Apparato Respiratorio - Patologia

Asma bronchiale

pag. 2

Terapia inalatoria

Il trattamento per via inalatoria è preferibile alla via sistemica perché permette di ottenere concentrazioni maggiori in loco riducendo gli effetti indesiderati (per approfondire clicca aerosolterapia). La somministrazione per via inalatoria può essere eseguita con diversi sistemi: aerosol dosati, erogatori attivati dal respiro, erogatori di polvere secca e nebulizzatori. Con gli aerosol predosati (MDI) il paziente deve imparare a coordinare l’attivazione dell’inalatore e la manovra inspiratoria. Soprattutto nei bambini e negli anziani il coordinamento dei movimenti può risultare difficile, l’impiego dei distanziatori facilita la manovra e ottimizza l’assunzione del medicamento. Gli erogatori di polvere (DPI) erano poco utilizzati in passato perché poco precisi ed efficaci. Attualmente i nuovi sistemi a disposizione consentono una miglior assunzione del farmaco, hanno la stessa efficacia clinica degli aerosol predosati, con una tecnica di inalazione più semplice. La nebulizzazione è particolarmente utile nei bambini di età inferiore ai 5 anni, negli anziani e nel trattamento di gravi riacutizzazioni asmatiche nelle quali l’insufficienza respiratoria impedisce l’uso di altri apparecchi.

Aerosol predosati (MDI)

Erogatori attivati dal respiro (BAI)

Erogatori di polvere (DPI)

Nebulizzatori

 

Scelta dei farmaci antiasmatici

La terapia si avvale di broncodilatatori, mucolitici, fluidificanti le secrezioni bronchiali, antistaminici e cortisonici. Molti di questi farmaci, soprattutto quelli da assumere per la terapia di fondo, possono essere nebulizzati e quindi inalati per aerosol. I farmaci antiasmatici sono classificati in due categorie:sintomatici e di fondo. E’ importante ricordare che tutte le forme di asma persistente richiedono l’impiego di farmaci di fondo, oltre l’eventuale somministrazione di farmaci sintomatici. Tutte le forme di asma intermittente possono essere trattate con i soli farmaci sintomatici.

a) Farmaci antiasmatici sintomatici

Per quanto riguarda i farmaci sintomatici abbiamo i β2-agonisti inalatori a breve durata d’azione (β2-agonisti short acting ), i glucocorticoidi per via sistemica, gli anticolinergici inalatori  , le aminofilline.

b) Farmaci antiasmatici di fondo

Per quanto riguarda la categoria dei farmaci di fondo la carattereristica che li accomuna  è di mantenere l’asma sotto controllo. Questi sono rappresentati da:

In questo ambito i più importanti sono i  glucocorticoidi per via inalatoria.

 

Terapia dell’attacco acuto di asma

Per quanto riguarda  la terapia dell’attacco acuto questa si basa sull’uso di β2-agonisti a breve durata d’azione per via inalatoria (preferibilmente attraverso un distanziatore) al dosaggio di 2 spruzzi ripetuti ogni 15-30 minuti fino ad un massimo di 3-4 volte, a questo si deve aggiungere la somministrazione di uno steroide sistemico. Attualmente i teofillinici rappresentano una terapia di seconda scelta. I corticosteroidi non hanno un effetto broncodilatante diretto ma agiscono attraverso la riduzione del processo infiammatorio, il tempo di comparsa dell’effetto è ritardato di circa 4 ore dalla somministrazione. I corticosteridi assunti per os hanno la stessa efficacia se somministrati per via endovenosa.

Terapia di mantenimento

Abbiamo già visto in precedenza come i corticosteroidi inalatori ed i beta2-agonisti a lunga durata d’azione rappresentino il cardine della terapia di mantenimento,nella tabella 1 sono riassunte le diverse nozioni.

