Action Plans Keep Asthma in Check
During the mid-1980s, Sandra Fusco-Walker's life was filled with sleepless
nights, ruined vacations, emergency room visits, and her children's frequent
school absences. Two of her three children--all under age 6 at the time--had
"I was always worried about when the next bad thing would happen," says the
Kinnelon, N.J., resident. "But that was before we had a plan."
The "plan" was an asthma action plan that guided her on how to track her children's
symptoms, monitor their breathing, and give them medication. "A plan tells you
what to do and when," she says. "Without it, asthma is out of control, and that's
when the disease wreaks havoc on your life."
Asthma causes the airways to be inflamed or swollen, and the surrounding muscles
are tight. When people with asthma react to various triggers, such as dust,
pollen or smoke, their airways become narrow, which causes labored breathing,
wheezing, chest tightness, or coughing. About 15 million people in the United
States have asthma and almost 5 million are children, according to the National
Heart, Lung, and Blood Institute (NHLBI). Every year, asthma causes roughly
2 million emergency room visits, up to 500,000 hospitalizations, and 4,500 deaths.
Fusco-Walker says she learned to control asthma after she followed her doctor's
advice and called a nonprofit organization called Allergy & Asthma Network Mothers
of Asthmatics (AANMA). The woman who answered the phone was Nancy Sander, who
founded the organization in 1985 after facing challenges in dealing with her
own daughter's asthma. Fusco-Walker says, "Nancy assured me that I wasn't going
With support and advice from AANMA, Fusco-Walker learned to look for patterns
in her children's illness. For example, her kids got sick every time they visited
her mother, and her mother smoked. Her oldest daughter had an asthma attack
when she visited their horse barn. Fusco-Walker also learned to spot early warning
signs of trouble. "I noticed that one of my daughters rubbed her nose when breathing
became difficult," she says. "If I saw her rubbing her nose, I knew to get the
peak flow meter." A peak flow meter is a small tool that measures how fast air
moves out of the airways. Fusco-Walker attributes the success of her asthma
action plan to the regular use of a peak flow meter.
By the time Fusco-Walker's youngest child was diagnosed with asthma at age
5, her family had a much better understanding of the disease. Shannon, who is
now 16, Jared, 19, and Morgan, 21, grew up learning how to use their asthma
medicine. "They know when to use their inhalers, they know when they need refills,
and they know when they need to take medication before doing an activity," she
says. They also grew up participating in just about any activity they wanted
to, including football, swimming, soccer, and snowboarding.
Experts say most people with asthma can live a normal, active life. What it
takes is avoiding the triggers that make your asthma worse, keeping track of
your symptoms, and sticking to an effective treatment regimen. Many people with
asthma need short-term medicine for when they experience symptoms, and also
long-term daily medicine that reduces inflammation in the airways and helps
prevent asthma attacks.
"I'll hear people say they skipped their medication because they haven't been
coughing that much," says Richard L. Wasserman, M.D., Ph.D., clinical associate
professor of pediatrics at the University of Texas Southwestern Medical School.
"But I tell them they probably wouldn't have coughed at all if they kept to
the regimen." He says it's important to understand that asthma is a chronic
inflammatory lung disease. "Like high blood pressure, asthma is there all the
time even when there are no symptoms."
The first step in controlling asthma is an accurate diagnosis. Fusco-Walker
says doctors diagnosed her kids with all kinds of illnesses before she knew
the problem was asthma. According to Kathleen Sheerin, M.D., an asthma specialist
with the Atlanta Allergy and Asthma Clinic, this is a common problem, and both
consumers and doctors play a role. "Some people are scared of the word 'asthma'
because they only think of an emergency room scene on TV," she says. "I tell
them there are a whole range of asthma symptoms, and the disease doesn't have
to be scary if it's properly managed."
Sheerin says, "Doctors may call asthma other things like wheezy bronchitis
or reactive airway disease." Asthma symptoms vary by individual, and the disease
can look like other lung diseases. Also, asthma symptoms usually surface before
age 6, but it can be difficult to establish a firm diagnosis in young children.
"Babies up to age 2 or 3 may wheeze only when they get a cold, and we call them
'transient wheezers,'" Sheerin says. "For other kids, the wheezing continues
as they grow." These children, often considered "persistent wheezers," have
chronic asthma. (Also see "What Causes Asthma?")
