As the death rate from bronchial asthma escalates nationwide, physicians are beginning to treat even mild asthma more aggressively. Attention has focused on asthma management and treatment of the underlying inflammation as well as the airway muscle spasms.
Asthma is a chronic but reversible obstruction of the airways-specifically the bronchi and bronchioles, the large and small tubes that carry air from the windpipe into the lungs. People with asthma inherit or develop extra-sensitive bronchial passages that react with muscle spasms, swollen mucus membranes, and increased mucus production when confronted with various triggers, such as pollutants, allergens, and infectious agents.
Peak Flow Meter
If you or a member of your family has asthma, your physician may recommend regular use of a peak flow meter at home. This simple-to-use device measures the flow of air through the larger bronchial passages and can detect asthma symptoms even before the patient is aware of them. Studies have shown that wheezing may not be felt or even heard until the flow of air through the larger bronchial tubes has decreased to 65 percent of normal or less.
People with asthma should also know-and try to avoid-the many factors or triggers that may aggravate their condition. These factors may act alone or only in combination. They may produce infrequent, sporadic symptoms or daily, chronic symptoms. Allergies to pollens, dust mites, animal danders, mold spores, or other substances are important asthma triggers for many people. Avoiding such allergens can greatly reduce the frequency and severity of asthma episodes.
A board-certified allergist-immunologist can help determine whether allergies are causing or contributing to asthma. The specialist will take a careful history and may perform allergy skin tests. For people with significant allergies, allergy shots may be of help.
Infections-particularly bad colds and sinusitis-are another major asthma trigger. Strenuous exercise, weather changes, and even laughter or crying bring on asthma symptoms in many people.
Tobacco smoke, hair spray, paint or kerosene fumes, and strong perfumes are notorious for provoking asthma. Other triggers include food preservatives, especially bisulfites; medications such as aspirin; and hormonal changes such as those that occur during the menstrual cycle or in pregnancy.
If exercise causes bronchospasms, pretreatment with medication such as a beta-agonist bronchodilator or cromolyn sodium (Intal) may be sufficient. If you can predict when you’ll be exposed to an asthma-provoking allergen, pretreatment with a metered inhaler likewise may be appropriate. If your asthma occurs only with respiratory infections, your physician may recommend you use medications just when you have a cold or bout of sinusitis. Most people with asthma, however, need continuous, preventive treatment.
Discuss your medication plan with your physician. It’s usually best to get it in writing. Be sure you know what you should do if you should experience a severe asthma attack.
A bronchodilator is the first-line therapy when asthma begins to flare up. Beta-adrenergic drugs help to moisturize the inflamed mucous membranes and dilate the bronchial tubes. These drugs, such as albuterol (Proventil, Ventolin); metaproterenol (Alupent, Metaprel); terbutaline (Brethaire); bitolterol (Tornalate); or pirbuterol (Maxair) provide prompt relief of mild bronchospasm. They are available by prescription as metered-dose inhalers.
The effectiveness of these inhalers is dependent upon proper technique, however. Your doctor may suggest that you use a “spacer” to enhance delivery of the drug to your lungs. The medications are also available in solution for use during times of worsening asthma or for use in the routine therapy of small children.
Avoid Overuse of Inhalers
It’s important not to overuse metered-dose inhalers. Some people with worsening asthma may rely on the inhalers instead of seeking needed medical attention. That’s unwise and risky! One recent study found increased asthma deaths among people who overused their inhalers. The study was unable to determine whether overuse of medication or worsening asthma was to blame. In general, a metered-dose inhaler which contains 200 puffs should last a minimum of three weeks.
Other studies suggest daily, routine use of beta-adrenergic medications may actually increase bronchial sensitivity. As a result, many specialists now try to limit such use of the agents. Instead, physicians are turning to antiinflammatory medication as the first-line therapy for chronic asthma.
According to recent guidelines for asthma management, use of a metered-dose inhaler more than three times per week indicates a state of increased bronchial hyperreactivity and the need for antiinflammatory medication.
Intal and Tilade
These antiinflammatory inhalers include the non-steroidal medications Intal and Tilade as well as steroidal medications. Inhaled steroids are increasingly popular among physicians for use in treating adult asthmatics. Intal, because it has few side effects, is often the drug of choice for children and people whose asthma is triggered by allergens, exercise, or cold air exposure. Recently released nedocromil (Tilade) appears to be even more antiinflammatory-and requires less frequent daily dosing.
If metered-dose inhalers aren’t adequate to alleviate symptoms, physicians may prescribe second-line medications such as anticholinergic agents that dry the mucous membranes or theophylline. Theophylline has lost much of its popularity in recent years, however, because of concerns regarding such potential side effects as decreased appetite, nausea, diarrhea, vomiting, headache, nervousness, irritability, insomnia, and palpitations. At toxic levels, seizures and death have been reported. Careful monitoring of theophylline blood levels can be required.
Anticholinergic medications are often underused. Ipratropium bromide (Atrovent), in combination with beta-adrenergic agents, is especially helpful in asthma that isn’t triggered by allergy and in asthma in which coughing is the primary symptom. Although is takes up to 20 minutes to act, it is extremely safe and may provide prolonged relief.
Oral corticosteroids may be required in patients fail to respond to other forms of therapy. Short courses of these drugs can be used with minimal risk, and may prevent the need for hospitalization in severe episodes of asthma.
With careful asthma management, a normal lifestyle should be possible. Children and adults shouldn’t miss school or work because of asthma, and should be able to participate in most activities.