Asthma Education

Childhood Asthma

Tips to Remember: Childhood Asthma

Asthma is the most common serious chronic disease of childhood, affecting nearly five million children in the United States. Asthma in children is the cause of almost three million physician visits and 200,000 hospitalizations each year.

Children with asthma cough, wheeze, experience chest tightness and shortness of breath. Many parents do not realize that a chronic cough may be the only symptom of asthma and that a child does not have to wheeze to have asthma! Children with reactive airway disease, recurrent bronchitis or wheezy bronchitis probably have asthma.

Diagnosis

Up to 80% of children with asthma develop symptoms before age five. The child's physician must rely heavily on parents' observations to make a proper diagnosis.

To make a diagnosis of asthma your child's physician will want to know about the following:

• Does your child cough, wheeze (a whistling sound when breathing), have chest tightness or shortness of breath?
• Do colds go right to your child's chest and last much longer than other siblings?
• Does your child cough or wheeze with exercise, play and laughter or during temper tantrums?
• Is there a family history of asthma or allergies?
• What triggers your child's symptoms - colds, allergens (like the family pet) or exercise?
• How often are the symptoms and how bad?
• Is your child missing school?
• Is coughing or wheezing keeping you and your child up at night?

If your child is old enough (usually older than 5-6), he or she may do a Pulmonary Function Test. The results will tell the physician about how the child's lungs actually work. This test helps not only in the diagnosis but will help the doctor follow the response to medication.

For children, asthma symptoms can interfere with many school and extracurricular activities. Parents may notice their child has less stamina during play than his or her peers, or they may notice the child trying to limit or avoid physical activities to prevent coughing or wheezing. More subtle signs of asthma, such as chest tightness, are often not identified as such by children. Sometimes they will complain that their "chest hurts" or that they cannot "catch their breath." Often, recurrent or constant coughing spells may be the only observable symptom.

The two most common triggers of asthma in children are colds and allergens (substances that trigger allergies). In fact, most kids with asthma are allergic and should have an allergy evaluation as part of their care. Common allergens include dust mite, animal dander, cockroach, pollen and molds. We cannot do a lot about viral illnesses but there are ways to limit allergen exposure in the home environment if you know what you need to avoid.

Management

The goals for managing childhood asthma are simple. Children with asthma should be able to:

SLEEP, LEARN and PLAY

If asthma is waking the family at night: if the child cannot play soccer or dance ballet; if he or she is chronically missing school (and parents missing work) then the asthma is not controlled!

Every child with asthma should have a written asthma management plan. This tells the child and parents what medications to take when well; how to go up on medication when the child has increasing symptoms and when to call the physician. This plan gives control to the patient and their parents and allows for early treatment of symptoms, before the asthma flare gets out of control.

As part of an effective asthma management plan, the child's physician may prescribe specific medications and devices. These can include a peak flow meter to measure ease of breathing, metered dose inhalers, spacers that attach to inhalers, nebulizer that deliver medication in a mist, dry powder inhalers, or oral (tablet) medications. The physician should not only prescribe these medications and devices, but should teach children and parents how to use them correctly.

Asthma medications include rescue medication or quick relievers to treat symptoms (ie albuterol) and long-term controller medicines to control the inflammation that causes asthma. If a child has symptoms more than twice a week or wakes more than twice a month at night, they should be on long-term controller therapy. For more information on asthma medications, please see the Tip brochure in this series.

Answers to commonly asked questions

Will my child outgrow his/her asthma?

The challenge to the physician who cares for children and the parent is to identify the child who wheezes early in life and will outgrow their asthma, vs. the child who will continue to have persistent wheezing. Some babies who wheeze with viral respiratory illnesses will stop wheezing as they grow and their airways get bigger. If a child has atopic dermatitis(eczema), there is smoking in the home or if the mom has asthma, there is a greater chance that the child will have persistent wheezing. Some children have asthma symptoms that improve during adolescence, while others worsen. Often, symptoms in young children seem to resolve, but their asthma may flare up later in life.

Can asthma be cured?

Currently there is no cure for asthma. However, for most children, asthma can be controlled with appropriate management and treatment. While asthma is a chronic illness, it should not be a progressively debilitating disease - a child with asthma can have normal or near-normal lung function with appropriate management and medications.

Should my child exercise?

Parents may have the urge to restrict their asthmatic child's physical activity to prevent wheezing. But once a child is taking proper medications, aerobic exercise needs to become part of his or her daily activities, because it improves airway function. Children must be encouraged to participate in normal activities as much as possible. It is also very possible for a child with asthma to excel in athletics - several Olympic athletes have asthma.

Asthma at school

The child, family, physician and school personnel must work together to prevent and/or control asthma symptoms at school. Many children with asthma are embarrassed about their need for medication. In some cases, children may have difficulty because they are required to go to another part of the school building, such as a nurse's office, to take their medication. School officials and parents must create a supportive environment. With the approval of physicians and parents, school-age children with asthma should be allowed to carry metered dose inhalers with them at all times and use them as appropriate. Many states have now passed laws to allow responsible children to keep their inhaler in their book bag.

