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What is adult asthma?
Asthma is a chronic lung disease that affects approximately 20 million Americans. Asthma is characterized by inflammation of the airways.
The inflammation makes the airways smaller, therefore making it more difficult for air to move in and out of the lungs.
When to see an allergist/immunologist:
Your asthma or allergies are interfering with your ability to carry on day-to-day activities.
You are experiencing warning signs of asthma, such as having to struggle to catch your breath; wheezing or coughing often, especially at night or after exercise; or being frequently short of breath or feeling tightness in your chest.
You have been previously diagnosed with asthma, but despite treatment you have frequent acute asthma attacks.
Antihistamines and other over-the-counter medications do not control your allergy symptoms, or they create unacceptable side effects, such as drowsiness.
The AAAAI suggests patients use the following checklist on the next visit to their allergist/immunologist:
Ask about steps you can take to make your home a better living environment; most people with asthma also have allergies that make their symptoms worse. It's important to know what you are allergic to and how you can create an allergen free environment.
Work with your allergist/immunologist to create a daily management plan, which describes the regular medications and measures to keep your asthma under control.
Ask the doctor for a peak flow meter - an instrument that measures the airflow when you blow into it quickly and forcefully. Experts recommend using them at home to guide decisions about when medications need to be increased or decreased, and to determine when to call a physician or seek urgent care.
Ask for a demonstration on how to properly use an inhaler.
Ask about creating an asthma action plan, which describes actions to take when asthma worsens, including what medications to take and when to contact a physician.
How Referral to an Allergy/Immunology Physician can Help in the Diagnosis and Management of Asthma
Allergy/Immunology Physicians Can Help to Diagnose Asthma:
Because asthma is a disorder characterized by intermittent blockage of the airways, a person may be bothered by asthma symptoms, but have normal lung functions while in the doctor’s office. The Allergy/Immunology Physician can perform specialized tests, such as methacholine or exercise challenge, to confirm a diagnosis of asthma.
Sometimes people with asthma have exercise-induced shortness of breath that does not respond as expected to pre-treatment with asthma medications. When this is the case, it is important to confirm that the shortness of breath is due to asthma, as opposed to other medical conditions. An Allergy/Immunology Physician can perform specialized tests, such as exercise challenge tests, to confirm the diagnosis.
People with asthma may be at risk of damaging their lungs while scuba diving. Thus, a person with a history of asthma should ensure that their asthma is not currently active before scuba diving. An Allergy/Immunology Physician can perform specialized testing, such as an exercise challenge, to assess current risk.
Allergy/Immunology Physicians Can Identify and Manage Environmental Asthma Triggers
Allergens, whether indoor or outdoor, are a common trigger for asthma, especially for persons who experience seasonal flares in their asthma symptoms. An Allergy/Immunology Physician can perform testing to identify allergen triggers. Once identified, the Allergy/Immunology Physician is specially trained to teach the allergic individual practical ways to avoid exposure to the identified allergens. Allergen avoidance has been demonstrated to reduce asthma severity and improve asthma control.
The introduction of a new pet into the home is sometimes accompanied by the emergence, or worsening, of asthma symptoms. The Allergy/Immunology Physician can perform diagnostic testing to confirm whether or not the asthmatic individual is allergic to the new pet. Avoidance of pets to which one is allergic can reduce asthma symptoms.
Allergy/Immunology Physicians Can Treat the Allergic Asthmatic with Allergy Immunotherapy
When there is a clear relationship between asthma symptoms and exposure to one’s diagnosed allergens (pollen, animals, mold, dust mite), allergy immunotherapy (allergy shots) can improve asthma symptoms by markedly reducing the degree to which the individual is sensitive to his/her allergens. An Allergy/Immunology Physician is specially trained in prescribing and administering allergy immunotherapy. Allergy immunotheapy is appropriate for allergic asthmatics who:
Have had an inadequate response to asthma medications
Have had an inadequate response to allergen avoidance
Are experiencing unacceptable side effects from medications
Wish to avoid the need for long term medications
Children with allergic rhinitis (nasal allergies) are at risk of developing asthma. Allergy immunotherapy can reduce the risk of developing asthma, and can also reduce the risk of developing allergies to new allergens. An Allergy/Immunology Physician is specially trained in prescribing and administering allergy immunotherapy under these circumstances.
