Asthma

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Asthma is a lung disease that narrows the lungs’ airway passages and leads to obstructed air flow. It can be episodic or chronic and can occur at any age.

Asthma occurs when the muscles around the midsized airways tighten (bronchospasm) and the size of the airway decreases. The tissue lining the airways swells and becomes inflamed. Cells may shed, causing further narrowing and plugging of the airways. There is also increased production of thick, sticky mucus, which clogs the airways in the lungs.

Symptoms

• coughing, particularly at night or early in the morning
• wheezing
• chest tightness
• shortness of breath, especially when lying down or exercising
• anxiety or restlessness

Not all of these symptoms are present in every individual with asthma or occur with every asthmatic episode. The intensity of symptoms ranges from mildly annoying to severely distressing; the latter requires medical attention. Asthma symptoms are reversible with medical treatment. Untreated asthma, however, may result in permanent changes in airway tissue.

Triggers

Many factors can bring on asthma symptoms or make them worse. Some common triggers include:

• allergens (any substance that triggers allergies) such as animals, dust mites, cockroaches, mold, pollen, or food (particularly shellfish or nuts)
• irritants: strong perfumes, smoke of any kind, sulfur dioxide, ozone, or other airborne chemicals
• weather changes, especially cold air
• exercise
• respiratory illnesses: a cold, sinusitis, or influenza
• medications: aspirin, ibuprofen, beta-blockers, and others
• stress, fatigue, or strong emotions
• heartburn
• menstruation and/or pregnancy

Treatment

The goals of asthma treatment include:

• few daytime symptoms
• no nighttime awakenings due to asthma
• able to keep up normal activity and exercise levels
• normal lung function
• prevent flare-ups and the need for emergency room visits or hospitalization
• minimize use of quick-relief medications
• few to no side effects from medication

Successful treatment of asthma requires three components:

• a quick-relief medication to use as needed for immediate relief of asthma symptoms
• the determination of the need for daily use of preventive medication to prevent worsening or exacerbation of asthma symptoms
• a plan for emergencies or worsening symptoms

Treatment is customized for each individual and may vary depending on triggers and severity of symptoms.

The following are common errors in treating asthma:

• failing to use enough medication
• not using medication soon enough when asthma worsens
• failing to use preventive medication when needed

Medications

Several classes of medication are used to treat asthma. Some are used alone, but often a combination of medications is necessary. It is important to understand which medications provide immediate, short-term relief and which provide more sustained, long-term preventive control of symptoms.

Quick-relief medications

SABAs (short-acting beta2-agonists) and anticholinergic medications provide quick relief by relaxing the muscles around the tightened airways, making breathing and mucus removal easier.

Quick-relief medications are usually inhaled through a hand¬held device that the person with asthma uses to deliver the dose. Some of these medications can be dispensed as a fine mist using a treatment device called a nebulizer.

The most common medications used for short-term, quick-relief and prevention of exercise-induced asthma symptoms include inhaled SABAs: albuterol (Proventil, Ventolin), pirbuterol (Maxair), and levalbuterol (Xopenex). Using any of these medications more than twice a week (except for the prevention of exercise-induced symptoms) means that the asthma is not sufficiently controlled and indicates a need for starting or increasing anti-inflammatory medication.

Ipratropium (Atrovent) is an inhaled short-acting anticholinergic bronchodilator that acts on the smooth muscles of the large airways and is sometimes used for treating asthma. One type of inhaler combines both ipratropium and albuterol.

A person may feel jittery or restless and the heart may beat stronger and faster when using bronchodilators. These side effects are most noticeable for the first 10 to 15 minutes after inhaling the medication.

Inhaled corticosteroids

Inhaled corticosteroid medications play a major role in preventing asthma, especially when allergies are involved. They dramatically reduce inflammation, swelling, and mucus production in the airways, and can help other asthma medications work better. They must be used regularly—it takes several days to notice benefits.

Inhaled corticosteroids do not provide quick relief and should not be used during an asthma attack. They are always preventive. They are not well-absorbed except in the lungs and, therefore, have minimal side effects. Long-term use at a high dosage can cause more side effects.

Always rinse the mouth with water after each use to prevent fungal infections.

Low-, medium-, and high-potency forms are available.

Beclomethasone (Vanceril, Beclovent), budesonide (Pulmicort), flunisolide (AeroBid), fluticasone (Flovent), and triamcinolone (Azmacort) are the most common.

