Asthma can cause symptoms which vary from a cough to wheezing or shortness of breath. Some patients will have tightness in the chest, and other patients have no symptoms at all. Asthma can also be induced by exercise, but is also very treatable. If you have exercise induced asthma, you are in good company. 15-20% of Olympic athletes also have exercise induced asthma!
Asthma occurs as a result of constriction of the airways in the lungs. Constriction typically occurs as a result of inflammation, and now the focus of treatment of asthma is to reduce the amount of inflammation in the lungs. This represents a dramatic change in the past several years – it used to be that we would just focus on trying to open the lungs, rather than treating the cause.
Inflammation can occur as a result of exposure to irritants such as tobacco smoke, pollution, ozone, infectious agents such as bacteria and viruses, and also allergens such as dogs, cats, horses, guinea pigs, feathers, wool, dust, pollens, cockroaches and foods. Sinusitis can also worsen asthma. Workplace exposures can also be a problem and so can the cold weather and cold water. Most people are surprised to learn that 80% or 90% of patients with asthma have what is called “extrinsic” asthma. In other words, it is typically made worse as a result of exposure to things they are allergic to. Some patients also have exercise induced asthma.
Treatment of asthma focuses on a multi-step approach. The initial step is to eliminate those items in the environment which cause problems such as allergens, tobacco smoke, etc.
The next step is to use an inhaler called a bronchodilator ( Proventil, Ventolin, Maxair or Tornalate, et. al.) which immediately opens the lungs up, but should not be used more than twice a week without other asthma medications. If it is necessary to use the inhaler more than twice a week, treatment should proceed to the next step which may involve increasing the bronchodilator dose and also adding a drug which reduces inflammation.
These drugs are inhaled cortisone preparations ( Vanceril, Beclovent, Aerobid, Azmacort, Flovent,Asmanex or Pulmicort). Some are now available in a dry powder formulation which are preferable for some patients if they cannot tolerate the propellant. These include Pulmicort and Flovent. They also have a built in counter so you can tell how many puffs are left. There is also a formulation called QVAR which contains the same drug as Vanceril and Beclovent in a metered dose inhaler, but does not contain any chlorofluorocarbons (see below). there is also a combination drug calledAdvair which contains an inhaled steroid as well as a bronchodilator (see below).
There are also 2 other inhaled drugs ( Intal or Tilade) which are not cortisone preparations and are not quite as strong as the cortisone preparations. These drugs also reduce inflammation. Another drug, Atrovent, is sometimes helpful in treatment of patients with asthma, but is more commonly used in patients with emphysema. The initial dosages of these inhaled drugs may need to be increased if not initially successful in relieving symptoms.
There is a class of drugs which block or inhibit a class of compounds called leukotrienes. Leukotrienes are important causes of lung inflammation and contribute to asthma. Three drugs have been released called Singulair, Accolate and Zyflo. These drugs work as anti-inflammatory medications, similar to the inhaled steroids but are not as potent. They can be used in addition to the inhaled steroids, or can be used by themselves These drugs have been used successfully in about 50% of patients, including some very severe asthmatics. They are also helpful in patients with sensitivity to aspirin.
These drugs have been found to rarely cause abnormalities in liver functions, and Zyflo must be monitored with blood tests on a monthly basis for the first several months. Accolate may cause a rare disease called the Churg-Strauss syndrome. It typically may present with symptoms such as fever, weight loss and generalized aches and pains. It is caused by inflammation of the blood vessels. More information can be found on the FDA’s website listed in bookmarks. There is some recent concern about suicidal ideations with Singulair, however most physicians still feel it is safe.
A possible association of Churg-Strauss-like symptoms has also been found with Singulair and Flovent. It is also suspected that it may be associated with other steroid inhalers. It is thought in many cases to be due to an “unmasking” of the Churg-Strauss syndrome. In other words, the disease was there beforehand, but in the course of starting on these new medications, other medications such as oral cortisone were reduced, and the Churg Strauss symptoms started appearing. The only reason that the symptoms occurred was because the cortisone was either stopped or the dosage reduced.
Nocturnal asthma occurs in the vast majority of patients who have problems with asthma. It typically occurs during sleeping because of a change in the hormone levels and oxygen content, as well as exposure to allergens such as dust mites. As allergists we would like to keep the asthma controlled all the time, especially at night, so that we both can sleep at night. There are now several medications that will last an entire night.
