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Asthma
Introduction

Asthma occurs when the main air passages of your lungs, the
bronchial tubes, become inflamed. The muscles of the bronchial walls
tighten, and cells in the lungs produce extra mucus further narrowing
your airways. This can cause minor wheezing to severe difficulty in
breathing. In some cases, your breathing may be so labored that an
asthma attack becomes life-threatening.

Asthma is a chronic but treatable condition. You can manage your

condition much like someone manages diabetes or heart disease. You
and your doctor can work together to control asthma, reduce the
severity and frequency of attacks and help maintain a normal, active
life.

Mechanism
If you have asthma, the inside walls of the airways in your lungs are
inflamed and swollen. This makes the muscles surrounding your
airways very sensitive, so they tighten and constrict spontaneously. In
addition, membranes in your airway linings secrete excess mucus. The
result is narrowed airways and obstructed airflow that typically lead to
coughing, wheezing and shortness of breath.

Signs and symptoms

Asthma signs and symptoms can range from mild to severe. You may
have only occasional asthma episodes with mild, short-lived symptoms
such as wheezing. In between episodes you may feel normal and have
no difficulty breathing. Some people with asthma have chronic
coughing and wheezing punctuated by severe asthma attacks.

Most asthma attacks are preceded by warning signs. Recognizing

these warning signs and treating symptoms early can help prevent
attacks or keep them from becoming worse.

Warning signs and symptoms of asthma in adults may include:

• Increased shortness of breath or wheezing

• Disturbed sleep caused by shortness of breath, coughing or

wheezing

• Chest tightness or pain

• Increased need to use bronchodilators — medications that open

up airways by relaxing the surrounding muscles

• A fall in peak flow rates as measured by a peak flow meter, a

simple and inexpensive device that allows you to monitor your
own lung function

Children often have an audible whistling or wheezing sound when

exhaling and frequent coughing spasms.
Causes

Asthma is probably due to a combination of environmental and genetic

factors. You're more likely to develop asthma if it runs in your family
and if you're sensitive to environmental allergens or irritants. Early,
frequent infections and chronic exposure to secondhand smoke or
certain allergens may increase your chances of developing asthma.

Exposure to various allergens and irritants may trigger your asthma

symptoms. The following are common things that trigger asthma
symptoms:

• Allergens, such as pollen, animal dander or mold

• Cockroaches and dust mites
• Air pollutants and irritants
• Smoke
• Strong odors or scented products or chemicals
• Respiratory infections, including the common cold
• Physical exertion, including exercise
• Strong emotions and stress
• Cold air
• Certain medications, including beta blockers, aspirin and other
nonsteroidal anti-inflammatory drugs
• Sulfites, preservatives added to some perishable foods
• Gastroesophageal reflux disease (GERD), a condition in which
stomach acids back up into your esophagus. GERD may trigger
an asthma attack or make an attack worse.
• Sinusitis

Risk factors

Approximately 14 million adults and 6 million children in the U.S. have

asthma. In fact, asthma is the most common chronic illness of
childhood and a common reason for missed school days. Asthma is
more common in boys than in girls. But after puberty asthma is more
common in females.

A number of factors may increase your chances of developing asthma.

These include:

• Living in a large urban area, especially the inner city, which may
increase exposure to environmental pollutants
• Exposure to secondhand smoke
 • Exposure to occupational triggers, such as chemicals used in
farming and hairdressing, and in paint, steel, plastics, and
electronics manufacturing
• Having one or both parents with asthma
• Respiratory infections in childhood
• Low birth weight
• Obesity
• Gastroesophageal reflux disease (GERD)

When to seek medical advice

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

• If you think you have asthma. Wheezing, difficulty breathing,

pain or tightening in your chest, or coughing are common signs
and symptoms of asthma. Wheezing, especially, is a frequent
sign of asthma in children. However, some people with asthma
never wheeze. Instead, they have recurrent, spasmodic coughs
that are often worse at night. If you or your children have
frequent coughs that last more than a few days or any other
signs or symptoms of asthma, see your doctor.

