TREATMENT OF ACUTE ASTHMA: A New Look at the Old and at the New

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Along with the increasing prevalence of asthma comes an increase in acute asthma flares and asthma morbidity. This is reflected by more than 1.8 million emergency department visits for asthma in the United States annually, leading to nearly 500,000 hospitalizations.26 Of the estimated $6 billion spent yearly for asthma-related expenses, up to 50% goes toward in-patient expenditures.129 Because of the significant morbidity and economic costs, clinicians are constantly searching for new interventions to treat acutely ill patients as well as more effective ways of using existing agents. With most asthma hospitalizations coming from patients treated in the emergency department, more effective treatment strategies are needed to reduce the need for admission. For patients who are more severely ill and whose hospitalization is inevitable, the initial goal may be to prevent further deterioration or even a fatal outcome. This review of managing the acutely ill asthmatic explores the optimal use of agents whose efficacy is well established, highlights controversies regarding existing therapeutic regimens, and identifies newer agents that hold promise.

Section snippets

A WORD ON THE PATHOBIOLOGY OF ACUTE ASTHMA

Although there is limited information describing the pathobiology of acute asthma, abnormal airway narrowing is a fundamental problem. Airway luminal caliber is influenced by smooth muscle constriction, edema of the mucosa, increased mucous production, and plugging with tenacious material. Asthmatic airways are characterized by hyperresponsiveness and the resulting smooth muscle constriction may be directly caused by a variety of stimuli; inflammation and the release of various mediators may

CAVEATS FOR EVALUATING THE LITERATURE

Before considering evidence from the literature that would support a particular treatment strategy, it is important to consider the following points. First, β-agonists provide the most robust and immediate clinical response. Although pathologic changes associated with airway inflammation play an important role in acute and chronic asthma, bronchospasm is characteristic of the acute episode, and β-agonists will provide at least partial relief in most patients. Any treatment regimen therefore

β2-Agonists

β2-Adrenergic receptors play an important role in the regulation of smooth muscle tone and selective β-agonists can reverse bronchospasm regardless of the stimulus. In addition to their bronchodilatory properties, these agents inhibit the release of histamine as well as cholinergic neurotransmission.10 Overall, β-agonists are the mainstay of treatment for acute asthma. They are easy to administer, begin to work almost immediately, have a robust effect, can be given repeatedly, and have few

TREATMENTS TO HASTEN OUTPATIENT RECOVERY AND PREVENT RELAPSE

Therapy for the acutely ill asthmatic who is successfully treated in the emergency department and sent home does not end upon discharge; an important phase of their asthma care just begins. Although emergent treatment may allow enough recovery to prevent hospitalization, severe symptoms may persist for days to weeks after an acute episode. Symptoms may recur or worsen after the patient leaves the emergency department because they no longer have the benefit of highly supervised and aggressive

EMERGENCY DEPARTMENT DISCHARGE ON CONTROLLER AGENTS?

Because many patients who present to the emergency department are not using controller agents at home but, instead, rely on rescue agents to manage their acute and chronic symptoms, the prescription of an agent on discharge that may have both short- and long-term benefits is an attractive option.

Leukotriene-modifying agents have been evaluated for the prevention of relapse among patients with acute asthma who are sent home. In a recently completed multicenter trial of 545 patients discharged

CONCLUSION

Although many agents currently considered mainstays of therapy have been in the clinical arena for many years, their role in optimal treatment strategies, or even usage in the management of acute asthma, have not been clearly defined. This is related to the complex biochemical and pathologic processes underlying the clinical symptoms, the difficulty or inability to identify specific underlying abnormalities in individuals during an acute episode, the heterogeneity of the causes of chronic

SUMMARY

β-Agonists remain the mainstay of therapy for acute asthma and, for most patients, standard doses are acceptable. Although the onset of action of systemic steroids is still not clear, steroids promote recovery and should be given to patients with acute illness. Intravenous magnesium sulfate appears to improve pulmonary function in the most severely ill patients but is not useful in patients with more moderate episodes. Ipratropium bromide is a weak bronchodilator that still needs to be tested

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    Address reprint requests to Robert Silverman, MD, Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, NY 11042, e-mail: [email protected]

    *

    Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park; and Departments of Emergency Medicine, Epidemiology, and Social Medicine, Albert Einstein College of Medicine, Bronx, New York

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