Patient Education

 UNDERSTANDING YOUR ASTHMA

Copyright 2002, Regional Allergy & Asthma Consultants, PA

WHAT IS ASTHMA?

Asthma is a common lung disorder in which the inner lining of the small breathing tubes of the lungs, the bronchioles, becomes inflamed and swollen. At times this leads to spasms or narrowing of these tubes. This may cause wheezing, shortness of breath, and/or tightness of the chest. Cough, especially with exercise or in the middle of the night, is particularly common in asthma. In mild asthma, the only symptom may be cough. Wheezing may not occur, or may only be heard by your doctor listening with a stethoscope.

WHO GETS ASTHMA?

Asthma may develop at any age, but most commonly does so in early childhood, or mid-adulthood. Most cases that occur in childhood improve greatly over time and with appropriate treatment. Many cases that occur in adulthood respond well to treatment, but remain chronic.

Approximately one person in ten has asthma. Many people with mild asthma may not even be aware they have it. The tendency to asthma is often inherited, and is often strongly related to allergies, particularly in childhood. In over 70% of children with asthma, allergies cause or significantly aggravate their asthma.

WHAT CAUSES ASTHMA?

As with many medical conditions, a combination of heredity and environment plays the biggest role in both causing and aggravating asthma. The most common triggers of asthma are allergies, respiratory infections, exercise, and cigarette smoke.

The allergens that most commonly trigger asthma are inhalants, such as house dust mites, pollens, molds, and animal danders. When these allergens are inhaled into the lungs, they directly provoke asthma by inflaming the internal lining of the bronchioles, just as they cause swelling and mucus in the nose during an attack of "hay fever." Asthma is indirectly worsened by allergies for two reasons: first, nasal congestion interferes with the normal filtering and humidification of inspired air; and second, the postnasal drainage from allergies aggravates the cough and wheeze associated with asthma.

Indoor allergens (dust mites, mold, and animal dander) may provoke symptoms year-round, and often more severely during the winter months as people spend more time indoors. Pollen may provoke asthma in the spring, summer, and fall. Outdoor mold spores may cause problems in the summer, fall, or early winter. 

Viral respiratory infections commonly cause asthma to flare temporarily, especially in young children, and account for some of the wintertime worsening seen in this age group. Smoldering sinus problems will worsen asthma as well.  

Exercise, or any hyperventilation such as occurs with heavy laughter or emotional upset, will cause the bronchioles to tighten. This is because the asthmatic lung is overly sensitive to the sudden cooling and drying of the airway caused by rapid and deep breathing. For this reason, exercise in cooler weather often causes more trouble.

Cigarette smoking, both active and secondhand, is extremely harmful to patients with asthma. Smoke contains numerous toxic gases and particles that further irritate the already inflamed airway of the asthmatic. Children whose parents smoke in the home have four to five times more trouble with asthma, and are much more likely to require hospitalization or emergency room care than children not exposed to smoke. Cigarette smoking by asthmatics increases the severity of the asthma immediately, and further increases the likelihood of permanent lung damage.

HOW IS ASTHMA DIAGNOSED?

Asthma is usually suspected when the characteristic symptoms occur, especially at nighttime, with exercise, with colds, or with allergy flare-ups.  A favorable response to asthma medicines is suggestive as well. 

 

Definitive diagnosis and optimal treatment of each individual case requires not only periodic exams, but also measurement of lung function, starting by five or six years of age.  This is done by measuring the amount and rate of air flow from your lungs.  We often check to see how this changes after using an asthma inhaler.  These results, along with your progress since your last visit, allow us to customize and update your treatment plan.

 

Since allergies are a common trigger in up to 85% of individuals with asthma, we will usually perform allergy testing as part of the initial evaluation in order to optimize your treatment.  Chest x-rays, blood work, and other tests are rarely needed for the diagnosis and management of asthma, unless other medical problems are suspected.  Some other conditions can cause or aggravate asthma; in these cases we will work with your primary care physician to optimize your evaluation and treatment. 

HOW IS ASTHMA TREATED?

There are four general areas of asthma treatment.  We will often recommend a combination of more than one, or even all, of these depending on your unique situation. 