To ensure optimal care at school, parents can also take the following proactive steps:

• Meet with teachers, the school nurse, coach and perhaps the principal at the beginning of the school year.
• Have your child's doctor provide a written asthma plan for school such as the Asthma School Action Plan. You can find this on the Patients & Consumers resources page of the AAAAI Web site, www.aaaai.org.
• Encourage local educational programs to improve education for schools about asthma.

For children with asthma to function normally, school personnel, families and health care providers must effectively communicate and work together to encourage them to fully participate in activities with their peers. This team effort will help create a positive, healthy and safe environment for the child - both in and out of school - and ensure the best asthma care possible.

Your allergist/immunologist can provide you with more information on childhood asthma.

Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology. This brochure was updated in 2003.

The content of this brochure is for informational purposes only. It is not intended to replace evaluation by a physician. If you have questions or medical concerns, please contact your allergist/immunologist.

Excercise Induced Asthma

Tips to Remember: Excercise Induced Asthma

Do you experience coughing, wheezing, or chest tightness when you exercise? Do you feel extremely tired or short of breath when you exert yourself? If you have these symptoms, you may be one of many people with exercise-induced asthma (EIA). Approximately 7% of the population, or about 18 million Americans, are reported to suffer from asthma. With strenuous physical exercise, most of these individuals experience asthma symptoms. In addition, many non-asthmatic patients - up to 13% of the population, up to 40% of patients with allergic rhinitis and often people who have a family history of allergy - experience asthma associated with exercise.

Symptoms and triggers

If you have exercise-induced asthma, you may experience breathing difficulty within 5-20 minutes after exercise. Symptoms may include wheezing, chest tightness, coughing and chest pain. Other EIA symptoms include prolonged shortness of breath, often beginning 5-10 minutes after brief exercise.

Patients with EIA have airways that are overly sensitive to sudden changes in temperature and humidity, especially when breathing colder, drier air. During strenuous activity, people tend to breathe through their mouths, allowing the cold, dry air to reach the lower airways without passing through the warming, humidifying effect of the nose. With mouth breathing - also common in patients with colds, sinusitis and allergic rhinitis ("hay fever") - air is moistened to only 60-70% relative humidity, while nose-breathing warms and saturates air to about 80 to 90% humidity before it reaches the lungs.

In addition to mouth-breathing, air pollutants, high pollen counts, and viral respiratory tract infections can also increase the severity of wheezing with exercise.

Diagnosis

To confirm a diagnosis of EIA, a physician:

• Obtains a patient history.
• Performs a breathing test when the patient is at rest to ensure that the patient does not have chronic asthma.
• Often may perform a breathing test after exercise.

Measurement can be done in a medical facility or "on the field." In the office setting, a patient exercises for six to eight minutes using a treadmill or cycle to create enough exertion to maintain a heart rate at 80-90% of the age-related maximal predicted value. The patient breathes into a breathing machine called a spirometer, which processes the patient's ability to breathe out, or expire air. This test is performed before exercise and at various intervals from two to 30 minutes after exercise stops. A decrease of at least 12-15% in the volume of air blown out (as compared to the starting value) by the patient in one second (termed the forced expiratory value in one second, or FEV 1) indicates possible EIA.

On the field, expiratory airflow can be evaluated before and after a six- to eight-minute "free run" or after participation in a sport or activity that usually induces respiratory symptoms. Airflow is again measured for 30 minutes after exercise ends. Although a portable spirometer can be used, physicians often recommend a small, relatively inexpensive peak flow meter to demonstrate the characteristic post-exercise decrease in expiratory airflow. In this case a 15-20% decrease is required for the test to be considered positive for EIA.

Recommended activities

Although the type and duration of recommended activity varies with each individual, some activities are better for those with EIA. Swimming is often considered the sport of choice for asthmatics and those with a tendency toward bronchospasm because of its many positive factors: a warm, humid atmosphere, year-round availability, toning of upper body muscles, and the way the horizontal position may help mobilize mucus from the bottom of the lungs. Walking, leisure biking, hiking and free downhill skiing are also activities less likely to trigger EIA. In cold weather, wearing a scarf or surgical mask over the mouth and nose can decrease symptoms by warming inhaled air.

Team sports that require short bursts of energy, such as baseball, football, wrestling, golfing, gymnastics, short-term track and field events or surfing are less likely to trigger asthma than sports requiring continuous activity such as soccer, basketball, field hockey or long-distance running. Cold weather activities such as cross-country skiing and ice hockey are also more likely to aggravate airways. However, many asthmatics have found that with proper training and medical treatment, they are able to excel as runners or even basketball players.

Treatment

Inhaled medications taken prior to exercise are helpful in controlling and preventing exercise-induced bronchospasm. The medication of choice in preventing EIA symptoms is a short-acting beta2agonist bronchodilator spray used 15 minutes before exercise. These medications, which include albuterol, pirbuterol, and terbutaline, are effective in 80 to 90% of patients, have a rapid onset of action, and last for up to four to six hours. These drugs can also be used to relieve symptoms associated with EIA after they occur.

