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how do we treat asthma essentially it's
viral hairs which inhaler the patient
use depends on which they get on with
there's a huge variety of different
types of inhalers and they all have
their little pros and cons and it
depends really which the patient prefers
it's important that the patient is
compliant with treatment and is
effective at using the inhaler so one of
the major things that a respiratory
physician and the respiratory nurses
need to be sure about and need to teach
the patient about is the inhaler
technique to ensure that they're taking
an adequate amount of drug and it's
reaching the lungs with asthma we use a
stepwise treatment with increasing
levels of severity we use the
increasingly more treatment mostly
that's inhaled but more severe chronic
disease may need oral medication as well
when somebody comes to hospital with an
exacerbation the main death state of
treatment there are nebulized
bronchodilators and we'll discuss that a
little bit more detail later in the talk
so what's the aim of treatment well the
aim of treatment really is for the
patient not to realize they have asked
for anymore to get rid of their symptoms
so they don't have asthma symptoms when
they're running for a bus they don't
wake up the image of like coughing and
they can do whatever exercise they want
to do without feeling that the asthma
might kick off in addition we want to
prevent acute exacerbations we want to
prevent patients having an exacerbation
that means they come into hospital
because that's both life-threatening
inconvenient and unpleasant for the
patient and also expensive to the health
and health care services and in theory
we want to minimize the need for using
bronchodilator
rescue treatment so that we use regular
inhaler to prevent the asthma causing
problems that then the patient we use
evented in us our beauty mode
bronchodilator inhaler to improve the
symptoms for because the century'
bronchodilators don't treat the cause of
asthma they treat the symptoms
so this is a description of the UK
guidelines and really what happens here
is you have a stepwise treatment step
one step two step three step four Step
five and you go up these steps depending
on house on whether the asthma is
controlled by the the first step
especially if the lung function shows
that there's ongoing evidence of Airways
obstruction with variable P flow or an F
even lower than predicted
or the best of the patients have ever
achieved so for very mild disease this
is Aston which only occurs very
occasionally and it's very and can be
relieved easily by our butyl our inhaler
and that's not being used very
frequently I mean less than once a week
for example then you probably can just
give them a short act in bronchodilator
and that would be adequate for treatment
however the majority of patients require
the mainstay therapy for asthma which is
inhaled corticosteroids asthma
inflammation is very easily treatable in
the majority of patients with
corticosteroids and inhaled
corticosteroid means that corticosteroid
is delivered directly to the lung in
high enough doses to settle the lung
information but in low enough doses that
does not get absorbed and there are no
systemic complications or it's unlikely
the patient will develop systemic
complications of steroid inhaler therapy
unless they take very high doses an
inhaled steroid will reverse the
information associative asthma and
minimize the symptoms the patient has so
the step two is to start inhale steroid
now it may be that an inhaled steroid in
itself is not adequate enough to control
the patient's symptoms the next step
actually would be to increase the amount
of in-house steroids the patient is
taken so you start off a relatively low
dose and then if the patient's still not
well controlled you increase to a
moderate dose in addition we do know
that adding in a long-acting beta
agonists bronchodilator
such as soemitro or formoterol he is
scientistic with inhaled steroids and
improving control of asthma
so if somebody's still getting symptoms
despite a medium dose to inhaled steroid
then the addition of a long-acting beta
agonist is a good move and will likely
make a substantial difference to their
symptoms it's particularly useful
patients will wake here at night with
cough because the long-acting beta
agonists will cover the period when
they're asleep and make the mess less
likely to wake up at night with the
cough other medications that could be
considered at this stage are all off the
Orleans and leukotriene inhibitors an
oral feel Flynn is a isn't a tablet that
is a bronchodilator acts for a different
mechanism to the b2 agonists and is a
useful additional bronchodilator that
can be used in some patients a look at
Ryan inhibitor look at Ryan's are one of
the main mediators of asthma and the
inhibitors can prevent information due
to asthma and in some patients a look at
Ryan inhibitor has a very beneficial
effect but not all now an important
point about this medication is that if
the patient's well controlled on a
higher dose of inhaled steroid they've
had porcelain scroll control with lots
of cough lots of breathlessness wheeze
maybe the occasional admission to