Farmaci da evitare

I mucolitici per via inalatoria vanno assolutamente evitati perché possono scatenare broncospasmo. Gli antibiotici vanno usati solo in caso di escreato mucopurulento. I  pazienti asmatici devono evitare le cure termali perché possono scatenare l’attacco asmatico, in particolare se le acque contengono zolfo.

 Quiz-Autovalutazione

INDIETRO

 HOME PAGE  

BIBLIOGRAFIA

1.    National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the diagnosis and Management of Asthma. National Institutes of Health pub. no 97-4051. Bethesda, MD, 1997.

2.    Fabbri L., Burge PS, Croonenborg L, et al. On behalf of an International Study Group. Comparison of fluticasone propionate with beclomethasone dipropionate in moderate to severe asthma treated for one year. Thorax 1993; 48.817-23.

3.    Cochrane GM. Compliance in asthma. Eur Respir Rev 1998; 8:239-242.

4.    Horn CR, ClarkTJH, Cochrane GM. Can the morbidity of asthma be reduced by high dose inhaled terapy? A prospective study. Respir. Med 1990; 84: 61-66.

5.    Doull IJM, Freezer NJ, Holgate ST. Growth of-puberal children with mild asthma treated with inhaled beclometasone dipropionate. Am J Respir Crit Care Med 1995; 151:1715-9.

6.    Albazzaz MK, Neale MG, Patel KR. Dose-response study of nebulized nedocromilsodium in exercise induded asthma. Thorax 1989; 44: 816-9.

7.    Barnes PJ Pedersen S, Busse WW. Efficacy and safety of inhaled corticosteroids. Am J Respir Crit Care1998; 157 (suppl. 1):S1-S53.

8.    Woolcock A, Lundback B, Ringdal N, Jacques LA. Comparison of addition of salmeterol to inhaled steroids with doublinng of the dose of inhaled steroid. Am J Respir Crit Care Med 1996;153:1481-8.

9.    Dahl R, Lundback E, Malo JL, et al. A dose-ranging study of fluticasone propionate in adult patients with moderate asthma. Chest 1993;104:1352-8.

10.  Juniper EF, Kline PA, Vanzieleghem MA, Ramsdale EH, O’Byrne PM, Hargreave FE. Effect of long-term treatment with an inhaled corticosteroid (budesonide) on airway hyperresponsiveness and clinical asthma in non steroid-dependent asthmatics. Am Rev Respir Dis 1990; 142:832-836.

11.  Birgs GG, Freeman RK, Yaffe SJ. Drugs in Pregnansy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 2 nd ed.Baltimore, MD: Williams & Wilkins, 1986.

12.  Reed CE. The natural history of asthma in adults: the problem of irreversibility. J Allergy Clin Immunol 1999; 103(4): 539-47.

13.  Jonasson G, Carlsen KH, Sodal A, Jonasson C, Mowinckel P. Patient compliance in a clinica trial with inhaled budesonide in children with mild asthma. Eur Respir J 1999; 14(1):150-4.

14.  Bisgaard H. Role of leukotrienes in asthma pathophisiology. Pediatr Pulmonol 2000; 30(2):166-76.

BIBLIOGRAFIA 1

1. Sears MR. Natural history and epidemiology. In: Fitzgerald JM, Ernst P, Boulet LP, O’Byrne PM, eds. Evidence-based asthma management. Hamilton, BC: Decker; 2001. p. 1-12.

2. Helms PJ. Issues and unmet needs in pediatric asthma. Pediatr Pulmonol 2000;30:159-65.

3. Wilson NM. Wheezy bronchitis revisited. Arch Dis Child 1989;64:1194-9.

4. Abramson MJ, Hensley MJ, Saunders NA, Wlodarczyk JH. Evaluation of a new asthma  questionnaire. J Asthma 1991;28:129-39.

