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•	Highlights
•	Introduction
•	Symptoms
•	Causes
•	Prognosis
•	Risk Factors
•	Diagnosis
•	Treatment
•	Quick-Relief Medications...
•	Long-Term Relief Medication...
•	Other Treatments
•	Managing Asthma at Home
•	Resources
•	References

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Asthma in adults

Highlights

New Asthma Guidelines Released

In 2007, the U.S. National Asthma Education and Prevention Program (NAEPP) released updated guidelines for the diagnosis and management of asthma. The new guidelines are the first to be released in a decade. Key points include:

• Assessment and Monitoring. Doctors should use multiple measures to determine a patient’s current condition and future risk for worsening of condition. Even patients who show few daily effects of asthma may be in danger of sudden worsening of symptoms.
• Patient Education. Patients should be taught skills to self-monitor and manage asthma. Doctors should give patients a written asthma action plan, which includes information on daily treatment and ways to recognize worsening asthma.
• Control of Environmental Factors and Other Asthma Triggers. The guidelines outline new approaches for reducing exposure to allergens. They also address how treating co-existing chronic conditions (rhinitis, sinusitis, gastroesophageal reflux, obesity) can help improve asthma control.
• Medications. A stepwise approach is recommended where medication types and doses are increased or decreased based on the level of asthma control.

New Inhaled Corticosteroid Approved

In January 2008, the Food and Drug Administration (FDA) approved ciclesonide (Alvesco), a new inhaled corticosteroid drug, for patients ages 12 years and older.

Introduction

The word asthma originates from an ancient Greek word meaning panting. Essentially, asthma is an inability to breathe properly. When any person inhales, the air travels through the following structures:

• Air passes into the lungs and flows through progressively smaller airways called bronchioles. The lungs contain millions of these airways.
• All bronchioles lead to alveoli, which are microscopic sacs where oxygen and carbon dioxide are exchanged.

The major features of the lungs include the bronchi, the bronchioles, and the alveoli. The alveoli are the microscopic blood vessel-lined sacks in which oxygen and carbon dioxide gas are exchanged.

Asthma is a chronic condition in which these airways undergo changes when stimulated by allergens or other environmental triggers. Such changes appear to be two specific responses:

• The hyperreactive response (also called hyperresponsiveness)
• The inflammatory response

These actions in the airway cause coughing, wheezing, and shortness of breath (dyspnea), the classic symptoms of asthma.

In the hyperreactive response, smooth muscles in the airways of the lungs constrict and narrow excessively in response to inhaled allergens or other irritants. Everyone's airways respond by constricting when exposed to allergens or irritants, but a special hyperreactive response occurs in people with asthma:

• When people without asthma breathe in and out deeply, the airways relax and open to rid the lungs of the irritant.
• When people with asthma try to take those same deep breaths, their airways do not relax and narrow, causing patients to pant for breath. Smooth muscles in the airways of people with asthma may have a defect, perhaps a deficiency in a critical chemical that prevents the muscles from relaxing.

The hyperreactive stage is followed by the inflammatory response, which generally contributes to asthma in the following way:

• In response to allergens or other environmental triggers, the immune system delivers white blood cells and other immune factors to the airways.
• These so-called inflammatory factors cause the airways to swell, to fill with fluid, and to produce a thick sticky mucus.
• This combination results in wheezing, breathlessness, an inability to exhale properly, and a phlegm-producing cough.

Click the icon to see an image of a normal bronchiole versus an asthmatic bronchiole.

Inflammation appears to be present in the lungs of all patients with asthma, even those with mild cases, and plays a key role in all forms of the disease.

Symptoms

Asthma symptoms vary in severity from occasional mild bouts of breathlessness to daily wheezing that lasts even when a patient takes large doses of medication. After exposure to asthma triggers, symptoms rarely develop abruptly but progress over a period of hours or days. Occasionally, the airways have become seriously obstructed by the time the patient calls the doctor.

The classic symptoms of an asthma attack include:

• Wheezing when breathing out is nearly always present during an attack. Usually the attack begins with wheezing and rapid breathing, and, as it becomes more severe, all breathing muscles become visibly active.
• Shortness of breath (dyspnea). Shortness of breath is a major source of distress in patients with asthma. However, the severity of this symptom does not always reflect the degree to which lung function is impaired. Some patients are not even aware that they are experiencing shortness of breath. These patients are at particular risk for very serious and even life-threatening asthma attacks, since they are less conscious of symptoms. Those at highest risk for this effect tend to be older, female, and to have had the disease for a longer period of time.
• Coughing. In some people, the first symptom of asthma is a nonproductive cough. Some patients find this cough even more distressing than wheezing or sleep disturbances.
• Chest tightness or pain. Initial chest tightness without any other symptoms may be an early indicator of a serious attack.
• Rapid heart rate
• Sweating

The end of an attack is often marked by a cough that produces thick, stringy mucus. After an initial acute attack, inflammation lasts for days to weeks, often without symptoms. (The inflammation itself must still be treated, however, because it usually causes relapse.)

The following signs and symptoms may indicate a life-threatening situation:

• As the chest labors to bring enough air into the lungs, breathing often becomes shallow.
• Lacking enough oxygen, the skin becomes bluish.
• The flesh around the ribs of the chest appears to be sucked in.
• The patient may begin to lose consciousness.

Asthma often progresses very slowly to a serious condition or may develop to a fatal or near-fatal attack within a few minutes. It is very difficult to predict when an attack will become very serious.

Early symptoms or lack thereof do not always reflect the ultimate severity of an attack. In fact, some studies suggest that people at high risk for fatal or near-fatal asthma attacks are those with poor awareness of their own reduced ability to breathe and who are therefore slow in seeking help. Those at highest risk for this effect tend to be older, female, and have had the disease for a longer period of time. Monitoring peak flow rates is an important management component since it provides a more accurate assessment of lung function than symptoms alone.

Exercise-induced asthma (EIA) is a limited form of asthma in which exercise triggers coughing, wheezing, or shortness of breath. This condition generally occurs in children and young adults, most often during intense exercise in cold dry air. Symptoms are generally most intense about 10 minutes after exercising and then gradually resolve.

EIA is triggered only by exercise and is distinct from ordinary allergic asthma in that it does not produce a long duration of airway activity, as allergic asthma does. (However, some people have both forms of asthma.) People who have only EIA do not appear to need long-term maintenance therapy.

Asthma occurs primarily at night (nocturnal asthma) in as many as 75% of patients with asthma. Attacks often occur between 2 and 4 a.m. Some experts believe that nocturnal asthma may actually be a unique form, with its own specific biologic mechanisms occuirng only at night and reducing natural steroid hormones (which block inflammation).

Causes

Asthma has dramatically risen worldwide over the past decades, particularly in developed countries, and experts are puzzled over the cause of this increase. The mechanisms that cause asthma are complex and vary among population groups and even from individual to individual. Many asthma sufferers have allergies, and some researchers are targeting common factors in both these conditions. Not all people with allergies have asthma, however, and asthma is not always due to an allergic response.

Asthma is most likely caused by a several factors that can include genes and environmental and biologic triggers (such as infections, dietary patterns, hormonal changes in women, and allergens).

Nearly half of adults with asthma have an allergy-related condition, which, in most cases developed first in childhood. (In patients who first develop asthma during adulthood, the allergic response usually does not play a strong causal role.)

The Allergic Process. The allergic process, called atopy, and its connection to asthma are not completely understood. The process involves various airborne allergens, or other triggers, that set off a cascade of events in the immune system, leading to inflammation and hyperreactivity in the airways. Here is an example of the allergic process:

• The conductor in an orchestra of immune factors that contribute to allergies and asthma appears to be a category of white blood cells known as helper T cells, in particular a subgroup called Th2 cells.
• Th2 cells overproduce interleukins (ILs), immune factors that are molecular members of a family called cytokines, which are involved in the inflammatory process.
• During an allergic attack, these IgE antibodies can bind to special cells in the immune system called mast cells, which are concentrated in the lungs, skin, and mucous membranes. This bond triggers the release of several active chemicals, importantly potent molecules known as leukotrienes. These chemicals cause airway spasms, overproduce mucus, and activate nerve endings in the airway lining.
• One specific cytokine, interleukin 5, attracts white blood cells known as eosinophils. These cells accumulate and remain in the airways after the first attack. They persist for weeks and mediate the release of other damaging particles that remain in the airways.

