Course #3039 — 10 CONTACT HOURS Release Date: 11/01/09 Expiration Date: 10/31/12
Asthma:
Diagnosis and Management
Faculty Division Planner
Sharon M. Griffin, RN, PhD, specializes in Health Jane Norman, RN, MSN, CNE, PhD
Education and Chronic Disease Management especially
Division Planner Disclosure
as it relates to her primary areas of study and research.
The division planner has disclosed no relevant financial
She has over twenty years of healthcare experience
relationship with any product manufacturer or service
nationwide and is an accomplished author, presenter
provider mentioned.
and consultant. She frequently lectures on the subjects
of Attention Deficit/Hyperactivity Disorder (AD/HD), Audience
Obsessive-Compulsive Disorder (OCD) and related This course is designed for nurses and nurse practitio-
disorders. Dr. Griffin is the cofounder of the Univer- ners who may care for patients with asthma.
sity Center for Assessment and Learning (UCAL) of Accreditation
Andrews University in Berrien Springs, Michigan. CME Resource is accredited as a provider of continu-
She enjoys writing and teaching and has been listed ing nursing education by the American Nurses Cre
in Who’s Who in American Nursing, Two Thousand dentialing Center’s Commission on Accreditation.
Notable American Women, and the eleventh edition
of the World Who’s Who of Women, Cambridge, Designation of Credit
England. CME Resource designates this continuing education
activity for 10 ANCC contact hours.
Patricia Walters-Fischer, RN, BS, has worked in the
healthcare field since 1992. Starting out as a nurse’s CME Resource designates this continuing education
aide, she worked her way from LVN to ASN while activity for 12 hours for Alabama nurses.
working in several hospital units, including ICU/ CME Resource designates this continuing education
CCU and adult and pediatric trauma. During her activity for 2 pharmacology contact hours.
career, she worked at the busiest pediatric emergency
center in the country, Children’s Medical Center of AACN Synergy CERP Category A.
Dallas Emergency Room. While there, she cared for Individual State Nursing Accreditations
and educated asthmatic children and their caregiv- In addition to states that accept ANCC, CME Resource
ers. Ms. Walters-Fischer is also an honors graduate of is accredited as a provider of continuing education
Washington University, St. Louis, with a Bachelor’s in nursing by: Alabama, ABNP0353 (valid through
Degree in Communications and Journalism and has December 12, 2013); California, CEP9784; California
been writing for the past ten years in local, national, BVNPT Provider #V10662; Florida Provider #50-2405;
and international publications. Iowa, #295; Kentucky, 7-0054, Kentucky Board of
Faculty Disclosure Nursing approval of an individual nursing continuing
Contributing faculty, Sharon M. Griffin, RN, PhD, has education provider does not constitute endorsement of
disclosed no relevant financial relationship with any program content; Texas, ANCC/Type I Provider.
product manufacturer or service provider mentioned.
Contributing faculty, Patricia Walters-Fischer, RN, BS,
has disclosed no relevant financial relationship with any
product manufacturer or service provider mentioned.
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 3
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
British surgeon John Hutchinson developed the stricting the airways and filling them with mucus;
first spirometer in about 1850. It was originally constricted airways interfere with the movement
intended for his research in respiratory physiology, of air in and out of the lungs, making breathing
as a tool to measure respiratory flow rates. Soon, difficult [8].
smaller devices were being widely used by patients Asthma is marked by recurrent episodes of wheez-
with lung disease in Europe, Australia, and the ing, breathlessness, chest tightness, and coughing.
United States [5]. Usually, these periods are associated with wide-
By the end of the 19th century, many companies spread but variable airflow obstruction followed
were shipping asthma “medications” all over the by a period of relief, either spontaneously or in
country and around the world. These were in the response to treatment [9]. Asthma has many puz-
form of powders, tablets, and liquids and often zling aspects, and its symptoms may wax and wane,
times labeled as secret formulas. It was not uncom- especially seasonally [8]. Unlike other respiratory
mon to find alcohol, cocaine, and/or morphine as diseases, such as congestive obstructive pulmo-
active ingredients. Until the late 20th century, nary disease (COPD) and emphysema, in which
inhaling medications via steam or smoke was one of air trapping and hyperinflation of the lungs also
the only ways of introducing medications directly occur, asthma is reversible with the use of proper
into an asthmatic’s bronchial tubes and lungs [5]. medications and therapies. Long-term lung tissue
damage can occur when asthma attacks occur
frequently or the disorder is poorly controlled.
DEFINITION Permanent damage would require many instances
of severe attacks.
Since 1958, several attempts have been made to
establish a consensus definition of asthma. The last
of these was published in August 2007 as part of EPIDEMIOLOGY
the National Asthma Education and Prevention
Program (NAEPP) “Guidelines for the Diagnosis Global Impact
and Management of Asthma” [6]. Asthma was not The World Health Organization (WHO) estimates
recognized as a specific disease with a single cause.
that 300 million people worldwide suffer from
Instead, asthma is considered to be a “condition”
asthma. In 2005, asthma was the cause of death
and an incompletely understood abnormality. of 255,000 individuals [11]. The incidence and
Asthma is considered a chronic, albeit reversible, severity of the condition varies globally.
respiratory disorder. Inflammatory in nature, the Although for many years asthma was characterized
condition produces hyper-reactive and hyper- as a condition limited to industrialized countries, it
responsive airway and lungs, causing episodic, has now been identified as a health issue in devel-
reversible airway obstruction through bronchos- oping countries as well. Nearly 40 million people
pasms, increased mucus secretions, and mucosal in Central and South America have asthma. In
edema [7; 8]. An asthmatic’s hyper-reactive lungs Mexico, there was a sharp increase in asthma cases
are more sensitive than most individuals’ and may in the 1990s; however, that rate has since started
become inflamed or edematous when exposed to to decline [50]. The countries of Brazil, Paraguay,
irritants, such as cold air, animal dander, dust, Peru, and Uruguay all have childhood asthma
tobacco smoke, or grass [8]. The asthmatic’s prevalence rates in the top quartile of countries
immune system overreacts to these irritants, con- worldwide [10]. More than 80% of asthma deaths
occur in developing countries [11].
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 5
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
diet for 14 weeks, during which time pulmonary
RISK FACTORS function was regularly tested. At the end of the
14 weeks, the subjects had a mean weight loss of
Although experts have been unable to definitively
31.2 pounds and a 7.2% improvement in their
identify the cause or causes of asthma, there are
pulmonary function tests [19].
several factors that increase the risk of developing
the condition in one’s lifetime. Identifying possible Unless contraindicated, moderate exercise is
risk factors specific to certain patients may allow encouraged for all people with asthma, as it
lifestyle changes or more strenuous observation of strengthens the lungs and improves respiratory
symptoms for better control of asthma symptoms. function. Those patients whose asthma is triggered
Overweight/obesity, heredity, and low birth weight by activity may be advised to take a short-acting
have all been linked to the development of asthma. beta2 agonist or other bronchodilator 30 minutes to
Additional risk factors include living in an urban 1 hour prior to exercising. Regular aerobic activity
area, exposure to secondhand smoke, exposure to is essential for any asthmatic, taking into consider-
occupational triggers (such as chemicals used in ation contraindications or complications.
