Acute Asthma Exacerbation Medication
An asthma exacerbation, sometimes called an asthma attack, occurs when the airways become inflamed and swollen. Usually, the muscles surrounding the airways contract, causing the airways to release extra mucus and the bronchial to shrink. During an asthma attack, the patient might experience wheezing, coughing, or difficulty in breathing (Zaidan et al., 2020). Because an asthma attack can be life-threatening, recognizing the disease and seeking treatment early enough is critical. Patients are also often advised to strictly follow the treatment plan they had previously formulated with their doctors, which often stipulates how to deal with asthma when it starts flaring up and how to handle an asthma exacerbation in progress. In this paper, I will explain long-term and quick-relief medication for my 26-year-old female patient who has been admitted for an acute asthma attack. I will also describe the stepwise approach to asthma management and treatment and then apply it to the patient. Finally, I will highlight the benefits of stepwise management to patients and care providers in terms of helping them gain and sustain control of their condition.
Long-term Control and Quick Relief Treatment for the Patient
The first emergency treatment that can be administered to the patient includes short-acting beta-agonists, which serve the same purpose as those contained in the rescue (quick-acting) inhaler. This requires using a specialized machine known as a nebulizer, which can convert the drug into an inhalable mist. Albuterol is an example of a short-acting beta-agonist that can help stop shortness of breath as well as wheezing. Also, oral corticosteroids (which are taken in tablet form) must be given to the patient to lower lung inflammation and other symptoms. If the patient is experiencing respiratory failure or vomiting, an intravenous injection of corticosteroids is recommended. However, in case of albuterol is ineffective, a bronchodilator substance, such as ipratropium, can be used to neutralize spasms, wheezing, and shortness of breath. Finally, intubation (a mechanical ventilator) can be inserted into the patient’s throat if the exacerbation is life-threatening. Then an oxygen pump can then be used to push oxygen into the patient’s lungs while albuterol or ipratropium and corticosteroids are administered (Ramsahai, Hansbro, & Wark, 2018).
Whereas these short-term remedies are often taken in case of an acute life-threatening attack, an individual usually takes long-term control drugs every day throughout their lifetime to maintain and achieve control of chronic asthma. The common drugs used to control asthma in the long term include corticosteroids, leukotriene modifiers, immunomodulators, long-acting beta-agonists (LABAs), and theophylline (methylxanthines).
The first medications, corticosteroids, are often taken to inhibit inflammatory cell activation and migration, lower airway hyper-responsiveness, as well as prohibit late-phase reactions to allergens. Corticosteroids are either inhaled (with adverse reactions including oral thrush, voice changes, and cough) or oral corticosteroids (which can cause worse preexisting conditions, such as peptic ulcers, hypertension, mood changes, fluid retention, as well systemic side effects, such as Cushing’s disease). Therefore, patients are advised to take the lowest effective dose.
On the other hand, immunomodulators (such as omalizumab) are monoclonal antibodies designed to block the binding of IgE to receptors (high-affinity) on mast cells and basophils. They lower exacerbations, nighttime awakenings, and disruption of daily activities. The drug is administered via the subcutaneous route, and patient dosage is often recommended based on the concentration of immunoglobulin E and body weight.
Leukotriene modifiers block chemicals, especially LTRAs (leukotriene receptor antagonists, such as zafirlukast) and zileuton (5-lipoxygenase pathway inhibitor), that can cause the extension of and dilation of the pathways. Specifically, leukotriene modifiers serve to block pro-inflammatory and bronchoconstrictor actions of cysteinyl leukotrienes within the airways. The side effects and adverse reactions of this medication include elevated liver enzymes, vasculitis, and systemic eosinophilia. Therefore, physicians are advised to monitor for these reactions.
LABAs (long-acting beta-agonists), such as formoterol and salmeterol, are taken (usually together with corticosteroids) to relax airway muscles, allowing the tubes to remain open. This makes breathing easier. The therapeutic effects of this type of medication include hypokalemia, shakiness, and increased heart rate. The drug should not be taken to block acute flare-ups or symptoms which occur during acute asthma exacerbations (Ramsahai, Hansbro, & Wark, 2018).
Finally, methylxanthines are often used as a top-up treatment to anti-inflammatory therapies for prolonged management of asthma symptoms, especially nocturnal symptoms. These drugs work by increasing mucus clearance in the airways and diaphragm contractility. They also improve bronchodilation by enhancing smooth muscle relaxation. The possible side effects include sleeplessness, difficulty in urination, stomach upsets, irregular heartbeat, vomiting and nausea, increased heart rate, as well as central nervous stimulation.
