March 18, 2020

CASE STUDY NO. 6

ASTHMA
GROUP#3

MEMBERS:
CASIPIT, SABINA
CAPUA, ROSS DHECEL
DE VERA, JAYA MAE
MENDOZA, MYLENE
MURILLO, GENERRA ANNE
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CASE STUDY NO 6
ASTHMA

A. Abbreviations
CC – Chief Complaint
HPI – History of Present Illness
PMH – Past Medical History
Meds – Medicines / Medications
PE – Physical Examination
Gen – General
VS – Vital Signs
BP – Blood Pressure
RR – Respiratory Rate
HR – Heart Rate
SABA – Short-Acting Beta-2- agonist
ED – Emergency Department

B. Medical Terms and Meanings

Asthma – recurrent bouts of reversible narrowing of bronchial airways due to
lymphocyte and eosinophilic inflammation of bronchial mucosa

Dyspnea – difficulty or labored breathing

Coughing - known as tussis, is a voluntary or involuntary act that clears the

throat and breathing passage

of foreign particles, microbes, irritants, fluids, and mucus; it is a rapid expulsion

of air from the lungs

Upper Respiratory Tract Infection - an illness caused by an acute infection,

which involves the upper respiratory tract, including the nose, sinuses, pharynx,
or larynx. This commonly includes nasal obstruction, sore throat, tonsillitis,
pharyngitis, laryngitis, sinusitis, otitis media, and the common cold

Sore throat - pain, scratchiness or irritation of the throat that often worsens
when you swallow. The most common cause of a sore throat (pharyngitis) is a
viral infection, such as a cold or the flu. A sore throat caused by a virus resolves
on its own

Rhinorrhea - condition where the nasal cavity is filled with a significant amount
of mucus fluid. The condition, commonly known as a runny nose, occurs
relatively frequently. Rhinorrhea is a common symptom of allergies (hay fever) or
certain viral infections, such as the common cold
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Albuterol - inhalation is used to treat or prevent bronchospasm, or narrowing of

the airways in the lungs, in people with asthma or certain types of chronic
obstructive pulmonary disease (COPD)

Nebulization - changes medication from a liquid to a mist so that it can be

more easily inhaled into the lungs. Nebulizers are particularly effective in
delivering asthma medications to infants and small children and to anyone who
has difficulty using an asthma inhaler.

Anxious - experiencing worry, unease, or nervousness, typically about an

imminent event or something with an uncertain outcome

Respiratory Distress – is a condition wherein pulmonary activity is deemed

insufficient to regulate oxygen and extract carbon dioxide from the blood

Wheezing – is a whistling sound produced by turbulent airflow through a

constricted opening and usually is more prominent on expiration

Expiratory Wheeze - means that the wheeze happens on an exhale of breath

Inspiratory Wheeze - is a wheeze on the inhale

Respiratory Rate - the number of breaths you take per minute

Heart Rate - also known as pulse, is the number of times a person's heart beats
per minute

Pulsus Paradoxus - also paradoxic pulse or paradoxical pulse, is an abnormally

large decrease in stroke volume, systolic blood pressure and pulse wave
amplitude during inspiration. The normal fall in pressure is less than 10 mmHg.
When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.

Hyper Inflated Chest - occur when air gets trapped in the lungs and causes
them to overinflate. Hyperinflated lungs can be caused by blockages in the air
passages or by air sacs that are less elastic, which interferes with the expulsion
of air from the lungs

Suprasternal Retraction - when the skin in the middle of your neck sucks in.
It's also called a tracheal tug

Superclavical Retractions - indrawing of the skin of the neck above the

collarbone. The location of a patient's retractions can roughly tell you where an
obstruction is in the respiratory tract.

Intercostal Retraction - occur when the muscles between the ribs pull inward.
The movement is most often a sign that the person has a breathing problem.
Intercostal retractions are a medical emergency.
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Auscultation - the action of listening to sounds from the heart, lungs, or other
organs, typically with a stethoscope, as a part of medical diagnosis.

Bilateral Inspiratory – inspiratory wheezing often accompanies expiratory

wheezing when heard over the lungs, specifically in acute asthma.

Arterial Oxygen Saturation - called your oxygen saturation level.

