Asthma

Asthma is primarily an inflammatory disorder of the airway, with inflammation caused by allergens or other stimuli leading to bronchial hypersecretion and bronchospasm.7-10 Airborne substances, such as pollens, dust mites, mold spores, animal dander, and insect waste have been implicated.7-10 Other factors include viral infections, physical activity (exercise-induced asthma), and cold air. In recent decades, environmental and work-related pollutants are becoming increasingly implicated.7-10

Coughing, shortness of breath and wheezing are the sine qua non of asthma.7,8 In a moderate to severe attack, tightness or pain in the chest occurs due to spasm of the bronchial tubes. In severe cases the individual may use the accessory muscles of respiration (sternocleidomastoid, trapezius, and scalenus) and may be found sitting down, leaning forward against a support in order to fix the shoulder muscles so that these accessory muscles may obtain better leverage on the chest wall.7,8

The treatment of asthma is a stepwise approach based on current impairment and the anticipated risk of an acute attack.9,10 In patients with intermittent asthma an inhaled short-acting beta2‑adrenergic receptor agonist such as albuterol is preferred (Step 1).2,3,9,10 For patients with persistent mild asthma, daily medication with low-dose inhaled corticosteroid such as budesonide is preferred (Step 2); montelukast, a cysteinyl leukotriene (CysLT)-receptor antagonist, is an alternative.2,3,9,10

The treatment of patients with persistent moderate asthma is reflected in the recommendations in Steps 3 and 4. Treatment is Step 3 is less aggressive with low-dose inhaled corticosteroid plus an inhaled long-acting, selective beta2‑adrenergic receptor agonist such as fluticasone w/salmeterol or medium-dose inhaled corticosteroid; low-dose inhaled corticosteroid plus montelukast, a cysteinyl leukotriene (CysLT)-receptor antagonist, is an alternative regimen.2,3,9,10

Treatment of persistent moderate asthma in Step 4 is more aggressive with medium-dose inhaled corticosteroid plus inhaled long-acting selective beta2‑adrenergic receptor agonist; or medium-dose inhaled corticosteroid plus montelukast, cysteinyl leukotriene (CysLT)-receptor antagonist, as an alternative regimen.2,3,9,10 Persistent severe asthma (Step 5) is treated with high-dose inhaled corticosteroid plus inhaled long-acting selective beta2‑adrenergic receptor agonist.2,3,9,10

In oral healthcare settings consider strong emotions and stress as potential factors that may precipitate an acute asthma attack during the perioperative period. In susceptible patients metabisulfite, an antioxidizing agent included in local anesthetics to minimize oxidation of the vasoconstrictor, may exacerbate asthma; and NSAIDs such as ibuprofen and naproxen increase endogenous leukotriene concentrations and may precipitate symptoms of asthma (intolerance).

Mild exacerbation of asthma is characterized by dyspnea only with activity. The patient experiences prompt relief with inhaled short-acting beta2‑adrenergic receptor agonist such as albuterol.9 Moderate exacerbation is characterized by dyspnea that interferes with or limits physical activity. The patient experiences prompt relief with inhaled short-acting beta2‑adrenergic receptor agonist and requires routine referral for a medical evaluation.9

Sever exacerbation is characterized by dyspnea at rest that interferes with conversation. The patient experiences partial relief from frequent inhaled short-acting beta2‑adrenergic receptor agonist and should be referred to an emergency room.9 The patient with severe, life-threatening asthma is diaphoretic and is unable to speak because of dyspnea. Frequent inhaled short-acting beta2‑adrenergic receptor agonist provides mild/no relief and the patient requires hospitalization.9