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