Obstructive airway disease from
asthma needs to be distinguished from other causes, classified with regard to clinical pattern, and assessed to identify severity and precipitating factors. Intervention of acute symptoms is most effective with inhaled
sympathomimetic bronchodilators backed up with short courses of high-dose oral
corticosteroids for symptoms that are suboptimally responsive to bronchodilation alone, especially for those patients with a history of emergency care requirements and/or hospitalization. Maintenance
therapy with scheduled daily use of inhaled beta2 agonists,
cromolyn, and slow-release
theophylline can be used prophylactically for patients with
chronic disease. The inhaled beta2 agonists are the most effective therapeutic agents for relieving acute
bronchospasm and for decreasing responsiveness of the airways to specific stimuli such as exercise; however, even the newer agents have sufficiently short duration of effect to limit efficacy for maintenance
therapy.
Cromolyn and slow-release
theophylline are commonly used for chronic
therapy;
cromolyn has the merit of virtually no toxic potential but is less convenient and less likely to be effective, at least for more severe
asthma, than
theophylline.
Corticosteroids uniquely decrease the inflammatory component of
asthma, thereby decreasing or preventing
airway obstruction from mucosal
edema and secretions. Short courses of high-dose oral
steroids without tapering provide useful and safe intervention for acute symptoms, whereas alternate-morning oral use and the new generation of topical inhaled agents provide acceptably safe alternatives for managing
chronic disease not controlled with other measures. Nonpharmacological factors that require therapeutic consideration include environmental factors such as cigarette
smoke and aeroallergens, and general physical conditioning. Compliance with the medical recommendations requires dealing with dysfunctional attitudes and beliefs held by the patient and/or family and the fostering of an internal locus of control by including the patient in the decision-making process.