Checkup on Health
Take control of your asthma
By Samuel Louie, M.D.
Every asthma sufferer knows that spring and summer are the seasons to be wheezing.
Asthma and allergies strike one out of four Americans, according to the American Academy of Allergy, Asthma & Immunology. Asthma incidence in both children and adults has increased over the past 25 years. The disease is particularly prevalent in California’s Central Valley, where our warm air holds a high concentration of pollens and other allergens, common triggers for asthma attacks. However, many asthma patients suffer from uncontrolled symptoms at different times of the year, particularly autumn and winter.
About the author
Asthma develops in children and adults through several mechanisms, all of which cause the airways to work less effectively and make breathing difficult. The first mechanism is a spasm or contraction of the muscles surrounding the airways (bronchi) that bring air containing oxygen into the lungs. This “bronchospasm” causes the airway passages to narrow, making breathing hard work.
Secondly, the skin or lining of the bronchi and other air passages become inflamed, swollen and irritated, further limiting airflow in and out of the lungs. To add insult to injury, mucus clogs the already-narrowed airways to an even greater degree.
Dealing with an asthma attack
An asthma attack is extremely frightening, both to experience and to observe. It can also be deadly. Try to stay calm: excitement will exacerbate an attack. Go immediately to an emergency room or call 911 if the attack worsens despite the use of rescue albuterol, or if any of the following signs and symptoms appear:
- Too exhausted to speak — a late and dangerous sign suggesting total exhaustion and lack of sleep
- Grunting sound during exhalations
- Any mental changes, including restlessness or confusion — a late and dangerous sign suggesting poor oxygen delivery to the brain!
- Bluish skin, lips or fingernails — very late and dangerous signs!
When asthma is not well controlled, it impairs patients from enjoying sleep and exercise. Living well stops and patients begin depending on albuterol inhaler, a very short-acting bronchodilator. More importantly, they are at increased risk for a serious asthma attack.
An asthma attack makes a person feel a need to fight for each breath. Attacks almost always involve rapid and difficult breathing, wheezing (a breathy whistle or accordion-like noise), coughing without fever, chest tightness, and a relatively long expiration with each breath. This leads to “air-trapping” inside the lungs, a situation that I call “acute air constipation” to better explain the patients and their families what happens during an asthma attack. In turn, uncontrolled asthma can lead to chronic air constipation. A few asthmatics do not have the characteristic wheezing with asthma attacks, but instead have a persistent cough as their only symptom.
The good news is virtually all asthma symptoms can be better controlled with patient education and an asthma action plan.
'The Good, the Bad and the Ugly' of asthma control
Asthma control is determined by the patient’s impairment from having uncontrolled asthma, and the physician or healthcare provider’s assessment of risk for an asthma attack. Asthma control is a dynamic state of health and is either well-controlled or “good,” not well-controlled aka “bad,” or very poorly controlled aka “ugly” depending on many variables and factors, including responsiveness to medications. Asthma is not well controlled if you experience:
- More than 2 days of asthma symptoms per week
- More than 2 days per week needing albuterol for relief of symptoms
- Two or more acute asthma attacks per year requiring prednisone
Asthma usually worsens during sleep, and for most asthma sufferers, at night. This is believed to be due to our body’s natural circadian rhythm. Hormones we make that help asthma, such as cortisol and epinephrine, are low during sleeping hours, causing bronchial inflammation to increase.
Most asthma sufferers are aware of circumstances that bring on their attacks. This is why healthcare professionals must LISTEN to patients and their family members. Children and adults can take a specialized written asthma test to help recognize uncontrolled asthma.
Strenuous exercise or cold air, or typical allergens such as perfumes, aspirin, animals (especially cats and even dogs), or foods such as nuts or eggs can trigger an asthma attack. Environmental triggers such as dust mites and pollens or urban air pollution like smog may be so pervasive that they are difficult to avoid. The majority of people can control their asthma well until they get sick with something else, such as a cold or flu.
Asthma patients must actively participate in their asthma management. The best treatment for asthma attack is PREVENTION! Prevent asthma attacks with common sense and medications that work for your individual asthma.
Common sense is not common
I encourage my patients in our UCAN Clinics to participate actively in their asthma care and to demand better control of their asthma symptoms. The key is balancing common sense with a healthy lifestyle, regular exercise and regular visits to the doctor to make certain the patient using the written asthma action plan controls asthma.
There is no cure for asthma. Medications for controlling asthma will not work if patients do not take them as directed and daily. Albuterol is a rescue medication. When asthma is controlled, a single canister of albuterol should last over one year! Albuterol relieves asthma symptoms temporarily. Patient must recognize that albuterol can not control asthma and continued use may delay proper treatment that can prevent an asthma attack, an emergency room visit, hospitalization and even death.
Treatment must be carefully tailored to each patient’s needs. Asthma medications can be divided into “rescue” and “control” categories; some are best once symptoms have started and others are better for good overall symptom control and asthma attack prevention.
The most effective asthma control drugs remain inhaled corticosteroids, which are preferred by the National Institutes of Health (NIH) for treating persistent asthma symptoms. The preferred add-on asthma control drugs to inhaled corticosteroids are called long-acting beta-2 agonists (LABA) according to the NIH. These LABA drugs, when used alone or in combination with inhaled corticosteroids, carry a FDA “Black Box” warning linking their use to increased asthma deaths.
These drugs remain highly effective when the individual patient responds with better asthma control, and safe when used properly. This is the reason for regular clinic visits every one to six months once the patient achieves asthma control.
Alternative controller drugs called leukotriene receptor antagonists act by blocking the action of certain mediators derived from lipids or fats — called leukotrienes — that promote the inflammatory response. Omalizumab is a controller drug recommended when asthma is very difficult to control despite use of inhaled corticosteroids, LABAs and anti-leukotriene drugs. Omalizumab is an antibody that binds the asthma patient’s IgE antibodies formed in response to perennial allergens.
Daily oral prednisone for asthma control is recommended only after these drug treatments have failed. The NIH recommends allergy shots as adjunctive treatments to NIH-preferred and alternative controller drugs.
The most effective asthma rescue drug is albuterol, a very short-acting bronchodilator. The hormone prednisone will be need to be taken orally when albuterol fails to provide immediate relief of symptoms in accordance with a written asthma action plan. These inhaled aerosols relax the smooth muscle around the airways, allowing them to open. They should be used on an as-needed basis for mild, chronic asthma and during asthma attacks.
For more information or to take an asthma test, contact UCAN Program Coordinators Claudia Vukovich, RRT, AE-C (916 734-5676) or Celeste Kivler, RRT, AE-C (916 734-8380), or ask your doctor or primary care provider.
Demand better control of your symptoms
I encourage my patients in our UC Davis Asthma Network or "UCAN" clinics to participate actively in their asthma care and to demand better control of their asthma symptoms.
Control of asthma is particularly important during pregnancy. Accompanying conditions such as gastroesophageal reflux, chronic rhinosinusitis, and vocal cord dysfunction in asthma patients can make asthma control difficult to achieve. The key is balancing common sense with a healthy lifestyle, regular exercise and regular visits to the doctor to make certain the patient using the written asthma action plan controls asthma.