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Asthma

Updated : February 15, 2024





Background

Asthma is a chronic inflammatory disease. The severity of asthma varies from a relatively mild, infrequent wheeze to abrupt, life-threatening airway closure. It commonly presents in childhood and is related with characteristics of atopy to hay fever and eczema.

Childhood asthma is a common condition that results in numerous hospital stays and higher healthcare costs. The main characteristic is airway hyperresponsiveness. If left untreated, asthma has a significant fatality rate.

Epidemiology

Asthma affects 15%–20% of people in developed nations and 2–4% in less developed nations. Children are commonly affected. Childhood asthma affects up to 40% of children and is usually reversible. Asthma is more prevalent in populations exposed to cigarette smoke, inhaled particles, and environmental factors.

Asthma is more prevalent in boys during childhood, with a male-to-female ratio of 2:1 until adolescence, then the ratio changes to 1:1. After adolescence, females are more likely to develop asthma, and after age 40, females account for most adult-onset cases.

Due to decreased lung function and airway reactivity, asthma prevalence is higher in older individuals. About 66% of all cases of asthma are diagnosed before the age of 18 years. About 50% of asthmatic children’s symptoms completely resolve after attaining early adulthood.

Anatomy

Pathophysiology

An acute and reversible airway inflammation frequently develops after contact with an environmental trigger. The pathogenic process starts with inhaling an allergen or irritant, such as pollen, which results in airway inflammation and increases mucus production due to bronchial hypersensitivity.

As a result, there is a significant rise in airway resistance, which is most noticeable during expiration. Airway blockage occurs due to inflammatory cell infiltration, hypersecretion with mucus plug development, and smooth muscle contraction.

If asthma is not treated soon, it may deteriorate further because the formation of mucus blocks the inhaled medicine from accessing the mucosa. The swelling from the inflammation becomes worse.

Etiology

Asthma is a disease with a wide range of comprehensive and varied phenotypes. Genetic predisposition, specifically the family history and tendency to allergy, is typically observed as hay fever, eczema, and documented factors associated with asthma.

Asthma has a multi-factorial etiology that is influenced by genetics and environmental exposure, even though the general cause is complicated and still not completely understood, particularly when it comes to predicting that children with pediatric asthma will continue to have asthma in adulthood.

The following factors usually trigger asthma:

  • Tobacco smoke
  • Chronic sinusitis
  • Viral respiratory tract infections
  • Gastroesophageal reflux disease (GERD)
  • Obesity
  • Stress or emotional response
  • Use of beta-blockers, aspirin
  • Chemical fumes, insects, plants

Genetics

Prognostic Factors

Asthma causes one mortality per 100,000 individuals, making it a severe condition. Asthma causes missed work and school days and multiple hospitalizations, which increases healthcare costs. Poor asthma control can make the functioning difficult and lower quality of life

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment paradigm for asthma typically involves a combination of medications, lifestyle modifications, and long-term management strategies. The goal is to achieve and maintain asthma control, reduce symptoms, prevent exacerbations, and improve overall quality of life for individuals with asthma. It’s important to note that while I strive to provide accurate and up-to-date information, treatment approaches may have evolved beyond my knowledge cutoff in September 2021. It’s always best to consult a healthcare professional for the most recent guidelines and recommendations.

Quick-relief medications (short-acting bronchodilators): These are used as needed to relieve acute symptoms and provide immediate relief during asthma attacks. Examples include albuterol (salbutamol) and levalbuterol.

Long-term control medications:

  • Inhaled corticosteroids (ICS): These are the most effective medications for long-term control of asthma. They reduce airway inflammation and help prevent asthma symptoms. Examples include fluticasone, budesonide, and beclomethasone.
  • Long-acting beta-agonists (LABAs): These medications are often used in combination with ICS to provide additional bronchodilation and control of symptoms. Examples include salmeterol and formoterol.
  • Combination inhalers: Some medications combine an ICS and LABA in a single inhaler device for convenience and improved adherence. Examples include fluticasone/salmeterol and budesonide/formoterol.
  • Leukotriene modifiers: These medications block the action of leukotrienes, which are substances involved in inflammation. They are used as an alternative to ICS or in combination with them. Examples include montelukast and zafirlukast.
  • Other medications: In certain cases, other medications such as theophylline or oral corticosteroids may be prescribed.

