Internal Medicine

P1: SBT

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

Asthma 173

➣Severe persistent:symptoms continuously; frequently at night;

FEV 1 ≤60%; PEF variability >30%

General Measures

■Therapy aimed at reducing chronic inflammation ubiquitous in

asthma

■Goals: reduce symptoms, prevent exacerbations, normalize pul-

monary function

■Classes of pharmacotherapy:

➣Relievers (albuterol, bitolterol, ipratropium, pirbuterol, meta-

proterenol, terbutaline)

➣Constrollers (inhaled corticosteroids, LTRAs, long-acting beta-

agonists)

Acute Exacerbation of Asthma

What to Do First

■Quick history and physical

■Chest x-ray (only if suspect pneumonia, pneumothorax)

■Assess SaO 2 , PEF, or FEV 1

■Administer oxygen if SaO 2 <93%

■Albuterol MDI or nebulizer q 20–30 min× 4

■Levalbuterol by nebulizer may be useful if beta 2 side effects a

problem

■Ipratropium may add to beta 2 effect

■All patients should receive systemic steroids (oral=IV unless GI

problem)

■Continue inhaled corticosteroid

■PEForFEV 1 to assess response

■Arrange follow-up within 48 h

■Fatigue, altered mental status, PaCO 2 ≥42 suggest respiratory failure

■Intubation, ventilation can be difficult

specific therapy

■Mild intermittent:

➣rescue beta-agonist PRN

■Mild persistent:

➣low-dose inhaled steroid+rescue beta-agonist PRN, or

➣LTRA+rescue beta-agonist PRN

■Moderate persistent:

➣Moderate dose inhaled steroid+rescue beta-agonist PRN, or