In the school setting, these medications may be administered to children by school nurses. A long-acting bronchodilator spray that lasts up to 12 hours is also available. By using this before school, many children are able to participate in gym class and other sports throughout the day without needing short-acting sprays.

If symptoms are not readily controlled by medications, patients should talk to their physician about using daily medication that treats the underlying asthma-the inflammatory process that is causing increased "twitchiness" or sensitivity of the airways. In addition to medications, a warm-up period of activity before exercise may lessen the chest tightness that occurs after exertion. A warm-down period, including stretching and jogging after strenuous activity, may prevent air in the lungs from changing rapidly from cold to warm, and may prevent EIA symptoms that occur after exercise.

Athletes should restrict exercising when they have viral infections, when temperatures are extremely low, or - if they are allergic - when pollen and air pollution levels are high. Pursed (narrowed) lip breathing may also help reduce airway obstruction.

Asthma and the Olympics

According to a recent study, at least one in six athletes representing the United States in the 1996 Olympic Games had a history of asthma. Although 4-7% of the general population is reported to have asthma, the number of Olympic athletes who reported asthma was considerably higher. Out of 699 athletes, 117 (16.7%) were found to have a history of asthma, or to have used asthma medications, or both. Seventy-three (10.4%) of the athletes had active asthma, based on their need for asthma medication at the time of the games, or their need for medication on a permanent or semi-permanent basis. Among the Olympic athletes, asthma was most common among cyclists and mountain bikers and least common in athletes competing in badminton, beach volleyball, table tennis and volleyball. Interestingly, nearly 30% of the 1996 U.S. Olympians who had asthma or took asthma medications won team or individual medals in their Olympic competition, faring as well as athletes without asthma (28.7%) who earned team or individual medals.

Exercise is beneficial to both physical health and emotional well-being. Even if they are not striving for an Olympic medal, almost all people with EIA should be able to exercise to their full ability with appropriate diagnosis and treatment.

Your allergist/immunologist can provide you with more information on exercise-induced asthma.

Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology. This brochure was updated in 2003.

The content of this brochure is for informational purposes only. It is not intended to replace evaluation by a physician. If you have questions or medical concerns, please contact your allergist/immunologist.

Asthma & Pregnancy

Tips to Remember: Asthma & Pregnancy

During pregnancy, mothers-to-be may feel uneasy taking medications. However, if a pregnant woman has asthma, it is doubly important that her symptoms be well-managed to increase both her health and her baby's health. Uncontrolled asthma can be a threat to maternal well-being and fetal growth and survival. The goals of asthma management and treatment during pregnancy are the same as for other patients - to prevent hospitalization, emergency room visits, work loss and chronic disability.

Pregnant women, like others with asthma, should avoid asthma triggers, including specific allergens such as house dust mites and animal dander, and irritants such as cigarette smoke. After discovering you are pregnant, see your allergist/immunologist soon after to discuss the best way to manage your asthma and what medications to take. He or she will be able to prescribe effective asthma and allergy medications that are appropriate to use during pregnancy, and will continue to work with you throughout your pregnancy to ensure your treatment is effective, without side effects.

If you are pregnant and have asthma, you may have questions regarding the best care for both your asthma symptoms and your baby. Following are some common questions and answers to assist you.

Common questions

Can women with asthma have safe, full-term pregnancies?

Studies show maternal asthma that is well-managed during pregnancy does not increase the risk of maternal or infant complications. With appropriate asthma management, you can have a healthy baby. Conversely, there is a direct relationship between lower birth weight and uncontrolled asthma. So, it benefits you and your baby to control asthma symptoms.

Why would uncontrolled asthma affect the fetus?

Uncontrolled asthma causes a decrease in the amount of oxygen in the mother's blood. Since the fetus receives its oxygen from the mother's blood, decreased oxygen in her blood can lead to decreased oxygen in the fetal blood. This, in turn, can lead to impaired fetal growth and survival, since a fetus requires a constant supply of oxygen for normal growth and development.

How do asthma medications affect the fetus?

Studies and observations of hundreds of pregnant women with asthma have demonstrated that most inhaled asthma medications are appropriate for patients to use while pregnant. The risks of uncontrolled asthma appear to be greater than the risks of necessary asthma medications. However, oral medications (pills) should be avoided unless necessary to control symptoms.

What effect does pregnancy have on asthma?

Pregnancy may affect the severity of asthma. One study showed that asthma symptoms worsened in 35% of pregnant women, improved in 28% and remained the same in 33% of the pregnant women. These changes in severity are another reason to stay in close contact with your allergist/immunologist so he or she can monitor your condition and alter your medications or dosages if necessary.

During what part of pregnancy will asthma change?

Asthma has a tendency to worsen during pregnancy in the late second and early third trimesters; however, women may experience fewer symptoms during the last four weeks of pregnancy. Troublesome asthma during labor and delivery is extremely rare in women whose asthma has been adequately controlled during pregnancy.

Why does asthma improve for some women during pregnancy?

The exact reason is unknown. Higher levels of cortisone in the body during pregnancy may be an important cause of this improvement.