Lifestyle modifications:

  • Identify and avoid triggers: Common triggers include allergens (pollen, dust mites, pet dander), irritants (tobacco smoke, strong odors), respiratory infections, and exercise. Taking steps to minimize exposure to these triggers can help reduce symptoms.
  • Regular exercise: Although exercise can trigger asthma symptoms, regular physical activity is beneficial for overall health and can help improve lung function. It’s important to work with your healthcare provider to develop an appropriate exercise plan.
  • Maintain a healthy lifestyle: Eating a balanced diet, staying hydrated, getting adequate sleep, and managing stress can contribute to better asthma control.

Long-term management:

  • Asthma action plan: Developing a written action plan in consultation with your healthcare provider helps you understand how to adjust medication use based on symptoms and peak flow measurements. It also guides you on when to seek medical assistance.
  • Regular monitoring: Monitoring your symptoms, peak flow readings (a measure of lung function), and response to medications helps assess asthma control and determine if any adjustments are needed.
  • Periodic check-ups: Regular follow-up visits with your healthcare provider are crucial to evaluate your asthma control, adjust medications as necessary, and address any concerns or questions.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Allergen Control

Tobacco smoke: Avoid smoking or exposure to secondhand smoke.

Strong odors and chemicals: Use fragrance-free and non-toxic cleaning products, avoid using air fresheners, and limit exposure to strong-smelling chemicals.

Dust mites: Use dust-proof covers on pillows and mattresses, wash bedding regularly in hot water, and keep humidity levels below 50%.

Improve Air Quality

Keep your home clean and free of dust by regular vacuuming, using allergen-proof covers for mattresses and pillows, and washing bedding frequently in hot water.

Consider using air purifiers with HEPA filters to remove airborne allergens. Minimize the use of harsh chemicals, strong perfumes, and cleaning products with strong fumes that may irritate your airways.

Stay informed about the outdoor air quality in your area, especially during times when pollution or allergen levels are high. On days with poor air quality, consider staying indoors or taking precautions like wearing masks designed to filter out allergens or pollutants.

Pet management

If you are allergic to pet dander, it may be necessary to keep pets out of your home or at least restrict them from certain areas like the bedroom. Regularly groom your pets, vacuum upholstered furniture and carpets, and wash bedding that may have come in contact with pet dander.

 

Use of Beta-Agonists in Acute Exacerbation

Short-acting beta-agonists (SABAs) are the first-line medications used in the acute management of asthma exacerbations. The most commonly used SABA is albuterol (salbutamol). Here’s how beta-agonists are typically used in this situation:

  • Inhalation via Metered-Dose Inhaler (MDI): Albuterol is often administered using a handheld inhaler, also known as a metered-dose inhaler. The patient should shake the inhaler, remove the cap, exhale fully, and then place the inhaler mouthpiece in their mouth while maintaining a tight seal with their lips. They should then inhale deeply while simultaneously pressing down on the inhaler to release the medication. After holding their breath for a few seconds, they can exhale slowly. The inhaler should be used as directed by a healthcare professional, usually with a recommended number of inhalations per dose.
  • Inhalation via Nebulizer: In more severe cases or when the patient has difficulty using an inhaler, nebulized albuterol may be utilized. A nebulizer is a device that converts the medication into a fine mist, allowing the patient to inhale it more easily. The nebulizer is connected to a mask or mouthpiece, and the patient breathes in the mist for a specified duration as instructed by a healthcare professional.

The frequency of beta-agonist administration during an acute exacerbation depends on the severity of symptoms and the individual patient’s response. Initially, a healthcare professional will determine the appropriate dosage and frequency of beta-agonist use. Patients may be advised to administer the medication every 4 to 6 hours as needed, with close monitoring of their symptoms. It is essential for patients to follow the prescribed dosing regimen and seek medical attention if their symptoms worsen or do not improve with medication.

