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A Shift in Asthma Strategy

A Shift in Asthma Strategy

They say “nothing stays the same” and as I keep aging, I couldn’t agree more! Change is always occurring in medical guidelines as well.  What I’d like to address here is how this applies to asthma therapy. 

For quite some time now, the standard of care for asthmatics has been to have both a rescue inhaler and a maintenance inhaler.  The majority of rescue inhalers use albuterol, a bronchodilator, which relaxes airway smooth muscles that are constricted.  The benefit is brief, lasting 3 to 6 hours, and the medication does not address the underlying inflammation which is the cause of the muscle constriction, that’s where a maintenance inhaler comes in.  Most maintenance inhalers are either single entity topical steroid or a combination steroid and long-acting bronchodilator. 

Overuse of albuterol is associated with excess risk for severe asthma exacerbations and even death.  Globally the majority of asthma related deaths are due to this scenario.  And a contributing cause is the cost of different inhalers: albuterol being relatively inexpensive while maintenance inhalers being expensive. 

This has led the Global Initiative for Asthma (GINA) to a new guideline that adds a topical steroid to all albuterol inhalers.  So far, the United States has not adopted this strategy.  Multiple international studies have documented a major improvement in patient outcomes with this approach:  marked reduction in the need for systemic steroids (oral or injected), reduced visits to emergency departments, reduced hospitalizations and reduced death. 

Mastering asthma rescue dose technique a ‘must’

Mastering asthma rescue dose technique a ‘must’

Dear Dr. K: How can I be sure my four-year old asthmatic daughter actually gets her rescue inhaler dose?

That is an excellent question and one that all parents of asthmatics should ask themselves.

There are actually several ways to answer your question. On a very practical level, if the symptom you were treating (cough, wheeze, shortness of breath) goes away within a few minutes of the treatment, then most likely, your daughter got the medicine and it helped. Also, most of the rescue medicines have mild side effects, especially increasing the heart rate and causing a slight hand tremor.

You could check her pulse before and after the inhalations to see any change.

Your best bet to ensure medicine delivery is to use proper technique. Most research studies looking into whether or not parents use proper technique reveal that only about 10 percent are doing everything right.

The crucial steps include:

  1. 1.  Shake the inhaler before use.
  2. 2.  If the inhaler is new “out of the box,” be sure the indicated priming has been done.
  3. Make sure a good seal is made with the spacer.

              a. For young children the spacer has a face mask that covers the nose and mouth.

              b. For somewhat older children the seal is made by ensuring the lips cover the mouthpiece.

  1. 4.  Do one puff at a time.
  2. 5.  Have the child exhale first, then deliver puff.
  3. 6.  Take six slow, deep breaths for the first puff.
  4. Wait 30 seconds between puffs.
  5. Then repeat steps 5 and 6. If you’re still not sure, bring your spacer and medicine to the next visit with your pediatrician, pulmonologist or allergist, for a critique of your technique.