Bronchodilators

BRONCHODILATORS

Bronchodilators, such as inhaled albuterol, are rapidly effective, safe, and inexpensive. Patients with only occasional symptoms of asthma require no more than an inhaled β₂-receptor agonist taken on an as-needed basis. If symptoms require this “rescue” therapy more than twice a week, if nocturnal symptoms occur more than twice a month, or if the FEV₁ is less than 80% predicted, addi-tional treatment is needed. The treatment first recommended is a low dose of an inhaled corticosteroid, although treatment with a leukotriene receptor antagonist or with cromolyn may be used. Theophylline is now largely reserved for patients in whom symp-toms remain poorly controlled despite the combination of regular treatment with an inhaled anti-inflammatory agent and as-needed use of a β₂ agonist. If the addition of theophylline fails to improve symptoms or if adverse effects become bothersome, it is important to check the plasma level of theophylline to be sure it is in the therapeutic range (10–20 mg/L).

An important caveat for patients with mild asthma is that although the risk of a severe, life-threatening attack is lower than in patients with severe asthma, it is not zero. All patients with asthma should be instructed in a simple action plan for severe, frightening attacks: to take up to four puffs of albuterol every 20 minutes over 1 hour. If they do not note clear improvement after the first four puffs, they should take the additional treatments while on their way to an emergency department or some other higher level of care.