Managing Your Asthma

Do I have asthma?

Is it asthma or something else?  It’s important to see your health care provider about any breathing problems or symptoms you may have, so you get the right diagnosis and a treatment plan that works for you. There are a number of (lung) respiratory related conditions that can mimic or accompany asthma but may be treated differently; like vocal cord dysfunction or chronic obstructive pulmonary disease. That’s why it’s important to see a health care provider who really understands asthma. A provider can be your primary care doctor, nurse practitioner, physician assistant or for people whose asthma is hard to control, they may need to see a specialist like allergy and immunologist or pulmonologist.

Common asthma symptoms

• Wheezing – a whistling or squeaky sound that you hear coming from your lungs when you breathe.
• Frequent coughing- especially coughing at night or when you exercise, laugh or cry.
• Feeling short of breath – like you can’t pull enough air into your lungs.
• Chest feels tight – this can happen when breathing in cold air or during exercise or anytime you exert yourself. It may feel like something is squeezing your chest.
• Breathing really fast – or just having trouble breathing.
• Having frequent colds (viral) that settle in the chest – especially in children.

Diagnosing whether or not you have asthma – or something else- requires a visit to your health care provider. Don’t wait until symptoms force you to go to an urgent care or the emergency room. The right place to start figuring out what’s going on with your lungs is by seeing a health care provider at the clinic or a health center. 

How is asthma diagnosed?

Asthma is a condition that lasts a lifetime but it can develop at any age. If you have asthma (and have been tested and diagnosed correctly), you don’t grow out of it but symptoms can disappear for long periods of time. Even when you don’t have symptoms and feel great, asthma is always present but can be silent. Your immune system changes throughout your life and your asthma symptoms may too. You will always have the potential to experience asthma symptoms and must be aware that they can return at any time. Being diagnosed is the FIRST STEP towards preventing symptoms and controlling asthma.

During your first visit, a health care provider will ask you a lot of questions about your health, such as:

• What are your symptoms, how long and often have you had them and when are you most likely to develop them?
• Do your symptoms develop only during certain seasons or weather?
• Do you have any allergies?
• What kind of work do you do?
• Do you get a lot of colds or viruses and do they seem to last a long time?
• What medicine you take to relieve your symptoms – prescription or over the counter?
• What medicinal herbs or supplements do you take? Some traditional medicines or herbs/supplements can cause symptoms or react with new medications you are prescribed.
• Do you smoke or are you around people who do smoke?

Your health care provider also needs to know about your personal and family’s history, especially if someone in your immediate family - like mom, dad, siblings or children – have been diagnosed with asthma or have similar symptoms. Asthma tends to run in families so if a close relative has asthma, it increases the likelihood that you will too.

A health care provider will also do a physical exam, he/she may draw some blood to send to the lab, and depending on the patient’s age and what testing facilities are available, do a chest x-ray and order a very common lung function test called spirometry.

Testing

Spirometry

• Spirometry is one type of pulmonary function (PFT) test. There are different types of breathing tests to measure how well your lungs are functioning, like lung volume and diffusing capacity tests, but spirometry is the gold standard to test for asthma and can easily be done in a provider’s office.  While no testing is fool proof, spirometry is a safe, simple test that is easy to do. Testing is done with a machine called a spirometer which measures how much air you inhale and exhale and how quickly you exhale.
• Some people who have asthma, but aren’t experiencing symptoms, may have normal spirometry results. Spirometry helps providers determine if a patient has asthma or some other lung condition. 
• This video shows how testing is done Spirometry Testing Video.

Fractional nitric oxide (FeNO)

• People who have asthma have airways that are swollen or inflamed. When the airways are swollen, a person exhales more nitric oxide (a gas produced by the cells in your airways). A FeNO test measures how much nitric oxide a patient exhales and the amount helps determine how much airway swelling is present, and in some cases, how well inhaled corticosteroids are working.
• Spirometry and FeNO testing may also be done periodically to help you and your health care provider manage your asthma and adjust your treatment plan accordingly. Talk with your health care provider about lung testing on at least a yearly basis.

Allergy testing

People who have asthma have airways that are sensitive to things that might not bother people who don’t have asthma. These things are called triggers and every person who has asthma is uniquely sensitive to different triggers. Many triggers can be tested for by an allergist in his/her office. 

