How do you treat asthma? Essentially, it’s
via inhalers, 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
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
mainstay 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 asthma anymore, to
get rid of their symptom so they don’t have
asthma symptoms when they’re running for
a bus. They don’t wake up in the middle
of the night 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
for the healthcare services. 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 will
use ventolin salbutamol bronchodilator inhaler
to improve the symptoms for. Because essentially,
bronchodilators don’t treat the cause of
asthma, they treat the symptoms. So, this is a
description of the U.K. 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 whether the
asthma is controlled by the first step, especially
if the lung function shows that there’s
ongoing evidence of airways obstruction with
variable peak flow or an FEV1 lower than predicted
or the best that the patient has ever achieved.
S, for very mild disease, this is asthma which
only occurs very occasionally and can be relieved
easily by salbutamol 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-acting bronchodilator,
and that will 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.
An inhaled corticosteroid means that corticosteroid
is delivered directly to the lung in high
enough doses to settle the lung inflammation,
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
associated with asthma and minimize the symptoms
the patient has. So the step two is to start
an inhaled 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, will be to increase
the amount of inhaled steroid the patient
is taking. So you start over relatively with some
low dose. And then if the patient is still
not well controlled, you increase to a
In addition, we do know that adding in a long-acting
beta-agonist bronchodilator, such as salmeterol
or formoterol is synergistic with inhaled
steroids in improving control of asthma.
So if somebody is still getting symptoms despite
a medium dose with inhaled steroid, then the
addition or long-acting beta-agonist is a
good move and would likely make a substantial
difference to their symptoms. It’s particularly
useful for patients who are waking at night
with cough because the long-acting beta agonist
will cover the period when they’re asleep
and make them less likely to wake up at night
with the cough.
Other medications that could be considered at this
stage are oral theophyllines and leukotriene
inhibitors. An oral theophylline is a tablet,
is a bronchodilator that acts for a different
mechanism to the beta-agonist and is a useful
additional bronchodilator that can be
used in some patients. A leukotriene inhibitor,
leukotrienes are one of the main mediators
of asthma, and the inhibitors can prevent
information due to asthma. And in some patients,
a leukotriene inhibitor has a very beneficial
effect but not all.
Now, an important point about this medication
is that if the patient is well controlled
on a high dose of inhaled steroid, they’ve
had poor control with lots of cough, lots
of breathlessness and wheeze and maybe
an occasional admission to hospital, and
they’re needing quite a high dose inhaled
steroid 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 give up and down
the stepwise model depending on the severity
of the disease. Once it’s being controlled,
they drop down a step or two. And then if
the symptoms returned, they may need to go
back up to the higher step treatment.
Step four is when you’re actually giving
patients triple therapy, essentially they
have an inhaled steroid, they have a long-acting
beta agonist, they may have an oral theophylline,
or we may add instead a long-acting muscarinic
antagonist such as tiotropium or to a leukotriene
inhibitor. And then step five is really very
limited number of patients reach this step.
These has patients who have got poorly controlled
disease and they may need oral 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 that’s
poor controlled, however, we sometimes need
to use a low dose of oral corticosteroids,
prednisolone 5-10 milligrams, for example,
to control their disease. But they are very
much the very severe under the spectrum and
there should be a very limited number of people
who recall oral corticosteroids because the
side effects are very complicated and
So additional treatment considerations. Right, If
the patient loses weight, if they stop smoking,
if they avoid the allergens, then that’s
all going to make the control of the asthma
much better. If they’re working in a job
where they are exposed in occupational trigger,
clearly, it needs to be addressed as well.
There are certain breathing exercises and
psychological input can be beneficial as well.
Of these, probably the most likely and most
important here is to stop smoking. There’s
something very specific about 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 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, then there are various considerations
you can 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 asthma gets a bit better,
they will stop the inhaler corticosteroid,
and guess what, the asthma comes back.
Inhaled corticosteroids take about 10 to 14
days to actually improve asthma control.
It’s actually difficult then for the patient to
associate stopping inhaler with reduced control
of the asthma in some ways because what will
happen is that they will stop the corticosteroid
and it would be a week or two before the asthma
starts kicking off again. So education to
make sure they’re compliant is very important.
The other thing that needs to be checked is
inhaler technique because it’s quite possible
that the inhaler is being used in a way which
means that most of the drug is not being delivered
to the lung. And in that situation, it’s very
easy to resolve a situation with a better
inhaler technique, a different inhaler which
the patient is more able to use or whatever
to make sure they’re actually getting drug
delivery. 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
and is very difficult to deal with because
that’s outside the remit of the doctor.
The patient may have a pet, that are setting
things off, and there may be occupational
asthma that’s been previously unrecognized.
And the last thing to consider is that some patients
who develop a complication of asthma called
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 later talks of this series.
The other treatment considerations are for
patients with very severe disease where they
require oral 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
the asthmatic information in some patients.
And then there’s a a procedure called bronchial
thermoplasty where the smooth muscle discoursing
bronchoconstriction is damaged by applying
heat within the bronchial tree. It's a slightly
unusual sounding treatment. But there are
reasonable data showing that it can be affected
in very selected patients.