Why does asthma worsen for some women during pregnancy?

Again, the exact reasons are not known. Because the stomach area is compacted during pregnancy, some women may experience gastroesophageal reflux, a condition that causes heartburn and other symptoms. This reflux can worsen asthma symptoms. Other conditions, such as sinus infections, viral respiratory infections and increased stress, may also aggravate asthma during pregnancy.

Can I continue to receive allergy shots during pregnancy?

Allergy shots do not have an adverse effect on pregnancy, so they can be continued. As always, your allergist/immunologist will monitor your dose to reduce the risk of an allergic reaction to the shots. These reactions are rare; however, such a reaction could be harmful to the fetus. And, allergy shot treatments should not be started for the first time during pregnancy.

Can women with asthma perform Lamaze?

Most women with asthma are able to perform Lamaze breathing techniques without difficulty.

Can I breast feed if I have asthma?

Breast feeding is a good way to increase your child's immunity, and is encouraged. The transfer of most drugs into breast milk has not been precisely evaluated; however, there appears to be no evidence that asthma medications adversely affect nursing infants. (However, some infants may become irritable from theophylline transferred by breast milk.) Also, if you have allergy symptoms while nursing, it is appropriate to treat these as well. Again, make sure to see your allergist/immunologist for the best treatment of allergies and asthma while nursing.

Although these are common questions during pregnancy, each patient's individual treatment varies. Managing asthma and avoiding asthma flare-ups during pregnancy is important to the health of the mother and fetus. It is best if women see their allergist/immunologist regularly during pregnancy so that any worsening of asthma can be countered by appropriate changes in the management program. Make sure to discuss any specific concerns with your doctor to ensure the healthiest pregnancy - for your well-being and that of your baby.

Your allergist/immunologist can provide you with more information on asthma and pregnancy.

Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology. This brochure was updated in 2003.

The content of this brochure is for informational purposes only. It is not intended to replace evaluation by a physician. If you have questions or medical concerns, please contact your allergist/immunologist.

Triggers & Management

Tips to Remember: Triggers & Management

Asthma is a chronic lung disease that affects more than 17 million Americans. Asthma is characterized by inflammation of the airways. The inflammation makes the airways smaller and therefore making it more difficult for air to move in and out of the lung. This creates the symptoms of asthma:

• Cough
• Chest tightness
• Shortness of breath
• Wheezing

Triggers of asthma

Asthma symptoms can be triggered by several factors, including:

• Allergens
• Irritants such as tobacco smoke, strong odors
• Weather changes
• Viral or sinus infections
• Exercise
• Reflux disease (Stomach acid flowing back up the esophagus, or food pipe)
• Medications or foods
• Emotional anxiety

Every person has their own triggers. If you have asthma you can minimize your symptoms by avoiding the factors that trigger your symptoms, and by working with your physician to develop an effective management and treatment plan.

Allergens

Allergic rhinitis, or "hay fever," is a risk factor in developing asthma. Symptoms of both can be triggered by allergens - any substance that triggers allergies. These include:

Allergens

Irritants such as tobacco smoke, strong odors

• Weather changes
• Viral or sinus infections
• Exercise
• Reflux disease (Stomach acid flowing back up the esophagus, or food pipe)
• Medications or foods
• Emotional anxiety

Every person has their own triggers. If you have asthma you can minimize your symptoms by avoiding the factors that trigger your symptoms, and by working with your physician to develop an effective management and treatment plan.

Allergens

Allergic rhinitis, or "hay fever," is a risk factor in developing asthma. Symptoms of both can be triggered by allergens - any substance that triggers allergies. These include:

• Pollens
• Molds
• Animal dander
• House dust mite
• Cockroach droppings

If your asthma is triggered by allergens, it is important to avoid exposure to them. See your allergist/immunologist for recommendations on control measures to help avoid allergens.

Irritants

Inflamed asthmatic airways are sensitive to environmental irritants. Irritants that can trigger and aggravate asthma include:

• Air pollutants such as tobacco smoke, wood smoke, chemicals in the air and ozone
• Occupational exposure to vapors, dust, gases or fumes
• Strong odors or sprays such as perfumes, household cleaners, cooking fumes (especially from frying), paints or varnishes
• Other airborne particles such as coal dust, chalk dust or talcum powder
• Changing weather conditions, such as changes in temperature and humidity, barometric pressure or strong winds

All of these irritants can aggravate asthma, particularly tobacco smoke. Several studies have reported an increased incidence of asthma in children whose mothers smoke. No one should smoke in the home of an asthmatic.

Infections

Viral infections such as colds or viral pneumonia can trigger or aggravate asthma, especially in young children. These infections can irritate the airways, nose, throat, lungs, and sinuses, and this added irritation often triggers asthma flare-ups. Additionally, sinusitis - an inflammation of the hollow cavities found around the eyes and behind the nose - can trigger asthma.

Exercise

Strenuous physical exercise can also trigger attacks. Mouth breathing, exercising in cold, dry air, or prolonged, strenuous activities such as medium- to long-distance running can increase the likelihood of exercise-induced asthma (EIA). For more information, please see the Tips brochure in this series or speak to your allergist/immunologist.

