Asthma and adults

Asthma is a chronic inflammatory disorder of the airways that causes constriction of the breathing passages in the lungs. Asthma is considered a reactive airway disease (RAD), a category of illnesses that cause wheezing and is improved by bronchodilators (medications that open narrowed airways) or anti-inflammatory medications that reduce airway inflammation, swelling and mucus.


Causes/associated factors
Asthma affects 5 percent of Americans and is responsible for about 5,000 deaths each year. Although the cause of asthma is not clearly understood, it's thought that both genetic and environmental factors play a role.
For people who have asthma, the bronchial tubes (air passages in the lungs) overreact to allergens and irritants, causing an allergic reaction or swelling. Specific allergens or irritants that cause asthma symptoms are known as asthma triggers. Common allergens include pollen, dust mites, animal dander or hair, mold spores, cockroach remnants, sulfites (a common food preservative) and tartrazine (a food-coloring agent). Common irritants include respiratory infections, cigarette smoke, cold air, certain medications (especially aspirin and nonsteroidal anti-inflammatory medications such as ibuprofen and naproxen), emotional upset, exercise or various other factors. Often asthma attacks are caused by a combination of these triggers. Sometimes, asthma triggers are never determined.

During an asthma attack, the breathing passages become narrower than normal. The passages begin to make too much mucus, and the lining of the passages becomes swollen with fluid. These changes work together to interfere with airflow, which leads to the classic symptoms of wheezing, coughing and difficulty breathing. Asthma attacks may last a few minutes, hours or even days, and can range from mild to life threatening. After an asthma attack, the airways may continue to be overly reactive during the recovery phase.


Signs/symptoms
Some people who have asthma experience infrequent, mild symptoms. Others are affected daily. People who have asthma often have a nasal discharge and sometimes skin conditions, such as eczema. Asthma attacks caused by environmental or allergic triggers develop the quickest. Those related to respiratory infections tend to progress and resolve more slowly. Again, asthma attacks may last a few minutes, hours or days.
Three classic symptoms include wheezing, shortness of breath and coughing. Nighttime symptoms are common in people who have more persistent asthma. Immediate medical treatment can help prevent an asthma attack from becoming severe or life threatening.

Symptoms of a severe asthma attack may include:

severe difficulty breathing, both inhaling and exhaling
difficulty talking or walking due to shortness of breath)
sitting hunched over (This position makes breathing somewhat easier.)
sweating
bluish coloring to the face, lips or nail beds
increased pulse rate
severe coughing
high-pitched wheezing
severe agitation
drowsiness or confusion
It's important to remember that one or any combination of the symptoms listed above may be present during an asthma attack. It's a myth that wheezing must always be present. Sometimes during a severe attack, extreme airway obstruction or constriction can prevent air from moving enough to cause wheezing.


Diagnosis
To diagnose asthma, the doctor will ask about your medical history and do a physical exam. Because asthma is usually characterized by a classic symptom pattern, your doctor may ask you to keep a diary of symptoms that can help in making a diagnosis. The diary may also help you identify factors that improve or worsen your condition.
Blood tests may sometimes be done to help evaluate if an infection is present or determine how much oxygen is being carried in your blood. Chest X-rays may highlight common physical changes in the lungs related to asthma. Pulmonary function tests can help the doctor evaluate how well your lungs are working, as well as the effectiveness of the treatment.

Because allergies can trigger asthma attacks for some people, your doctor may recommend skin testing to determine if you're allergic to substances such as dust mites, molds, grasses or tree pollens. With this type of testing, a small amount of the substance in question is placed just under the skin's surface. Redness and swelling at the site indicates an allergy to the substance.

Radioallergosorbent testing (RAST, a blood test) is sometimes used to diagnose allergies to inhaled substances. With this type of testing, your blood is mixed with particles of allergens and monitored for responses that indicate an allergy. RAST offers an alternative to skin testing, especially for those who can't be skin tested or have unclear results from skin testing.

Classification
Your doctor may classify your asthma symptoms according to severity.

These classifications include:

Mild intermittent: Symptoms occur one or two days a week. Nighttime symptoms occur once or twice a month.

Mild persistent: Symptoms occur more than twice a week, but not every day. Nighttime symptoms occur more than twice a month. Attacks can disrupt activities.

Moderate persistent: Symptoms occur daily. Nighttime symptoms occur more than once a week.

Severe persistent: Constant symptoms limit physical activity. Nighttime symptoms occur frequently.
If the frequency of your symptoms changes over time, your classification may also change.


Treatment
Asthma management plans
If you have asthma, the American Medical Association encourages you to develop an individualized asthma management plan with your doctor. With a successful plan, you'll be able to take charge of your asthma and lead a more active lifestyle. Appropriate self-care can help you prevent or limit symptoms and reduce the number of asthma attacks, as well as trips to the doctor or hospital.

