Asthma is a chronic inflammatory disease for which the airway obstruction, hyper-responsiveness, bronchoconstriction, and mucus secretion are typical symptoms (Bårnes & Ulrik, 2015). Although many treatment options are available to persons who suffer from asthma, this condition still requires the detailed examination as the disease “affects about 300 million people worldwide, causes 250,000 deaths annually” (Olin & Wechsler, 2014, p. 1). To discuss pharmacological and non-pharmacological options to treat individuals with asthma, it is important to focus on a concrete patient situation.
It is necessary to examine the recent literature on treating asthma and select medications appropriate to address symptoms of the disease in an adult patient (21-35 years old), who is interested in physical activities and minor adjustments to a lifestyle. A potential patient suffers from a dry and non-productive cough that can worsen at night. The purpose of this paper is to discuss the pathophysiology of asthma, describe genomic issues, present a review of the literature on the topic, discuss available evidence-based treatment options, describe the most appropriate approach, and propose a follow-up plan.
Pathophysiology of Asthma
Asthma is a heterogeneous disorder, and its pathophysiology depends on a range of factors. Different types of cells mediate an inflammatory process when asthma develops, including T lymphocytes, mast cells, macrophages, and epithelial cells. The inflammation can be a response to allergic and non-allergic factors that differ depending on the participation of IgE antibodies in the process (Maslan & Mims, 2014). Factors that provoke the development of asthma include allergens, air pollution, dust, secondhand smoke, and viral infections. The response to allergic and non-allergic factors is characterized by stimulating the work of mast cells and leukocytosis.
The inflammation leads to changes in airways, and long-term processes result in active mucus production, muscle hypertrophy, and edema. Thus, the subbasement membrane can become thicker, and hyperplasia and hypersecretion can be observed (Olin & Wechsler, 2014). Furthermore, it is possible to observe the airway hyper-responsiveness and bronchoconstriction as processes that follow an inflammatory process. All these processes are associated with clinical symptoms of asthma, and differences in symptoms depend on the severity of the problem. Thus, the pathophysiology of asthma explains such symptoms typical of the disorder as a cough, shortness of breath, and wheezing.
It is also important to note that signs of asthma can be observed in patients of different ages, including children and older people. According to Maslan and Mims (2014), “asthma is the third leading cause of hospitalization among children younger than age 15” (p. 18). Furthermore, asthma is often noticed in young and unmarried males, as it is reported in many studies (Maslan & Mims, 2014; Olin & Wechsler, 2014). Also, the symptoms of asthma usually develop in older people in association with such diseases as Chronic Obstructive Pulmonary Disease and pneumonia.
Genomic Issues Associated with Asthma
Researchers note that asthma can be explained concerning multiple genes, and the genomic features of this disorder are not studied effectively to state what particular genes can cause the development of different subtypes of asthma. It is possible to identify several groups of asthma susceptibility genes that include immunoregulation genes and genes responsible for the Th2 cell differentiation. Also, there are genes responsible for mucosal immunity and genes responsible for the lung function (Maslan & Mims, 2014). Much attention should be paid to fetal programming of genes and environments that influence asthma susceptibility according to the results of recent studies (Maslan & Mims, 2014; Sharma et al., 2014). Still, more research is required to explain how genes interact with different environments to affect asthma susceptibility in individuals.
To find the literature on modern approaches to diagnosing and treating asthma, it was important to search six databases that include peer-reviewed articles on the topic: PubMed, PsycINFO, CINAHL, Ovid MEDLINE, ProQuest, and Google Scholar. The following keywords were used in different combinations to guide and limit the search: “asthma,” “pathophysiology,” “genome,” “treatment,” “pharmacology,” “pharmacological treatment,” “non-pharmacological treatment.” To combine these keywords in phrases appropriate for the search, such Boolean connector as AND was used. The search was also limited to find articles published within the past seven years (2011-2017). As a result, 72 articles directly related to the topic were found and retrieved for further analysis. Among these articles, 20 articles were identified after examining their abstracts as related to the topic and providing the required evidence. The detailed examination of these articles allowed for selecting seven studies for further review in this paper.
Review of Relevant Literature
Recent studies on diagnosing and treating asthma discuss the effectiveness of modern approaches to determining different types of asthma as a heterogeneous disorder and identifying the most appropriate treatment options. In their article, Maslan and Mims (2014) discussed how it is possible to diagnose asthma concerning such symptoms and signs as the airflow obstruction, hyper-responsiveness, and shortness of breath that can be determined after the communication with a patient, physical examination, and a spirometry test. In addition to these traditional examinations, physicians also focus on distinguishing between allergic and non-allergic asthma to prescribe the most effective medication. Maslan and Mims (2014) paid attention to the fact that allergic asthma is typical of young people, and non-allergic asthma is usually observed in older patients. These statements are also supported by other studies on the problem (Olin & Wechsler, 2014; Sharma et al., 2014).