Allergy/Immunology Physicians Can Help Prevent Unpleasant Consequences (Morbidity) of Asthma
For persons who have previously required emergency room care or hospitalizations for their asthma, care by an Allergy/Immunology Physician has been shown to reduce both subsequent hospitalizations and subsequent emergency room visits.
People with uncontrolled asthma have frequent symptoms that interfere with sleep and/or daily activities, and use excessive amounts of short acting reliever medications, such as albuterol. Treatment by an Allergy/Immunology Physician has been shown to reduce asthma symptoms, reduce the use of short acting reliever medications, improve the ability of the asthmatic to function physically, and improve asthma-related quality of life.
People with persistent asthma (symptoms more than twice a week when untreated) need controller medications to treat the inflammation associated with persistent asthma. Treatment by an Allergy/Immunology Physician is more likely to include controller medications, some of which (e.g., anti IgE) are not available to be used in the Primary Care Physician’s office.
Asthma symptoms and severity vary depending upon the degree of exposure to asthma triggers. Thus the ability of the asthmatic individual to participate in the management of his/her asthma (self-management) is an important factor in keeping asthma under control. Care by an Allergy/Immunology Physician is more likely to lead to education in self-management, including use of written asthma management plans and the use of peak flow meters to self-monitor asthma severity. Self-management and written asthma action plans have been shown to improve asthma outcomes in both children and adults. Care by an Allergy/Immunology Physician is associated with more effective self-management education and knowledge.
Severe asthmatics require costly medical care, including hospitalizations and emergency room treatment. Severe asthmatics also require numerous expensive medications to treat their asthma. Treatment by an Allergy/Immunology Physician reduces the financial cost of asthma care.
Allergy/Immunology Physicians Can Help Reduce Asthma-Related Deaths
Persons with prior severe, life-threatening asthma episodes, including episodes requiring intubation, are at risk of dying from their asthma. Treatment by an Allergy/Immunology Physician can the reduce the risk of asthma death because:
Regular treatment with inhaled corticosteroids and use of oral corticosteroids for the treatment of asthma attacks have both been associated with a reduction in the risk for fatal and near-fatal asthma exacerbations. Not only do Allergy/Immunology Physicians prescribe inhaled corticosteroids more often than do primary care physicians, but their patients are more likely to be using inhaled corticosteroids regularly. Patients managed by Allergy/Immunology Physicians are also more likely to receive appropriate treatment with oral corticosteroids.
Allergen exposure may trigger fatal asthma attacks. The Allergy/Immunology Physician is specially trained in diagnosing allergy triggers, education of allergy avoidance techniques, and treatment of appropriate patients with allergy immunotherapy. Allergy immunotherapy has been shown to provide significant benefits, including immunotherapy for the mold alternaria, which has been associated with life-threatening asthma.
People who have difficulty perceiving asthma symptoms are at higher risk of asthma-related death. Allergy/Immunology Physicians obtain objective measurement of lung functions more frequently than other physicians, thus reducing risk in “poor perceivers.”
Asthma action plans provide at-home instructions for adjusting medications in the event of an asthma attack, and may reduce asthma mortality. Asthma specialists, such as Allergy/Immunology Physicians, are more likely to provide asthma action plans to their patients.
Allergy/Immunology Physicians Can Help Improve Patient Adherence to the Asthma Treatment Plan
Asthmatics who are not adherent to their asthma management plan may be limiting themselves from achieving optimal control of their asthma. The Allergy/Immunology Physician can improve adherence.
Misunderstanding of what controller medications are supposed to do can lead to the expectation of immediate symptom relief from controller medications and, when that doesn’t occur, subsequent discontinuation by the patient of appropriately prescribed controller medications. Such misunderstanding of controller medications is more likely to be seen in patients not treated by asthma specialists, such as Allergy/Immunology Physicians.