"What we do is look for factors that make it more likely that a child's asthma
will persist," Sheerin says. These factors include having a family history of
asthma. Asthma is also more likely to persist if symptoms aren't only associated
with a cold, but if there are also symptoms associated with other triggers such
as smoke. People with asthma that persists also tend to experience wheezing
that occurs at night, with exercise, or with seasonal changes. They also may
have other allergic symptoms, such as allergic rhinitis or eczema, an itchy
Sheerin participates in a state education program called Breathe Georgia, which
uses the slogan "Call it what it is" to encourage doctors to accurately diagnose
asthma. "You have to know that you have it in order to understand it and manage
it," she says. "And an earlier diagnosis usually means better health outcomes."
The older someone is, the easier asthma is to diagnose. Doctors rely on a combination
of a medical history, response to medications, and lung function tests. Such
tests are generally hard to use in children under 6. One common lung function
test, spirometry, involves inhaling and exhaling through a tube for several
seconds. In some cases, allergy tests are performed to help determine asthma
Doctors determine whether asthma is intermittent (occurring from time to time),
or persistent, defined as having symptoms at least twice a week during the day
or twice a month during the night. Asthma that is considered persistent is further
categorized as mild, moderate or severe. Fusco-Walker, who was diagnosed with
mild asthma in her thirties, says these categories help doctors determine an
appropriate treatment plan. "But remember that regardless of the type, you still
have asthma and it is still a life-threatening illness," she says. "Some people
hear the word 'mild' and think they don't have to worry about it. But they do."
Though asthma can't be cured, it typically can be treated, and scientists are
currently studying whether untreated asthma causes a permanent change in the
airways. As a natural part of aging, we begin losing lung function in our twenties.
Untreated asthma might further accelerate that loss.
Brian Thomas, 41, a book distributor in New York City, has childhood memories
of vaporizers by the side of his bed. "I remember wheezing the night away, often
with my mother sitting with me," he says. He noticed some relief from asthma
symptoms when he went off to college in Syracuse, N.Y. But the symptoms returned
whenever he came home to his childhood bedroom. The culprits were dust mites,
tiny bugs that are too small to see. They live on mattresses, bed linens, carpet,
and stuffed animals. When Thomas' parents removed the carpet from his room,
his asthma symptoms improved considerably.
In people with asthma, inflamed airways
react to triggers such as smoke, dust, or pollen. The airways become narrow,
making it difficult to breathe.
(Infographic: FDA/Renée Gordon)
He went about 10 years without problems, but after a bad cold in 1989, he began
wheezing and using an inhaler as needed. In 1990, Thomas had the worst asthma
attack of his life when his roommates began building an addition to their New
York apartment. "They were doing a lot of woodwork, and I noticed some wheezing,"
Thomas says. "I thought I had it under control with my inhaler." Then his roommates
painted, and that's when things got much worse.
"My chest felt tight and burned, and I just couldn't catch my breath," he says.
Luckily, his landlord got a cab to take him to the emergency room at Beth Israel
Hospital, and doctors were able to quickly get Thomas' asthma under control.
But it was the longest cab ride of his life. "I thought I would die right there
on the bridge" that connects the Williamsburg section of Brooklyn to the Lower
East Side of Manhattan.
Common asthma triggers include dust, pollen, cockroaches, cold air, smoke,
and other strong odors, such as paint, cleaning fluids, perfume, hair spray,
and powder. For some people, the problem is animal dander, flakes of skin and
dried saliva from furry or feathered animals. For others, asthma can be triggered
by medication, such as aspirin, or sulfites, preservatives used in food.
Stress is thought to be a trigger of asthma. Stress can create strong physiologic
reactions that lead to airway constriction. Stress can also alter the immune
system, which can, in turn, increase the likelihood of an asthma attack in people
with asthma. According to the Centers for Disease Control and Prevention (CDC),
after the Sept. 11, 2001, attacks on the World Trade Center, some adults in
Manhattan reported an increase in their asthma symptoms due to stress, as well
as from smoke and debris.
It's not always possible to avoid triggers, but experts suggest that you can
track what causes problems and limit exposure as much as possible. Also, talk
with your doctor about preventive steps you can take. When Thomas cleans up,
for example, he wears a dust mask, available at many hardware stores. To get
rid of dust mites, you can encase pillows and mattresses in dust-proof covers
and wash bed linens and stuffed animals in hot water each week.
The NHLBI recommends keeping furry and feathered pets out of the home, or at
least out of bedrooms, if pets are known to trigger asthma symptoms. Recent
research, however, suggests that children with high exposure to cat allergens
early in life develop an immune response to cats, reducing the risk for asthma.
