1. Classifications Of Drugs Used To Treat Asthma
   1. Long-Term Control
   2. Quick Relief
2. Drugs Used For Long-Term Asthma Control
   1. Leukotriene receptor antagonists (LRTA)
      1. 2 Subclasses:
         1. enzyme 5-lipoxygenase inhibitor:
            1. Zileuton (Zyflo)
            2. Primary therapeutic effect: Block the effects of leukotrienes in the body, reducing inflammation, bronchoconstriction & mucus production. Adverse effects: headache, nausea, dizziness, insomnia, liver dysfunction.
         2. D4 leukotriene receptor subtype binders:
            1. montelukast (Singulair)
            2. zafirlukast (Accolate)
            3. Primary therapeutic effect: Block the effects of leukotrienes in the body, reducing inflammation, bronchoconstriction & mucus production. Adverse effects: headache, nausea, diarrhea, liver dysfunction.
   2. Mast cell stabilizers
      1. cromolyn
      2. nedocromil
      3. Primary therapeutic effect: Inhibit release of inflammation-producing mediators from MAST cells. Rarely used.
   3. Inhaled corticosteroids
      1. beclomethasone dipropionate (Beclovent)
      2. budesonide (Pulmicort Turbuhaler)
      3. dexamethasone sodium phosphate (Decadron Phosphate Respihaler)
      4. flunisolide (Aerobid)
      5. fluticasone (Flovent)
      6. triamcinolone acetonide (Azmacort)
      7. ciclesonide (Omnaris)
      8. Primary therapeutic effect: Treatment of bronchospastic disorders to control infammatory responses that cause them. Adverse effects: pharyngeal irritation, coughing, dry mouth, oral fungal infections.
   4. Anticholinergic agents
      1. Bronchodilator
         1. ipratropium (Atrovent)
         2. tiotropium (Spiriva)
         3. Primary therapeutic effect: Block ACh receptors, prevent bronchoconstriction, cause airway dilation. Adverse effects: dry mouth/throat, nasal congestion, heart palpitations, GI distress, urinary retention, increased IOP, headache, coughing, anxiety.
   5. Long-acting beta2 agonists (LABA)
      1. Bronchodilator
         1. arformoterol (Brovana)
         2. formoterol (Foradil, Perforomist)
         3. salmeterol (Serevent)
         4. Primary therapeutic effect: prevention or relief of bronchospasm. Adverse effects: insomnia, restlessness, cardiac stimulation, tremor, anginal pain, vascular headache.
   6. Theophylline (Xanthine derivative)
      1. Bronchodilator
      2. Primary therapeutic effect: Increase cAMP levels causing bronchodilation. Adverse effects: nausea, vomiting, anorexia, gastroesophageal reflux during sleep.
   7. Long-acting beta2 agonists in combination with inhaled corticosteroids
      1. Fluticasone/salmeterol (Advair)
      2. Primary therapeutic effect: Combined effects of LABA and corticosteroid drugs. Adverse effects: combined adverse effects of both drugs; of particular concern: oral fungal infections.
   8. Omalizumab (Xolair) (Injection)
      1. Monoclonal antibody antiasthmatic
      2. Primary therapeutic effect: Prevents release of mediators that cause allergic responses. Adverse effects: Anaphylaxis, hypersensitivity reactions.
3. Drugs Used For Quick Relief Of Asthma Symptoms
   1. Systemic corticosteroids
      1. prednisone (oral)
      2. methylprednisolone (intravenous or oral)
      3. Primary therapeutic effect: presumed dual effect of reducing inflammation and enchancing beta agonist activity. Used to treat only acute exacerbations or severe asthma. Adverse effects: adrenocortical insufficiency, increased susceptibility to infection, fluid & electrolyte disturbances, endocrine effects, CNS effects (insomnia, seizures), dermatologic/connective tissue effects (brittle skin, bone loss, osteoporosis & Cushing's syndrome.
   2. Short-acting inhaled beta2 agonists (Rescue agents) (SABA)
      1. Bronchodilator
         1. albuterol (Ventolin)
         2. levalbuterol (Xopenex)
         3. pirbuterol (Maxair)
         4. terbutaline (Brethine)
         5. metaproterenol (Alupent)
         6. Primary therapeutic effect: prevention or relief of bronchospasm. Adverse effects: insomnia, restlessness, cardiac stimulation, tremor, anginal pain, vascular headache.
