California Allergy and Asthma Medical Group

What are the symptoms of asthma?

Typical symptoms include chest tightness, shortness of breath, coughing, and wheezing. The symptoms can be brought on by certain exposures (irritants, allergens, exercise), or they can be persistent.

How is asthma diagnosed?

The diagnosis is best done by a visit to the doctor. The diagnosis is based on typical symptoms, the patient’s medical and family history, physical exam, and often with breathing tests.

What causes asthma?

Good question! We know that allergies (mostly to things in the air like pollens and dust mites) contribute to the asthma of many children and young to middle-aged adults. But there are many people who have asthma and no allergies at all. Although we are not sure of all the fundamental causes of asthma, we believe that both environmental and genetic factors play a role in the inflammation of the airways typical of asthma.

Is asthma a serious disease?

Yes, it can be. Asthma is unique because the intensity of disease varies widely. Asthma can be merely an inconvenience in one person, and it can be a potentially life-threatening disease in another. A given individual may fall anywhere between these two points. Also, an asthmatic may move up or down this scale during the course of a lifetime - some lucky patients going into remission as they age. The overwhelming majority of asthmatics can be effectively be treated with medications (as well as anti-allergy measures) with minimal, if any, side effects.

What different kinds of asthma medications are used?

There are many different types and brands of asthma drugs on the market. We believe it is helpful to classify the drugs to help understand how they are used. The two main types are bronchodilators and anti-inflammatory medications (steroid/cortisone-type medications and cromolyn-type medications). Two other types of medications - Leukotriene modifiers (e.g., Accolate and Zyflo) and phosphodiesterase inhibitors (e.g. theophylline) - are difficult to classify since they seem to have properties of both bronchodilators and anti-inflammatory medications.

What are bronchodilators?

Bronchodilators are medications that dilate (open up) the bronchial tubes to permit easier breathing and relieve symptoms. There are short-acting bronchodilators that are used for quick relief of asthma symptoms (e.g., albuterol, metaproterenol, and trade names including Ventolin, Proventil HFA, Primatene, and Alupent). Most doctors instruct patients to use them as needed - the moment that asthma symptoms arise. In children, bronchodilators are sometimes used on a regular basis, because kids may not let their parents know when they are having symptoms.

Long-acting bronchodilators (Serevent) keep the bronchial tubes dilated over many hours. Important to know, however, is that these medications may take a while (maybe an hour or so) to start working. They should never be used for quick relief of asthma symptoms. That is, they are prescribed as maintenance medications - they are taken daily without regard for the symptoms the patient is having at that particular moment . Most of the asthma experts believe that this type of long-acting bronchodilator should be used in conjunction with daily anti-inflammatory medications, as well as a short-acting bronchodilator for quick relief.

Theophylline and leukotriene modifiers are considered by some to be long-acting bronchodilators also, but have been used as the sole medication in some patients.

How are anti-inflammatory drugs used in asthma?

The two main types of anti-inflammatory are steroids (oral [pill or syrup] and inhaled forms) and cromolyn-type medications. Both of these drugs, in the inhaled form, are safe and effective in asthma. They should be used as daily, maintenance medications as they do not result in immediate relief of symptoms. These anti-inflammatory medications may prevent the permanent damage to the lungs that experts believe is occurring over many years in the uncontrolled asthmatic. Examples of inhaled steroid medications are Flovent, Vanceril, Azmacort, and Pulmocort. Examples of cromolyn-type inhaled medications are Intal and Tilade.

Consequently, national expert guidelines for the treatment of asthma recommend that any asthmatic experiencing symptoms more that twice a week should be treated with maintenance medications like inhaled steroids or cromolyn-type medications. These recommendations also apply to children and pregnant women. In children, the cromolyn-type is usually the first choice, with inhaled steroids being used in more persistent cases. For most adults, inhaled steroids are much more effective than cromolyn-type medications, and they are considered to be extremely safe drugs when given in low to moderate doses.

