Long-term management of asthma

Long-term management of asthma includes identification and avoidance of precipitating factors of asthma, pharmacotherapy and home management plan. Common precipitating factors include viral upper respiratory infections, exposure to smoke, dust, cold food and cold air. Avoidance of common precipitating factors has been shown to help in better control of asthma. Pharmacotherapy is the main stay of treatment of asthma. Commonly used drugs for better control of asthma are long and short acting bronchodilators, mast cell stabilizers, inhaled steroids, theophylline and steroid sparing agents. After assessment of severity most appropriate medications are selected. For mild episodic asthma the medications are short acting beta agonists as and when required. For mild persistent asthma: as and when required bronchodilators along with a daily maintenance treatment in form of low dose inhaled steroids or cromolyn or oral theophylline or leukotriene antagonists are required. Moderate persistent asthma should be treated with inhaled steroids along with long acting beta agonists for symptom control. For severe persistent asthma the recommended treatment includes inhaled steroids, long acting beta agonists with or without theophylline. If symptoms are not well controlled, a minimal dose of oral prednisolone preferably on alternate days may be needed in few patients. Patients should be followed up every 8–12 weeks. On each follow up visit patients should be examined by a doctor, compliance to medications should be checked and actual inhalation technique is observed. Depending on the assessment, medications may be decreased or stepped up. For exercise induced bronchoconstriction: cromolyn, short or long acting beta agonists or leukotriene antagonists may be used. In children with seasonal asthma, maintenance treatment according to assessed severity should be started 2 weeks in advance and continued throughout the season. These patients should be reassessed after discontinuing the treatment. Parents should be given a written plan for management of acute exacerbation at home     

哮喘的长期控制治疗

哮喘是一种慢性炎症性疾患,需要长期治疗。到目前为止发表的共5版GINA方案中,哮喘的药物治疗所占篇幅最大,是哮喘治疗的首选、主要疗法。1哮喘治疗目标哮喘的治疗目标是达到并维持哮喘临床控制,即无(或≤2次/周)白天症状;无日常活动受限,包括运动受限;无夜间症状和因哮喘憋醒;无需(或≤2次/周)使用缓解药物;肺功能正常或接近正常;无哮喘急性加重。该治疗目标在大多数哮喘患者中可以实现,这已被GOAL研究所证实。2哮喘急性发作的治疗为适合基层需要,将急性发作简略划分如下。2.1轻度发作可以平卧,说话能成句,有条件的可测PEF、FEV1均>80…     

Bronchial asthma. Long-term therapy and prognosis

Bronchial asthma is not a disease entity but a nonspecific reaction of the lung characterized by recurrent reversible airway obstruction. Successful treatment depends on identification of the type of asthma according to causative factors such as allergens, respiratory tract infections, complicating factors (sinusitis, smoking parents) and the degree of severity. For allergic or mixed asthma the identification and elimination of relevant allergens may be the only therapy required. Drugs for long-term treatment are Beta-2-mimetics, chromolynglycate and theophylline as a slow-release preparation. Corticosteroids should only be used after failure of these drugs, following the exclusion of complicating factors and for limited periods of time. Specific Hyposensitization is suited for moderate to severe types of pollen-induced asthma. Hyposensitization against non-pollen-allergens is of doubtful value. Estimates on the persistence of asthmatic symptoms into adulthood range between 26% and 78%. An earlier age of onset of asthma means a better prognosis except when asthma begins under two years of age. Concurrent atopic dermatitis or atopic rhinitis increase the probability that asthma will persist into adulthood.     

Day-to-day management of asthma.

Asthma remains a major cause of morbidity and an occasional cause of mortality in children despite greatly increased knowledge of its pathophysiology and newer improved medications. Management of asthma requires consideration of the two components of airway obstruction, spasm of bronchial smooth muscle and inflammation resulting in mucosal edema and mucous secretions. The pharmacologic alternatives include medications that relax bronchial smooth muscle, prevent the release of mediators that induce bronchospasm and inflammation and anti-inflammatory corticosteroids that can reverse or prevent the inflammatory component of asthma. Therapeutic decisions in asthma also require consideration of the clinical pattern of disease which can be classified as intermittent, seasonal allergic or chronic. Therapeutic strategies for the use of pharmacologic agents include intervention measures for reversal of acute symptoms and maintenance measures to prevent symptoms. While all patients need available intervention measures to reverse acute symptoms when present, only those patients with prolonged periods of symptomatology, i.e. seasonal allergic or chronic, require pharmacologic agent for maintenance therapy. When evaluation identifies environmental factors as clinically important precipitants of asthma, appropriate environmental manipulation offers a potentially useful nonpharmacologic approach to therapy. The use of injections of allergenic extracts in selected patients with appropriate inhalant allergen sensitivity offers an immunologic approach for decreasing symptoms in patients with a predominant inhalant allergic component to their disease. Success in the treatment of asthma requires careful consideration of health care delivery. Available measures, when appropriately delivered to the patients when needed, have been convincingly demonstrated to greatly decrease morbidity.     