In the study, published in the March 10, 2001, issue of The Lancet, Thomas Platts-Mills
and colleagues at the University of Virginia found that exposure to cats may
be protective for some kids but a risk factor for others. The research suggests
you might not have to get rid of your cat when the baby comes, but if you or
your child experience asthma symptoms because of the cat, the cat should go.
Consult with a doctor about when or how much to increase medications as a preventive
measure, such as before allergy season starts or if you're traveling to a place
where it may be impossible to know what you will encounter in the way of pollution
or environmental allergens.
Types of Medication
There are two main categories of asthma drugs: short-term, quick-relief medications
that relieve asthma symptoms, and long-term controller medications that are
used every day by people with persistent asthma, even when they feel fine.
Wasserman, who works with The Dallas Asthma Consortium, says the organization
advises consumers with "The Rules of Two": If you take your quick-relief inhaler
more than two times a week, if you wake up with asthma more than two times a
month, or if you refill your quick-relief inhaler more than two times a year,
the group recommends that two medicines for asthma are needed and that you should
talk with your doctor about a long-term controller.
Short-term reliever medication refers to short-acting inhaled beta-2 agonists
such as albuterol and pirbuterol. Beta-2 agonists, also known as bronchodilators,
relax the muscles surrounding the airways. In addition, systemic corticosteroids,
such as prednisone and prednisolone, are drugs that help relieve the inflammation
or swelling in the airway. Taken in tablet or syrup form, they are often used
to treat severe asthma attacks.
As for long-term controller medication, inhaled corticosteroids are the most
consistently effective. Other long-term controller medications include long-acting
beta-agonists, which are used in addition to inhaled steroids. Examples of long-acting
beta-agonists are salmeterol and formoterol. (For recent news about salmeterol,
see "Safety Study on Serevent.") Cromolyn
sodium, nedocromil, and methylxanthines are also in the controller anti-inflammatory
category. Another class of long-term controller drugs is called anti-leukotriene
medication, and examples include Singulair (montelukast) and Accolate (zafirlukast).
These drugs block the action of chemicals called leukotrienes, which are involved
in the development of asthma.
In June 2003, the FDA approved Xolair (omalizumab), the first biotechnology
product to treat people 12 years and older who have moderate-to-severe allergy-related
asthma. The product, which is given as an injection under the skin, is a second-line
treatment, recommended only after first-line treatments have failed.
National guidelines on managing asthma now recommend that inhaled corticosteroids
are the preferred first-line treatment for people of all ages with persistent
asthma. (See "NIH Updates Asthma Guidelines.") Developed
by an expert panel of the National Asthma Education and Prevention Program (NAEPP),
the guidelines also recommend that if inhaled corticosteroids are not achieving
optimal control, dual-control therapy should be used. "We're advising doctors
that if inhaled corticosteroids are not proving effective, before increasing
the dose, add a long-acting beta-2 agonist," says James Kiley, Ph.D., director
of the Division of Lung Diseases at the NHLBI.
Badrul Chowdhury, M.D., Ph.D., acting director of the FDA's Division of Pulmonary
and Allergy Drug Products, says significant advances in asthma drugs include
the approval of Advair (fluticasone and salmeterol) in 2000. "This drug might
improve adherence because you don't have to go between two drugs," Chowdhury
says. It's the first drug approved by the FDA that combines an inhaled corticosteroid
and a long-acting bronchodilator in one device, which has a built-in counter
that tracks the number of doses. Chowdhury says also significant is the recent
FDA approval of the inhaled corticosteroid Pulmicort (budesonide) for children
as young as 1 and the approval of Xolair (omalizmab) in 2003.
Monitoring Symptoms, Using Medicine
Thomas says he felt lucky to survive his bad asthma attack in New York, but
the experience was so traumatic that he took a month off work and went back
home to his parents' house to recover. "I had panic attacks and a lot of anxiety
about having another attack," he says. His anxiety level eased as he got a better
handle on monitoring and preventing symptoms and using medicine.
Thomas has gone for 10 years without a major asthma attack, and he attributes
that to several factors. He uses a daily long-term inhaled corticosteroid called
Azmacort (triamcinolone acetonide) to relieve the inflammation that can cause
an asthma attack, and he uses a Ventolin (albuterol) inhaler as needed for short-term
quick relief of acute symptoms. He says that in the weeks before his bad asthma
attack, he was using a quick-relief inhaler several times a day, even sometimes
several times in the same hour. He now recognizes such use as a sign of trouble.