• If you know you have asthma. If you know you have asthma,
talk to your doctor about ways to manage your condition.
Working as a team, you and your doctor can develop a plan to
help you control your signs and symptoms, prevent an attack or
stop an attack in progress. Don't try to treat asthma yourself.
Many asthma deaths result from a lack of proper treatment.

• If your medication isn't working. Sometimes your

medications may not offer the relief you need. Be sure to contact
your doctor right away if a prescribed dosage of medication
doesn't work for you. In some cases you may not be using your
inhalers correctly. Don't try to solve the problem by taking more
medication without consulting your doctor — overusing inhalers
or taking too much medication can be dangerous.

Screening and diagnosis

Diagnosing asthma can be difficult. Signs and symptoms can range

from mild to very severe and are often similar to those of other
conditions, including emphysema, early congestive heart failure or
vocal cord problems.
In order to rule out these and other possible conditions, your doctor
will likely use several tests to arrive at a diagnosis. In most cases
you'll be asked to give a complete medical history and have a physical
exam. You may also be given lung (pulmonary) function tests to
determine how much air moves in and out as you breathe.

The two most common tools to measure lung function are:

• Spirometer. A spirometer is used by a medical professional to

measure narrowing of your bronchial tubes. This device
measures the volume of air you can exhale after you've taken a
deep breath. A spirometer also shows how quickly you can get
air out of your lungs.

• Peak flow meter. A peak flow meter can be used at home to

help detect subtle increases in airway obstruction before you
notice symptoms. If the readings are lower than usual, it's a sign
your asthma may be about to flare up. Your doctor can give you
instructions on how to deal with low readings.

Lung function tests often are done before and after taking a
medication known as a bronchodilator to open your airways. If your
lung function improves with use of a bronchodilator, it's likely you
have asthma.

If there is uncertainty about a diagnosis of asthma, your doctor may

also recommend a methacholine bronchial challenge. If you have
asthma, inhaling a known asthma trigger called methacholine will
cause mild constriction of your airways, which can be measured with a
lung function test. A positive methacholine test supports a diagnosis of
asthma.

How asthma is classified

The results of your physical exam and diagnostic tests can help your
doctor classify how severe your asthma is, which helps guide how it
should be treated. The four main classifications of asthma are:

• Mild intermittent. This is the mildest form of asthma.

Generally, people with mild intermittent asthma have mild
symptoms up to two days a week and up to two nights a month.

• Mild persistent. You have mild persistent asthma if you have

asthma symptoms more than twice a week, but no more than
once in a single day.
 • Moderate persistent. If you have asthma symptoms once a
day and more than one night a week, you may have moderate
persistent asthma.

• Severe persistent. This is the most severe form of asthma,

causing symptoms throughout the day on most days and
frequently at night.

Complications

Asthma accounts for millions of missed school days and workdays each
year. It's also a common reason for emergency room visits and
hospitalizations. You can reduce your risk of severe attacks by making
sure your asthma is well controlled and by knowing how to recognize
and treat attacks before they occur.

Controlling your asthma can also help you avoid serious side effects
from long-term use of some medications used to stabilize severe
asthma. Using inhaled corticosteroids, which have fewer side effects
than oral corticosteroids, can help you reduce the need for emergency
treatment of asthma.

Treatment

There are several types of medications available for treating asthma.

Most people use a combination of long-term control medications and
quick relief medications. Your doctor can help you decide which option
is best for you based on your age and the severity of your symptoms.
In general, the main types of asthma medications are:

• Long-term-control medications. These are used regularly to

control chronic symptoms and prevent asthma attacks.

• Quick-relief medications. You use these as needed for rapid,

short-term relief of symptoms during an asthma attack.

• Medications for allergy-induced asthma. These decrease

your body's sensitivity to a particular allergen and prevent your
immune system from reacting to allergens.
Long-term control medications

These medications are usually taken every day on a long-term basis,

to control persistent asthma.

