Asthma

Definition
Asthma occurs when the airways in your lungs (bronchial tubes) become inflamed
and constricted. The muscles of the bronchial walls tighten, and your airways produce
extra mucus that blocks your airways. Signs and symptoms of asthma range from
minor wheezing to life-threatening asthma attacks.

Asthma can't be cured, but its symptoms can be controlled. Management includes
avoiding asthma triggers and tracking your symptoms. You may need to regularly
take long-term control medications to prevent flare-ups and short-term "rescue"
medications to control symptoms once they start. Asthma that isn't under control can
cause missed school and work or reduced productivity due to symptoms. Because in
most people asthma changes over time, you'll need to work closely with your doctor
to track your signs and symptoms and adjust your treatment as needed.

Symptoms
Asthma signs and symptoms range from minor to severe, and vary from person to
person. You may have mild symptoms such as infrequent wheezing, with occasional
asthma attacks. Between episodes you may feel normal and have no trouble breathing.
Or, you may have signs and symptoms such as coughing and wheezing all the time or
have symptoms primarily at night or only during exercise.

Asthma signs and symptoms include:

 Shortness of breath
 Chest tightness or pain
 Trouble sleeping caused by shortness of breath, coughing or wheezing
 An audible whistling or wheezing sound when exhaling
 Bouts of coughing or wheezing that are worsened by a respiratory virus such as a cold or
the flu
Signs that your asthma is probably getting worse include:

 An increase in the severity and frequency of asthma signs and symptoms

 A fall in peak flow rates as measured by a peak flow meter, a simple device used to check
how well your lungs are working
 An increased need to use bronchodilators — medications that open up airways by relaxing
the surrounding muscles

Work with your doctor to determine when you need to increase your medications or
take other steps to treat symptoms of worsening asthma and get your asthma back
under control. If your asthma keeps getting worse, you may need a trip to the
emergency room. Your doctor can help you learn to recognize emergency signs and
symptoms so you'll know when to get help.

Causes
It isn't clear why some people get asthma and others don't, but it's probably due to a
combination of environmental and genetic (inherited) factors.

Asthma triggers are different from person to person. Exposure to various allergens
and irritants can trigger signs and symptoms of asthma, including:

 Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust
mites
 Respiratory infections, such as the common cold
 Physical activity (exercise-induced asthma)
 Cold air
 Air pollutants and irritants such as smoke
 Certain medications, including beta blockers, aspirin and other nonsteroidal
anti-inflammatory drugs
 Strong emotions and stress
 Sulfites, preservatives added to some perishable foods
 Gastroesophageal reflux disease (GERD), a condition in which stomach acids
back up into your throat
 Menstrual cycle in some women
 Allergic reactions to foods such as peanuts or shellfish

Risk factors
Asthma is common, affecting millions of adults and children. A growing number of
people are diagnosed with the condition each year, but it isn't clear why. A number of
factors are thought to increase the chances of developing asthma. These include:

 A family history of asthma

 Frequent respiratory infections as a child
 Exposure to secondhand smoke
 Living in an urban area, especially if there's a lot of air pollution
 Exposure to occupational triggers, such as chemicals used in farming,
hairdressing and manufacturing
 Low birth weight
  Being overweight

When to seek medical advice

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

 If you think you have asthma. If you have frequent coughs that last more
than a few days or any other signs or symptoms of asthma, see your doctor.
Treating asthma early, especially in children, may prevent long-term lung
damage and prevent worsening of the condition over time.
 To monitor your asthma after diagnosis. If you know you have asthma,
work with your doctor to keep it under control. Good asthma control not only
helps you feel better on a daily basis, but also can prevent a life-threatening
asthma attack.
 If your asthma symptoms get worse. Contact your doctor right away if your
medication doesn't work for you. Asthma changes over time, and you'll need
periodic adjustments to your treatment to manage your symptoms. Don't try to
solve the problem by taking more medication without consulting your doctor.
Overusing asthma medication can cause side effects and may even make your
asthma worse.

Severe asthma attacks

Severe asthma attacks can be life-threatening and require emergency treatment. If
your asthma isn't getting better with quick-relief medications, seek emergency help
right away. Work with your doctor ahead of time to determine what to do when your
signs and symptoms worsen — and when you need emergency treatment. Signs of an
asthma attack that needs emergency treatment include:

 Rapid worsening of shortness of breath or wheezing

 No improvement even after using short-acting bronchodilators
 Shortness of breath with minimal activity

Tests and diagnosis

Diagnosing asthma can be difficult. Signs and symptoms can range from mild to
severe and are often similar to those of other conditions, including emphysema, early
congestive heart failure or vocal cord problems. In children, it can be hard to
differentiate asthma from wheezy bronchitis, pneumonia or reactive airway disease.