farming and hairdressing), respiratory infections Asthma and obesity present a unique problem with
in childhood, and gastroesophageal reflux disease pediatric patients. With the growing number of
(GERD) [16]. both overweight and obese children and instances
Overweight and Obesity of asthma in the United States, it has been theo-
rized that the rise in obesity in children has contrib-
There have been many studies indicating a link
uted to the rise of asthma. Studies have concluded
between obesity and asthma in adults and children.
that overweight children are 1.5 to 2 times more
Research indicates that being overweight or obese
likely to develop asthma than other children [20;
significantly increases one’s chances of developing
21]. The causative link between obesity and asthma
asthma. Studies have shown that an overwhelming
remains unclear, but the sedentary lifestyle may be
majority, approximately 75%, of asthma patients
a risk factor for both asthma and obesity. Further
who seek emergency medical care are obese [17].
research is underway to determine the impact of
Patients who are excessively overweight place an
obesity on pediatric lung development and possible
additional burden on their bodies, especially on
implications in the development of asthma.
their heart and lungs. Researchers in one study
found that both functional residual capacity (the Genetic Predisposition/
amount of air left in the lungs after exhalation) and Family History
tidal volume were decreased in obese individuals A genetic predisposition to develop immunoglobu-
[18]. These decreases were associated with several lin E (IgE) antibodies has been shown to increase
factors, including changes in lung development and the incidence of allergy and asthma. However,
chronic systemic inflammation, that may affect, since the mapping of the human genome has been
induce, or exacerbate asthma symptoms. completed, additional genetic factors contribut-
Additional studies have revealed that weight loss ing to the development of asthma have been
can increase respiratory function. In one random- recognized. The first gene associated with asthma
ized, controlled study, conducted by the Division susceptibility and airway hyper-responsiveness,
of Pulmonary Medicine and Allergology, Helsinki ADAM33, was mapped in 2002. Researchers at
University Central Hospital, subjects with a body Channing Laboratory, Brigham and Women’s
mass index (BMI) between 30 and 42 and a diag- Hospital in Boston, were able to link variants of
nosis of asthma were studied for the effect that a this gene to a familial history of asthma and asthma
controlled diet had on their experiences of asthma symptoms. In 2003, two more genes relating to
symptoms. Participants were placed on a regulated asthma, PHF11 and DPP10, were identified [22].
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 7
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Deep inside the lungs, surrounding each bronchi- When the inflammatory cascade, the physiological
ole, are millions of tiny balloon-like air sacs called process of an asthma attack, is not treated, rebound
alveoli. These structures provide the environment of acute symptoms can occur, resulting in extreme
for the exchange of gases, allowing oxygen from damage and potentially permanent scarring.
inhaled air to pass into the bloodstream through Inflammation is a process involving the immune
the capillaries within the sacs [8]. system’s reaction to what it identifies as foreign
Asthma is considered a disorder of exhalation, not or harmful items. The immune system consists
inhalation. Patients with asthma are uncomfort- of three primary components: the thymus gland,
able not because they cannot inhale enough air, lymph nodes, and bone marrow. These parts pro-
but because obstructed airways are preventing duce two major types of blood cells: red blood
them from exhaling the air that is already in their cells, which transport oxygen from the lungs to the
lungs. In fact, autopsies of patients who died of tissues of the body, and white blood cells, which
asthma complications have revealed lungs full of defend the body against invasion and infection.
air [8]. When bronchioles narrow during an asthma Lymphocytes, a type of white blood cell, are divided
attack, upstream obstruction causes premature clo- into two categories: B cells, which manufacture
sure of airways with expiration, as pleural pressure
antibodies or immunoglobulins that identify for-
becomes greater than the pressure inside the airway
eign contacts as harmful agents, and T cells (from
(the equal pressure point, or EPP). Downstream the thymus gland), which release chemicals known
airways become compressed with expiration, trap- as cytokines that kill the invading antigen [8].
ping air in the alveolar sacs. Reduced respiratory Antibodies aid the immune system in recogniz-
muscle efficiency and function can be caused by ing organisms that have infected the body in the
lung hyperinflation and thoracic hyperexpansion, past, allowing the immune system to fortify and
resulting in air trapping. Respiratory muscle advan- strengthen the body against future invasions by
tage is compromised, and the flattened diaphragm the recognized antigen [8].
is forced to contract with shortened muscle fibers,
resulting in a feeling of chest tightness. This
can lead to airway rupture, manifested as pneu- PATHOgenesis OF ASTHMA
mothorax, pneumomediastinum, or subcutaneous
emphysema. The pathogenesis of an asthma attack can be best
described as an inflammatory cascade composed
Inflammation and of triggered, acute inflammation and chronic
the Immune System inflammatory changes. In a nonasthmatic body,
The most common features of asthma are inflam- the immune responses in the bronchi (swelling,
mation and edema (swelling) of the airways, excretion of mucus, recruitment of inflammatory
and treatments have focused on the connection cells, etc.) are present in a lesser degree to protect
between inflammation and asthma since the the body against any infectious agents or foreign
mid-1980s. At that time, researchers developed objects. However, an asthmatic’s system produces
fiber-optic bronchoscopes, with which they were an extreme reaction to otherwise relatively harm-
able to view the lungs (and take samples of airway less irritants, referred to as asthmagens or triggers.
tissues) of those with chronic asthma [8]. With this Exposure to a trigger causes inflammatory mast
advancement, researchers concluded that airway cells to release specific inflammatory mediators,
inflammation in asthmatics never clears, even including histamine and interleukins, resulting in
with mild asthma; therefore, treatment focusing an acute response. Histamine causes local tissue
on inflammation reduction was determined to be edema; interleukins generally act as chemotactic
the most effective for long-term management [8]. factors and activate other inflammatory cells.
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 9
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Excess Mucus Note with importance that a patient with severe
Inflammation can produce excess mucus as a asthma has acute airway inflammation during an
protective mechanism. During an asthma attack, episode, and as stated previously, patients with
glands secrete excessive amounts of thick mucus to chronic asthma have continuous symptoms of
compensate for the increased amount of irritants airway inflammation, which can eventually destroy
or allergens. The excess mucus clumps together in airway tissue and alter lung function. Prolonged
the airways, further narrowing the bronchial tubes inflammation may result in permanent obstruc-
by partially blocking the passageway and hindering tion as a result of alteration of the bronchial walls.
breathing. This increased amount of mucus can Unfortunately, after this change occurs, the airways
also form plugs that clog very small airways. During may not respond to common treatment as quickly
an asthma episode, some patients attempt to clear or at all, which is the reason medication to reduce
their airways by coughing up what seems to be a airway inflammation, subsequently preventing
mucous plug. However, patients may produce many permanent obstruction, is so important [8].
plugs; consequently, they may have a continuous,
Fatigue
irritating hacking cough. If left untreated, mucous
plugs can prolong asthma episodes and increase the Breathing with asthma can fatigue the body. As
risk of infection [8]. exhalation is blocked and air is trapped in the
lungs, more force is required to maintain adequate
Coughing oxygen supply. To aid in exhalation, accessory
When secretions become too thick for cilia to muscles become involved, which can deplete the
handle, the system responds by coughing to remove body of energy. Untreated asthma can produce
the unwanted substance. Dry coughs in asthmatic severe degrees of fatigue for the patient, and this
patients are generally the product of extra-thick can become a critical situation warranting immedi-
mucous plugs or bronchioles so blocked that the ate intervention [8]. Lethargy, decreased response
mucus cannot be removed or move through. Nasal time, and weakness are all late signs of fatigue.
