What is Asthma?
Asthma is a chronic lung disease where the linings of the airways become swollen and inflamed and muscle spasms restrict the flow of air to the lungs. There is increased sensitivity of the airways to a variety of triggers that can cause airway narrowing or obstruction. The airways can become so narrow that air has trouble moving in and out of the lungs leading to symptoms of wheezing and difficulty breathing.
Research shows that inflammation of the lining of the airways is a major characteristic of asthma. When exposed to triggers, cells lining the airways release chemical substances like histamine and leukotrienes which lead to inflammation which cause the airway lining to swell and narrow the opening. Most people with asthma have some degree of inflammation all the time whether or not they feel short of breath or have wheezing. Medications that prevent or control inflammation are called “anti-inflammatory“.
Another characteristic of asthma is increased sensitivity of the airways. Increased sensitivity leads to muscle spasm around the airways and further narrowing of the airway opening. This is relieved by medications called “bronchodilators“.
When inflamed airways react to a trigger, the mucous glands in the swollen and narrowed airways produce extra thick mucus which plug up and further block the airways. Corticosteroid medications and other anti-inflammatory medications decrease swelling and lessen mucus production.
What Causes Asthma?
The exact cause of asthma is not completely understood, bu it is known that the airways of a person with asthma are more sensitive to triggers in the environment. Some of the most common triggers include exposure to allergens (pollen, dust, mold, pet dander); irritants in the air such as smoke, gas, odors; infections such as colds, flu, and sinusitis; exercise; emotional stress; cold air; sensitivity to aspirin and additives like sulfites; hormonal changes; and gastroesophageal reflux.
Many substances, while not allergens, can irritate sensitive airways. Cigarette smoke is one of the most common of all irritants and is a strong asthma trigger. No one should smoke in the home of a person with asthma. Aerosol sprays, perfumes, cleaning products and other strong odors should also be avoided.
Asthma Signs and Symptoms
The narrowing of the airways during an asthma attack produces the following symptoms: cough, wheeze, shortness of breath, and chest tightness.
Asthma symptoms can vary at different times and range from mild to severe. Some people with asthma have only occasional or seasonal symptoms. Other have daily symptoms while some have “asthma attacks” when symptoms seem to develop suddenly. You can learn to recognize signals so you can take precautions and lessen the severity of an episode. It is important to recognize and treat even mild symptoms. This helps lessen the amount of inflammation and reduces the risk of a more serious episode. Asthma is a serious and possibly life-threatening condition if not properly treated.
You may receive clues that an asthma episode is developing before breathing difficulty begins. These clues are called early warning signs. Some common early warning signs include: chest tightness, sleeping difficulty (coughing or wheezing at night), diffculty taking a deep breath, and fatigue. The Asthma Control Test helps you monitor if your asthma is getting worse.
Another way to monitor your asthma is to use a device called a peak-flow meter. Blowing into this device reveals how well your lungs are working and can alert you to an asthma flare. Peak flow measurements will decrease within hours or days before an asthma episode. Monitoring peak flow values on a daily basis will identify this drop and help you take steps to prevent an impending episode. Asthma specialists use the zone system similar to the colors of a traffic light and will mark the values, specific to the patient, according to the following zones:
Green zone- all clear and indicates good lung function
Yellow zone- signals caution and additional medication is needed
Red zone- signals a medical alert which requires immediate medication and emergency medical treatment
AAAI tip: What is a peak flow meter?
Take the Asthma Control Test
Because there is no cure for asthma, you must learn to manage the disease so that a normal life is possible. With such control, you can transform asthma from a major disruption to a minor annoyance. Treatment consists of 2 approaches:
1. Evaluating the triggers and directing treatment toward the control or removal of those triggers. This means making changes in your environment. (See Avoiding Allergy Triggers) especially if you are allergic.
2. Lessening inflammation and sensitivity of the airways with medication.
There are many excellent medications for treating asthma. Some are used to prevent asthma symptoms and attacks and reduce inflammation in the airways. Others relieve symptoms. Most of the medications fall into 2 major groups:
1. Quick Relief medications- also called “Bronchodilators”, these medications work quickly to open the airways and make it easier to breathe right away.
a. Short Acting Bronchodilators:
- Relax muscles that tighten around the airways and loosen mucus
- Help stop flare-ups once they’ve started
- Help prevent asthma flare caused by exercise
- Are available in metered dose inhalers (Proventil, Max-Air, Ventolin, albuterol, Xopenex); dry powder inhalers (Proventil HFA, Albuterol HFA), nebulizer solutions (DuoNeb, albuterol, Xopenex), and tablets (albuterol)
- Bronchodilators belong to the “beta-agonist” class of medications. They begin working within a few minutes and last 4-6 hours
- Side effects include: tremors, palpitations, nervousness, dizziness, and increased blood pressure
- Short acting bronchodilators should be used as prescribed on an “as needed” basis to relieve symptoms
2. Long Term Control Medications- help keep asthma under control and reduce chances of having a flare-up. Long-term control medications will not stop a flare-up once it has begun and to work properly, must be used regularly on a daily basis. It is also important to remember that these medications do not work quicly like bronchodilators and must be taken regularly for several days to weeks before you notice improvement.
a. Anti-Inflammatory Medications- Reduce inflammation causing the swelling, mucus production, and increased sensitivity to triggers in the asthmatic airways. These medications include:
- Corticosteroid inhalers (Flovent, Advair, Asmanex, Pulmicort, Symbicort, Q-Var)
- Systemic steroids tablets/ syrup and injection (prednisone, Medrol, Decadron, Solumedrol)
- Leukotriene antagonists tablets (Zyflo,Singulair, Accolate)
b. Long Acting Bronchodilator inhalers (Serevent, Advair, Foradil, Symbicort)
- Work by relaxing mucles that tighten around airways
- Unlike short-acting bronchodilators, they work more slowly but for a longer period of time
- They control nighttime symptoms and symptoms related to exercise
- It is very important to remember that these medications will not stop an asthma flare-up in progress and can not be used as emergency medications like the short acting bronchodilators.