Researchers agree that much attention should be paid to examining asthma phenotypes and endotypes to provide patients with the most relevant medications and treatment plans (Sharma et al., 2014). According to Maslan and Mims (2014), “the asthma phenotype can be quite variable because of complex interactions between the environment and underlying genetic factors” (p. 15). As a result, researchers and clinicians propose to use targeted therapies to address different asthma phenotypes and endotypes.
According to Holgate (2013), traditional inhaled controllers used to address asthma symptoms should be changed with more innovative stratified approaches that are based on proposing a treatment concerning a certain causal pathway associated with asthma subtypes. For instance, specific treatment options should be proposed to address symptoms associated with the T-helper 2 allergic pathway (Holgate, 2013). These treatment options are discussed as targeted ones, and relievers are selected depending on the pathophysiology of a concrete type of asthma. A similarly innovative approach was also discussed by Olin and Wechsler (2014) who noted that the identification of asthma subtypes resulted in developing unique medications that can contribute to addressing the causes of asthma in patients.
However, the problem is that more research is required in this field to study how persons with asthma respond to specific targeted treatments and conclude about significant changes in diagnosing and treating asthma with the help of a stratified approach. Thus, Olin and Wechsler (2014) noted that traditional short-acting beta2-agonists, leukotriene antagonists, and inhaled corticosteroids are still discussed as effective medications to address asthma symptoms and contribute to their decrease. According to the researchers, the regular use of inhaled corticosteroids leads to improving patients’ quality of life and reducing symptoms. The researchers also propose the use of Omalizumab in treating severe forms of asthma (Olin & Wechsler, 2014). These conclusions are also supported by other studies. Bårnes and Ulrik (2015) found that inhaled corticosteroids are important to treat different types of asthma to guarantee long-term positive outcomes. If patients focus on increasing adherence to inhaled corticosteroids (beclomethasone, ciclesonide, mometasone, fluocinonide, and fluticasone), it is possible to expect decreases in symptoms, improvements in the quality of life, and reduced levels of mortality among patients (Bårnes & Ulrik, 2015).
These claims and findings are also supported concerning the studies by Daley‐Yates (2015) and Corrao et al. (2016). According to Daley‐Yates (2015), inhaled corticosteroids should be actively used to treat patients, but much attention should be paid to selecting the dosage to affect the therapeutic index. Traditional divisions into low, mid- and high doses can be viewed as inappropriate to improve the therapeutic index in individuals. In their turn, Corrao et al. (2016) claimed that inhaled corticosteroids are the most relevant choices for treating asthma as they can be used independently and in combination with long-acting beta-agonists to guarantee the highest therapeutic effect. From this perspective, the literature provides insights regarding innovative targeted treatment options and traditional inhaled corticosteroids as approaches to addressing symptoms of asthma in patients. Nevertheless, the reviewed literature does not provide enough information regarding the safety of innovative stratified or targeted treatment options, and it does not include data on possibilities to use these medications to prevent airway remodeling. Further research can be required to address these issues.
The reviewed literature provides guidelines for determining one non-pharmacological and two pharmacological approaches to treating asthma in a patient who suffers from a night cough during several weeks and who plans to continue his physical activity that can be affected by regular asthma attacks.
To address or prevent symptoms of asthma without using medications, it is possible to apply certain techniques. According to the clinical practice guidelines developed by experts of the National Asthma Education and Prevention Program that was supported by the U.S. Department of Health and Human Services and the National Heart, Lung, and Blood Institute, patients with asthma should avoid allergy triggers, including dust, certain foods, animal fur, and secondhand smoke. Furthermore, patients should also pay attention to exercising to develop lung capacity, but exercising will be controlled and planned according to a patient’s needs (National Heart, Lung, and Blood Institute, 2012). Also, it is important to use breathing techniques and exercises that are helpful to prevent and control asthma attacks while guaranteeing a relaxing effect.
According to National Heart, Lung, and Blood Institute (2012), inhaled corticosteroids can be used in a therapy based on one medication when nighttime awakenings are often observed (but not daily), and asthma attacks can be characterized as rare. In this case, short-acting beta2-agonists can be used only in those cases when attacks are associated with exercising or high-stress levels (Bårnes & Ulrik, 2015). Depending on the frequency and severity of asthma symptoms, it is important to propose the use of low-dose inhaled corticosteroids that serve as long-term control medications (Daley‐Yates, 2015). For a patient with the aforementioned symptoms, the use of fluticasone propionate can be recommended. The market name of the fluticasone propionate is Flovent HFA. Thus, a low dosage proposed in the clinical practice guidelines for treating asthma symptoms is 88 mcg or two puffs that are consumed twice a day.