5. Burney PG, Laitinen LA, Perdrizet S, Huckauf H, Tattersfield AE, Chinn S, et al. Validity and repeatability of the IUATLD (1984) Bronchial Symptoms Questionnaire: an international comparison. Eur Respir J 1989;2:940-5.

6. Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999;14:902-7.

7. Juniper EF, Guyatt GH, Cox FM, Ferrie PJ, King DR. Development and validation of the Mini Asthma Quality of Life Questionnaire. Eur Respir J 1999;14:32-8.

8. Jones PW. Quality of life measurement in asthma. Eur Respir J 1995;8:885-7.

9. Killian KJ, Summers E, Watson RM, O’Byrne PM, Jones NL, Campbell EJ. Factors contributing to dyspnoea during bronchoconstriction and exercise in asthmatic subjects. Eur Respir J 1993;6:1004-10.

10. Ryan G, Latimer KM, Dolovich J, Hargreave FE. Bronchial responsiveness to histamine: relationship to diurnal variation of peak flow rate, improvement after bronchodilator, and airway calibre. Thorax 1982;37:423-9.

11. O'Byrne P, Cuddy L, Taylor DW, Birch S, Morris J, Syrotiuk J. The clinical efficacy and cost benefit of inhaled cortiocosteroids as therapy in patients with mild asthma in primary care practice. Can Respir J 1996:3;169-175.

12. van Essen-Zandvliet EE, Hughes MD, Waalkens HJ, Duiverman EJ, Pocock SJ, Kerrebijn KF. Effects of 22 months of treatment with inhaled corticosteroids and/or beta-2-agonists on lung function, airway responsiveness, and symptoms in children with asthma. The Dutch Chronic Non-specific Lung Disease Study Group. Am Rev Respir Dis 1992;146:547-54.

13. Standardized lung function testing. Official statement of the European Respiratory Society. Eur Respir J 1993;16 Suppl:1-100.

14. Standardization of spirometry, 1994 update. American Thoracic Society. Am J Respir Crit Care Med 1995;152:1107-36.

15. Lung function testing: selection of reference values and interpretative strategies. American Thoracic Society. Am Rev Respir Dis 1991;144:1202-18. 16. Quanjer PH, Lebowitz MD, Gregg I, Miller MR, Pedersen OF. Peak expiratory flow: conclusions and recommendations of a Working Party of the European Respiratory Society. Eur Respir J 1997;24 Suppl:2S-8S.

17. Killian KJ, Watson R, Otis J, St Amand TA, O'Byrne PM. Symptom perception during acute bronchoconstriction. Am J Respir Crit Care Med 2000;162:490-6.

18. Kendrick AH, Higgs CM, Whitfield MJ, Laszlo G. Accuracy of perception of severity of asthma: patients treated in general practice. BMJ 1993;307:422-4.

19. Nowak RM, Pensler MI, Sarkar DD, Anderson JA, Kvale PA, Ortiz AE, et al. Comparison of peak expiratory  flow and FEV1 admission criteria for acute bronchial asthma. Ann Emerg Med 1982;11:64-9.

20. Gibson PG, Wong BJ, Hepperle MJ, Kline PA, Girgis-Gabardo A, Guyatt G, et al. A research method to 76 DIAGNOSI E CLASSIFICAZIONE induce and examine a mild exacerbation of asthma by withdrawal of inhaled corticosteroid. Clin Exp Allergy 1992;22:525-32.

21. Sawyer G, Miles J, Lewis S, Fitzharris P, Pearce N, Beasley R. Classification of asthma severity: should the international guidelines be changed? Clin Exp Allergy 1998;28:1565-70.

22. Eid N, Yandell B, Howell L, Eddy M, Sheikh S. Can peak expiratory flow predict airflow obstruction in children with asthma? Pediatrics 2000;105:354-8.

