Assignment: Asthma and Stepwise Management
NURS 6521 Assignment: Asthma and Stepwise Management
Introduction
uAsthma is a chronic respiratory disease
uAssociated with inflammation and bronchospasm
uActs as a source of disease burden
uLowers quality of life of patients
uManaged using pharmacological interventions
uStep-wise approach utilized in chronic cases
Asthma is one of the respiratory problems that can be either acute or chronic in nature. It arises from the exposure to environmental triggers such as allergens. Asthma is characterized by symptoms such as dyspnea, tightness in the chest with wheezing , cough, and cyanosis due to increased bronchospasm, inflammation and production of mucus. Asthma often tends to be recurring in nature. The recurrence makes asthma a critical source of disease burden to the patients. The disease burden is seen from the increased need for frequent hospitalizations, loss of productivity, and high costs incurred in the treatment process. The effects of asthma have a negative effect on patients, hence, lowering their quality of life. Pharmacological interventions however exist for use in the management of asthma. The interventions are classified into those used for quick relief of symptoms or those used for long-term management of asthma. In addition, the step-wise approach has been developed to enhance the outcomes in chronic and recurrent asthma.
Long-Term Treatment
uLong-acting beta agonists (LABA)
uLeukotriene modifiers
uInhaled corticosteroids
uCromolyn
uAnti-IgE medications
The long-term treatment of asthma is achieved with a number of medications. One of them is the long-acting beta-2-agonists (LABA). LABA is a group of medications that work by getting attached to the beta-receptors of the respiratory system to cause extended bronchodilation. The bronchodilation enhances air-flow, dyspnea, chest pain,
Assignment Asthma and Stepwise Management
and minimizes resistance to air flow. The other category of long-term treatment of asthma is the use of inhaled corticosteroids. Inhaled corticosteroids work by suppressing the inflammation of the respiratory muscles. The drugs achieve this outcome by inhibiting histone activation and its correlates that include histone deacetylase 2 that is responsible for airway inflammation. The other category of drugs is leukotriene modifiers. Leukotriene modifiers work by inhibiting mucus production as well as the inflammation of airway muscle. The other category of medications is cromolynes that produce their work by blocking the opening of chloride channels by mast cells. The inhibition of chloride ion
Assignment Asthma and Stepwise Management
channels reverses mucus production and inflammation. The last category of long-term medications used in asthma is the anti-IgE medications. The Anti-IgE medications produce their effect by interfering with the binding of the antigens of the Fc sub-unit to the IgE molecule. The inhibition results in the stabilization of the mast cells as well as mucus production and inflammation of the airways (White et al., 2018). Cromolyn is used as prophylaxis, an inhaler drug that subdues bronchial inflammation
Quick Treatment
uBeta-2-agonists
uTheophylline
uAnti-cholinergic medications
The treatment of asthma can also be achieved using medications that provide quick relief. The medications relief symptoms such as wheezing, chest pains, and difficulty in breathing in asthma patients. One of the categories of asthma medications with quick effect is theophylline. Theophylline produces its effects by relieving bronchospasms as well as the symptoms of asthma. The mechanism of action of theophylline includes the inhibition of phosphodiestarate, which leads to bronchodilation and suppressed hyper-responsiveness of the respiratory system to the allergen. The other group of medications that provide quick relief of asthma symptoms is beta-2-agonists. Beta-2-agonists produce their effect by dilating the bronchioles. They act by activating the beta-adrenergic receptors of the lungs and bronchioles to open the airways. They include medications such as salbutamol and terbutaline. The last category of quick acting asthma medications are the anti-cholinergics. Anti-cholinergics work by preventing acetylcholine from binding to muscarinic receptors. The effect of the inhibition includes prevention of mucus production, bronchospasms, inflammation, and airway remodeling. An example of an anti-cholinergic is Ipatropium bromide (White et al., 2018).
