Asthma Highlights

• Control triggers (tobacco, pollutants, sulfite sensitivity/foods, BBls, ASA, NSAIDs)
• Control contributing conditions (GERD, Rhinitis

• Daytime asthma Sx 2 or fewer days/week
• 2 or fewer nocturnal awakenings/month
• Use of SABA to relief Sx fewer than 2 times/week
• NO interference with nl activities between exacerbations
• Normal FEV1 between exacerbations ( greater or equal to 80% of predicted nl)
• Normal FEV1/FVC ratio between exacerbations (based on age-adjusted values) 
• 1 or NO exacerbations needing po steroids/year

• STEP 1: Inhaled SABA 
• prn Sx 
• If trigger of Sx can be predicted (e.g. exercise-induce), 10 mnts gefore exposure to trigger

• Sx >2 times/week (but NOT daily)
• 3-4 nocturnal awakenings/month 
• Use of SABA for Sx relief >2/week (but NOT daily)
• MINOR interference with nl activities
• Normal FEV1 between exacerbations (greater or equal to 80% of predicted nl)
• Normal FEVI/FVC ratio between exacerbations (based on age-adjusted values)
• 2 or more exacerbations needing po steroids/years

• STEP 1: Inhaled SABA
• prn Sx 
• If trigger of Sx can be predicted (e.g. exercise-induce), 10 mnts gefore exposure to trigger

STEP 2: Daily long-term controller medication = LOW-dose Inhaled Glucocorticoid

• DAILY asthma Sx
• >1 noctural awakening/week
• DAILY need for SABA for Sx relief
• Some limitation in nl activity
• LOW FEV1 (60-80% of predicted nl)
• LOW FEV1/FVC ratio (based on age-adjusted values)
• 2 or more exacerbations needing po steroids/years

• STEP 3:
• LOW-dose Inhaled Glucocorticoid + LABA 
• or 
• MEDIUM-dose Inhaled Glucocorticoid 

• Asthma Sx throughout the day 
• NIGHTLY nocturnal awakenings
• Need for SABA for Sx relief several times/day
• EXTREME limitation in nl activity
• VERY LOW FEV1 (,60% of predicted nl)
• LOW FEV1/FVC ratio (based on age-adjusted values)
• 2 or more exacerbations needing po steroids/year

STEP 4:  MEDIUM-dose Inhaled Glucocorticoid + LABA

STEP 5: HIGH-dose Inhaled Glucocorticoid + LABA

Increased in Sx and/or Decreased Peak Expiratory Flow 

• SELF-administered:
• SABA 2-6 puffs from metered dose inhaler, repeat every 20 mnts prn
• or
• SABA nebulizer treatment, repeat after 20 mnts prn

• Use of accessory mx of respiration
• Brief, fragmented speech
• Inability to lie supine
• Profound diaphoresis
• Agitation

Severe Sx refractory to initial ER Rx

Predictors of Imminent Respiratory ARREST = Inability to maintain resp effort, Cyanosis, AMS

Inhaled SABA: Albuterol 2.5-5mg every 20mnts x 3 by nebulizer or 4-8 puffs by metered dose inhaler with spacer for up to 4h

Oxygen: Sufficient to maintain SaO2 at least of 92% (>95% in prego)

IV access: bolus nl saline if prolonged episode to replace insensible losses

Ipratropium Bromide: 500mcg by nebulizer every 20mnts x 3 or 8 puffs by metered dose inhaler with spacer every 20mnts for up to 3 hrs

Systemic Glucocorticoids: Prednisone 40-60mg po.  If impending respiratory failure, Methylprednisolone 60-125mg IV

Magnesium sulfate: If life-threatening exacerbation or refractory severe exacerbation after 1 hour of intensive bronchodilator, 2g IV over 20 mnts

• Mainstay of Bronchodilator Rx
• PNR use for Sx relief
• Rx for all asthma levels

• Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff. 2 puffs every 4-6h prn or 10mnts before exercise. 
• Levalbuterol (Xopenex-HFA) 45mcg/puff.  2 puffs every 4-6h prn. 
• Metaproterenol 
• Pirbuterol

• Agents of choice for Persistent asthma.  Rx for PERSISTENT MILD, MODERATE, and SEVERE asthma. 
• DAILY long-term controller medication
• Inhaled delivery for Persistent Mild-Severe asthma
• PO/IV delivery for ER Rx of acute asthma exacerbation

Mometasone (Nasonex): ONCE-daily dosing. 2 prays (100mcg) in each nostril qd.  Prevention: 2 sprays (100mcg) in each nostril qd, starting 2-4 weeks before pollen season. 

Budesonide (Rhinocort Aqua): Safe for PREGO.

For treatment of Persistent MODERATE-SEVERE asthma 

Budesonide/Formoterol HFA (Symbicort): Reliever and Controller med. 80mcg/4.5mcg 2 puffs bid.  160mcg/4.5mcg 2 puffs bid.  

Mometasone/Formoterol HFA: 100mcg/5mcg  2 puffs bid. 200mcg/5mcg 2 puffs bid. 

Fluticasone/Salmeterol HFA (Advair Diskus, Advair HFA): 45mcg/21mcg 2 puffs bid.  115mcg/21mcg 2 puffs bid. 230mcg/21mcg 2 puff bid. 

Fluticasone/Salmeterol DPI: 100mcg/50mcg 1 inhalation bid.  250mcg/50mcg 1 inhalation bid. 500mcg/50mcg 1 inhalation bid.

• Control triggers
• Control contributing conditions

Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff 2 puffs every 4-6h prn or 10mnts before exercise

• Control triggers
• Control contributing conditions

Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff 2 puffs every 4-6h prn or 10mnts before exercise

• Maintenance medication: Mometasone (Nasonex): ONCE-daily dosing. 2 prays (100mcg) in each nostril qd

• Control triggers
• Control contributing conditions

Combination Inhaled Glucocorticoid/LABA = Budesonide/Formoterol HFA (Symbicort): Reliever and Controller med. 80mcg/4.5mcg 2 puffs bid.   

• Control triggers
• Control contributing conditions

Combination Inhaled Glucocorticoid/LABA = Budesonide/Formoterol HFA (Symbicort): Reliever and Controller med.  160mcg/4.5mcg 2 puffs bid.