Asthma

Wellington S.Tichenor, M. D.
New York, New York

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Asthma can cause symptoms which vary from a cough to wheezing or shortness of breath. Some patients will have tightness in the chest, and other patients have no symptoms at all. Asthma can also be induced by exercise, but is also very treatable. If you have exercise induced asthma, you are in good company. 15-20% of Olympic athletes also have exercise induced asthma!

Asthma occurs as a result of constriction of the airways in the lungs. Constriction typically occurs as a result of inflammation, and now the focus of treatment of asthma is to reduce the amount of inflammation in the lungs. This represents a dramatic change in the past several years - it used to be that we would just focus on trying to open the lungs, rather than treating the cause.

Inflammation can occur as a result of exposure to irritants such as tobacco smoke, pollution, ozone, infectious agents such as bacteria and viruses, and also allergens such as dogs, cats, horses, guinea pigs, feathers, wool, dust, pollens, cockroaches and foods. Sinusitis can also worsen asthma. Workplace exposures can also be a problem and so can the cold weather and cold water. Most people are surprised to learn that 80% or 90% of patients with asthma have what is called "extrinsic" asthma. In other words, it is typically made worse as a result of exposure to things they are allergic to. Some patients also have exercise induced asthma.

Treatment of asthma focuses on a multi-step approach. The initial step is to eliminate those items in the environment which cause problems such as allergens, tobacco smoke, etc.

The next step is to use an inhaler called a bronchodilator (Proventil, Ventolin, Maxair or Tornalate, et. al.) which immediately opens the lungs up, but should not be used more than twice a week without other asthma medications. If it is necessary to use the inhaler more than twice a week, treatment should proceed to the next step which may involve increasing the bronchodilator dose and also adding a drug which reduces inflammation.

These drugs are inhaled cortisone preparations (Vanceril, Beclovent, Aerobid, Azmacort, Flovent, Asmanex or Pulmicort). Some are now available in a dry powder formulation which are preferable for some patients if they cannot tolerate the propellant. These include Pulmicort and Flovent. They also have a built in counter so you can tell how many puffs are left. There is also a formulation called QVAR which contains the same drug as Vanceril and Beclovent in a metered dose inhaler, but does not contain any chlorofluorocarbons (CFC's)(see below). In the near future all metered dose inhalers will not contain CFC's. Pulmicort is also available as a liquid preparation which can be used in a nebulizer, which is useful for childen as well as situations when patients may have a hard time taking in a deep breath. Pulmicort has also been used as drops in the nose for patients with sinusitis.

There are also a combination drugs: Advair and Symbicort, which contain an inhaled steroid as well as a bronchodilator (see below).

There are also 2 other inhaled drugs (Intal or Tilade) which are not cortisone preparations and are not quite as strong as the cortisone preparations. These drugs also reduce inflammation. Another drug, Atrovent, is sometimes helpful in treatment of patients with asthma, but is more commonly used in patients with emphysema. The initial dosages of these inhaled drugs may need to be increased if not initially successful in relieving symptoms.

There is a class of drugs which block or inhibit a class of compounds called leukotrienes. Leukotrienes are important causes of lung inflammation and contribute to asthma. Three drugs have been released called Singulair, Accolate and Zyflo. These drugs work as anti-inflammatory medications, similar to the inhaled steroids but are not as potent. They can be used in addition to the inhaled steroids, or can be used by themselves These drugs have been used successfully in about 50% of patients, including some very severe asthmatics. They are also helpful in patients with sensitivity to aspirin.

These drugs have been found to rarely cause abnormalities in liver functions, and Zyflo must be monitored with blood tests on a monthly basis for the first several months. Accolate may cause a rare disease called the Churg-Strauss syndrome. It typically may present with symptoms such as fever, weight loss and generalized aches and pains. It is caused by inflammation of the blood vessels. More information can be found on the FDA's website listed in bookmarks.

A possible association of Churg-Strauss-like symptoms has also been found with Singulair and Flovent. It is also suspected that it may be associated with other steroid inhalers. It is thought in many cases to be due to an "unmasking" of the Churg-Strauss syndrome. In other words, the disease was there beforehand, but in the course of starting on these new medications, other medications such as oral cortisone were reduced, and the Churg Strauss symptoms started appearing. The only reason that the symptoms occurred was because the cortisone was either stopped or the dosage reduced.