Characteristics of asthma attack with long-term management for bronchial asthma

Background:  There have been no reports on the evaluation of the usefulness of long-term asthma management based on the Japanese Pediatric Guideline for the Treatment and Management of Bronchial Asthma 2005 (JPGL 2005).
Methods:  The purpose of the present study was to retrospectively investigate the records of 350 patients admitted to Yamaguchi University Hospital who had asthma attacks from January 2006 to June 2008. There were 149 patients who were treated for more than 3 months in accordance with the guideline (long-term management group) and 201 who were not (non-long-term management group). The patients were divided into three age groups: 100 infants, 159 toddlers, and 91 schoolchildren.
Results:  The onset age of asthma in the long-term management group was earlier than that in the non-long-term management group in toddlers and schoolchildren. The white blood cell counts and C-reactive protein levels were higher in the non-long-term management group in schoolchildren, suggesting the complication of some infections. The severity of asthma in the long-term management group was greater than that in the non-long-term management group among all three age groups. There were no significant differences, however, in the severity of asthma attack at admission between the long-term and non-long-term management groups in the three age groups.
Conclusion:  Patients who had severe asthma tended to be treated with long-term management, which suggests that long-term asthma management according to JPGL 2005 may reduce the severity of asthma attack at that admission, because the severity of asthma in patients undergoing long-term management correlates with the severity of asthma attack.     

哮喘管理新进展

哮喘是最常见的儿科慢性呼吸系统疾病 ,美国统计数字表明该病为儿童就医的最普遍的原因。尽管适当的门诊治疗有效 ,其住院率仍最高 (占 0～ 1 4岁出院诊断的 1 2 %～ 1 7% ) [1] ,急诊也经常遇到儿童哮喘病人 ,甚至多于成人[2 ] 。中心城市中少数民族和丧失社会经济地位的人受儿童哮喘的影响比其他地区和人群更显著 ,继发于哮喘的早期损伤也增加。急诊、住院和死亡等所有费用可达到 1年 1 4 0亿美元[1] 。严重影响了患儿的生活质量 ,影响儿童及其家长的学习、工作 ,加重了经济负担。目前世界公认的哮喘规范化管理已经起到了巨大作用 ,明显减…     

Therapeutic education in asthma management

All guidelines, protocols and recommendations underline the importance of therapeutic education as a key element in asthma management and control. Considerable evidence supports the efficacy and effectiveness of this measure. Health personnel, as well as patients and their parents, can and should be educated with two main objectives: to achieve the best possible quality of life and to allow self control of the disease. These goals can be attained through an educational process that should be individually tailored, continuous, progressive, dynamic, and sequential. The process poses more than a few difficulties involving patients, health professionals, and the health systems. Knowledge of the various psychological factors that can be present in asthmatic patients, as well as the factors related to the highly prevalent phenomenon of non-adherence, is essential. Awareness of the factors influencing physician-patient-family communication is also highly important to achieve the objectives set in therapeutic education. The educational process helps knowledge and abilities to be acquired and allows attitudes and beliefs to be modified. Patients and caregivers should be provided with an individual written action plan based on symptoms and/or forced expiratory volume in 1 second. Periodic follow-up visits are also required.     

Montelukast in pediatric asthma management

Leukotriene modifiers (receptor antagonist and biosynthesis inhibitor) represent the first mediator specific therapeutic option for asthma. Montelukast, a leukotriene receptor antagonist is the only such agent approved for use in pediatric patients. Montelukast modifies action of leukotrienes, which are the most potent bronchoconstrictors, by blocking Cysteinyl leukotriene receptors. Systemic drug like mountelukast can reach lower airways and improves the peripheral functions which play a crucial role in the evolution of asthma. Review of existing literature showed that montelukast compared to placebo has proven clinical efficacy in better control of day time asthma symptoms, percentage of symptom free days, need for rescue drugs and improvement in FEV₁. Studies also demonstrated improvement in airway inflammation as indicated by reduction in fractional exhaled nitric oxide, a marker of inflammation. Studies comparing low dose inhaled corticosteroids (ICS) with montelukast are limited in children and conclude that it is not superior to ICS. For moderate to severe persistent asthma, montelukast has been compared with long acting beta agonists (LABA) as an add-on therapy to ICS, montelukast was less efficacious and less cost-effective. It has beneficial effects in exercise induced asthma and aspirin-sensitive asthma. Montelukast has onset of action within one hour. Patient satisfaction and compliance was better with montelukast than inhaled anti-inflammatory agents due to oral, once a day administration. The recommended doses of montelukast in asthma arechildren 1–5 years: 4 mg chewable tablet, children 6–14 years: 5mg chewable tablet, adults: 10 mg tablet; administered once daily. The drug is well tolerated. Based on the presently available data montelukast may be an alternative treatment for mild persistent asthma as monotherapy where ICS cannot be administered. It is also an alternative to LABA as an add-on therapy to ICS for moderate to severe persistent asthma. The other indications for use of montelukast include: allergic rhinitis, exercise induced bronchoconstriction and aspirin-induced asthma.     