- Side effects are less than short-acting bronchodilators but include palpitations, tremors, headache, insomnia, and nervousness
c. Theophylline (Theodur)
Theophylline comes in tablet or liquid form and has been used to treat asthma for more than 40 years. Long acting theophylline is prescribed for many breathing conditions and is helpful for people who have nighttime asthma symptoms or need high doses of oral or inhaled steroids. However, it has many side effects which can be dangerous when used with other medications. Side effects include:
- Stomach ache
- Trouble sleeping
- Seizures/ convulsions
When used and monitored properly under a doctor’s care, it is a safe and useful medication for asthma treatment.
If you are taking theophylline, be sure to remind your pharmacist and physician of this specially when they are giving you new medications such as antibiotics or antifungals.
d. Xolair (Omalizumab)
XOLAIR is a new type of medication, called a monoclonal antibody, the first to treat the attacks and symptoms of allergic asthma by blocking immunoglobulin E (IgE), an underlying cause of allergic asthma. It is given in the form of an injection that the patient receives every 2-4 weeks. It is given to asthma patients who have severe disease or who are not well controlled on their other controller medications such as inhaled steroids, long-acting bronchodilators, and leukotriene antagonists.
(See AAAI: Allergy and Asthma Medications)
TREATING OTHER FACTORS:
1. ALLERGY IMMUNOTHERAPY (ALLERGY INJECTIONS):
If you are allergic, it is recommended that you avoid your allergens as much as possible. This can be difficult if you are allergic to mold spores, dust mites, and pollen. Allergy medications help control symptoms. If these medications are not effective, if you develop side effects that prevent you from taking these medications, or if you have to take medications daily for more than 6 months during the year, consider immunotherapy.
Allergy immunotherapy has been shown to reduce symptoms associated with allergic rhinitis related to pollen, pets, molds, and dust mites and prevent the development of asthma. (See AAAI tip, “What are Allergy Shots?”)
2. SINUS CARE
Many people with asthma also have chronic sinusitis. This interferes with normal sinus drainage and cause increased mucus production. This drainage from the nose and sinuses (or post-nasal drip) may cause increased reactivity in the lungs. Sinusitis is a common trigger for asthma, especially at night and a sinus infection can trigger an asthma flare-up. Treating the sinus infection and decreasing post-nasal drip reduces cough and inflammation. Treatment can include antibiotics, nasal wash, steroid nasal spray or sinus surgery in severe cases.
(see AAAAI tip: Sinusitis)
3. GASTROESOPHAGEAL REFLUX (HEARTBURN)
In some people, the valve between the esophagus and stomach allows leakage of stomach acid into the esophagus causing heartburn. The acid may trigger a reflex response that results in coughing and airway spasm in people with asthma. This is a common cause of asthma symptoms especially at night or after meals. Treatment for reflux include measures such as weight loss, avoiding food and liquids at least 3 hours before bedtime, and medications to decrease or neutralize the acid.
4. VIRAL RESPIRATORY INFECTIONS
Viral respiratory tract infections (“colds”) damage the lining of the airways and increase airway reactivity and inflammation. People with asthma usually experience increased symptoms and often need additional medications when they have viral URIs. Prevention includes frequent hand washing or use of antibacterial wipes/ gels especially during the flu season or when coming in contact with someone who is sick. Yearly flu vaccination is recommended.
Exposure to certain hazards at work can cause asthma. Some chemicals can act as sensitizers and induce allergic reactions in the airways. Complete avoidance is often the only solution. More often, other chemicals act as airway irritants, triggering symptoms in workers who have asthma or who are exposed to high concentrations of chemicals. Better ventilation, respiratory protection, or moving to another area within the workplace may help control asthma from these sources.
(See AAAAI tip: Occupational Asthma)
6. SENSITIVITY TO ASPIRIN/ NSAIDS OR FOOD ADDITIVES
Some people with asthma have unexpected asthma flares to normally harmless medicines and other chemicals. One example is aspirin and aspirin-like medications (NSAIDs) such as ibuprofen. These patients develop severe wheezing, nasal congestion, sneezing and sinusitis when exposed to aspirin. Treatment consists of aspirin desensitization.
A small percentage of persons with asthma also react negatively to metabisulfite, a preservative sometimes added to dried fruits, processed foods, and vegetables, wine, and beer. If you are sensitive to sulfites, avoid foods and beverages that contain these preservatives. It is important to read labels on food and over the counter medications to determine if sulfites, aspirin, or NSAIDs are included.
Some medications can also trigger asthma or make it worse in asthmatic patients. Ask your doctor for a list of medications to avoid. One of these is a group of blood pressure/ glaucoma medications called beta-blockers.
A true asthmatic/ allergic reaction to chemicals or medications must be documented and verified by an allergy specialist before labeling a patient as “allergic”. (See Multiple Chemical Sensitivity Syndrome)