Over several years, the repetition of the inflammatory events involved in asthma can cause irreversible structural and functional changes in the airways, a process called remodeling. The remodeled airways are persistently narrow and can cause chronic asthma. Researchers are trying to determine how this process occurs:

• Interleukins. Some researchers are looking at potent immune factors, including interleukins 11 and 13. They have been linked to a number of processes possibly involved in remodeling, including scarring in the airways and overgrowth of cells in the smooth muscles that line the airways.
• Growth Factors. Compounds known as vascular endothelial growth factor (VEGF) have been observed in the airways of patients with asthma. VEGF is a powerful promoter of cell growth in blood vessel linings, and some researchers believe it may be major factor in remodeling.

An asthma attack can be induced or aggravated by direct irritants to the lungs. Studies indicate that the more indoor allergens a child is allergic to, the higher the risk for severe asthma. Important irritants or allergens include:

• Dust mites, specifically mite feces, which are coated with enzymes that contain a powerful allergen. These are the primary allergens in the home.
• Animal dander. Cats harbor significant allergens, which can even be carried on clothing; dogs usually cause fewer problems. People with asthma who already have pets and are not allergic to them probably have a low risk for developing allergies later on.
• Smoking, or exposure to secondhand smoke
• Pollen. An asthma attack from an allergic response to pollen is more likely to occur during extreme air changes, such as thunderstorms. Major weather changes, such as El Nino, can affect the timing of allergy seasons. For example, in 1998, when the effects of El Nino were very strong, allergy and asthma attacks occurred earlier and were markedly increased.
• Molds might produce a worse asthma attack in adults than other allergens.
• Fungi
• Cockroaches. Cockroaches are major asthma triggers and may reduce lung function even in people without a history of asthma.
• Fossil Fuels. Certain chemicals may trigger allergic rhinitis. Some experts believe that refined fossil fuels, such as diesel fuel and particularly kerosene, may be important triggers for allergic rhinitis. And, in people who already have allergies or asthma, exposure to such fossil fuels may worsen symptoms.

About one-third of all persons with asthma share this condition with another member of their immediate family. Asthma may be more likely to pass to children from their mother than from their father. Both allergies and asthma are strongly associated with hereditary factors, sharing certain genetic markers, but they are not always inherited together.

Research on the genetics of these conditions is confusing. Of some significant promise, researchers have identified a gene (ADAM33), which has been linked to asthma. The gene regulates one of the enzymes called metalloproteases, which are involved with the smooth muscle in the airway. A mutation of this gene could play a role in airway changes that occur after inflammation.

Infections. The role of infections in asthma is complicated. Respiratory infections may play a role in some cases of adult-onset asthma. In both children and adults with existing allergic asthma an upper respiratory tract infection often worsens an attack.

Researchers are particularly interested in the organisms Chlamydiapneumoniae and Mycoplasmapneumoniae adenovirus. They are major causes of both mild and serious respiratory infections and are becoming important suspects in many cases of severe adult asthma. (If such respiratory infections occur in young children, they are unlikely to affect adult-onset asthma.)

In any age group, respiratory infections worsen existing asthma in people who have it already. Rhinovirus (the common cold virus) has been reported to be the most common infection associated with asthma attacks. In one study, it was associated with 61% of asthma exacerbations in children and 44% in adults. Some research suggests that colds promote allergic inflammation and increase the intensity of airway responsiveness for weeks.

Prognosis

About 1.8 million emergency room visits each year are due to asthma. The number of deaths from asthma increased from about 2,900 in 1908 to a high of 5,667 in 1996. The numbers appear to be declining slightly. In 2005, 3,884 people died because of asthma. Death from asthma is still a very uncommon event, considering that about 20 million people in the U.S. have this condition. Most deaths from asthma, even when they occur in elderly adults, are preventable. It is very rare for a person who is receiving proper treatment to die of asthma. And, studies suggest that the use of inhaled corticosteroids can reduce the risk for death by 90%. In spite of this and similar research, these important drugs are greatly underused.

About 55% of U.S. deaths from asthma occur among the elderly (over age 65), and an estimated 25% occur in adults aged 45 - 64. Women have a higher risk for fatal asthma than men. Being poor is also a significant risk factor for severe asthma. Hispanics and African-Americans are at higher risk for death from asthma than Caucasians. Other specific risk factors for fatal asthma include:

• Previous history of respiratory failure
• Frequent visits to the emergency room
• Lack of continuous care and poor compliance with medications
• Having stopped treatment, particularly withdrawal from corticosteroids
• Having an emotional or psychiatric disorder. (Some evidence suggests that depression, anxiety, and stressful life situations can worsen asthma.)
• Being a drug abuser
• Being in a lower socioeconomic and educational group

The severity of asthma is graded using the following categories: intermittent and mild, moderate, and severe persistent. A patient in any of these categories, even intermittent, can still have a severe and even life-threatening attack. In fact, according to one report, 30% of asthma deaths occur in patients with mild asthma.

Asthma is usually chronic, although it occasionally goes into long periods of remission. Long-term outlook generally depends on severity:

• In mild-to-moderate cases, asthma can improve over time, and many adults even become symptom free.
• Even in some severe cases, adults may experience improvement depending on the degree of obstruction in the lungs and the timeliness and effectiveness of treatment.
• In about 10% of severe persistent cases, changes in the structure of the walls of the airways lead to progressive and irreversible problems in lung function, even in aggressively treated patients.

Lung function declines faster than average in people with asthma, particularly in those who smoke and in those with excessive mucus production (an indicator of poor treatment control). Overall, one study reported that 72% of men and 86% of women with asthma had symptoms 15 years after an initial diagnosis. Only 19% of these people, however, were still seeing a doctor, and only 32% used any maintenance medication.

Patients who develop occupational asthma often have symptoms for years, even after avoiding the harmful triggers. Improvement does occur over time in most people who leave jobs that cause this problem.

Emotional Problems. Even when it is not life threatening, asthma is debilitating and frightening. It significantly lowers the quality of life.

Sleep Disorders. Sleeplessness and daytime sleepiness are common problems.

Heart Disease. There have been some reports of an association between asthma and a heightened risk for heart disease. Some experts believe that the inflammatory process may be the common factor linking the two conditions, although there is no evidence to date confirming any causal association.

Risk Factors

American adults have a 10% lifetime risk for developing asthma. From 1980 - 1996 the prevalence of asthma increased by nearly 74%, but it may be stabilizing. Other respiratory diseases, sinusitis, and ear infections are also on the rise, suggesting that airborne or environmental factors may be at work that affects all of these conditions, including asthma.

Before puberty, asthma occurs more often in males, but after adolescence, it appears to be more common in females. In adults with similar cases of actual airway obstruction, women are likely to report more severe symptoms than men are. In addition, women may be at much greater risk of death from asthma than men.

Hormones or changes in hormone levels appear to play a role in the severity of asthma in women.

Menstrual-Related Asthma. Between 30 - 40% of women with asthma experience fluctuations in severity that are associated with their menstrual cycle. One study indicated that women with menstrual-associated asthma tend to have the following characteristics:

• Older age
• Had asthma for a long time
• Had severe asthma attacks that were likely to occur 3 days before and 4 days into the menstrual period

Oral contraceptives (OCs) theoretically should help asthma sufferers by leveling out hormonal changes, but they do not appear to have much effect. (There have been a few reports of asthma exacerbation with OCs, but they are uncommon.)

Asthma and Pregnancy. Uncontrolled asthma in pregnant women puts them at higher risk for complications that can include early labor, hypertension, gestational diabetes, and hemorrhage. Asthma also places the babies at risk for lower birth weight and breathing disorders. Teenage mothers with asthma face higher risks than older women. Fortunately, studies indicate that most asthma drugs are safe to take during pregnancy, and good control of asthma reduces these risks to normal levels.

Menopause and Asthma. Around the time of menopause (called perimenopause) when estrogen declines, the risk for hospitalization in women with asthma increases fourfold compared to previous years. Studies have not demonstrated that hormone replacement therapy (HRT), which contains estrogen, has much benefit.

