Otumdi Omekara, MD., MPAHA MD., MPAHA - Member of Society of Physician Entrepreneurs
Once the diagnosis of bronchial asthma has been made, the physician then has to decide on the most appropriate treatment option based on the specific cause(s). There are at least nine treatment options for bronchial asthma without inhaler:1) IV/IM short-acting beta agonist for quick rescue of mild intermittent attacks; 2) IV/IM low-dose synthetic steroids for quick rescue; 3) IV/IM long-acting beta agonists; 4) mast cell stabilizers; 5) anti-leukotriene or IV low dose long-acting steroids for moderate persistent attacks; 6) IV/IM low to moderate dose long-acting steroids and long-acting beta agonists for moderate persistent attacks; 7) IV/IM high dose long acting steroids with long-acting beta agonists for severe persistent attacks; 8) Trigger identification and elimination through behavior therapy and allergic desensitization through immunotherapy; 9) Antibiotic or antifungal or antiviral therapy to control trigger infections.
Under certain circumstances, it may not be possible for an asthmatic patient to use an inhaler: for instance in a patient with throat cancer or a semi-conscious patient. The choice of medication route under such conditions will be intravenous (IV), intramuscular (IM) or subcutaneous (SC) injection. The second consideration will be which component of the airway targeted.
Most inhalers used to rescue patients from acute exacerbation of asthma, usually target the constricted bronchial muscles to relax them in a matter of minutes. The third consideration will be the classification of the asthmatic attack, whether it is mild intermittent, mild persistent, moderate persistent or severe persistent.
Mild intermittent asthmatic attacks occurring less than twice a week, with less than two night attacks a month, will be treated with IV quick-acting rescuer beta agonist drugs like salmeterol, pirbuterol, or terbutaline. Instead of the usually ipratropium inhaler used to improve the delivery of beta agonist drugs, intravenous anticholinergics like atropine could be administered. IV low dose steroids like hydrocortisone will then complete the quick rescue treatment.
Mild persistent asthmatic attacks occurring more than two to six times a week, with less than two night attacks per month, will be treated with IM low dose steroids like prednisolone, or mast cell stabilizers like cromolyn sodium or, anti-leukotrienes like montelukast and zafirlukast.
Moderate persistent asthma occurring daily with more than one night attack per week will need low to medium dose IM steroids like prednisolone, plus long acting beta agonist drugs like salmeterol and theophylline
For the severe persistent asthma with flares and frequent nighttime symptoms per week, long-acting beta agonist drugs like salmeterol or theophylline is given. IV or IM to keep the bronchi dilated. IV/IM long-acting steroids like prednisolone, to control airway swelling, follow the beta agonist treatment.
For the asthma treatment to be effective, the triggers must be identified and avoided through behavior modification. Aspirin or exercise or cold or dust or smoke sensitive asthmatics must avoid those triggers in their homes of work sites. Allergic desensitization through immunotherapy is needed in allergic asthma. Antibiotics or anti-fungal treatments are added if the trigger is infection.