Thomas avoids known triggers and monitors his breathing with a peak flow meter.
"As a kid, I just dealt with the asthma attacks as they happened," he says.
"Now, I pay attention to what's going on before it gets bad."
According to the NAEPP Expert Panel Report, peak flow meters may be most helpful
for people with moderate or severe asthma. A meter reading will tell you your
peak flow zones, which are based on the colors of a traffic light. The green
zone signals that your asthma is in good control, the yellow zone signals caution
and is a sign to use quick-relief medicine to relieve symptoms, and the red
zone signals a medical alert that means you should contact a doctor. Written
plans can be useful for telling you what kind of medicine to take and how much
to take when you're in each zone.
Inhaled asthma medications are delivered through many different devices, including
metered dose inhalers, dry powder inhalers, and nebulizers. It's important to
get instructions on how to use each medicine you take, and to have your doctor
or nurse check your technique. To improve effective use of medication for kids
or adults, plastic devices called spacers are often used with inhalers. Spacers
create a space between the inhaler and the person's mouth to help more medicine
get into the lungs. A nebulizer, which delivers medicine in a fine mist, also
is useful for young children.
The issue of using asthma medications in school remains a challenging area
for children and parents. To date, 18 states have laws or policies allowing
children to carry inhalers in schools, according to AANMA. Many schools require
an inhaler to be kept in the nurse's office because it's a drug. "But if a child
is in gym class and the nurse is three buildings away, that could be a problem,"
says Sheerin, the asthma specialist in Atlanta. Experts say the two best things
we can do for children with asthma are to teach them how to manage their asthma
as they grow up, and to share a written plan from your doctor with the school.
Fusco-Walker, who now works with AANMA as an educator, points to the American
Lung Association's asthma camp program as a good support system for parents
of children with asthma. "It's a great place for children to learn how to manage
their asthma, and parents can enjoy peace of mind while their children experience
summer camp," she says. Kids participate in regular camp activities like swimming
and biking, and there are trained medical personnel who teach the kids proper
use of medication and other aspects of asthma management.
Sheerin says all kids should be able to sleep, play and learn. "If parents
are up at night, if kids can't play, or if they are missing a lot of school
because of asthma, then the asthma management plan is not right."
NIH Updates Asthma Guidelines
When it comes to managing asthma, adherence has two parts. "The first is that
doctors use the guidelines on asthma management, and the second is that people
with asthma follow their plans," says William Busse, M.D., professor of medicine
in allergy and immunology at the University of Wisconsin Medical School. Busse
is also chairman of the National Asthma Education and Prevention Program Expert
Panel, which updated the Guidelines for the Diagnosis and Management of Asthma
in June 2002.
Targeted to doctors, these guidelines were first published in 1991 and then
revised in 1997. An update in June 2002 reflects scientific advances over the
last five years. Here are highlights from the most recent update:
Inhaled corticosteroids, which treat chronic inflammation of the airways, are
safe, effective, and preferred first-line therapy for children and adults with
Inhaled corticosteroids are safe at recommended dosages. There has been concern
about slowed growth in children due to use of inhaled corticosteroids. Research
shows that this potential risk is temporary and possibly reversible. Nonetheless,
doctors should monitor children's growth while giving inhaled corticosteroids,
because slowing of growth is a good marker for side effects in other organs
in the body. The expert panel also found that other concerns associated with
use of corticosteroids, such as reduced bone mineral density, suppressed adrenal
function, and increased risk of cataracts, are not considered significant risks
for children. The risk-benefit assessment favors the use of inhaled corticosteroids
for the treatment of persistent asthma.
When inhaled corticosteroids are not achieving optimal effectiveness, doctors
should add a long-acting beta-2 agonist. These types of drugs, also known as
bronchodilators, relax the muscles surrounding the airways.
Asthma Death Rates Higher for Minorities
Black Americans have only a slightly higher prevalence rate of asthma than
whites (8.5 percent versus 7.1 percent), but blacks are three times more likely
to die or be hospitalized because of the disease. According to the Centers for
Disease Control and Prevention, while asthma mortality rates have gone down
overall since 1995, racial disparities remain.
Floyd Malveaux, M.D., dean of Howard University's College of Medicine in Washington,
D.C., says the reasons are complex. "We know that this is one of many diseases
in which minorities and underserved populations are disproportionately affected,"
he says. "A lot of the disparities are related to poverty."
