Step№4 – Severe persistent BA

Treatment: symptomatic therapy plus one or more controlling medicines. Combined intaking of inhalation GCS in average – high daily doses with inhalation prolonged β 2-agonists (it may be in one preparation) has the advantages.

If efficiency is not enough leucohienes modificators and/or prolonged xantines may be prescribed. If it is necessary at severe non-controlled BA with everyday limiting of activity and frequent exacerbations oral GCS are prescribed supplementary in minimal doses which allow to achieve effect.

When high doses of inhalation GCS are prescribed after oral GCS, monitoring of adrenocortical insufficiency symptoms is necessary.

At severe BA with high 1gE level prescribing of recombinant human anti 1gE antibodies is effective.

At low GCS clinic-functional effect, their expressed system side effects, absence of effect of other medicines.

Sparring therapy is prescribed with using of immunesuppressors (methotrexat, cyclosporine A, preparations of gold).

At that their efficiency is estimated in test course. Although, that treatment has low effectiveness, and side effects, which may by more severe, in comparison with side effects of steroids.

Steroid-sparring therapy may be used only if its advantage in BA treatment is proved. Patient should be informed about risk and advantages of the treatment, and the therapy should be conducted under observation of specialists, which have experience of such therapy and monitoring of the patient’s general condition. It is necessary to remember, resistant to treatment persistent BA may be the precursor of non-diagnosed, dangerous for life diseases (system vasculitis) which require for proper treatment schemes.

Steps for achievement and keeping up of the control of the BA

If control of disease motion is achieved for a period of 3 months, using scheme which corresponds with the determined at patient control step, it is possible to reduce supporting therapy, to use treatment of lower step, that allows to determine minimal necessary to keep up control volume of treatment.

If proper control at clinical symptoms is not achieved using prescribed treatment, you should use the next higher classification step of the scheme, at first having insured oneself that patient fulfilled right doctor’s prescription.

It is necessary to inform a patient about early symptoms of BA exacerbation, teach him to control his condition, to conduct peakflowmetry. To form rules of behavior, which may prevent undesirable outcomes of their violation.

Treatment efficiency criteria: disease control achievement.

Treatment duration: basic therapy is conducted unceasing.

BA exacerbation

BA exacerbation – episodes of progressive laboured breathing, cough, whistling breathing, chest constraint, or combination of this symptoms, is characterized by decrease of air slow at exhalation (PVES, FEV 1.0).

4 stage of exacerbation are distinguished: mild moderate severity, severe and danger of respiratory standstill. Mild and moderate severity disease may be treated in the out patient setting.

If the patient gives response on increasing of treatment intensity, there is no necessity in treatment at emergency department. The patient remains under physician control. Teaching of the patient is recommending therapy reconsideration. Severe exacerbations potentially are dangerous for patient’s life, their treatment demands medical monitoring, such patients must be treated in the hospital.

It is necessary to monitor clinical symptoms, objective sighs, stabilization or returning to functional index (PVES, FEV 1.0) best for patient.

Initial therapy at ambulatory stage: increase of inhalation β ₂-agonists dose: 2-4 inhalations every 20 minutes during the first hour.

After that dose taking into attention patient’s individual response and severity of exacerbation must be reconsidered.

Intaking of dosed inhalator or using spacer or nebulization

If the patient gives complete response on bronchi spasmolytic therapy (PVES increases > 80% or proper or best for the patient and last to 3-4 hours) it is not needed to introduce other medicines.

At noncomplete response: to continue inhalation β ₂-agonists taking 6-10 inhalations every 1-2 hours;

to add oral GCS (0, 5-1 mg/kp of prednisolone or equivalent doses of other oral GCS for 24 hours).

Inhalation cholinolitics:

It is possible to take combined form inhalation cholinolitics plus β 2-agonists; consult a doctor)

At low effect:

To continue taking of inhalation β 2-agonists – to 10 inhalations (better using spacer) or complete doses with less then 1 hour interval nebulization; to add inhalation cholinolitics, it is possible to use combined forms: inhalation cholinolitics + inhalation β 2-agonists to add oral GCS, to take an immediate medical advice, call an ambulance.

Severe exacerbations are dangerous for patient’s life and should be treated at emergency department

Ininial treatment:

- Oxygenetherapy

- Inhalation β ₂-agonists of short action constantly during 1 hour (nebulization is recommended);

- System GCS

Secondary estimation with therapy correction is 1 hour: if exacerbation corresponds to moderate severe stage:

- Oxygenetherapy

- Inhalation β ₂-agonists + cholinolitics

- system GCS

Next estimation in 1-2 hours:

At good effect: during 1-2 hours after the last manipulation patient may be discharged.

At home: - to continue treatment by β ₂-agonists;

- Oral GCS are recommended in most cases;

- Combined inhalators are recommended;

- Teaching of the patient (how to take medicines reconsideration or individual treatment plan, active medical observation)

At non complete response:

- Oxygenetherapy

- Inhalation β ₂-agonists + cholinolitics

- system GCS

- Intravenous xantines

- Monitoring of: PVES, O₂ saturation in arterial blood (SaO₂), Pulse.

If therapy is not effective during 1-2 hours:

Treatment in the intensive care department:

- Oxygenetherapy

- Inhalation β ₂-agonists + cholinolitics

- intravenous GCS

- Parenteral β ₂-agonists

- Intravenous xantines

- Intubation and artificial pulmonary ventilation

Prognosis:

Most patients with asthma adjust well to the necessity for continued medical treatment throughout life Inadequate control or persistent aggravation by unmodified environmental conditions favors the development of incapacitating or even life threatening complications