 

1.     Avoidance of allergens and irritants:  Depending on your history and the results of any allergy testing, we may recommend specific measures to reduce your exposure to the substances to which you are allergic.  This will help reduce the amount of medication you need to control your asthma.

 

All patients with asthma are significantly worse if exposed to cigarette smoke.  It is therefore mandatory that patients with asthma not smoke and that there be no smoking in their home, car, or workplace by others.  It is not adequate for other family members to smoke only in a designated room or area of the house, or to smoke only when the patient is away from home.  The fine cigarette smoke particles harmful to our airways stay airborne for up to 24 hours and rapidly spread throughout the entire home.  Even the most sophisticated and powerful air cleaning devices are quickly outpaced by cigarette smoke, and are not a substitute for always keeping smoking outdoors. 

 

2.     Treatment of underlying medical conditions:  Chronic sinus problems, stomach acid reflux, obesity, and other conditions may cause or aggravate asthma.  It is important that these problems be addressed in order to have ideal control of your asthma.  We will work with you and your primary care physician on these issues if needed.  Since viral infections are common triggers of asthma, we generally recommend yearly flu vaccinations for our patients with asthma who require daily preventive medications. 

 

3.     Medications:  There are two basic categories of asthma medications - the first are bronchodilators, which temporarily relieve symptoms by relaxing constricted bronchial tubes.  These are typically used only when needed.  The second are anti-inflammatory medications, which prevent or heal the inflammation inside the bronchial tubes.  These are generally used every day, even when you feel well. 

 

Most patients with asthma will require a bronchodilator for occasional, as-needed, use.  In more persistent or chronic asthma, we will also usually recommend daily preventive therapy with an anti-inflammatory medication.  Occasionally, patients with milder asthma will require anti-inflammatory therapy for short periods as with respiratory infections, or during their allergy season.  Most patients, however, do best with year-round use of these preventive medications. 

 

Bronchodilators:  Although available in both oral (tablet or syrup), and inhaled form, we generally prefer inhalers for adults and most children since these are easy to use, work quickly, and have minimal or no side effects.  Examples include Albuterol, Proventil, Ventolin, Maxair, Xopenex, Atrovent, and Combivent.  For very young children and the very elderly who are unable to use an inhaler adequately, we may prescribe a nebulizer machine. 

 

We may have our patients use their bronchodilator before heavy exercise as well as every four hours whenever needed for asthma symptoms.  Most bronchodilators have minimal side effects, but some patients may experience shakiness, heart racing, or hyperactivity.  In general, a patient who requires their bronchodilator more than once or twice a week, or needs it in the middle of the night more than once or twice a month, should be on an anti-inflammatory medication or temporarily increase their existing anti-inflammatory medication. 

 

Some bronchodilators are designed for regular, daily use (e.g. every 12 hours) rather than for acute symptom relief.  This type of medication, when needed, is generally prescribed in conjunction with an anti-inflammatory medication.  Examples include Serevent and Foradil.

 

Anti-inflammatory medications:  These medications are designed to be taken every day, even when you feel well, to prevent future asthma flare-ups and chronic lung damage.  These include inhaled medicines that need to be taken anywhere from 1-4 times per day, and tablets that are taken 1-2 times per day.  Some of the inhalers contain steroids, which in general are the most effective anti-inflammatory medications.  Examples include Flovent, Pulmicort, Azmacort, Aerobid, QVAR, Vanceril, and Beclovent.  Advair combines a steroid with a 12 hour bronchodilator.  These are not the type of steroid some athletes abuse, and, at standard doses, are not typically absorbed into the bloodstream enough to cause any significant side effects.  Instead, they act solely on the lining of the bronchioles, to relieve the swelling and inflammation of asthma, much like cortisone cream relieves a skin rash.  They need to be used regularly for at least several days to a few weeks to have much benefit, and are designed for long-term use.  Occasionally, patients may need these for only brief periods, but most patients do best with regular use.  In some cases, we may recommend that a patient on inhaled steroids temporarily increase the dose at the first sign of an asthma flare-up.  Side effects are rare, with the most frequent being a yeast infection inside the mouth.  This is minimized by using steroid inhalers with a spacer, and rinsing and spitting afterward.