• Inhaled corticosteroids. These anti-inflammatory drugs are

the most effective medications for asthma. They reduce
inflammation in your airways and prevent blood vessels from
leaking fluid into your airway tissues.

Corticosteroids help decrease the frequency of your attacks and

reduce the need for other medications you may use to control
your symptoms. Because inhaled corticosteroids control most
forms of asthma by delivering medication directly to your
airways, they have a lower risk of side effects than are
associated with oral corticosteroids. Inhaled corticosteroids
include fluticasone (Flovent), budesonide (Pulmicort),
triamcinolone (Azmacort), flunisolide (Aerobid) and
beclomethasone (Qvar). Advair Diskus is a combination inhaler
containing fluticasone and salmeterol.

Side effects associated with inhaled corticosteroids can include

hoarseness or loss of voice, oral yeast infections (thrush), and
cough. Long-term use of inhaled corticosteroids may slightly
increase the risk of skin thinning, bruising, osteoporosis, eye
pressure and cataracts. In children, inhaled corticosteroids may
slow growth.

If you're using a metered-dose-inhaler form of corticosteroid, be

sure to use a spacer and rinse your mouth with water after each
use. This reduces the amount of drug that can is swallowed and
absorbed into your body. It also reduces side effects, such as
mouth and throat irritation and oral yeast infections (thrush).

• Long-acting beta-2 agonists (LABAs). These medications are

part of a group of medications called bronchodilators, which
open up constricted airways. Long-acting beta-2 agonists, such
as salmeterol (Serevent Diskus) and formoterol (Foradil), last at
least 12 hours. They're used to control moderate and severe
asthma and to prevent nighttime symptoms. Salmeterol or
formoterol are used on a regular schedule along with inhaled
corticosteroids and should not be used as the main treatment for
asthma.
 On Nov. 18, 2005, the Food and Drug Administration (FDA)
issued a public health advisory for three LABA medications,
stating the medications may increase the risk of severe asthma
episodes and possibly death if a severe asthma episode occurs.
The three asthma medications included in the advisory are:
Advair Diskus, Foradil Aerolizer and Serevent Diskus. If you
experience asthma attacks and you're taking one of these
medications, you'll need to talk with your doctor to determine
the best course of action.

• Leukotriene modifiers. These drugs reduce the production or

block the action of leukotrienes — substances released by cells
in your lungs during an asthma attack. Leukotrienes cause the
lining of your airways to become inflamed, which in turn leads to
wheezing, shortness of breath and mucus production.
Leukotriene modifiers include montelukast (Singulair) and
zafirlukast (Accolate).

Leukotriene modifiers are used with other medications — such as

inhaled corticosteroids — to help prevent asthma attacks.
Although generally not as effective as inhaled corticosteroids,
leukotriene modifiers are an option if you have mild asthma and
want to avoid corticosteroids.

• Cromolyn and nedocromil. Although they're not effective for

everyone, daily use of inhaled cromolyn (Intal) or nedocromil
(Tilade) may help prevent attacks of mild to moderate asthma.
They may also be used to help prevent asthma triggered by
exercise.

• Theophylline. You take this bronchodilator in pill form every

day. It may be helpful for relieving your nighttime symptoms of
asthma. But theophylline may cause side effects, such as nausea
and vomiting, severe abdominal pain, diarrhea, acid reflux,
confusion, fast or irregular heartbeat, and nervousness. If you're
taking theophylline, get regular blood tests to make sure you're
getting the correct dosage.

Quick-relief medications

Short-acting bronchodilators — often called "rescue" or "quick-relief"

medications —stop the symptoms of an asthma attack in progress. You
take these medications when you begin to have symptoms, such as
coughing, wheezing, chest tightness or shortness of breath. You may
also use short-acting bronchodilators to prevent an asthma attack
when your peak flow meter shows that your readings are lower than
normal.

• Short-acting beta-2 agonists. These bronchodilators begin

working within minutes and last four to six hours. But they can't
keep symptoms from coming back. The most commonly used
short-acting bronchodilator for asthma is albuterol.