and sinus drainage, a common symptom of aller-
gies, may also irritate airways and produce a nag-
ging, unproductive cough [8]. If a patient has been DIAGNOSIS
mouth breathing, the airways may become dry and
Physical Examination
have decreased elasticity, making it more difficult
and Patient History
to clear them. If this is the case, the patient should
be encouraged to take frequent sips of water or In some instances, a physical examination and a
isotonic fluids (electrolyte replacement drinks). thorough exploration of a patient’s medical his-
tory offer enough information for an accurate
Wheezing asthma diagnosis. There are several main criteria
Wheezing is considered to be a trademark of that must be present for a diagnosis of asthma to
asthma, but it is not a definite indicator. The be ascertained. It is vital that a history of episodic
wheezing sound associated with asthma results from asthma symptoms, characterized by airflow obstruc-
a forceful rush of air pushing through narrowed, tion, be established. Symptoms that increase the
constricted airway lumens. The surge of air causes probability of an asthma diagnosis include episodic
vibrations that make the wheezing sound. In some wheeze, chest tightness, allergic rhinitis, atopic der-
cases, airways can be so constricted that the air matitis, shortness of breath, and cough. It should
flowing past a blockage is not sufficient to produce also be noted if symptoms worsen at night or in
a wheeze. In very severe attacks, the absence of the presence of aeroallergens, irritants, or exercise.
wheezing is a worrisome sign. A family history of asthma, allergies, sinusitis, or
rhinitis is also an indication of potential asthma.
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 11
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Peak Flow Meter There are two main challenge tests that are use-
A peak flow meter measures the speed of exhala- ful in assessing a patient for a possible asthma
tion. The highest speed or best flow is referred to diagnosis. The first is an inhalational or chemical
as peak expiratory flow rate (PEF) or peak flow. challenge, whereby patients inhale a small amount
The peak flow meter is less sophisticated than a of either a suspected asthma trigger or one of two
spirometer, which provides a more thorough assess- chemicals: histamine, which occurs naturally in
ment of lung function. However, the meter has the the body and may induce asthma-like symptoms,
advantages of being less expensive, portable, and or methacholine, which is known to cause airway
easy to use. The severity of a patient’s asthma can constriction only in people with asthma [8]. After
be determined by careful and consistent monitor- exposure, spirometry is performed. If a reaction
ing of peak flow and comparing it to a patient’s best does not occur initially, the concentration of the
peak flow and to standard measurements. Studies substance is increased and spirometry is repeated.
confirm that short-term peak flow measurements The procedure is repeated until it is determined
assist healthcare providers in assessing asthma that there is no sensitivity or until FEV1 decreases
severity [8]. by 20%, which would be indicative of asthma.
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 13
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Although cystic fibrosis can be a multisystem ties resulting from cardiac problems. Conversely,
disorder, the respiratory system is almost always asthma can aggravate heart disease when oxygen
involved and tends to dominate the clinical pic- supplied by the lungs is inadequate for the reduced
ture. Common respiratory complications include blood supply to the heart. Any diseases or condi-
air trapping and wheezing, chronic cough and tions that may cause dyspnea are considerations
sputum production, retractions, tachypnea, and when determining a differential diagnosis of
recurrent or chronic pneumonia. However, the asthma.
earliest signs of cystic fibrosis can be gastrointesti- A particular form of an infection-plus-allergy
nal and pancreatic, not respiratory. Signs of cystic condition known as allergic bronchopulmonary
fibrosis include radiograph abnormalities such as aspergillosis, often shortened to aspergillosis or
bronchiectasis, atelectasis, infiltrates, and hyper- ABPA should also be considered [28]. The condi-
inflation. Therefore, a chest x-ray or computed tion initiates with the introduction of the fungus
tomography scan may be useful in determining the Aspergillus fumigatus, a mold that is abundant in
correct diagnosis, especially in children. damp straw, compost heaps, birdcages, and any
GERD decomposing material. A. fumigatus does not usu-
ally have an adverse effect on those with normal
Excessive mucosal secretion secondary to GERD or
immune systems [28]. However, in asthmatic
gastrointestinal malformation may cause wheezing
or immunocompromised individuals, the spores
in both children and adults and should be consid-
from this mold may begin to grow in the lung tis-
ered during evaluation. It is reported that 34% of
sue [74; 75]. An allergic reaction may then occur
patients with GERD experience chronic cough
in response to the fungus. This is an important
and/or wheezing as part of their symptomology
consideration for those who work in agricultural
[29]. Additionally, bronchiole irritation result-
occupations and is one example of the usefulness
ing from repeated exposure to gastric acid may
of a thorough history and lifestyle questionnaire in
trigger asthma symptoms. Generally, asthma-like
the diagnosis and management of asthma.
symptoms that stem from GERD can be controlled
with initiation of reflux medications and lifestyle ABPA may present comorbid with asthma or the
modification. similar symptoms may result in a false asthma
diagnosis [28]. The signs and symptoms of ABPA
Structural Issues include rubbery plugs of golden-brown or green
If respiratory difficulties are suspected to be more sputum; a fever apparent only when the asthma
of a structural issue, a bronchoscopy may be symptoms are severe; worsening symptoms despite
performed. This is especially important if con- treatment; dependence on steroid medications; and
genital abnormality, such as laryngomalacia or very high levels of serum IgE [28]. ABPA is nor-
tracheobronchomalacia, or tumors or growths are mally treated with steroids to control the allergic
suspected. It can also rule out foreign body aspira- reaction and with physiotherapy to clear the mucus
tion. Samples of tissue and sputum to be used in from the lungs [28].
additional testing may be taken during the proce-
There are also certain medications that may
dure, if necessary.
induce asthma-like symptoms. Specifically, there
Adult and Geriatric Concerns are two conditions, aspirin-sensitive triad and
In adults, CHF and other cardiac conditions, such nonallergic rhinitis with eosinophilia syndrome
as mitral valve disease, should be considered in (NARES), known for their similar presentation
the differential diagnosis of asthma. Establishing to asthma. The diagnosis of aspirin-sensitive triad
an asthma diagnosis is difficult for patients older is based on three distinct symptoms: perennial
than 55 years of age due to the increased incidence rhinitis, nasal polyps, and asthma. Patients with an
of CHF and “cardiac asthma,” respiratory difficul- aspirin-sensitive triad diagnosis tend to collect all
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 15
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
STEPWISE APPROACH FOR MANAGING ASTHMA IN PATIENTS 12 YEARS OF AGE AND OLDER
Step Preferred Treatment Alternative Treatment Indication
1 Short-acting beta2 agonist as needed -- Intermittent asthma
2 Low-dose inhaled corticosteroid Cromolyn, leukotriene antagonist, Persistent asthma
nedocromil, or theophylline (Consider subcutaneous
3 Either low-dose inhaled corticosteroid Low-dose inhaled corticosteroid allergen immunotherapy
and long-acting inhaled beta2 agonist AND either leukotriene antagonist, for patients who have
OR medium-dose inhaled corticosteroid theophylline, OR zileuton allergic asthma)
4 Medium-dose inhaled corticosteroid Medium-dose inhaled corticosteroid
AND long-acting inhaled beta2 agonist AND either leukotriene antagonist,
theophylline, OR zileuton
5 High-dose inhaled corticosteroid --
AND long-acting inhaled beta2 agonist
Consider omalizumab for patients with
allergies
6 High-dose inhaled corticosteroid, --
long-acting inhaled beta2 agonist,
AND oral corticosteroids
Consider omalizumab for patients
with allergies
Quick-relief of asthma exacerbations in all patients short-acting beta2 agonist, up to 3 treatments at 20-minute
intervals as needed. Short course of oral systemic corticosteroids may be needed. Use of short-acting beta2 agonists
>2 days a week for symptom relief generally indicates inadequate control and the need to step up treatment.