Biologic Agents used for Severe or Poorly Controlled asthma

Biologic agents, also known as biologics or monoclonal antibodies, are a relatively newer class of medications used in the treatment of severe or poorly controlled asthma. These medications specifically target and modulate specific components of the immune system that play a role in asthma inflammation. Biologics can be a beneficial option for individuals who have not achieved adequate control with conventional asthma medications. Here are some commonly used biologic agents for asthma:

  • Omalizumab (Xolair): This biologic targets immunoglobulin E (IgE), which is involved in the allergic response that triggers asthma symptoms. It is typically used in individuals with allergic asthma who have elevated IgE levels.
  • Mepolizumab (Nucala), Reslizumab (Cinqair), and Benralizumab (Fasenra): These biologics target eosinophils, a type of white blood cell involved in the allergic and inflammatory response in asthma. They are used in individuals with eosinophilic asthma, characterized by elevated eosinophil levels.
  • Dupilumab (Dupixent): This biologic targets interleukin-4 (IL-4) and interleukin-13 (IL-13), which are signaling proteins involved in the inflammatory response. It is used in individuals with moderate-to-severe asthma, often with features of allergic and eosinophilic inflammation.

Biologic agents are administered through subcutaneous injections, typically every few weeks or months, depending on the specific medication. They are usually prescribed by specialists, such as allergists, pulmonologists, or immunologists, who have experience in managing severe asthma.

 

Treatment for poorly controlled asthma

When asthma is poorly controlled, the primary goal is to improve symptoms, reduce the frequency and severity of asthma attacks, and enhance overall lung function. Treatment typically involves the use of various pharmaceutical agents, such as:

  • Inhaled Short-Acting Beta-Agonists (SABAs): Medications like albuterol provide quick relief by relaxing the muscles around the airways, making breathing easier during an asthma attack. These are usually used on an as-needed basis.
  • Inhaled Long-Acting Beta-Agonists (LABAs): LABAs like salmeterol or formoterol are used for long-term control of asthma symptoms. They work by opening the airways and are typically combined with inhaled corticosteroids.
  • Inhaled Corticosteroids: These anti-inflammatory medications, such as fluticasone or budesonide, are often the mainstay of asthma treatment. They help reduce airway inflammation and prevent asthma symptoms from occurring.
  • Combination Inhalers: Some inhalers combine both a LABA and an inhaled corticosteroid, such as fluticasone/salmeterol or budesonide/formoterol. These provide both long-term control and quick relief in a single device.
  • Leukotriene Modifiers: Medications like montelukast or zafirlukast can be used as an alternative or addition to inhaled corticosteroids. They help reduce inflammation and control asthma symptoms.
  • Systemic Corticosteroids: In severe cases or during exacerbations, oral or intravenous corticosteroids may be prescribed for a short period to quickly reduce inflammation and improve symptoms.

The administration of these medications depends on the specific agent and the individual’s needs. Inhaled medications are commonly delivered through handheld inhalers or nebulizers. It’s crucial to follow the instructions provided by the healthcare professional or pharmacist for proper administration techniques.

It’s important to work closely with a healthcare professional to determine the most suitable medication and dosage for poorly controlled asthma. They will assess your symptoms, medical history, and lung function tests to develop an individualized treatment plan tailored to your needs.

 

 

Administration of a pharmaceutical agent

The medications used in asthma management can be broadly categorized into two main types: long-term control medications and quick-relief medications.

Long-term control medications:

Inhaled Corticosteroids (ICS): These medications are considered the most effective long-term control treatment for asthma in children. They reduce airway inflammation and help prevent asthma symptoms. Examples include beclomethasone, budesonide, fluticasone, and mometasone.

Leukotriene modifiers: These medications block the action of leukotrienes, which are inflammatory chemicals released during an asthma attack. Montelukast is a commonly used leukotriene modifier in pediatric asthma management.

Long-acting beta-agonists (LABAs): These medications relax the muscles around the airways and are often used in combination with inhaled corticosteroids for better asthma control. Common examples include salmeterol and formoterol.

Immunomodulators: In certain cases, pediatricians may consider immunomodulatory agents like omalizumab for children with severe allergic asthma that is not well-controlled with other medications.

Quick-relief medications:

  • Short-acting beta-agonists (SABAs): These medications provide quick relief by relaxing the muscles around the airways during an acute asthma attack. Albuterol is a commonly used SABA in pediatric asthma treatment.
  • Oral corticosteroids: In severe asthma exacerbations, oral corticosteroids may be prescribed for a short period to reduce inflammation and improve symptoms.

