Asthma

1. What is Asthma? 
2. Asthma in the African-American community
3. Manifestations of Asthma
4. Classification of Asthma 
5. Factors that can trigger an Asthma Attack
6. Keeping Asthma under control
7. The Ten Commandments for Asthma patients
8. Resources for Asthma patients

• Chronic airway inflammation - meaning long-term puffiness and swelling of the airways of the lungs.
• Reversible airway obstruction - the obstruction is due to the tightening of the muscles around the airways.
• Airway hyper-responsiveness - meaning very sensitive airways that twitch easily and produce secretions when they get sensitized.
• Excessive mucus (secretions) in the lumen of the airways and this extra mucus can block the airways making breathing difficult.

Although one of these components alone can effectively narrow the breathing pipes; in reality what you find is a combination of these components, which leads to narrowing of the airways. This can make it hard to breathe. It is very important for both the healthcare providers and the patients to appreciate asthma via this new and expanded definition, since it now well established that for treatment approaches to work effectively in asthma patients, all these four components need to be addressed.

Asthma in the African-American community
Despite the development of new treatment options, asthma remains a major health problem in the United States. According to the National Heart, Lung and Blood Institute (NHLBI), about 15 million Americans have or carry a diagnosis of asthma. Asthma is the third leading cause of preventable hospitalizations in the United States. The disease inflicts a hefty economic and social toll on our society. It is estimated to cost the US taxpayers about $9 billion dollars in direct and indirect costs annually, while accounting for more lost school days for our children than any other chronic illness. About 500,000 hospitalizations and 5000 deaths occur annually from asthma, and the mortality rate continues to rise. This rise is especially dramatic in the African-American community, despite the absence of a known racial predilection for asthma. What is rather known is that blacks are twice as likely to die from asthma than whites, and one does not have to be a rocket scientist to understand that this racial difference in death rate from asthma is most likely secondary to socio-economic factors that limit access to healthcare and preventive information within the African-American community. This web site is an exercise in solving the latter problem. It is now well established that undertreatment and inappropriate treatments are the leading contributors to asthma morbidity and mortality in the United States. The African-American community, for reasons alluded to earlier, is the most affected from these two factors. These sobering statistics should convince all of us who care for asthma patients that we could be doing a better job.

Manifestations of Asthma
To understand the symptoms and signs of asthma, we need to review again the four components of the new definition of asthma:

• Chronic airway inflammation meaning long-term puffiness and swelling of the airways of the lungs.
• Reversible airway obstruction - the obstruction is due to the tightening of the muscles around the airways.
• Airway hyper-responsiveness - meaning very sensitive airways that twitch easily and produce secretions when they get sensitized.
• Excessive mucus (secretions) in the air tubes and this mucus is very thick and sticky, and can clog up the tubes making breathing difficult.

From the foregoing, the hallmark of asthma is narrowing of the airways, which results from a combination of these four mechanisms above. The typical patient has wheezing, difficulty breathing, chest tightness and coughing. These symptoms need not all begin at the same time or be present for asthma diagnosis. For some patients, these symptoms occur only with exercise - the so called exercise induced asthma. For other patients, persistent cough is the only symptom they have. Most people that have asthma often know the trigger factors that induce their asthma attack. In otherwords, they know the things that make their hyperresponsive airways "twitch", and in turn these airways go into excess mucus production leading to coughing spells and difficulty breathing due to narrowing of the airways. When asthma symptoms get real bad, the patients can become so breathless that they look frightened, sweaty, and have a very fast heart rate. As they are less and less able to breathe, they may have trouble talking. Their neck muscles may become tight as they breathe. The fingernails and lips might turn bluish or grayish in color. The skin around the ribs of their chests might be sucked in, and if the asthma continues to worsen, they may sometimes actually pass out. You really do not want patients getting to this extreme before intervening. The goal for asthma management is to prevent this late stage of the disease.

Classification of Asthma
Aware of the fact that asthma death rates continue to increase in the United States, and armed with the knowledge that inappropriate therapy and undertreatment are the major contributors to asthma morbidity and mortality, the expert panel of the NHLBI has provided us with improved classification and guidelines for asthma management. The most recent publication was released in 1997, and is the basis for the classification discussed below. The new classification and the accompanying treatment guidelines have been praised as being pragmatic and relevant to the effective management of asthma patients. It is hoped that the new grouping with the accompanying treatment guidelines, will help healthcare providers improve the asthma care they give and reduce the emergency department visits and admissions needed by their patients. We expect patients to demand application of the new classification and guidelines in their treatment programs. The new classification essentially makes it easy to choose the most appropriate treatment for each stage or step of the disease. It uses frequency of symptoms along with lung function tests to group the patients. Basically, the patients are grouped as either having Intermittent or Persistent asthma symptoms. Thus the Mild Intermittent Asthma patient has:

• Symptoms two or fewer times per week.
• Two or fewer times of night symptoms per month.