Source: [6] Table 2
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 17
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Some short-acting inhaled medications begin to the canister to remind themselves when to reorder
reverse airway constriction within 5 minutes; how- another inhaler [8]. In the past, some patients have
ever, long-acting medications have been developed utilized the so-called “float test” to determine the
in inhalant form as well [8]. Inhaled medications amount of medication remaining in the canister.
have advantages over oral administration because This has been proven to be inaccurate and should
the medication is able to enter directly into the not be recommended [36]. Some canisters may
lungs rather than through the circulatory system. require cleaning to prevent the accumulation of
Some MDIs discharge medication after a trigger is bacteria.
pressed, but newer versions are breath activated. Breath-activated dry powder inhalers incorporate
For patients with poor coordination or impaired the same benefits as other breath-activated inhal-
hand function, such as those with arthritis or with ers; patients are not required to coordinate inhal-
a history of stroke, breath-activated devices may ing with releasing medication. Some dry powder
improve medication delivery. The drawback of the inhalers have a different delivery system involving
breath-activated inhalers is that, during a severe the insertion of a capsule with medicated, fine
attack, a lack of air may make device triggering powder into the canister. In general, each capsule
difficult [8]. contains a single dose that equals two sprays of
Some patients require the assistance of a spacer medication (although double doses are available)
when using an inhaler. A spacer is a plastic tube [8]. One disadvantage of the dry powder is the
that attaches to an MDI; its function is to momen- amount of coordination needed to load the cap-
tarily trap medication as it exits the inhaler, allow- sule into some inhalers. This can be a problem for
ing the medication to be inhaled more easily and the young or elderly or for people with arthritis,
preventing it from being lost. Spacers may benefit Parkinson’s disease, or other neurological diseases
patients who find it difficult to squeeze the trigger affecting coordination or dexterity. Furthermore,
and inhale at the same moment, such as young depending upon the patient’s ability to breathe
children or older adults [8]. As medicine deposited in deeply, variable amounts of medication may
in the mouth area can produce side effects, spacers be inhaled. Another concern involves the effect
can help limit this and ensure that more medica- of humidity on dry powder, which may influence
tion reaches the lungs instead of the tongue or dose strength [8].
back of the throat. The nebulizer is a form of inhaler that acts as a
A major problem with MDIs is knowing when they vaporizer or humidifier, delivering microdroplets
are empty. Usually, a patient cannot see, hear, or of asthma medication in spray form and allowing
taste when a canister is empty or delivering less a patient to breathe it in through a mouthpiece
medication than intended; in fact, at times, inhal- or face mask. Larger doses from nebulizers may
ers may feel heavy enough to hold medication but increase the risk of side effects, and studies have
only contain propellant and preservatives [8]. In shown MDIs to be as effective as nebulizers in
some cases, empty inhalers may leave a strange delivering medication to the lungs [53; 54]. Nebu-
taste or heavier spray in the patient’s mouth [8]. lizers are used frequently in children as they are
easier to administer and provide more accurate
Each inhaler should have a label that indicates how
dosing. In the past, hospitals frequently provided
many measured metered doses the canister holds.
medication in nebulizers to treat emergency asthma
For regularly scheduled medications, it is best to
episodes, but now many facilities have converted
calculate the number of usable doses before a new
to the use of MDIs [8].
inhaler is needed. Patients may mark calendars or
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 19
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
usually taken twice a day and last up to 12 hours.
According to the National Asthma
Education and Prevention Program Expert Their longer action can help prevent interruptions
Panel, long-acting beta2 agonists are used in from nighttime symptoms and/or allow patients to
combination with inhaled corticosteroids engage in activities that they would otherwise be
for long-term control and prevention of advised to avoid.
symptoms in moderate- or severe-persistent
asthma (step 3 care or higher in adults and children However, even longer-acting beta2 agonists cannot
5 years of age or older). control unstable asthma. These medications are
(http://www.guideline.gov/summary/summary.aspx?doc_ unable to reverse the chronic airway inflammation
id=11674. Last accessed September 16, 2009.) found in asthma patients, necessitating the addi-
Level of Evidence: A (randomized controlled trials, tional use of an anti-inflammatory drug to prevent
rich body of data) and B (randomized controlled trials, symptoms in the long-term [8]. And, as discussesd,
limited body of data)
overuse of these medications can lead to poor
asthma control and possibly desensitization.
Beta2 agonists may cause negative side effects, espe- Theophylline Derivatives
cially if fast-acting forms are taken too frequently Before inhalers became widely available, meth-
for too long. Overuse can lead to poor asthma ylxanthines were the leading asthma medications.
control and possibly desensitization. Inhaling more They could be administered intravenously or
than one canister a month indicates an excessive orally. Theophylline was formerly the most widely
reliance on bronchodilators to improve asthma. prescribed bronchodilator in the methylxanthine
Patients with severe asthma may prefer a beta2 category and a keystone of asthma treatment in
agonist for quicker action than anti-inflammatory the United States. However, controversies over
medications, which take days to act. However, the medication’s benefits and action have clouded
patients may then expose themselves to potentially its popularity [8]. Exactly how theophylline works
fatal attacks due to decreased beta2 agonist effec- in the lungs remains unclear. Some believe that
tiveness if asthma flares out of control [8]. theophylline inhibits mast cells in the airway lin-
Inhaled beta2 agonist medications are associated ing from discharging chemicals, such as histamine,
with fewer major side effects than orally adminis- which suppresses the cell migration that triggers
tered beta2 agonists. However, patients who use allergic asthma symptoms [31]. Theophylline may
inhalers may report problems as well. The most also relax airway muscles, allowing the tubes to
common complaint is shakiness; other noticeable open and airflow to continue [8].
side effects may include tachycardia, heart palpi- Theophylline provides a short- and long-term
tations, headache, dizziness, and increased serum alternative for patients who cannot tolerate beta2
glucose [30]. These side effects tend to diminish agonists. The drug reduces mucus buildup and
over time. Patients using oral beta2 agonists have blocks nighttime symptoms in mild-to-moderate
reported tremors, nervousness, tachycardia, muscle asthma. Its long-term benefits for preventing
cramps, and sleeplessness [8]. symptoms are well documented for up to 12 hours,
There are more than 10 beta2 agonists approved although theophylline is generally less effective
by the FDA for use as bronchodilators [30]. Beta2 than beta2 agonists [8]. It should be noted that
agonists come in every administration form, which caffeine is considered a methylxanthine drug, so
can assist in individualizing treatment. Injections patients must be advised to monitor coffee, tea, and
may work quickly in case of emergency, although chocolate intake while using this medication [8].
the effect lasts only about 20 minutes. Two to Many factors may affect the metabolism or serum
four puffs of an inhaled beta2 agonist taken before concentration of theophylline, including diet,
exercise or travel in cold air can block wheezing viral infections, hypoxia, age, some antibiotics,
for up to 4 hours [8]. Long-acting beta2 agonists are and smoking [23].