• Allergy testing can sometimes include drawing blood to measure the amount of allergen-specific antibodies in your blood.
• Skin testing is the preferred method to test for allergies. These tests use a tiny bit of concentrated allergen that is pushed under skin either by scratching the area lightly after a drop has been placed or by injecting a small amount of just under the skin with a tiny needle (intradermal). These tests can be done in an allergist’s office and can take less than 30 minutes. How much you react to the allergens (or don’t react) can help your provider determine a treatment plan for you.

How do I control my asthma? 

• Asthma is like breathing through a straw. That’s how people who have asthma describe what asthma feels like. But for most people, it doesn’t have to be that way. 
• Most people should be able to control their asthma and keep it under control by seeing their health care provider 1-2 times per year, taking their asthma medicine in the amounts and frequency agreed upon with their provider and by following their asthma management (action) plan. Once asthma is controlled, a person should be able to do anything people without asthma can do – whether it’s sleeping through the night, going on a hike in the woods, competing in a soccer game or taking a long swim in the pool or lake.

Patient and family resource:  

So You Have Asthma: A Guide for Patients and Their Families (NIH) This easy-to-read guide offers asthma basics, lists of asthma triggers and how to avoid them, how asthma medicines work and how to take them, tools to help keep asthma under control, and how to communicate with your health care providers. 

Well controlled asthma means meeting your health goals

• No coughing or wheezing
• No difficulty breathing or chest tightness
• No waking up at night due to asthma symptoms (like coughing)
• Not having to use a rescue inhaler (albuterol) or more times a week for symptoms
• Being able to do whatever activity you want, without limitations and without symptoms
• Not missing school or work days due to asthma symptoms
• Taking your prescribed medicines without having side effects

If your asthma is well controlled, you’ll be able to avoid urgent visits to the emergency room or urgent care center and urgent visits to your clinic. Well controlled asthma means you’re doing all the things you’re supposed to! Uncontrolled or Very Poorly Controlled asthma can happen when you’re not taking your medicines the way your provider prescribed them or you’re skipping doses. Many people take asthma medications (usually inhalers but sometimes in a pill form as well) once or twice a day. Some people don’t need a daily medicine but EVERYONE who has asthma should have a rescue inhaler (albuterol) with them at all times.

The goals of successful asthma treatment mean your asthma is well controlled. So, how do you actually control your asthma?

By taking these six steps

1. Meet with your health care provider and support staff to learn how to manage your asthma and keep it under control with regular asthma visits (at least twice yearly).
2. Work with your health care provider to create an asthma management plan (action plan) that works for you.
3. Learn which medicines to take, when to take them and how to use inhaler devices correctly. Ask your provider about getting a prescription for a holding chamber or spacer. This is a device that attaches to metered-dose inhalers (MDI) that slows the spray down enough so you can breathe it in deeply and more efficiently into your lungs.
4. Identify what things (asthma triggers) cause your asthma symptoms to flare up and avoid them or reduce your contact with them if possible.
5. Watch for changes in your asthma and keep track of symptoms and when you need a rescue inhaler by using an asthma diary. You need to know when an asthma attack is brewing and how to treat it before it gets worse. If you act quickly and follow your asthma action plan, you can prevent your symptoms from getting worse.
6. Eat healthy foods focusing on fruits and vegetables, get plenty of heart healthy exercise, don’t smoke, and avoid being exposed to secondhand smoke.  Get your flu shot each fall and keep up to date on other immunizations as well.

Treating asthma

• Asthma is categorized by how severe your asthma symptoms are and how much those symptoms affect your daily life. Your health care provider will evaluate your symptoms and determine if you have: Intermittent, Mild, Moderate or Severe Persistent Asthma. 
• Your provider will talk with you about what treatment plan and medicine options would control your asthma and work best for you. The goal is to get the best level of asthma control possible using the least amount of medicine.
• How severe your asthma is affects how much and how many medicines you’ll take, but once your asthma is under control, your provider may reduce dosing on some medicines or tell you to stop taking some altogether. 
• If your asthma is NOT well controlled at follow-up visits, your provider might add different types of medicines to your treatment plan or increase the doses. This is called ‘stepping up or down’ your treatment plan and it’s based on how well controlled your asthma is. It’s to your benefit to take medicines prescribed for you exactly as your provider has directed – no skipping doses!

