Nonpharmacologic Therapy

The Big Asthma Lie

Effective Home Remedy to Cure Asthma

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Patients should play an active role in their therapy, and an active partnership should be developed with the patient and family. Goals for asthma treatment should be shared, and the patient and health care provider should jointly agree on the patient's personal treatment goals.

Nonpharmacologic therapy should be incorporated into each step of therapy, and patient education should occur at all points where health care professionals interact with patients. Patient education should begin at the time of diagnosis and be tailored to meet individual patient needs.1 Patients should understand: the difference between the asthmatic and normal lung, what happens to the lung during an asthma attack, differences between controller and relief medications, how to take inhaled medications correctly, and environmental control measures. Patients should also learn: self-management of asthma, including assessing level of control, recognizing signs and symptoms of worsening asthma, skills for self-monitoring of pulmonary function, when and how to take rescue actions, and when to seek medical care.

The importance of understanding asthma as a chronic disease and the need for daily treatment with long-term control medications should be stressed. The importance of proper use of medication-delivery devices should be reinforced.1

Risk Factor Avoidance

Patients who smoke should be strongly encouraged to quit; cigarette smoking decreases the efficacy of ICS and can trigger an acute asthmatic response.1 All patients should also avoid second-hand smoke. Patients should avoid outdoor activities when air quality is poor and avoid exposure to other irritants such as hairspray, paint, exhaust fumes, and smoke from any fire.

Patients sensitive to specific allergens should be educated on ways to avoid them. Environmental controls to reduce the allergen load in the patient's home may reduce asthma symptoms, school absences because of asthma, and unscheduled clinic and emergency visits for asthma.15 Patients allergic to warm-blooded pets should remove them from home if possible or at least keep them out of the bedroom. Allergies to cockroach antigens and dust mites should be identified and appropriate measures taken to reduce or eliminate them.

Table 14-1 Usual Dosages for Quick-Relief Medications in Asthma

Medication

Dosaqo Form 0 4 Vpars S-11 Yoars

Adult*

Comments

Inhaled Short-Acting p-Agonists

Albuterol HFA 90 trcq/p>Ji,

200 puffs/ conisler levdlbuterol HFA

45 mctypuif, 200 puffs/ canister

I-2 puffs S ■ronutes before exercise 2 Duffs •ivery 4-6 ■»ours as wedcd

2 puffs S minutes before exercise 2 puffs every 4-6 hours as needed

2 puffs every 4-6 hours as needed

Nebulize! Solution:

Albuterol

0.63 mg/3 ml

063-2.5 mg

1.25-5 mg in

I.2S mg/3 mL

n3mL

3 mL saline

2.5 mg/3 ml

.aline every

every 4-8

S mg/ml <0.S%)

4-6 hours

hours as

as needed

needed

Levatbuterol

0.31 ml

0.31 -US

0.31-0.63

0.63 mg/3 ml

ngin3

mg every

1.25 mgiO.Sml

nL every

8 hours as

1.25 mg/3 mL

4-6 hours

needed

«needed

1.25-5 mg in 3 ml sal me every 4-8 hours as needed

0j63-I.2S mg every 8 hours as needed

2 puffs S minutes before exercise 2 puffs every 4-6 hours as needed

2 puffs 5 minutes before exercise 2 puffs every 4-6 hours as needed

1.25-5 mg in 3 ml sal me every 4-8 hours as needed

0j63-I.2S mg every 8 hours as needed

Applies to both SABAs.

Increasing use or tack of expected of fee t indicates dminshed control of asthma Not recommended for long term doily treatment. Regular use exceeding 2 days/week for symptom control (not prevention of EIB) Indcates the need for additional long term control therapy May double usual dose for mild exacerbations Prime the inhaler by releasing 4

actuations prior to use Periodically clean HFA actuator, as drug may plug orifice Nonselective agents (ie. epinephrine, isoproterenol, metaproterenol) are not recommended due to their potential for excessive cardiac stimulation. espe< ially in high doses

May mix with cromolyn solution budesonide inhalant suspension, or ipratropium solution for nebulizalkxi May double dose for severe exacerbations Does not have FDA-approved labeling for children less than 6 years of ogc Ihe product is a sterile-filled preservative-free unit dose vial Compattole with bodesonide inhalant suspension

Anticholinergic*

Ma-

IpiairtipujiVi UFA

17 nvriy'fHift

JOOpiiffs/

canifief

WfMaer iaàitfciT

N/A

H/A

2-Î fKiffS every fi hours

tvideixe i; iackir-i) fit* ■mtkhabteegks prxiicing added benefll 1o ft ■.iijftni'.ri in Img-m m çtinnnJ asthma thetapy.

OiJS mg/mt.

N fA

H/A

Û.ÎÎ mg e^ery

COJCiSW

ihfitfs

Ipr an opium with

Ifi mcg/pulf

H/A

H/A

2-ïpulfseveryé

albulpcfl

ipiaticpium Ljfi:"!iLS,' Jnd 00 meg/buff albutetof puffi/tamsier

hours

Nrimlïm ia^rjlntifv

H/A

H/A

SrriL every 4-6

Confirm LL?IAH> Dievefii distortion

04' mg/î-ml.

hows

of the solution, this addltrrf does not

ipialiupuni and

induce tnoncliospaim

2.5 iriV

3 mL albuleiol

SyiCcrniç CartiçDïIrraidi

M<ihyfpiiidnisoksne

SyiCcrniç CartiçDïIrraidi

M<ihyfpiiidnisoksne

FTednrsolo™

Piednrione

Methylprednisolone SCtHStÎ!

