Choice of Treatment - Bronchial Asthma

CHOICE OF TREATMENT

A stepwise guideline to the treatment of asthma as per needs of the patient has been recommended:

1. Mild Episodic Asthma

(symptoms less than once daily, normal in between attacks): Inhaled shortacting β₂ agonist at onset of each episode. No regular prophylactic therapy (Step1).

2. Seasonal Asthma

Start regular inhaled cromoglycate/low dose inhaled steroid (200–400 μg/day) 3–4 weeks before anticipated seasonal attacks and continue till 3–4 weeks after the season is over. Treat individual episodes with inhaled short acting β₂ agonist.

3. Mild Chronic Asthma With Occasional Exacerbations

(symptoms once daily or so) Regular inhaled lowdose steroid (Step2). Alternatively, inhaled cromoglycate. Episode treatment with inhaled shortacting β₂ agonist.

4. Moderate Asthma With Frequent Exacerbations

(attacks affect activity, occur > 1 per day or mild baseline symptoms) Increasing doses of inhaled steroid (up to 800 μg/day) + inhaled long-acting β₂ agonist (Step3). Leukotriene antagonists may be tried in patients not accepting inhaled steroids and in those not well controlled. Theophylline may be used as alternative additional drug. Episode treatment with inhaled shortacting β₂ agonist.

5. Severe Asthma

(continuous symptoms; activity limitation; frequent exacerbations/hospitalization) Regular high dose inhaled steroid (800– 2000 μg/day) through a large volume spacer device inhaled long-acting β₂ agonist (salmeterol) twice daily. Additional treatment with one or more of the following (Step4):

Leukotriene antagonist/sustained release oral theophylline/oral β₂ agonist/inhaled ipratropium bromide.

Rescue treatment with shortacting inhaled β₂ agonist.

In patients not adequately controlled or those needing frequent emergency care—institute oral steroid therapy (Step5). Attempt withdrawing oral steroid periodically.

6.  Status Asthmaticus/Refractory Asthma

Any patient of asthma has the potential to develop acute severe asthma which may be life-threatening. Upper respiratory tract infection is the most common precipitant.

1)    Hydrocortisone hemisuccinate 100 mg (or equivalent dose of another glucocorticoid) i.v. stat, followed by 100–200 mg 4–8 hourly infusion; may take upto 6 hours to act.

2)    Nebulized salbutamol (2.5–5 mg) + ipratropium bromide (0.5 mg) intermittent inhalations driven by O₂.

3)    High flow humidified oxygen inhalation.

4)    Salbutamol/terbutaline 0.4 mg i.m./s.c. may be added, since inhaled drug may not reach smaller bronchi due to severe narrowing/plugging.

5)    Intubation and mechanical ventilation, if needed.

6)    Treat chest infection with intensive antibiotic therapy.

7) Correct dehydration and acidosis with saline + sod. bicarbonate/lactate infusion.

Aminophylline 250–500 mg diluted in 20–50 ml glucose (5%) solution injected i.v. over 20–30 min had been routinely used, but recent evidence shows that it does not afford additional benefit; may even produce more adverse effects; use is restricted to resistant cases.