hospital and they needing it quite a
high dose in house story to control that
once it's been brought under control in
fact many patients can get away with a
lower dose inhaled steroid so the
patient's treatment may go up and down
this stepwise model depending on the
severity disease once it's been
controlled they drop down a step or two
and then if the symptoms return they may
need to go back up to the higher step
treatment step four is when you're
actually giving patients and triple
therapy essentially they have an inhaled
steroid they have a long-acting beta
agonist they may have an all free
offline or you may add instead a
long-acting muscular antagonists such as
tiotropium or t only coat ryan inhibitor
and then step 5 is really very limited
number of patients reach this step this
is patients who have got poorly
controlled disease and if they may need
oral contrast killers corticosteroids
now we use those very frequently for
exacerbations but only for five days
seven days at a time
for patients with long-term asthma it's
poorly controlled however we sometimes
need to use a low dose of oral
corticosteroids prednisone 5 to 10
milligrams for example to control their
disease but they are very much the very
severe end of the spectrum and there
should be a very limited number of
people who require oral corticosteroids
because the side effects are very
complicated and not good so additional
treatment considerations right
if a patient loses weight if they start
smoking if they avoid the allergen then
that's all going to make the control of
the asthma much better if they're
working in a job where they're exposed
an Occupational trigger clearly there it
needs to be addressed as well there are
certain breathing exercises and
psychological input can be beneficial as
well all these probably the most likely
and most important here is to stop
smoking there's something very specific
about is cigarette smoking that makes
the ability of inhaled steroids to
control asthma much worse so if you
smoke and have asthma then inhaled
steroids essentially are much less
effective than they should be
so not only is it the smoking
stimulating the Airways information and
kicking off the asthma it also prevents
the mainstay of therapy inhaled or
corticosteroids from actually
controlling the disease so smoking and
asthma is a very big problem and
patients who have asthma must be
strongly encouraged to stop smoking so
if somebody has poor control despite
going through the stepwise treatment and
increasing the treatment and they're
still not doing well there are various
considerations you need to think about
the first and the most obvious is are
they actually taking the inhaler do they
fully understand that the inhaler has to
be taken regularly because many patients
will actually take the inhaler regularly
when the Astra gets a bit better they'll
stop the inhaled corticosteroid and
guess what the asthma comes back inhaled
corticosteroids take about 10 to 14 days
to actually improve asthma control and
it's actually difficult then for the
patient to associate stopping the
inhaler with reduced control of the
asthma in some ways because what will
happen is
that there will stop the in-house
corticosteroid and it would be a week or
two before the asthma starts kicking off
again so education to make sure that
compliant is very important the other
thing that needs to be checked is
inhaler technique because it's quite
possible that the inhale has been used
in a way which means that most of the
drug has not been delivered to lung and
in that situation it's very easy to
resolve the situation with a better
inhaler technique different inhaler
which the patient's more able to use or
whatever to make sure they actually
getting drug to different the third
thing to think about are continuing
triggers now we've already discussed
smoking that is the most important
continuing trigger but psychosocial
stress is often a problem it's very
difficult to deal with because that's
outside the remit of the doctor the
patient may have a pet they're setting
things off and there may be occupational
asthma that's been previously
unrecognized and the last thing to
consider is that some patients develop a
complication or asthma could allergic
bronchopulmonary aspergillosis which in
itself leads to poor control of the
disease and it's worth screening in the
patients for that using the blood tests
which are relevant for that and I
discussed this disease in one of the
latest talks of this series the other
treatment considerations are for
patients with very severe disease where
they require all prednisolone there are
some additional treatments that you may
come across one is an antibody treatment
to deplete IgE because the IgE is the
antibody that drives the allergic
response and therefore drives you at the
asthmatic information in some patients
and there's a it can a procedure called
bronchial thermoplasty
where the smooth muscle which is causing
bronchoconstriction is damaged by
applying heat within the bronchial tree
it's a slightly sour unusual sounding
treatment but there are reasonable data
showing that it can be effective in very
selected patients
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