Take your medicine

• There are many different combinations of medicines available to treat asthma. Some insurance companies only cover certain medicines so it’s important for you to work with your health care provider to choose medicines that work for you but also tell your provider if you continue to have symptoms even though you’re taking your medicines properly.
• Many people who have asthma need two kinds of medicines: long-term control medicines and quick-relief or ‘rescue’ medicines. But, anyone who has asthma should have a rescue inhaler with them all the time.
• National Resource Center for Rx Assistance Plans – Minnesota Assistance Programs This site provides a list of prescription assistance programs that may help lower the cost of prescription medications. All of the programs listed on this site have the lowest price featured built into them so that cardholders get the best price on prescription drugs at pharmacies across the country. 

Long-term control or preventive medicines

Corticosteroids 

• These are medicines that you take every day. They can be an inhaler or sometimes, a pill or liquid, and they work by stopping and preventing the swelling (inflammation) in your airways. These medicines work to prevent symptoms and attacks from coming on in the first place.
• If your asthma is not well controlled on one medicine, your provider may increase the dose or add another medicine to your treatment. Once your asthma is under control, your provider may be able to reduce how much you take of some of these medicines.
• The most effective control medicines are anti-inflammatory medicines--inhaled corticosteroids-- also called ICS’s. ICS’s reduce the swelling in your airways, making the airways less sensitive and less likely to react to your asthma triggers.  These steroids are not the same steroids taken by some athletes. They are not habit-forming even if you take them every day for years. These medicines work slowly, and you may need to take them for several weeks or longer before you feel better.

Leukotriene modifiers (LTRA) 

• Another type of controller medicine is in pill or liquid form that you swallow.  Leukotriene modifiers work by blocking the action of chemicals in your airways that lead to swelling. They are generally used to treat mild persistent asthma or in combination with ICS’s for moderate to severe asthma.
• Anti-inflammatory medicines are most effective when you take them EVERY day, even when you don’t have symptoms. If you stop or forget to take these medicines, your symptoms will return.
• Inhaled long-acting beta2-agonists (LABA) - These inhaled medicines can help prevent symptoms when taken with inhaled steroids by helping to keep airway muscles relaxed. With some LABA’s, you can feel your airways relaxing quickly, but they are NOT to be used as rescue or emergency medicines. These inhalers should not be used alone. Combination medicines that contain both ICS’s and LABA’s are available making it easier to take your controller medicines every day.

Quick-relief or rescue medicines

• Quick-relief medicine works well to stop or relieve asthma symptoms or a flare-up but it does NOT control the swelling in your lungs that cause your symptoms. If you need to take your quick-relief rescue inhaler more than 2 days a week or it’s not relieving your symptoms completely, you might need a long-term control medicine or to increase your current controller medicine. See your provider if your symptoms aren’t relieved by your rescue inhaler or you’re using your quick-relief medicine frequently.

Short-acting beta 2 – agonist or SABA 

• These quick relief medicines start to work quickly, usually within 5-15 minutes by relaxing the tightened muscles around your airways, opening them up so more air can get in. You take these medicines to relieve asthma symptoms or flare-ups. Everyone who has asthma needs to carry a quick-relief medicine –usually an inhaler but sometimes from a nebulizer – to stop symptoms before they get worse.
• Always take your quick-relief medicine at the first sign of asthma symptoms or, if your provider recommends it, before exercise or activities that will increase your heart rate.

Anticholinergics 

• These medicines are primarily used in the ER but some people use them in  combination with their SABA inhalers when they have difficult to control or severe asthma.

Systemic corticosteroids 

• These medicines are usually in a pill or liquid form and are taken when you have asthma flare-ups/attacks that won’t resolve by just taking your reliever inhaler. These medicines work fairly quickly and help speed up your recovery. You might be instructed to take them for 3-10 days. Some people who have severe asthma might take this medicine on a daily basis along with their control medicine.

Biologics

• Some people (up to 10%) who have severe asthma find that their disease can’t be controlled by traditional asthma treatment plans – like ICS’s and combination medicines. Biologics are medicines that target the specific cells and pathways that cause the allergic inflammation of the airways. 
• People who have severe uncontrolled asthma are treated with biologics, through an IV or subcutaneous (small needle injection just under the skin) shot ever 2 weeks or once a month depending on the type of biologic prescribed. The amount of allergens in the system decreases when these cells are treated and people don’t have as many asthma attacks.  
• Biologics are always given to the patient in the doctor’s office – usually by an asthma and allergy specialist.   