• Ipratropium (Atrovent). Your doctor might prescribe this

anticholinergic for the immediate relief of your asthma
symptoms.

• Oral and intravenous corticosteroids for asthma attacks.

These corticosteroids — including prednisone,
methylprednisolone, hydrocortisone and others — may be taken
to treat acute asthma attacks or very severe asthma. They may
take a few hours or a few days to be fully effective. Long-term
use of these medications can cause serious side effects,
including cataracts, loss of bone mineral (osteoporosis), muscle
weakness, decreased resistance to infection, high blood pressure
and thinning of the skin. Asthma attacks can be life-threatening
and should be managed by a doctor.

Medications for asthma triggered by allergies

Other medications focus on treating allergy triggers for asthma and
include:

• Immunotherapy. Allergy-desensitization shots

(immunotherapy) may help if you have allergic asthma that can't
be easily controlled by avoiding triggers. You'll begin with skin
tests to determine which allergens trigger your asthma
symptoms, followed by a series of therapeutic injections
containing small doses of those allergens. You generally receive
injections once a week for a few months, then once a month for
a period of three to five years. Over time, you should lose your
sensitivity to the allergens. Immunotherapy isn't for everyone,
though. You're most likely to benefit if it's clear you have allergic
asthma. In addition, immunotherapy carries the risk of an
allergic reaction to the shot. Life-threatening reactions are rare
but possible.

• Anti-IgE monoclonal antibodies. If you have allergies, your

immune system produces allergy-causing IgE antibodies to
attack substances that generally cause no harm, such as pollen,
 dust mites and pet dander. If you have allergic asthma that's
difficult to control, omalizumab (Xolair) may reduce the number
of asthma attacks you experience by blocking the action of these
antibodies. That way your immune system isn't prompted to
react and cause the inflammation that makes breathing difficult.

Xolair is used in children over 12 years old and adults with

moderate to severe asthma caused by an allergy, if all other
treatments have failed.

Xolair is delivered by injection every two to four weeks. Risks

include the possibility of a severe reaction within two hours of
receiving the shot, blood-clotting problems, and a possible link
to cancer. That link is currently being studied. Also, if you're
pregnant or breast-feeding, tell your doctor beforehand.

Treatment by severity for better control

Treatment based on asthma severity can help you control your

asthma. According to guidelines from the American Academy of
Allergy, Asthma & Immunology and the American College of
Allergy, Asthma & Immunology, asthma therapy should be
flexible and based on changes in symptoms, which should be
assessed thoroughly each time you see your doctor. Then,
treatment can be adjusted accordingly.

For example, if your asthma is well controlled, your doctor may

prescribe less medicine. If your asthma is not well controlled or
getting worse, your doctor may increase your medication and
recommend more frequent visits.

Prevention

The best way to prevent asthma attacks is to identify and avoid indoor
and outdoor allergens and irritants. That's easier said than done
because thousands of outdoor allergens and irritants — ranging from
pollen and mold to cold air and air pollution — can trigger your
attacks. A number of indoor allergens, including dust mites,
cockroaches, pet dander and mold, can do the same. A common
asthma irritant is tobacco smoke.

Even if you reduce indoor and outdoor allergens and irritants,

managing asthma can be challenging. It often takes ongoing
communication and teamwork with your doctor. But by working
together, you and your doctor can design a step-by-step plan for living
with your condition. In addition to knowing and avoiding your triggers,
develop an action plan, monitor your breathing and treat attacks early.

• Develop an action plan. With your doctor and health care

team, write a detailed plan for taking maintenance medications
and managing an acute attack. Then be sure to follow your plan.
Asthma is an ongoing condition that needs regular monitoring
and treatment. Taking control of your treatment can make you
feel more in control of your life in general.

• Monitor your breathing. You may learn to recognize warning

signs of an impending attack, such as slight coughing, wheezing
or shortness of breath. But because your lung function may
decrease before you notice any signs or symptoms, regularly
measure your peak airflow with a home peak flow meter.