Nocturnal asthma occurs in the vast majority of patients who have problems with asthma. It typically occurs during sleeping because of a change in the hormone levels and oxygen content, as well as exposure to allergens such as dust mites. As allergists we would like to keep the asthma controlled all the time, especially at night, so that we both can sleep at night. There are now several medications that will last an entire night.

There are two drugs which are available which function as long acting bronchodilators called Serevent, and Foradil. They last 12 hours, and are especially helpful for patients with night time symptoms. (It also is obviously effective for daytime symptoms). They can be used to decrease the amount of inhaled steroids. It is also available in a dry powder form. They should be used as directed, no more than twice per day, as they will not give immediate relief of symptoms. They take 30 - 60 minutes to start working. There are two combination agents available. The first was a combination of Serevent and Flovent called Advair which is available in a dry powder formulation in a variety of strengths. The second was Symbicort which contains Foradil and Pulmicort. These drugs have advantages. They reduce the number of times patients have to use medications, and Advair eliminates the need for spacer devices, which need to be used with inhaled steroids. (See below). For patients that have acute symptoms, short acting drugs like albuterol or Xopenex need to be used.

Another drug called theophylline can be used for nighttime symptoms. It is in pill form and can open the lungs up for 12-24 hours at a time. There are also other long acting pills which are oral forms of the bronchodilators mentioned above( Proventil Repetabs, Volmax) which also last 12 hours. Neither if these drugs are used commonly anymore.

Patients who are not controlled by using low doses of their inhaled steroids (typically 2-8 puffs per day depending on the strength), can often be controlled by adding Serevent to the regimen, so that higher doses of the inhaled cortisone do not have to be added. Higher doses of inhaled cortisone may be more likely to cause side effects. Most specialists prefer using the combination of the inhaled steroids with Serevent or Foradil instead of the leukotriene inhibitors.

The cortisone preparations are important to use in order to prevent what is now called "airway remodeling". Usually when people think of remodeling, it is beneficial. In this case it is not, because it leads to worsening of the asthma. the inflammation in asthma can lead to scarring, which can make it more difficult to transport oxygen into the bloodstream. This may not be reversible, causing a similar effect as emphysema. Cortisone preparations ( and possibly leukotriene inhibitors ) can reduce this remodelling.

Patients who have more severe asthma may need oral cortisone preparations to be used in order to give adequate relief of symptoms. Usually a short course of treatment lasting a few days to a few weeks is adequate. Very rarely, patients may need longer treatments or with other drugs.

The first of a class of drugs which blocks IgE, called Xolair can be used to treat asthma. It may also help other allergic problems, but has not been approved by the FDA for that use. Because the anticipated cost is approximately $1000/month, we anticipate that many insurance companies will only pay for it for more severe asthma. It is given every few weeks by injection. If it is stopped, symptoms will come back, so it is not like allergy shots in that symptoms will often continue to be relieved after discontinuing allergy shots. Reactions are rare, but there were reports of a non-statistically significant increase in cancer in the treated groups in clinical trials. It is not thought that this was related to the drug, but was serendipity.

We will not deal here with asthma which may need to be treated in a hospital situation. Treatment by an allergist rarely requires hospitalization. Most patients that we see who do need to be hospitalized have either just been seen by their allergist or not followed their treatment regimen.

Patients who have severe asthma should usually have a nebulizer available at home. A nebulizer is a small machine which creates a mist of one of the bronchodilator medications. It can also be more easily used by young children. When the mist is breathed in, it will rapidly open up the lungs. Oxygen also may be helpful in those patients with severe asthma. It is very important to use a nebulizer under the supervision of a physician well trained in treatment of asthma since overuse of this device can be dangerous and can make asthma extremely difficult to treat.

When you see an allergist or other lung specialist, you will in all likelihood have a lung function test done. This test is performed using a sophisticated computerized device which determines the severity of your asthma by measuring how forcefully you can blow air through a tube the size of a doughnut hole. Usually after doing this, your doctor will have you breathe in a bronchodilator medication to open up your lungs, and after waiting a few minutes, repeat the test. A comparison can then be made of the lung function before and after treatment. As a result, the severity of your asthma can be determined. This will guide your doctor in making an assessment of the medications that you need to use. These lung function tests are periodically repeated during the course of treatment in order to assess your progress. Occasionally it may be necessary to administer the lung function test before and after exposure to an agent such as an allergen or medication which may temporarily worsen the asthma. This is typically done in situations where the doctor may not be sure if a patient has asthma.

