Asthmatics can breathe more easily with effective treatment.
Some men think of asthma as "kid's stuff," a childhood illness. But they're wrong: the disease strikes people of all ages. Fortunately, lifestyle adjustments and proper medication will allow most asthmatics to lead full, active lives.
Your lungs, in health and in asthma
Some patients will also benefit from skin tests or blood tests to detect allergies that may trigger attacks.
The average man takes more than 20,000 breaths a day. With each, air travels down the windpipe, then through smaller tubes called bronchi. Finally, the air arrives at the lungs' 300 million tiny air sacs, where oxygen crosses into the blood and carbon dioxide is removed, asthma is a disease of the bronchi.
These small tubes must be open to allow the free passage of air. But in asthma, the muscles that surround the bronchi tighten, narrowing the passages. In addition, the tissue that lines the tubes becomes inflamed, and the bronchial glands produce too much mucus, clogging the small airways and making breathing difficult.
Who gets asthma?
About 22 million Americans have asthma. The disease often begins in childhood, but can also develop later in life; in fact, more than half of all asthma patients are adults. It's usually a chronic disease in adults, but symptoms wax and wane, and long periods of well-being are typical.
Many patients with asthma also have allergies, and some have relatives with one or both of these conditions. Genes that make the immune system overactive may explain the link. But an outside event, such as an infection or exposure to dust or pollen, often triggers the asthma attack. That's why treatment requires both medication to quiet inflammation and widen the air tubes and lifestyle adjustments to avoid triggers.
The major symptoms are wheezing, coughing, bringing up sputum (phlegm), shortness of breath, and chest tightness. They can occur singly or in various combinations, but the diagnosis can be tricky when wheezing is absent.
In particular, doctors may overlook asthma when a man's only complaint is a recurrent or chronic cough.
Asthma attacks can begin abruptly or slowly, and they can be brief or prolonged. Attacks are usually mild or moderate, but nearly 5,000 Americans die from asthma each year; that's why the disease must always be taken seriously and managed carefully.
The first step is an evaluation of your symptoms and what triggers them. If you are examined between attacks, your lungs will sound normal, but during an attack, your doctor will hear wheezing. In a severe attack, your breathing will be fast and shallow, your pulse will be rapid, you'll be sweaty and anxious, and your lips may look bluish.
If you are having a moderate to severe attack, your doctor will want to measure the amount of oxygen in your blood, obtain a chest x-ray, check your blood counts, and check your sputum for signs of infection. But even between attacks, you can take two tests to diagnose asthma:
• Spirometry. You exhale into a device that measures the force, speed, and volume of your airflow. If you have active asthma, your numbers will be low, and you may be given a bronchodilator medication to see if you improve, as most asthmatics do.
• Peak flow meter. You can use this small, hand-held device to monitor your own air flow. Simply take in a deep breath, put the device to your lips, and blow out as hard as you can. Compare your reading with your personal best and with normal values. If your peak flow begins to decline, you're having a flare that needs treatment. If you fall below 50% to 60% of normal, you are at risk for a severe attack, and you need prompt medical care. Everyone with moderate or severe asthma should use a peak flow meter at least once a day. Some patients will also benefit from skin tests or blood tests to detect allergies that may trigger attacks. Your therapeutic partnership
The treatment of asthma is complex, and it's changing rapidly as new drugs replace older ones. One of the most important changes reflects scientists' new understanding of the disease. In the past, doctors focused on drugs to relax the bronchial muscles.
These medications have been improved, and they remain important today. Still, the new approach is to focus first on the basic problem in asthma by using treatments that fight inflammation.
If you need an inhaled steroid, start with the lowest dose, then increase if necessary.
Your doctor will determine what medication is best for you, depending mainly on the severity of your asthma. But a good result requires your full partnership. That means making the lifestyle changes you need, taking your medications as directed, using your peak flow meter, and staying in touch with your doctor.
Major asthma medications
There are two types of asthma medications. Quick relievers (rescue drugs) are used to provide rapid relief of symptoms. Inhaled short-acting beta-agonists are the standard rescue drugs.
In contrast, controller medications are used to prevent attacks; many types are available, but most doctors recommend inhaled steroids as the basis for long-term asthma control.
Beta-agonists act by relaxing the bronchial muscles, thus widening the breathing tubes. The short-acting beta-agonists remain the best quick relievers for self-treatment of attacks, but both short- and long-acting members of this drug class must be used with care.
Short-acting beta-agonists include albuterol (Proventil, Ventolin, ProAir), pirbuterol (Maxair), levalbuterol (Xopenex), and terbutaline (Brethine). They are usually inhaled through a metered dose inhaler (MDI). These medications start to act in about five minutes and last for four to six hours.
The short-acting beta-agonists are best used to treat symptom flares or to prevent exercise-induced asthma. The most common side effects are a rapid heartbeat and trembling. These drugs should never be used more than four times a day because long-term overuse can produce serious side effects.
