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Asthma

Medically reviewed on Mar 24, 2017 by L. Anderson, PharmD

What Causes Asthma?

Asthma is a common inflammatory lung disease which can lead to attacks of wheezing, shortness of breath, chest tightness, and coughing. When an asthma attack occurs, the muscles surrounding the airways become tight and the lining of the air passages swell and narrow. This reduces the amount of air that can pass through the airways and can lead to wheezing sounds, coughing, chest tightness and shortness of breath. Asthma that is triggered by exercise is known as exercise-induced asthma and has similar symptoms to traditional asthma.-

Millions worldwide are affected by asthma. Approximately 25 million Americans have asthma according to the latest CDC statistics.

Most people with asthma have wheezing attacks separated by symptom-free periods. Some patients have long-term shortness of breath with episodes of increased shortness of breath. In others, a cough may be the main symptom. Asthma attacks can last from minutes to days and can become dangerous if the airflow becomes severely restricted.

In sensitive individuals, asthma symptoms can be triggered by breathing in allergy-causing substances (called allergens or triggers). Identifying triggers and avoiding them are essential to asthma control. Asthma triggers might include:

  • Pet dander
  • Dust mites
  • Cockroach allergens
  • Molds
  • Pollens

Asthma symptoms can also be triggered by:

  • Respiratory infections
  • Exercise (exercise-induced asthma)
  • Cold air
  • Tobacco smoke and other pollutants
  • Stress
  • Food
  • Drug allergies

Aspirin and other non-steroidal anti-inflammatory medications (NSAIDS) such as ibuprofen or naproxen, and blood pressure medications known as beta blockers can also provoke asthma in some patients.

Many people with asthma have an individual or family history of allergies, such as hay fever (allergic rhinitis) or eczema. Others have no history of allergies. Desensitization procedures, such as allergy injections may be options for patients who cannot avoid triggers.

Common Symptoms of Asthma

Symptoms of asthma include:

  • Wheezing (a whistling sound when exhaling (a common sign of asthma in children)
  • Usually begins suddenly
  • Comes in episodes
  • May be worse at night and interfere with sleep; may worsen in early morning
  • Gets worse with cold air, exercise, and heartburn
  • May go away on its own
  • Is relieved by bronchodilators (drugs that open the airways)
  • Cough with or without sputum (phlegm) production
  • Shortness of breath that gets worse with exercise or activity
  • Intercostal retractions (pulling of the skin between the ribs when breathing)
  • Nasal flaring
  • Chest pain
  • Tightness in the chest
  • Abnormal breathing pattern --breathing out takes more than twice as long as breathing in

How Is Asthma Diagnosed?

Allergy testing may be helpful in identifying allergens in patients with persistent asthma. Common allergens include pet dander, dust mites, cockroach allergens, molds, and pollens. Common respiratory irritants include tobacco smoke, pollution, and fumes from burning wood or gas.

The doctor will use a stethoscope to listen to the lungs. Asthma-related sounds may be heard. However, lung sounds are usually normal between asthma episodes.

Tests may include:

Should I See a Doctor About My Asthma?

Call for an appointment with your health care provider if you or your child experience mild asthma symptoms (to discuss treatment options).

Call your health care provider (or go to the emergency room) for:

  • Moderate shortness of breath (shortness of breath with talking, peak flow 50-80% of personal best)
  • If symptoms worsen or do not improve with treatment
  • An attack requires more medication than recommended in the prescription

Go to the emergency room for severe shortness of breath (shortness of breath at rest, peak flow less than 50% of personal best), if drowsiness or confusion develops, or for severe chest pain.

Peak Flow Meter

A peak flow meter is a simple and inexpensive device which can be used to monitor your lung function. It can be used at home to help you predict an upcoming attack and to take appropriate action, sometimes even before any symptoms appear. If you are not monitoring asthma on a regular basis, an attack can take you by surprise.

Peak flow measurements can help show when medication is needed, or when other action needs to be taken. Peak flow values of 50-80% of an individual's personal best results indicate a moderate asthma attack, while values below 50% indicate a severe attack.

Emergency Symptoms of Asthma

  • Extreme difficulty breathing
  • Breathing temporarily stops
  • Bluish color to the lips and face
  • Severe anxiety due to shortness of breath
  • Rapid pulse
  • Sweating
  • Decreased level of alertness, such as severe drowsiness or confusion, during an asthma attack

Seek immediate medical care if any of these symptoms appear.

How is Asthma Treated?

Asthma treatment is aimed at avoiding known allergens and respiratory irritants, and controlling symptoms and airway inflammation through medication. The main goals are to restore normal airway function and prevent severe acute attacks.

Medication for asthma is either delivered by inhalation, orally or parenterally (by injection).

