William Berger (Allergist and Immunologist) gives expert video advice on: How is asthma treated?; How important is it to identify my asthma triggers?; What side effects should I expect from my asthma medication? and more...
How is asthma treated?
The approach to the treathment of asthma and other allergic disorders is a three fold approach. First is to identify the triggers and do everything we can to avoid those triggers, whether they be allergic triggers or non allergic triggers. Second is medications, which are very effective, and third is immunotherapy when patients aren't completely controlled by avoiding their triggers, and the medications that are given. Immunotherapy is another term for allergy shots. The medications certainly are extremely important when you are dealing with a chronic disease such as asthma. An asthma treatment essentially falls into two classes of medications; controller medications: medications that need to be taken on a regular basis to control their symptoms with these medications, and the other, what we refer to as rescue medications: medications that are needed when the patient is having severe symptoms despite the use of their controller medications. It's important that the patients understand which are their controller medications and which are their rescue medications and use them appropriately.
How important is it to identify my asthma triggers?
It's extremely important to identify the triggers of asthma. Asthma's symptoms are relatively easy to recognize, but the triggers may be more difficult. Coughing, wheezing, shortness of breath is a symptom of the disease, and so if you can't find out what's triggering it, whether it be viral infections, whether it be allergens, whether it be even something as unusual as reflux, gastroesophoginal reflux, heartburn, then you're never going to get better. You're going to just need to take more and more medicine and wonder why your condition is not improving.
What are "asthma inhalers"?
Respiratory medicine - asthma inhalers - is very unique in that opposed to other treatments of other diseases, not only is the medication important, but the delivery of the medication is just as important. There are essentially three types of inhalers: One is what we refer to as a “metered-dose” inhaler. That's an inhaler where the medication is in a canister. You press down on the canister and a propellant that is either Freon or a non-Freon propellant pushes the medication out of the canister, through the plastic sleeve, and into your mouth and lungs. That requires a very coordinated effort to use properly. There's a second type of inhaler called a “dry powder” inhaler, and in that situation there's a dry powder reservoir or a little packet that you then break, and then breathe in the powder. That requires a type of inhalation that is very rapid and gets into your lungs. If you don't breathe it in rapidly enough it won't get all the way into the periphery of the lungs. The third inhalation device is what we call a “nebulizer”, where there's a nebulizer connected to a compressor, and the medicine is put into an aerosol form and the patient slowly breathes it in. That requires less coordination and very often we use this type of delivery system in infants and young children who can't coordinate the use of the metered-dose inhaler or the dry powder inhaler. What's most important when you use a nebulizer is that you use a proper-fitting mask or mouthpiece and that the patient has it tightly on their face. If not, if there's any leakage of the medication, the patient won't get it properly.So it's important when you get a prescription for any of these types of delivery devices that you have a doctor or nurse show you how to use it properly so you get the maximal benefit from this treatment.
What are "controller asthma medications"?
Asthma medications fall into two major classifications. The first major classification are what we refer to as controller medications, and just like their name they control the asthma. They in most cases have to be taken on a regular basis, and treat the underlying cause of asthma which is the inflammation. The most common types of controller medications are the inhaled corticosteroids. These medications are great advances in the treatment of asthma because the number of patients who are under very good control with inhaled corticosteroids has made a dramatic improvement in our ability to control this disease. There are other controller medications. Another class are called the leukotriene modifiers; these are usually in tablet forms that help to decrease some of the inflammatory process, but are not as effective as the inhaled corticosteroids. There are other medications called nedocromil and cromolyn that are what we refer to as mast cell stabilizers which help to stabilise the cells. However, without any doubt, the inhaled corticosteroids are the most effective controller medications. The bottom line is, ask your doctor which is the best controller medication for your type of asthma, especially you have persistent asthma. You are not going to be symptom free unless you are on a controller medication on a regular basis.
What side effects should I expect from my asthma medication?
Fortunately, the majority of asthma medications are very safe and very well tolerated. When we have asthma patients who use inhalers, especially inhalers that contain inhaled corticordsteriods, we always advise them to rinse their mouth out and spit out the water so that they won't have any residual medication in their throat. Inhaled corticordsteriods in the throat can sometimes lead to thrush or yeast infection. Although a very rare complication, it's important that patients know that they should rinse their mouth and throat out after they use their medications. The other side effect that asthma patients very often will complain about is with the short acting, quick-relieve medications that are the inhaled bronchodilators. Inhaled bronchodilators stimulate a certain part of the nervous system that dilates the airway. Unfortuantely, that same nervous system also speeds up the heart and makes you a little bit jittery, so we tell asthma patients to be prepared for the fact that if they are using their quick relieve medications, they may feel a little jittery or jumpy for a short period of time. The third side effect that we are concerned about involves patients with severe asthma that have to take oral corticordsteriods, as opposed to inhaled corticordsteriods. Oral corticordsteriods certaintly do have side effects because they get into the blood stream and they stay within your body. We try to minimize those side effects, such as increased water retention and difficulty sleeping, by using these medications very sparingly and for short periods of time.
What is a "relief", "quickrelief" or "rescue drug"?
