Asthma is an inflammatory condition of varying severity that causes hyperreactivity of the bronchial airways. Patients experience episodes of bronchospasm, swelling of the bronchial tissues, and increased mucus, causing airway narrowing and plugging. Symptoms typically include variable amounts of cough, wheeze, difficulty breathing, inability to exercise, or inability to sleep through the night. There is a tendency for asthma to be inherited. A strong association with allergy is common in children and young adults with asthma, but only about 50% of all adults with asthma are allergic. Fortunately, with goal-oriented medical treatment and patient education emphasizing asthma prevention, the majority of patients can lead normal lives.
The immediate goal of treatment is to prevent the need for emergency room use and hospitalization—and to provide therapy such that patients can sleep through the night, attend work or school regularly, and participate in normal exercise and sports activities. Long-range goals are to desensitize against chronic allergic inflammation, avoid irreversible airway narrowing, and educate patients in fundamental principles of asthma management. Management includes appropriate environmental control and avoidance of asthma triggers, objective measurement of lung function, use of asthma preventive medications, recognition of early symptoms, and knowledgeable use of step-up treatment, such as an "asthma action plan."
Medicines are used to prevent and control asthma symptoms. Asthma medications are grouped in two classes: (1) Long-term control medications which are taken on a long-term basis to achieve and maintain control of asthma—these medications are also called long-term preventive, controller, or maintenance medications. (2) Quick relief medications which are taken to provide relief of symptoms of cough, wheeze, or shortness of breath—these medications are also called relievers or rescue medications.
EVERYONE WITH ASTHMA – even if it is mild, should carry a quick relief medication such as Proventil, Ventolin, albuterol or Maxair with them at all times.
These medications are taken daily on a long-term basis to achieve and maintain control of asthma. The three types of long-term control medications are:
Anti-inflammatory medications including inhaled corticosteroids (Flovent, Pulmicort, Asmanex, Azmacort, Q-Var, and Alvesco) and non-corticosteroids including nedocromil (Tilade) and cromolyn sodium (Intal). The corticosteroids are the most effective long-term-control medications for asthma. Nedocromil and cromolyn sodium are not as effective as corticosteroids, have more frequent dosing schedules, and have excellent safety profiles.
Long-acting bronchodilators (Serevent or Foradil) are used to control bronchoconstriction. They are not recommended for quick relief of asthma symptoms. These medications are used in addition to anti-inflammatory medication. There is a combination corticosteroid and long-acting bronchodilator called Advair.
Leukotriene modifiers (Accolate or Singulair) are mild asthma medications that come in pill or granule form that may decrease bronchospasm, mucus production, and inflammation.
Quick-relief medications are used for immediate relief of bronchoconstriction and asthma symptoms such as cough, chest tightness, and wheezing.
There are three types of quick-relief medication:
Short-acting beta2-agonists (Proventil, Ventolin, Maxair, Xopenex and albuterol), which rapidly relax airway smooth muscle in 10-20 minutes. These are the medications of choice in treating an asthma episode. Increased need for short-acting beta2-agonist and/or inadequate relief of symptoms for four hours, are warning signs of worsening asthma. If you need the beta2-agonist more than 2-3 times a week except prior to exercise, this is a sign of unstable asthma, and you need to talk with your provider promptly.
Anticholinergics (Atrovent, Combivent) are sometimes used in conjunction with short-acting beta2-agonists during an asthma episode.
Systemic corticosteroids (Prelone, Orapred, Pediapred, prednisone, Deltasone, Medrol) are potent anti-inflammatory agents used to treat flares of asthma. These agents take up to eight hours to become effective. The asthma action plan your provider will create for you/your child will give specific instructions on when to start this medication.
Occasionally, patients with severe asthma will need daily oral corticosteroids to manage their asthma. Oral steroids have many side effects and frequent use must be monitored closely by your/your child's provider.
Patients should never discontinue their preventive asthma medications without discussion with their doctor. In addition, if patients find that they are regularly using their as-needed medications more frequently than prescribed, that should be discussed with their doctor.
Some or all of the triggers listed below may be important in an individual patient, and the effects of each can combine with the others to provoke asthma:
ALLERGY. Exposure to materials (allergens) to which a patient has allergy can cause sudden or persistent symptoms from day to day. Such exposure can also cause the lungs to be more twitchy for several hours or days, or even every day if there is exposure on a regular basis (pets, dust mites, pollens, molds, etc.). One purpose of allergy testing is to identify these troublemakers so that they may be avoided.
RESPIRATORY INFECTIONS. Colds, viruses, flu, and sinus infections are common triggers of asthma. In these cases, the patient cannot escape the trigger, and a flare-up period of days to weeks may develop. An annual flu vaccine will help prevent or reduce flu symptoms and asthma flares. Sinus infections should be treated promptly and thoroughly.
EXERCISE. Some patients have asthma only with exercise. Most patients with frequent asthma also have exercise-induced bronchospasm (EIB). This typically begins 5-10 minutes after beginning continuous aerobic-type activity. Activity in dry, cold air tends to provoke EIB more often than does warm, humid air. (For example swimming is less likely to cause an attack.) In patients with recurrent EIB, it is best to prevent attacks with inhaled bronchodilator and/or cromolyn/nedocromil 10-20 minutes before exercise. Patients with asthma should be encouraged to participate in athletics if at all possible, even if added use of bronchodilators is required.
