Accurate Diagnosis and Prevention Are Vital to Asthma Management

Asthma is an inflammatory disorder of the airways. When an asthma attack occurs, the muscles surrounding the airways become tight and the lining of the air passages swells. This reduces the amount of air that can pass through, and can lead to wheezing, shortness of breath, chest tightness, and coughing. There are approximately 15 million adults and 6 million children with asthma in the US today. For these people, appropriate treatment can be a matter of life and death.

Jordan Fink, MD, Medical College of Wisconsin Professor of Pediatrics, Medicine and Allergy & Immunology, says that treatment of asthma first begins with an accurate diagnosis to rule out other conditions. Dr. Fink, who practices at the Allergy and Asthma Center at Children's Hospital of Wisconsin, says that in rare cases, physicians can't make a diagnosis; but in general, an accurate diagnosis is made in patients of all ages.

Is it Asthma?
"We first find out how long the patient has had the symptoms," he explains. "These can include coughing, shortness of breath, wheezing, or coughing at night." This is especially telling in children. "Kids who cough at night are generally assumed to have asthma, until proven otherwise," says Dr. Fink. He also looks for complications of asthma, such as sinusitis, heartburn, or acid reflux.

Pulmonary testing is used in diagnosis as well. "Asthma is an obstructive lung disease," says Dr. Fink, "so we want to see if there's any obstruction of the pulmonary functions." If asthma is suspected, a Methocholine Challenge Test is performed. The patient is given an inhaled chemical called methocholine when pulmonary functioning is at its normal stage. Methocholine causes the nervous system to trigger an airway spasm in patients with asthma, but not in patients without asthma. "We're inducing an asthma attack - which we can reverse right away, of course. And that helps us make a diagnosis," says Dr. Fink. "Chest x-rays can also help, to show us if the chest is overinflated."

If allergic asthma is suspected, Dr. Fink recommends skin testing, "especially if the patient has symptoms that are intermittent, or that occur during certain environmental exposures such as ragweed or a dog in the house."

Managing with Medications
Asthma must be treated as an ongoing condition. "Asthma is a chronic disease, and within that disease there can be acute episodes," says Dr. Fink. Usually asthma isn't just one episode but several, unless it's caused by a one-time event such as a drug allergy. In that case, the patient does not get the drug again, so never has asthma again. "But most asthmatics we see have a chronic disease," says Dr. Fink.

Although there is no known cure for asthma, there are several common treatments. So-called "rescue medications bring the patient out of an acute episode. "If the patient is acutely wheezing and has shortness of breath caused by airway obstruction, we use the drug called Albuterol, which is a bronchodilator - it causes the airways to respond and open up. It's usually inhaled but can also be taken as a liquid or a pill." Albuterol is only lasts for a short period of time. "Too much is deleterious to the heart, so we don't recommend taking more," emphasizes Dr. Fink.

Controller medications manage asthma on a daily basis and help prevent acute attacks, says Dr. Fink. "The drugs we use to control inflammation include steroids, which are usually inhaled. These do wonders for patients who cough at night, especially children." In addition to steroids, "we also use other controllers called leukotriene inhibitors. These inhibit the action of leukotrienes, which can contribute to inflammation of the airway." Controller medications also include long-acting bronchodilators because they last up to 12 hours - much longer than rescue medications such as Albuterol.

For asthma caused by an allergy, Dr. Fink often recommends allergen immunotherapy. "We change the patient's response by injecting the allergen into the patient," says Dr. Fink. "For example, if the patient is ragweed-sensitive, we can inject increasing amounts of ragweed into the patient over a period of time, and it alters the immune response so it becomes more 'normal' than allergic."

Additionally, "We always look for the factors that activate asthma, and urge avoidance of those," says Dr. Fink. In children, especially, avoidance of dust mites often makes a marked difference, so covering the mattress, box spring, and pillows in allergen-impermeable covers; removing carpeting and stuffed animals; and vacuuming regularly will often make a child's asthma much easier to control. Other allergens such as pet dander, cockroach allergens, molds, and pollens should be avoided as well. Smoking is especially harmful to people with asthma, says Dr. Fink: "If the patient smokes or the patient's parents smoke, we try to get them to quit."

Asthma and Antibiotics
"Antibiotics are effective in patients of any age if they have an infection," Dr. Fink notes. "Right now in Milwaukee we are having an epidemic of sinusitis; it happens about every six weeks, all year round. This is activating patients' asthma. We don't know how it triggers asthma - possibly because it triggers more inflammation - but we treat it with antibiotics. And once the sinusitis is under control, the asthma becomes easier to control, and we can get the patient on the less-potent controller medications. So we can treat the infectious process that's accompanying the asthma with antibiotics, and that will help control the asthma.

Researchers have also begun to look at the possibility of treating asthma with long-term antibiotic therapy. "There have been some studies on the use of specific kinds of antibiotics called macrolides - probably the most well known of the macrolides is a drug called Biaxin, which is an antibiotic that's used to treat a variety of infections. Some investigators have found that macrolides have anti-inflammatory action as well," and might reduce the inflammatory process in the lungs. This is a different anti-inflammatory action than that of medications like ibuprofen, which can often make asthma worse. "Again, this is long-term use of these antibiotics, not for infection but for their anti-inflammatory action."

Overall, it's too early to tell whether use of long-term antibiotics is an effective treatment for asthma. As far as antibiotic resistance, Dr. Fink says, "It's possible that antibiotic resistance can occur when the patient uses an antibiotic long term, but we don't use large doses for people with asthma. We treat them with moderate-to-small doses of antibiotics."

Current Treatments Satisfactory If Used Properly
People with asthma should take action to reduce the effects of the environment on their asthma, not just during acute episodes, but all the time. "Some patients only take their medicine when they're acute, but we're more interested in preventing the asthma from occurring, and using the appropriate medication to prevent it."

Dr. Fink emphasizes that patient cooperation is vital to the success of treatment. Like any other chronic disease, asthma needs to be treated on a regular basis in order to be managed optimally. "The current treatments we have for asthma are quite satisfactory in most cases," he says. "Our goal is to keep the asthma under control so patients can live a normal life."

P.J. Early
HealthLink Contributing Writer

This article includes information from the National Institutes of Health and the US Centers for Disease Control and Prevention.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.