First, your doctor will develop a treatment plan based on your symptoms and the severity of your asthma attacks. Then, the doctor will help you learn about asthma and your treatment. You'll become familiar with asthma triggers and early warning signs and symptoms. (These tip-offs can be different for everyone. They may even change with each episode.) You'll learn how to measure your peak flow, as well as how and when to take medication. Your plan should also include instructions on how to make medication adjustments in response to specific symptoms or peak flow readings.

As part of your asthma management plan, tell your doctor what works best for you. For example, talk about the most convenient times to take your medications and test your peak flow rates. Mention any medicines you have trouble taking or any other concerns you may have. If the management plan is too difficult or you don't understand something, tell your doctor.

Medications
Medication can be an important part of controlling asthma and relieving your symptoms. It's important to follow your doctor's instructions and take prescribed medications exactly as directed and never use more than prescribed. Some asthma medications can be given through a nebulizer (a device that turns the medication into vapor) or a metered-dose inhaler (a handheld inhaler device). Ask your doctor about the need for a spacer (a device that's attached to the inhaler to ensure the medication gets into your lungs, not just the back of your throat).

There are two groups of asthma medications, those designed to get asthma attacks under control immediately (rescue medications), and those designed to provide continuous treatment to prevent or minimize attacks (controller medications). It's important to understand the difference and know when to use each medication.

Rescue inhalers

Short-acting bronchodilators
These are known as short-acting beta-2 agonists, and they relieve sudden asthma attacks. They can also be taken before exercise to prevent asthma symptoms. These medications relax the muscles around the airway to prevent or reverse airway narrowing. They start to work within minutes, and the effect lasts four to six hours. These medications may be inhaled through a metered dose inhaler or nebulizer.

Common brands include:

albuterol (Proventil, Ventolin)
bitolterol (Tornalate)
metaproterenol (Alupent)
pirbuterol (Maxair)
terbutaline (Brethaire)
Benefits: Short-acting bronchodilators start to work within minutes, and the effect lasts four to six hours.

Risks: Side effects may include nervousness, trembling, restlessness, dry mouth, or a rapid or irregular heartbeat. It's important to discuss these side effects with your child's doctor.

Anticholinergic bronchodilators
Ipratropium (Atrovent) can provide added benefit to inhaled beta-2 agonists in severe asthma attacks.

Benefits: Anticholinergic bronchodilators start to work within minutes.

Risks: Common side effects of ipratropium include cough, headache, dizziness, nervousness and nausea. It's important to discuss these side effects with your doctor.

Controller medications

Anti-inflammatory medication

Corticosteriods
Inhaled corticosteroids, if taken for long periods, gradually reduce the likelihood of asthma attacks by making the airways less sensitive to various common asthma triggers.
Common brands of inhaled steroids include:


budesonide (Pulmicort Turbuhaler)
flunisolide (Aerobid)
fluticasone (Flovent)
triamcinolone (Azmacort)
Oral corticosteroids such as prednisone (Deltasone) have broad anti-inflammatory effects. They can be used for short-term therapy (three to 10 days) to gain control over a severe asthma attack (often called a "steroid burst"). For people who have severe, persistent asthma, oral steroids may need to be taken regularly.

Benefits: These drugs may slow the progression of severe asthma.

Risks: Long-term side effects of inhaled corticosteroids may include a cough or yeast infection in the mouth (also called thrush). To help prevent these side effects, you may want to rinse your mouth after taking the medication.


Nonsteroidal anti-inflammatory medication
These medications can control or limit airway swelling, mucus production and sensitivity to allergic substances (triggers), which helps prevent narrowing of the airways.
Common brands include:


cromolyn sodium (Intal)
nedocromil sodium (Tilade
These medications usually begin to work after four to six weeks of regular use. To be effective, they must be taken as directed by your doctor, even when you don't have symptoms.

Benefits: These medications are especially helpful for people who develop asthma from exercise. They can also be taken before exposure to a substance that may trigger an asthma attack.

Risks: Side effects of cromolyn sodium or nedocromil sodium may include a cough or headache. Some people complain that nedocromil leaves a bad taste in their mouths. (Drinking a few sips of water before and after using the inhaler may help.) It's important to discuss these side effects with your doctor.


Leukotriene modifiers
These oral medications are a newer class of asthma medication. They decrease airway inflammation and narrowing, as well as sensitivity to asthma triggers. They're usually taken in combination with other medications.
Common brands include:


montelukast (Singulair)
zafirlukast (Accolate)
zileuton (Zyflo)
Benefits: These medications can decrease sensitivity to asthma triggers.

Risks: Common side effects are headache, stomach upset and nausea. It's important to discuss these side effects with your doctor.

Long-acting bronchodilators
Salmeterol (Serevent) is also known as a long-acting beta-2 agonist, and it controls symptoms by decreasing airway inflammation and narrowing, as well as sensitivity to asthma triggers. The maximum benefit from long-acting bronchodilators, which provide relief for up to 12 hours, occurs after four to six weeks of regular use. These medications must be taken regularly as directed by your doctor, even when you don't have symptoms. Newer combination medications that contain salmeterol and fluticasone, a corticosteroid (Advair Diskus), are now available.