Rescue medications are usually quick relief medications that are given in a metered dose. An inhaler, it can be given by injection, or they can also be given by nebulizer. These are what are referred to as bronchodilators. They dilate the airways. Very commonly these medications are called "albuterol" or by their brand name such as Proventil or Ventolin. There are also quick-relief medications that people can buy over-the-counter, but these contain epinephrine, which is really a dangerous drug. In fact, this is one of those situations where the prescription medication is actually safer than the over-the-counter medication. Patients very often make the mistake that if you could buy something over-the-counter, it must be safer than something you need a prescription. In this case, it is safer to take the prescription medication, but what's important is that if patients are using these quick-reliever medications more frequently than twice a week, then they need to talk to their doctor because it sounds like they may need to be on a controller medication that would then reduce their need for the rescue medication.
What are the benefits of an "inhaled corticosteroid"?
Inhaled corticosteroids have become, for physicians who treat asthma, the most important medication to not only control the asthma but many doctors believe that the use of inhaled corticosteroids can prevent the deterioration of asthma. In asthma, you have chronic inflammation and normal cells are replaced by inflammatory cells and normal tissue eventually could be replaced by connective tissue or scar tissue. It doesn't function the way normal respiratory tissue should function.
Can I overdose on my inhaler?
With a quick relief medication, such as bronchodilators, very often patients, when they're having difficulty breathing, feel if they could just continue to use the bronchodilator over and over again that the asthma attack would go away. In fact, the more often you use that quick relief bronchodilator rescue medication, the more likely you are that you're going to get worse and worse and worse. So not only will you have side effects--increased heart rate, increased jitteriness, maybe even an increase in your blood pressure--but you may be actually delaying the onset of the appropriate treatment for the severe asthma attack. So if your medications at the recommended doses are not working, seek medical attention. Taking more of the medication is not going to relieve your problem.
How do "allergy shots" treat asthma?
One of the things that doctors will suggest is using immunotherapy. Immunotherapy is the medical term for allergy shots - immuno meaning affecting the immune system and therapy is a form of treatment. What allergy shots do is prevent the allergic reaction from occurring. It causes the production of blocking antibodies and decreases the sensitivity of the cells. As a result, it allows patients to be able to breathe normally even when there is pollen, dander, dust or dust mites in the air. In many cases allergy shots have been so successful that many asthma patients are able to decrease their medications in terms of the amount and the frequency of the medication and can go through spring or fall without having an asthma attack.
What is a "dry powder inhaler"?
Dry powder inhalers are a new delivery system that has been used in the last ten to fifteen years here in the United States that allows patients to breathe in the medication without a freon propellant. Dry powder inhaler is an alternative form of inhaling medication. It comes usually in little packets or in multi-dose reservoir systems. And it requires that the patient put it in their mouth but the thing that they have to remember is they have to breathe it in very fast. There has to be a fast inspiration, because the dry powder has to get all the way into the periphery of the lungs. Dry powders are very effective if they're used properly and not only are controller medications administered this way, but there are some rescue medications. But the majority of these dry powder inhalers are mainly to administer inhaled corticosteroids.
What are "corticosteroids"?
Corticosteroids are very commonly used to treat asthma. In the majority of cases, the corticosteroids are given in an inhaled form, which have minimal side effects. There are corticosteroids that are given orally, or by syrup, tablet or injection, that are systemic, and do have side effects. Corticosteroids are very effective in decreasing inflammation. They're not only used in asthma, but in other diseases where inflammation is a major problem.
What are "bronchodilators"?
Bronchodilators are by their very term medications that dilate, relax or widen the airways. Bronchodilators come in many different forms and formulations. Bronchodilators come by injection, they come by syrup, they come by tablet, and they're most commonly used in inhaled form. There are inhaled bronchodilators that are short-acting and there are inhaled bronchodilators that are long-acting. The type of bronchodilator that you use and the formulation that you use should be tailored to your particular condition and should be appropriate for the type of problem that you had. That can be only achieved by discussing the medication with your doctor and using it as prescribed. Overusing bronchodilators is unfortunately a common reason why people end up in the emergency room in the hospital, so don't be one of those patients.
What is a "holding chamber" or "spacer"?
A spacer is any device that creates a space between the opening of the inhaler and your mouth. As I mentioned, when the medicine in a meter-dose inhaler comes out, it comes out at 8 to 9 miles per hour. Most of it's going to impact in the back of your throat and never make that turn into your lungs. What a spacer does is it creates a space so that the velocity of the particles coming out slows down so that by the time that space between the inhaler and your throat is reached, the particles are going at a much slower velocity and can make the turn. It, therefore, causes less problems with the throat. Now we use the term spacer for any type of space. It is not the same thing as a holding chamber which has a much larger volume and allows the medicine to stay in that chamber and then allows you to then, or your child, to then breathe in at a slower rate and allows a patient to use a meter-dose inhaler but doesn't have to have the coordination to breathe in the exact moment that the inhaler spits out the medicine. But it's really important when you use holding chambers that you don't wait more than a second or two from the time you spray it out 'til the time you get it into your lungs or you're gonna lose a lot of the medications that actually end up on the inside lining of the holding chamber.