Any patients who have moderate to severe asthma should have a device called a peak flow meter. The peak flow meter is a small, inexpensive ($15- $25) simplified version of the lung function test that patients can use at home to measure how strong the force of the breath is. It is a good indicator of how bad the asthma is. Unfortunately, a patient's sensations of wheezing is not a good indicator of how bad the asthma is.

When asthma starts to worsen, the peak flow often starts to drop before patients are aware the asthma is worsening. This allows the patient some time to alter the medications and if necessary to call their doctor with that information. Then dosage adjustments can be made in the medication.

We ask patients to measure the peak flow on a regular basis and establish a personal best, which is the average maximum peak flow. If there is a 20% drop in the peak flow, it is considered in the yellow zone, and patients need to add medication. If there is a 50% drop in the peak flow, then it is considered in the red zone, and patients need to immediately add medication or risk getting severely ill.


Aspirin and NSAID (Non-Steroidal Antiinflammatory Drug) Allergy

Aspirin, Advil and other related drugs (not Tylenol) can cause problems with polyps, asthma, and hives. Many patients who are allergic to aspirin will also be allergic to other drugs in the same category such as aspirin. Patients will commonly develop worsening of symptoms such as asthma and nasal polyps and must consequently avoid these drugs in order to avoid having symptoms. A small proportion of patients may also need to avoid a variety of items which may have aspirin-like compounds contained in them or have a yellow vegetable dye called tartrazine contained in them in order to have relief of symptoms. Some patients with this problem may be helped with the new leukotriene inhibitors. It is possible to desensitize patients to aspirin in some cases, but patients must take aspirin daily for the rest of their lives in order to remain desensitized.


Sulfite Sensitivity

A substantial number of people with asthma are sensitive to sulfites. These are preservatives used in foods in order to keep them fresh. They are commonly used in salad bars and in wines. They must be carefully avoided by patients who have problems with them.


Frequently Asked Questions (FAQ's)


Should I get allergy shots for asthma?

Allergy shots have been shown to be clearly helpful for asthma. Allergy testing should be done in most patients with significant asthma so that modifications can be made in the environment. Many patients can be managed with medications, so that a decision needs to be made about whether allergy shots should be given. Some primary care doctors and pulmonologists may not be aware of the beneficial effects of allergy shots on asthma so the decision should be made by an allergist, since they have the most experience with the effect of allergens on asthma.

I have been told two different ways to use my inhaler, one in the mouth and one outside. What do you suggest?

We usually suggest that patients use what is called the open mouth technique in which the inhaler is held several inches away from the mouth and prior to activating the inhaler the patient starts to take a deep breath. Shortly after starting the deep breath, the patient activates the inhaler and then holds the breath for ten seconds. Some patients are unable to take a large enough breath and other patients are unable to coordinate the activation of the inhaler with breathing. It helps to have the correct technique demonstrated by your doctor. There is also another technique using a spacer device which can also be used. The spacer device must be used with inhaled steroids ( unless you are using the dry powder formulation).

What is a spacer device?

A spacer device is a cylindrical tube (Ellipse, Aerochamber, InspirEase and also a self contained mini spacer which is incorporated into the Azmacort inhaler). The inhaler is activated in such a way that the medication is released into the chamber and the patient then breathes the medication through the other end of the spacer device. People who have difficulty coordinating the activation of the inhaler with breathing the medication into the lungs are often helped by using the spacer. In addition, this technique allows the medication to be diluted with the air inside the spacer and, consequently, because it is less concentrated, the inhaled cortisone preparations are less likely to cause a yeast infection in the back of the throat. It is also important to rinse the mouth out after using the cortisone preparations to reduce the likelihood of getting a yeast infection.

Can I use over-the-counter drugs for asthma?

Over-the-counter drugs such as Primatene mist should NOT be used on a regular basis. That is what killed a young model not too long ago - she used too much Primatene. See your doctor.

I see a GP for my asthma - why should I see an allergist?

Anyone who has moderate to severe asthma needs to be evaluated to determine if environmental agents may worsen the asthma. Allergies, chemicals, sinusitis or exposure in the workplace may all cause worsening of these problems. Unfortunately, non-allergists don't usually deal with those problems (please be sure to read the allergy section). Many patients don't know how bad their asthma is, so I would suggest that anyone who needs to use their inhaler more than twice a week should see an allergist at least once for an evaluation.

What kind of side effects occur with the asthma inhalers?

