A Thorough Look at Managing Asthma

Asthma may develop at any age, although the majority of people are diagnosed in childhood. There is often a strong family history of asthma or allergies. Asthma can be very mild in some people, and vary to the extreme of severe and life-threatening (and even death) in some people.

Definition – a reversible inflammatory disorder of the airways, often triggered by allergen exposure, exercise, and cold air

Diagnosis is based on 2 key elements:

• The first is a history or presence of respiratory symptoms that are consistent with asthma. E.G. wheezing and coughing (typically worse at night), and/or shortness of breath (that are better with a bronchodilator like albuterol)

• The second is the demonstration of variable airflow obstruction (by formal pulmonary function testing or in office or at home peak expiratory flow measurement=peak flow).

Other conditions which may simulate asthma – post nasal drip syndrome (can cause upper airway wheeze-like sounds), gastroesophageal reflux disease (GERD), post-viral cough, habitual/psychological cough, vocal cord dysfunction, panic disorder, cough from ACE inhibitor blood pressure medicines, COPD (emphysema), and congestive heart failure

Treatment & Management

1. Monitoring of patients with asthma – symptom assessment and office/home monitoring with peak flow meters

2. Patient Education – learn how to monitor their symptoms and pulmonary function, and use their medicines

3. Controlling Triggers – this can help decrease need for medications, and patients need to be aware and decrease trigger exposure like:

• Allergens at home, workplace, daycare, or school, indoor allergens (dust mites, animal dander, molds, cockroaches)

  • Consider formal allergy testing.

• Respiratory irritants (tobacco smoke, wood smoke, cleaning products, perfumes, air pollutants)

• Medical conditions that can worsen asthma like:

  • Sleep apnea

  • GERD

  • Obesity

  • Rhinitis/sinusitis

  • Vocal cord dysfunction

  • Depression

  • Chronic stress

• Medications that can worsen asthma:

  • Blood pressure medicine

  • Beta blockers

  • Aspirin in some people

4. Medicine Treatment for Asthma

• The goal is to minimize symptoms, reduce the chance of bad outcomes (hospitalizations or loss of lung function), and minimize adverse effects from medicines

• Inhaled medicines can be taken in metered dose inhalers (some can be used with a spacer for younger children) and in an aerosol nebulizer breathing treatments

• Treatment depends upon the asthma severity–

  • intermittent asthma (symptoms less than 2 days/week, and usually just needing a rescue inhaler=short acting bronchodilator as needed)

  • mild persistent asthma (symptoms greater than 2 days/week-usually treated with a low dose inhaled cortisone or Singulair)

  • moderate persistent asthma (symptoms daily-usually treated with a medium dose inhaled cortisone and long acting bronchodilator or Singulair)

  • severe persistent asthma (symptoms throughout the day – usually treated with a high dose inhaled cortisone with long acting bronchodilator and Singulair, and often additional medicines)

• Rescue Inahlers – short acting bronchodilators

  • All asthma patients need to have one available when/if needed for cough/wheeze/shortness of breath flares, and can be used a maximum of 4x/day for not longer than 1 week, and if needed 4x/day for more than 1 day you must see your physician- only brand name metered dose inhalers are now available in the U.S. because of regulations that they need to be ozone friendly

  • Brand names are: Proventil HFA, Ventolin HFA, ProAir HFA, and Xopenex HFA, the least expensive available is a small size Ventolin HFA which you can get only at Walmart and Target pharmacies, and if needed due to cost, you can get generic ones at www.medisave.ca– generic albuterol solution is available for nebulizers (and brand name Xopenex is also available for nebulizers)

Daily Controller Medicines

• Inhaled Glucocorticoid (cortisone)-the most potent anti-inflammatory agents available for asthma treatment

  • Rinsing the mouth is required after using to avoid developing thrush/yeast infections

  • Brand names include: Flovent-Pulmicort-Qvar-Asmanex-Azmacort and AeroBid

• Inhaled Glucocorticoids with Long Acting Bronchodilators

  • Advair (available in a powder round inhaler, or HFA inhaler)

  • Symbicort

• Long Acting Bronchodilators – must be used only along with a cortisone inhaler

  • Serevent

  • Foradil

• Leukotriene Receptor Antagonists – decrease infammation and bronchoconstriction

  • Singulair

  • Accolate

• Chromones – decrease the early stages of asthmatic response/infammation

  • Cromolyn (available in inhaler and nebulizer)

• Theophylline – has both bronchodilatory and anti-inflammatory properties, but

  • Can have irritating and serious side effects

  • Requires blood tests to keep the blood level adequate (want 5-15mcg/ml)

• Oral Glucocorticoids(cortisone) – A short 7-10 day course can be required for asthma flares, or rarely for long term asthma control