Malveaux says lack of access to care plays a large role. "It's not just about
having health insurance," he says, "but also about whether there is access to
transportation and knowing how to use the health care system. There may be no
access to asthma specialists, perhaps because of limitations in managed care.
So then what you have is a reactive situation and a lot of emergency room visits
versus a proactive situation that focuses on prevention."
He also points out that when you're living in poverty you can't control the
environment like you may want to. "I think of an area in Detroit where big diesel
trucks come across from Canada," he says. "You can see the line of trucks emitting
diesel fuel in a poor neighborhood, and the people who live there can't control
Other factors may be the challenge of paying for asthma medications and exposure
to smoking and cockroaches. Research supported by the National Institute of
Allergy and Infectious Diseases has found that children in inner-city areas
who were both allergic to cockroaches and heavily exposed to them had higher
rates of hospitalization for asthma, missed school more often, and suffered
more sleep loss.
Hispanics also have higher death rates from asthma compared with whites, with
Puerto Ricans experiencing the highest burden.
What Causes Asthma?
Inflammation (swelling) of the airways is the underlying cause of asthma, and
there are two main reasons that people develop the disease, says Fernando Martinez,
M.D., director of the Arizona Respiratory Center at the University of Arizona
College of Medicine in Tucson. "Some people develop asthma because they react
to viral infections like the common cold. Another group is genetically predisposed
to it, and for them, asthma is associated with the way the lungs grow and the
way the immune system develops." It is in this second group that asthma tends
to be persistent, and there is often a family history of asthma and allergies.
"Over the next decade," Martinez says, "determining which genes are involved
will help scientists prevent and treat the disease."
William Busse, M.D., professor of medicine in allergy and immunology at the
University of Wisconsin Medical School, says the causes of the increasing asthma
rates are not fully understood. He says that the prevalence of asthma is higher
in developed countries, such as the United States, Europe, and New Zealand,
and is lower in less developed areas, such as China and Africa. This suggests
a possible role of environmental or lifestyle factors that may affect the type
and magnitude of exposure to environmental allergens and immune response to
that exposure. Researchers are exploring possible factors such as diet, frequent
use of antibiotics, and fewer and less severe infections in early life. Busse
says studies have shown that children who are enrolled in day care before 6
months of age have more frequent infections in early life, but significantly
less asthma after age 6.
Asthma also occurs more in urban environments than in farming ones. The Hygiene
Hypothesis, first proposed in 1989, remains under debate and requires further
study, according to Busse. This hypothesis states that environments that are
too clean may actually make immune function more likely to develop allergic
responses. In a study published in the Sept. 19, 2002, issue of The New England
Journal of Medicine, researchers studied 812 children ages 6 to 13 living
in rural areas of Germany, Austria, and Switzerland, and found that children
in farming households experienced a decreased risk of hay fever and asthma.
Safety Study on Serevent
In January 2003, the FDA announced that an interim analysis of a large safety
study of the asthma drug Serevent (salmeterol) Inhalation Aerosol suggests that
the drug may be associated with an increased risk of life-threatening asthma
episodes or asthma-related deaths. Further analyses of the data suggest that
the risk might be greater in blacks. Also, people not taking inhaled corticosteroids
when they entered the study appeared to have greater risk for serious outcomes
than those who were taking inhaled corticosteroids.
Serevent Inhalation Aerosol belongs to the class of asthma medications known
as beta-2 receptor agonists, commonly called beta-agonists. The FDA approved
the drug in 1994 to treat asthma, and approval was later extended for treatment
of chronic obstructive pulmonary disease (COPD).
The safety study began in 1996 after the FDA received reports of several asthma
deaths associated with the use of Serevent Inhalation Aerosol, and after studies
raised concern about the regular use of short-acting and long-acting beta-agonists.
Because people with asthma can sometimes suffer sudden, serious life-threatening
episodes of bronchospasm, the deaths and serious adverse events reported for
Serevent could neither be attributed to use of the product, nor could Serevent
be excluded as a cause. The drug's manufacturer, GlaxoSmithKline of Research
Triangle Park, N.C., stopped the study, mostly due to difficulties in enrollment
and the likelihood the study would not give a clear result.
The FDA is considering what steps are warranted to address this important new
risk information. The FDA has emphasized that, based on available data, the
benefits of Serevent for people with asthma continue to outweigh the risks and
that serious problems reported in the trial were rare. The FDA has strongly
advised that people who take Serevent should not stop taking it, or any other
asthma drug, without first talking with their physicians.