Asthma: Waiting to inhale
AN APPLE A DAY - AN APPLE A DAY By Tyrone M. Reyes, M.D. () - May 8, 2007 - 12:00am
I t’s your favorite time of the summer — time to be outdoors, in the field, the mountains, or the sea. But this year, while working in your garden, you were wheezing and struggling a bit to breathe. And last night, you were awakened with trouble breathing.

It’s possible that your problem is late-onset asthma, triggered by exercise or allergens. Studies have found that asthma is becoming more common among people over 65. In addition, a recent Mayo Clinic study found that over 40 percent of older adults with asthma are hospitalized at least once for asthma-related problems, some of them life-threatening.

Although there’s no known cure, asthma can be managed. It’s now understood that asthma is primarily related to an inflammation of the airways in your lungs. Anti-inflammatory medications have become a mainstay of treatment — a way to reduce symptoms and prevent attacks for people with chronic asthma.
Airway Obstruction
In asthma, inflammation and obstruction of your airways make breathing difficult. You inhale less deeply, and exhalation is further impaired because your smaller airways collapse and trap air in your lungs. Asthma can range from mild to severe. You may experience only occasional episodes of asthma with short-lived signs or symptoms such as wheezing. You also may have an unexplained cough or wheeze most of the time. Many people with asthma often experience coughing and wheezing while sleeping, which can cause nighttime awakenings.

In addition to physical exercise, common triggers for an asthma attack include respiratory infections; cold, dry air; allergens such as household dust mites, pollen, molds, and dander from pets; smoking (including secondhand smoke), air pollutants, and irritants; emotional stress; and esophageal reflux. In addition, certain medications, including some used to treat heart disease or high blood pressure (hypertension), may cause problems in some people.
Is it asthma?
If you think you may have asthma, see your doctor. Diagnosis usually starts with a history and physical examination. Further evaluation may include a chest x-ray, blood tests and lung (pulmonary) function tests. Allergy tests may be used to help pinpoint triggers that could make asthma worse. Lung function tests are often used to diagnose asthma and evaluate its severity. A peak flow meter used at home can help detect and measure the severity of airflow obstruction. It can help you detect subtle changes in airway function hours or even days before you notice symptoms. Once proper treatment is started, it can also help you monitor improvement. Your doctor may use a more sophisticated device called a spirometer to measure your lungs’ ability to inhale and exhale air.

If the diagnosis still isn’t clear, a methacholine challenge test may help rule out asthma. In this test, you inhale a dose of methacholine, a drug used only for study purposes. If you have asthma, the drug causes temporary, measurable airway obstruction.
Avoid Triggers
For most people, treatment involves limiting triggers and taking the appropriate medications properly. Identify your triggers and eliminate those that apply by:

• Avoiding nonsteroidal anti-inflammatory medications if you’re sensitive to aspirin.

• Avoiding food preservatives called sulfites — often found in salads in restaurants and wines.

• Dusting regularly while wearing a dust mask, cleaning and decontaminating filters on air conditioners and humidifiers, and using mite-proof encasements on pillows and mattresses.

• Maintaining optimal humidity to reduce dust mites and growths of mold and fungi.

• Washing bedding in hot water weekly to minimize dust.

• Asking your doctor whether non-asthma medications you’re taking — including even aspirin — may be contributing to your attacks.
Asthma medications generally fall into two categories: anti-inflammatory medications and bronchodilators. Anti-inflammatories are the mainstay of asthma treatment. Bronchodilators are used to provide prompt relief during asthma attacks.

By reducing inflammation, anti-inflammatories reduce swelling of airway walls and limit excess secretions. The most widely used anti-inflammatories are steroids. Inhaled steroids are the foundation of treatment and, used properly, generally cause the fewest side effects. Oral or injected steroids generally are reserved for severe asthma attacks or persistent severe asthma. Inhaled steroids include beclomethasone (Candibec, Qvar), budesonide (Budecort), flunisolide, and fluticasone (Cultivate, Flexotide). For moderate or severe asthma, inhaled steroids usually are used one or more times daily. They can help control symptoms and decrease how often you have attacks. Inhaled steroids have made the use of regular oral steroids unnecessary for most people with asthma.

Your doctor may advise you to use a four- to eight-inch-long spacer tube when inhaling steroids to distribute the medication evenly in the bronchial tubes. Gargling with water after use may help decrease side effects such as throat irritation or an oral yeast infection (thrush). Unlike inhaled steroids, inhaled bronchodilators don’t reduce airway inflammation but act to open up constricted airways and provide prompt relief during an attack. Although these medications can also be delivered orally or intravenously, inhalers are most frequently used because they deliver the drug directly to the lungs, which lowers the frequency and severity of side effects. Bronchodilators can be short acting (lasting for four to six hours) or long acting (lasting eight to 12 hours). The most commonly used are short-acting beta agonists, which are typically prescribed alone for mild, occasional symptoms.

Beta agonists, such as albuterol (Ventolin), metaproterenol, pirbuterol, and levalbuterol, act quickly against acute attacks. They may also be used before exercise or exposure to allergens to prevent an attack. They’re frequently prescribed for use every four to six hours or "as needed." Salmeterol (Serevent, Seretide) and formoterol (Foradil) are long-acting beta agonists. They’re used to relieve airway constriction for up to 12 hours and are helpful in preventing signs and symptoms, especially nighttime attacks. They’re not recommended for immediate relief from an asthma attack.

Another class of bronchodilators includes the anticholinergic ipratropium bromide (Atrovent). It works by opening up the big airways, and in some people it can work in combination with albuterol (Combivent). Another combination inhaler is available abroad as Advair, which contains salmeterol plus the steroid fluticasone. A special class of inhaled drugs that’s useful only as a preventive treatment includes cromolyn and nedocromil.

Oral medications often used in asthma include corticosteroids such as prednisone, a type of bronchodilator called theophylline, and a class of drugs called leukotriene modifiers, which includes montelukast (Singulair, Kastair, Montair), zafirlukast (Accolate), and zileuton.
Difficult-To-Control Asthma
If your asthma is difficult to control or isn’t responding to treatment, your doctor may want to further investigate the reason. Common causes are:

• You continue to be exposed to your personal asthma triggers.

• You’re not timing your inhaler or spacer properly, or you’re using your inhaler too often or not regularly.

• You’re taking a drug for another condition, such as hypertension, that’s having an adverse effect on your asthma.

• You have a condition other than or in addition to asthma (foreign body in the airway or a small tumor obstructing the airway).

Shortness of breath mimicking bronchial asthma can also be related to a heart condition (cardiac asthma). Among other causes, your vocal cord (larynx) may be functioning improperly. This is vocal cord dysfunction.
Shaping Your Treatment
Your doctor may be able to help you develop an asthma action plan that details how you can best monitor and manage your asthma and how you should respond to any changes in your signs and symptoms. An asthmatic attack can be prevented, and if it occurs, can be treated. You need only to follow your doctor’s action plan for an effective preventive and treatment program, specifically tailored to your individual needs.

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