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Severe asthma may require higher doses for longer [8]. To prevent candidiasis, advise patients to rinse
periods and may be tapered off over a period of 1 their mouths after each inhaler treatment and to
to 3 weeks. Corticosteroids are usually taken upon gargle with warm water to remove any medication
awakening, mimicking the body’s natural steroid left in the throat. The use of a spacer may also be
production schedule. Nighttime symptoms may advisable, as it should ensure that medicine par-
be managed with split doses taken in the morning ticles are delivered to the lungs rather than to the
and at night [8]. mouth and throat [8].
A major disadvantage of oral corticosteroids is Mast Cell Stabilizers
the array of negative side effects associated with Mast cell stabilizers or inhibitors are considered
taking large doses over long periods of time [8]. mild-to-moderate anti-inflammatory agents and
Because these medications enter the circulatory are most effective in the treatment and prevention
system, there is potential for damage to other of exercise- or allergen-induced asthma. Mast cell
organs. If taken for severe asthma, patients should stabilizers interfere with the inflammatory process
be diligent about identifying and reporting any by stabilizing mast cell membranes and inhibiting
side effects [8]. the activation and release of mediators such as
Inhaled corticosteroid therapy concentrates on histamine and leukotrienes [33]. They may also
reducing airway edema and improves results restrain the development of early and late broncho-
obtained from bronchodilators while eliminat- constriction responses to inhaled antigens. Mast
ing extraneous effects to other systems. A beta2 cell stabilizers used to treat asthma are generally
agonist may be prescribed in conjunction with an administered by inhalation, but eye and nasal drops
inhaled corticosteroid; the beta2 agonist is used are also available. Common mast cell inhibitors
first to unblock airways so the corticosteroid can available for the management of asthma include
penetrate deeper [8]. Common inhaled corticos- cromolyn and nedocromil. These medications are
teroids include beclomethasone, dexamethasone, considered less effective than inhaled steroids in
flunisolide, triamcinolone, and budesonide (avail- the treatment of moderate-to-severe persistent
able in a dry powder inhaler) [8]. asthma in adults. However, they are more desirable
in the treatment of children and other patients for
Patients who take inhaled corticosteroids may
whom the side effects experienced as a result of
complain about the lack of immediate symptom
steroid therapy may be debilitating.
relief and cite it as a reason for not taking the medi-
cation [8]. It is important to stress the long-term Other Antiallergic Medications
benefits when discussing this therapy with patients. Similar to mast cell stabilizers, the concept of
Although risks of corticosteroid side effects are antiallergic medications as a separate category is
greatly reduced with inhalers, they do exist; pro- under intense study. The idea behind antiallergic
longed use of high doses can increase chances for drugs is simple—eliminate the allergic reaction so
the same types of unpleasant symptoms attributed allergic asthma symptoms are greatly reduced [8].
to the oral or injected forms. Particularly, some studies have been undertaken to
The doses of the inhaled corticosteroid must be research the effectiveness of antihistamine medica-
very high to equal the risk of side effects associated tions on the long-term control of asthma symptoms
with oral corticosteroids [8]. Two more common [56]. However, research generally shows that the
adverse reactions to inhaled corticosteroids are effect of antihistamines for the control of asthma
throat irritation and candidiasis. Candidiasis can is modest, especially if the patient is receiving
develop when a patient is taking antibiotic medica- the recommended treatment with corticosteroids.
tions in addition to the corticosteroid inhaler or If the patient also has allergic rhinitis, as many
if other medical problems, such as diabetes, exist asthmatics do, antihistamine medications may
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Nonpharmacologic Management
According to the American Academy
The most effective nonpharmacologic intervention of Allergy, Asthma, and Immunology,
for the treatment and/or prevention of asthma at immunotherapy is effective in the
this time is trigger avoidance, which will be dis- management of allergic asthma, and
allergen immunotherapy might prevent
cussed in detail later in this course. Knowing and the development of asthma in individuals
eliminating any possible asthma triggers is one of with allergic rhinitis.
the most important elements of any management (http://www.guideline.gov/summary/summary.aspx?doc_
plan. Additionally, the use of peak flow meters id=13113. Last accessed September 16, 2009.)
and increased patient education contribute to an Strength of Recommendation: A (Directly based on
enhanced understanding and control of asthma evidence from at least 1 randomized controlled trial
symptoms. Immunotherapy and complementary or a meta-analysis of randomized controlled trials)
medicine modalities have also been utilized by
asthma patients. Strong patient education and
communication is vital to the successful manage- Complementary or Alternative Treatments
ment of asthma. There are many alternative or complementary
Immunotherapy therapies available to asthma patients. In general,
these therapies should be regarded as adjuncts, not
For some patients, particularly those with allergy-
replacements, to conventional treatment [28]. The
induced asthma, immunotherapy may result in a
most common complementary therapies used in the
reduction of airway sensitivity, which should help
management of asthma include acupuncture, yoga,
prevent asthma attacks [8]. With immunotherapy,
postural drainage, massage therapy, homeopathy,
small amounts of diluted allergen are injected,
and herbal medications [57; 58]. There has been
causing the patient’s immune system to produce
relatively little research into the effectiveness of
the antibodies associated with an allergic reaction.
complementary treatments in the management of
This process is repeated once or twice a week for 3
asthma. However, some inconclusive, small trials
to 4 months, sensitizing the patient with gradually
support the further investigation of these treat-
higher concentrations of allergen, until the body
ment modalities. For example, studies focusing
is able to tolerate the trigger without reaction [8].
on magnesium’s role in lung function have found
The frequency of injections may be reduced, but
that the element appears to block chemicals that
the allergen dose may be increased for up to 3 to
inflame the lungs by stabilizing mast cells and T
5 years [8]. Successful immunotherapy results in
cells released during exposure to allergens [59].
fewer symptoms and decreased need for medication
The results are relaxed airway muscles and open
to control allergies and allergy-related asthma [8].
bronchioles, which contribute to improved lung
Studies report that this preventive treatment is
function and a reduction in wheezing and other
effective in reducing symptoms of allergic asthma
allergy-induced asthma symptoms [8]. However,
if the allergies involve animal dander, house dust
patients and/or their caregivers should be cau-
mites, pollen or fungi; to date, research has not
tioned not to self-prescribe these and other agents
confirmed that the positive effects are lasting [8].
without consent or supervision by a qualified
Also, immunotherapy may be costly and time-
healthcare provider.
consuming and may not result in a complete cure.
Even without cure, lessening an allergic reaction
can result in better control of asthma and asthma-
like symptoms. It may also provide additional
time for medical interventions in cases of severe
asthmatic reactions.
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
ated ADHD symptoms while on continued treat- on a 10-day period of antibiotic therapy and an
ments. Any increase in ADHD symptoms may be albuterol aerosol inhaler, 1 or 2 inhalations every
cause to consider reducing allergy and/or asthma 4 to 6 hours as needed. It was also recommended
medication dosages or trying an alternative medi- that a nebulizer be kept at home, for faster results in
cation altogether [37]. However, the treatment of case of sudden onset of moderate-to-severe cough-
a potentially life-threatening respiratory condition ing, chest congestion, wheezing, and/or tightness
should always be the management priority [37]. in the chest.