When symptoms are more frequent than above, it is called Persistent asthma. Depending on the frequency of the symptoms and the degree of abnormality of lung function tests, Persistent asthma category is further grouped into:

• Mild Persistent Asthma.
• Moderate Persistent Asthma.
• Severe Persistent Asthma.

It is extremely important to diagnose asthma early, classify the patient appropriately and tailor treatment programs stepwise using the classification above. It should be remembered that patients should be assigned to groups consistent with their symptoms, and it needs to be mentioned that individual patients may overlap groups with the patient's classification changing over time.

Factors that can trigger Asthma attack
One of the most important aspects of asthma management is recognizing the factors or agents that can trigger an asthma attack in a given individual. These factors that trigger asthma attacks do so by influencing one or more of the mechanisms that lead to asthma. For instance, when an individual with normal airways is afflicted with ordinary cold (upper respiratory tract viral infection), what you get is congestion, cough and mild discomfort. In contrast, when an asthmatic patient with hyperresponsive (i.e. "sensitive and twitchy") airways develops a similar infection, the airways go into spasm, get excessively inflamed and start pouring out tons of mucus inside the airways. The end result of all these processes is narrowing and clogging of the breathing pipes, which can lead to difficulty breathing, wheezing, chest tightness and cough. Thus it is very essential that both the healthcare providers and the patients remain vigilant in the search for trigger factors for asthma attacks in a given individual. In order to prevent asthma symptoms or an asthma attack, efforts should be made to eliminate or control the factors that make asthma worse. Some of the factors known to induce asthma attack or worsen asthma symptoms include:

• Tobacco smoke - Both nicotine (the chemical in cigarette) and smoke are irritants to the airways and should be avoided. Individuals with asthma should eliminate second-hand smoking both at home and public places. Having asthma and smoking cigarettes can be likened to pouring gas on a burning car! It is a no win situation.

• Allergens - common allergens include feathery or furry animals, cockroaches, pollens, dust mites and mold. Sometimes a skin test will suggest to your doctor know what you are allergic to. If you are allergic to any one of these things, it is essential that you stay away from it.
• Medication interactions - Certain medications are known to worsen asthma symptoms. Individuals with asthma should be familiar with these medications and avoid them. And it helps to remind any doctor treating you about your asthma condition, so they don't inadvertently prescribe these medications for you. Medications that are known, or have the potential, to worsen asthma symptoms include beta-blockers (commonly used for hypertension, heart diseases, and as eye drops for glaucoma), aspirin and aspirin like-drugs. When you need pain medication, stick to drugs that do not contain aspirin or aspirin-like drugs.
• Occupational chemicals - at the work place can be trigger factors for asthma symptoms.
• Strong emotions - from anger, playing video games, laughing, crying really hard etc., are all possible trigger factors for asthma.
• Environmental factors - sudden and dramatic changes in temperature and humidity.
• Respiratory tract infections - including common cold and flu. Annual flu shot is recommended for all patients with persistent asthma.
• Exercise - for some patients with asthma this is the only known trigger factor for asthma symptoms and taking a quick-relief medicine before exercise can help open the airways and prevent an attack.
• Sulfite sensitivity - sulfite is often a preservative in dried fruits, processed potatoes and wine. The key point here is that these factors and many more we have not even recognized, can worsen asthma symptoms and the burden is on the patients and the healthcare providers to be on the alert and avoid them.

Keeping Asthma under control
Aware of the fact that the major contributors to asthma morbidity and mortality are undertreatment and inappropriate therapy, it is only logical that treatment programs should aim to correct these two problems. Correcting them requires a constant reflection of these two aspects of the management, namely:

• Classifying the patient's disease early into one of the four groups: mild intermittent, mild persistent, moderate persistent and severe persistent asthma.
• Appreciation of the four components of the disease : inflammation, muscle spasm, airway hypersensitivity and excess mucus production.