There is a little concern about long-term inhaled steroids in children because of possible growth delay. However, most of the experts believe that if the asthma is serious enough, it’s well worth the small risk of treating with inhaled steroids.

The oral form of steroids (e.g. prednisone) should be reserved for two situations because long-term use is fraught with serious side effects

1.	For short courses (5 - 14 days) used in asthma exacerbations - when a patient is having to use their bronchodilator very frequently or when the asthma is interfering with their daily routine (nighttime awakenings, missing work or school).
2.	Chronic, daily use of oral steroids is reserved for the most severe asthmatic when all other types of asthma drugs have been tried. I believe that any asthmatic taking chronic, daily oral steroids should definitely be followed by an asthma specialist (Allergy/Immunologist or Pulmonary specialist).

Should I continue to take asthma medications during my pregnancy?

YES! Although your doctor may want to switch which drugs you are taking, you must continue to take appropriate treatment during pregnancy. Very effective anti-asthma drugs are available that are considered to be safe for pregnancy. The fetus depends on his mother’s lungs for oxygen . If your doctor refuses to put you on medications to control your asthma during pregnancy, find another doctor willing to do it.

Should I limit my activity because I have asthma?

No and yes. First of all, asthma is very treatable. If you can’t do your normal activities or are unable to exercise as much as you want, then there is something wrong with your asthma treatment program. There are Olympic athletes (e.g., Jackie Joyner-Kersey) who have significant asthma! In general, there are very few activities that asthmatics need to avoid (e.g., SCUBA , see below).

So, having asthma is no excuse for being a couch potato . It is a shame that some asthmatic children are kept from physical education classes or recess, because they are not being treated appropriately for their asthma. In fact, some experts theorize that inactivity can, over the long run, worsen asthma.

If your asthma is not under control , then you should limit your activity briefly until you can get treated adequately by your doctor. It is the rare asthmatic who has such severe symptoms that they must limit their activity despite maximal medical treatment.

How do I know if my asthma is serious?

Most agree that you should consider getting specialist care for your asthma with an Allergy/Immunology or a Pulmonary physician in the following instances:

1.	You have been hospitalized (kept overnight in the hospital) for your asthma in the recent past.
2.	You are chronically taking oral steroids (pills or syrup) for your asthma.
3.	You are chronically taking more than 2 different types of medications for your asthma.
4.	You have been to the emergency room for asthma more than once or twice in the past year.
5.	You are going through more than one bronchodilator inhaler each month.
6.	You are missing work, school, or not sleeping well regularly because of the asthma.

Do allergy injections (allergen immunotherapy) work for asthma?

Scientific evidence shows that immunotherapy does improve asthma in allergic patients, as shown in a recent meta-analysis (a statistic analysis of many studies pooling all the information from hundreds or thousands of patients) in the pulmonary journal The American Review of Respiratory and Critical Care Medicine. Although some recent studies have shown that immunotherapy is not necessarily better than full medication treatment for asthma, these allergen injections will often lessen the amount of medication needed to control asthma. These injections are a great choice for those patients who don’t comply well with medications, those who don’t want to rely too much on medication, and especially for those patients who also have allergic rhinitis ("hay fever"). Allergen immunotherapy in appropriately selected patients should improve allergic rhinitis and asthma symptoms, and decrease the requirement for medicating both conditions.

What about theophylline-based medications (Theo-dur, Slo-bid)?

This type of oral medication is effective in treating asthma, particularly nighttime asthma. Some asthma specialists believe that the side effects of these medications have made them a bit obsolete, especially since long-acting bronchodilator inhalers are now available.

What about the new leukotriene drugs (Accolate, Zyflo)?

These oral medications, recently released on the market, have also been shown to be effective in treating asthma. Some doctors are using them in mild to moderate asthmatics to replace or add to anti-inflammatory medications (see above). Because of some rare side effects of these medications, asthma experts aren’t sure where these drugs fit in the asthma armamentarium. They might be particularly beneficial for patients who are already on high doses of inhaled steroids, those who are aspirin sensitive ("allergic"), and those who have nasal polyps.

