Asthma

Asthma and allergies go hand in hand the majority of the time, especially in young children and adults. Determining how and when symptoms appear, whether they are seasonal or year-round, and whether they can be associated with any particular activity, place or exposure, is critical in the management of asthma.

Asthma occurs when the airways in your lungs (bronchial tubes) become inflamed and constricted. The muscles of the bronchial walls tighten, and your airways produce extra mucus that blocks your airways. Signs and symptoms of asthma, range from minor wheezing to life-threatening asthma attacks.

Asthma can’t be cured, but its symptoms can be controlled. Management includes avoiding asthma triggers and tracking your symptoms. You may need to regularly take long-term “control” medications to prevent flare-ups and short-term “rescue” medications to decrease symptoms once they start. Asthma that isn’t under control can, if severe, require hospitalization, and if milder, cause missed school and work or reduced productivity.

As asthma changes over time, the need to work closely with a doctor to track your signs and symptoms to stay controlled. This may require adjustment to your treatment as needed.

Asthma signs and symptoms range from minor to severe and vary from person to person. You may have mild symptoms such as infrequent wheezing or coughing, with occasional asthma attacks. Between episodes, you may feel normal and have no trouble breathing. Alternatively, you may have signs and symptoms such as coughing and wheezing all the time or have symptoms primarily at night or only during exercise.

Asthma signs and symptoms include: shortness of breath, chest tightness or pain, trouble sleeping caused by shortness of breath, and coughing or wheezing (while exhaling). Asthma also may be present if you experience bouts of coughing or wheezing that are worsened by a respiratory virus such as a cold or the flu. Continual night time coughing can also be a sign of asthma.

Signs that your asthma is probably getting worse include:

  • An increase in the severity and frequency of asthma signs and symptoms
  • A fall in your lung function measured by Spirometry. This test measures the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath, and how fast you can breathe out.
  • An increased need to use bronchodilators — medications that open up airways by relaxing the surrounding muscles (“rescue” medications).

Work with a doctor can better determine when you need to increase your medications or take other steps to treat symptoms of worsening asthma and get your asthma back under control. If your asthma keeps getting worse, you may need a trip to the emergency room. Learning to recognize emergency signs and symptoms is critical, so you’ll know when to get help.

Causes of Asthma

It isn’t clear why some people get asthma and others don’t, but it’s probably due to a combination of environmental and genetic (inherited) factors.

Asthma triggers are different from person to person. Exposure to various allergens and irritants can trigger signs and symptoms of asthma, including:

  • Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust mites. Dust mites have been shown to be the major triggers in children and young adults and are the most common trigger in people under 50.
  • Respiratory infections, such as the common cold
  • Physical activity (exercise-induced asthma)
  • Cold air
  • Air pollutants and irritants such as smoke
  • Certain medications, including beta blockers, aspirin and other nonsteroidal anti-inflammatory drugs
  • Strong emotions and stress
  • Sulfites, preservatives added to some perishable foods
  • Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat
  • Menstrual cycle in some women
  • Allergic reactions to foods such as peanuts or shellfish
  • Rapid worsening of shortness of breath or wheezing
  • No improvement even after using short-acting bronchodilators
  • Shortness of breath with minimal activity

Three key circumstances may lead you to talk to a doctor about asthma:

If you think you have asthma
If you have frequent coughs that last more than a few days or any other signs or symptoms of asthma. Treating asthma early, especially in children, may prevent long-term lung damage and prevent worsening of the condition over time.

To monitor your asthma after diagnosis
If you know you have asthma, work with your doctor to keep it under control. Good asthma control not only helps you feel better on a daily basis but also can prevent a life-threatening asthma attack.

If your asthma symptoms get worse
Contact your doctor right away if your medication doesn’t work for you. Asthma changes over time, and you’ll need periodic adjustments to your treatment to manage your symptoms. Don’t try to solve the problem by taking more medication without consulting your doctor. Overusing asthma medication can cause side effects and may even make your asthma worse.

Severe asthma attacks
Severe asthma attacks can be life-threatening and require emergency treatment. If your asthma isn’t getting better with quick-relief medications (albuterol), seek emergency help right away. Work with your doctor ahead of time to determine what to do when your signs and symptoms worsen — and when you need emergency treatment.


How Asthma is Classified

To classify your asthma severity, the doctor will evaluate your answers to questions about symptoms (such as how often you have asthma attacks and how bad they are), along with the results of your physical exam and diagnostic tests. Determining the severity level of your asthma will help your doctor choose the best treatment for you. Asthma severity often changes over time, requiring an adjustment to treatment.