There are two drugs which are available which function as long acting bronchodilators calledSerevent, and Foradil. They last 12 hours, and are especially helpful for patients with night time symptoms. (It also is obviously effective for daytime symptoms). They can be used to decrease the amount of inhaled steroids. It is also available in a dry powder form. They should be used as directed, no more than twice per day, as they will not give immediate relief of symptoms. They take 30 – 60 minutes to start working. A combination of Serevent and Flovent called Advair is available in a dry powder formulation in a variety of strengths which has a number of advantages. It reduces the number of times patients have to use medications, and it means that spacer devices, which need to be used with inhaled steroids, can be avoided (see below). Short term relief of symptoms needs to be treated with a shorter acting bronchodilator like Proventil. Symbicort is another combination drug which utilizes Foradil. It seems to have a bit more of an acute onset with this bronchodilator.
Another drug called theophylline can be used for nighttime symptoms. It is in pill form and can open the lungs up for 12-24 hours at a time. There are also other long acting pills which are oral forms of the bronchodilators mentioned above( Proventil Repetabs, Volmax) which also last 12 hours. Neither if these drugs are used commonly anymore.
Patients who are not controlled by using low doses of their inhaled steroids (typically 2-8 puffs per day depending on the strength), can often be controlled by adding Serevent to the regimen, so that higher doses of the inhaled cortisone do not have to be added. Higher doses of inhaled cortisone may be more likely to cause side effects. Most specialists prefer using the combination of the inhaled steroids with Serevent or Foradil instead of the leukotriene inhibitors.
The cortisone preparations are important to use in order to prevent what is now called ” airway remodeling“. Usually when people think of remodeling, it is beneficial. In this case it is not, because it leads to worsening of the asthma. the inflammation in asthma can lead to scarring, which can make it more difficult to transport oxygen into the bloodstream. This may not be reversible, causing a similar effect as emphysema. Cortisone preparations ( and possibly leukotriene inhibitors ) can reduce this remodelling.
Patients who have more severe asthma may need oral cortisone preparations to be used in order to give adequate relief of symptoms. Usually a short course of treatment lasting a few days to a few weeks is adequate. Very rarely, patients may need longer treatments or with other drugs.
The first of a class of drugs which blocks IgE, called Xolair can be used to treat asthma. It may also help other allergic problems, but has not been approved by the FDA for that use. Because the anticipated cost is approximately $1000/month, we anticipate that many insurance companies will only pay for it for more severe asthma. It is given every few weeks by injection. If it is stopped, symptoms will come back, so it is not like allergy shots in that symptoms will often continue to be relieved after discontinuing allergy shots. Reactions are rare, but there were reports of a non-statistically significant increase in cancer in the treated groups in clinical trials. It is not thought that this was related to the drug, but was serendipity.
We will not deal here with asthma which may need to be treated in a hospital situation. Treatment by an allergist rarely requires hospitalization. Most patients that we see who do need to be hospitalized have either just been seen by their allergist or not followed their treatment regimen.
Patients who have severe asthma should usually have a nebulizer available at home. A nebulizer is a small machine which creates a mist of one of the bronchodilator medications. It can also be more easily used by young children. When the mist is breathed in, it will rapidly open up the lungs. Oxygen also may be helpful in those patients with severe asthma. It is very important to use a nebulizer under the supervision of a physician well trained in treatment of asthma since overuse of this device can be dangerous and can make asthma extremely difficult to treat.
When you see an allergist or other lung specialist, you will in all likelihood have a lung function testdone. This test is performed using a sophisticated computerized device which determines the severity of your asthma by measuring how forcefully you can blow air through a tube the size of a doughnut hole. Usually after doing this, your doctor will have you breathe in a bronchodilator medication to open up your lungs, and after waiting a few minutes, repeat the test. A comparison can then be made of the lung function before and after treatment. As a result, the severity of your asthma can be determined. This will guide your doctor in making an assessment of the medications that you need to use. These lung function tests are periodically repeated during the course of treatment in order to assess your progress. Occasionally it may be necessary to administer the lung function test before and after exposure to an agent such as an allergen or medication which may temporarily worsen the asthma. This is typically done in situations where the doctor may not be sure if a patient has asthma.
Any patients who have moderate to severe asthma should have a device called a peak flow meter. The peak flow meter is a small, inexpensive ($15- $25) simplified version of the lung function test that patients can use at home to measure how strong the force of the breath is. It is a good indicator of how bad the asthma is. Unfortunately, a patient’s sensations of wheezing is not a good indicator of how bad the asthma is.
When asthma starts to worsen, the peak flow often starts to drop before patients are aware the asthma is worsening. This allows the patient some time to alter the medications and if necessary to call their doctor with that information. Then dosage adjustments can be made in the medication.
We ask patients to measure the peak flow on a regular basis and establish a personal best, which is the average maximum peak flow. If there is a 20% drop in the peak flow, it is considered in the yellow zone, and patients need to add medication. If there is a 50% drop in the peak flow, then it is considered in the red zone, and patients need to immediately add medication or risk getting severely ill.