I’ve heard that antihistamines are bad for asthmatics - is this true?

I consider this an "old doctor’s tale." Some of the newer prescription antihistamines (Zyrtec, Claritin) have been shown in studies to be very safe in asthmatics - perhaps even making the asthma improve. There were studies done many years ago that suggested that older antihistamines (like some of the over-the-counter drugs available today) could worsen asthma. A recent meta-analysis showed that antihistamines do not increase asthma symptoms or decrease lung function in asthmatics. Indeed, many asthmatics have allergies, and I don’t believe that they should be denied the newer prescription antihistamines.

What different medical conditions can complicate asthma?

If your asthma is not well-controlled on a reasonable amount of medication, then you and your doctor should consider the following conditions which may worsen or mimic asthma symptoms:

1.	Sinusitis (sinus pain, thick post-nasal drip, nagging cough)
2.	Gastric reflux (usually manifested by heartburn, but sometimes only by cough)
3.	Certain hypertension medications (ask your doctor if you are on a beta-blocker or ACE inhibitor)
4.	Vocal cord dysfunction (a disorder of the larynx than involves involuntary spasm of the vocal cords)
5.	Other lung disorders besides asthma

Are over-the-counter (O-T-C) asthma inhalers safe?

This is a very complex and controversial question. There is no doubt that the common over-the-counter (O-T-C) bronchodilator inhalers and tablets (those containing epinephrine [adrenaline] or ephedrine) are effective for treating acute asthma symptoms. One problem is the side effects with these medications; as they can cause nervousness, insomnia, and fast heart rates among others. Older patients are at more risk with these O-T-C medications because of their effects on the heart. Although the effectiveness of prescription bronchodilators (e.g., inhaled albuterol) are about equal to the O-T-C types, they usually have less side effects. The important issue is whether a particular patient needs anti-inflammatory medicine in addition to their bronchodilator.

I believe a major problem with over-the-counter asthma medications is that it permits sufferers to treat the asthma on their own, without the advice of a physician. The same person can buy an O-T-C inhaler every other day, and no one will raise an eyebrow. If a person is on a prescription inhaler, the doctor and his staff will be aware when the patient is requiring too much bronchodilator and be able to take appropriate action (i.e., start anti-inflammatory treatment).

Getting to the point, I believe that asthma fatalities are more due to under-treatment with anti-inflammatory therapy (e.g., inhaled steroids) rather than to the overuse of O-T-C bronchodilators. That is, the seriousness of their asthma and lack of proper medical care led to their demise. However, O-T-C bronchodilators do have their place . For the asthmatic with very mild, infrequent symptoms and no other significant medical problems, these drugs are probably fine.

Will my child inherit my asthma or allergies?

There’s no doubt that there is a genetic component to allergies and asthma. Chances are that the tendency to be allergic will be passed down the line if both parents are allergic. However, the manifestations of the allergy are not necessarily inherited. That is, you may have asthma and your child may end up with allergic rhinitis ("hay fever"). Also, you may be allergic to cats, where your child may only wind up allergic to dust mites. If you are allergic, it is a good idea to limit your child’s exposure to common indoor allergens as soon as they’re born - a strategy that may prevent them from developing problems with allergy as they grow up. This might entail removing carpeting and/or using plastic mattress encasements (for dust mites) or even finding a new home for the family cat (or at least keeping it out of the child’s bedroom).

What is the treatment for exercise-induced asthma?

Two prescription medications, albuterol and cromolyn (see above), are recommended for the prevention of exercise-induced asthma symptoms. Usually, they are taken 15 to 30 minutes before exercise. Albuterol is thought to be the most effective in this regard. Long-acting bronchodilators are also thought to be helpful for prolonged exercise (e.g., more than 4 hours).

Can I go SCUBA diving if I have asthma?

This is another controversial question. Most asthma specialists would say that if you currently have symptomatic asthma, even if it’s well-controlled on medication, you shouldn’t dive. Some experts even go as far to state that even those with asthma in remission shouldn’t dive. There is still a some research to be done in this area.