Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

Asthma 175

■Immunotherapy (shots) more useful for allergic rhinitis than asthma,

but consider in severe disease

■For refractory disease consider macrolides (putative role of myco-

plasma, chlamydia)

■Monoclonal antibody against IgE promising

■Refer to asthma specialist for life-threatening exacerbation, refrac-

tory symptoms, frequent or continuous steroids

follow-up

■Q 6–12 mo if stable; more frequent if not

■Assess control by:

➣Spirometry or PEF at each visit

➣Rescue medication use

➣Frequency of nocturnal symptoms (ask!)

➣Exercise limitation

➣BID or periodic PEF monitoring in selected patients

complications and prognosis

Complications

■Inhaled steroids:

➣Local (thrush, dysphonia): dose- and technique-dependent; usu-

ally prevented by use of spacer and rinsing mouth

➣Systemic (adrenal suppression, osteoporosis, cataracts, growth

retardation): rare at doses≤400–800 mcg/d; titrate dose down-

ward to minimize risk

■Beta2-agonists:

➣Tremor, tachycardia, hypokalemia (levalbuterol useful if these

are problems)

➣Little evidence for deleterious effects from regular use

■Leukotriene receptor antagonists:

➣Transaminitis uncommon; assess for symptoms at each visit

➣Rare Churg-Strauss syndrome probably reflects unmasking of

preexisting disease

■Respiratory failure:

➣20–30% of near deaths occur in patients thought previously to be

mild

➣Barotrauma major complication of mechanical ventilation; dra-

matically less with permissive hypercapnea

Prognosis

■Normal life expectancy