Reflux disease

Gastroesophageal reflux disease (GERD), a condition in which stomach acid flows back up the esophagus, can affect patients with asthma. Symptoms include severe or repeated heartburn, belching, night asthma, increased asthma symptoms after meals or exercise, or frequent coughing and hoarseness. GERD reflux treatment is often beneficial for asthma symptoms as well.

Medications

Some adults with asthma may experience an asthma attack as a result of taking certain medications. These can include aspirin or other non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen; and beta-blockers (used to treat heart disease, high blood pressure or migraine headaches). Before taking any over-the-counter medications, those with asthma should consult their physicians.

Food

For some, eating certain foods or various food additives can trigger asthma symptoms. Culprits include milk, eggs, peanuts, tree nuts, soy, wheat, fish and shellfish. If any of these foods triggers asthma attacks, the best remedy is to avoid eating them.

Emotional Anxiety

Emotional factors alone cannot provoke asthma. However, anxiety and nervous stress can cause fatigue, which may also increase asthma symptoms and aggravate an attack. As with any other chronic health condition, proper rest, nutrition and exercise are important to overall well-being and can help in managing asthma.

Asthma management

Since asthma is a chronic disease, it requires continuous management and appropriate treatment. According to the national Guidelines for the Diagnosis and Management of Asthma (National Asthma Education and Prevention Program, National Institutes of Health, 1997), asthma treatment has four main components:

• The use of objective measure of lung function (such as peak flow meters and spirometers) to assess the severity of asthma and to monitor the course of treatment
• Environmental control measures to avoid or eliminate factors that trigger asthma symptoms or flare-ups
• Medication therapy for long-term management to reverse and prevent airway inflammation as well as therapy to manage asthma flare-ups
• Patient education to foster a partnership between the patients, his or her family, and the physician and other health care providers

According to the Guidelines, there are six goals for the effective management of asthma:

• Prevent chronic and troublesome symptoms
• Maintain (near) "normal" breathing
• Maintain normal activity levels, including exercise
• Prevent recurrent asthma flare-ups, and minimize the need for emergency room visits or hospitalizations
• Provide optimal medication therapy with no or minimal adverse effects
• Meet patients' and families' expectations of satisfactory asthma care

You and your physician can work together on these goals to ensure that your asthma is well-managed. Having asthma should not stop you from participating in normal activities.

Medication treatment

Asthma management includes using proper medications to prevent and control asthma symptoms and to reduce airway inflammation. Asthma medications are thus categorized into two general classes, quick-relief and long-term control medications. Quick-relief medications that are used to provide temporary relief of symptoms include:

• Bronchodilators, generally used as "rescue medications," open up the bronchial tubes so that more air can flow through. Bronchodilators include beta-agonists and anticholinergics, and come in inhaled, tablet, liquid or injectable forms.
• Corticosteroids are administered for short-term use orally or by injection to speed up the resolution of airway inflammation.

Long-term control medications are taken daily to control the airway inflammation in persistent asthma. This class includes:

• Inhaled corticosteroids are the most effective long-term therapy available for persistent asthma. They are generally well tolerated and safe at recommended dosages.
• Cromolyn or Nedocromil stop the development of inflammation in the lungs, as well as help to prevent it. Response to these two are less predictable then the response to inhaled corticosteroids. These medications are very safe.
• Leukotrienes modifiers fight potent chemicals called leukotrienes (lu-ko-try-eens) responsible for airway inflammation within the body. They are generally safe.
• Inhaled beta 2-agonists are long-acting and beneficial when added to inhaled corticosteroids.
• Methylxanthines provide mild to moderate dilation of the airways and may have a mild anti-inflammatory effect. Theophylline is the most frequently used methylxanthine.
• Omalizumab was approved in 2003 as a new class of therapy, known as anti-IgE, for patients with moderate to severe persistent allergic asthma. IgE is an antibody that we all have and it is responsible for causing allergic problems in some people. It may reduce allergic reactions by causing free IgE to disappear from the body so that the IgE cannot attach to pollen (and other substances that are present).

Combination therapy, with the addition of a long-acting beta2-agonist to low-to-medium doses of inhaled corticosteroids, results in improvement in asthma control. Adding a leukotriene modifier or theophylline to inhaled corticosteroids also improves asthma control but the evidence is not as substantial.

Make sure you follow your physician's instruction on the appropriate use and dosage of your prescribed medications.

The better informed you are about your asthma triggers and management, the less asthma symptoms will interfere with your activities. It is important to avoid your triggers, work with your physician on a management plan and take appropriate medications as prescribed. Together, you and your allergist/immunologist can work to ensure that asthma does not interfere with your optimal quality of life.

For more information on any of the topics mentioned in this brochure, please see the appropriate Tips brochures in this series or speak with an allergist/immunologist.

Your allergist/immunologist can provide you with more information on asthma triggers and management.

Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology. This brochure was updated in 2003.

