Asthma Health Article

Managing asthmatic attacks

A severe asthma attack should be treated as quickly as possible. It is most important for a patient suffering an acute attack to be given extra oxygen. Rarely, it may be necessary to use a mechanical ventilator to help the patient breathe. A beta-receptor agonist is inhaled repeatedly or continuously. If the patient does not respond promptly and completely, a steroid is given. A course of steroid therapy, given after the attack is over, will make a recurrence less likely.

Maintaining control

Long-term asthma treatment is based on inhaling a beta-receptor agonist using a special inhaler that meters the dose. Patients must be instructed in proper use of an inhaler to be sure that it will deliver the right amount of drug. Once asthma has been controlled for several weeks or months, it is worth trying to cut down on drug treatment, but this must be done gradually. The last drug added should be the first to be reduced. Patients should be seen every one to six months, depending on the frequency of attacks.

Starting treatment at home, rather than in hospital, makes for minimal delay and helps the patient to gain a sense of control over the disease. All patients should be taught how to monitor their symptoms so that they will know when an attack is starting, and those with moderate or severe asthma should know how to use a flow meter. They should also have a written "action plan" to follow if symptoms suddenly become worse, including how to adjust their medication and when to seek medical help. If more intense treatment is necessary, it should be continued for several days. Over-the-counter "remedies" should be avoided. When deciding whether a patient should be hospitalized, the past history of acute attacks, severity of symptoms, current medication, and whether good support is available at home all must be taken into account.

Referral to an asthma specialist should be considered if:

• there has been a life-threatening asthma attack or severe, persistent asthma
• treatment for three to six months has not met its goals
• some other condition, such as nasal polyps or chronic lung disease, is complicating asthma
• special tests, such as allergy skin testing or an allergen challenge, are needed
• intensive steroid therapy has been necessary

Special populations

INFANTS AND YOUNG CHILDREN. It is especially important to closely watch the course of asthma in young patients. Treatment is cut down when possible and if there is no clear improvement, some other treatment should be tried. If a viral infection leads to severe asthmatic symptoms, steroids may help. The health care provider should write out an asthma treatment plan for the child's school. Asthmatic children often need medication at school to control acute symptoms or to prevent exercise-induced attacks. Proper management will usually allow a child to take part in play activities. Only as a last resort should activities be limited.

THE ELDERLY. Older persons often have other types of obstructive lung disease, such as chronic bronchitis or emphysema. This makes it important to know to what extent the symptoms are caused by asthma. Giving steroids for two to three weeks can help determine this. Side-effects from beta-receptor agonist drugs (including a speeding heart and tremor) may be more common in older patients. These patients may benefit from receiving an anti-cholinergic drug, along with the beta-receptor agonist. If theophylline is given, the dose should be limited, as older patients are less able to clear this drug from their blood. Steroids should be avoided, as they often make elderly patients confused and agitated. Steroids may also further weaken the bones.

Prognosis

Most patients with asthma respond well when the best drug or combination of drugs is found, and they are able to lead relatively normal lives. More than half of affected children stop having attacks by the time they reach 21 years of age. Many others have less frequent and less severe attacks as they grow older. Urgent measures to control asthma attacks and ongoing treatment to prevent attacks are equally important. A small minority of patients will have progressively more trouble breathing and they run a risk of going into respiratory failure and they must receive intensive treatment.