In both adults and children, the incidence of obesity and asthma has been increasing in parallel over recent years. Studies report a strong association between the two conditions. Some experts suggest that excess weight pressing on the lungs may trigger the hyperreactive response in the airways typical of asthma. Others believe that asthma leads to obesity by inhibiting physical activity, although several studies have found no difference in activity levels between people with or without asthma. Some studies suggest that many obese people may be misdiagnosed as having asthma when in fact they are simply short of breath, possibly because of the increased effort required for breathing.

In any case, there is evidence that losing weight can relieve asthma symptoms. Some evidence also suggests that people who are overweight (body mass index greater than 25) have more difficulty getting their asthma under control. Weight loss in anyone who is obese and has asthma or shortness of breath reduces airway obstruction and improves lung function. [For more information, see In-Depth Report #53: Weight control and diet.]

In one study of older people with severe adult-onset asthma, smoking was the most significant risk factor for developing this condition. Smoking, in any case, contributes to decline in lung function in everyone.

GERD. At least half of patients with asthma have gastroesophageal reflux disease (GERD), the cause of heartburn. It is not entirely clear which condition causes the other or whether they are both due to common factors.

Heartburn is a condition where the acidic stomach contents back up into the esophagus, causing pain in the chest area. This reflux usually occurs because the sphincter muscle between the esophagus and stomach is weakened. Standing or sitting after a meal can help reduce the reflux that causes heartburn. Continuous irritation of the esophagus lining as in gastroesophageal reflux disease is a risk factor for the development of adenocarcinoma.

GERD is sometimes hard to detect and might be a contributor in the following patients:

• Those who do not respond to asthma treatments
• Those whose asthma attacks follow episodes of heartburn
• Those whose attacks worsen after eating or exercise
• Those whose coughs follow episodes of acid reflux. (One study found that GERD was associated with about half of the episodes of coughs and wheezes in patients with asthma.)

[For more information, see In-Depth Report #85: Heartburn and gastroesophageal reflux disease.]

Sinusitis. Almost half of children and adults with allergic asthma have sinus abnormalities, and in various studies, 17 - 30% of patients with asthma develop true sinusitis. Having sinusitis, however, does not appear to increase the severity of asthma.

Aspirin-Induced Asthma. About 10% of adults and fewer children have aspirin-induced asthma (AIA). With this condition, asthma gets worse when patients take aspirin. Aspirin is one of the drugs known as nonsteroidal anti-inflammatory drugs (NSAIDs). Although aspirin is used to reduce inflammation in other disorders, it appears to have the opposite effect in many asthma cases. It is not wholly known why this occurs. AIA often develops after a viral infection. It is a particularly severe asthmatic condition, associated with up to 25% of asthma-related hospitalizations. In about 5% of cases, aspirin is responsible for a syndrome that involves multiple attacks of asthma, sinusitis, and nasal congestion. Such patients also often have polyps (small benign growths) in the nasal passages.

Patients with aspirin-induced asthma (AIA) should avoid aspirin and most likely other NSAIDs, including ibuprofen (Advil) and naproxen (Aleve).

Urban Life and Poverty. African-Americans have higher rates of asthma than Caucasians or other ethnic groups. They are also more likely to die of the disease. Ethnicity and genetics, however, are less likely to play a role in these differences than socioeconomic differences, such as having less access to optimal health care. Poverty is a consistent risk factor in most studies. Both the elderly and the urban poor have the highest risk for severe asthma and death. Urban life, in fact, has been associated with a higher risk for asthma in all income groups and among both children and adults. Twin studies also suggest that people who have lower educational levels (as well as those who exercise less) are at higher risk for adult-onset asthma, further suggesting a link to lower economic status.

Geographical Differences. Asthma rates vary widely among different populations regardless of socioeconomic or other factors. For example, asthma and hospitalization rates are dramatically higher in New York Puerto Ricans than in Hispanic Americans who live in Los Angeles or the Southwest. Among the U.S. states, rates are lowest in Louisiana and highest in Maine.

Diagnosis

When asthma is suspected, the patient should describe for the doctor any pattern related to the symptoms and possible precipitating factors, including:

• Whether symptoms are more frequent during the spring or fall (allergy seasons).
• Whether exercise, a respiratory infection, or exposure to cold air has ever triggered an attack.
• Any family history of asthma or allergic disorders, such as eczema, hives, or hay fever.
• Any occupational or long-term exposure to chemicals. Early detection of occupational asthma is very important. If symptoms improve on weekends and vacation and are worse at work, the job is the likely source of the asthma, although not always. Asthma is common, and exacerbation at work may be coincidental.

A number of disorders may cause some or all of the symptoms of asthma:

• Asthma and chronic obstructive lung diseases (chronic bronchitis and emphysema) affect the lungs in similar ways and, in fact, may all be present in the same person. Unlike other chronic lung conditions, asthma usually first appears in patients younger than age 30 and with chest x-rays that are normal. Still, it may be difficult to distinguish among these disorders in some adults with late onset asthma.
• Panic disorder can coincide with asthma or be confused with it.
• Other diseases that must be considered during diagnosis are pneumonia, bronchitis, severe allergic reactions, pulmonary embolism, cancer, heart failure, tumors, psychosomatic illnesses, and certain rare disorders (such as tapeworm and trichomoniasis).

If symptoms and a patient's history suggest asthma, the doctor will usually perform pulmonary function tests to confirm the diagnosis and determine the severity of the disease.

Using a spirometer, an instrument that measures the air taken into and exhaled from the lungs, the doctor will determine several values:

• Vital capacity (VC), the maximum volume of air that can be inhaled or exhaled.
• Peak expiratory flow rate (PEFR), commonly called the peak flow rate, the maximum flow rate that can be generated during a forced exhalation.
• Forced expiratory volume (FEV1), the maximum volume of air expired in one second.

Spirometry is a painless study of air volume and flow rate within the lungs. Spirometry is frequently used to evaluate lung function in people with obstructive or restrictive lung diseases such as asthma or cystic fibrosis.

If the airways are obstructed, these measurements will fall. Depending on the results, the doctor will take the following steps:

• If measurements fall, the doctor typically asks the patient to inhale a bronchodilator. This drug is used in asthma to open the air passages. The measurements are taken again. If the measurements are more normal, the drug likely has cleared the airways and a diagnosis of asthma is likely.
• If measurement results fail to show airway obstruction, but asthma is still suspected, the doctor may perform a challenge test. This involves administering a specific drug (histamine or methacholine) that usually increases airway resistance only when asthma is present. The challenge test may be quite useful in ruling out occupational asthma. It is not always accurate, particularly in patients whose only symptom is persistent coughing.
• Administering cold air is another method for inducing airway resistance. This test is very accurate for ruling out asthma, but it is not sensitive enough to accurately identify asthma in adults.

The patient may recieve skin or blood allergy tests, particularly if a specific allergen is suspected and available for testing. Allergy skin tests may be the best predictive tests for allergic asthma, although they are not recommended for people with year-round asthma.

Click the icon to see an image of allergy testing.

Tests that either rule out other diseases or obtain more information about the causes of asthma include:

• A complete blood count
• Chest and sinus x-rays
• Computed tomography (CT) scans. CT scans may be helpful in certain cases, such as for determining wall thickness in airways in patients who are difficult to treat, which could signify a higher risk for lung damage.
• Examination of the patient's sputum for eosinophils (white blood cells that in high levels are associated with severe allergic asthma). One 2002 study suggested that treatment goals based on achieving a normal eosinophil count might effectively manage asthma.
• Researchers are investigating measurements of certain chemicals in sputum or exhaled air that indicate airway inflammation. Such chemical markers include nitric oxide and hydrogen peroxide. For example, high levels of nitric oxide in exhaled air is proving to be a simple and noninvasive way of diagnosing asthma.
• If aspirin-induced asthma (AIA) is suspected, a non-invasive test called acoustic rhinometry may be useful. A solution of lysine acetylsalicylic acid (L-ASA) is instilled into the patient's nostril. Patients with symptoms such as sneezing, itching, congestion, and secretion are likely to have AIA.