In order to rule out other possible conditions, your doctor will do a physical exam and
ask you questions about your signs and symptoms and about any other health
problems. You may also be given lung (pulmonary) function tests to determine how
much air moves in and out as you breathe.

Tests to measure lung function include:

 Spirometry. This test measures the narrowing of your bronchial tubes by

checking how much air you can exhale after a deep breath, and how fast you
can breathe out.
  Peak flow. A peak flow meter is a simple device that can be used at home to
help detect subtle changes 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
will give you instructions on how to track and deal with low readings.

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

Other diagnostic tests to diagnose asthma include:

 Methacholine bronchial challenge. If you have asthma, inhaling a known

asthma trigger called methacholine will cause mild constriction of your
airways. A positive methacholine test supports a diagnosis of asthma. This test
may be used if your initial lung function test is normal.
 Nitric oxide test. This test is sometimes used to diagnose and monitor asthma.
It measures the amount of a gas called nitric oxide you have in your breath. If
your airways are inflamed — a sign of asthma — you may have higher than
normal levels of nitric oxide. This test isn't widely available.

How asthma is classified

To classify your asthma severity, your doctor will evaluate your answers to questions
about symptoms (such as how often you have asthma attacks and how bad they are),
along with the results of your physical exam and diagnostic tests. Determining the
severity level of your asthma will help your doctor choose the best treatment for you.
Asthma severity often changes over time, requiring an adjustment to treatment.

Asthma is classified into four general categories:

Asthma
Signs and symptoms
classification
Mild symptoms up to two days a week and up to two nights a
Mild intermittent
month
Symptoms more than twice a week, but no more than once in a
Mild persistent
single day
Moderate persistent Symptoms once a day and more than one night a week
Symptoms throughout the day on most days and frequently at
Severe persistent
night

Complications
Asthma may cause a number of complications, including:

 Emergency room visits and hospitalizations for severe asthma attacks

 Permanent narrowing of the bronchial tubes (airway remodeling)
  Side effects from long-term use of some medications used to stabilize severe
asthma

Treatments and drugs

Treatment for asthma generally involves avoiding the things that trigger your asthma
attacks and taking one or more asthma medications. Treatment varies from person to
person.

 Most people with persistent asthma use a combination of long-term control

medications and quick-relief medications, taken with a hand-held inhaler.
 If your asthma symptoms are triggered by airborne allergens, such as pollen or
pet dander, you may also need allergy treatment.
 You may need to try a few different medications before you find what works
best.
 Because asthma changes over time, you will need to work with your doctor to
monitor your symptoms and learn how to make needed adjustments.

Medications used to treat asthma include long-term control medications, quick-relief

(rescue) medications and medications to treat allergies. The right medication for you
depends on your age and symptoms, and what seems to work best to keep your
asthma under control.

Long-term control medications

In most cases, these medications need to be taken every day. Types of long-term
control medications include:

 Inhaled corticosteroids such as fluticasone (Flovent Diskus), budesonide

(Pulmicort), triamcinolone (Azmacort), flunisolide (Aerobid), beclomethasone
(Qvar) and others. These medications reduce airway inflammation and are the
most commonly used long-term asthma medication. Unlike oral
corticosteroids, these medications are considered relatively low risk for long-
term corticosteroid side effects. You may need to use these medications for
several days to weeks before they reach their maximum benefit.
 Long-acting beta-2 agonists (LABAs) such as salmeterol (Serevent Diskus)
and formoterol (Foradil Aerolizer). These inhaled medications, called long-
acting bronchodilators, open the airways and reduce inflammation. They are
often used to treat persistent asthma in combination with inhaled
corticosteroids. Long-acting bronchodilators should not be used for quick
relief of asthma symptoms.
 Leukotriene modifiers such as montelukast (Singulair), zafirlukast (Accolate)
and zileuton (Zyflo CR). These inhaled medications work by opening airways,
reducing inflammation and decreasing mucus production.
 Cromolyn and nedocromil (Tilade). These inhaled medications reduce
asthma signs and symptoms by decreasing allergic reactions. They're
considered a second choice to inhaled corticosteroids, and need to be taken
three or four times a day.
 Theophylline, a daily pill that opens your airways (bronchodilator). It relaxes
the muscles around the airways.
Quick-relief medications
Also called rescue medications, you use quick-relief medications as needed for rapid,
short-term relief of symptoms during an asthma attack, or before exercise, if your
doctor recommends it. Only use these medications as often as your doctor tells you to.
If you need to use these medications too often, you probably need to adjust your long-
term control medication. Keep a record of how many puffs you use each day. Types
of quick-relief medications include:

 Short-acting beta-2 agonists, such as albuterol. These inhaled medications,

called bronchodilators, ease breathing by temporarily relaxing airway muscles.
They act within minutes, and effects last four to six hours.
 Ipratropium (Atrovent). Your doctor might prescribe this inhaled
anticholinergic for the immediate relief of your symptoms. Like other
bronchodilators, ipratropium relaxes the airways, making it easier to breathe.
Ipratropium is mostly used for emphysema and chronic bronchitis.
 Oral and intravenous corticosteroids to treat acute asthma attacks or very
severe asthma. Examples include prednisone and methylprednisolone. These
medications relieve airway inflammation. They may cause serious side effects
when used long term, so they're only used to treat severe asthma symptoms.

Medications for allergy-induced asthma. These decrease your body's sensitivity to a

particular allergen or prevent your immune system from reacting to allergens. Allergy
treatments for asthma include:

 Immunotherapy. Allergy-desensitization shots (immunotherapy) are

generally given once a week for a few months, then once a month for a period
of three to five years. Over time, they gradually reduce your immune system
reaction to specific allergens.
 Anti-IgE monoclonal antibodies, such as omalizumab (Xolair). This
medication reduces your immune system's reaction to allergens. Xolair is
delivered by injection every two to four weeks.

Albuterol inhaler changes: Know what to expect

The Food and Drug Administration (FDA) has required that metered-dose albuterol
inhalers that use chlorofluorocarbon (CFC) propellent be replaced with
hydrofluoroalkane (HFA) inhalers by the end of 2008. HFA inhalers work as well as
CFC inhalers and are as safe, but they don't harm the ozone layer. If you're used to
using a CFC inhaler, talk to your doctor about making the switch to an HFA inhaler.
There are a few differences you should know about:

 Your HFA inhaler may have a different taste and feel from your older CFC
inhaler.
 HFA inhalers have a less forceful spray than the older CFC inhalers. Make
sure you know how to use your inhaler correctly - otherwise, you may not get
the full dose of medication with each spray.
 HFA inhalers are more costly than the older, generic albuterol CFC inhalers.
 HFA inhalers should be cleaned with water every week.

Treatment by severity for better control: A stepwise approach

Treatment based on asthma control can help you manage your asthma. Asthma
treatment 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
Working together, you and your doctor can design a step-by-step plan for living with
your condition and preventing asthma attacks.

 Develop a written asthma 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.
 Identify and avoid asthma triggers. A number of outdoor allergens and
irritants — ranging from pollen and mold to cold air and air pollution — can
trigger asthma attacks. Find out what causes or worsens your asthma, and take
steps to avoid those triggers.
 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.
 Identify and 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.
 Don't let up on your medication program. Just because your asthma seems
to be improving, don't change anything without first talking to your doctor. It's
a good idea to bring your medications with you to each doctor visit, so your
doctor can double-check that you're using your medications correctly and
taking the right dose.

Lifestyle and home remedies

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.

Avoid your triggers

Taking steps to reduce your exposure to things that trigger asthma symptoms is a key
part of asthma control. Here are some things that may help:
  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. If you're likely to stir
up dust, wear a mask or have someone else do the cleaning.
 If it's cold out, cover your face. If your asthma is worsened by cold, dry air,
wearing a face mask can help.

Stay healthy
Taking care of yourself and treating other conditions linked to asthma will help keep
your asthma under control. A few things you can do include:

 Exercise. Having asthma doesn't mean you have to be less active. Treatment
can prevent asthma attacks and control symptoms during activity. Regular
exercise can strengthen your heart and lungs, which helps relieve asthma
symptoms. 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.
 Maintain a healthy weight. Being overweight can worsen asthma symptoms,
and it puts you at higher risk of other health problems.
 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. You may need treatment for GERD
before your asthma symptoms improve.

Coping and support

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