Advances in the management of asthma

Exciting new data are increasing the evidence base for the management of paediatric asthma. To inform the treatment of preschool wheeze, the best current classification is into episodic (viral) and multitrigger wheeze, rather than according to epidemiological pattern (transient versus persistent) and the presence or absence of atopy. Episodic (viral) wheeze is treated intermittently, with either inhaled bronchodilators or oral montelukast at the time of viral colds. If this approach fails, intermittent high-dose inhaled corticosteroids may be tried. Oral prednisolone is ineffective in the treatment of all but the severest attacks of preschool episodic (viral) wheeze, and is not a primary-care medication in this context. In older children the role of long-acting β₂ agonists has been explored. They are not indicated as first-line prophylactic therapy. In children with more severe symptoms, a single-inhaler strategy using budesonide/formoterol should be considered. In children who do not respond to conventional asthma therapy, the diagnosis and the way in which the prescribed treatment is being used should be reviewed rather than more treatment being blindly given. Most cases will improve with conventional management which is properly undertaken, and will not require novel therapies.     

The pharmacologic management of childhood asthma

Asthma treatment is based on the appropriate recognition and classification of children warranting treatment. Adequate treatment requires that children and parents have a good understanding of the disease and expectations for good control. Assessment requires a thorough history of symptoms, impairments of physical activity, past history of exacerbations, and understanding of triggering events. Therapy then must be appropriately implemented to reverse the symptoms and prevent future exacerbations. The approach in pediatrics is to be conservative, to use the safe and proven therapy, and to prevent the potential morbidity of the disease. These goals provide the rationale in childhood immunization. The literature suggests that the appropriate and conservative approach for children with persistent asthma, of any disease severity, is the use of low-dose inhaled corticosteroids that may be combined with an inhaled long-acting bronchodilator. This therapy is the most effective in reducing symptoms and exacerbations and preventing the potential mortality from the disease. It also allows children to be able to enjoy physical activity with their friends. Expectations should be high. Concerns about the potential for adverse effects should always be addressed proactively and should be balanced with the potential of adverse events from the disease.     

Leukotriene modifiers in pediatric asthma management

Cysteinyl leukotrienes (Cys-LTs) are mediators released in asthma and virus-induced wheezing. Corticosteroids appear to have little or no effect on this release in vivo. Cys-LTs are both direct bronchoconstrictors and proinflammatory substances that mediate several steps in the pathophysiology of chronic asthma, including inflammatory cell recruitment, vascular leakage, and possibly airway remodeling. Blocking studies show that Cys-LTs are pivotal mediators in the pathophysiology of asthma. Cys-LTs are key components in the early and late allergic airway response and also contribute to bronchial obstruction after exercise and hyperventilation of cold, dry air in asthmatics. LT modifiers reduce airway eosinophil numbers and exhaled nitric oxide levels. Together these findings support an important role for the Cys-LTs in the asthma airway inflammation. Cys-LT receptor antagonists (Cys-LTRA) are generally well-tolerated. Phase III randomized, controlled clinical trials (RCT) show that LT modifiers are moderately effective, apparently with a particular between-patient variability in their clinical response. The clinical effects of LT modifiers are additive to those of beta-agonists and corticosteroids. The onset of action of LT modifiers is within 1 to several days, and not rapid enough to make them useful as rescue treatment. Although LT modifiers possess some antiinflammatory activity, they cannot substitute for corticosteroids for inflammation control. LT modifiers are alternatives to long-acting beta-agonists as complementary treatment to inhaled corticosteroids in pediatric asthma management because they provide bronchodilation and bronchoprotection without development of tolerance, and complement the antiinflammatory activity unchecked by steroids. In addition, the Cys-LTRA montelukast has been shown to ameliorate asthmatic symptoms and provide bronchoprotection in asthmatic preschool children from 2 years of age, which is of particular importance in this difficult-to-manage group of asthmatics. Given their efficacy, antiinflammatory activity, oral administration, and safety, LT modifiers will play an important role in the treatment of asthmatic children.