What is the treatment for reactive airway disease?

Treatment of Reactive Airway Disease

Short-acting beta-agonists (SABAs) such as albuterol are the first-line treatment for reactive airway disease, with inhaled corticosteroids (ICS) added as controller therapy for persistent symptoms. 1

Pharmacological Management

Rescue Medications

• Short-acting beta-agonists (SABAs):
  • First-line treatment for acute symptom relief
  • Examples: salbutamol (albuterol) or terbutaline
  • Delivery method: Metered-dose inhaler (MDI) with spacer preferred over nebulizer when possible 2
  • Dosing: 2-4 puffs (200-400 μg) every 4-6 hours as needed 2
  • Note: Levalbuterol (R-isomer only) may offer advantages over racemic albuterol in some patients 3

Controller Medications

• Inhaled corticosteroids (ICS):

  • First-line controller medication for persistent symptoms
  • Reduces airway inflammation and prevents exacerbations
  • Should be initiated early when symptoms occur more than once weekly 1
  • Regular use reduces frequency of exacerbations and improves quality of life

• Combination therapy:

  • For inadequate response to single agents, consider:
    • ICS + long-acting beta-agonist (LABA) for persistent symptoms
    • ICS + SABA as needed for symptom relief 4

Treatment Algorithm Based on Severity

Mild Intermittent Symptoms

1. SABA as needed for symptom relief
2. No daily controller medication required

Mild Persistent Symptoms (symptoms >1×/week but <daily)

1. Low-dose ICS as daily controller
2. SABA as needed for breakthrough symptoms
3. Consider leukotriene receptor antagonists as alternative controller 1

Moderate Persistent Symptoms

1. Low to medium-dose ICS + LABA
2. SABA as needed for breakthrough symptoms
3. Consider adding anticholinergics if inadequate response

Severe Persistent Symptoms

1. High-dose ICS + LABA
2. Consider adding anticholinergics (ipratropium bromide)
3. Consider systemic corticosteroids for severe exacerbations
4. Consider referral to pulmonologist

Management of Exacerbations

Mild to Moderate Exacerbation

1. Increase frequency of SABA (4-8 puffs every 20 minutes for first hour)
2. Add oral corticosteroids if no improvement (prednisone 40-60 mg daily for 5-7 days)
3. Continue controller medications at higher doses

Severe Exacerbation

1. Immediate SABA via nebulizer (5 mg salbutamol or 10 mg terbutaline) 2
2. Consider adding ipratropium bromide 500 μg to beta-agonist if inadequate response 2
3. Oxygen therapy to maintain saturation >92%
4. Systemic corticosteroids
5. Consider hospital admission if poor response

Special Considerations

Comorbidities

• Allergic triggers: Consider antihistamines and environmental control measures
• Sinus disease: Treat with appropriate antimicrobials as this can significantly improve reactive airway disease 5
• Heart failure: Cardioselective beta-blockers can be used cautiously in patients with mild to moderate reactive airway disease 6

Monitoring and Follow-up

• Regular assessment of symptom control and lung function
• Spirometry with bronchodilator reversibility testing to confirm diagnosis and assess response
• Adjust therapy based on symptom control and lung function
• Written action plan for all patients

Common Pitfalls

• Overreliance on SABAs without addressing underlying inflammation
• Inadequate inhaler technique leading to poor medication delivery
• Failure to identify and address environmental triggers
• Misdiagnosis of other conditions (COPD, vocal cord dysfunction) as reactive airway disease
• Delayed initiation of controller medications in patients with persistent symptoms

Remember that reactive airway disease is often used as a placeholder diagnosis, and a proper diagnostic workup for asthma should be conducted to ensure appropriate long-term management 1.