Status asthmaticus therapy

Asthma is a chronic inflammatory disease. Therefore steroids represent the most important and most frequently used medication. Already after the fust treatment, steroids reduce cellular infiltration, inflammation, and the LAR, whereas changes in the EAR require prolonged treatment to lower the existent IgE levels. The mechanisms of steroid actions are complex and only incompletely understood. Besides their general antiinflammatory properties (see chapter glucocorticoids), the reduction of IL-4 and IL-5 production from T-lymphocytes is particularly important for asthma therapy. The introduction of inhaled steroids, which have dramatically limited side effects of steroids, is considered one of the most important advancements in asthma therapy. Inhaled steroids (beclomethasone, budesonide, fluticasone, triamcinolone, momethasone) are used in mild, moderate, and partially also in severe asthma oral steroids are used only in severe asthma and the treatment of status asthmaticus. Minor side effects of most inhaled steroids are hoarseness and candidasis, which are avoided by the prodrug steroid ciclesonide. 

Acute asthma attacks Montelukast is not indicated for use in acute asthma attacks, including status asthmaticus. Advise patients to have appropriate rescue medication available. Montelukast therapy can be continued during acute exacerbations of asthma. 

The corticosteroids are effective in most children and adults with asthma. They are beneficial for the treatment of both acute and chronic aspects of the disease. Inhaled corticosteroids, including triamcinolone ace-tonide (Azmflcort),beclomethasone dipropionate (Beclo-vent, Vancerit), flunisolide AeroBid), and fluticasone (Flovent), are indicated for maintenance treatment of asthma as prophylactic therapy. Inhaled corticosteroids are not effective for relief of acute episodes of severe bronchospasm. Systemic corticosteroids, including prednisone and prednisolone, are used for the short-term treatment of asthma exacerbations that do not respond to (32-adrenoceptor agonists and aerosol corticosteroids. Systemic corticosteroids, along with other treatments, are also used to control status asthmaticus. Because of the side effects produced by systemically administered corticosteroids, they should not be used for maintenance therapy unless all other treatment options have been exhausted. 

Shibata Y, Kukita I, Baba T, Goto T, Yoshinaga T. [A critical patient relieved from status asthmaticus with isoflurane inhalation therapy.] Masui 1993 42(1) 116-19. 

If a patient with bronchial hyperreactivity requires /3-blocker therapy, one of the selective /3i-blockers (e.g., acehutolol, atenolol, metoprolol, or pindolol) should be used at the lowest possible dose. Celiprolol and betaxolol appear to possess greater cardioselectiv-ity than currently marketed drugs. " Fatal status asthmaticus has occurred with the topical administration of the nonselective timolol maleate ophthalmic solution for the treatment of open-angle glaucoma. Early investigations with ophthalmic hetaxolol suggest that it is well tolerated even in timolol-sensitive asthmatics. - ... 

Routine modern therapy of severe exacerbations of asthma includes oxygen in addition to frequent inhalation of p -selective bronchodilators and. frequently, systemic corticosteroids. Therapy of status asthmaticus is more complicated, requiring intubation and respiratory assistance, sedation, parenteral corticosteroids, and bronchodilators. 

The use of subcutaneous sympathomimetic bronchodilator is indicated for the severe asthma attack that requires emergency treatment. Epinephrine and terbutaline are available for subcutaneous therapy and, in usual doses, are comparable in efficacy. By this route, terbutaline appears to be no more 3z selective than epinephrine and is reported to have more adverse effects (22). Aqueous suspension of epinephrine provides a longer duration of action. In status asthmaticus sympathomimetics are often not helpful. Intravenous aminophylline is the basic therapy in this setting. The acute therapy should be instituted with a loading dose, but this should be proportionally reduced if the patient has been on regular theophylline therapy. 

Status asthmaticus not responsive to intravenous amino-phylline and sympathomimetic therapy is an indication for hospitalization. Intravenous aminophylline should be continued, and intravenous corticosteroids may be required in doses equivalent to that described for orally administered prednisone. The intravenous steroid should be limited to five to seven days, and therapy switched to beclomethasone or an alternate-day oral... 

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