Inhalation is the preferred route of administration as this allows the drug to be delivered directly into the airways in smaller doses. This causes fewer side effects than if given orally or parenterally. When delivered by inhalation, bronchodilators also have a faster onset of action and give better protection from constriction of the lung bronchi.

Patients with persistent asthma should use preventative medicine such as inhaled corticosteroids on a regular basis to prevent asthma attacks. Medication is added in a step-up progression depending on the severity and frequency of attacks. It is also important to step-down the treatment when control is good.

Patients should have a personalized asthma action plan developed in conjunction with their health care provider to control their asthma. Long-term control medications and short acting medications are an important part of every asthma action plan.

Long-Term Control Medications

Long-term control medications are used on a regular basis to prevent attacks. These are not appropriate as treatment during an acute asthma attack. Long-term treatment includes inhaled corticosteroids, long-acting bronchodilators, leukotriene inhibitors, mast cell stabilizers, and interleukin inhibitors. Oral theophylline can also be used as a preventive in patients with chronic asthma, but it isn't used as often as in the past.

  • Inhaled Corticosteroids

Inhaled corticosteroids help to decrease inflammation and narrowing of the airways. These agents must be used regularly to get maximum benefit, and are recommended to help prevent asthma symptoms, reduce the need for rescue inhalers, and decrease the risk of serious attacks, and improve the quality of life.

Most inhaled corticosteroids are used once or twice daily. In case of exposure to a trigger, or to prevent exercise-induced asthma, a rescue inhaler (bronchodilator) can still be used as needed. However, regular use of a bronchodilator may mean that the dose of the inhaled corticosteroid is not optimal and that your asthma is worsening, so see your doctor.

Common side effects of inhaled corticosteroids include: oral candidiasis (thrush), sore throat, or hoarse voice. Rinsing your mouth or using a spacer can often help to prevent oral side effects of inhaled corticosteroids.

Brand Name Generic Name
Aerospan HFA flunisolide
Alvesco ciclesonide
Asmanex Twisthaler, Asmanex HFA mometasone
Flovent Diskus, Flovent HFA, Arnuity Elipta, ArmonAir Respiclick fluticasone
Pulmicort Flexhaler, Pulmicort Respules budesonide
Qvar 40, Qvar 80 beclomethasone
  • Long-Acting Beta-2 Agonist Bronchodilators

Long-acting beta-2 agonist bronchodilators relax muscles in the airways and improve breathing. Although good asthma control may be established with long acting beta-2 agonists, inhaled steroid therapy should not be discontinued. In fact, all long-acting beta-2 agonists are contraindicated in patients with asthma without use of a long-term asthma control medication such as a corticosteroid.

High doses of inhaled corticosteroids may not be needed when combined with a long-acting beta-2 agonist. Most long-acting beta-2 agonists and corticosteroids are used as combination products to ease administration.

Brand Name Generic Name
Brovana (used mainly for COPD) arformoterol
Foradil formoterol
Serevent salmeterol
  • Leukotriene Modifiers

Leukotriene modifiers are oral tablets used once or twice daily to treat and prevent chronic asthma and allergic rhinitis. They may be used in combination with an inhaled corticosteroid for an enhanced effect. They can also be used to prevent symptoms due to triggers or exercise, but must be taken at least 3 hours before exposure. If you already take a leukotriene modifier to prevent asthma or allergy symptoms, do not use an extra dose to treat exercise-induced asthma. All patients should still have available for rescue a short-acting β-agonist.

Leukotriene modifiers block an inflammatory substance called leukotriene. The release of leukotrienes causes airway constriction, increased mucus production, swelling and inflammation in the lungs resulting in the characteristic wheezing and shortness of breath in asthma. Leukotriene modifiers open narrowed airways, decrease inflammation, and lower the mucous production.

Rare but possibly serious side effects of leukotriene modifiers include mood changes and risk for depression. Common side effects include upper respiratory infection, fever, headache, sore throat, and cough, among others.

Brand Name Generic Name
Accolate zafirlukast
Singulair montelukast
Zyflo CR zileuton
  • Mast Cell Stabilizers

Mast cell stabilizers work by stabilizing mast cells and preventing them from releasing their irritating chemicals. Some forms of recurrent or chronic asthma are due to the release of irritating chemicals from mast cells located in the bronchial tubes.

Cromolyn, usually given as a nebulized solution, should not be added to treatment during an acute episode; therapy should be started once asthma is controlled, the airway is cleared, and the patient is able to inhale adequately.

Brand Name Generic Name
Brand discontinued cromolyn
  • Monoclonal Antibodies or Anti-IgE Therapy

Anti-IgE therapy is an antibody that helps decrease allergic response in the body and is administered by injection to patients with severe asthma. It is usually given after other asthma medications have been unsuccessful, and in patients who cannot avoid severe asthma triggers.