Use of holding chambers/spacers

• Ask your provider about getting a holding chamber or spacer and use it each time you use your MDI inhaler. 
• Spacers /holding chambers give inhaled medicine a chance to slow down so you can breathe it in while reducing how much of the medicines droplets land on the back of your throat or tongue, making sure it goes directly and deeply into your lungs. Chambers or spacers should NOT be used with dry powder inhalers or inhalers that look like an MDI but they  automatically dispense the medicine when you inhale – (breath actuated) ex. RespiClick®.   
• Always rinse your mouth out and gargle with fresh clean water after you’ve used your ICS inhaler and don’t swallow until you do rinse.

A word about ‘summer breaks’ from asthma medicines

• Asthma is a chronic yet variable disease; everyone’s asthma is different. Asthma attacks or flare-ups are more common the spring and fall so children with asthma need to take their asthma medicines year round – even in the summer (as directed by the health care provider). Control or preventive medicines keep airways from swelling due to exposure to allergens, irritants or respiratory illnesses but they can take weeks to be fully effective again. Stopping controller medicines in the summer allows the airways to lose their protective armor against triggers. It can take weeks before the protection is gone but it also can take up to 3 months of daily use to get that protection back.
• Because children returning to school are more likely to be exposed to the flu and colds, it creates a much greater risk that their asthma will flare up resulting in extra visits to a provider’s office or the ER and missed school days. Remember, summer break doesn’t apply to asthma medicines.

Source: ‘Biologics for Asthma: Attacking the Source of the disease, not the symptoms’, American College of Allergy, Asthma & Immunology

Use an Asthma Action Plan (AAP)

How do you keep track of your medicines, when to take them and what to do when your symptoms are flaring up? Your provider should work with you to develop an asthma action plan (AAP), also called an asthma management plan (AMP). An AAP is a written document that is developed with your provider and individualized for each patient. Some AAP’s use a green, yellow and red zone format. Each zone tells a patient when their asthma is green - doing well, yellow - getting worse and needs to be treated with rescue medicines or red – emergency and you need to call 911 or get to an emergency room right away.

An AAP will include:

• What daily control medicines to take, when to take them and how often.
• What symptoms indicate your asthma is flaring up, how severe that symptom might be and what to do when having symptoms.
• What rescue (reliever) inhalers or nebulized medicine you should use, how much and when.
• What typically triggers your asthma.
• When your asthma is out of control and you need to call 911 or get to an emergency room.
• Some AAP’s will also include Peak Flow Meter readings which measures how well/poorly your lungs are working. A very low peak flow reading (below 50%) is an emergency.

Asthma action plans should be put in a place in your home where you can refer to it quickly – like on your refrigerator door, picture of it on your smart phone.  If your child is the one with asthma, ask the health care provider for copies to give to the school nurse, daycare provider, coaches or anyone who takes care of your child when you’re not there. An AAP should be reviewed each time you see your provider and a new one made every year with copies for everyone involved in your child’s care.

Exercise-induced bronchoconstriction/Asthma (EIB)

• Everyone needs exercise and people with asthma are no exception. In fact, being healthy, eating right, getting your yearly flu shot and exercising regularly is good for you and your asthma. Exercise increases your heart rate and how fast you breathe which, for some people with asthma, can result in asthma symptoms occurring while exercising. 
• Asthma and Allergy Foundation of America has good information about EIB; how to recognize it, causes, diagnosis and treatment.

Asthma in schools

• Visit Asthma Management in Schools for information on working with your school health office and licensed school nurse to make sure they have a copy of your child’s AAP, a non-expired albuterol inhaler, a holding chamber and any other information required.

• School health offices and daycare providers should also have a rescue inhaler or nebulizer for your child. It’s important that you ask your child’s provider to write a prescription for at least TWO rescue inhalers. The prescription should include one inhaler for school and one inhaler for home - prescription should also include a holding chamber/spacer.

Learn more

• Managing Asthma (ALA). Get tips and tools to help you take control of your asthma.  
• KidsHealth Asthma Center. Created by Nemours, this user friendly site features an Asthma Center for parents, kids, teens and educators. Each section offers age appropriate educational materials, interactive games, videos and tools.