Side effects of some of the inhaled bronchodilators include: palpitations, rapid heart beat, nervousness, lightheadedness, dizziness and tremors. Most of the time these medications can be given but patients who have other medical problems need to be followed carefully. Inhaled steroids can also sometimes cause yeast infections in the throat. The likelihood of this happening is less if the mouth is rinsed after inhaling and spacers are used. There are numerous other potential side effects with the inhalers, but they are unusual.

I have problems with foods repeating. Could that problem cause asthma?

Repeating or reflux of food from the stomach back into the mouth (often causing a bitter or sour taste in the mouth), can also cause the same kind of irritation in the lungs. This commonly may cause night time asthma. Treatment is the same as with other types of asthma, but medications such as acid blockers are also often needed to reduce the reflux. Sometimes there can be reflux without symptoms. Occasionally patients may even need to have surgery to correct this.

What should I do if my peak flow drops?

You should talk to your doctor about exactly what to do, but in general, if your peak flow drops by 20% your doctor will generally suggest medication changes. If it drops by 50%, a more intense treatment regimen may be needed.

What can I do in an emergency situation for asthma?

Instead of going to the emergency room or your doctor's office, it is sometimes possible to use medications at home in a regimen designed by your doctor. Depending on the severity, the initial treatment may be to use your metered dose inhaler. If it is more severe, you may need to use a bronchodilator delivered via a nebulizer. All of these emergency treatments must be designed in conjunction with your doctor, and if you don't get better you may need to go to the emergency room. If there is any doubt, go to the emergency room. Remember that asthma still kills about 5000 people in the U.S. every year.

I have heard you can die from taking too much in the way of medication for asthma?

There has recently been a significant increase in the number of deaths as a result of asthma. Some people believe that it is due to overuse of medications (such as the model who died as a result of taking Primatene). It just emphasizes the importance of seeing a specialist in treatment of asthma.

I have a cough but I don't wheeze, can I still have asthma?

There is a kind of asthma which is called "cough-type" asthma. Patients who have this kind of a problem have a chronic cough. It doesn't resolve with all of the usual cough medications. They cough because of irritation in the airways but don't actually wheeze or feel tight. Treatment of this kind of asthma is the same as other kinds of asthma however it can sometimes be due to a side effect from other medications. Obviously under those circumstances the offending drug must be stopped.

What kind of exercise can I do?

Exercise is important for patients with asthma since it will improve the asthma. You may be able to use medications such as bronchodilators, Intal or Tilade before exercising in order to reduce the likelihood of developing symptoms. Swimming is usually less likely to cause symptoms than many other forms of exercise.

Why hasn't my doctor given me Serevent or an inhaled steroid?

Some doctors are not aware that it is important to use inhaled steroids and long acting medications to treat asthma. You may want to suggest that they review the newer guidelines on asthma treatment.

I often get asthma when I am under stress. What can be done?

Emotional factors can play a significant role in asthma. There are a number of relaxation techniques, including deep breathing exercises, biofeedback, meditation and hypnosis which are often helpful in reducing symptoms in addition to using medications. You should talk with your doctor about what is recommended.

I have asthma and I am pregnant. My obstetrician said I shouldn't take any medications but I still have symptoms. What should I do?

Obviously if you have asthma and are wheezing, it is very important to use medications. There are a limited number of medications which should not be used in pregnancy. Most of the medications which are used for treatment of asthma can be used in pregnancy. You should discuss with your doctor which drugs can be used. Under these circumstances it's often important to get treatment from an asthma specialist.

I have asthma and my doctor hasn't told me all of these things. How come?

Treatment for asthma has changed dramatically in the past several years. Allergists and other specialists in asthma are still trying to make sure that other doctors and the public in general have enough information to have their asthma treated correctly. In addition to the information at this website, you may be able to get further information through the Asthma and Allergy Foundation of America, the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and also Mothers of Asthmatics, the websites of which are located in the Bookmarks section.

Should antihistamines be used in the treatment of asthma?

For the most part, antihistamines are not necessary to use in asthma since the other medications typically are adequate. In some patients who have allergic symptoms as well, antihistamines may be helpful, but because of their drying effect they can occasionally cause a problem.

My mucus is very thick and dry. What can be done about that?

There are a number of medications which thin the mucus, including guaifenesin and iodine preparations. In addition, breathing in a salt water solution through a nebulizer is helpful in thinning the mucus out. Some patients may develop plugs of mucus which may actually have to be removed by a lung specialist. It is also important to drink large amounts of fluid in order to keep the mucus thin, especially in the middle of an asthma attack.

I have asthma at work. What can that be from?