4. National Institute Of Health (NIH) Recommended Stepwise Therapy For The Management Of Asthma
   1. STEP 1
      1. Short-acting inhaled beta2 agonist as needed
   2. STEP 2
      1. Preferred: low-dose inhaled corticosteroid (ICS)
      2. Alternative: cromolyn, nedocromil, leukotriene receptor antagonist (LRTA), or theophylline
   3. STEP 3
      1. Preferred: low-dose ICS and long-acting beta2 agonist (LABA) or medium-dose ICS
      2. Alternative: low-dose ICS and either LRTA, theophylline or zileuton
   4. STEP 4
      1. Preferred: medium-dose ICS plus LABA
         1. Goals of Therapy:
      2. Alternative: medium-dose ICS plus either LTRA, theophylline or zileuton
   5. STEP 5
      1. High-dose ICS and LABA, and consider omalizumab for patients with allergies
   6. STEP 6
      1. High-dose ICS and LABA and oral corticosteroid, and consider omalizumab for patients with allergies
5. Potential Nursing Diagnoses
   1. Impaired gas exchange related to pathophysiologic changes caused by respiratory distress
   2. Fatigue related to the disease process and lack of oxygen saturation
   3. Noncompliance with the medication regimen related to undesirable adverse effects of drug therapy
6. Goals of Therapy: Asthma Control
   1. Minimal or no chronic symptoms (day or night)
   2. Minimal or no exacerbations
   3. No limitations on activities (no missed school or work)
   4. Maintain (near normal pulmonary function)
   5. Minimal use of short-acting beta2 agonist
   6. Minimal or no adverse effects from medications
7. Medication Teaching Tips
   1. Beta Agonists
      1. Provide instructions about the proper use of MDIs & dry powder inhalers
      2. Emphasize importance of not overusing the medication due to risk of rebound bronchospasm
   2. Xanthines
      1. Educate patients about interactions between xanthines and smoking and charcoal-broiled foods
      2. Instruct patients to decrease caffeine intake due to increased CNS effects
      3. Instruct patients how to take their pulse rate
   3. Anticholinergics
      1. Instruct patients that ipratropium is used prophyllactically and must be taken as ordered and generally year round to be effective
      2. Encourage forcing fluids unless contraindicated to decrease viscosity of secretions and increase expectoration
      3. Instruct patient to take no more than prescribed number of puffs in inhaler forms of the drugs (and all other inhaler respiratory drugs)
      4. Assess for the need for a spacer, instruct the patient on how to clean and store the inhalers properly
   4. Leukotreine Receptor Antagonists
      1. Educate patients on action and purpose of LRTAs
      2. Emphasize that they are indicated for prevention and not treatment of acute asthma attacks
   5. Corticosteroids
      1. If inhaled forms are used, encourage good oral hygeine (mouth rinsing with water) after the last inhalation
      2. Instruct the patient in how to clean the inhaler, including a weekly wash with soap & water
      3. Remind the patient of the increased risk of oral fungal infections when good hygeine is not practiced
      4. Instruct the patient to keep track of the number of doses left in the MDI so they can obtain a refill before running out
      5. Educate the patient about the risk for Addisonian crisis if corticosteroids are abruptly stopped and the importance of weaning off to prevent this
   6. General Tips
      1. Remind the patient to check expiration dates
      2. Encourage them to keep a journal (including medications, effects, asthma symptoms)
      3. Counsel the patient to wear a med alert bracelet and keep a medication card as well as emergency contact number list
      4. Educate the patient about the risk for Cushing's syndrome and the signs & symptoms
8. Prevention Tips
   1. Know your "triggers" and avoid them!
   2. Minimize exposure to irritants!
   3. Know how each medication works and when to use them!
   4. Know the signs & symptoms of an asthma attack & when (and how) to take rescue action!
   5. Keep living area clean and free of dust, mites, animal dander and smoke (smoking cessation if smoker or around them)!
   6. Take long-acting preventative asthma medications exactly as prescribed!
9. Signs and Symptoms
   1. Wheezing (inspiratory or expiratory) (recurrent/acute)
   2. Cough (particularly worse at night) (recurrent/acute)
   3. Difficulty in breathing (recurrent/acute)
   4. Chest tightness (recurrent/acute)
   5. Symptoms occur or worsen in the presence of external factors known as "triggers": ie: mold, dust, animal dander, tobacco or wood smoke, weather changes, exercise or at night.
10. Types Of Asthma
    1. Intrinsic
       1. Patients with no history of allergies
          1. Idiopathic in nature
          2. Stress
          3. Respiratory infections (Viral or bacterial)
          4. Cold weather
    2. Extrinsic
       1. Patient is exposed to known allergen, immune response occurs
          1. Cigarette smoke
          2. Animal dander
          3. Dust
          4. Mold
          5. Food allergies
    3. Exercise Induced
    4. Drug Induced
11. What Is Asthma?
    1. Bronchial Asthma
       1. Recurrent and reversible shortness of breath
       2. Bronchospasm
       3. Airway Inflammation and edema
       4. Mucus production
    2. Asthma Attack
       1. Sudden and dramatic episode
       2. Generally short in nature
       3. May be prolonged
       4. At risk for status asthmaticus
    3. Status Asthmaticus
       1. Prolonged asthma attack
       2. May not respond to therapy
       3. Requires hospitalization
12. Patient Education
    1. What is asthma?
    2. Signs and Symptoms
    3. Prevention tips
    4. Medication Teaching Tips