Treatment

While medications play an essential role in the management of asthma, appropriate management of asthma involves much more:

• Identifying and avoiding allergens and other asthma triggers
• Following appropriate drug treatments
• Home monitoring performed by either patient or family
• Good communication between the doctor and patient
• Needed psychosocial support
• Treatment of asthma in all environments (school, work, exercise)

The severity of asthma has now been classified into four groupings: Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent. Six specific components of severity are used to classify patients. These components are:

• Symptom frequency, ranging from fewer than 2 days per week to throughout the day
• Nighttime awakenings, ranging from none to nightly
• Short-acting beta2-agonist use for symptom control, ranging from 2 or fewer days per week to several times per day
• Interference with normal activity, ranging from none to extremely limited
• Lung function as measured by FEV1 and FEV1/FVC, measured with pulmonary function testing at the doctor's office
• Number of exacerbations (sudden worsening) requiring oral corticosteroids, ranging from none to two or more in the last 6 months

Patients can greatly reduce the frequency and severity of asthma attacks by understanding the difference between coping with asthma attacks and controlling the disease over time.

Medications for asthma fall into two categories:

• Rescue (Quick-Relief) Medication. Medications that open the airways (bronchodilators, or inhalers) are used to quickly relieve any moderate or severe asthma attack. These drugs are usually short-acting beta-adrenergic agonists (beta2-agonists). Other drugs used in special cases include corticosteroids taken by mouth and anticholinergic drugs. Beta2-agonists and anticholinergics do not have any effect on the disease process itself. They are only useful for treating symptoms.
• Long-Term Control (Maintenance) Medication. Simply coping with asthma symptoms without also controlling the damaging inflammatory response is a common and serious error. For adults and children over age 5 with moderate-to-severe persistent asthma, experts now recommend inhaled corticosteroids and long-acting beta2-agonists.

Patients can greatly reduce the frequency and severity of asthma attacks by understanding the difference between coping with asthma attacks and controlling the disease over time. Unfortunately, many patients do not understand the difference between medications that provide rapid short-term relief and those that are used for long-term symptom control. Many patients with moderate or severe asthma overuse their short-term medications and underuse their corticosteroid medications. The overuse of bronchodilators can have serious consequences; not using steroids can lead to permanent lung damage.

These are the signs of well-controlled asthma:

• Asthma symptoms occur twice a week or less
• Rescue bronchodilator medication is used twice a week or less
• Symptoms do not cause nighttime or early morning awakening
• Symptoms do not limit work, school, or exercise activities
• Peak flow meter readings are normal or the patient’s personal best
• Both the doctor and the patient consider the asthma to be well controlled

A stepwise approach is recommended for treating asthma. Medications and dosages are increased when needed, and decreased when possible. Based on severity of patients' asthma and their age, there are specific recommendations regarding whether to use long-term control medications and which ones to use. Patient education, environmental control measures, and management of any other conditions are also included. Doctors may always adjust these recommendations based on a specific patient.

In choosing therapy, doctors must also consider the risk an individual patient has for more severe exacerbations. Factors that may contribute to this include parental history of asthma, atopic dermatitis, and known sensitivity to different allergens or foods. Patients should be reevaluated within 2 - 6 weeks to assess response.

Key points regarding recommendations for adults include:

• Inhaled corticosteroids are the preferred long-term control therapy. Long-acting beta2-agonists and leukotriene antagonists are additional therapies usually used in addition to inhaled corticosteroids.
• Avoiding or managing environmental triggers is always important.

Most asthma drugs are inhaled using various forms of inhalers or nebulizers. The patient must use inhaled drugs regularly as prescribed and be carefully trained in their use for these medicines to be effective and safe. The basic devices are the metered-dose inhaler (MDI), breath-actuated inhalers, dry powder inhalers, and nebulizers.

MDIs have used chlorofluorocarbons (CFCs) as their propellants. CFCs are damaging to the environment. CFCs are now being replaced with other propellants (such as hydrofluoroalkane) that are equally effective to CFCs, are environmentally safe, and do not chill the device as CFCs do. Devices without propellants are also available.

Metered-Dose Inhaler. The standard device for administering any asthma medication has been the metered-dose inhaler (MDI). This device, particularly when used with a holding chamber, allows precise doses to be delivered directly to the lungs.

Click the icon to see an image of a holding chamber.

MDI-delivered drugs must be used regularly as prescribed, and the patient carefully trained in their use, for the drugs to be effective and safe. Some patients hold the MDI too close to their mouths, or even inside them. Others may exhale too forcefully before inhalation. The holding chamber, or spacer, allows the patient additional time to inhale the medication, improving delivery. They vary, however, in their ability to deliver medication. Often MDIs continue to deliver propellant after the drug has been used up. Patients should track their medicine and throw the device away when the last dose has been administered.

Click the icon to see an illustrated series detailing metered dose inhaler use.

Breath-Actuated Inhalers. Breath-actuated rotary inhalers (Easi-Breathe and Autohaler) deliver the drug directly to the back of the throat as the user inhales. Their primary advantage over the MDI is their ease of use. They also do not use CFCs as propellants. In comparison studies, patients have been very successful with the breath-actuated inhalers.

Dry Powder Inhalers. Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. They also do not use CFCs. Such devices include Rotahaler, Spinhaler, Turbohaler, Clickhaler, Easyhaler, Diskhaler, Discus, Twisthaler, Spiros, and others. DPIs are as effective as the older devices, and generally have a better taste and are easier to manage. They may differ, however, in their ability to deliver drugs into the airways. In one study, for example, the Turbohaler was easier to use than the Diskhaler, achieving better delivery. The Discus is another effective DPI. It has a dose counter and protects against exhalation effects.

Humidity or extreme temperatures can affect the performance of these inhalers, so they should not be stored in humid places (bathroom cabinets) or locations subject to high temperatures (glove compartments during summer months).

Dry-powder may cause tooth erosion, and children are advised to rinse their mouths out right after using a DPI and to brush twice a day with a fluoride toothpaste.

Nebulizers. A nebulizer is a device that administers the drug in a fine spray that the patient breathes in. They are mostly used in hospital settings or when the patient cannot use an inhaler. Nebulizers may be important for delivering newer drugs used in asthma treatment.

Click the icon to see an illustrated series detailing nebulizer use.

People who self-manage their asthma with peak air flow measurements and adjust their medications as needed have fewer hospitalizations and unplanned doctors visits, and, generally, have a better quality of life than those who rely only on the occasional doctor or emergency room visit to control symptoms. Doctors recommend that patients with even mild asthma monitor their own conditions.

In general, monitoring involves the following steps:

• A peak flow meter is the standard monitoring device for measuring peak expiratory flow rate (PEFR).

Click the icon to see an image of a peak flow meter.

• Patients with severe asthma should take PEFR readings two or three times a day. The overall goal should be to achieve less than a 20% (and ideally only 10%) variation in readings between evening and morning rates. For mild-to-moderate asthma, a single determination each morning usually suffices, but patients should check with their doctors.
• It is important to use the meter at the same times each day and to stand or sit in the same position to keep an accurate record.
• Patients should keep an ongoing record of their peak flow readings to help them detect worsening of their condition.
• They should also record attacks, exposure to any allergens or triggers, and medications taken.
• After about 2 months, patients and doctors can use the recorded data for administering medications effectively and to recognize problems before they become serious.

In general, many people fail to monitor their asthma. Experts believe that, ideally, portable monitors should be available to measure forced expiratory volume (FEV1), a more accurate gauge of lung function, and the results should be electronically transmitted to the doctor.

New guidelines released in 2005 by the National Asthma Education and Prevention Program (NAEPP) emphasize that most asthma medications are safe for pregnant women. The guidelines recommend that pregnant women with asthma have albuterol available at all times. Inhaled corticosteroids should be used for persistent asthma. Patients whose persistent asthma does not respond to standard dosages of inhaled corticosteroids may need a higher dosage or the addition of a long-acting beta-agonist to their drug regimen. For severe asthma, oral corticosteroids may be necessary. The NAEPP notes that while it is not clear if oral corticosteroids are safe for pregnant women, uncontrolled asthma poses an even greater risk for a woman and her fetus.

Quick-Relief Medications

These medications quickly control acute asthma attacks.