Benefits: Long-acting bronchodilators combined with anti-inflammatory medications can help prevent nighttime asthma symptoms or exercise-induced asthma.

Risks: Side effects from long-acting bronchodilators may include nervousness, restlessness, trembling, dry mouth, or a rapid or irregular heartbeat. It's important to discuss these side effects with your doctor.

A 2003 study found that salmeterol poses a small but significant risk of a serious asthma episode or an asthma-related death. Be sure to use this and all medications exactly as instructed by your doctor, never use more than prescribed, and don't stop taking this medication without first talking to your doctor.

Methylxanthine bronchodilator
Theophylline (Theo-dur or Slo-bid) opens up narrowed breathing passages and prevents the accumulation of fluid in the lungs. When used in combination with other medications, this medication can be a helpful alternative to prevent nighttime symptoms.

Peak flow meters
A small, inexpensive monitor called a peak flow meter can be used at home to measure your lung function. After a baseline normal reading is established with this handheld device, your doctor may ask you to record peak flow readings every day or create a peak flow chart. By taking regular readings, you can:

detect an impending asthma attack, even before early symptoms appear, by noticing a decrease from the baseline reading.
begin treatment early
determine the severity of an attack
determine treatment effectiveness, especially if your condition has been difficult to manage
help diagnose exercise-induced asthma
Follow your doctor's instructions on how to use the peak flow meter, what actions or medications to take when your readings are low, and when to seek immediate medical treatment.

Recommendations
The National Asthma Education and Prevention Program (NAEPP) promotes low-dose inhaled corticosteroids as the preferred treatment for adults who have symptoms needing treatment more than twice a week (mild persistent asthma). Additional medications can be added to provide the best control of symptoms.


Complications
If the asthma attacks are frequent and severe, the tissue in your airways may become permanently thickened. Researchers are studying if early diagnosis, prompt treatment and avoiding substances that trigger attacks may prevent or limit these airway changes. Other complications of asthmamay include exhaustion, dehydration and airway infection.
A prolonged, severe asthma attack that doesn't respond to medication therapy is referred to as "status asthmaticus." This condition has the potential to include generalized seizures or lung collapse. It is considered a medical emergency. Without emergency treatment in a hospital, status asthmaticus can be fatal.


Pregnancy-specific information
The impact of asthma on pregnancy depends on the severity of the disease. Achieving optimal control of asthma before and during the pregnancy can minimize the risks, however. Most women with well-controlled asthma have healthy babies.
If your asthma is severe or not well-controlled during pregnancy, you have an increased risk of preeclampsia (a complication that involves high blood pressure, protein in the urine and swelling) or preterm labor. Your baby has an increased risk of poor growth prior to birth, low birthweight or premature birth. There's also an increased risk of fetal death, either before or after birth.

Even mild asthma symptoms may reduce the amount of oxygen your developing baby receives, so optimal asthma control is especially important. Your doctor will help you develop an asthma management plan for pregnancy that includes continued avoidance of known triggers, measurement of your peak flow and proper use of medications. You'll need to pay careful attention to early warning signs and symptoms of an asthma attack so that treatment can be started immediately.

Medications are an important part of your asthma management. Your doctor will prescribe the safest medications for use during pregnancy. Medications commonly used during pregnancy include inhaled and oral corticosteroids and inhaled short-acting bronchodilators and cromolyn sodium. Oral theophylline may also be used. It's important to take your medications as prescribed. Be sure to discuss any concerns about your medications with your doctor.

If you have severe or uncontrolled asthma, your doctor will monitor you and your baby more closely for complications. Weekly visits and testing may be necessary.


Senior-specific information
Initial asthma attacks are unusual for older adults. However, a history of asthma may coexist with chronic bronchitis or emphysema. When prescribing asthma medications, your doctor will consider any other medical conditions you have and how your current medication could be affected by the asthma medication.

Prevention
Although you can't prevent asthma, you can minimize the attacks and quickly stop those that do occur to help prevent complications. Here are some suggestions to help you cope with asthma:
Develop an asthma management plan with your doctor to help prevent or limit symptoms and/or the number of asthma attacks.

Avoid asthma triggers such as animal dander and hair, feathers (including feather pillows), aspirin, cockroach remnants, pollen, dust, mold, strong fumes of any kind and anything else that may trigger an attack. You may want to keep a diary to help identify triggers.

Don't smoke, and avoid smoky environments.

Pay attention to early warning signs. Prompt treatment may limit the severity of an attack. You can also monitor the effectiveness of treatment with a peak flow meter.

Consult your doctor before taking an over-the-counter medication, and always read the instructions and warnings on the label.

Carefully follow your doctor's instructions for all prescription medications. Keep your medications in a consistent spot so you know where they are in case of an emergency. Discard outdated medications.

To prevent respiratory infections, ask your doctor about yearly flu shots and immunization against pneumococcal pneumonia.

Wear a medical identification or Medic Alert bracelet, especially if your asthma is easily triggered or severe.