Why Asthma Treatment May Require Multiple Inhalers
Introduction
When I was a child I suffered from an occasional wheeze whenever I came down with a cough or cold. Several of my friends did as well, but it was not considered serious. We were not diagnosed with obstructive disorders or told to seek care via allergists or pulmonologists. It was not until 1995, when Krissy Taylor (a young model) died at the age of 17 after using a Primatene inhaler that people began to take asthma seriously.
Today, asthma is known to be dangerous. More than 1 in 13 people have asthma, which accounts for 25 million Americans (7.7 percent of adults and 8.4 percent of children). Since the 1980’s, asthma has been increasing among all age groups, as well as all ethnicities. Nearly everyone has a family member with asthma or knows someone who has been treated.
Defining Asthma
Asthma is an obstructive disorder that is diagnosed by specific testing. Signs of an asthma attack include chest tightness, wheezing on exhalation, shortness of breath, rapid breathing, coughing that does not stop, and a pale, sweaty face. Patients have described asthma attacks as an elephant sitting on their chest and a panicked sensation of “not getting enough air to breathe”. Asthma is classified into four categories:
Mild intermittent Mild symptoms up to 2 days/week & up to 2 nights/week
Mild persistent Symptoms > twice/week, but not > once per day
Moderate persistent Symptoms once/day & > one night a week
Severe persistent Symptoms throughout the day on most days & frequently @ night
Diagnosis
Before a patient can be treated for asthma, they need to be diagnosed. Symptoms of shortness of breath could easily be mistaken for asthma or labeled as bronchitis or reactive airway disease. An infection may exist that needs to be treated before testing could take place. Ideally, if patients are smoking or using e-cigarettes or smoking marijuana those activities should decrease or be eliminated prior to testing for an obstructive disorder.
Patients could believe they have asthma an entire lifetime and never be officially diagnosed. That is because asthma symptoms may be intermittent. They are initiated based on “triggers”, such as dust, pollen, animal dander (if allergies are present), exercise, anxiety, cold air, smoke, mold, excess air pollution, or even upper respiratory infections such as a cold or the flu.
A patient could be wheezing at a primary care provider’s office but asymptomatic at an allergist’s visit or during pulmonary consultation. Tracking symptoms is vitally important. An asthma diary is pivotal in noting when symptoms occur and during what circumstances. Pulmonologists and Pediatricians also state it is difficult to diagnose children under the age of 5 for just that reason.
Office Spirometry and Peak flow meters may be the initial tools that are used to evaluate patients for asthma, after performing a comprehensive patient history and thorough physical exam.
Spirometry evaluates how much air can be forcefully exhaled after a deep, full breath. Narrowing (constriction) of the bronchial tubes is assessed by the amount of air that is rapidly exhaled, and then examining the “curve” on a printout. The office may give a dose of bronchodilator and repeat the spirometry test to determine if the exam improves after dosing. A positive test (demonstrating improvement in the amount and rapidity of air exhaled) is significant for asthma.
Peak flow testing can be performed in the physician office or by the patient at home, looking at trends over time. A peak flow meter is a handheld device that functions very similarly to spirometry. The patient holds the device in one hand, standing upright, inhales deeply, then exhales forcefully into the meter, which measures the strength of the exhalation (usually in ml., or green, yellow, and red zones). Patients learn their normal values when they are asymptomatic (green zones), caution values (yellow zones) and when they need to go to the ER (red zones). As they are treated, an asthma “action plan” can be developed for each zone.
More Formalized Testing
For further testing and work-up, chest imaging (both Xray and CT) are often completed to rule out structural abnormalities and/or diseases when a patient complains of shortness of breath. Allergy testing and blood work, such as checking for elevated white blood counts and eosinophils may be performed as well. Sputum can also be examined for pathogens and for eosinophils.