Pulse Oximetry - test used to measure the oxygen level (oxygen saturation) of
the blood. It is an easy, painless measure of how well oxygen is being sent to
parts of your body furthest from your heart, such as the arms and legs.

Blood Pressure - the pressure of the blood in the circulatory system, often
measured for diagnosis since it is closely related to the force and rate of the
heartbeat and the diameter and elasticity of the arterial walls. wheezing often
accompanies expiratory wheezing when heard over the lungs, specifically in
acute asthma.

Pulmonary Obstruction - chronic inflammatory lung disease that causes

obstructed airflow from the lungs.

Acute Bronchial Obstruction - occurs when there is a blockage in the airway,

which can partially or totally prevent air from reaching the lungs. Swallowing or
inhaling a foreign object, an allergic reaction, asthma and even certain types of
infections can cause the airway to become obstructed.

Clinical Test - rigorously controlled test of a new drug or a new invasive

medical device on human subjects; in the United States it is conducted under the
direction of the FDA before being made available for general clinical use.

Broncholidator - a medication that relaxes and opens the airways, or bronchi,

in the lungs. Short-acting and long-acting bronchodilators treat various lung
conditions and are available by prescription

Aminophylline – is a drug combination of theophylline and ethylenediamine in

a ratio of 2 to 1. FDA approved for relieving symptoms of reversible airway
obstruction due to asthma or other chronic lung diseases like chronic bronchitis
and emphysema.

Ipratropium - sold under the trade name Atrovent among others, is a

medication which opens up the medium and large airways in the lungs. It is used
to treat the symptoms of chronic obstructive pulmonary disease and asthma. It is
used by inhaler or nebulizer.

Corticosteroid therapy - (cortisone-like medicines) are used to provide relief

for inflamed areas of the body. They lessen swelling, redness, itching, and
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allergic reactions. They are often used as part of the treatment for a number of
different diseases, such as severe allergies or skin problems, asthma, or arthritis.

ED Management – accurate diagnosis in a minimum of time is critical to ensure

the best patient outcomes. Every minute counts: you need to identify patients at
high risks of a life threatening condition and rapidly initiate appropriate
treatment. At the same time, cost containment and optimized patient flow
management

Non – Pharmacological Treatment – are science based and non invasive

interventions on human health. They aim to prevent, care or cure help problems.
They may consists in products, methods, programs or services whose contents
are known by users is a drug combination of theophylline and ethylenediamine in
a ratio of 2 to 1. It is FDA approved for relieving symptoms of reversible airway
obstruction due to asthma or other chronic lung diseases like chronic bronchitis
and emphysema. It is also used to prevent apnea in preterm infants

Inhalation Devices - Nebulizers are a group of devices that generate an

aerosol from a solution, which can be inhaled by patients. The aerosol droplets
are typically within the range of 1–5 μm. The patient uses a mask or mouthpiece
and inhales the aerosol as they breathe normally. They offer many advantages
over other devices.

Monitoring Equipment - An essential part of any environmental monitoring or

measurement project is the equipment used. Some equipment, like meters and
field kits, are intended for spot sampling. Others, like sondes, data loggers and
data buoys, are designed for long term monitoring applications.

C. Medication

Albutarol 2.5 for nebulization Generic name:

albuterol ( salbutamol )

Indication:

Mechanism of action:

Drug Interaction:

 Tricyclic anti depressants and MAOIs mono amine oxydase inhibitors should
not be combined with albutarol sulfate because of their additive effects on the
vascular system (increase blood pressure heart rate)
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 Use of albuterol sulphate with other stimulant medications is discouraged

because of their combined effects on heart rate, blood pressure, and the
potential for causing chest pain in patients with underlying coronary heart
disease.

 Beta-blockers, for example, propranolol (Inderal, Inderal LA), block the effect
of albuterol sulphate and may induce bronchospasm in asthmatics.

 Albuterol sulphate may cause hypokalemia (low potassium). Therefore,

combining albuterol sulphate with loop diuretics, for example, furosemide (Lasix)
may increase the likelihood of hypokalaemia. Use to relieve bronchospasm
associated with bronchial asthma, emphysema and chronic bronchitis and other
conditions associated with reversible airways obstructions; premature labour
Essentially relaxing the smooth muscles of the airways. It activates the beta2-
adrenergic receptors in the lungs, which begins a cascade of actions that result
in bronchodilation. Albuterol is effective in opening the airways regardless of the
cause of bronchoconstriction.