Long-acting bronchodilators

Long-acting bronchodilators are used in conjunction with inhaled steroids and should never be used alone.

These medications are similar to the short-acting drugs except they do not provide quick relief; they have a more long-term, preventive effect. They are especially helpful for night-time symptoms.

Fluticasone or budesonide combined with a long-acting bronchodilator can control asthma symptoms at a lower dose of steroid (Advair, Symbicort).

Oral corticosteroid

A corticosteroid pill is occasionally prescribed for five to ten days for moderate and severe asthma exacerbations. These drugs should be taken with food.

Short-term use may cause side effects including increased appetite, heartburn, mood changes, fluid retention, high blood sugar, elevated blood pressure, stomach irritation, and difficulty sleeping.

Leukotreine modifiers

These are newer medications that interfere with leukotreines, potent chemicals that play a part in causing airway inflammation. These medications are used with inhaled steroids and are used for prevention, not for quick relief. They can lessen exercise-induced symptoms.

The pill form includes montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo).

Proper inhaler technique

Many people do not use their inhalers properly, resulting in inadequate treatment and increased side effects due to medicine landing on the tongue instead of in the airway. It is extremely important to use an inhaler properly. Bring the inhaler to a clinic appointment so the technique can be checked. A clinician can demonstrate proper use. Sometimes a spacer will be recommended. When attached to the mouthpiece of an inhaler, a spacer can increase the amount of medicine delivered to the airways.

Get ready.

1. Take off the cap and shake the inhaler.
2. Breathe out all the way.
3. Hold the inhaler one to two inches away from the lips. If using a spacer or holding chamber, seal the lips around the mouth piece.

Breathe in slowly.

4. Start breathing in slowly through the mouth and press down on the inhaler one time.
5. If using a spacer or holding a chamber, seal the lips around the mouth piece, press down on the inhaler, and breathe in slowly.
6. Keep breathing in as slowly and deeply as possible.

Hold breath.

7. Hold the breath while counting to ten slowly.
8. For quick-relief medicine (SABAs), wait about 15 to 30 seconds between puffs.

Other tips

Smoking: Smoking prevents the cleaning action of the cilia inside the lungs. Cilia are the tiny hairs in the lungs that constantly remove the mucus that traps dust, bacteria, and other foreign materials. Likewise, smoking makes it more difficult to clear the thick secretions of mucus that can occur during an exacerbation. Smoke itself irritates the lungs and can trigger bronchial spasms.

Any smoke (including tobacco, marijuana, clove, or any others) can worsen asthma symptoms. Talk to a clinician about quitting.

Medications: Medications cannot help unless taken properly. Take regularly and as directed for best results.

Hydration: Be sure to drink enough fluids, especially water. Fluids help liquefy the mucus in the lungs, making it easier to remove and easing breathing.

Flu shots: Getting a flu shot every fall will reduce the odds of an asthma exacerbation from influenza.

Avoid asthma triggers:

• Don’t smoke and avoid those who do.
• Avoid restaurants, bars, and other locations that do not provide smoke-free areas.
• Use dehumidifiers in basement areas to lessen mold.
• Avoid exposure to animals.
• Minimize dust as much as possible. Carpets can harbor dust mites and other allergens.
• Cover pillows and mattresses with allergen-reducing covers.
• Wash sheets and bedding weekly in hot water.

Exercise

With good asthma control, participating in any activity should be possible without experiencing symptoms. Exercise-induced symptoms should not limit participation or success in vigorous activities.

• Frequent or severe exercise-induced symptoms may indicate the need to start or increase long-term control medications.
• Using a SABA inhaler five minutes before exercise prevents symptoms for most people. The effects of this pretreatment should last two to three hours.
• Cromolyn (sodium cromoglycate) used before exercise is helpful for some people and lasts for one to two hours but is not as effective as a SABA.
• Some individuals have fewer exercise-related symptoms with daily use of a leukotreine inhibitor.
• A warm-up period before more vigorous exercise may reduce symptoms.
• If exercising in the cold, wear a mask or scarf over the mouth.

When to contact a clinician

Consult a clinician if any of the following are experienced:

• Usual medications are not effective for control of asthma. Using a quick-relief inhaler more than two times per week or at night can be an indication of the worsening of asthma.
• Asthma worsens suddenly or exercise becomes hard.
• Undesirable side effects of the medications occur.

[HU404 : updated 04/08]