Case Study Patient J was subsequently diagnosed with an
extrinsic, mild-intermittent asthma, triggered by
Patient J is a boy, 5 years of age, residing in South-
several sensitivities, specifically to wood, dust, pol-
west Michigan. One March evening, Patient J
len, and cold weather. Recommendations for con-
was home with a conscientious babysitter. He had
trol of the patient’s asthma symptoms were made to
experienced several coughing episodes during the
the patient and his family in an effort to manage
previous days and began to cough while playing
the condition. He was encouraged to sleep with
hide-and-seek with the babysitter. She noticed that
his head propped up with pillows about 30 degrees.
the coughing was continuing and that the more he
Outdoor play and activities at home or at school
coughed, the more he cried. She was not able to
were evaluated for appropriate participation based
calm the patient and telephoned his parents at a
on severe weather, particularly when accompanied
nearby restaurant. Within 20 minutes, the parents
by wind. On very cold days or days with high mold
returned home and found Patient J upset, crying,
or pollen counts, Patient J was instructed to wear
and coughing. They could hear audible wheezing
a mask. Spring and fall proved to be difficult times
on exhalation and could see the young boy’s chest
for outdoor activities. His lungs became sensitive to
retract on inspiration. A physician was called
the smell of burning leaves and the mold-infested
immediately, and the parents were instructed to
fallen leaves in autumn.
meet the pediatrician at his office located next to
the area’s hospital; they arrived within 30 minutes. At home, Patient J’s room was evaluated for sources
The pediatrician administered a nebulizer treat- of asthma triggers. Stuffed animals, carpeting,
ment with albuterol in a 0.083% solution for inha- and heavy draperies were kept to a minimum. He
lation, which seemed to resolve the cough, wheeze, had no feather-filled pillows, and his bedding was
and labored breathing after 15 to 20 minutes. washed weekly in hot water. He slept with a room
air purifier. When his asthma flared up, the patient
The patient’s history was also reviewed. According
was given his prescribed medications and warm
to his parents and office records, Patient J’s first few
liquids. A soothing bath or shower allowed him to
years of life were essentially medically uneventful
be in an area of humidified, misty air, which often
with the exception of occasional benign rashes,
relaxed and dilated the bronchial airways.
several that were specifically found to be related to
a wood sensitivity. By 4 years of age, Patient J had One decade later, Patient J’s asthma remains in
experienced a number of cold viruses and allergies, control. At 15 years of age, he continues to take
with severe bouts of nasal and chest congestion. his medication and stays aware of his asthma trig-
He had no history of medical emergencies related gers. The frequency and severity of asthma episodes
to labored breathing or otherwise. have gradually lessened over time. He and his
family, however, are aware that the condition is
As a precaution, the physician was prepared to
capable of changing or worsening at any time and
recommend hospital admission to provide inten-
may return with increased frequency and severity
sive respiratory tent therapy in the event that the
in later years. For now, Patient J is living a normal,
symptoms did not improve. However, the symp-
healthy, active adolescent life.
toms seemed to resolve completely, and Patient
J was sent home with his parents and was placed
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Pharmacological treatments for asthma are gener- Successful adaptation to this chronic, cyclical,
ally considered more beneficial than the possible sometimes unpredictable condition demands
harmful side effects and are therefore recommended attention to emotional, mental, and social issues as
for the management of asthma during pregnancy, well as the physical pulmonary problems [42]. The
with the exception of antileukotrienes, which biopsychosocial approach to treating asthma
should be discontinued. The goal of pharmacologi- appears to be one of the most successful; health-
cal treatment should be to gain and maintain con- care practitioners have found that clearing away
trol of asthma symptoms. After control is obtained psychological and social obstacles affects treatment
and asthma symptoms stabilize for several months, compliance and improves the patient’s experience
less intensive treatment should be initiated. In of asthma. Additionally, as discussed, ADHD and
some patients with severe or persistent asthma, other learning and behavioral disorders commonly
the risk of a possibly harmful asthma episode may co-occur with asthma. Most would agree that
outweigh the benefits of lessening the intensity of managing and treating asthma emotionally and
asthma therapy. If this is the case, the step down mentally, as well as physically, leads to a happier,
to less intensive treatment may be deferred until healthier lifestyle [42]. Referring an asthma patient
after giving birth. The greatest amount of efficacy to a counselor or psychologist may help alleviate
and safety data supports the use of albuterol as the some of the stresses of managing the illness. Con-
beta2 agonist for use during pregnancy. Albuterol is nection with others with asthma, through support
a selective receptor and has a good safety record for groups or community involvement, may also be
both pregnant and nonpregnant patients [41]. The helpful.
recommended inhaled corticosteroid for long-term
management is budesonide, as more research has
been conducted regarding the effects of this medi- Patient Education
cation on pregnant individuals. No data regarding
As stressed throughout this course, patient educa-
the unsafe or safe properties of other corticosteroids
tion and communication are imperative to the
in pregnant patients has been published [41].
treatment and management of asthma symptoms.
It is important that healthcare providers are able
Psychosocial Management to discuss the different aspects of asthma symptoms
as well as treatment and management to ensure
Asthma does not just affect the lungs. It is a con- that patients are able to understand and follow the
dition that touches all aspects of life. As such, established plan. In addition to the treatment plan
treatment of the asthma patient should include and common symptoms associated with asthma
treatment of the whole person. Because so much episodes, patient education should outline the
of the success of the treatment depends on the importance of compliance, trigger avoidance, and
individual’s adherence to the prescribed manage- the continuous monitoring of their condition.
ment plan, patients and caregivers may be stressed
by the added responsibility. By managing these
The National Asthma Education and
and any other stresses, patients may experience Prevention Program Expert Panel asserts
increases quality of life and, by extension, may be that asthma self-management education is
more compliant to treatment plans. essential to provide patients with the skills
necessary to control asthma and improve
outcomes.
(http://www.guideline.gov/summary/summary.aspx?doc_
id=11672. Last accessed September 16, 2009.)
Level of Evidence: A (randomized controlled trials,
rich body of data)
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Irritants are nonspecific; in fact, irritants affect For certain asthmatic patients, it may be useful to
every person, if sufficiently concentrated, caus- realize that pollen settles quickly in the country,
ing bronchospasm aggravating the airway lining reaching ground level between 8:00 p.m. and 10:00
[28]. These irritants include, but are not limited p.m., but in the city, hot pavements and buildings
to: smoke, some industrial fumes, ozone, sulfur keep upward air currents going and pollen stays
dioxide, insecticides, air freshener, perfumes, and aloft longer [28]. As most pollen lands in the city
other aerosols [28]. At levels usually encountered, between roughly midnight and 2:00 a.m., it may
irritants do not adversely affect most individuals. contribute to nighttime symptom aggravation in
Asthmatics, however, can have dramatic responses urban asthmatic patients [28]. If an asthma patient
to exposure to some or most irritants due to the has a noticeable response to a specific type of pol-
chronic inflammation of the airways and their len, staying indoors or avoiding heavily wooded
hyper-responsive system. For these patients, an areas at release times may help alleviate symptoms.
allergy test would reveal no specific allergies. A daily pollution index figure should be available
from a regional office of your state’s Department of
There are many different types of triggers; some
Environmental Conservation. Many local weather
act in isolation, and others work together. The
severity of an asthma attack depends upon the stations include pollen counts in their daily reports
number of irritants, allergens, or other stimuli in as well.
