IM28.{15-19,21-22} | Obstructive Airway Disease Treatment — Summary & Reflection

KEY TAKEAWAYS

Treatment of obstructive airway disease requires drug selection, device proficiency, exacerbation management, oxygen knowledge, and patient communication.

Pharmacology: SABAs (salbutamol) — relief; LABAs (salmeterol, formoterol) — maintenance (never LABA alone in asthma); SAMAs (ipratropium) — acute COPD; LAMAs (tiotropium) — COPD maintenance; ICS (budesonide, fluticasone) — asthma backbone (anti-inflammatory); LTRAs (montelukast) — add-on, AERD, exercise-induced, rhinitis; theophylline — third-line, narrow therapeutic window.

Stable asthma (GINA): Step 1–2: as-needed ICS-formoterol (preferred reliever). Step 3: low-dose ICS/LABA. Steps 4–5: medium-high dose ICS/LABA ± add-ons ± biologics. Stable COPD (GOLD): Group A: bronchodilator; Group B: LAMA+LABA; Group E: LAMA+LABA ± ICS (if eos ≥300). Plus: smoking cessation, pulmonary rehabilitation, LTOT (PaO₂ ≤55 mmHg), vaccinations.

Acute asthma: O₂ SpO₂ 94–98%; high-dose SABA + ipratropium nebulised; prednisolone 40 mg × 5 days; MgSO₄ IV for life-threatening; escalate to IV salbutamol/aminophylline, NIV, intubation.

AECOPD: Controlled O₂ SpO₂ 88–92% via Venturi mask; salbutamol + ipratropium nebulised; prednisolone 30–40 mg × 5 days; antibiotics if Anthonisen type-1 or requiring ventilation; NIV for pH <7.35 with elevated PaCO₂.

Inhaler technique: pMDI = slow deep breath (with spacer preferred); DPI = rapid forceful breath; check technique at every visit. Oxygen at home (LTOT): ≥15 hr/day; PaO₂ ≤55 mmHg; proven survival benefit. Annual influenza vaccine + pneumococcal vaccine for all OAD patients.

REFLECT

Return to the two patients from the opening hook. The asthmatic woman with correct pharmacology but no inhaler instruction, and the COPD patient receiving optimal treatment but still smoking. Each case represents a different failure mode of treatment delivery — one pharmacological (correct drug, wrong delivery), one motivational (correct drug, unaddressed behaviour). Reflect on this: as a doctor, which part of the treatment encounter do you feel most prepared for — and which most uncertain? What would it take to become as confident and skilled in inhaler counselling and smoking cessation counselling as you are in pharmacology? Consider: the consultation where you demonstrate correct inhaler technique and secure the patient's commitment to a smoke-free day may have more clinical impact than any prescription you write.