23. Brand PL, Duiverman EJ, Waalkens HJ, van Essen-Zandvliet EE, Kerrebijn KF. Peak flow variation in childhood asthma: correlation with symptoms, airways obstruction, and hyperresponsiveness during long-term treatment with inhaled corticosteroids. Dutch CNSLD Study Group. Thorax 1999;54:103-7.

24. Quackenboss JJ, Lebowitz MD, Krzyzanowski M. The normal range of diurnal changes in peak expiratory flow rates. Relationship to symptoms and respiratory disease. Am Rev Respir Dis 1991;143:323-30.

25. Reddel HK, Salome CM, Peat JK, Woolcock AJ. Which index of peak expiratory flow is most useful in the management of stable asthma? Am J Respir Crit Care Med 1995;151:1320-5.

26. D’Souza WJ, Te Karu H, Fox C, Harper M, Gemmell T, Ngatuere M, et al. Long-term reduction in asthma morbidity following an asthma self-management programme. Eur Respir J 1998;11:611-6.

27. Venables KM, Chan-Yeung M. Occupational asthma. Lancet 1997;349:1465-9.

28. Cockcroft DW, Hargreave FE. Airway hyperresponsiveness. Relevance of random population data to clinical usefulness. Am Rev Respir Dis 1990;142:497-500.

29. O’Byrne P. Bronchial challenges by pharmacologic agents. In: Clark TJH, Godfrey S, Lee TH, Thomson NC, eds. Asthma, 4th edition. London: Arnold; 2000. p. 92-103.

30. Ramsdale EH, Morris MM, Roberts RS, Hargreave FE. Asymptomatic bronchial hyperresponsiveness in rhinitis. J Allergy Clin Immunol 1985;75:573-7.

31. van Haren EH, Lammers JW, Festen J, Heijerman HG, Groot CA, van Herwaarden CL. The effects of the inhaled corticosteroid budesonide on lung function and bronchial hyperresponsiveness in adult patients with cystic fibrosis. Respir Med 1995;89:209-14.

32. Ramsdale EH, Morris MM, Roberts RS, Hargreave FE. Bronchial responsiveness to methacholine in chronic bronchitis: relationship to airflow obstruction and cold air responsiveness. Thorax 1984;39:912-8.

33. Pizzichini MM, Popov TA, Efthimiadis A, Hussack P, Evans S, Pizzichini E, et al. Spontaneous and induced sputum to measure  ndices of airway inflammation in asthma. Am J Respir Crit Care Med 1996;154:866-9.

34. Kharitonov S, Alving K, Barnes PJ. Exhaled and nasal nitric oxide measurements: recommendations. The European Respiratory Society Task Force. Eur Respir J 1997;10:1683-93.

35. Horvath I, Barnes PJ. Exhaled monoxides in asymp-tomatic atopic subjects. Clin Exp Allergy 1999;29:1276-80.

36. Warner JO, Gotz M, Landau LI, Levison H, Milner AD, Pedersen S, et al. Management of asthma: a consensus statement. Arch Dis Child 1989;64:1065- 79.

37. Pullan CR, Hey EN. Wheezing, asthma, and pulmonary dysfunction 10 years after infection with respiratory syncytial virus in infancy. BMJ (Clin Res Ed) 1982;284:1665-9.

38. Sporik R, Holgate ST, Cogswell JJ. Natural history of asthma in childhood--a birth cohort study. Arch Dis Child 1991;66:1050-3.

39. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995;332:133-8.

40. Holt PG, McMenamin C, Nelson D. Primary sensitization to inhalant allergens during infancy. Pediatr Allergy Immunol 1990;1:3-13.

41. Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000;162:1403-6.

42. Stick SM, Arnott J, Turner DJ, Young S, Landau LI, Lesouef PN. Bronchial responsiveness and lung function in recurrently wheezy infants. Am Rev Respir Dis 1991;144:1012-5.

43. Sly PD, Cahill P, Willet K, Burton P. Accuracy of mini peak flow meters in indicating changes in lung function in children with  asthma. BMJ 1994;308:572-4.

