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Asthma

Jul 25, 2019

Asthma is characterized by reversible airflow obstruction, and bronchospasm. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath.

Medications:

Intermittent asthma (symptoms less than 2 days per week)

  • Inhaler Asthalin (Salbutamol 100 mcg per dose) – 2 puffs every six hours (maximum dose – 800 mcg per day) OR
  • Nebulized Asthalin Respirator Solution (Salbutamol 5 mg/ml) adjusted for patient weight – If less than 10 kg – 1.25 mg (0.25 ml); between 10 kg to 35 kg – 2.5 mg (0.5 ml); above 35 kg – 5 mg (1 ml). Dilute in 2 ml normal saline every six hours, delivered over 10 minutes.

Mild persistent asthma (symptoms more than 2 days per week)

  • Respule Budecort (Budesonide 0.5 mg/2ml) by nebulization once a day for up to  8 years.
  • Inhaler Budecort 100 (Budesonide 100 mcg) – 1 puff twice a day for ages 8 – 18 years.
  • Inhaler Budecort 200 (Budesonide 200 mcg) – 1 puff twice a day for adults.
  • Add inhaler Asthalin (Salbutamol 100 mcg per dose) – 2 puffs every six hours (maximum dose – 800 mcg per day)

Moderate persistent asthma (symptoms on a daily basis)

  • Inhaler Maxiflo-125 (Fluticasone 125 mcg, Formoterol 6 mcg) – 1 puff twice a day (for patients above age of 5 years). For patients with contra-indications to Formeterol use Budecort as above.
  • Syrup Montair LC Kid (Montelukast 4 mg/5ml, Levocetrizine 2.5 mg/5ml) – 5 mls  once a day for ages 1 – 5 years.
  • Tab. Montair 5 mg Chewable (Montelukast 5 mg) 1 tablet once a day for ages 6 – 14 years.
  •  Tab. Telekast 10 (Montelukast 10 mg) 1 tablet once a day for age 15 years and older.

Use Asthalin as rescue medicine for asthmatic attacks. Increasing use of Asthalin or usage for more than 2 days per week for symptom relief indicates need to step up treatment.

Moderate to severe persistent asthma (symptoms throughout the day)

  • Inhaler Maxiflo-250 (Fluticasone 250 mcg, Formoterol 6 mcg) – 1 puffs twice a day (for patients above age of 5 years). For patients with contra-indications to Formeterol use Budecort as above.
  • Syrup Montair LC Kid (Montelukast 4 mg/5ml, Levocetrizine 2.5 mg/5ml) – 5 mls  once a day for ages 1 – 5 years.
  • Tab. Montair 5 mg Chewable (Montelukast 5 mg) 1 tablet once a day for ages 6 – 14 years.
  • Tab. Telekast 10 (Montelukast 10 mg) 1 tablet once a day for age 15 years and older.
  • Use Asthalin as rescue medicine for asthmatic attacks. Increasing use of Asthalin or usage for more than 2 days per week for symptom relief indicates need to step up treatment.

Very severe persistent asthma (persistent symptoms throughout the day)

  • Inhaler Maxiflo-250 (Fluticasone 250 mcg, Formoterol 6 mcg) – 2 puffs twice a day (for patients above age of 5 years). For patients with contra-indications to Formeterol use Budecort as above.
  • Tab. Wysolone 10 (Prednisolone 10 mg) – day 1 and 2 – 1 tablet thrice a day; day 3 and 4 – 1 tablet twice a day; day 5 till 7 – 1 tablet once a day.
  • Add Montelukast as mentioned above.
  • Inhaler Asthalin as required (maximum 8 puffs in a day).

Step down plan – Review treatments every 3 to 6 months with a view to stepping down treatment as symptoms improve.

Management of acute severe asthma

  • Oxygen supplement (as tolerated by patient) to achieve saturation more than equal to 90%.
  • Add nebulised Asthalin Respirator Solution (Salbutamol 5 mg/ml) – adults 2.5 to 5 mg every 6 hours and children – 2.5 mg every 6 hours.
  • Add nebulised Ipravent (Ipratropium 250 mcg/ml respirator solution) – for adults – 0.5 mg every 6 hours; for children – 0.25 mg every 6 hours. 
  • Add inj. Deriphyllin (Aminophylline) i.v. – In adults – give 250 mg over 20 minutes and repeat after 30 minutes if necessary. In children – give 3 – 5 mg/kg over 20 minutes as a slow bolus injection or by infusion.
  • Add inj. Primacort 100 (Hydrocortisone 100 mg) i.v. – to be given based on age – less than 1 year – 5 mg 8 hourly; for 1 – 5 years – 50 mg 8 hourly; for 6 – 20 years – 100 mg 8 hourly; for adults – 200 mg stat then 100 mg 6 hourly until clinical improvement.

Once patient improves –

  • Change to oral steroids – tab. Wysolone 10 (Prednisolone 10 mg) – adults 30 – 60 mg daily; Children 1 – 2 mg/kg daily (40 mg maximum dose) for acute phase. Taper off oral steroids over a period of 7 days. Wean off aminophylline and stop in 12 – 24 hours.
  • Reduce frequency of nebulised Asthalin and substitute with inhaled Asthalin after 24 hours.

General advice:

  • Advice weight reduction plan if patient is overweight
  • Avoid allergy triggering foods – milk, eggs, shellfish, peanuts, wheat, soya, food additives
  • Add apples and coffee in limited quantity.
  • Exercises – advice abdomino-thoracic breathing exercises and incentive spiromety.

Investigations:

  • Spirometry – shows small airway obstruction which is reversible on taking bronchodilators
  • CBC – to rule out infection
  • Stool routine and for ova parasites – to rule out hypersensitive bronchi due to worm infestation
  • Chest x ray – to rule out other causes of breathlessness

Referrals:

Consider referring the patient to secondary care and/or respiratory physician if patient fails to respond or in case of clinical deterioration.