• Treat attacks early. If you act quickly, you're less likely to

have a severe attack. You also won't need as much medication
to control your symptoms. When your peak flow measurements
decrease and alert you to an impending attack, take your
medication as instructed and immediately stop any activity that
may have triggered the attack. If your symptoms don't improve,
get medical help as directed in your action plan.

Self-care

Although many people with asthma rely on medications to relieve

symptoms and control inflammation, you can do several things on your
own to maintain overall health and lessen the possibility of attacks:

• Exercise. You don't have to be sedentary if you have asthma.

Regular exercise can strengthen your heart and lungs so that
they don't have to work so hard. Aim for 30 minutes of exercise
on most days. If you've been inactive, start slowly and try to
gradually increase your activity over time. Keep in mind that
exercising in cold temperatures may trigger symptoms. If you do
exercise in cold temperatures, wear a face mask to warm the air
you breathe. And don't exercise in temperatures below zero.
Activities such as golf, walking and swimming are less likely to
trigger attacks, but be sure to discuss any exercise program with
your doctor.
• Use your air conditioner. Air conditioning helps reduce the
amount of airborne pollen from trees, grasses and weeds that
finds its way indoors. Air conditioning also lowers indoor
humidity and can reduce your exposure to dust mites. If you
don't have air conditioning, try to keep your windows closed
during pollen season.

• Decontaminate your decor. Minimize dust that may aggravate

nighttime symptoms by replacing certain items in your bedroom.
For example, encase pillows, mattresses and box springs in
dust-proof covers. Remove carpeting and install hardwood or
linoleum flooring. Use washable curtains and blinds.

• Maintain optimal humidity. Keep humidity low in your home

and office. If you live in a damp climate, talk to your doctor
about using a dehumidifier.

• Keep indoor air clean. Have a utility company check your air
conditioner and furnace once a year. Change the filters in your
furnace and air conditioner according to the manufacturer's
instructions. Also consider installing a small-particle filter in your
ventilation system. If you use a humidifier, change the water
daily.

• Reduce pet dander. If you're allergic to dander, avoid pets

with fur or feathers. Having pets regularly bathed or groomed
also may reduce the amount of dander in your surroundings.

• Clean regularly. Clean your home at least once a week.

Because cleaning stirs up dust, however, wear a mask or, if you
can, have someone else clean.

• Limit use of contact lenses. Try substituting eyeglasses for

your contact lenses when the pollen count is high. Pollen grains
can become trapped under the lenses.

• Control heartburn and gastroesophageal reflux disease

(GERD). It's possible that the acid reflux that causes heartburn
may damage lung airways and worsen asthma symptoms. If you
have frequent or constant heartburn, talk to your doctor about
treatment options.
Coping skills

Asthma can be challenging and stressful. You may sometimes become

frustrated, angry or depressed because you need to cut back on your
usual activities, to avoid environmental triggers. You may also feel
hampered or embarrassed by the symptoms of the disease and by
complicated management routines. Children in particular may be
reluctant to use a metered dose inhaler in front of their peers.

But asthma doesn't have to be a limiting condition. The best way to

overcome anxiety and a feeling of helplessness is to understand your
condition and take control of your treatment. Here are some
suggestions that may help:

• Identify the things that trigger your symptoms. This can be

one of the most important ways to take control of your life. Also
take peak flow measurements regularly and follow your action
plan for using medications and managing attacks.

• Pace yourself. Take breaks between tasks and avoid activities

that make your symptoms worse.

• Make a daily to-do list. This may help you avoid feeling
overwhelmed. Reward yourself for accomplishing simple goals.

• Talk to others with your condition. Chat rooms and message

boards on the Internet or support groups in your area can
connect you with people facing similar challenges and let you
know you're not alone.

If you have a child with asthma, be encouraging and supportive. Focus

attention on the things your child can do, not on the things he or she
can't do. Involve teachers, school nurses, coaches, friends and
relatives in helping your child manage an asthma condition.

Jun 1, 2006
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