Step-Wise Treatment
uStep 1: short-acting beta-agonist
uStep 2: low-dose inhaled corticosteroids; leukotriene blocker or cromolyn
uStep 3: low-dose inhaled corticosteroid + long-acting beta agonist or medium-dose inhaled steroid alt: low-dose inhaled steroid + leukotriene blocker
uStep 4: Medium-dose inhaled steroid + long-acting beta agonist Alt: medium-dose inhaled steroid + leukotriene blocker
uStep 5: High-dose inhaled steroid + long-acting beta agonist and omaluzimab if allergies
uStep 6: high-dose inhaled steroid + long-acting beta agonist + oral oral steroid plus omaluzimab if allergies
The step-wise treatment is an evidence-based approach used in the management of asthma. The management begins at step 1 and ends in step 6. The management is in ascending manner in case of unresponsiveness to treatment and descending if the patient improves in symptoms. Step 1 of the stepwise treatment of asthma entails the use of short-acting beta-agonists. The use of short-acting beta-agonists is recommended for patients of all ages. Step 2 of the management entails the use of low-dose inhaled steroid as a preferred treatment. An alternative is the use of leukotriene blockers or cromolyn. For children aged 0-4 years, the management entails referring the patient especially in cases when one is doubting the diagnosis. In step 3, the management of children aged 12 years and above entails the use of low-dose inhaled steroid with long-acting beta agonist or medium-dose inhaled steroid. The alternative entails the use of low-dose inhaled steroid + leukotriene blocker. The management of children aged 5-11 years in this step entails the use of low-dose inhaled steroid + long-acting beta agonist or leukotriene blocker or medium-dose inhaled steroid. For children aged 0-4 years, the management entails medium-dose inhaled steroid plus referral (Beasley et al., 2020).
The management in step 4 in 12 year old and above entails the use of medium-dose inhaled steroid + long-acting beta agonist as the preferred treatment. The alternative entails the use of medium-dose inhaled steroid + leukotriene blockers. Similar management is used in children aged 5-11 years. For 0-4 year-olds, the treatment entails the use of medium-dose inhaled steroid + either long-acting beta-agonist or leukotriene blocker. The step 5 management of 12 year olds and above entails the use of high-dose inhaled steroid + long-acting beta agonist and consideration of omaluzimab in case of allergies. For 5-11 year olds, the preferred treatment entails the use of high-dose inhaled steroid + long-acting beta agonist. The alternative entails the use of high-dose inhaled steroid + leukotriene blocker. For 0-4 year-olds, the management entails the use of high-dose inhaled steroid + long-acting beta-agonist or leukotriene blocker. For step 6, 12 year-olds and above are managed using high-dose inhaled steroid + long-acting beta agonist+ oral steroid and consideration of omaluzimab in case of allergies. For those aged 5-11 years, the preferred treatment is high-dose inhaled steroid + long-acting beta agonist with the alternatives being high-dose inhaled steroid + leukotriene blocker + oral steroid. For 0-4 year-olds, the treatment entails the use of high-dose inhaled steroid + either long-acting beta-agonist or leukotriene blocker + oral steroid (Bernstein & Mansfield, 2019).
Impact of Step-Wise Treatment
uPrevent and reduce impairment
uPrevent recurrent exacerbations
uImproves quality of life
u Promote optimal pulmonary functioning
uPrevents loss of lung function
uMinimize side effects of treatment
The step-wise treatment is associated with a number of benefits to healthcare providers and patients. One of the benefits is that it prevents and reduces the risk of impairment of the airways due to asthma. The effective management of asthma symptoms such as remodeling of the airway prevents impairment, hence, optimal pulmonary functioning. The other benefit is the prevention of recurrent exacerbations. Asthma may be associated with recurrent exacerbations, which affect the integrity of the airways. The step-wise treatment optimizes the management of symptoms and exacerbations to enhance the pulmonary functioning as well as the quality of life for patients. The step-wise treatment also minimizes complications that would otherwise lead to loss of lung function. The stepwise treatment also provides systematic approaches to asthma treatment, which minimizes the side effects of the adopted treatments (Bernstein & Mansfield, 2019).
Conclusion
uAsthma is a chronic respiratory disease
uHas severe impacts on patients
uIncreases the risk of reduced lung function
uStep-wise management is an effective approach
uMinimizes complications of asthma
uImproves quality of life of patients
References
Asthma is a chronic, inflammatory disease which affects the airways. It is associated with various symptoms such as wheezing, difficulty in breathing, chest pain, and cyanosis in severe cases. It is very prevalent in America where 22 million people are affected. The situation raises hospitalization levels to more than 497,000 annually (Kirenga et al., 2018). With such a high number, the country is significantly affected both economically and socially. Many children missed school days due to asthma and some caregivers are also forced to leave work to take care of their sick children. As productivity of the country lowers, a lot of money is used in managing the disease (Rothe et al., 2018). However, treatment options have been improved to address the situation.