There is no gainsaying the fact that it's only after we have applied this approach that we should expect any appreciable decrease in asthma morbidity and mortality. With this knowledge in mind, the expert panel of NHLBI recommends four components of therapy to keep asthma under control. Inherent in these four components of asthma control is the application of the knowledge of the mechanisms of the disease, along with the stepwise grouping noted above. The components are listed below and can be remembered with the mneumonic PACT (the mneumonic is mine). In other words, the asthma patient should consider being an equal partner with his/her doctor, and keeping the asthma under control should be an agreement (PACT) between the doctor and the patient. Let's not forget, it is not the doctor who is having difficulty breathing, it is the asthma patient.

The PACT between the asthma patient and the doctor will include:

1. Patient education for a partnership in the control of asthma

2. Assessment and monitoring of disease

3. Control of factors contributing to asthma severity

4. Treatment - appropriate medications

Patient Education

The goal of patient education is to assist patients take the actions necessary to control their asthma. The following points need to be addressed with patients during office visits or whenever they are hospitalized. The same attitude we have towards diabetic education as a major component of diabetes management, should be the approach towards asthma education. Emphasis should be made on these key issues:

• Taking medications as prescribed by physicians.
• Identifying and controlling trigger factors that make asthma worse.
• Using delivery devices effectively-nebulizers, spacers, metered-dose inhalers.
• Monitoring peak flow and assessment of their symptoms.
• Establishing written plans of action when symptoms or attacks of asthma occur.

Assessment and Monitoring of disease

One of the recommendations of the Expert Panel Report 11, published in 1997 by the National Asthma Education and Prevention Program is patient education and active participation. This is not surprising considering the fact that in similar chronic illnesses such as Diabetes and Hypertension (high blood pressure), the best outcomes are seen in patients who are well informed of their conditions and play active roles in their outpatient treatments. One of the objective and reproducible ways patients can play active roles in their keeping their asthma under control is by self-monitoring of their disease, using a device called the peak flow meter. This is a portable device that measures how well air moves out of your lungs. During use, the individual blows into the device, the exhaled air pushes a piston inside the meter up the scale. When the piston rises, it carries with it an indicator that shows a value, measured in liters per minute. When your peak flow number is high, it means your breathing pipes (airways) are open and you are breathing well. When your peak flow number is low, it means your airways are narrow and you may require help to breathe better. In fact, the real significance of these numbers rests not only in the fact that it can help doctors make important decisions about asthma treatments but when checked on a regular basis (preferably daily), it can help pick subtle changes in the airways even before the patient is aware of the symptoms of asthma. This is analogous to a diabetic patient checking their blood sugar levels at home.

Peak flow meters come in many different shapes and sizes, but they all basically measure the same thing - breathing. To use your peak flow meter correctly, you must remember to blow fast and hard into the peak flow meter each time you are using it. In an attempt to make the peak flow meters user-friendly, it is now common to use the term "peak flow zones" rather than numbers. Another reason for this zoning is the fact that there are really no set normal ranges for the numbers. Everyone's peak flow zones differ from others. Hence, healthcare providers should assist asthma patients define their peak flow zones, once their personal best peak flow numbers are determined. The zones help the patients and their physicians to check how well the asthma is being controlled. There should also be written specific plans of action that need to be followed for each zone. The colors used with each zone come from the traffic light. Just like the colors of a traffic light tell motorists what to do, the peak flow zones tell asthma patients what they need to be doing.

Green zone (The peak flow number is 80 to 100% of your personal best) - means GO! That is to say the patient is breathing fine and asthma is under control

Yellow zone (The peak flow number is 50 to 79% of your personal best) - means CAUTION! In other words, your asthma is getting worse. Plan of action: use your quick-relief medicine, stay away from trigger factors, and you may need to contact your doctor if you are not improving.

Red zone (The peak flow number is below 50% of your personal best) - means MEDICAL ALERT! In this situation, the plan of action is take your quick-relief medicines, and seek emergency medical help right away. This may require calling 911 depending on the situation. You can get into trouble if you wait too long to get help. This is how people die from asthma.

It is strongly recommended that every asthma patient who can be taught how to use a peak flow meter, regardless of the severity of their illness, should discuss the device with their doctor and be instructed on how to use it in monitoring their asthma outpatient management, using the zone system.