What are "beta-agonists"?
The bronchodilators that we use are in a chemical classification called "beta-agonists". "Beta-agonists" mean that these are medications that stimulate the beta receptors. The beta receptors are receptors that are found in many organs of the body. They are found in the lungs, and these receptors cause dilation or opening of the airways. That's why when we use a "beta-agonist" we're stimulating the beta receptor in the lung, specifically in the bronchi (which are the airways), to open up. Beta receptors are also found in the heart and in the blood vessels. So, as a result, very often one of the side effects of using a "beta-agonist" is that it stimulates the heart, in terms of increasing the strength and the frequency of the heartbeat, and in some cases can actually increase the blood pressure.
What is "albuterol"?
Albuterol is the most commonly prescribed of the beta-agonists that we use in treating patients with quick reliever medications. Albuterol comes in many different formulations. The most common formulations are in the metered dose inhalers. Albuterol is a drug that is prescribed to all asthmatics, whether they have intermittent asthma or mild, moderate or severe persistent asthma. It is the most common rescue medication used. It is also available in nebulized form, so we also give it to infants. The important thing to understand with albuterol and other beta-agonists is they need to be used properly. They can be used not only as a rescue medication, but very often are effective when given 15 to 20 minutes prior to exercise to prevent exercise-induced asthma.
What are "cromolyn" and "nedocromil"?
Cromolyn and nedocromil are two medications that are classified as MAST cell stabilisers. The way they work is they prevent the MAST cell from releasing the chemical mediators of inflammation, in other words, the cell is stabilized so that it doesn't release the histamines, the leukotrienes and the other chemicals that cause the allergic and asthmatic response. The problem with cromolyn and nedocromil is that they are not as effective as the inhaled corticosteroids. They have to be taken several times a day. Cromoyln is available in a dry powder inhaler, in a nebulised form, and also in a metered dose inhaler. Nedocromil is only available in metered dose inhalers. These drugs were used many years ago before inhaled corticosteroids became more available to physicians.
What is "ipratropium bromide"?
Ipratropium bromide is a medication referred to as an anticholinergic medication. Essentially, this medication is available in a meter dose inhaler, and in a nebulized form. The anticholinergic medications are used in patients who might not respond to a betagonist, and that may be a patient, for example, who is on a beta blocker. Beta blockers are very commonly used for patients who have heart arithmeas, high blood pressure, or even migraines. And if a patient is having an asthma attack, and has a beta blocker in their system, then a betagonist may not work because it's being blocked, and so one of the medications that occasionally is used by doctors are these anticholinergic medications that work through a different mechanism to open up the airwaves.
What are "leukotriene modifiers"?
One of the chemicals that gets released in an asthma attack is a chemical called leukotriene. Leukotrienes are chemicals that cause bronchoconstriction, tightening of the airways. We used to refer to these chemicals as slow reacting substance of anaphylaxis, but recently they've developed a new name called leukotrienes. If we could somehow block leukotrienes, then we might be able to relieve the bronchospasm, the tightening of asthma. So there are new medications called leukotriene modifiers. They occur in tablet form, chewable tablet form, and there are several different brands. The key with leukotriene modifiers is that in the majority of cases these are add-on medications to patients who are already on inhaled cortical steroids. Rarely they're used as single agents because leukotriene is only one of many, many chemicals that cause the asthma reaction. So, as a result, leukotrienes will effect that chemical, leukotriene, but may not effect the other things that are going on in the inflammatory reaction, which is one of the things that inhaled cortical steroids can do.
What is "theophylline"?
Theophylline has been used for many years and is available in a serum form, in a tablet form, in a capsule form, even in intravenous working; it can go directly into the veins. It was used for many, many years but with the introduction of inhaled coriticosteroids which are much more effective drugs, theophylline use has fallen off considerably. In addition, theophyllline has what we call a very narrow therapeutic margin which basically means that you have to reach a certain level in the bloodstream for it to work, but if you go too high, you can have side effects such as nausea and vomiting and even seizures. So as a result, we tend to use theophylline very sparingly today, and it is very unusual with patients who are on inhaled corticosteroids that you have to add theophylline to their treatment.
What are the new advances in asthma diagnosis?
There is a tool on the horizon that should be available very soon that is called exhaled nitric oxide. When you have asthma you have inflammation of the cells that line your lungs. These cells produce a gas called nitric oxide which is a byproduct of inflammation. When the inflammation occurs the nitric oxide level goes up and this device measures that elevated level of nitric oxide. It helps the diagnosis of asthma to be made by the physician because there are a lot of reasons why people can cough and wheeze and this way you can diagnose that the patient has asthma. Even more importantly, the level goes down when the patient is being treated with inhaled corticosteroids and so we are able to tell if the medication is working and we're also able to tell if the patient is taking their medications. One of the things that I think we're going to see in the future which is not available quite yet is genetic testing for patients that will also help us to not only diagnose asthma but predict the severity of the asthma and even determine which medications will work for their particular type of asthma. There are certainly a lot of exciting things to look forward to and the future is bright for patients with asthma.