Asthma Types and Symptoms

• Asthma is a chronic, reversible respiratory disorder where hyperreactive airways lead to episodic destruction and is often underdiagnosed and overtreated
• COPD is a chronic, irreversible respiratory disease with progressive airflow obstruction (remodeling) which can be fatal.
• Rhinitis is a chronic respiratory disease with symptoms including red, itchy, watery eyes, and runny nose.
• Airflow obstruction in asthma is caused by bronchoconstriction, contraction of bronchial smooth muscle, inflammation of the bronchial wall, and increased mucous production
• Underlying inflammation in asthma leads to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity

Intermittent Asthma

• Bronchoconstrictive episodes last less than 2 days per week.
• Peak flow or spirometry results are near normal.
• Management includes no daily medications and using SABA for quick relief.

Mild Persistent Asthma

• Bronchoconstrictive episodes last more than 2 days per week, but not daily.
• Peak flow or spirometry results are near normal.
• It is managed with low-dose ICS and SABA for quick relief.

Moderate Persistent Asthma

• Bronchoconstrictive episodes occur daily.
• Peak flow or spirometry results are 60-80% of normal.
• It is managed with low-dose ICS + LABA or medium-dose ICS, and SABA or ICS/formoterol for quick relief.

Severe Persistent Asthma

• Bronchoconstrictive episodes are continual.
• Peak flow or spirometry results are less than 60% of normal.
• Managed with medium-dose ICS + LABA or high-dose ICS + LABA, and SABA or ICS/formoterol for quick relief.
• LABA should not be given alone without a corticosteroid

SABA Kinetics

• Provides quick relief, with symptom onset in 5-30 minutes and duration of 4-6 hours.
• SABAs are used as monotherapy in mild or intermittent asthma or for exercise-induced asthma, and as an adjunct in moderate persistent and severe persistent asthma.
• Albuterol and levalbuterol are types of SABAs.

LABA Kinetics

• LABA causes bronchodilation for at least 12 hours.
• Salmeterol and formoterol are types of LABAs
• LABA is used as an adjunct to ICS in moderate and severe asthma, but never as monotherapy, which is contraindicated, and never for acute relief.

Corticosteroids

• Beclomethasone, budesonide, fluticasone, and mometasone are examples of corticosteroid drugs.
• Corticosteroids are the drug of choice for long-term control of persistent asthma
• They inhibit phospholipase A2 to decrease the release of arachidonic acid, decreasing the inflammatory cascade and reducing hyperresponsiveness of airway smooth muscle.
• Inhaled corticosteroids are preferred to reduce systemic adverse effects, and technique is important.
• Oral/systemic corticosteroids (prednisone, methylprednisolone) are used in severe exacerbations.
• Oropharyngeal candidiasis and hoarseness are adverse effects of ICS and to rinse the mouth out after use to prevent thrush (oropharyngeal candidiasis).
• Osteoporosis, hyperglycemia, hypokalemia, hypertension, peripheral edema, immunosuppression, and increased appetite are adverse effects of systemic corticosteroids.

Leukotriene Modifiers

• Zileuton, zafirlukast, and montelukast are leukotriene modifier drugs.
• Leukotriene modifiers inhibit the production or action of leukotrienes, resulting in decreased inflammation, arteriolar constriction, and mucus production.
• They are second-line for prevention of asthma symptoms and prevention of exercise-induced asthma.
• Increased liver enzymes, headache, and dyspepsia are adverse effects of leukotriene modifiers.

Cromolyn

• Cromolyn inhibits mast cell degranulation and histamine release.
• It is an alternative for mild persistent asthma if the patient can't tolerate ICS.
• Short duration of action limits its use.

Cholinergic Antagonists

• Cholinergic antagonists are short-acting, except for tiotropium.
• Ipratropium is a short-acting cholinergic antagonist.
• Tiotropium is a long-acting cholinergic antagonist
• Ipratropium is used with COPD-asthma overlap syndrome, with SABA in the ER, or when SABA is not tolerated and tiotropium as add on in adults with severe asthma with a history of exacerbations
• Xerostomia and bitter taste are adverse effects of cholinergic antagonists.
• Theophylline is a bronchodilator for chronic asthma.
• It has a narrow therapeutic index, poor adverse effect profile, requires drug level monitoring, and has numerous drug interactions

Monoclonal Antibody Drugs

• Monoclonal Ab drugs are used for severe persistent asthma that is poorly controlled on ICS, LABA, and other standard therapies.
• Omalizumab binds to and inhibits IgE.
• Mepolizumab, benralizumab, and reslizumab are interleukin-5 antagonists
• Use is limited by cost, route, and adverse effects.
• Smoking cessation and pharmacologic therapy to relieve symptoms and slow progression are two main treatments for COPD.