the environment and the degree of lung sensitiv- Outdoor Pollution
ity to these triggers [8]. The following information The verdict regarding the effects of outdoor pol-
regarding specific asthmagens and how they may lution on the condition of asthma remains con-
be effectively avoided may be constructive to the troversial. Consider two main types of outdoor
patient education process. pollution: industrial smog (such as sulfur dioxide)
Pollen and photochemical smog (a combination of ozone
and nitrogen oxides). Physicians and scientists are
Pollen is likely the most difficult allergen to avoid.
cautious about implicating these and other envi-
To a great degree, this is because pollen release
ronmental pollutants as asthma triggers [8]. But
occurs at different times of day for different plants.
the findings of several studies confirm a relation-
For example, most grasses release pollen from
ship between pollutants and asthma, particularly
about 7:30 a.m. throughout the day; however, if
when nitrogen oxide, acid aerosols, and ozone are
the ground is damp, the release will be delayed
involved [63].
until the moisture has evaporated [28]. A few spe-
cies of grass and other plants delay pollen release Air pollution plays a variety of roles in asthma and
until afternoon hours, so pollen may be entering allergy. Some pollutants irritate the nose, airways,
the air all day. All types of plants generally favor and in some cases the skin, making them more
warm, sunny days for releasing pollen and avoid sensitive to allergens [28]. Specifically, ozone can
rainy, wet weather [28]. Rain also washes residual increase the effects of allergens and may take 4 to
pollen out of the air. So, days of rain may be a 24 hours to produce its effects on the lungs and
relief to pollen-sensitive asthmatics. However, on airways [28]. Such pollutants can worsen existing
cloudy and/or wetter days, there is a pollen buildup, asthma symptoms and may even promote devel-
which results in a massive release of pollen on the opment of allergies and/or asthma, particularly in
next day of good weather [28]. These pollen release children, whose airway membranes are more per-
patterns may correspond with incidences of asthma meable [28]. Other chemical pollutants may affect
symptoms in sensitive patients. the immune system directly, which would tend to
increase any existing tendency to allergic reactions.
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
the production of so many different items makes it Chlorine
a very commonly encountered irritant. Materials For a patient with asthma, bleach and other chlo-
that produce formaldehyde should be eliminated rine-based cleaning products, such as toilet cleaner
from an asthmatic patient’s environment as much and scouring powder, should be used sparingly
as possible. If a product contains formaldehyde, and with plenty of ventilation. These products
it should be noted that the emissions generally release chlorine gas, which, in large amounts, can
decrease as the item ages. irritate air passages [28]. Bleach and toilet cleaner
should not be mixed with any other products, as
Aerosol and Scented Sprays
chemical reactions may exacerbate the amount of
Cleaning products, furniture polish, and even chlorine gas expelled. Patients should be instructed
deodorant were never intended to enter the nasal to use care when utilizing any manufactured good
airways, but substances sprayed from aerosols containing hypochlorite, chloramines, ammonia,
do just that and can trigger asthma attacks [28]. acids, morpholine, or chemicals used for swimming
Asthmatic patients should be advised to avoid the pool water, as all of these agents have the ability
use of aerosols as much as possible. Additionally, to trigger asthma attacks [28].
air fresheners and perfumes with strong odors can
trigger asthma attacks in sensitive individuals. Paint
Avoidance of strong fragrances may help alleviate The possible harmful effects of paint for asthmatics
symptoms. are mainly due to the presence of solvents; these
solvents can act as irritants to nasal air passages
Sulfur Dioxide
[28]. Areas where paint is being used should be
The Food and Drug Administration (FDA) esti- well ventilated. Solvent-free, odorless paints are
mates that 1 out of every 100 people is sulfite- also available and may be useful for patients who
sensitive and that 5% of those who have asthma are unable to avoid paint fumes as part of their
are at risk of suffering an adverse reaction to the occupation or daily lives.
substance [44]. Patients with asthma should be
aware of instructions and ingredients listed on all Isocyanate
usable or edible products. It is important not only One of the most powerful asthmagens is iso-
to be knowledgeable as to what is in the product cyanate. “Instant foam” kits sold for do-it-yourself
but also as to what gases may be given off when insulation can provoke asthma in those who were
used. One such example is sulfur and sulfur diox- previously not asthmatic [28]. This is due to two
ide gas [28]. “Sulfuric,” “sulfate,” or “sulfite” in a different substances that are mixed to create the
list of ingredients should serve as a warning for an polyurethane foam, one of which is unreacted
asthma patient; the product may give off sulfur isocyanate. The combination of these substances
dioxide gas [28]. results in the release of isocyanate at potentially
In 1986, the federal government established guide- harmful levels [28]. The most common incidences
lines for sulfites, and a partial ban on sulfites was of isocyanate asthma occur in patients who have
enacted for restaurant and market fresh salad bars high exposures in their occupation. Although IgE
[8]. Regulations also require labels to indicate if antibodies against isocyanate may be detected by
sulfites have been added to prepared products [8]. a RAST, this test is positive in only a minority of
Many medications and processed foods, including cases of isocyanate asthma.
some wines, juices, and shellfish, contain sulfites.
Due to the fact that inhaled asthma medications
may include sulfur-based preservatives, care should
be taken when prescribing or administering medi-
cations to patients with sulfite sensitivity [8].
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Cold air, which usually does not limit airflow with Physiological Triggers
other lung diseases, is a major trigger for many indi- Hormone Changes
viduals with asthma. Bronchial muscles constrict
in cool, dry air, and muscles may not relax until The relationship between hormonal changes and
temperatures rise [8]. Even ingesting cold foods asthma is unclear. However, there are types of
or drinks can cause muscle constriction. Exercise asthma that are triggered by changes in hormone
during cold weather increases the risk of bronchial levels [8]. The number of girls who develop asthma
constriction by forcing inhalation of cold air. at puberty, when large amounts of estrogen are
produced, is growing. A higher incidence of asthma
Diet among women, as compared to men, continues
An anti-asthma diet is generally neither an avoid- through reproductive years [8].
ance diet nor a diagnostic diet, but rather a health- Many women have reported that their asthma
promoting diet, designed to protect against asthma worsens when they menstruate [8]. Indeed, research
and asthma symptoms [28]. However, if specific suggests that the decreased levels of progesterone
food allergies or triggers are identified, they should and estrogen during menstruation alters the body’s
be avoided as much as possible. Asthma patients water and salt balance and may negatively affect
who suffer from food sensitivities and/or those who bronchial muscles and smooth muscles [8]. A few
care for them must be made aware of potentially studies concur that premenstrual hormone changes
allergenic-specific food ingredients (Appendix). stimulate airway constriction [8].