Both quick-relief and long control medicines are used in treating asthma. Long-term control medicines (also called controller medicines or maintenance medicines). Long-acting beta-adrenergic (LABA) is one of the quick relief medication used. The LABAs help in providing long-term control of symptoms (Kirenga et al., 2018). Inhaled corticosteroids (ICS) are commonly used as anti-inflammatory drugs because they reduce inflammation caused by a vast diversity of inflammatory mediators (Yawn & Han, 2017). Rothe et al. (2018) highlight omalizumab (Xolair) as the most common Immuno-modulators used to prevent the binding of IgE to its receptor and in turn, inhibit IgE-mediated asthma from cascading before it begins.
STEP 1. Step one and two are recommended for all ages. In asthma treatment, inhaled corticosteroids (ICS) are commonly used as anti-inflammatory drugs because they reduce inflammation caused by a vast diversity of inflammatory mediators (Yawn & Han, 2017). STEP 2. Referrals can be considered for ages between 0-4 (White et al., 2018). This treatment is recommended for patients who show no improvement in step one. The intensity of the medications are increased, and other treatment options are introduced to address the problem. According to Yawn & Han (2017), leukotriene receptor antagonists (LTRAs) are introduced as the alternative category of drugs because they help in blocking leukotrienes from binding to the proinflammatory cells in the airways. Most commonly used LTRAs are montelukast, which is effective in allergic asthma.
STEP 3. According to Yawn and Han (2017), this step applies for ages above 12 years. At this stage, either the ICS dose is increased, or a long-acting beta-adrenergic (LABA) is added. The LABAs help in providing long-term control of symptoms (Kirenga et al., 2018). Some of the most commonly used combinations of LABAs and ICS (ICS/LABA) are fluticasone + salmeterol (available as a dry powder inhaler) and formoterol + budesonide (available as an HFA inhaler) (Yawn & Han, 2017). STEP 4. Applies for ages above 12 years. Also, patients who experience recurring severe exacerbations requiring ED visits, oral prednisone, or hospitalizations should be considered for this step. The same applies for patient of ages between 5 and 11.
STEP 5. Applies for ages above 12 years. For ages between 5-11 years, Rothe et al. (2018) recommends a High-dose inhaled steroid plus long-acting beta-agonist. Alternative can be a High-dose inhaled steroid plus leukotriene blocker. Rothe et al. (2018) highlight omalizumab (Xolair) as the most common Immuno-modulators used to prevent the binding of IgE to its receptor and in turn, inhibit IgE-mediated asthma from cascading before it begins. STEP 6. Applies for ages above 12 years. For age 5-11 years, a High-dose inhaled steroid plus long-acting beta-agonist are preferred. A combination of High-dose inhaled steroid, either long-acting beta-agonist or leukotriene blocker, oral steroid is preferred for age 0-4.
In 2007, the National Asthma Education and Prevention Program (NAEPP) published its third report, which reinforced the guidelines for the Diagnosis and Management of Asthma. According to Rothe et al. (2018), the Expert Panel recommends that asthma therapy should be aimed at maintaining control of the disease with the least amount of medication which, in turn, minimizes the risks for adverse effects. The stepwise approach increases or decreases the dose administered and also changes them and their frequency till the best medication and with its best amount and frequency of dosage is established. Efforts are focused on suppressing inflammation over the long term and preventing exacerbations (Yokoyama & Yokoyama, 2019).
References
uKirenga, B. J., Schwartz, J. I., de Jong, C., van der Molen, T., & Okot-Nwang, M. (2015). Guidance on the diagnosis and management of asthma among adults in resource limited settings. African health sciences, 15(4), 1189-1199.
uRothe, T., Spagnolo, P., Bridevaux, P. O., Clarenbach, C., Eich-Wanger, C., Meyer, F., & Sauty, A. (2018). Diagnosis and management of asthma–the swiss guidelines. Respiration, 95(5), 364-380.
uYawn, B. P., & Han, M. K. (2017, November). Practical considerations for the diagnosis and management of asthma in older adults. In Mayo Clinic Proceedings (Vol. 92, No. 11, pp. 1697-1705). Elsevier.
uWhite, J., Paton, J. Y., Niven, R., & Pinnock, H. (2018). Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE. Thorax, 73(3), 293-297.