Beta2-agonists do not reduce inflammation or airway responsiveness but serve as bronchodilators, relaxing and opening constricted airways during an acute asthma attack. They are used alone only for patients with mild and intermittent asthma. Patients with more severe cases should use them in combination with other drugs.

Asthma is a disease in which inflammation of the airways causes airflow into and out of the lungs to be restricted. When an asthma attack occurs, mucus production is increased, muscles of the bronchial tree become tight, and the lining of the air passages swells, reducing airflow and producing the characteristic wheezing sound.

Specific short-acting beta2-agonists include:

• Albuterol (Proventil, Ventolin), called salbutamol outside the U.S., is the standard short-acting beta2-agonist in America. Other similar beta2-agonists are isoproterenol (Isuprel, Norisodrine, and Medihaler-Iso), metaproterenol (Alupent, Metaprel), pirbuterol (Maxair), terbutaline (Brethine, Brethaire, and Bricanyl), and bitolterol (Tornalate).
• Newer beta2-agonists, including levalbuterol (Xopenex), have more specific actions than the standard drugs. Studies have indicated that levalbuterol is as effective as albuterol with fewer side effects.

Short-acting bronchodilators are generally administered through inhalation and are effective for 3 - 6 hours. They relieve the symptoms of acute attacks, but they do not control the underlying inflammation. If asthma continues to worsen with the use of these drugs, patients should discuss corticosteroids or other drugs to treat underlying inflammation.

Side Effects of Beta2-Agonists. Side effects of all beta2-agonists include:

• Anxiety
• Tremor
• Restlessness
• Headache
• Fast and irregular heartbeats. Notify a doctor immediately if this side effect occurs, particularly in people with existing heart conditions. Such patients face an increased risk for sudden death from cardiac related causes.

Beta2-agonists have serious interactions with certain other drugs, such as beta-blockers, and patients should tell the doctor about any other medications they are taking. Individuals with diabetes, heart disease, high blood pressure, hyperthyroidism, an enlarged prostate, or a history of seizures should take these drugs with caution.

Loss of Effectiveness and Overdose. There has been some concern that short-acting beta2-agonists become less effective when taken regularly over time, increasing the risk for overuse. Over time some patients may become tolerant to many effects of short-acting beta2-agonists. The degree to which this affects the airways is uncertain. In some studies, the duration of action has declined but the peak effect appears to be preserved, making these drugs still useful for acute attacks. Regular use of long-acting beta2-agonists may reduce the effect of short-acting forms.

Differing clinical responses to albuterol may be based on patients' genotype for the beta-adrenergic receptor. Patients with certain forms of the receptor may find their asthma symptoms improve when not taking albuterol.

Patients who perceive beta2-agonists as being less effective may overuse them. Overdose can be serious and in rare cases even life threatening, particularly in patients with heart disease.

Inhaled ipratropium bromide (Atrovent) acts as a bronchodilator over time. Ipratropium bromide alone is only modestly beneficial for acute asthma attacks. Moreover, the drug is not approved specifically for asthma. It may, however, have some benefits:

• It may be useful for certain older patients with asthma who also have emphysema or chronic bronchitis.
• Combining it with a beta2-agonist might help patients who do not initially respond to treatment with a beta2-agonist alone.

Common oral corticosteroids include prednisone, prednisolone, methylprednisolone, and hydrocortisone. They very effectively reduce inflammation. They are generally used for asthma flareups that do not respond to inhaler medications. In some severe cases, they may be used as maintenance therapy. Usually, the dosage starts out higher and is then gradually reduced over a 5 - 7 day period.

Adverse effects of prolonged use of oral steroids include cataracts, glaucoma, osteoporosis, diabetes, fluid retention, susceptibility to infections, weight gain, hypertension, capillary fragility, acne, excess hair growth, wasting of the muscles, menstrual irregularities, irritability, insomnia, and psychosis. Osteoporosis is a common and particularly severe long-term side effect of prolonged steroid use. Medications that can prevent osteoporosis include calcium supplements, parathyroid hormone, bisphosphonates, or hormone replacement therapy in post-menopausal women.

Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

Long-term use of oral steroid medications suppresses secretion of natural steroid hormones by the adrenal glands. After withdrawal from these drugs, this so-called adrenal suppression persists, and it can take the body a while (sometimes up to a year) to regain its ability to produce natural steroids again. There have been a few cases of severe adrenal insufficiency that occurred when switching from oral to inhaled steroids, which, in rare cases, has resulted in death.

No one should stop taking any steroids without consulting a doctor first. If the doctor orders steroids withdrawn, regular follow-up monitoring is necessary. Patients should talk to their doctor about ways to prevent adrenal insufficiency during withdrawal, particularly during stressful times when the risk increases.

Long-Term Relief Medications

These medications are taken on a regular basis to prevent asthma attacks and control chronic symptoms.

Corticosteroids, also called glucocorticoids or steroids, are powerful anti-inflammatory drugs. Steroids are not bronchodilators (they do not relax the airways) and have little effect on symptoms. Instead, they work over time to reduce inflammation and prevent permanent injury in the lungs. They can also help prevent asthma attacks from occurring. Many studies have shown that the use of inhaled corticosteroids in patients with moderate-to-severe asthma significantly reduces the rate of rehospitalizations and deaths from asthma.

Inhalation of corticosteroids makes it possible to provide effective local anti-inflammatory activity in the lungs with minimal systemic effects. (By contrast, steroids taken by mouth have considerable side effects throughout the body.) Inhaled corticosteroids are recommended as the primary therapy for any patient needing long-term control medications for persistent asthma. (Low-doses of inhaled steroids may even be safe and effective for some people with mild asthma, particularly those who find themselves using beta2-agonists daily.)

Examples of inhaled corticosteroids:

• The most recent generation of inhaled steroids include fluticasone (Flovent), budesonide (Pulmicort), triamcinolone (Azmacort and others), flunisolide (AeroBid), mometasone furoate (Asmanex), and ciclesonide (Alvesco). In general, these newer steroids are more powerful than the older generation of inhaled drugs. These steroids are sometimes combined with a long-acting beta2-agonist in a single inhaler.
• The older corticosteroid inhalants are beclomethasone (Beclovent, Vanceril) and dexamethasone (Decadron Phosphate Respihaler and others). They are less powerful than the newer steroids when delivered with standard inhalers. New inhaler systems include QVAR, which uses extra fine formulations of beclomethasone to allow deep delivery into the lungs. Such systems may prove to be as effective as the newer, more potent steroids. Beclomethasone is believed to be safe during pregnancy.
• Inhalers that combine both long-acting beta2-agonists and corticosteroids are also available. These include Symbicort (budesonide/formoterol), which in 2006 was approved for patients ages 12 years and older.

Optimal timing of the dose is important and may vary depending on the medication. Most of the newer inhaled steroids and even some older ones are now available as a single daily dose.

Inhaled steroids are generally considered safe and effective and only rarely cause any of the more serious side effects reported with prolonged use of oral steroids. The following are side effects of inhaled steroids:

• The most common side effects are throat irritation, hoarseness, and dry mouth. using a spacer device and rinsing the mouth after each treatment can minimize or prevent these effects.
• Rashes, wheezing, facial swelling (edema), fungal infections (thrush) in the mouth and throat, and bruising are also possible but not common with inhalators.
• Inhaled corticosteroids are associated with a higher risk for cataracts in patients over age 40, particularly with higher dosages. (No higher risk is observed in younger people.)
• Some studies report a higher risk for bone loss in patients who take inhaled steroids regularly, a side effect known to occur with oral steroids. A number of bone-preserving medications are now available that might safely offset this problem.
• There is some concern that the more potent drugs, particularly fluticasone, suppress the adrenal system (which secretes natural steroids) to a greater degree than other steroid inhalants. (This is a serious side effect of oral steroids.)

Long-acting beta2-agonists are used in combination with inhaled corticosteroids for treating patients with moderate-to-severe asthma. These drugs include salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer). Combination single inhalers are available. One combines salmeterol and the corticosteroid fluticasone (Advair Diskus), and another combines formoterol and the corticosteroid budesonide (Symbicort).