Adverse Drug Reaction:

- Fine tremor of skeletal muscle (particularly hands)

- Palpitation and muscle cramps
- Tachycardia
- Nervous tension
- Hypokalemia
- Decrease appetite
- Nausea
- Vomiting
- Difficulty in micturition
- Urinary retention
- Insomnia - Confusion - Irritability - Weakness
- Psychotic States
- Dyspnea
- Altered Metabolism
- Sweating
- Hypersalivation
- Hypersensitivity Reactions
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PE

Gen
Anxious appearing young girl in moderate respiratory distress with audible expiratory
wheezes
 Asthma is an obstructive lung disease; therefore, the primary limitation to airflow
occurs during expiration. This outflow obstruction leads to the classic findings of
dyspnea, expiratory wheezes, and a prolonged expiratory phase during the
ventilatory cycle. Wheezing is a whistling sound produced by turbulent airflow
through a constricted opening and usually is more prominent on expiration.
VS
BP 110/83mmHg; RR 30 breaths/min; HR 130 beats/min; temperature 37.8 degree
Celsius; pulsus paradoxus 18mmHg
 Classification of blood pressure JNC VII
Systolic BP (mmHg) Diastolic BP (mmHg)
Normal <120 mmHg <80 mmHg
Prehypertention 120-139 mmHg 80-89 mmHg
Stage 1 hypertention 140-159 mmHg 90-99 mmHg
Stage 2 hypertention >160 mmHg >100 mmHg
Interpretation: the blood pressure of the patient is normal.
 Respiratory rate
Normal 12-20 breaths/min
Tachypnea Faster respiratory rate >20 breaths/min
Bradypnea Slow respiratory rate <12 breaths/ min
Interpretation: the respiratory rate of the patient is tachypnea.
 Heart rate
Normal 60-100 beats/min
Bradycardia <60 beats/min
Tachycardia >100 beats/min
Interpretation: the heart rate of the patient is tachycardia.
 Temperature
Normal body temperature: 37 degree Celsius
Generally accepted fever to be oral body temperature of 38 degree Celsius
Oral body temperature is 1 degree Celsius lower than rectal body temperature
Axillary body temperature is 2 degree Celsius lower than rectal body temperature

Interpretation: the body temperature of the patient is normal.

 Pulsus paradoxus
-Pulsus paradoxus is defined as a fall of systolic blood pressure of >10 mmHg
during the inspiratory phase. 
Interpretation: fall of systolic blood pressure.
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 The increased pulse, RR, and anxiety experienced by the patient can be
attributed both to hypoxemia and the feeling of suffocation. The hypoxemia in
acute asthma is due principally to an imbalance between alveolar ventilation and
pulmonary capillary blood flow,known as ventilation-perfusion mismatching.
When ventilation is decreased to an area of the lung, the alveoli in ithat area
become hypoxic, and the pulmonary artery to that region constricts as a normal
physiologic response. As a result, blood flow is shunted to the well-ventilated
portions of the lung because of the need to preserve adequate oxygenation of
the blood.

Chest
Hyperinflated chest and suprasternal , supraclavicular and intercostal retractions
 The small airways become completely occluded during expiration, and air can be
trapped behind the occlusion; therefore, the patient has to breathe at higher
than normal lung volumes. Consequently, the thoracic cavity becomes
hyperexpanded, and the diaphragm is lowered. As a result, the patient must use
the accessory muscles of respiration to expand the chest wall. Hyperinflated
chest and her use of suprasternal, supraclavicular, and intercostal muscles to
assist in breathing also are compatible with obstructive airway diseases.

Other findings:
Upon auscultation, the doctor heard a bilateral inspiratory and expiratory wheezes with
decreased breath sound on the left side heard on auscultation.
 The audible expiratory wheezing in patient is compatible with bronchial
obstruction. Patient’s obstruction is so severe that even inspiratory wheezes and
decreased air movement were detected on auscultation. The classic symptom of
wheezing requires turbulent airflow; therefore, effective therapy of acute asthma
may result in increased of wheezing initially 9as airflow increases throughout the
lung. As a result, patient’s increased wheezing on auscultation is compatible with
her clinical improvement following the albuterol nebulizer treatments.