COPD Treatment

• For low-risk patients with fewer symptoms (Group A): SABA or LABA or short-acting anticholinergic or LAMA is the first choice, and escalation involves trying an alternative class.
• For low-risk patients with more symptoms (Group B): LABA or LAMA is the first choice, and escalation involves LABA + LAMA.
• For high-risk patients with fewer symptoms (Group C): LAMA is the first choice, and escalation involves LAMA + LABA or LABA + ICS.
• For high-risk patients with more symptoms (Group D): LAMA + LABA is the first choice, and escalation involves LAMA + LABA + ICS.
• ICS is first-line in asthma, not COPD!
• Long-acting bronchodilators (LABA and LAMA) are first-line for COPD.
• Indacaterol, olodaterol, and vilanterol are LABA drugs taken once daily
• Aformoterol, formoterol, and salmeterol are LABA drugs taken twice daily.
• Aclidinium, tiotropium, glycopyrrolate, and umeclidinium are LAMA drugs.
• SABA is for patients with low risk and fewer symptoms
• Combo LABA and LAMA may be recommended for high-risk patients with more symptoms or if there is an inadequate response to one agent alone
• ICS can be added if FEV1 < 60% predicted, with long-acting bronchodilatory if FEV1

Inhaler Technique

• For Metered Dose Inhalers (MDI): Exhale first, begin to inhale as you press the canister, and continue inhaling throughout actuation.
• For Dry Powder Inhalers (DPI): Puncture the capsule and inhale quickly and deeply to deposit the drug in the lungs.
• Spacers: Spacers are large canisters attached to an MDI that allow large drug particles to drop out and minimizes the amount of drug deposited in the mouth and pharynx and masks can be attached to a spacer for easy delivery to young children.

Allergic Rhinitis

• Allergic rhinitis's pathophysiology involves inflammation of the mucous membranes of the nose, typically caused by inhalation of an allergen, such as dust, pollen, or animal dander.
• Symptoms include sneezing, itchy nose and eyes, watery rhinorrhea, nasal congestion, and nonproductive cough.
• Antihistamines, intranasal corticosteroids, and decongestants are used to treat it.
• Antihistamines block H1 receptors to manage symptoms caused by histamine release.
• Antihistamines are good for preventing symptoms of mild to moderate disease and have a rapid onset of action.
• Second-generation antihistamine agents are preferred
• Intranasal corticosteroids are the most effective agents for allergic rhinitis
• Corticosteroids improve symptoms, such as sneezing, itching, rhinorrhea, and congestion, in 3-36 hours after the first dose.
• Localized adverse effects are adverse effects of intranasal corticosteroids, and to avoid deep breathing while administering.
• Beclomethasone, budesonide, fluticasone, mometasone, and triamcinolone are intranasal corticosteroids.
• Decongestants MoA: Alpha antagonists cause arteriole constriction in the nasal mucosa.
• Intranasal decongestants are limited to phenylephrine and oxymetazoline, and have a rapid onset of action and few systemic side effects.
• Limited use to 3 days leads to rebound congestion, also called rhinitis medicamentosa.

Oral Decongestant

• Pseudophedrine is not recommended because of longer DOA and increased systemic side effects.
• It is also not recommended for the long term treatment of allergic rhinitis.
• A cough due to an underlying infection should not be inhibited, and to identify its cause and treat the cause before treating cough

Opiod Drugs

• Codeine and dextromethorphan are opioid drugs.
• Dextromethorphan decreases the sensitivity of cough centers in the CNS with an addictive potential and poor adverse effect profile
• It is a synthetic derivative of morphine but has less antitussive effects and better adverse effect profile and is best for over the counter
• Benzonatate suppresses the cough reflex peripherally but do not break capsules
• Dizziness, numbness of the tongue, mouth, and throat are adverse effects.

Clinical Scenarios

• For a 26-year-old with moderate persistent asthma using albuterol (SABA) almost daily and experiencing nocturnal awakenings due to coughing 3-4 times per week, treatment should be ICS + LABA.
• For a 65-year-old male with COPD (Group C) using LAMA for maintenance therapy but still having frequent exacerbations, with a PMH of HTN and DM, and eosinophil count of 350 cells/uL, the treatment should be to add a LABA.
• For a 28-year-old male with seasonal allergic rhinitis, sneezing, clear rhinorrhea, nasal congestion, and itchy eyes, using benadryl but feeling too dizzy, and wanting a more effective long-term option, the treatment should start with intranasal fluticasone.
• For a 42-year-old female with moderate persistent asthma using fluticasone/salmeterol (ICS/LABA) via MDI but reporting frequent wheezing and nighttime awakenings, it should be ensure that she use spacer.
• For a 32-year-old woman with severe nasal congestion worsening over the past two weeks and using (oxymetazoline) Afrin but with congestion back and worse than before, the issue is rhinitis medicamentosa.