Use of Systemic corticosteroids in severe asthma exacerbations

Systemic corticosteroids are an important treatment option for severe asthma exacerbations in pediatric patients. Severe asthma exacerbations are characterized by a significant worsening of asthma symptoms, including shortness of breath, wheezing, chest tightness, and coughing. These exacerbations can be life-threatening and require prompt medical intervention.

When a child experiences a severe asthma exacerbation, systemic corticosteroids are often prescribed to help reduce airway inflammation and improve lung function. Here are some key points regarding the use of systemic corticosteroids in severe asthma exacerbations:

  1. Administration: Systemic corticosteroids are typically given orally, either in tablet or liquid form. In some cases, intravenous administration may be necessary if the child is unable to take oral medications or if the exacerbation is particularly severe.
  2. Dosage and Duration: The specific dosage and duration of systemic corticosteroid treatment will vary depending on the severity of the exacerbation and the child’s individual factors. Generally, a short course of high-dose corticosteroids is prescribed, typically lasting from 3 to 10 days. The healthcare provider will determine the appropriate dosage based on the child’s age, weight, and overall health.
  3. Mechanism of Action: Corticosteroids exert their effects by reducing inflammation in the airways, suppressing the immune response, and improving the responsiveness of the bronchial smooth muscles. This helps to relieve symptoms, improve lung function, and prevent further deterioration.
  4. Side Effects: While short-term use of systemic corticosteroids is generally well-tolerated, they can have potential side effects. These may include increased appetite, mood changes, temporary increase in blood glucose levels, gastrointestinal symptoms, and temporary suppression of the immune system. However, the benefits of treating severe asthma exacerbations usually outweigh the risks of these short-term side effects.
  5. Follow-up Care: After starting systemic corticosteroid treatment, it is important for the child to have close follow-up with their healthcare provider. This allows monitoring of their response to treatment, adjustment of medication as needed, and evaluation of any potential side effects.

It is crucial to strictly adhere to the prescribed dosage and duration of systemic corticosteroid treatment. Abrupt discontinuation or improper use of corticosteroids can lead to inadequate control of asthma

Medication

 

formoterol

Initial:

6 - 12

mcg

via dry powder inhaler every 12 hours. (Do not exceed 24 mcg/day)
Maintenance: 1 capsule inhaled every 12 hours. (Do not exceed 2 capsules/day)



levalbuterol

Metered-dose inhaler: 2 to 4 oral inhalations (45 mcg/actuation) with spacer every 20 minutes for 3 doses
Nebulization solution: 1.25mg to 2.5mg oral inhalation every 20 minutes for 3 doses

Asthma with intermittent symptoms:
Metered-dose inhaler: 2 oral inhalations with a spacer every 4 to 6 hours as needed. Nebulization solution: 0.63 mg to 1.25 mg oral inhalation every 6 to 8 hours as needed up to 3 doses per 24 hours



zileuton

for immediate release:

600

mg

Orally 

4 times a day


1200 mg twice a day for extended release



prednisone (Rx)

40 - 60

mg

Orally 

once a day

3 - 10

days

40-60 mg/day orally for 3-10 days 



montelukast

10

mg

Orally 

qPM



ipratropium



reslizumab

severe asthma:

3

mg/kg

over 20 to 50 minutes

4

weeks



mepolizumab

100

mg

Subcutaneous (SC)

4

weeks



benzralizumab

30

mg

Subcutaneous (SC)

4

weeks

first three doses, following every eight weeks thenafter



mometasone and formoterol

initial:

2

actuation

of 100 mcg/5 mcg inhaled two times a day and may increase to a higher dose after two weeks; following with 2 actuation of 200 mcg/5 mcg inhaled two times a day
If treatment fails, continue with a Maximum daily dose of 800 mcg/20 mcg



fluticasone furoate and vilanterol

Initial dose:

1 inhalation 100mcg/25mcg or 200mcg/25mcg (fluticasone furoate/vilanterol) once daily
Maximum dose: 1 inhalation 200mcg/ 25mcg (fluticasone furoate/vilanterol) once daily



fluticasone furoate umeclidinium and vilanterol

Initial dose:

1 inhalation of 100 mcg/62.5 mcg/25 mcg or 200 mcg/62.5 mcg/25 mcg (fluticasone/umeclidinium/vilanterol) orally once a day
Maximum dose: 1 inhalation of 200 mcg/62.5 mcg/25 mcg (fluticasone/umeclidinium/vilanterol) once a day



ciclesonide inhaled

Prophylaxis:
Receiving Bronchodilators: 80 mcg inhaled orally two times a day; may increase to 160 mcg
Receiving Oral Corticosteroids: 80 mcg inhaled orally two times a day; may increase up to 320 mcg
Asthma guidelines: Global Initiative for Asthma guidelines (GINA 2020): HFA inhaler: Metered-dose inhaler:
80-160 mcg required as low dose treatment once a day or in divided doses two times a day
>160-320 mcg required as medium-dose therapy once a day or in divided doses two times a day
>320 mcg required as high-dose therapy once a day or in divided doses two times a day



tezepelumab (Rx)

210

mg

Subcutaneous (SC)

4

weeks



omalizumab 

150 - 375

mg

Subcutaneous (SC)

every 2-4 weeks



amoxicillin 

Mild/moderate/severe:

875

mg

every 12 hrs or 500mg every 8hrs



ephedrine/guaifenesin 

12.5 - 200

mg

ephedrine/guaifenesin: 1-2 tablets orally 6 times a day as required

Do not exceed 12 tablets a day

25mg/400mg -ephedrine/guaifenesin: 1tablet orally 6 times a day as required

Do not exceed 6 tablets a day



orciprenaline 

Indicated for Bronchospasm:

20

mg

Tablet

Orally 

3 to 4 times a day



fenoterol 

Oral inhalation

Solution for nebulization:
Moderate symptoms
0.5 to 1.25mg every 4 hours when needed

Maximum dose-8 inhalations/day
Severe symptoms
2.5 to 5mg inhaled through nebulization of 3 doses for 20 mins maximum

Oral tablets
2.5mg thrice daily



forskolin 

10

mg

Powder

as Spinhaler inhalator



ciprofloxacin 

In the case of mild/moderate infections: 500 mg orally every 12 hours or 400 mg intravenously every 12 hours for 7-14 days
In the case of severe/complicated infections: 750 mg orally every 12 hours or 400 mg intravenously every 8 hours for 7-14 days
Limitations for usage: Reserve the fluoroquinolones for patients who are voided of available treatment options for chronic bronchitis



epinephrine racemic 

Indicated for Bronchial Asthma
:


Asthmanefrin- whenever needed, take 0.5ml nebulizer solution of 1 to 3 inhalations using the EZ breath atomizer
S2- 0.5 mL of a 2.25 percent solution mixed in 3 millilitres of normal saline via jet nebulizer every three to four hours as needed



tiotropium 

For long-term indication, use once daily, as the maintenance of asthma in people more than 12 years
Spiriva Respimat- 2 actuation of 1.25 mcg each, inhaled orally daily
Dose Modifications
In the case of CrCl<50ml/min, use the drug only when the benefits are more than the potential risks



dyphylline 


Indicated for Asthma or Reversible Bronchospasm
Nearly 15 mg/kg orally four times a day as needed
Note:
Renal impairment
Sr CrCl >50 ml/min: Reduce 25% of an actual dose
Sr CrCl 10-50 ml/min: Reduce 50% of an actual dose
Sr CrCl <10 ml/min: Reduce 75% of an actual dose



epinephrine inhaled 

Indicated for mild asthma:


1 to 2 inhalations orally every 4 hours whenever needed.
After the first inhalation, wait for a minute before giving the second puff. Do not exceed 8 puffs for 24 hours.



fluticasone and salmeterol 

Inhalation powder (generic or Advair Diskus): one actuation Orally every 2 times a day; should not exceed more than one actuation, about 50mcg salmeterol /500mcg fluticasone every 2 times a day; should not use with the spacer
Inhalation powder (AirDuo Digihaler, AirDuo RespiClick): One actuation orally every 2 times a day; should not exceed more than one actuation, about 14mcg salmeterol /232mcg fluticasone every 2 times a day; should not use with the spacer or the volume holding chamber.
Inhalation aerosol (Advair HFA): Two actuations Orally every 2 times a day; should not exceed more than two actuations of about 21mcg salmeterol /230mcg fluticasone every 2 times a day



pirbuterol 

Indicated for the maintenance of asthma
1-2 actuations every 4-6 hours as required
Do not exceed more than 12 actuations each day
Metered dose inhalers propelling chlorofluorocarbons are out of phase (Discontinued)



budesonide inhaled 

Inhaled powder (Treatment for maintenance)
Administer 360 mcg every 12 hours orally.
Some people may start with 180 mcg every 12 hours. Do not exceed 720 mcg every 12 hours.