Patients being treated by an Allergy/Immunology Physician are more likely to have been dispensed the “optimal” number of inhaled corticosteroid canisters for the year, suggesting good patient adherence to the asthma management plan.
Further evidence that patients treated by an Allergy/Immunology Physician are more adherent to their asthma management plan include data that specialty care (including that provided by Allergy/Immunology Physicians) is associated with more refills of anti-inflammatory medications (such as inhaled corticosteroids), and data demonstrating that compliance with national asthma treatment guidelines was higher in patients treated by asthma specialists, such as Allergy/Immunology Physicians.
Allergy/Immunology Physicians Can Help Diagnose Occupational (Work-Related) Asthma
People with asthma symptoms that are markedly increased or occur exclusively while at work should be referred to an Allergy/Immunology Physician for evaluation. The Allergy/Immunology Physician can evaluate whether the asthma is being caused by or triggered by agents at the workplace, and initiate appropriate avoidance therapy.
A normal history and physical examination is insufficient to diagnose occupational asthma, and inaccurate conclusions can easily be drawn. The Allergy/Immunology Physician can perform and interpret specialized tests, such as serial tests of pulmonary function performed during work periods vs. off work periods.
The Allergy/Immunology Physician can design a program of investigation into potential work-related asthma using specialized tests such as challenges with methacholine, cold air, and exercise. Such tests require expert interpretation, (which the Allergy/Immunology Physician can provide) since the results can vary depending on the timing and degree of relevant occupational exposures.
The Allergy/Immunology Physician can review Material Safety Data Sheets for potential exposures, observe for potential exposure during an onsite work evaluation, or assist in obtaining professional testing of the workplace. The Allergy/Immunology Physician can arrange and interpret diagnostic “challenges” performed at the workplace and can assist in referral to highly specialized centers for specific challenges when indicated.
It is important to identify specific workplace agents responsible for causing/exacerbating asthma because continued exposure can lead to worsening asthma and possibly persistent asthma even after exposure to the offending agent is discontinued. Thus, early diagnosis and removal of the individual from further exposure offers the best prognosis for individuals with occupational lung disease.
Tips to Remember: ASTHMA AND PREGNANCY
During pregnancy, mothers-to-be may feel uneasy taking medications. However, if a pregnant woman has asthma, it is doubly important that her symptoms be well-managed to increase both her health and her baby's health. Uncontrolled asthma can be a threat to maternal well-being and fetal growth and survival. The goals of asthma management and treatment during pregnancy are the same as for other patients-to prevent hospitalization, emergency room visits, work loss and chronic disability.
Pregnant women, like others with asthma, should avoid asthma triggers, including specific allergens such as house dust mites and animal dander, and irritants such as cigarette smoke. After discovering you are pregnant, see your allergist/immunologist soon after to discuss the best way to manage your asthma and what medications to take. He or she will be able to prescribe effective asthma and allergy medications that are appropriate to use during pregnancy, and will continue to work with you throughout your pregnancy to ensure your treatment is effective, without side effects.
If you are pregnant and have asthma, you may have questions regarding the best care for both your asthma symptoms and your baby. Following are some common questions and answers to assist you.
Can women with asthma have safe, full-term pregnancies?
Studies show maternal asthma that is well-managed during pregnancy does not increase the risk of maternal or infant complications. With appropriate asthma management, you can have a healthy baby. Conversely, there is a direct relationship between lower birth weight and uncontrolled asthma. So, it benefits you and your baby to control asthma symptoms.
Why would uncontrolled asthma affect the fetus?
Uncontrolled asthma causes a decrease in the amount of oxygen in the mother's blood. Since the fetus receives its oxygen from the mother's blood, decreased oxygen in her blood can lead to decreased oxygen in the fetal blood. This, in turn, can lead to impaired fetal growth and survival, since a fetus requires a constant supply of oxygen for normal growth and development.
