Originally published in The Ottawa Citizen November 12, 2002
Original Title: A Puff of Fresh Air

Part I – Be alert for early warning signs of asthma

Asthmatics can suddenly crash and burn. Last week’s column made note that asthma is an inherently unstable disease. Some patients unknowingly play with fire by ignoring the symptoms. A good web site to determine the risk of asthma in children and adults is found at http://allergy.mcg.edu/home.html.

Most physicians agree that aggressive treatment to stabilize and control asthma is a top priority. What approaches do physicians apply to prevent the serious consequences of asthma?

An initial patient history provides valuable information. Although medications are a mainstay of treatment, treating asthma is not just about prescribing them and wishing people well. The ultimate goal is a comprehensive approach that includes the minimum amount of medications to provide a maximum positive benefit.

An individualized approach includes determination of a history of allergies, sporting activities, smoking, medication use and work environment among other factors.

Removing asthma-triggering substances or optimizing protection from the elements or noxious substances is a helpful step. Indeed, piling on ever-increasing doses and types of medication to compensate for worsening asthma without determining its triggers misses an important aspect of care.

For arguments sake, assume that correcting for the above factors has not led to stable asthma control. The patient continues to suffer from his or her asthma. The choice of medication follows a rational stepwise approach.

The goal of asthma treatment is to reduce the inflammation and airflow resistance of the airways to improve lung function. The choice of medication depends on the severity of the illness.

Short-acting bronchodilators, usually packaged in blue-coloured inhaler delivery systems, include salbutamol, found in Ventolin, Apo-Salvent and Airomir, Bricanyl (turbutaline), Berotec (fenoterol) and Atrovent (ipatropium bromide). In very young children, liquid Alupent (orciprenaline) may be used to help diagnose Asthma prior to the use of inhalers. These fast-acting agents relax the smooth muscle bands around the airway. The diameter of the airway increases making it easier to breathe.

Bronchodilators can cause jitteriness and a temporary increase in heart rate. This usually subsides within ten to 20 minutes. Overuse of these medications can render them less effective.

Longer acting bronchodilators (turquoise packaging), Oxeze (formoterol) and Serevent (salmeterol), last up to eight to 12 hours between doses. They remain effective with long-term use.

The anti-inflammatory agents (inhaled steroids) are the key to treating asthma. They shrink the swollen inner walls of the airways curtailing mucous secretion and blockage. These medications (brown or orange packaging) include Flovent (fluticasone), Pulmicort (budesonide), Q-Var and Becloforte (Beclomethasone). A non-steroid formulation, Tilade, is available but is not commonly used for compliance and taste reasons.

Long-term studies indicate that there is little to no growth suppression in children who use them. They provide excellent asthma control. The most common side effects of inhaled steroids are a hoarse voice and oral thrush. Rinsing and gargling immediately after use reduces this risk.

Two combination inhalers, Advair (Serevent and Flovent) and Symbicort (Pulmicort and Oxeze) can improve overall asthma control.

Leukotriene inhibitors (Singulair and Accolate) block a specific biochemical pathway related to a delayed allergic response that stimulates inflammation. They are an adjunct to the standard asthma medications and tend to work better for people with exercise-induced asthma. A daily tablet for some people may reduce their daily dose of inhaled steroids.

For severe asthma exacerbations, oral or intravenous prednisone may be required. Prednisone, a steroid, rapidly reduces inflammation over 12 to 24 hours. It is used when asthma does not respond to the usual treatment regimen or the patient is temporarily unable to inhale their medication. The severity of the asthma exacerbation dictates whether the patient ends up at home or in hospital.

Asthmatics can have different symptoms. Those that wheeze and cough only while participating in aerobic activities have treatment that differs from someone who has symptoms at any time of the day or night. The bottom line is to prevent the progression of the disease. Some, as they age, will suffer fewer attacks while others have it for life.

Many people do not correctly use their inhalers. The proper technique is critical to successful therapy. These patients usually conclude that the medication did not work when in fact little medication reached the lungs. Your doctor, public health nurse or respiratory technician can show you how to use them.

Bronchodilator use more than two to three times per week indicates poor asthma control. Asthmatics experience more bouts of pneumonia, colds and flu. Some cannot keep up with the physical demands of their job or sport. There are Olympic athletes that depend on their asthma medications in order to compete.

Some asthmatics continue to smoke. Their asthma attacks become progressively more severe and frequent. In my practice, several wonderful patients continue to deteriorate. Each asthma attack is worse than the last. I fear they will soon succumb to their asthma if they do not quit smoking.

There is a tendency to experience our illnesses from an individual perspective. In fact, most illnesses affect the entire family. As difficult as it is to quit smoking, the challenge is to stay alive to see your children grow up. Consult with your doctor and do what you must to succeed, for everyone’s sake.

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© Dr. Barry Dworkin 2002