mometasone and indacaterol 

Patients who require low-dose inhaled corticosteroids: Inhaled once a day, the contents of 1 capsule contain indacaterol 150 mcg and mometasone 80 mcg.
Do not exceed one capsule in a day.
Patients requiring a medium or high dose of inhaled corticosteroid: Inhaled once a day, the contents of 1 capsule contain indacaterol 150 mcg/mometasone 160 mcg or indacaterol 150 mcg/mometasone 320 mcg.
Do not exceed 1 capsule in a day.



lily of the valley 

Cardiac Glycosides
Take a dose of 600 mg orally daily
Tincture: take a dose of 6 g daily orally divided three times a day
Liquid extract: take a dose of 600 mg daily orally divided three times a day
Dried extract: take a dose 150 mg orally daily



alfalfa 

Administer 5 to 10g orally thrice a day



mometasone/glycopyrrolate (glycopyrronium)/ indacaterol 

One capsule inhaled orally one time a day
Maximum dose not more than one capsule a day
Dosing modification
Renal Impairment
Dose modification not required
Hepatic impairment
Dose modification not required



pranlukast 

The recommended dose is 225 mg twice a day



oxtriphylline 

Take a maintenance dose orally of 4.7 mg/kg in each 8 hours



ciclesonide/formoterol/tiotropium 


Indicated for Asthma, chronic obstructive pulmonary disease
160 mcg of ciclesonide/12 mcg of formoterol/18 mcg of tiotropium of one puff one time a day



nedocromil (Oral Inhalation) 


Indicated for Asthma
Two inhalations four times in a day at the regular interval



procaterol 

Inhaled a dose of 20 mcg up to 4 times daily



bamifylline 

Take a dose of 600 to 1800 mg daily in 2 to 3 divided doses



reproterol 


Indicated for Acute bronchospasm
10 mg to 20 mg orally three times a day
Or
One-two inhalations of 500 mcg/inhalations, repeat it for every three-six hours as necessary
Status asthmaticus
90 mcg slow intravenous injection; if necessary may repeat it after 10 min



aminophylline, ephedrine and phenobarbitone 

1 to 2 tablets taken orally every 3 times a day



pine bark extract 

100 mg daily



vilanterol 

off-label:

Take 62.5 mcg two times a day
Note: A daily regimen of vilanterol therapy were best tolerated & enhancements in pulmonary function was observed



etophylline 

take 1.5 gms daily with a glass of water



cefodizime 

Administer 1 to 2 g once or twice a day intramuscularly or intravenous infusion.
Maximum dose-4 g/day.

Renal impairment
CrCl 10 to 30ml/min-Administer 1 to 2 g every day.
CrCl<10ml/min- Administer 0.5 to 1 g every day.



ozagrel hydrochloride 

In vivo, data suggests taking one tablet of 200 mg two times daily after the morning meal & prior to sleep



acebrophylline 

Take a dose of 100 mg orally two times daily



cromolyn sodium, inhaled 

Administer 20 mg as an inhaler through nebulization four times a day
The dose may be reduced to twice/thrice a day when the condition is stable



bromotheophylline 

Take one tablet/capsule after the breakfast with a glass of water. Dose can be repeated every six hours, should not exceed more than four capsules daily



mofebutazone 

Off-label dosing
:

300

mg

Tablet

Orally 

twice a day

15

days



bambuterol 

starting dose: 10-20mg is given once a day at bedtime. Following the dose to 20mg after one to two weeks



Dose Adjustments

Dosing modifications
Renal impairment
5 mg is given as a starting dose. Following it to 10 mg after one to two weeks

isoetharine 

0.005 - 0.090 mg/k is inhaled by mouth every 4 times a day