Arterial oxygen saturation by pulse oximetry 90%

 Normal arterial blood oxygen saturation levels in humans are 95–100%.

References: applied therapeutics,Lippincott Wiliams & Wilkins book

https://www.ncbi.nlm.nih.gov/pubmed/4051208
https://www.ncbi.nlm.nih.gov/books/NBK9633/table/A32/

Questions:

1. What signs and symptoms are consistent with acute bronchial

obstruction?
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 Symptoms include episodes of dyspnea, chest tightness, coughing

(particularly at night), wheezing, or a whistling sound when breathing.
These often occur with exercise but may occur spontaneously or in
association with known allergens.
 Signs include expiratory wheezing on auscultation; dry, hacking cough; and
atopy (eg, allergic rhinitis or eczema)

2. What additional tests would be helpful in assessing the extent of

pulmonary obstruction in this patient?
CHRONIC ASTHMA
 Diagnosis is made primarily by history of recurrent episodes of coughing,
wheezing, chest tightness, or shortness of breath and confirmatory spirometry.
 Patients may have family history of allergy or asthma or symptoms of allergic
rhinitis. History of exercise or cold air precipitating dyspnea or increased
symptoms during specific allergen seasons suggests asthma.
 Spirometry demonstrates obstruction (forced expiratory volume in 1 second
[FEV1]/ forced vital capacity [FVC] <80%) with reversibility after inhaled β2-
agonist administration (at least 12% improvement in FEV1). If baseline
spirometry is normal, challenge testing with exercise, histamine, or methacholine
can be used to elicit BHR.
ACUTE SEVERE ASTHMA
 Peak expiratory flow (PEF) and FEV1 are less than 40% of normal predicted
values. Pulse oximetry reveals decreased arterial oxygen and O2 saturations. The
best predictor of outcome is early response to treatment as measured by
improvement in FEV1 at 30 minutes after inhaled β2-agonists.
 Arterial blood gases may reveal metabolic acidosis and low partial pressure of
oxygen (PaO2).
 History and physical examination should be obtained while initial therapy is
provided. History of previous asthma exacerbations (eg, hospitalizations,
intubations) and complicating illnesses (eg, cardiac disease, diabetes) should be
documented. Patient should be examined to assess hydration status; use of
accessory muscles of respiration; and the presence of cyanosis, pneumonia,
pneumothorax, pneumomediastinum, and upper airway obstruction. Complete
blood count may be appropriate for patients with fever or purulent sputum.

3. Which clinical test is predictive of the need for admission or whether

she will relapse if sent home from the emergency department?
 Patients at high risk for a fatal attack require immediate medical attention
after initial treatment.
 Symptoms and signs suggestive of a more serious exacerbation such as
marked breathlessness, inability to speak more than short phrases, use of
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accessory muscles, or drowsiness should result in initial treatment while

immediately consulting with a clinician.
 Less severe signs and symptoms can be treated initially with assessment
of response to therapy and further steps as listed below.
 •If available, measure PEF—values of 50%–79% predicted or personal
best indicate the need for quick-relief mediation. Depending on the
response to treatment, contact with a clinician may also be indicated.
Values below 50% indicate the need for immediate medical care.

