Overview
This lecture reviews the acute and chronic management of asthma and COPD, key drug therapies, and related respiratory conditions in both emergency and maintenance settings.
Acute Asthma Management
- For severe asthma unresponsive to albuterol and ipratropium, consider steroids, magnesium, and epinephrine instead of more beta agonists.
- Excessive beta agonists can increase heart rate and anxiety without improving symptoms.
- Magnesium sulfate IV can be used for refractory asthma to relax airway smooth muscle.
- Epinephrine (inhaled or IM) is effective in severe, refractory asthma, and is guideline-recommended after failed beta agonists.
Chronic Asthma & COPD Management
- Asthma is a reversible obstructive airway disease with immunological or viral triggers, causing airway narrowing and mucus production.
- COPD is commonly caused by chronic smoking; includes emphysema (barrel chest) and chronic bronchitis (productive cough).
- COPD patients may have CO2 retention, especially with chronic bronchitis.
- Smoking cessation is crucial to reduce ongoing lung damage and exacerbations.
Respiratory Drug Therapies
- Anticholinergics/antimuscarinics reduce mucus, inflammation, and relax airways; mainly used for COPD, also helpful in asthma.
- Beta-2 agonists (albuterol, levalbuterol) are first-line for acute asthma/COPD; overuse leads to systemic effects.
- LABAs (long-acting beta agonists) should always be combined with inhaled corticosteroids (ICS) for chronic asthma.
- ICS reduce airway inflammation; essential for persistent asthma and COPD.
- Systemic steroids are used for acute exacerbations; short courses do not require tapering.
- Monoclonal antibodies (mabs) are used for severe, refractory asthma and target immune pathways.
- Theophylline is rarely used due to toxicity risks.
- Inhaled medications reduce systemic side effects but can cause oral/esophageal fungal infections—rinse mouth after use.
Special Respiratory Conditions
- Croup is an acute viral infection causing stridor and barky cough, mainly in children; racemic or regular epinephrine is effective.
- Watch for return of stridor after racemic epinephrine as effects wear off.
Antihistamines
- First-generation antihistamines (e.g., diphenhydramine) cause sedation and anticholinergic effects.
- Second-generation antihistamines are less sedating and are preferred for allergic rhinitis/seasonal allergies.
- Tolerance can develop with chronic antihistamine use.
- Antihistamines are not effective for asthma treatment.
Key Terms & Definitions
- Asthma — Chronic, reversible airway inflammation and constriction, often triggered by allergens or infections.
- COPD — Chronic, irreversible airway obstruction, mainly due to smoking; includes emphysema and chronic bronchitis.
- Beta-2 agonist — Drug class (e.g., albuterol) that relaxes airway smooth muscle.
- Anticholinergic/Antimuscarinic — Drugs reducing mucus/inflammation, primarily for COPD.
- ICS (Inhaled Corticosteroid) — Aerosol steroids for reducing airway inflammation.
- LABA — Long-acting beta agonist for maintenance, always used with ICS in asthma.
- SABA — Short-acting beta agonist (rescue inhaler).
- Monoclonal antibody (mab) — Biologic therapy targeting immune mediators for severe asthma.
Action Items / Next Steps
- Initiate ICS in any patient with persistent asthma; consider starting in ED if not already prescribed.
- Educate patients on inhaler technique and mouth rinsing post-ICS use.
- Ensure access to SABA for all asthma/COPD patients.
- Refer patients for follow-up care and pulmonary rehabilitation as needed.