Long-acting beta2-agonists are used for preventing an asthma attack (not for treating attack symptoms). The effects of one dose of a long-acting beta2-agonist last for about 12 hours, so these medicines are particularly effective during the night. These drugs also may be used for prevention of exercise-induced asthma in people and to protect against aspirin-induced asthma.

However, research indicates that long-acting beta2-agonists can worsen asthma by increasing symptom severity. These drugs may also increase the risk for asthma-related deaths, particularly when used alone. Experts are still trying to determine when long-acting beta2-agonists should be added to an asthma treatment plan. If your symptoms do not improve or if symptoms worsen with this type of drug, your doctor will recommend discontinuing it. Do not, however, stop taking this drug or other asthma medications without first talking with your doctor.

Side Effects. Side effects of long-acting beta2-agonists are similar to the short-acting drugs.

Specific Warning on Salmeterol and Formoterol. In 2003, a "black box" warning was added to product packaging for drugs that contain salmeterol, including Serevent Diskus and Advair Diskus. The warning was based on a study that demonstrated more serious and even fatal asthma episodes in patients who used the drug than in patients who used a placebo. The risk for serious asthma episodes with salmeterol appears to be highest in African-Americans and elderly patients with severe asthma.

In 2006, the FDA updated the warning to include formoterol (Foradil Aerolizer). Warnings for salmeterol and formoterol products emphasize that these medicines can increase the risk of severe asthma episodes. If these episodes occur, they can be fatal. Long-acting beta2-agonists require up to 20 minutes to achieve effectiveness, and there is a danger of overdose if a patient is not aware of this delay and takes additional doses to achieve faster relief. The FDA recommends that patients:

• Use long-acting beta2-agonists only if other medicines (such as steroids) have not helped control asthma.
• Use a short-acting bronchodilator, not a long-acting beta2-agonist, to treat sudden wheezing.
• Do not use long-acting beta2-agonists to treat wheezing that is getting worse. Call your doctor if this situation occurs.
• Do not stop using any asthma medicines without first talking to your doctor.

Cromolyn sodium (Intal) is both an anti-inflammatory drug and has antihistamine properties that block asthma triggers, such as allergens, cold, or exercise. Nedocromil (Tilade) is similar to cromolyn. A cromolyn nasal spray called NasalCrom has been approved for over-the-counter purchase, but only to relieve nasal congestion caused by allergies. Patients should not use it for self-medication without the advice of a doctor.

Candidates. Cromolyn is a treatment option for exercise-induced asthma (EIA) in all age groups, for pregnant women, and possibly for preventing allergic asthma in adults as well as children. Cromolyn and nedocromil may be used as an alternative to inhaled corticosteroids, but they are not as effective as inhaled corticosteroids. Therefore, inhaled corticosteroids are considered the preferred choice over cromolyn and nedocromil for long-term control of persistent asthma.

Side Effects. Side effects of cromolyn include nasal congestion, coughing, sneezing, wheezing, nausea, nosebleeds, and dry throat. Nedocromil has an unpleasant taste, and some people have complained of nausea, headache, and spasms in the airways, but no serious side effects have been reported.

Leukotriene-antagonists (also called anti-leukotrienes or leukotriene modifiers) are oral medications that block leukotrienes. Leukotrienes are powerful immune system factors that, in excess, produce a battery of damaging chemicals that can cause inflammation and spasms in the airways of people with asthma. As with other anti-inflammatory drugs, leukotrienes are used for prevention, NOT for treating acute asthma attacks.

Leukotriene-antagonists include zafirlukast (Accolate) and montelukast (Singulair). These drugs are considered an alternative for long-term control of asthma, but inhaled corticosteroids should always be used first. Other potential uses include preventing exercise-induced asthma.

Side Effects and Complications. Gastrointestinal distress is the most common side effect of leukotriene-antagonists. Very few other side effects have been reported. In general, these drugs appear to be safe and well tolerated. The FDA is evaluating reports of suicidal tendencies associated with these medications.

Other concerns are indications of liver injury in patients when taking zafirlukast at higher than standard doses. No adverse effects on the liver have been reported to date with montelukast.

Theophylline. Theophylline (Theo-Dur, Theolair, Slo-Phyllin, Slo-bid, Constant-T, and Respbid) relaxes the muscles around the bronchioles and also stimulates breathing. The use of inhaled corticosteroids and long-acting beta2-agonists has dramatically reduced the need to use theophylline in most patients with asthma. It may be useful for treating nocturnal asthma. Available in tablet, liquid, and injectable forms, some theophylline sustained-release tablets and capsules work for a long time and can, therefore, be taken once or twice a day with good results.

If theophylline is not taken exactly as prescribed, an overdose can easily occur. Toxicity can cause nausea, vomiting, headache, insomnia, and, in rare cases, disturbances in heart rhythm and convulsions. Contact a doctor immediately if any of these side effects occur.

The risks for these adverse effects are small if the drug is taken exactly as prescribed, but patients should note the following precautions:

• Chronic smokers metabolize theophylline much more quickly and need higher doses of the drug than nonsmokers; prolonged-release versions are helpful for such people.
• Too much caffeine can increase the concentration of this drug and the amount of time it stays in the body.
• Theophylline also interacts with many other drugs that are taken for other common medical conditions, including asthma. Use caution when taking beta2-agonists and theophylline together.
• No one with a peptic ulcer should take theophylline. The elderly and anyone with heart disease, liver disease, hypertension, seizure disorders, or heart failure should take theophylline with caution. Of special note, people with heart conditions who take theophylline by mouth have an increased risk for sudden death from heart-related problems.

Omalizumab (Xolair) is FDA-approved for patients age 12 and older who have moderate-to-severe persistent asthma related to allergies. The first drug of this type to be approved for asthma, omalizumab is a monoclonal antibody (MAb), a genetically developed drug designed to attack very specific targets. Omalizumab is given by injection every 2 - 4 weeks. It is used only to treat patients who have moderate-to-severe persistent asthma related to allergies whose symptoms are not controlled by inhaled corticosteroids.

Omalizumab prevents the antibody immunoglobulin E (IgE) from triggering the inflammatory events that lead to asthmatic attacks. Studies have shown excellent benefits of the drug, including a reduced need for corticosteroids, fewer hospitalizations, and significant symptomatic improvements.

However, about 1 in 1,000 patients who take omalizumab develop anaphylaxis (a life-threatening allergic reaction). In 2007 the FDA requested that the manufacturers of omalizumab put a “boxed warning” on the medicine’s label, emphasizing the drug’s risk for anaphylaxis (a potentially life-threatening allergic reaction). The boxed warning notes that patients can develop anaphylaxis after any dose of omalizumab, even if they had no reaction to a first dose. Anaphylaxis may occur up to 24 hours after the dose is given.

Omalizumab should always be injected in a doctor’s office. The FDA recommends that health care providers observe patients for at least 2 hours after an injection. Patients should also carry emergency self-treatment for anaphylaxis (such as an Epi-Pen) and know how to use it. With an Epi-Pen, or similar auto-injector device, patients can quickly give themselves a life-saving dose of epinephrine.

Anaphylaxis symptoms include:

• Difficulty breathing
• Chest tightness
• Dizziness
• Fainting
• Itching and hives
• Swelling of the mouth and throat

Other Treatments

Patients with asthma should receive the flu vaccine annually, and they should receive the vaccination against pneumococcal pneumonia at least once. [For more information, see In-Depth Report #94: Colds and influenza.]

Patients with asthma and chronic allergic rhinitis may need to take medications daily. Patients with severe seasonal allergies may need to start medications a few weeks before the pollen season, and to continue medicine until the season is over.

Immunotherapy ("allergy shots") may help reduce asthma symptoms, and the use of asthma medications, in patients with known allergies. They may also help prevent the development of asthma in children with allergies. Immunotherapy poses some risk for severe allergic reactions, however, especially for children with poorly controlled asthma.

Treatment of allergies and sinusitis can help control asthma.

[For more information, see In-Depth Reports #77: Allergic rhinitis, #5: Asthma in children and adolescents, and #62: Sinusitis.]

Respiratory infections, including the common cold, can act with allergies to worsen asthma. People with asthma should try to minimize their risk for respiratory tract infections. Washing hands is a very simple but effective preventive measure.

