What is asthma?
Asthma is a chronic respiratory disease often linked to allergies, heredity, and the environment. Asthma is a special form of inflammation in the air passages of the lung. Inflammation of this sort leads to swelling of the airway lining, a thick mucus secretion, and spasm of the muscles surrounding the airway. Asthmatic inflammation results in repeated attacks of wheezing, coughing, chest constriction and labored breathing. Most asthmatics have a variety of triggers that initiate their asthma. These triggers will vary by individual and by episode.
How long these symptoms last and how severe they are will vary from time to time for asthma sufferers. It is the job of your allergy and immunology specialist to help you identify the type of asthma you have, what the triggers are, and how best to treat them.
We don’t yet know what causes asthma except that, in general, heredity and environment have a combined effect. Most studies have suggested that there is a strong link between asthma and allergies, at least in children and young adults.
Some triggers that can cause an asthma attack are:
- Animal Dander
- Viral Infection
- Breathing Cold Air
- Reactions to Certain Medications
- Workplace exposure to certain allergens or toxins
- Chemical exposures (also usually in the workplace)
- Cigarette Smoke
How is asthma diagnosed?
The diagnosis of asthma requires a physician examination in which you doctor listens for wheezing when you breathe. The diagnosis is confirmed by a favorable response to an asthma medication and/or a breathing test, called a pulmonary function test, which demonstrates reversal of the airway blockage.
How is asthma treated?
The general approach to asthma treatment is avoidance of triggers and medical treatment of inflammation or its consequences. If allergies or chemical exposures are the asthma trigger, then avoidance measures are the first mode of therapy. Avoidance is followed by the cautious use of medications chosen according to the type and severity of the asthma being treated. Asthma medications generally fall into three categories: anti-inflammatory medications, bronchodilators and natural anti-inflammatory antibodies.
Anti-inflammatory medications take center stage because asthma is first and foremost an inflammatory disease. Anti-inflammatory medications include: mast cell stabilizers, corticosterods (also known as steroids) and anti-leukotrienes.
- Mast Cell Stabilizers are not steroid medications. Still they can reduce inflammation by preventing the release of inflammatory chemicals. They include cromolyn, nedocromil and lodoxamide and are available in various forms to treat allergic disease.
- Corticosteroids, when taken properly, are a very effective method of treatment for asthma and allergies. Corticosteroid use must be supervised by a physician. They are available in topical creams or ointments, nasal sprays, inhalers, pills and by injection. Minor side effects from using corticosteroid inhalers can include hoarseness and thrush (a fungal infection of the mouth and throat). Both are less likely when rinsing, gargling and spitting is done with water after use. Long-term use of inhaled corticosteroids in children could potentially result in reduced growth velocity but usually does not change a child’s normal adult height. In most situations the benefit of having the asthma controlled with inhaled steroids is greater than the potential for a side effect. Inhaled corticosteroids are considered the most effective medications for long-term control over persistent asthma.
Oral corticosteroids are usually considered as short-term medications for asthma flare-ups, marked nasal congestion and, at times, for skin conditions such as poison ivy or any severe eczema. They generally have more side effects than inhaled steroids or steroid creams. Short-term use (up to several weeks) of oral corticosteroids is usually not a problem for an otherwise healthy person. Side effects of short-term use include slight weight gain, increased appetite, menstrual irregularities, cramps, heartburn or indigestion. These side effects will go away shortly after stopping the corticosteroids. Long-term use (months to years) of oral corticosteroids is associated with more severe and potentially permanent side effects such as ulcers, weight gain, cataracts, weakened bones, thinner skin, high blood pressure, elevated blood sugar, easy bruising and decreased growth in children.
- Leukotrienes: When the body is having problems with allergy and asthma, there are many damaging chemicals that are produced. One of these is called leukotrienes (lu-ko-try-eens). Leukotrienes are responsible for increasing inflammation in the airway and causing contraction of the airway muscle and swelling of the airway lining. Currently we have several oral anti-leukotriene medications available (Singulair and Accolate) to help fight allergic inflammation. These drugs are primarily used to help gain control over persistent asthma. One (Singulair) is also approved to treat allergic rhinosinusitis. These medications are available only in tablet form, which some people prefer.
