Originally published in The Ottawa Citizen November 5, 2002
Original Title: Every Breath You Take
Part II: Medication only part of asthma care

Asthma management continues to be a problem for some patients. This is borne out by the telephone call from a patient who frequently runs out of their Ventolin puffer. A review of their chart shows repeat monthly or bimonthly renewal requests; a red flag denoting poor asthma control.

Despite newer medication formulations and treatment protocols, asthma rates continue to climb. The Centers for Disease Control review of rates during 1982 to 1992 showed an increase of 52 percent (34.6 to 52.6 per 1000) for people between the ages of five to 34 years. The greatest increase occurs in people under 18 years of age.

The next two columns will review what causes asthma, its diagnosis and treatment in children and adults. It will provide the tools to improve your ability to take charge of this condition.

Asthma is an inflammatory disease that plugs up the lungs and obstructs the ability to breathe. Its principal causes include genetic factors, allergies, chronic exposure to cigarette smoke and other chemical airborne irritants.

The bronchi are the tubes that carry air into the lungs. Lining their inside walls are cells that produce mucous. Other cells have sweeping and cleaning functions that clear the airway of contaminants, viruses and bacteria.

Elastic bands of muscle wrap around the bronchi’s outer walls. Their function is to dilate and constrict the bronchi in response to environmental or physiological factors. The terms for these actions are bronchodilation and bronchoconstriction. This action is important for proper lung function.

For example, inhaling cold winter air can cause the airways to produce mucous and bronchoconstrict. This increases the time to fill the lungs with air. The net result is more time to warm the air to prevent a reduction in core body temperature.

A combination of factors in asthma impairs normal breathing function. The bronchi become irritated and swollen under different conditions thereby causing bronchoconstriction and abnormal amounts of mucous secretions. The swelling of inner bronchial wall decreases its diameter. The net result is airflow obstruction.

Asthma triggers include exposure to allergic substances (allergens), colds and flu, pneumonia, aerobic exercise, cold air and smoking.

It is easy to overlook or ignore the initial physical symptoms associated with asthma. Many people do not seek medical attention for that intermittent nagging cough. They adapt to their symptoms and assume it is their normal state.

Most people associate wheezing with asthma. Although a common adult symptom, it can be absent in some young children. Children may have a deep hacking non-wheezy nighttime cough. The coughing fits can be so strong that the child vomits thereafter. Many parents will bring their child to the office not for the cough but rather because of the vomiting.

The spirometer is a tool used to diagnose asthma. It measures a wide variety of lung functions. These measurements determine if there is any airway obstruction during rapid exhaling and inhaling through the device.

If there is obstruction Ventolin, a bronchodilator medication, may be administered to the patient prior to repeating spirometry. A measurable improvement in lung function may indicate asthma.

Young children are unable to perform spirometry. Careful observation, physical examination and a detailed medical history can help establish the diagnoses.

To wit, some factors are particularly useful in establishing a diagnosis in young children. Does the child cough at night, during physical activity, playing outside in the cold winter air or when they catch a cold virus? Do they wheeze more than three times a year? Do they have eczema? Do the parents smoke in the house or car? Is there a family history of asthma or eczema?

Often, physicians will initiate a trial of a Ventolin inhaler or liquid Alupent to see if it relieves the cough and wheezing. If successful it may indicate asthma.

There is a straightforward way to determine whether asthma treatment needs adjustment. All asthmatics that use their bronchodilators (Ventolin and Airomir (salbutamol), Apo-Salvent and Berotec) more than two to three times a week have by definition unstable asthma. This instability increases the risk of a more severe asthma attack. More definitive approaches are in order.

Next week we will look at the five principles of effective asthma treatment;

• individualized continuing care,
• the ways the medications work in preventing and relieving symptoms,
• medication side effects and how to manage them,
• preventive treatment to reduce inflammation when symptoms are absent,
• early treatment to reduce inflammation when symptoms are present.

Get a head start and consult your doctor should you be using your bronchodilator medication more often than usual.

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© Dr. Barry Dworkin 2002