2, «¡6,8,16,32

Short

Short course-

Shflft course

App/vs tcthrli rs r three cort/rosteratfs.

mg oral Stolen

OOUiie-

Tmm^

■hull': 40-60

ihi*T courses or "bunsti'are effective

4 mg oral

bursr;

JO-tÛmg/

mg/daypo

for establishing control when initiating

labk'ts;

1-2

d^rpûit

as sirnjk-yi 2

thn-apyor ckirirvp j pc-iiud of gradual

i mg/i m|.

fejida/

single or

divicted doses

deitiifUdTori

and IS mg/5

po.

1 divided

for 3-10 days.

The-burs! shou-ld be conlmued until

ml ml lia |.JKJ

nuidrnuiri

dows

^iiK'-ii achieves ftont H1 perwrwH

1, ÎA 5, tOt

60 mg/

1-10 days

bast of symploira resolve. This

SOmaiaWrts;

daypo,

usually icqv'rci -10 days byi may

î mg/mLand

for 3-10

require longei. Tlieie is no «videoce

S mg>5 m

days

that tapering the dose tallowing

r:r.i li:|iiiit

ImprOvf lïïtnl prCvfflflf rcLifnr

iJdnJiitetyfriiitriOT

■lOmg/ml 7.Smg/kgiM MO mg IM (Mice MOmglMonce iOmg^nl once

May tn> used in place of a shor5 burst ti eral sttsokk Irt patierw whbs* vomlring t* if nir^icoc it a pcoblem

<H'. ■. hlùfoiluowAfbon; l;il[A,enhylinedlamlne teiraafelic arid; f lit, fseii IjrorwIwsfMSfi i; Hfft, liydioiluor^llmni1; IM, intramuscutaf; MCI. nielenjd dow inhalei : M/A. salety and cfficacy not osldblishmt CEF. peak ÉHEiNatoty llowi SABA- shot t acting J.-agcumt.

Dowiji^ ,.n<Lp<uvkJi."d 1or [ïwfcKts kiw bwn dut^r^t'ij 1 jy 1 US, FthAyi hjvi-yjfiCliiTl Uinir.jl irLil vik'ty jnd i.'Mkit y data in (In.1 jfjfmjfauif ¿^ranges to fe^ppcxT dwlruse.

The inactivated influenza vaccine should be considered in patients having asthma to decrease their risk of complications from influenza.1 The pneumococcal vaccine may decrease the risk of invasive pneumococcal disease in asthmatics, but current guidelines do not include routine administration to asthma patients.1,16

Drug Delivery Devices

O Direct airway administration of asthma medications through inhalation is the most efficient route and minimizes systemic adverse effects. Poor inhaler technique can result in increasedoropharyngeal deposition of the drug with decreased efficacy and increased adverse effects. Figure 14-1 provides steps for the appropriate use of inhaled delivery devices. Inhaled asthma medications are available in metered-dose in halers (MDIs), dry powder inhalers (DPIs), and nebulized solutions. Because inhaler technique deteriorates over time, health care providers should take every opportunity to reinforce appropriate inhaler technique. Although nebulizers have often been used for drug delivery in children, their use is expensive and time consuming.

Patients should be educated to keep track of inhaler use. Some inhalers have a built-in counter or device to notify the patient of how many doses are remaining (e.g., Ventolin, hydrofluoroalkane [HFA], and Twisthaler).

Spacers or holding chambers with valves decrease the need for coordination of actuation of MDI devices with inhalation, decrease oropharyngeal deposition of drug,

17 18

and increase pulmonary drug delivery. Patients using a spacer or holding chamber should be counseled to place only one puff of the drug into the chamber at a time, because actuating the MDI more than once into the chamber before inhalation decreases drug delivery. However, taking multiple breaths after a single actuation is ap-

propriate and does not decrease drug efficacy. Spacers or holding chambers with valves are equipped with a mouthpiece or a facemask allowing the use of an MDI in children younger than 5 years of age.

Asthma Self-Management

Asthma self-management plans give patients the freedom to adjust therapy based on personal assessment of disease severity and a predetermined action plan. These plans reduce morbidity and the need for medical services.19 For self-management plans to be effective, patients should be given a written action plan that is part of a global educational program.1 The plan should include instructions on daily management and how to recognize and handle worsening asthma.1

Asthma control is assessed by evaluating signs and symptoms of worsening asthma and/or monitoring PEF. Early signs of deterioration include increasing nocturnal symptoms, increasing use of inhaled SABA, or symptoms that do not respond to increased use of inhaled SABAs. Measurement of PEF should be considered for patients with moderate to severe asthma, a poor perception of worsening asthma or airflow obstruction, and those with an unexplained response to environmental or occupational exposures.1 If PEF measurements are used to assess control, the patient must be able to use a peak flow meter properly. PEF should be measured daily in the morning on waking, before using a bronchodilator. For PEF-based asthma action plans, the patient's personal best PEF should be established over a 2-to 3-week period using established methods when the patient is receiving optimal treatment.1 Subsequent PEF

measurements are evaluated in relation to their variability from the patient's best.19 PEF measurements in the range of 80% to 100% of personal best (green zone) indicate that current therapy is acceptable. A PEF in the range of 50% to 79% of personal best (yellow zone) may indicate an impending exacerbation, and therapy should be intensified based on the self-management plan. A PEF less than 50% (red zone) signals a medical alert; patients should use their SABA immediately and consult their asthma action plan.

FIGURE 14—1. Instructions for using an inhaler. (From Ref. 20.)

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