Patients with obvious symptoms of reflux may consider the following lifestyle changes:

• Avoiding heavy meals and meals with fried food
• Avoiding caffeine
• Avoiding eating or drinking at least 3 hours before bedtime
• Elevating the head of the bed by 6 inches
• Taking medications treating gastroesophageal reflux. Be sure to talk to your doctor before taking these medicines.

Women who suspect that menstrual-related changes may influence asthma severity should keep a diary of their menstrual dates and times of asthma attacks. Sometimes, adjusting medications in anticipation of menstruation may help prevent attacks. Some small studies have suggested that hormonal drugs called gonadotropin-releasing hormone (GnRH) analogues may help women with severe premenstrual asthma. These drugs reduce or suppress estrogen levels, however, and can have severe side effects. More research is needed to determine if the disadvantages outweigh the benefits.

Children, adolescents, and adults with asthma are widely using alternative therapies. In one study, nearly half of asthma or allergy sufferers resorted to alternative treatments. To date, however, evidence does not support any value from most alternative therapies, including high-dose vitamins, urine injections, homeopathic remedies, and most herbal remedies.

Relaxation and Stress-Reduction Techniques. Some patients report benefits from many stress reduction techniques, such as acupuncture, hypnosis, breathing relaxation techniques, massage therapy, and meditation practices. There have been very few well-conducted studies supporting their use, however.

Acupuncture, hypnosis and biofeedback are all alternative ways to control pain. Acupuncture involves the insertion of tiny sterile needles, slightly thicker than a human hair, at specific points on the body.

The Buteyko Breathing Method. The Buteyko breathing method is an experimental approach designed to increase levels of carbon dioxide in the body. To do this, patients are trained to reduce their volume of breath and to avoid hyperventilation (over-breathing). Some studies have reported that patients using this method take fewer medications and improve their quality of life. The system originated in Australia and is not yet widely available in the U.S.

Probiotics. Probiotics are beneficial bacteria that some believe may help protect against allergies and asthma. Probiotics can be obtained in active yogurt cultures and supplements, which are being studied for protection. However, evidence to date does not support efficacy in preventing or treating asthma.

Herbal Remedies. Few rigorous studies have evaluated herbal remedies for asthma. Manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Managing Asthma at Home

Asthma action plans create a written document for patients to manage asthma during stable times and to more easily identify when asthma is worsening. Important components of a home program include:

• A clearly written plan for taking asthma medications when condition is stable
• A complete education regarding the difference between long-term control medications and quick-relief medications
• Monitoring of asthma on a daily basis. Symptom monitoring is adequate for patients with intermittent or mild persistent asthma. Peak flow monitoring should be performed in patients with moderate or severe persistent asthma or those with a history of more severe exacerbations (sudden worsening or increase in severity of symptoms).
• A list of environmental control measures that need to be taken
• When to seek medical care

Managing Asthma Exacerbations. Always refer to the written action plan from your doctors and nurses. Treatment approaches generally include:

• Recognizing symptoms and measuring peak flow
• Using for the first time or increasing usage of short-acting medications
• Eliminating or withdrawing from any triggers or irritants that may be responsible for increase in severity of symptoms
• Depending on written instructions from doctor, begin oral corticosteroids if available
• Monitoring response to treatments and communicating with doctor if symptoms worsen or if severe symptoms occur. (See: "Symptoms" section.)

Follow-up generally depends on the severity of asthma, how recently asthma was diagnosed, patient compliance, and whether recent changes in treatment were made.

Avoiding and controlling triggers that lead to asthma attacks are as much a priority as treatment of the disease.

Controlling Pets. Patients who already have pets and are not allergic to them probably have a low risk for developing allergies. If pets trigger asthma, take the following precautions:

• If possible, keep pets outside
• If this isn't possible, confine pets to carpet-free areas outside the bedroom. Cats harbor significant allergens, which can even be carried on clothing. Dogs usually cause fewer problems.
• Wash animals once a week to reduce allergens. Dry shampoos, available for both cats and dogs, can remove allergens from the skin and fur and are easier to administer than wet shampoos.

Controlling for Dust. Spray furniture polish is very effective for reducing both dust and allergens. Air cleaners, filters for air conditioners, and vacuum cleaners with High Efficiency Particle Arresting (HEPA) filters can help remove particles and small allergens found indoors. Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergens. If possible, avoid carpets and rugs.

A High Efficiency Particle Arresting (HEPA) filter can remove the majority of harmful particles, including mold spores, dust, dust mites, pet dander and other irritating allergens from the air. Along with other methods to reduce allergens, such as frequent dusting, the use of a HEPA filtration system can help control the amount of allergens circulating in the air. HEPA filters can be found in most air purifiers, which are usually small and portable.

Bedding, Curtains, and Bedroom Environment.

• Replace curtains with shades or blinds, and wash bedding using the highest temperature setting.
• Encase mattress and pillow in special dust mite proof covers (synthetic pillows may pose a higher risk for asthma attacks than feather pillows, or no pillow at all).
• Wash pillow in water hotter than 150° F, or in cooler water with detergent and bleach.
• Wash sheets and blankets weekly in hot water.
• Avoid sleeping or lying on cushions or furniture that are cloth covered.

Reducing Humidity in the House. Living in a damp house is counterproductive. Dust mites thrive in humidity and damp houses increase the risk for mold. Humidity levels should not exceed 30-50%:

• Fix all leaky faucets and pipes, and eliminate collections of water around the outside of the house.
• Dehumidify basements, but empty humidifiers and clean them daily with a vinegar solution.
• Clean often any moldy surfaces in the basement or in other areas of the home.
• Avoid prolonged used of vaporizers to manage symptoms during asthma attacks.

Gas Stoves, Kerosene, and Cooking. People with asthma should choose electric ovens. Gas ovens release nitrogen dioxide, a substance that can aggravate asthma symptoms. Even smoky cooking can worsen asthma. Kerosene (used in space heaters and lamps) may also produce allergic reactions.

Exterminating Pests (Cockroaches and Mice).

• Use a professional exterminator to eliminate cockroaches. (One study reported that ridding a home of cockroaches and cleaning the house using standard housecleaning techniques failed to eliminate the cockroach allergens themselves.)
• Exterminate mice and attempt to remove all dust, which might contain mouse urine and dander.
• Keep food and garbage in closed containers.
• Keep food out of bedrooms.

Avoiding Smoking and Cigarette Smoke. Cigarette smoke can accelerate the decline in lung function related to asthma. Even exposure to secondhand smoke can double the risk of asthma-related emergency room visits. In one study, it was the most frequently cited trigger of asthma symptoms. Everyone should quit smoking and encourage others around them to quit. [For help quitting, see In-Depth Report #41: Smoking.]

Click the icon to see an image of common asthma triggers.

Avoiding Outdoor Allergens.

• Avoid scheduling camping and hiking trips during times of high pollen count (generally, May and June for grass pollen and mid-August to October for ragweed).
• Avoid strenuous activity when ozone levels are highest, which usually occur in early afternoon, particularly on hot hazy summer days. Levels are lowest in early morning and at dusk.
• Asthma attacks are often higher during thunderstorms. It is not clear why. Some evidence points to a build-up of ozone that accompanies such storms. One study suggested that changing airflow patterns bring a sudden downdraft of air containing concentrations of pollens, small particles and allergens.
• Patients who are allergic to mold should avoid barns, hay, raking leaves, and mowing grass. Exposure to automobile fumes may worsen asthma. Fungi in car air conditioners can also be a problem.

A number of studies have linked air pollution to asthma. Evidence suggests that air pollution can worsen existing asthma and patients should take precautions if they are exposed to polluted air.

Click the icon to see an image of fungus.

A number of studies have estimated that 2 - 26% of adult-asthma cases are related to work history. Some experts encourage doctors to suspect occupational factors in all cases of adult-onset asthma. Although workers who have allergies, who smoke, or both are at higher risk than others, any worker exposed to occupational triggers may be at risk for asthma.

