhaled corticosteroids (ICS) budesonide-formoterol (bud-form) is the drug of choice irrespective of the disease severity.

Controller drugs

Step 1: Patients with intermittent severity are managed in this step. ICS bud-form is given in low dose as needed

Step 2: Patients with mild persistent disease are managed in this step. Low dose ICS is taken daily or as needed.

Step 3: Patients with moderate persistent disease are managed in this step. Low dose ICS along with long-acting beta-2 agonists (LABA) is the choice.

Step 4: Patients under severe persistent category are managed in this step. Medium dose ICS with LABA is the management of choice.

Step 5: Patients with severe persistent disease are treated in this step. High dose ICS-LABA is given.

Acute Exacerbations Of Asthma

Sometimes an asthma patient experiences an increase in symptoms due to increased airway inflammation. This often leads to deterioration in lung function. These acute exacerbations have to be managed effectively to avoid mortality.

These patients are treated with systemic corticosteroids, beta-2 agonists and given hospital care.

References

  1. Harrison’s Principles of Internal Medicine, 19e, Page No: 1669-1680.
  2. Clinical updates on the management of asthma Suzanne bollmeier, PharmD, bcps, ae-c <https://www.ajmc.com/journals/supplement/2017/advancements-in-asthma-therapy-and-their-impact-on-managed-care/clinical-updates-on-the-management-of-asthma>
  3. https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf
  4. https://www.ncbi.nlm.nih.gov/books/NBK7222/figure/A2213/

Author’s Footnote

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