4. Why was SABA selected as the bronchodilator of first choice in

preference to other bronchodilators such as aminophylline or
ipratropium?
 Short-acting β2-agonists are the most effective bronchodilators. Aerosol
administration enhances broncho selectivity and provides more rapid
response and greater protection against provocations (eg, exercise,
allergen challenges) than systemic administration.
 Albuterol and other inhaled short-acting selective β2-agonists are
indicated for intermittent episodes of bronchospasm and are the
treatment of choice for acute severe asthma and EIB. Regular treatment
(four times daily) does not improve symptom control over as-needed use.
 In acute severe asthma, continuous nebulization of short-acting β2-
agonists (eg, albuterol) is recommended for patients having
unsatisfactory response after three doses(every 20 min) of aerosolized
β2-agonists and potentially for patients presenting initially with PEF or
FEV1 values less than 30% of predicted normal.
 Theophylline appears to produce bronchodilation through nonselective
phosphodiesterase inhibition. Methylxanthines are ineffective by aerosol
and must be taken systemically (orally or IV). Sustained-release
theophylline is the preferred oral preparation, whereas its complex with
ethylenediamine (aminophylline) is the preferred parenteral product due
to increased solubility. IV theophylline is also available.
 Ipratropium bromide and tiotropium bromide produce bronchodilation
only in cholinergic-mediated bronchoconstriction. Anticholinergics are
effective bronchodilators but are not as effective as β2-agonists. They
attenuate but do not block allergen or exercise-induced asthma in a dose-
dependent fashion.
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5. Should Q.C. receive corticosteroid therapy as part of her ED

management?
 Yes.
 Inhaled corticosteroids are the preferred long-term control therapy for persistent
asthma because of potency and consistent effectiveness; they are the only
therapy shown to reduce risk of dying from asthma. Most patients with moderate
disease can be controlled with twice-daily dosing; some products have once-daily
dosing indications. Patients with more severe disease require multiple daily
dosing. Because inflammation inhibits steroid receptor binding, patients should
be started on higher and more frequent doses and then tapered down once
control has been achieved. Response to inhaled corticosteroids is delayed;
symptoms improve in most patients within the first 1 to 2 weeks and reach
maximum improvement in 4 to 8 weeks. Maximum improvement in FEV1 and
PEF rates may require 3 to 6 weeks.
 Systemic toxicity of inhaled corticosteroids is minimal with low to moderate
doses, but risk of systemic effects increases with high doses. Local adverse
effects include dose-dependent oropharyngeal candidiasis and dysphonia, which
can be reduced by using a spacer device.
 Systemic corticosteroids are indicated in all patients with acute severe asthma
not responding completely to initial inhaled β2-agonist administration
(every 20 min for 3 or 4 doses). Prednisone, 1 to 2 mg/kg/day (up to 40–60 mg/
day), is administered orally in two divided doses for 3 to 10 days. Because short
term (1–2 week), high-dose systemic steroids do not produce serious toxicities,
the ideal method is to use a short burst and then maintain appropriate long-term
control therapy with inhaled corticosteroids.
 In patients who require chronic systemic corticosteroids for asthma control, the
lowest possible dose should be used. Toxicities may be decreased by alternate-
day therapy or high-dose inhaled corticosteroids.

Other Questions:

6. Site some factors that would contribute in aggravating asthma?

 Airborne substances, such as pollen, dust mites, mold spores, pet dander or
particles of cockroach waste
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 Respiratory infections, such as the common cold

 Physical activity (exercise-induced asthma)
 Cold air
 Air pollutants and irritants, such as smoke
 Certain medications, including beta blockers, aspirin, ibuprofen (Advil, Motrin IB,
others) and naproxen (Aleve)
 Strong emotions and stress
 Sulfites and preservatives added to some types of foods and beverages,
including shrimp, dried fruit, processed potatoes, beer and wine
 Gastroesophageal reflux disease (GERD), a condition in which stomach acids
back up into your throat

7. What non-pharmacologic action treatment should be received by patients

with asthma?
• Patient education is mandatory to improve medication adherence, self-management
skills, and use of healthcare services.
• Objective measurements of airflow obstruction with a home peak flow meter may not
improve patient outcomes. NAEPP advocates PEF monitoring only for patients with
severe persistent asthma who have difficulty perceiving airway obstruction.
• Avoidance of known allergenic triggers can improve symptoms, reduce medication
use, and decrease BHR. Environmental triggers (eg, animals) should be avoided in
sensitive patients, and smokers should be encouraged to quit.
• Patients with acute severe asthma should receive oxygen to maintain PaO2 greater
than 90% (>95% in pregnancy and heart disease). Dehydration should be corrected;
urine specific gravity may help guide therapy in children when assessment of hydration
status is difficult.