Bronchodilators often dramatically help with asthma symptoms but do little else to help control the asthma as it occurs. There are several classes of bronchodilators available to treat asthma.
Adrenalin derivatives called beta-agonists relax the muscle around the bronchial tubes. Short-acting beta-agonist bronchodilators are used as quick-relief “rescue” medications. These are available as inhalations, liquids, injectables and pills. Long-acting beta-agonist bronchodilators (Albuterol and others) are used for long-term control of asthma. Side effects of this class include nervousness, increased heart rate, restlessness, insomnia and, rarely, headaches. Overall, these bronchodilators, whether short-acting or long-acting, are very safe in asthma as long as your physician has established that they work for you. Theophylline has been used for over 30 years to treat asthma and is another type of bronchodilator. These are available as tablets, capsules or intravenously. Blood levels need to be monitored when this drug is used. Side effects can include headaches, elevated heart rate and stomach upset. Anticholinergics are another form of bronchodilator and are available in inhaled form. These can be used alone or combined with the beta-agonist bronchodilators. This type of bronchodilator has the added feature of also reducing mucous in the airway, and is very safe. Ipratropium (Atrovent) is used for asthma treatment as a quick-relief medication. Tiotropium is like ipratropium but is a daily inhaler used once that lasts more than a day. Dry mouth and headache can be side effects, but not commonly.
Natural anti-inflammatory antibodies
Omalizumab (Xolair) was approved in 2003 as a new type of asthma therapy, known as anti-IgE, reserved for patients with moderate to severe persistent allergic asthma. IgE is an antibody that we all have and it is responsible for causing allergic problems in some people. Xolair reduces allergic reactions by causing IgE to disappear from the body so that the IgE cannot attach to pollen, dust mite, mold or whatever else you might be allergic to, even food.
Right now, the FDA has limited it’s use to those patients with moderate to severe persistent allergic asthma who: 1) are inadequately controlled with appropriate medication(s); 2) have complications due to inhaled or oral steroid use; 3) have increased urgent care, emergency department or inpatient service needs due to asthma exacerbations; 4) have significant problems with activities of daily living; or 5) have problems taking regular medication prescribed to treat asthma. These limitations are primarily due to cost and do not have anything to do with effectiveness or safety. Xolair has proven to be a very effective and safe agent although it does not cure allergy permanently. Once it is stopped, the IgE is once again free to cause allergy within a month or two. Xolair should be administered every two to four weeks by injection based on body weight and total serum IgE levels.
Some forms of asthma can be effectively treated and sometimes cured with immunotherapy. Immunotherapy works best for mild or intermittent asthma that has a clear allergic cause.
How can an asthma attack be avoided?
An important part of asthma care is understanding your asthma triggers and avoiding them. The other important part is to have an effective asthma action plan that you understand and adhere to. Your allergy and immunology specialist will help you decide what treatment is best for you on a day-to-day basis as well as during times of increasing asthma symptoms. For those with intermittent asthma, an action plan documents which medications to start at the earliest signs of asthma flare or even before asthma has occurred, in anticipation of a flare. For example, if you always get asthma when you run, if you take your rescue inhaler BEFORE you run and you won’t be bothered by your asthma. For those with persistent asthma, even if is very mild, it is generally best to take medications daily to prevent relapses. This will also slow down or stop any damage to the airway that could occur from the asthma inflammation. Then an action plan can be used to treat asthma flares as they occur.
- American Academy of Allergy, Asthma & Immunology http://www.aaaai.org/patients.stm
- American College of Allergy Asthma & Immunology http://acaai.org/public
- Allergy & Asthma Foundation of America http://www.aafa.org
- Food Allergy & Anaphylaxis Network http://www.foodallergy.org
- American Lung Association https://www.lungusa.org
- Center for Disease Control and Prevention http://www.cdc.gov/nceh/airpollution
- Environmental Protection Agency http://www.epa.gov/iaq
- MedicAlert Supplies https://www.medicalert.org