ACUTE ASTHMA  Quick Rescuers Short-acting PRN Relax and open airways

 Inhalation is the preferred route (parenteral or nebulization are equally effective)

SABA: Short-Acting β2 Agonists 1.Albuterol Preferred SABA in pregnancy (but Category C)
 4-8 hours Inhaler (onset 5 min): Proventil HFA, Ventolin HFA, ProAir HFA
 Acute bronchospasm 2 puffs q4-6h PRN (MDI 90mcg/puff) *Preferred*
 Drug of choice: exercise-induced asthma Solution for neb: AccuNeb
2 puffs right before exercise, ok for 2-3h 2.5 mg/ 3ml 0.9% NaCl (0.083%), 3-4 times daily PRN over 5-15min
Oral (onset in 30 min): Proventil tabs, Volmax sol.
S.E.: tremor, tachycardia, tachyphylaxis 2-4 mg tabs tid-qid (syrup is 2mg/5mL). Max 32mg/day
( K,  Mg,  Gly)
2.Levalbuterol (Xopenex HFA) R-isomer of albuterol
PRN- Not for scheduled use 2 puffs q4-6h PRN (MDI 45mcg/puff); 0.63-1.25mg q6-8h (NEB)
Use > 2 days/week indicates inadequate control and 3.Pirbuterol (Maxair Autohaler)
the need to step up treatment 2 puffs q4-6h PRN (MDI 200mcg/puff)
IV steroids (i.e. prednisone, methylpred) and anticholinergics (i.e. short-acting ipratropium) are also used in the ED for acute attacks
HFA: hydrofluoroalkane- propellant not harmful to the ozone layer

CHRONIC ASTHMA  Controllers LONG-TERM, DAILY Anti-inflammation

 Initial therapy: 1. ICS ± LTRA; 2. ICS/LABA; 3. ICS/LABA + LAMA |Advanced therapy: Anti-IgE or Anti-IL-5
ICS: Inhaled corticosteroid Fluticasone (Flovent)/+ Salmeterol= Advair MedGuide
Most powerful 1 (Advair) or 2 puffs BID Beclomethasone (QVAR)
 Ok in children (may slow growth) Triamcinolone (Azmacort)
 Consistent ICS use  death rates HFA Use spacer
Diskus Dry powder for Flunisolide (Aerospan, Aerobid)
 Oral candidiasis≡ thrush (rinse mouth or use
spacer)→ It usually goes away on its own. If
inhalation Ciclesonide (Alvesco)
persistent, may need nystatin Mometasone (Asmanex)/+ Formoterol= Dulera MedGuide
 Hoarseness, skin bruising,  bone density, Budesonide (Pulmicort)/+ Formoterol= Symbicort
Respules for neb.
 risk of pneumonia (no live vaccines!) (budesonide)
Budesonide→ preferred inhaled corticosteroid in pregnancy

12 hour duration 24 hours duration

LABA: Long-Acting β2 Agonist (bronchodilator) MedGuide Indacaterol
BBW: Asthma-related deaths NOT for monotherapy Salmeterol (Serevent Diskus) bid Vilanterol
Use w/ inhaled steroids and DC when possible Slower Onset- Take 30 min prior exercise
 Add on when uncontrolled on ICS
Olodaterol
Formoterol (Foradil Aerolizer) Inhale 1 cap bid Abediterol
 Use ICS + LABA combination inhaler
Quick Onset- Take 15 min prior exercise Carmoterol
LAMA: Long-Acting Muscarinic Antag 12 hr: Aclidinium; Darotropium 24 hr: Tiotropium; Glycopyrronium; Umeclidinium
Oral Systemic Corticosteroid Betamethasone = Dexamethasone 0.75mg
Oral steroids Methylprednisolone = Triamcinolone 4mg
 For severe persistent asthma Dose equivalents Prednisone = Prednisolone 5mg
 Maintenance prednisone: 5-60mg daily or every other day Hydrocortisone 20mg
 S.E.: ↑Gly, fluid retention, ulcer, immunosupp., K, myopathy
Cortisone 25mg
Mast Cell Stabilizer► Cromolyn sodium (Intal) (anti-inflammatory) prevent both early/late response to allergens
 For exercise-induced give 15min prior exercise/For allergen-induced use prior to exposure
 2-4 inhalations q6-8h (MDI); 20mg q6-8h (NEB)
 Minimal S.E. (unpleasant taste, cough) but less effective than inhaled corticosteroids
LTRA Leukotriene Rec. Antagonist► Montelukast (Singular) (age > 6 mo.) Once daily dosing
(anti-inflammatory, bronchodilator) Take 10mg hs since leukotriene is produced at night. Avoid in PKU (aspartame)
 Exercise induced/Asthma prophylaxis Zafirlukast (Accolate) (age >5) 20mg BID empty stomach
 Rare mood & behavior changes Zileuton (Zyflo CR) (age ≥12) 1200mg (2 tab) BID within 1 hr of a meal. Monitor liver
 Advantage: ORAL 5-Lipoxygenase inhibitor
3rd line Theophylline (Elixophyllin, Theo-24, TheoCap, Uniphyl, Theochron) (bronchodilator) 200-600mg daily (SR formulation only)
Narrow therapeutic range (5-15 (20) mcg/mL) Requires monitoring of serum concentration levels. Multiple drug interactions!!
Monoclonal antibodies (Asthma & COPD) MedGuide
Anti-IgE for patients with severe allergy: omalizumab (Xolair) SC q2-4wk given by the doctor. BBW: Rare delayed anaphylaxis
Anti IL-5 for patients with eosinophilic disease: benralizumab (Fasenra); mepolizumab (Nucala); reslizumab (Cinqair)