Stepwise Approach to Asthma Treatment and Management for the Patient
A stepwise approach refers to the process of increasing or decreasing the dosage of the asthma drugs given to patients, as well as altering the type of drugs used, usually depending on the individual’s symptoms and circumstances, to achieve disease control. When the physician first diagnoses the disease, drug dosage is gradually increased until symptoms begin declining. At this point, the dosage is then gradually lowered until some point when the symptoms completely disappear. Asthma drugs are classified into three age groups, including ages 0-4, 5-11, and 12+. In the stepwise approach, the first step involves the administration of short-acting beta-agonists. This treatment applies to all ages, and if taken more than two days in a week without improvement, individuals are advised to consider stepping up therapy (going to step 2). In the second step, the preferred/favored treatment is a low-dose inhaled steroid, while the alternative therapy is leukotriene (which applies to all ages). If step two therapy is ineffective, the third step of treatment is considered, whereby the preferred treatment for individuals aged 12 and above is a medium-dose inhaled therapy or low-acting beta-agonist plus low-dose inhaled steroid. The alternative medication is a leukotriene blocker plus a low-dose inhaled steroid. The first-choice treatment for patients aged 5-11 is either a medium-dose-inhaled steroid, leukotriene blocker, or long-acting beta-agonist + low-dose inhaled steroid. For ages 0-4, medium-dose inhaled steroids and referrals are recommended.
In step four, a long-acting beta-agonist plus a medium-dose inhaled steroid is the preferred therapy for all age groups. The substitute drug for ages 5-11 as well as persons 12+ years, is a mixture of a leukotriene blocker and a medium-dose inhaled steroid. In step five, a long-acting beta-agonist plus a high-dose inhaled steroid, as well as omalizumab (if allergies are present), is recommended for individuals aged 12+, while a high-dose inhaled steroid plus either a leukotriene blocker or long-acting beta-agonist is used for kids aged 0-4. On the other hand, for youngsters aged 5-11, a long-acting beta-agonist and a high-dose inhaled steroid is the preferred treatment, with an alternative being a leukotriene blocker combined with a high-dose inhaled steroid. Finally, in step six, individuals aged 12 and above are often prescribed a combination of a long-acting beta-agonist, an oral steroid, and a high-dose inhaled steroid. Similar to step 5, omalizumab is often considered if allergies are in the picture. For kids aged 0-4 and 5-11, only an oral steroid is added to the therapy in step five.
Therefore, since my patient has had just one exacerbation, long-term therapy is being initiated for the first time, and has no interference/limitation with normal activity, she falls under the intermittent category of severity. For that reason, her treatment plan should start from step 1 (administration of short-acting beta-agonists). If a follow-up visit is made within 2-6 weeks and no changes are experienced, therapy must be advanced to the next step (National Asthma Education and Prevention Program, 2007).
Benefits of Stepwise Management in Assisting Patients and Healthcare Providers to gain and maintain Control of Asthma
One benefit of the stepwise approach to the management of asthma is that drugs are deleted or added as the severity and frequency of the patient’s symptoms adjust. Therefore, since the stepwise approach considers the severity of both the risk domain and impairment, it offers a practical and most efficient guide for initiating treatment for individuals not yet enrolled in long-term treatment. Once a medication has been determined, or the individual is already on a long-term therapy plan, the person’s response to treatment will direct treatment decisions (made by nurses or other healthcare providers) about increasing or decreasing drugs, depending on the level of control obtained in both the risk and impairment domains (National Asthma Education and Prevention Program, 2007). In fact, stepwise management, plus the peak flow measurement, serves as the basis or foundation of a patient’s action plan that often offers instructions and information on how to manage and control asthma, including the medicines to take when the symptoms get worse, and what steps to take during an emergency. A peak flow meter is a small device that measures and records air movement out of the airways (Asthma and Allergy Foundation, n.d.). It can detect when airways narrow, which often signifies the onset of an asthma episode, even days before it worsens. It can also help a patient and doctor identify asthma triggers, choose when to seek emergency services, and decide when to increase or add and even stop the medication.
References
Asthma and Allergy Foundation. (n.d.). Asthma action plan. Retrieved from https://www.aafa.org/asthma-treatment-action-plan/
National Asthma Education and Prevention Program. (2007). Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK7222/
Ramsahai, J. M., Hansbro, P. M., & Wark, P. A. B. (2018). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 99(2). https://doi.org/10.1164/rccm.201810-1931CI
Zaidan, M. F., et al. (2020). Management of acute asthma in 2020. JAMA Insights, 323(6), 563-564. doi:10.1001/jama.2019.19987
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Question 
Acute Asthma Exacerbation Medication
My patient is a 26 years old female who has a history of Asthma. She was admitted to the hospital for acute asthma exacerbation
Acute Asthma Exacerbation Medication
- Describe long-term control and quick relief treatment options for the asthma patient from your practice as well as the impact these drugs might have on your patient. Discuss the groups of drugs used to treat asthma. Include counseling points, therapeutic effects, and possible adverse reactions for each group of drugs.
- Explain the stepwise approach to asthma treatment and management for your patient. Discuss the different steps. Review the treatment guidelines for the stepwise approach. Be specific and include lots of details on each step. Then apply it to your patient. You will need to determine which step your patient is currently on and then discuss treatment options to step up or step down. Include follow-up.
- Explain how stepwise management assists health care providers and patients in gaining and maintaining control of the disease. Be specific. In what way would the steps be helpful to you and to the patient? Include information on an asthma action plan and peak flow.