Because overweight and obesity have been linked Contraceptive pills and hormone replacement
to an increased risk for asthma, some asthma therapy (HRT) during menopause are being stud-
patients may benefit from weight loss and may be ied as possible asthma stimulants [8]. A Harvard
limiting their calorie intake to lose weight. Diet- research team surveyed 23,035 women in the
ing asthma patients should be taught that some Nurses’ Health Study and revealed that asthma
packaged goods, including some recommended by was twice as prevalent among women who took
several diet plans, contain sugar substitutes, food hormones for 10 years or more, during and after
coloring, and preservatives, all of which have been menopause, compared to those women who did
associated with exacerbation of asthma symptoms not take HRT [68]. However, more research is
in sensitive individuals [8]. necessary to discover how and when hormonal
Before any dietary treatment, investigation, or rec- changes during the menstrual cycle or menopause
ommendation is initiated, a physician or healthcare affect lungs and asthma symptoms.
provider must be aware of assessed risks; referral to Stress
a dietician or nutritionist may also be necessary
[28]. There was once a theory that asthma was the
body’s way of communicating emotions. The cur-
rent understanding of asthma is that emotions and
mental disorders do not cause asthma in otherwise
healthy patients [8]. However, there is evidence
that strong emotions may arouse symptoms in
asthmatic individuals; extreme bouts of laughter
or fear can cause bronchial lumens to narrow
abruptly [8]. Also, any activity that stresses the
respiratory system, including crying or shouting,
can stimulate nerves to constrict bronchial lumens.
Another theory suggests that the major cause of Known NSAID sensitivity should be noted in a
EIA is hyperventilation. In fact, the bronchial con- patient’s record, as prescribing any of these medi-
striction that occurs during exercise in EIA suffer- cations may be extremely hazardous. Other medi-
ers may also be induced by hyperventilation, even cations, such as paracetamol, may be prescribed
in the absence of vigorous physical activity [4]. instead.
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
Beta Blockers animal is in the room because dander and/or other
The beta-adrenergic system includes the neurologic allergens may remain in the air for long periods of
system, which relaxes the smooth muscle of the time [8].
bronchial tree and stimulates the heart. Blockage Cat dander is one of the smallest allergens; most
of this system can calm the heart but may also of the particles are less than 2.5 microns and the
constrict the muscles of the bronchi. This broncho- smallest may be only 0.5 micron [28]. A sensitive
constrictive tendency can occur in an exaggerated individual would require a very good dust mask
form in asthmatic patients [4]. Beta blockers are or high efficiency particulate air (HEPA) filter to
used in treating a number of conditions, includ- eliminate these particles in a contaminated indoor
ing hypertension, cardiac arrhythmias, glaucoma area [28]. It should be noted that, in many cases,
(as ophthalmic drops), migraines, and in the pre- dander can linger in house dust for approximately
vention of myocardial infarctions. Medications 6 months after a pet has been removed from an
within this category include propranolol, labetalol, environment [8].
atenolol, and timolol.
Other, less common pets may produce allergens
Asthmatic patients should be educated regarding through shedding of fur or dander. For example,
the risks of beta blockers and instructed on the horses are known to produce very powerful aller-
appropriate steps to take if they begin to experience gens [28]. In the case of small mammals, such as
asthma symptoms after taking beta blockers. mice or guinea pigs, urine is usually the main cause
Common Household Triggers of allergic and asthmatic reactions. Proteins in the
urine become airborne and are carried throughout
Pets the environment. Allergic reactions to reptiles and
The number of household pets is on the rise; amphibians are extremely rare; however, cases of
estimates indicate that there are 43 million dog reactions have been documented [46]. With pet
owners in the United States and 37.5 million cat insects and snakes, lizards, and other reptiles, the
owners [72]. These domestic animals, as well as allergens are found in tiny skin particles that float
mice, guinea pigs, and even horses and sheep, give in the air [28]. Because these animals are known to
off saliva, fur, and dander as they live their normal carry Salmonella, which can cause life-threatening
lives—showing affection by rubbing against or infection in young children, the CDC recommends
licking their owners or other individuals [8]. Expo- against keeping them in homes with children
sure to any of these elements may trigger asthma younger than 5 years of age [79].
symptoms in sensitive individuals.
Dust Mites, Cockroaches, and Rodents
Certain breeds of dogs and most cats shed clumps Allergy research reveals that dust mites play an
of fur throughout the year; saliva holds and spreads important role in the development of asthma symp-
dander and fur throughout a house [8]. Further, toms. The dust mite allergen provokes immune
animals that explore outdoors bring pollen and cells, and after an allergy to dust mites has devel-
mold spores indoors on their fur, another potential oped, other allergies become more likely [28].
problem for asthmatics [8].
It should also be noted that researchers have
For very sensitive asthma patients, even the demonstrated that 18% of children in urban areas
slightest exposure to dander can result in airway in the United States have an allergic reaction to
constriction. The situation can become dangerous mice, and this can surely contribute to asthma
for a child with allergies who keeps rodents in a [28]. Cockroaches are another significant cause
bedroom or sleeps with a dog or cat [8]. In fact, of asthma symptoms in urban environments.
those with asthma may react whether or not the
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#3039 Asthma: Diagnosis and Management_ _____________________________________________________
• Buildings that are damp or display In sensitive individuals, increased amounts of dust
mold infestation mites and other allergens, such as fungal spores,
• Houses with central evaporative embedded in bedding may trigger allergic asthma.
cooling systems (“swamp coolers”) This would, of course, only affect those patients
• Buildings built in damp environments, with specific sensitivities. Levels of the nocturnal
near lakes, rivers, or the ocean corticosteroid hormones epinephrine and cortisol,
which play an important role in keeping bronchial
• Rooms with humidifiers airways open, reach their lowest point between
• Bathrooms and shower rooms, unless midnight and 6:00 a.m. [8]. Additionally, histamine
the rooms are well ventilated levels, which may worsen asthma symptoms, peak
• Buildings with dry rot, although not at night [13]. Reduced adrenal gland function at
all mold-sensitive individuals react to night may also be responsible for the decreased
the spores of these timber-rotting fungi amounts of epinephrine and corticosteroids in the
• Buildings where central heating has blood [8].
recently been installed The cold night air may lower bronchial airway
• Buildings with many indoor plants temperatures, inducing lumen constriction and
• Cellars and basements triggering asthma symptoms. Furthermore, about
half of asthmatic individuals notice that their
• Sun rooms, unless well-maintained
symptoms intensify 4 to 12 hours after the first
• Antique shops and vacation homes reaction, suggesting that a nocturnal attack may
• Farms or mills result from a trigger encountered earlier in the day.
• Portable school classrooms Lastly, a reclining sleep position may increase the
likelihood of gastric reflux symptoms, which may
Nocturnal Asthma exacerbate or mimic an asthma episode [8].
Asthma symptoms can be influenced by the time
of the day. Often, asthma worsens at night, espe-
cially between 2:00 a.m. and 4:00 a.m., or in the Conclusion
early morning prior to or upon awakening [8; 13].
Many asthmatic patients awaken with a choking Asthma is one of the most common respiratory
cough, wheezing, breathlessness, or chest tight- conditions affecting children, adolescents, and
ness; symptoms may last a short period or may adults, and the number of individuals affected
persist for minutes or hours [8]. For patients with continues to grow each year. Diagnosis may be
recurring nocturnal asthma, symptoms disrupt complex, especially in certain populations, but it
sleep and may affect ability to function normally is a vital key to providing the effective treatment
during waking hours. Nocturnal asthma not only and management of the disorder. Affected indi-
leads to sleep loss but also usually indicates uncon- viduals’ signs and symptoms vary in severity, and
trolled asthma. There are many possible causes of treatment plans should be determined accordingly.
nocturnal asthma. Healthcare professionals must keep current with
the latest treatments and medications as well as
the latest studies and theories for asthma treatment
and exacerbation prevention in order to provide
the best patient-centered care.
CME Resource • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 41
#3039 Asthma: Diagnosis and Management_ _____________________________________________________
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