The content of this brochure is for informational purposes only. It is not intended to replace evaluation by a physician. If you have questions or medical concerns, please contact your allergist/immunologist.

Asthma Medications

Tips to Remember: Asthma Medications

More than 50 million people in the United States suffer from asthma and allergies. Fortunately, today there are many effective medications available to treat these conditions. The following information is intended to help asthma and allergy sufferers better understand the most commonly used types of medications.

Anti-inflammatory agents

Inflammation is an important part of allergic diseases and can affect the skin as in eczema; the nose as in allergic rhinitis; the conjunctiva of the eyes or the bronchial tubes as in asthma. There are three classes of medications that are used as anti-inflammatory agents to treat allergies and asthma:

Mast Cell Stabilizers: these are non-steroidal medications that reduce inflammation by preventing the release of inflammatory chemicals.

• They include cromolyn, nedocromil and lodoxamide and are available in various forms to treat allergic disease.

Corticosteroids [also known as "steroids"]: are effective anti-inflamammatory medications. These medications are very different from the anabolic steroids that are misused by some athletes to increase their performance.

• Corticosteroids are available in topical creams or ointments, nasal sprays, inhalers, pills and by injection.
• Corticosteroid use needs to be supervised by a physician.
• Minor side effects from using corticosteroid inhalers can include hoarseness and thrush (a fungal infection of the mouth and throat). Both are less likely with rinsing, gargling and spitting with water after use.
• Long-term use of inhaled corticosteroids in children could potentially result in reduced growth velocity; however in most situations the benefit of having the asthma controlled is greater than the potential for a side effect.
• Oral corticosteroids generally have more side effects than inhaled or topical agents.
• Short-term use (up to several weeks) of oral corticosteroids is usually not a problem for an otherwise healthy person.
• Side effects of short-term use include slight weight gain, increased appetite, menstrual irregularities, cramps, heartburn or indigestion. These side effects will go away shortly after stopping the corticosteroids.
• Long-term use (months to years) of oral corticosteroids is associated with ulcers, weight gain, cataracts, weakened bones and thinner skin, high blood pressure, elevated blood sugar, easy bruising and decreased growth in children.
• Corticosteroids, when taken properly, are a very effective method of treatment for asthma and allergies.
• Oral corticosteroids are usually considered as short-term medications for asthma flare-ups, marked nasal congestion, and at times for skin conditions such as poison ivy.
• Inhaled corticosteroids are considered the most effective medications for long-term control over persistent asthma.
• Please see the Tip brochure in this series for more information on the use of inhaled medications for asthma.

Anti-leukotrienes

• Many of the cells involved in causing airway inflammation are known to produce potent chemicals within the body called leukotrienes (lu-ko-try-eens).
• Leukotrienes are responsible for increasing inflammation within the body-causing contraction of the airway muscle and increasing leakage of fluid from blood vessels in the airways.
• Currently we have several oral anti-leukotriene medications available to help fight allergic inflammation.
• These drugs are primarily used to help gain control over persistent asthma.
• One is also approved to treat allergic rhinitis.
• These medications are available only in tablet form which some people prefer.

Bronchodilators

There are several classes of bronchodilators available to treat asthma.

Beta-agonist bronchodilators relax the muscle of the bronchial tubes.

• Short-acting beta-agonist bronchodilators are used as quick-relief medications. These are available as inhalations, liquids, injectables and pills. (Albuterol is the classic example.)
• Long-acting beta-agonists bronchodilators are used for long-term control of asthma. (Salmeterol and formoterol are two examples.)
• Side effects of this class include nervousness, increased heart rate, restlessness, insomnia and, rarely, headaches.

Theophylline has been used for over 30 years to treat asthma.

• These are available as tablets, capsules or intravenously.
• Their blood levels need to be monitored.
• Side effects can include headaches, elevated heart rate and stomach upset.

Anticholinergics are available in inhaled form.

• These can be used alone or combined with the beta-agonist bronchodilators.
• Ipratropium is used for asthma treatment as a quick-relief medication.
• Cough and headache can be side effects.

Omalizumab

Omalizumab was approved in 2003 as a new class of therapy, known as anti-IgE, for patients with moderate to severe persistent allergic asthma. IgE is an antibody that we all have and it is responsible for causing allergic problems in some people. It may reduce allergic reactions by causing free IgE to disappear from the body so that the IgE cannot attach to pollen (and other substances that are present).

Its use should be limited to those patients with moderate to severe persistent allergic asthma who: 1) are inadequately controlled with appropriate combination therapy; 2) have complications due to inhaled or oral steroid use; 3) have increased urgent care, emergency department or inpatient service needs due to asthma exacerbations; 4) have significant problems with activities of daily living; or 5) have problems taking regular medication prescribed to treat asthma. Omalizumab should be administered every two to four weeks by injection based on body weight and total serum IgE levels.

To treat your allergy and asthma symptoms, your allergist/immunologist will prescribe the medications that are best for you and your specific symptoms. If you have side effects from any medications, be sure to contact your doctor.

Your allergist/immunologist can provide you with more information on asthma and allergy medications.

Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology. This brochure was updated in 2003.

The content of this brochure is for informational purposes only. It is not intended to replace evaluation by a physician. If you have questions or medical concerns, please contact your allergist/immunologist.

Use of Inhaled Medications

Tips to Remember: Use of Inhaled Medications

People with asthma have inflamed airways that become narrowed, making it more difficult to breathe. Anti-inflammatory asthma medications lessen symptoms by treating the inflammation.

Bronchodilators are medicines that help relieve the constriction of smooth muscle within the inflamed airways. Inhalation is usually the most effective way to deliver medications to treat asthma. The major advantages of inhaled medications are their direct delivery to the area of difficulty - the large and small bronchial tubes - and their decreased side effects compared to many medications taken by mouth or by injection.

Classes of inhaled medication

Primary asthma medications available in inhaled form include:

• Inhaled corticosteroids, also referred to as topical corticosteroids or glucocorticosteroids, are effective anti-inflammatory medications used successfully to treat asthma for more than 50 years. These types of steroids are different from the anabolic steroids misused by some athletes to increase performance. These inhaled steroid medications decrease airway inflammation, mucus production, oversensitivity, swelling and constriction of the bronchial tubes.
• It is important to continue to take inhaled corticosteroids as prescribed even if you feel well, because the inflammation is constant even when you do not feel it and the medication helps to prevent asthma exacerbations. Examples of inhaled corticosteroids are beclomethasone, budesonide, flunisolide, fluticasone and triamcinolone. It is important to rinse, gargle and spit with water after each dose of inhaled steroids.
• Bronchodilators, also called beta2agonists, are non-steroid medications related to adrenalin and used as "rescue" medications to immediately relieve asthma symptoms. These include albuterol and levalbuterol, pirbuterol, and terbutaline. Sometimes these inhaled medications are overutilized. Using more than one canister per month or needing it more than three to four times a day is cause for concern. It indicates that underlying inflammation is not adequately controlled, and that you should see your physician for adjustment of your treatment. Salmeterol and formoterol are long-acting beta2agonist bronchodilators that are ordinarily intended to be used together with anti-inflammatory medication on a regular (daily) rather than an as-needed basis.
• Non-steroid anti-inflammatory medications, such as cromolyn or nedocromil, reduce inflammation and can help prevent asthma symptoms. These drugs are extremely safe but are less effective than inhaled corticosteroids.

Types of inhalation devices

There are three basic types of devices used to deliver inhaled medications. The most common is the metered dose inhaler (MDI), which uses a chemical propellant to push the medication out of the inhaler. Chlorofluorocarbon (CFCs), are used in many MDIs but are being replaced gradually by other propellants. Nebulizers deliver fine liquid mists of medication through a tube or a "mask" that fits over the nose and mouth, using air or oxygen under pressure. Rotary inhalers and other dry powder inhalers deliver medication without using chemical propellants.

Regardless of the type of inhalation device, effective delivery of medication to the lower airways is critical for the medication to work. For all devices, education and training of patients, and family or professional caregivers who administer these medications to patients, for the proper and effective use of these devices is an essential component of inhalation therapy. It is so important, in fact, that proper inhalation technique should be constantly ensured, demonstrated at routine physician visits, for example, with re-education and re-training as necessary.

Coordination of inhalation from inhalational devices varies from extremely easy with some devices (for example, nebulizers) to extremely difficult for some patients (for example, MDIs) and poor response to therapy can be due simply to such poor coordination with inhalational delivery that little or no drug reaches the airways. A device called a spacer can improve delivery of inhaled medication from MDIs.

Spacers help deliver a greater amount of medication directly into the lower airways, where it is intended to go, rather than into the throat. Many spacers fit on the end of an inhaler; for some, the canister of medication fits into the device. Some devices come with built-in spacers. Many people with asthma, especially young children, may have difficulties coordinating inhalation with using a metered dose inhaler. For these patients the use of a spacer is particularly recommended.

MDIs from which drug is dispensed automatically when the patient breathes in from the inhaler also are available. Technique for inhalation from dry powder inhalers is different and may feel more "natural" than with MDIs. Spacers are not needed for dry powder devices.

Nebulizer use

Nebulizers effectively deliver asthma medications in a fine mist through mouthpieces, through masks sized differently to fit infants through adults, or through T-tubes. Their use tends to be particularly easy, requiring only usual inspiration and expiration through the connection to the nebulizer. Nebulized asthma medication is especially useful for infants, young children and some elderly patients who are unable to use an MDI. Use of a nebulizer can be more time-consuming and is much less effective if an infant or child is crying.

Appropriate medication use

Your physician will prescribe inhaled medication that is most appropriate for you. If you have any questions about your prescribed inhaled medications or their proper use, make sure to contact your doctor. Many inhaled asthma medications are intended to be used on a daily basis to keep your airways open, even if you are not experiencing symptoms. It is important to follow your physician's instructions to ensure that you are optimally managing your asthma.

Your allergist/immunologist can provide you with more information on using inhaled asthma medications.

Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology. This brochure was updated in 2003.