How do asthma medications affect the fetus?
Studies and observations of hundreds of pregnant women with asthma have demonstrated that most inhaled asthma medications are appropriate for patients to use while pregnant. The risks of uncontrolled asthma appear to be greater than the risks of necessary asthma medications. However, oral medications (pills) should be avoided unless necessary to control symptoms.
What effect does pregnancy have on asthma?
Pregnancy may affect the severity of asthma. One study showed that asthma symptoms worsened in 35% of pregnant women, improved in 28% and remained the same in 33% of the pregnant women. These changes in severity are another reason to stay in close contact with your allergist/immunologist so he or she can monitor your condition and alter your medications or dosages if necessary.
During what part of pregnancy will asthma change?
Asthma has a tendency to worsen during pregnancy in the late second and early third trimesters; however, women may experience fewer symptoms during the last four weeks of pregnancy. Troublesome asthma during labor and delivery is extremely rare in women whose asthma has been adequately controlled during pregnancy.
Why does asthma improve for some women during pregnancy?
The exact reason is unknown. Higher levels of cortisone in the body during pregnancy may be an important cause of this improvement.
Why does asthma worsen for some women during pregnancy?
Again, the exact reasons are not known. Because the stomach area is compacted during pregnancy, some women may experience gastroesophageal reflux, a condition that causes heartburn and other symptoms. This reflux can worsen asthma symptoms. Other conditions, such as sinus infections, viral respiratory infections and increased stress, may also aggravate asthma during pregnancy.
Can I continue to receive allergy shots during pregnancy?
Immunotherapy or "allergy shots," do not have an adverse effect on pregnancy, so they can be continued. As always, your allergist/immunologist will monitor your dose to reduce the risk of an allergic reaction to the shots. These reactions are rare; however, such a reaction could be harmful to the fetus. And, allergy shot treatments should not be started for the first time during pregnancy.
Can women with asthma perform Lamaze?
Most women with asthma are able to perform Lamaze breathing techniques without difficulty.
Can I breast feed if I have asthma?
Breast feeding is a good way to increase your child's immunity, and is encouraged. The transfer of most drugs into breast milk has not been precisely evaluated; however, there appears to be no evidence that asthma medications adversely affect nursing infants. (However, some infants may become irritable from theophylline transferred by breast milk.) Also, if you have allergy symptoms while nursing, it is appropriate to treat these as well. Again, make sure to see your allergist/immunologist for the best treatment of allergies and asthma while nursing.
Although these are common questions during pregnancy, each patient's individual treatment varies. Managing asthma and avoiding asthma flare-ups during pregnancy is important to the health of the mother and fetus. It is best if women see their allergist/immunologist regularly during pregnancy so that any worsening of asthma can be countered by appropriate changes in the management program. Make sure to discuss any specific concerns with your doctor to ensure the healthiest pregnancy-for your well-being and that of your baby.
Tips to Remember: Exercise-induced Asthma
Do you experience coughing, wheezing, or chest tightness when you exercise? Do you feel extremely tired or short of breath when you exert yourself? If you have these symptoms, you may be one of many people with exercise-induced asthma (EIA).
Approximately 7% of the population, or about 20 million Americans, are reported to suffer from asthma, according to the American Lung Association. With strenuous physical exercise, most of these individuals experience asthma symptoms. In addition, many non-asthmatic patients-up to 13% of the population, up to 40% of patients with allergic rhinitis and often people who have a family history of allergy-experience asthma associated with exercise.
Symptoms and triggers
If you have exercise-induced asthma, you may experience breathing difficulty within 5-20 minutes after exercise. Symptoms may include wheezing, chest tightness, coughing and chest pain. Other EIA symptoms include prolonged shortness of breath, often beginning 5-10 minutes after brief exercise.