Control of Factors Contributing to Asthma Severity

Control and avoidance of all factors that worsen asthma is of paramount importance in the management of asthma patients. Most of the factors that worsen asthma have already been discussed in the preceding paragraphs. The key to achieving control of factors that make asthma worse is for the patients to be on the alert for trigger factors. When a factor has been identified, it needs to be clearly documented. Then ask your doctor or healthcare provider how to avoid or control these factors. For instance, if an asthma patient is known to have sensitivity to aspirin, there is a good chance the patient may have similar sensitivity to many other non-aspirin painkillers that are sold over the counter. Sharing this information with your doctor can be very helpful in choice of medications for you. So the key is, every asthma patient should always remind healthcare professionals about their medical condition to avoid getting medicines that can worsen their symptoms. For individuals whose asthma symptoms are worsened by occupational exposures, change of job may be necessary. Some patients may require allergy shots to control their asthma trigger factors. The expert panel of NHLBI recommends allergy shots in the following situations:

• There is clear evidence of a relationship between patient's symptoms and exposure to an avoidable allergen to which the patient is sensitive.
  
• Symptoms occur all year or during a major portion of the year, and
  
• there is difficulty controlling symptoms with medications.

Treatment/Medications for asthma control

• Quick-Relief Medicines

  The quick-relief medicines are used to provide fast relief to symptoms due to narrowed airways. Symptoms such as sudden onset chest tightness, wheezing, and difficulty breathing are best treated and relieved with these medicines. Think of these medications as rescue medicines for breathing problems. They work by primarily relaxing the "spastic muscles" of the airways. These medications come mainly in the form of inhalers or nebulizer treatments. Discuss with your doctor which medicines you need to keep in this category. For most patients with Mild Intermittent Asthma, (see the grouping mentioned earlier in the article), the only treatment they need for keeping asthma under control is the Quick-Relief medicine. For patients with persistent asthma, these Quick-Relief medications come in handy when they drop down to the yellow or red zone (i.e. their peak flow numbers drop below 80% of their personal best).

• Long-term Control Medicines

  This group of asthma medicines is used everyday usually on a long-term basis to keep asthma under control. They are able to accomplish this through their actions on reducing inflammation, clogging and hyperresponsiveness of the airways. Consider these medicines as symptoms preventers or airways protectors. These medicines come in the form of pills and inhalers. The key thing to remember is that the long-term control inhalers are not substitutes for the quick-relief inhalers. They have their specific role in asthma management but that role does not include being used as quick-relievers because they are not. In fact, when long-term control inhalers are used during an acute asthma attack, they can worsen asthma symptoms. In contrast, the pill or injection forms of some of the long-term control medicines (steroids to be specific) can be useful during management of acute asthma attacks, but again they are not first line of treatment. The quick-relief medicines remain the first line of treatment in acute attacks. Long-term control medicines are primarily designed for preventing asthma symptoms not for treating acute attacks. Virtually all patients with Persistent asthma (mild, moderate, and severe) should get some form of long-term control medicines on a regular, if not daily basis to prevent asthma symptoms and thus keep asthma under control. If you have asthma and your symptoms qualify you as having persistent asthma, and you are not using a long-term control medication, you need to ask your doctor why. In fact, the statement that " undertreatment and inappropriate therapy are major contributors to asthma morbidity and mortality in the United States", can accurately be said to refer to under utilization of long-term control medicines. Both patients and healthcare providers are jointly responsible for this. It is hoped that with patient education, establishment of goals of therapy and application of asthma therapy guidelines, we can improve this dismal state of asthma treatment in the United States, particularly in the African-American community where asthma deaths remain twice that of White Americans.

The Ten Commandments for Asthma Patients

1. Thou shall stay informed about asthma for the rest of your life.
2. Thou shall take your asthma seriously.
3. Thou shall try to find out your trigger factors and control them to the best of your ability.
4. Thou shall never smoke for as long as you live.
5. Thou shall have a peak flow meter, learn to use it and monitor your asthma with it.
6. Thou shall never run out of asthma medicines.
7. Thou shall be an active participant in your asthma treatment.
8. Thou shall call for help when your asthma symptoms don't improve.
9. Thou shall stay away from all medicines that can worsen your asthma.
10. Thou shall follow these commandments religiously and share them with other asthma patients.

Resources for Asthma patients

1. Asthma and Allergy Foundation of America - (1-800-727-8462).
2. American Academy of Allergy, Asthma, and Immunology - (1-800-822-2762).
3. American Lung Association - (1-800-LUNG-USA) - 1-800-586-4872 and their web site is http://www.lungusa.com

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