The content of this brochure is for informational purposes only. It is not intended to replace evaluation by a physician. If you have questions or medical concerns, please contact your allergist/immunologist.

Occupational Asthma

Tips to Remember: Occupational Asthma

Occupational asthma is generally defined as a lung disorder caused by inhaling fumes, gases, dust or other potentially harmful substances while "on the job." With occupational asthma, symptoms of asthma may develop for the first time in a previously healthy worker, or childhood asthma that had previously cleared may recur due to this exposure. In another form of work-related asthma, pre-existing asthma may be aggravated by exposures within the work place.

Symptoms of asthma include wheezing, shortness of breath, chest tightness, difficulty exercising and cough. Other associated symptoms may include runny nose, nasal congestion and eye irritation. The cause may be allergic or non-allergic in nature, and the disease may last for a lengthy period in some workers, even if they are no longer exposed to the agents that caused their symptoms. Commonly, symptoms worsen through the work week, improve on the weekend and recur when the worker returns to the job. Less frequently, an accident at work involving a high exposure to irritating fumes or dusts may cause asthma.

In many cases, a previous personal or family history of allergies will make a person more likely to develop occupational asthma. However, many individuals who have no such history still will develop this disease if exposed to conditions that trigger it. Workers who smoke are at greater risk for developing asthma following some occupational exposures. The length of occupational exposure that triggers asthma varies, and can range from months to years before symptoms occur. An accidental irritant exposure can cause asthma within 24 hours.

Many workers with persistent asthma symptoms caused by substances in the workplace are incorrectly diagnosed as having bronchitis. If occupational asthma is not correctly diagnosed early, and the worker protected or removed from the exposure, permanent lung changes may occur and asthma symptoms may persist even without exposure.

Prevalence

Occupational asthma has become the most prevalent work-related lung disease in developed countries. However, the exact proportion of newly diagnosed cases of asthma in adults due to occupational exposure is unknown. Up to 15% of asthma cases in the United States may have job-related factors.

The incidence of occupational asthma varies within individual industries. For example, in the detergent industry, inhalation of a particular enzyme used to produce washing powders has led to the development of respiratory symptoms in approximately 25% of exposed employees. About 5% of people working with laboratory animals or with powdered natural rubber latex gloves have developed occupational asthma. Isocyanates are chemicals that are widely used in many industries, including spray painting, insulation installation, and in manufacturing plastics, rubber and foam. These chemicals can cause asthma in up to 10% of exposed workers.

Causes

Occupational asthma may be caused by one of three mechanisms. These include:

• Direct irritant effects-Irritants that provoke occupational asthma include hydrochloric acid, sulfur dioxide or ammonia, which is found in the petroleum or chemical industries. Workers exposed to these substances will frequently begin wheezing and experiencing other asthma symptoms immediately after exposure to the irritant substance. This is an irritant reaction rather than an allergic reaction, since it does not involve the immune system. Workers who already have asthma or some other respiratory disorder are particularly affected by this type of exposure.
• Allergy (long-term exposure)-Allergies play a role in many cases of occupational asthma. This type of asthma generally develops only after long-term exposure (e.g., months or years) to a work-related substance. This is because the body's immune system needs time to develop allergic antibodies or other immune responses to a particular substance. For example, workers in the washing powder industry may develop an allergy to the enzymes of the bacteria Bacillus Subtilis, and food processing workers may develop an allergy and occupational asthma symptoms from exposure to castor beans, green coffee beans and papain. Allergic occupational asthma can occur in workers in the plastic, rubber or resin industries following repeated exposure to small chemical molecules in the air. Veterinarians, fishermen and animal handlers in laboratories can develop allergic reactions to animal proteins, and health care workers can develop asthma from breathing in powdered proteins from latex gloves or from mixing powdered medications.
• Pharmacologic mechanisms-Inhalation of some substances in aerosol form can directly lead to the accumulation of naturally occurring chemicals in the body, such as histamine or acetylcholine within the lung, which in turn lead to asthma. For example, insecticides, used in agricultural work, can cause a buildup of acetylcholine, which causes airway muscles to contract, thereby constricting airways.

See the accompanying table for common occupational substances that may cause asthma to develop or trigger temporary aggravation of asthma that is already present.

Prevention

Once the cause is identified, exposure levels should be reduced. For instance, a worker could be moved to another job within the plant. Employers might consider pre-screening potential employees with lung function tests and then continue to test for symptoms after certain periods on the job once the worker has been hired to ensure that he or she has not developed asthma. Work areas should be closely monitored so that exposure to asthma-causing substances is kept at the lowest possible levels.

Individuals with occupational asthma should see their allergist/immunologist for an evaluation. In some cases, pre-treatment with specific medications to counteract the effects of workplace substances may be helpful. In other situations, complete avoidance may be necessary.

Common substances that cause occupational asthma

Your allergist/immunologist can provide you with more information on occupational asthma.

Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology. This brochure was updated in 2003.

The content of this brochure is for informational purposes only. It is not intended to replace evaluation by a physician. If you have questions or medical concerns, please contact your allergist/immunologist.