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 Nebulizer Mouthpiece or mask I.e. Albuterol sol. (AccuNeb)
1. Twist the cap completely off the vial and squeeze the contents into the nebulizer reservoir.
2. Connect the nebulizer to the mouthpiece or face mask.
3. Connect the nebulizer to the compressor.
Inhaler Formulations

4. Place the mouthpiece in your mouth or put on the face mask; and turn on the compressor.
5. Breathe as calmly, deeply and evenly as possible through your mouth until no more mist is formed in the
nebulizer chamber (about 5-15 minutes).
MDI Metered Dose Inhaler HFA devices/spacers (aerosol) DPI Dry powder inhaler Diskus, cap, twist-cap
1. Priming not required
1. Prime prior to use (2-3 actuations) 2. Do not shake
2. Shake well susp. Don’t shake QVAR & Alvesco sol. 3. Use mouthpiece (No spacers!)
3. Use spacer (or rinse mouth with water) 4. Inhale dose fast and deep
4. Slowly breathe out, hold breathe & breathe normally 5. Do not inhale into diskus
5. Clean the inhaler weekly 6. Rinse mouth
7. Do not clean. Keep it dry

Steroid Asthma► Inhaler Allergic Rhinitis► Nasal

Spacers
Fluticasone Flovent Flonase, Veramyst
↓ oropharyngeal deposition of the med
Mometasone Asmanex Nasonex
 Prevent oral candidiasis Budesonide Pulmicort Rhinocort Aqua
↑ lung deposition of the medicine Beclomethasone QVAR Beconase AQ
↑ the response to beta2 agonists Flunisolide Aerospan, Aerobid Nasarel
Ciclesonide Alvesco Omnaris
Cromolyn sodium Intal NasalCrom

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Initial therapy: 1. LAMA or LABA*; 2. LABA/LAMA; 3. LABA/LAMA + ICS
*LABA monotherapy is safer in COPD than in asthma
Advanced therapy: 1. Chronic macrolides; 2. Roflumilast

SHORT-ACTING (6-8 hours)

LAMAs (long-acting muscarinic antagonists) Preferred: Ipratropium (Atrovent)/ Ipratropium+ Albuterol= Combivent
Anticholinergics (bronchodilator) 2 puffs q6h (QID) or 0.5mg tid-qid for neb.
LONG-ACTING
Use with caution if myasthenia gravis, Tiotropium (Spiriva) (24 hrs) 1 cap inhaled qd with handihaler (2 puffs)
glaucoma, BPH Do not swallow caps! Do not breathe into the handihaler. Breathe in slowly
S.E.: dry mouth, upper respiratory infections, Tiotropium/olodaterol (Stiolto Respimat) (24 hrs) 2 inhalations daily
bitter/ metallic taste (ipratropium) Aclidinium (Tudorza) (12 hrs) 1 inhalation (400mcg) BID
New 2019 aclidinium/formoterol (Duaklir Pressair) 400 mcg/12 mcg BID

LABAs (long-acting inhaled β2 agonists) (bronchodilator) MedGuide

S.E.: tremor, cough, palpitations, hypokalemia, hyperglycemia
 12 hours: Arformoterol (Brovana) 15mcg BID (NEB); formoterol (Foradil); salmeterol (Serevent).
 24 hours: Indacaterol (Arcapta) 75mcg cap via Neohaler daily; olodaterol (Striverdi Respimat).
 Daily long-term maintenance of COPD►
Anoro Ellipta: umeclidinium (anticholinergic) + vilanterol (LABA)
Breo Ellipta: fluticasone + vilanterol
Trelegy Ellipta: umeclidinium + fluticasone + vilanterol
Seebri Neohaler (glycopyrrolate dry powder inhaler) & Lonhala (glycopyrrolate inhalation sol.)

Roflumilast (Daliresp) Phosphodiesterase4 Inhibitor (anti-inflammatory) 500mcg tab daily MedGuide

 Only for severe COPD due to modest benefit. Always use in combination with LABA.
 S.E.: nausea, ↓ appetite, abdominal pain, diarrhea, insomnia, headache. CI if liver disease.
VACCINATIONS recommended for all patients with asthma or COPD: Influenza (each fall) + pneumococcal

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