Pulmonary function testing can be performed in a hospital setting or a pulmonologist’s office, depending upon the type of test. A pulmonary function test differs from spirometry testing in that it is more complex and looks at various parameters of lung function. The physician will be able to determine if more factors are involved in the shortness of breath, including body size and shape. Again, an inhaler or nebulizer might be used to see if improvement is achieved after the administration of a bronchodilator. If pulmonary function tests (PFT’s) are normal, but asthma is strongly suspected, a Methacholine challenge test may be performed.
Methacholine is a known asthma trigger. The medication, when inhaled, causes mild constriction of the airways & the test must be performed in the hospital where providers are prepared for adverse reactions, should they occur. If the patient reacts to Methacholine during PFT’s, it is considered a positive test for asthma.
Asthma Treatment
Once asthma is diagnosed, the goal is to determine appropriate treatment. The objective is to find what is exactly right, neither too much nor too slight. For a teen with exercise-induced asthma, a rescue inhaler (bronchodilator) that opens the airways prior to or during sports may be all that is needed to quickly relieve constricted airways. Bronchodilators are short-acting beta agonists and contain albuterol or levalbuterol (Xopenex). They can be inhaled via a hand-held inhaler or nebulizer. They are commonly prescribed as ProAir HFA or Ventolin HFA, among others.
Patients needing more control of their asthma symptoms may need the addition of an inhaled corticosteroid medication. These inhalers often need to be used for a few days to weeks before maximum benefit begins to appear, but unlike oral steroids, they demonstrate few side effects and are generally safe for long-term. Patients do need to be instructed to religiously rinse their mouths after use or oral yeast can be a problem. These inhalers are known by the names Qvar, Asmanex, Pulmicort.
For patients with more moderate asthma symptoms, combination inhalers have become the cornerstone of treatment. These inhalers combine both a long-acting beta-agonist medication (bronchodilator) and an inhaled steroid to decrease inflammation. You may know these medications by their prescribed names of Advair, Symbicort, Breo, or Dulera.
Oral medications: Theophylline can be used for acute cases that require bronchodilatation, although it is not used as commonly as it has been in the past. It is given daily to relax muscles around the airways and may be used in hospital settings.
Leukotriene modifiers: these oral medications relieve asthma symptoms up to 24 hours and are often used as an adjunct to inhaler therapy. You may recognize the names Singulair or Accolate. Patients on leukotriene modifiers typically have allergy triggers as a cause of their asthma symptoms.
Steroids: both oral and IV steroids have been used to treat asthma in crisis. Both prednisone and methylprednisolone work to relieve airway inflammation rapidly and improve airflow. Both can cause significant side effects and are used for short term treatment only.
Immunotherapy: allergy treatment is appropriate when allergic response is thought to be the main trigger for asthma. Generally, shots are given once per month for a period of months to years for effective response.
Omalizumab (Xolair): this medication (given by injection) can be utilized for those who qualify, generally patients with severe allergies and severe asthma. It is given by injection, typically every 2-4 weeks. It works by altering the immune response.
Myths About Asthma
People often believe that a hot cup of coffee (caffeine), inhalation of hot steam, essential oils such as lavender or eucalyptus may be helpful in reducing the symptoms of asthma. Yet, there is no significant clinical evidence to support these beliefs. A 2014 study found that inhaling lavender essential oil may assist with reducing inflammation from allergies, but it should not be relied on as relief from the potential dangers of acute asthma.
Another 2014 research review found that deep breathing (training) on a regular basis may assist in reducing asthma symptoms plus assist in mental well-being. It was also thought this may possibly reduce the need for rescue medications, yet it should not take the place of bronchodilators during an acute attack.
More research is needed on the use of alternative treatment in asthma. What we do know is that asthma, left untreated, can be deadly, as it was for Krissy Taylor in 1995. What works is to have an asthma action plan, one where the patient knows what to do to manage symptoms on both good days and bad, for inclement weather, and for days when the unplanned URI strikes. A patient with an asthma action plan has a Peak Flow meter and manages their symptoms proactively, knowing when to activate a system of support before assistance is truly needed.
Does your patient know what to do? It is time to find out.