IRRITANTS. Smoke, smog, and strong fumes or odors are particularly irritating to the asthmatic patient and may trigger asthma symptoms. Chronic indoor air pollution produces chronic asthma inflammation. Every effort and consideration should be made to eliminate cigarette smoke exposure. There should be no smoke in the home or in the car when asthma patients are present. Kerosene space-heaters and smoke from fireplaces are frequent troublemakers.
HEIGHTENED EMOTION. Laughing, crying, or simply strong emotional reaction may trigger an asthma reaction, but this should not affect usual interpersonal relationships.
RAPID WEATHER CHANGES. These are associated with asthma flares in some patients, particularly during cold and rainy weather fronts.
ASPIRIN. Nearly 10% of asthmatic patients experience severe asthma after taking aspirin or related drugs (Advil, Motrin, ibuprofen, Aleve, Indocin, etc.). About 20% have measurable asthma without obvious symptoms. Therefore, it is best for all asthma patients to avoid aspirin unless instructed otherwise.
GASTROESOPHAGEAL REFLUX DISORDER (GERD). GE reflux is a common condition in which vapors and materials from the stomach come back up into the esophagus. Transportation of respiratory mucus, saliva, food, and drink may become impaired. Signs of reflux include heartburn, overt regurgitation of fluid or food particles, throat irritation, hoarseness, cough, sensation of lump in the throat, pain or difficulty swallowing, and breath odor. The dynamics of asthma and some of the medicines used to treat asthma may provoke reflux. Studies show that 50-80% of patients with moderate or severe asthma have measurable GERD with or without typical reflux symptoms. Among those with symptoms, treating the reflux reduces chest symptoms, and controlling the asthma reduces reflux problems.
THE ASTHMA "FLARE-UP"
The need for long-term daily asthma medicines is best determined by the physician, but the treatment of asthma flares is, by necessity, first in the hands of the patient. In order to respond appropriately, you must be able to
Identify situations that may trigger or provoke asthma;
Recognize symptoms of an impending or actual attack;
Know which medicine(s) to use to treat or prevent asthma and when and how to use the medicine(s);
Monitor peak flow values;
Follow the Asthma Action Plan;
Decide when it is necessary to go to the emergency room or call your doctor;
Communicate accurately the asthma medicines being used and details of the attack, including peak flow values.
THE ASTHMA ACTION PLAN AND PEAK FLOW METERS
An Asthma Action Plan (AAP) focuses on early recognition of unstable or deteriorating asthma by monitoring Peak Flow (PF) and/or symptoms and includes written instructions that detail when and how to increase treatment during an exacerbation of asthma.
The essential components of an AAP include the following:
Collaboration and open communication with your healthcare provider;
Early recognition of worsening control;
Self-administered step-up therapy;
When to start oral steroids;
When to seek help.
Early recognition of asthma flare-up is the key to good treatment. Most flares are not severe, but repeated episodes deteriorate the quality of life and lead to more difficult asthma later. Once started, an asthma flare may become quite severe or may result only in repeated coughing without any wheeze. It is easier to stop asthma symptoms at the early and mild coughing stage.
Once an asthma flare-up is recognized, the AAP should be followed. The goal is to treat asthma flares before they reach the severe stages. The regular use of a peak flow meter can help patients, parents, and physicians with early recognition and timely control of asthma symptoms. A peak flow meter is a simple tool that measures the forced expiration of air from the lungs. This measurement is useful in developing an asthma management plan. The benefits of peak flow monitoring are potentially great. The peak flow meter gives the asthma patient a way to objectively assess his/her own condition, and monitoring allows for improved communication between patient and doctor. Routine use of the peak flow meter allows the person with asthma to detect the earliest stages of airway obstruction and to take measures to reverse the obstruction before it becomes too serious.
The peak flow meter removes much of the guess work from asthma management. Parents who once struggled with decisions such as when to administer medications, when to keep a child home from school, and when to take the child to the doctor, find they are able to make these decisions more easily based on the objective data provided by the meter.
In children, predicted peak flow rates are based on height; in adults, on height, age, and sex. However, the "true" 100% rate for a patient is the personal best Peak Expiratory Flow Rate (PEFR) during symptom-free intervals and is derived from daily monitoring. During exacerbation, this "usual best peak flow" is the 100% reference point. Severity of asthma flare-up and PEFR reduction can be divided into three zones of risk: green (80% PEFR or better), yellow (50 to 80% PEFR), and red (less than 50% PEFR).
Finally, PEFR measurement is sometimes useful to distinguish symptoms that can mimic asthma without actually producing air flow obstruction. Examples are hyperventilation, esophageal sensations, and cough from other conditions.
Early Warning Signs of Asthma Flare
Increase in exercise-induced asthma symptoms
Frequent or regular night-time awakenings with asthma symptoms
Increase in the requirement for bronchodilator medications
Bronchodilator medications not working well
Decrease from normal peak flow values
In summary, asthma is an inflammatory condition with potential for both acute and long-term problems. In many cases, overall severity can be reduced with avoidance of allergens and irritants, allergy injection therapy (when indicated), and regular use of daily asthma preventive medicines. Asthma flares or sudden attacks can often be managed successfully by the patient, rather than being a frightening experience with the patient rushing to the emergency room. Poorly controlled asthma is due to persistent inflammation, which requires anti-inflammatory medication. Form a partnership with your provider to keep your asthma in good control, and, thus, have a healthier and happier life!