Brand Name Generic Name
Xolair omalizumab
  • Methylxanthines

Methylxanthines are not frequently used anymore for asthma. When used, they are given orally, rectally or intravenously. These are regarded more as relievers but oral theophylline may be given long-term as well.

Theophylline has a narrow therapeutic index which means the level required for it to give therapeutic benefit is close to the toxic level. Patients should be monitored for serious toxic effects such as tachycardia (fast heart rate) and persistent vomiting. Once therapy is started and the patient is stabilzed, the same theophylline preparation should be used. Care should also be taken when medicines which interact with theophylline are added or withdrawn.

Brand Name Generic Name
Brand discontinued aminophylline
Elixophyllin, Theochron, Theo-24 theophylline
  • Antimuscarinic Bronchodilators

Antimuscarinic bronchodilators block muscarinic receptors in the bronchial smooth muscle and cause bronchodilation. Compared to beta-2 agonists, these have a slower onset of action but last longer. They may be useful if other therapy does not adequately control symptoms. These are used more often in patients with chronic obstructive pulmonary disease (COPD).

Brand Name Generic Name
Spiriva, Spiriva Respimat tiotropium
Atrovent HFA ipratropium (short acting)

Oral bronchodilators such as albuterol, theophylline or aminophylline may be given long term to patients who cannot use their inhalers properly.

Short-Acting Medications are quick acting or rescue medications used to relieve symptoms during an attack. These include short-acting beta-2 agonists and oral or injectable corticosteroids.

  • Short-Acting Beta-2 Agonist Bronchodilators

Short-acting beta-2 agonists relax muscles in the airways rapidly and improve breathing. They have a faster onset and a shorter duration of action compared to the long acting beta-2 agonist bronchodilators. These agents are often referred to as "quick acting relievers" or "rescue medications".

Patients with mild, intermittent asthma may only need these medications occasionally. Patients with exercise-induced asthma may only need them prior to the activity. These agents are not meant for regular, continuous use. If symptoms occur regularly 2 days or more per week, a physician should be consulted to determine an appropriate maintenance medication treatment regimen.

Common side effects of short-acting beta-2 agonists can include: nervousness, fast heart rate, and anxiety after use.

Brand Name Generic Name
Accuneb (Nebulizing Solution), ProAir HFA, ProAir RespiclickProventil HFA, Ventolin HFA (Inhalers) Vospire ER (Oral) albuterol
Brand discontinued metaproterenol
Brand discontinued terbutaline
Xopenex (Nebulizing Solution), Xopenex HFA (Inhaler) levalbuterol
  • Oral or IV Corticosteroids

When inhaled agents are not sufficient for asthma control, a course of oral corticosteroids might be given short-term (5 to 10 days) during asthma exacerbations or given intravenously (IV) during severe acute attacks.

Common side effects can include enhanced energy, difficulty sleeping, anxiety, increased appetite, altered blood sugar levels, and weight gain.

Brand Name Generic Name
Prednisone, Prednisone Intensol, Rayos prednisone
Millipred, OraPred ODTPediapred, Veripred 20 prednisolone
Depo-Medrol, Medrol methylprednisolone
A-Hydrocort, Cortef, Solu-Cortef hydrocortisone
  • Other Adrenoreceptor Agonists

Adrenoreceptor agonists such as ephedrine and metaproterenol are used less frequently than the selective beta-2 agonists, as they are more likely to cause arrhythmias (abnormal heart rhythms) and other side effects. These should be avoided.

Brand Name Generic Name
Epipen (used for anaphylaxis, not asthma)  epinephrine
Ephedrine - Generic Only (Tabs & Elixir) ephedrine
Brand discontinued metaproterenol
  • Combination Inhalers

There are several inhalers which have 2 types of medications for the treatment of asthma or COPD.

Brand Name Generic Name
Advair Diskus, Advair HFA, AirDuo Respiclick fluticasone and salmeterol
Combivent Respimat albuterol and ipratropium
Symbicort budesonide and formoterol
Dulera formoterol and mometasone
Breo Ellipta fluticasone and vilanterol
Bevespi Aerosphere formoterol and glycopyrrolate
Stiolto Respimat olodaterol and tiotropium
  • Interleukin Inhibitors

Some patients with asthma have a subtype known as "eosinophilic asthma". Interleukin inhibitors (IL inhibitors) help to reduce levels of a certain type of white blood cell that may contribute to the symptoms of this type of asthma. These drugs are given by injection.

Brand Name Generic Name
Cinqair reslizumab
Nucala mepolizumab

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