There are many different kinds of exposures to agents in the workplace which can cause asthma. Among the many agents which cause problems are chemicals (dyes, metals, enzymes), tobacco smoke, plants and dust. In addition, some patients work in "sick buildings". These are buildings which have toxic substances in the air which may also cause problems with asthma. You should discuss with your doctor whether these kinds of exposures may cause problems for you.

I have heard that there are other medical problems that can mimic asthma. What kinds of things can do that?

There are a number of other medical problems that must be excluded including "cardiac asthma" (in which there is heart failure), blood clots to the lung, blockage of the upper airway, or aspiration of foreign bodies into the lungs.

My child can't swallow pills. What can be done for him/her?

There are now a variety of different medications that are available in liquid form. There are also sustained release tablets which are small capsules with tiny pellets inside them that release medications slowly. These can be mixed with food such as applesauce. Most young children can tolerate them. In addition, by using special attachments to inhalers called spacer devices, young children can often breathe in medications through inhalers. And most importantly, young children can take the bronchodilators, inhaled steroids and other medications through a nebulizer.

What do I do if there is a pollution alert?

Air pollution is often a problem in patients with asthma. During times of increased pollution it is a good idea to avoid going outside, smoking and smoke-filled rooms, and any other irritants such as chemicals. Exposure to cold weather can also cause worsening of symptoms. Air filters are very helpful under those circumstances.

What will happen to metered dose inhalers now that freon propellants have been banned?

Chloroflorocarbons (also known as CFC's or generically as freon) were no longer produced after 1996 due to the fact that they destroy ozone, which protects us from the sun's ultraviolet rays. CFC's are the propellant used to provide the jet of spray in the metered dose inhalers. The FDA has grandfathered the MDI's so that they can continue to be used for the present time, but that will not last long.

The drug companies are in the process of reformulating the MDI's so that they will no longer contain CFC's, starting with albuterol (Proventil, Ventolin, a ndProAir ). There will be no difference in the medications, but unlike the noticeable puff of medication with the older CFC inhalers, the new inhalers will be much gentler. Although it may seem like there is little or no medication being delivered, you can be reassured that you will get the same effect as before.

There are also the dry powder inhalers which we mentioned above which do not contain a propellant. Some patients prefer them.

Tell me about the NIH asthma guidelines.

There is more of a discussion of this on the Update section of this website. You can also find the link there to the National Institute of Health's website where you can download the full text version.

Most of the suggestions have been used by allergists for some time. The most important change involved changing the classification of asthma from mild, moderate and severe to mild intermittent, mild persistent, moderate persistent, and severe persistent.

Patients with mild intermittent asthma typically have symptoms less than twice a week and have nighttime symptoms less than twice a month. Their peak flow is usually over 80% of normal. They can be managed with the Step 1 therapy of inhaled short acting bronchodilators.

Mild persistent asthmatics have symptoms > 2 times a week, but < 1 times a day. They have nighttime symptoms > 2 times a month. They can be managed with Step 2 therapy of inhaled short acting beta agonists and inhaled anti-inflammatory agents, theophylline or anti-leukotriene agents. (Most allergists would use the anti-inflammatory agents).

Moderate persistent asthmatics have daily symptoms, nighttime symptoms over once a week and a peak flow of 60%-80% of predicted. They are managed with Step 3 therapy which includes the above agents (sometimes in higher dose) as well as long acting beta agonists and possibly anti-leukotriene agents.

Severe persistent asthmatics have continual symptoms and frequent night time symptoms with a PEF < 60% of predicted. They are managed with Step 4 therapy which includes the above agents ( sometimes in high dose) and may need oral cortisone.

The guidelines also stress the importance of education, and also the importance of allergic management.

Morning peak flows are suggested in most circumstances. Medications are now classified under long-term control, such as inhaled steroids and quick-relief such as albuterol or Xopenex.

Patients will often move from one stage of asthma to another depending on exposures and adequacy of medication. A patient with a severe allergy to cats, for example, might have mild intermittent asthma most of the time, but if exposed to a cat for an extended period of time, might develop severe persistent asthma as a result.

The actual guidelines are in much more detail. You may wish to explore them.

The section on asthma ends here. We suggest

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The contents of sinuses.com © 1996-2007 by Wellington S. Tichenor, M.D. Last update April 22, 2007. Reproduction for educational, not-for-profit purposes is permitted if this source is credited and the author of this website is notified of any reproduction for other than personal use. If used on the internet, a link would be appreciated.
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