Asthma is classified into four general categories:

Asthma Classification
Signs & Symptoms
Mild intermittent Mild symptoms up to two days a week and up to two nights a month
Mild persistent Symptoms more than twice a week, but no more than once in a single day
Moderate persistent Symptoms once a day and more than one night a week
Severe persistent Symptoms throughout the day on most days and frequently at night


Treatment for Asthma

Asthma treatment generally involves avoiding the things that trigger your asthma attacks and taking one or more asthma medications. Treatment varies from person to person.
Medications used to treat asthma include long-term control medications, quick-relief (rescue) medications and medications to treat allergies. The right medication for you depends on your age and symptoms, and what seems to work best to keep your asthma under control.

  • Most people with persistent asthma use a combination of long-term control and long term-relief medications, taken with a hand-held inhaler.
  • Short acting “rescue” medications (broncho- dilators) should always be available in case of an acute asthma attack, but otherwise should NOT be used regularly.
  • You may need to try a few different medications before you find what works best.
  • Because asthma changes over time, you will need to work with your doctor to monitor your symptoms on a regular basis and learn how to make needed adjustments.
  • If your asthma symptoms are triggered by airborne allergens, such as dust mites, molds, pollen or pet dander, you may also need allergy immunotherapy treatment. (see ALLERGY section)


Long-term control medications

In most cases, these control medications need to be taken every day. The mainstay of treating asthma today is using either a plain inhaled steroid spray or powder (ICS) or a combination of this inhaled steroid and a long-acting beta-2 agonist (bronchodilator) (LABA), also either as a spray or powder.

Examples of these are:

Inhaled corticosteroids: Fluticasone proprionate (Flovent), Budesonide (Pulmicort), Triamcinolone (Azmacort), Beclomethasone (Qvar), Mometasone (Asmanex), and Fluticasone fuorate (Arnuity) and others. These medications reduce airway inflammation and are the most commonly used long-term asthma medication. Unlike oral corticosteroids, these medications are considered relatively low risk for long-term corticosteroid side effects. You may need to use these medications for several days to weeks before they reach their maximum benefit.

Long-acting beta-2 agonists (LABAs) are never used alone, but are used in combination with inhaled corticosteroids. These medications both open the airways and reduce inflammation. They are often used to treat more persistent or severe asthma. These long acting medications should not in the most part, be used for quick relief of asthma symptoms.

Quick-relief medications (rescue medications).

Types of quick-relief medications include:

Short-acting beta-2 agonists. These inhaled medications, called bronchodilators, ease breathing by temporarily relaxing airway muscles. They act within minutes, and effects last four to six hours. These medications are used as needed for rapid, short-term relief of symptoms during an asthma attack, or before exercise, if your doctor recommends it. These usually contain Albuterol. eg. Ventolin, Proventil, Proair and Zopinex.

Only use these medications as often as your doctor tells you to. If you need to use these medications too often, you probably need to adjust your long-term control medication. Keep a record of how many puffs you use each day.

A good rule of thumb of what excessive use is – when you are or becoming out of control, is the rule of 2’s –No more than 2 puffs a day, no more than 2 puffs a week and/ or no more than 2 puffs a month.

Obviously using 4 puffs a day breaks the rule, as does using your inhaler 4 times a week, or weekly – this means you are or getting out of control and you should consult your doctor.


Other medications:

Leukotriene modifiers
Montelukast (Singulair), Zafirlukast (Accolate) and Zileuton (Zyflo). These medications work by opening airways, reducing inflammation and decreasing mucus production. They’re considered a second choice to inhaled corticosteroids with or without a LABA, and need to be taken three or four times a day.

Ipratropium (Atrovent)
This is an inhaled anticholinergic for the immediate relief of symptoms, and is usually combined with Albuterol. Ipratropium is mostly used for emphysema and chronic bronchitis.

Oral and intravenous corticosteroids
These are used to treat acute asthma attacks or very severe asthma. Examples include prednisone and methylprednisolone. These medications relieve airway inflammation. They may cause serious side effects when used long term, so they’re only used to treat severe asthma symptoms or attacks when the use of either controller or recue inhalers are having little or no effect on asthma symptoms.


Medications for allergy-induced asthma:

In addition to the symptom controlling medications above, other medications that decrease the body’s sensitivity to a particular allergen or prevent the immune system from reacting to allergens can be used. . Allergy treatments for asthma do not differ from regular allergy treatment (see ALLERGY section), though anti-histamines have very little if any effect on asthma.

Immunotherapy
Allergy desensitization shots or drops gradually reduce your immune system reaction to the specific trigger (especially Dust mite allergens.)

Treating young dust mite sensitive children with dust mite immunotherapy has been shown in a number of clinical trials to help control asthma.

Biologics
This is a newer class of asthma medication used to treat more severe difficult to control asthma patients
eg. Anti-IgE monoclonal antibodies, such as omalizumab (Xolair). This medication reduces your immune system’s reaction to allergens. Xolair is delivered by injection every two to four weeks.