Patients with EIA have airways that are overly sensitive to sudden changes in temperature and humidity, especially when breathing colder, drier air. During strenuous activity, people tend to breathe through their mouths, allowing the cold, dry air to reach the lower airways without passing through the warming, humidifying effect of the nose. With mouth breathing-also common in patients with colds, sinusitis and allergic rhinitis ("hay fever")-air is moistened to only 60-70% relative humidity, while nose-breathing warms and saturates air to about 80 to 90% humidity before it reaches the lungs.
In addition to mouth-breathing, air pollutants, high pollen counts, and viral respiratory tract infections can also increase the severity of wheezing with exercise.
To confirm a diagnosis of EIA, a physician:
1. Obtains a patient history.
2. Performs a breathing test when the patient is at rest to ensure that the patient does not have chronic asthma.
3. Often may perform a breathing test after exercise.
Measurement can be done in a medical facility or "on the field." In the office setting, a patient exercises for six to eight minutes using a treadmill or cycle to create enough exertion to maintain a heart rate at 80-90% of the age-related maximal predicted value. The patient breathes into a breathing machine called a spirometer, which processes the patient's ability to breathe out, or expire air. This test is performed before exercise and at various intervals from two to 30 minutes after exercise stops. A decrease of at least 12-15% in the volume of air blown out (as compared to the starting value) by the patient in one second (termed the forced expiratory value in one second , or FEV 1) indicates possible EIA.
On the field, expiratory airflow can be evaluated before and after a six- to eight-minute "free run" or after participation in a sport or activity that usually induces respiratory symptoms. Airflow is again measured for 30 minutes after exercise ends. Although a portable spirometer can be used, physicians often recommend a small, relatively inexpensive peak flow meter to demonstrate the characteristic post-exercise decrease in expiratory airflow. In this case a 15-20% decrease is required for the test to be considered positive for EIA.
Although the type and duration of recommended activity varies with each individual, some activities are better for people with EIA. Swimming is often considered the sport of choice for asthmatics and those with a tendency toward bronchospasm because of its many positive factors: a warm, humid atmosphere, year-round availability, toning of upper body muscles, and the way the horizontal position may help mobilize mucus from the bottom of the lungs. Walking, leisure biking, hiking and free downhill skiing are also activities less likely to trigger EIA. In cold weather, wearing a scarf or surgical mask over the mouth and nose can decrease symptoms by warming inhaled air.
Team sports that require short bursts of energy, such as baseball, football, wrestling, golfing, gymnastics, short-term track and field events or surfing are less likely to trigger asthma than sports requiring continuous activity such as soccer, basketball, field hockey or long-distance running. Cold weather activities such as cross-country skiing and ice hockey are also more likely to aggravate airways. However, many asthmatics have found that with proper training and medical treatment, they are able to excel as runners or even basketball players.
Inhaled medications taken prior to exercise are helpful in controlling and preventing exercise-induced bronchospasm. The medication of choice in preventing EIA symptoms is a short-acting beta 2 agonist bronchodilator spray used 15 minutes before exercise. These medications, which include albuterol, pirbuterol, and terbutaline, are effective in 80 to 90 percent of patients, have a rapid onset of action, and last for up to four to six hours. These drugs can also be used to relieve symptoms associated with EIA after they occur.
In the school setting, these medications may be administered to children by school nurses. A long-acting bronchodilator spray that lasts up to 12 hours is also available. By using this before school, many children are able to participate in physical education class and other sports throughout the day without needing short-acting sprays.
If symptoms are not readily controlled by medications, patients should talk to their physician about using daily medication that treats the underlying asthma-the inflammatory process that is causing increased "twitchiness" or sensitivity of the airways.
In addition to medications, a warm-up period of activity before exercise may lessen the chest tightness that occurs after exertion. A warm-down period, including stretching and jogging after strenuous activity, may prevent air in the lungs from changing rapidly from cold to warm, and may prevent EIA symptoms that occur after exercise.
Athletes should restrict exercising when they have viral infections, when temperatures are extremely low, or-if they are allergic-when pollen and air pollution levels are high. Pursed (narrowed) lip breathing may also help reduce airway obstruction.
Please download our Asthma Action Plan and bring it to your next appointment.
* Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology.
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