8. What are the goals from asthma?

Goals for chronic asthma management include:

✓ Reducing impairment: (1) prevent chronic and troublesome symptoms (eg,
coughing or breathlessness in the daytime, at night, or after exertion), (2) require
infrequent use (≤2 days/wk) of inhaled short-acting β2-agonist for quick relief of
symptoms (not including prevention of exercise-induced bronchospasm [EIB]),
(3) maintain (near-) normal pulmonary function, (4) maintain normal activity
levels (including exercise and attendance at work or school), and (5) meet patients’
and families’ expectations and satisfaction with care.
✓ Reducing risk: (1) prevent recurrent exacerbations and minimize need for
emergency
department visits or hospitalizations; (2) prevent loss of lung function; for
children, prevent reduced lung growth; and (3) minimal or no adverse effects of
therapy.
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• For acute severe asthma, treatment goals are to (1) correct significant hypoxemia,
(2) rapidly reverse airway obstruction (within minutes), (3) reduce likelihood of
recurrence of severe airflow obstruction, and (4) develop a written action plan in
case of future exacerbation.

9. What non-pharmacologic treatment are needed in order to control

asthma?

• Patient education is mandatory to improve medication adherence, self-

management skills, and use of healthcare services.
• Objective measurements of airflow obstruction with a home peak flow meter
may not improve patient outcomes. NAEPP advocates PEF monitoring only for
patients with severe persistent asthma who have difficulty perceiving airway
obstruction.
• Avoidance of known allergenic triggers can improve symptoms, reduce
medication use, and decrease BHR. Environmental triggers (eg, animals)
should be avoided in sensitive patients, and smokers should be encouraged
to quit.
• Patients with acute severe asthma should receive oxygen to maintain PaO2
greater than 90% (>95% in pregnancy and heart disease). Dehydration
should be corrected; urine specific gravity may help guide therapy in children
when assessment of hydration status is difficult.

10. What pharmacologic recommendations can be made in order to control a

patient’s asthma?
• β2-Agonists
 Short-acting β2-agonists are the most effective bronchodilators. Aerosol
administration enhances bronchoselectivity and provides more rapid response
and greater protection against provocations (eg, exercise, allergen
challenges) than systemic administration.
 Albuterol and other inhaled short-acting selective β2 -agonists are indicated
for intermittent episodes of bronchospasm and are the treatment of choice
for acute severe asthma and EIB. Regular treatment (four times daily) does
not improve symptom control over as-needed use.
 Formoterol and salmeterol are inhaled long-acting β2 -agonists for
adjunctive long-term control for patients with symptoms who are already on
low to medium doses of inhaled corticosteroids prior to advancing to medium-
or high-dose inhaled corticosteroids. Short-acting β2-agonists should be
continued for acute exacerbations. Long-acting agents are ineffective for
acute severe asthma because it can take up to 20 minutes for onset and 1 to
4 hours for maximum bronchodilation.
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 In acute severe asthma, continuous nebulization of short-acting β2-agonists

(eg, albuterol) is recommended for patients having unsatisfactory response
after three doses (every 20 min) of aerosolized β2-agonists and potentially
for patients presenting initially with PEF or FEV1 values less than 30% of
predicted normal.
 Inhaled β2 -agonists agents are the treatment of choice for EIB. Short-acting
agents provide complete protection for at least 2 hours; long-acting agents
provide significant protection for 8 to 12 hours initially, but duration
decreases with chronic regular use.
 In nocturnal asthma, long-acting inhaled β2-agonists are preferred over oral
sustained-release β2 -agonists or sustained-release theophylline. However,
nocturnal asthma may be an indicator of inadequate anti-inflammatory
treatment
 Corticosteroids
 Methylxanthines
 Anticholinergics
 Mast Cell Stabilizers
 Leukotriene Modifiers
 Omalizumab

11. What considerations are important when recommending inhalation

devices and monitoring equipments?

• All patients on inhaled drugs should have their inhalation technique evaluated
monthly initially and then every 3 to 6 months.
• After initiation of anti-inflammatory therapy or increase in dosage, most
patients should experience decreased symptoms within 1 to 2 weeks and
achieve maximum improvement within 4 to 8 weeks. Improvement in
baseline FEV1 or PEF should follow a similar time course, but decrease in BHR
as measured by morning PEF, PEF variability, and exercise tolerance may
take longer and improve over 1 to 3 months.

References:

o Pharmacotherapy Handbook Ninth Edition

o https://www.medscape.com/