 

Occasionally a brief course of oral steroids, in pill or syrup form, is needed to achieve control of an asthma flare.  Examples include Prednisone, Prelone, Orapred, and Medrol.  While this may cause short-term side effects (bloating, mood change, increased appetite), there are no lasting or permanent side effects associated with brief courses of oral steroids.  We do aim to minimize or eliminate the need for oral steroids by using inhaled steroids and/or other preventive anti-inflammatory medications regularly in patients with persistent asthma. 

 

There are also anti-inflammatory inhalers for asthma prevention that do not contain steroids.  Examples include Intal (Cromolyn) and Tilade.  We use these primarily in children, or in patients with mild asthma.  Like steroid inhalers, they need to be used regularly, but are less effective and sometimes need to be given up to 3-4 times per day for maximum benefit.  Side effects are negligible.

 

“Leukotriene modifiers” are tablets for oral use (given once or twice daily on a regular basis) that are quite effective in reducing asthmatic inflammation in some patients.  Examples include Singulair and Accolate.  These have the advantage of being very easy to administer and can be used in both adults and children.  They are sometimes used alone, and sometimes in conjunction with other anti-inflammatory medications.  When used alone they are generally less effective than inhaled steroids.  Side effects are minimal.

 

In some cases, particularly with moderate to severe asthma, or if you have difficulty determining how you or your child is doing from day to day, we will recommend using a device at home, called a peak flow meter, on a daily basis to monitor lung function much like diabetics measure their blood sugars.  This can guide you regarding when to adjust medications up or down, or signal when to call the doctor.  We usually recommend measuring peak flows in the morning before using any asthma medications.  It is also important to give your best effort and to use the same peak flow meter over time.

 

4.     Allergy immunotherapy injections: Allergy injections are the most effective long-term preventive strategy for allergy treatment.  In the many cases of asthma where allergies are a significant trigger, injections help decrease asthma symptoms, reducing the amount of medications needed to control asthma.  Injections build up your immunity to the exact items to which you are allergic, reducing your level of sensitivity to pollens, dust mite, molds, or animal danders.  They improve asthma directly by reducing the sensitivity of the lungs themselves to allergens.  They indirectly improve asthma by reducing inflammation of the nasal and sinus passageways, thereby reestablishing the normal filtration and humidification of inspired air that is so important for lung health.  In addition, they reduce postnasal drainage and sinus infections, which irritate the asthmatic lung.  The length of treatment depends on the nature and severity of the allergy.  Patients whose asthma symptoms interfere with work, school, recreation, or sleep, or who are allergic to substances that are hard to avoid should seriously consider injections for long-term control.  We will advise you as to whether injections would be best for your situation. 

WHAT IS CONSIDERED GOOD ASTHMA CONTROL?

We consider your asthma to be well-controlled if you have asthma symptoms no more than once or twice a week, and wake up in the middle of the night with asthma no more than once or twice a month. You should be able to do most anything you would like to do, and miss little (or no) work or school. With proper treatment, you should not have to go to the emergency room or be hospitalized for asthma. Your measured lung functions (peak flows at home and breathing tests in the office) should be stable and ideally normal for your age and height. We expect nothing but the best for you, so please let us know if you are not meeting these goals.

WHY IS IT IMPORTANT TO TREAT ASTHMA?

The day-to-day symptoms of asthma - cough, wheeze, shortness of breath, and interference with school, work, exercise, or sleep - are enough to warrant treatment; however, the potential long-term complications of asthma makes treatment even more important. We now know that asthma can cause permanent lung damage if not recognized and treated.  The inflammation of the small airways of the lungs that occurs with asthma can lead to scarring and stiffness of the lungs, much like with chronic smoking. Early intervention and treatment can prevent this from happening, as well as dramatically improve day-to-day symptoms that may occur with allergen exposure, exercise, infections, or sleep.

As always, we are here to maximize your long-term health and well-being and will work with you in a number of ways to most effectively meet that goal.

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Last updated 05/02/2002

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