Hands-on instruction in your doctor's office can be very helpful. Ask about adding a holding chamber ("spacer") if you find your MDI hard to use or if you have oral side effects. Instruction will also help you learn to use other inhalation systems such as dry powder inhalers and nebulizers.
Long-acting beta-agonists include salmeterol (Serevent) and formoterol (Foradil, Perforomist), which are usually inhaled in powder form. Because their effects persist for 10 to 16 hours, these controller medications are used to prevent symptoms in patients with recurrent attacks, but not to relieve symptoms.
On the basis of several large studies that linked these medications to an increased risk of complications, including severe asthma attacks and even death, the FDA issued a "black box" warning about long-acting beta-agonists in 2006.
Many experts have questions about the studies, but until new research resolves the controversy, doctors often reserve these drugs for use in combination with inhaled steroids for patients whose symptoms cannot be controlled by other medications. If you are taking a long-acting beta-agonist, discuss it with your doctor, but do not stop treatment on your own.
Inhaled steroids include fluticasone (Flovent), budesonide (Pulmicort), and triamcinolone (Azmacort). Usually administered by MDI twice a day, these anti-inflammatory medications are the best way to control asthma and prevent attacks.
If you need an inhaled steroid, start with the lowest dose, then increase if necessary. Prolonged use of high doses may increase the risk of glaucoma, cataracts, and osteoporosis.
Leukotriene-modifying agents include montelukast (Singulair) and zafirlukast (Accolate). These anti-inflammatory medications are taken in pill form once or twice a day, depending on the preparation.
Some patients find these medications very helpful in preventing asthma symptoms. Serious side effects are uncommon, but the FDA is investigating reports of suicidal thinking that may be linked to montelukast.Cromolyn (Intal) is an inhaled anti-inflammatory medication. It is less potent than some other medications, but can help prevent attacks of asthma triggered by exercise or allergies.
Theophylline preparations are long-acting caffeine-like drugs that relax bronchial muscles. They were once widely used to prevent symptoms, but are less effective than inhaled steroids and may have side effects such as palpitations, restlessness, insomnia, and gastrointestinal upset.
But in light of the black box warning on long-acting beta-agonists, some doctors are returning to theophylline drugs when inhaled steroids don't achieve full control.
Inhaled anticholinergics include tiotropium (Spiriva) and ipratropium (Atrovent). These drugs widen the bronchial tubes, but are more helpful in chronic obstructive pulmonary disease (COPD, or "emphysema") than asthma. Still, they can help prevent asthma attacks in some people, particularly the elderly or those with both COPD and asthma.
Oral steroids include prednisone and methylprednisolone. These anti-inflammatories are reserved for severe asthma that does not respond to other measures. Long-term use has serious side effects.
Omalizumab (Xolair) is an injectable drug that should be reserved for patients with severe allergy-related asthma that cannot be controlled by other medications. It can trigger anaphylaxis, a life-threatening allergic reaction.
Every asthmatic needs a personal plan of lifestyle prevention and prescription medications. Here are some guidelines:
Mild intermittent asthma.Your symptoms occur no more than twice a week; you are not awakened by asthma more than twice a month; and your peak flow rates average at least 80% of normal. You should do well simply by using a short-acting beta-agonist MDI when you have symptoms or before you exercise or encounter triggers such as pets.
Mild persistent asthma.Your symptoms occur regularly, but not every day; you are awakened by asthma three to four times a month; and your peak flow rate is 80% or higher of normal. You'll probably benefit from regular use of a steroid inhaler to prevent episodes, along with a short-acting beta-agonist inhaler to relieve symptoms.
Moderate persistent asthma.Your symptoms occur daily, often interfering with normal activities; you are awakened more than once a week; and your peak flow rate is between 60% and 80% of normal. You probably need a moderate- or high-dose inhaled steroid along with an additional controller medication (one or more) such as a leukotriene modifier, theophylline, or cromolyn. Ask your physician about the pros and cons of a long-acting beta-agonist in combination with your inhaled steroid. In any case, continue using your short-acting beta-agonist for symptoms, but notify your doctor if you need it four times a day. Monitor your peak flow rate and symptoms, and keep an asthma log.
Severe persistent asthma.You have frequent symptoms despite all the measures described above; you are awakened four to seven nights a week; and your peak flow rate is less than 60%. You need all the treatments used for moderate asthma, and you are likely to need steroid pills as well. Your doctor will try to taper down your dose as much as possible, hoping to stop the tablets when your control is good. You may benefit from a referral to a specialist, and you may need additional tests and treatments. And like all asthma patients, you should be prepared to get immediate emergency treatment if your symptoms worsen.
In health, breathing is easy and automatic. Asthma can make breathing difficult, but effective treatment is available. Treatment can be difficult, too, but it's worth the effort. A therapeutic partnership with your doctor will reward you with the breath of life.
This article is provided courtesy of Partners Harvard Medical International. © 2008 President and Fellows of Harvard College.
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