44. Eggleston PA. Exercise-induced asthma. In: Tinkleman DG, Naspitz CK, eds. Childhood asthma: pathophysiology and treatment. New York: Marcel Dekker; 1992. p. 429-46.

45. Dow L. Asthma in older people. Clin Exp Allergy 1998;28 Suppl 5:195-202, discussion 3-5. DIAGNOSI E CLASSIFICAZIONE 77

46. Tracey M, Villar A, Dow L, Coggon D, Lampe FC, Holgate ST. The influence of increased bronchial responsiveness, atopy, and serum IgE on decline in FEV1. A longitudinal study in the elderly. Am J Respir Crit Care Med 1995;151:656-62.

47. Paggiaro PL, Dahle R, Bakran I, Frith L, Hollingworth K, Efthimiou J. Multicentre randomised placebo-controlled trial of inhaled fluticasone propionate in patients with chronic obstructive pulmonary disease. International COPD Study Group [published erratum appears in Lancet 1998;351:1968]. Lancet 1998;351:773-80.

48. Tarlo SM, Boulet LP, Cartier A, Cockcroft D, Cote J, Hargreave FE, et al. Canadian Thoracic Society guidelines for occupational asthma. Can Respir J 1998;5:289-300.

49. Chan-Yeung M, MacLean L, Paggiaro PL. Follow-up study of 232 patients with occupational asthma caused by western red cedar (Thuja plicata). J Allergy Clin Immunol 1987;79:792-6.

50. Harju T, Keistinen T, Tuuponen T, Kivela SL Seasonal variation in childhood asthma hospitalisations in Finland, 1972-1992. Eur J Pediatr 1997;156:436-9.

51. Mitakakis TZ, Tovey ER, Xuan W, Marks GB. Personal exposure to allergenic pollen and mould spores in inland New South Wales, Australia. Clin Exp Allergy 2000;30:1733-9.

52. O’Hollaren MT, Yunginger JW, Offord KP, Somers MJ, O’Connell EJ, Ballard DJ, et al. Exposure to an aeroallergen as a possible precipitating factor in respiratory arrest in young patients with asthma. N Engl J Med 1991;324:359-63.

53. Boulet LP, Cartier A, Thomson NC, Roberts RS, Dolovich J, Hargreave FE. Asthma and increases in nonallergic bronchial responsiveness from seasonal pollen exposure. J Allergy Clin Immunol 1983;71:399-406.

54. Corrao WM, Braman SS, Irwin RS. Chronic cough as the sole presenting manifestation of bronchial asthma. N Engl J Med 1979;300:633-7.

55. Gibson PG, Dolovich J, Denburg J, Ramsdale EH, Hargreave FE. Chronic cough: eosinophilic bronchitis without asthma. Lancet 1989;1:1346-8.

56. Irwin RS, Curley FJ, French CL. Chronic cough. The spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Am Rev Respir Dis 1990;141:640-7.

57. Mok Q, Piesowicz AT. Foreign body aspiration mimicking asthma. Intensive Care Med 1993;19:240-1.

58. Place R, Morrison A, Arce E. Vocal cord dysfunction. J Adolesc Health 2000;27:125-9.

59. Bousquet J, Chanez P, Lacoste JY, Barneon G, Ghavanian N, Enander I, et al. Eosinophilic inflammation in asthma. N Engl J Med 1990;323:1033-9.

60. Cockcroft DW, Swystun VA. Asthma control versus asthma severity. J Allergy Clin Immunol 1996;98:1016-8.

61. Strunk RC. Identification of the fatality-prone subject with asthma. J Allergy Clin Immunol 1989;83:477- 85.

62. Jalaludin BB, Smith MA, Chey T, Orr NJ, Smith WT, Leeder SR. Risk factors for asthma deaths: a populationbased, case-control study. Aust N Z J Public Health 1999;23:595-600.