A stratified approach
This treatment is also known as a biopharmaceutical approach, and today the typically used medication for this therapy is Omalizumab (Anti IgE) which is recommended by National Heart, Lung, and Blood Institute (2012) to be applied in moderate and severe cases. This stratified biological therapy can be discussed as targeting immunoglobulin E (IgE). While focusing on this asthmatic phenotype, it is possible to state that positive outcomes are observed in patients who cannot improve with the focus on other therapies and who suffer from an allergic-type of asthma (Olin & Wechsler, 2014). If there is a situation that a patient cannot respond to traditional medications, including inhaled corticosteroids, short-acting beta2-agonists, and long-acting beta2-agonists, Omalizumab can be proposed because of its effects on decreasing symptoms of asthma and preventing exacerbations.
Selected Treatment Approach
While referring to the evidence provided in the reviewed literature on the problem of treating asthma, it is possible to select the first variant of the pharmacological treatment that is based on using inhaled corticosteroids. The reason is that this traditional therapy usually contributes to improving symptoms in patients, and adverse effects are rare if a patient follows all recommendations (Corrao et al., 2016; Daley‐Yates, 2015; Maslan & Mims, 2014). Also, one can start the therapy by using a low and safe dose. In this case, it is possible to prevent all side effects. According to Bårnes and Ulrik (2015), the use of such inhaled corticosteroids as fluticasone propionate (Flovent HFA) is one of the most appropriate options for treating asthma because this medication can guarantee the effective control and prevention of asthma symptoms and night awakenings. Furthermore, Bårnes and Ulrik (2015) noted that the use of fluticasone propionate is associated with decreasing the frequency of asthma symptoms if a patient adheres to the treatment. As a result, the quality of a patient’s life improves.
Thus, for a patient who suffers from a night cough during several weeks, the use of short-acting beta2-agonists is not proposed because these medications cannot prevent asthma attacks (Maslan & Mims, 2014; National Heart, Lung, and Blood Institute, 2012). Furthermore, the use of a biopharmaceutical stratified approach is also not appropriate as there is a lack of evidence to support the effectiveness and safety of this treatment option (Corrao et al., 2016; Olin & Wechsler, 2014). Also, Omalizumab can provoke anaphylaxis as one of its side effects (National Heart, Lung, and Blood Institute, 2012). From this perspective, the use of such inhaled corticosteroids as fluticasone propionate can be discussed as the most effective treatment option for the analyzed disorder.
Follow-Up Treatment and Referrals
A patient should be educated that, during the first two weeks, he or she can observe no changes in his or her state and asthma symptoms. Therefore, the first follow-up session should be planned in about three or four weeks after starting the therapy to conclude about the effectiveness of the selected treatment (National Heart, Lung, and Blood Institute, 2012). If there are no improvements in a patient’s state after two weeks of using fluticasone propionate, a healthcare provider should recommend increasing the dose to 110 mcg per actuation. During the follow-up session, it is important to draw a patient’s attention to the fact that changes in a dose can provoke some side effects, including dry mouth or throat irritation. These symptoms can disappear in several days (Maslan & Mims, 2014). Still, it is important to inform a healthcare provider about the following symptoms: oropharyngeal candidiasis, skin rash, and changes in the heartbeat (Corrao et al., 2016; Daley‐Yates, 2015). Referrals to other specialists, including otolaryngologists, are possible if positive changes in a patient’s state are not observed after three weeks of using fluticasone propionate.
This paper has proposed the evidence-based analysis of such disorder as asthma with the focus on the treatment options to use to address symptoms in a patient who suffers from a dry night cough and who is diagnosed with asthma. Possible treatment options include non-pharmacological techniques and different types of pharmacological therapies. The traditional therapy is based on using inhaled corticosteroids, and modern therapy includes a stratified biological approach. The use of inhaled corticosteroids can be discussed as most appropriate to prevent and control asthma attacks regularly as this approach is evidence-based, and it is actively discussed and justified in the literature.
Bårnes, C. B., & Ulrik, C. S. (2015). Asthma and adherence to inhaled corticosteroids: Current status and future perspectives. Respiratory Care, 60(3), 455-468.
Corrao, G., Arfè, A., Nicotra, F., Ghirardi, A., Vaghi, A., De Marco, R.,… Zambon, A. (2016). Persistence with inhaled corticosteroids reduces the risk of exacerbation among adults with asthma: A real‐world investigation. Respirology, 21(6), 1034-1040.