pulmonary disorders
Asthma
Special Populations
Asthma is difficult to diagnose in infants; thus, under-recognition and undertreatment are common (see also Wheezing and Asthma in Infants and Young Children ). Empiric trials of inhaled bronchodilators and anti-inflammatory drugs may be helpful for both. Drugs may be given by nebulizer or metered-dose inhaler (MDI) with a holding chamber with or without a face mask. Infants and children Children>5 years and adolescents with asthma can be treated similarly to adults except that long-acting muscarinic antagonists are not recommended. Also,zileutonshould only be used in children ≥ 12 years. Children > 5 years of age and adolescents with asthma should be encouraged to maintain physical activities, exercise, and sports participation. Predicted norms for pulmonary function tests in adolescents are closer to childhood (not adult) standards. Adolescents and mature younger children should participate in developing their own asthma management plans and establishing their own goals for therapy to improve adherence. The action plan should be understood by teachers and school nurses to ensure reliable and prompt access to rescue drugs. Cromolyn andnedocromilare often tried in this group but are not as beneficial as inhaled corticosteroids. Long-acting drugs prevent the problems (eg, inconvenience, embarrassment) of having to take drugs at school. About one third of women with asthma who become pregnant notice relief of symptoms, one third notice worsening (at times to a severe degree), and one third notice no change. Gastroesophageal reflux disease (GERD) may be an important contributor to symptomatic disease in pregnancy. Asthma in Pregnancy is crucial because poorly controlled maternal disease can result in increased prenatal mortality, premature delivery, and low birth weight. Asthma drugs have not been shown to have adverse fetal effects, but safety data are lacking. (See also guidelines from the National Asthma Education and Prevention Program,Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment–Update 2004.) In general, uncontrolled asthma is more of a risk to mother and fetus than adverse effects due to asthma drugs. During pregnancy, normal blood PCO2 level is about 32 mm Hg. Therefore, carbon dioxide retention is probably occurring if PCO2 approaches 40 mm Hg. Suspect carbon dioxide retention and respiratory failure in pregnant women with uncontrolled asthma and PCO2 levels near 40 mm Hg. Older patients have a high prevalence of other obstructive lung disease (eg, Chronic Obstructive Pulmonary Disease (COPD) ), so it is important to determine the magnitude of the reversible component of airflow obstruction (eg, by a 2- to 3-week trial of inhaled corticosteroids or pulmonary function testing with bronchodilator challenge). Older patients may be more sensitive to adverse effects of beta-2 agonists and inhaled corticosteroids. Patients requiring inhaled corticosteroids, particularly those with risk factors for osteoporosis, may benefit from measures to preserve bone density (eg, calcium and 