Work-related asthma is one of two types:

• Work-aggravated asthma, in which existing asthma symptoms are triggered by irritants at the workplace
• Occupational asthma, which is new-onset asthma strongly associated with conditions at work

Occupational asthma is further categorized as:

• Nonlatent (symptoms occur right after exposure to an irritant, usually high concentrations of gas, fumes, dust, or chemicals)
• Latent (symptoms develop after prolonged exposure to substances in the workplace)

Occupational Triggers. Over 250 substances have been identified as potential occupational triggers of asthma, and the list is growing. These chemicals and substances include:

• Isocyanates used in the manufacture of polyurethane, paints, steel, and electronics
• Trimellitic anhydrides (TMA) used in many plastics and epoxies
• Western red cedar, oak, redwood, and mahogany
• Metal salts (platinum, nickel, and chrome) and metal working fluids
• Vegetable dusts (soybeans, grains, flour, cotton, and gums)
• Biologic organisms (Bacillus subtilis, pancreatic enzymes)
• Xylanase used in the baking industry
• Pharmaceuticals (penicillin, phenylglycine acid chloride)
• Glutaraldehyde used to sterilize medical equipment
• Red dye made from the cochineal insect
• Diacetyl, the main chemical in artificial butter flavoring used in popcorn

Workers in these industries and others, including farmers, hairdressers, and those who work in the garment industries, are at risk for asthma.

Preventing Occupational Asthma. People with occupational asthma may benefit from from improved ventilation or wearing face masks.

Sometimes, however, even low levels of chemical substances can trigger an asthma attack. Sometimes, leaving the job is the only way to prevent the condition from getting worse. Because such a step can be emotionally and financially threatening, workers should have a complete check-up with a lung specialistbe to be sure that occupational substances are the cause of their asthma.

If the diagnosis of occupational asthma is certain, patients should obtain advice on available compensation plans for disability. The effects of workplace asthma can be permanent. However, in one study, 70% of people with asthma experienced significant improvement in symptoms after leaving the job.

Weight Loss. People who have asthma and who are overweight may help reduce asthma symptoms with weight loss.

Fruits, Vegetables, and Whole Grains. Healthy foods are important for lung function. Specific foods that may be important for healthy lungs contain antioxidants (deep green and yellow-orange fruits and vegetables), selenium (fish, red meat, grains, eggs, chicken, liver, and garlic), plant chemicals called flavonoids (apples and onions), and magnesium (green leafy vegetables, nuts, whole grains, milk, and meats).

Vitamin D. There may be an association between a lack of vitamin D and asthma. Some research suggests that children are less likely to develop asthma at a young age if their mothers consume a lot of vitamin D during pregnancy. Vitamin D is available from dietary sources or vitamin supplements.

Fish Oil. Omega-3 fatty acids, found in cold water oily fish and supplements (preferably DHA-EPA, the important compounds in fish oil), have anti-inflammatory effects. Some evidence, although it is weak, suggests they may help people with asthma.

Caffeine. Caffeine has properties that are similar to theophylline, a drug used to treat asthma. A major analysis of studies reported that caffeine improved lung function for up to 4 hours after consumption. (People who are going to have their lung function tested should avoid drinking coffee, tea, or other caffeinated beverages for at least 4 hours before testing.)

Alcohol. Some research suggests that alcohol intake may influence allergy severity in adults. One study found that as little as one drink a day is enough to worsen dust mite allergies.

Role of Food Allergies. Although 67% of people with asthma believe their symptoms are aggravated by food allergies, studies indicate that this belief may be true only 5% of the time. The primary suspects are monosodium glutamate, or MSG (found in some canned soups, cheese, and certain vegetables), and sulfites (preservatives in wine and foods that include processed frozen potatoes and tuna). Contrary to what many people believe, dairy products do not appear to worsen asthma symptoms in people who are not already allergic to them.

Asthma is no reason to avoid exercise. Historically, about 10% of Olympic athletes have asthma. Some studies indicate that long-term exercise even helps control asthma and reduce hospitalization. Patients should consult their doctors before starting any exercise program, however. Uncontrolled asthma can be dangerous and, rarely, fatal for athletes, even some with mild asthma. Using an inhaler is extremely important.

People who enjoy running should probably choose an indoor track to avoid pollutants. Swimming is excellent for people with asthma. Yoga , which uses stretching, breathing, and meditation techniques, may have particular benefits. One study reported that two-thirds of patients who practiced yoga regularly were able to reduce or stop taking their asthma medications.

Hints for Reducing Exercise Induced Asthma (EIA). EIA occurs only after exercise and is more likely to happen during regular paced activities in cold, dry air. The following are some suggestions for reducing its impact:

• Comply with long-term control medications, particularly inhaled corticosteroids, when prescribed.
• Warm-up and cool-down before and after exercise.
• Participate in activities with short bursts of exercise (such as tennis and football) over exercises involving long-duration pacing (such as cycling, soccer, and distance running).
• Breathe through a scarf or through the nose. This helps warm up the airways when exercising in cold air.
• Restrict dietary salt.

Medications.

• Short-acting beta2-agonists taken before exercise are generally considered the first choice, and they last for 2 - 3 hours.
• Cromolyn or nedeocromil are other options, but they are not as effective.
• Leukotriene antagonists are another option, but they generally take hours to be effective.
• Pretreatment with long-acting beta2-agonists is generally discouraged.

Click the icon to see an image of exercise-induced asthma.

People with asthma have no higher rate of anxiety or depression than the general population. However, such emotions interact with the effects of asthma and its treatments in important ways:

• Negative emotions can discourage compliance with medication and the ability to cope.
• Poor control of asthma symptoms, in turn, increases the risk for negative emotions.
• Stress and depression have been associated with more severe symptoms and even an increased risk of fatal asthma attacks.

Some evidence suggests that stress reduction and positive attitude and relaxation techniques can be very helpful in the long-term management of asthma. [For more information, see In-Depth Report #31: Stress.]

Resources

• www.lungusa.org -- The American Lung Association
• www.acaai.org -- American College of Allergy, Asthma & Immunology
• www.aaaai.org -- American Academy of Allergy, Asthma & Immunology
• www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
• www.nationaljewish.org/disease-info/diseases/asthma/index.aspx -- National Jewish Medical and Research Center
• www.aafa.org -- Asthma and Allergy Foundation of America
• www.aarc.org -- American Association for Respiratory Care

References

American Lung Association. Trends in asthma morbidity and mortality. American Lung Association Epidemiology & Statistics Unit Research and Program Services. November 2007.

Ernst P, Baltzan M, Deschenes J, Suissa S. Low-dose inhaled and nasal corticosteroid use and the risk of cataracts. Eur Respir J. 2006 Jun;27(6):1168-74. Epub 2006 Feb 15.

Glassroth J. The role of long-acting ß-agonists in the management of asthma: Analysis, meta-analysis, and more analysis. Ann Intern Med. 2006 Jun 20; 144:936-7.

Kiljander TO, Harding SM, Field SK, Stein MR, Nelson HS, Ekelund J, et al. Effects of esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial. Am J Respir Crit Care Med. 2006 May 15;173(10):1091-7.

Kearney DM, Lockey RF. Osteoporosis and asthma. Ann Allergy Asthma Immunol. 2006 Jun;96(6):769-74.

Kukkonen K, Savilahti E, Haahtela T, Juntunen-Backman K, Korpela R, Poussa T, et al. Probiotics and prebiotic galacto-oligosaccharides in the prevention of allergic diseases: a randomized, double-blind, placebo-controlled trial. J Allergy Clin Immunol. 2007 Jan;119(1):192-8. Epub 2006 Oct 23.

National Asthma Education and Prevention Program Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics -- 2002. Rockville, MD. National Heart, Lung, and Blood Institute, US Dept of Health and Human Services; 2003. NIH publications 02-5074.

National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Rockville, MD. National Heart, Lung, and Blood Institute, US Dept of Health and Human Services; 2007. NIH publications 08-4051.

Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000195.

Salpeter SR, Buckley NS, Ormiston TM, Salpeter EE. Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths. Ann Intern Med. 2006 Jun 20;144(12):904-12.

Slavin RG, Haselkorn T, Lee JH, Zheng B, Deniz Y, Wenzel SE; TENOR Study Group. Asthma in older adults: observations from the epidemiology and natural history of asthma: outcomes and treatment regimens (TENOR) study. Ann Allergy Asthma Immunol. 2006 Mar;96(3):406-14.

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