Asthma inhaler not working

Key Facts

  • Asthma affects how you feel and breathe.
  • Asthma runs in families.
  • There’s no cure for asthma, but it can be controlled.

Asthma is a chronic condition of the lungs that affects how you feel and breathe. It’s not contagious-you can’t get asthma from someone else (like a cold), and you can’t pass it on to anyone else. You can have symptoms that occur every day, weekly, every few months, or hardly at all. Some children seem to outgrow it, but most teens with asthma will continue to have symptoms as an adult. Most importantly with the proper treatment, people with asthma can have normal and active lives.

What exactly happens when I have asthma symptoms?

When you have asthma, the airways in your lungs are swollen and inflamed. The airways are the tubes that carry air in and out of your lungs. When you are exposed to something that irritates the airways, they start to narrow, getting smaller with less air able to move in and out. Muscles in and around the swollen airways get tight and more mucous is made. This causes you to have trouble breathing, with chest tightness, coughing, and sometimes “wheezing”, or a whistling sound when you breathe.

What are of the most common symptoms of asthma?

  • Coughing, especially during the night, early morning, when outside in the cold air or while exercising
  • Wheezing that can be heard when you breathe
  • Shortness of breath or trouble breathing
  • Chest tightness or pain which may feel like someone is sitting on your chest or squeezing it

If you have any of these symptoms, talk to your health care provider!

Asthma symptoms can range from mild to severe – from being a little annoying to seriously affecting how you are feeling. When symptoms are severe, asthma can be life threatening.

Will I always have asthma?

Studies have shown that asthma usually does not go away, and that the swelling in your lungs actually stays there even when your asthma is not bothering you. This is important to know because you need to pay attention to how you feel and if your breathing changes.

It’s true that some people only have asthma as a child and never seem to have symptoms again. Others can have symptoms their whole lives. Finally, there are other people who have no symptoms for years and then have it bother them again, many years later. It’s important to remember that asthma is a chronic condition, which means it can keep coming back, unlike a common cold which is temporary. As a teen with asthma, you will probably have it as you grow into adulthood.

Remember: Asthma is very treatable and you should be able to live a normal, healthy life, and be as active as you would like. In fact, some teens forget to mention they have asthma (or a history of asthma) to a new health care provider or their school nurse. It is very important to remember to tell your health care provider or someone else involved in your health about your asthma and what medications you are taking even if you have not had any symptoms for a long time. Learn the name and dosage strength of your asthma medications as many medications come in different strengths- it’s not enough to just identify asthma medications by the color of the inhaler! And, ALWAYS use a spacer device when using your inhaler – it guarantees the right amount of medicine getting into your lungs instead of all over your mouth and throat.

Causes

What causes asthma?

No one knows for sure what causes asthma, but doctors have found that certain things in the environment can irritate a person’s breathing and cause symptoms. Asthma runs in families, and teens who are overweight are more likely to have asthma. Most teens who are diagnosed with asthma have allergies that can aggravate their breathing.

What are triggers?

Triggers are things in the environment that bring on asthma symptoms or “asthma flare-ups” (sometimes called asthma attacks). Some triggers such as pollen will only affect people with asthma during certain seasons and not throughout the year. Others may have symptoms only when they are around a cat, for example.

The following categories and list of “triggers” can cause asthma symptoms for some people.

Allergens (things that you’re sensitive to that cause a type of allergic reaction):

  • Dust mites
  • Animal dander – (which is from skin, fur or feathers of animals)
  • Cockroach and rodent droppings
  • Pollen from trees, grasses, weeds, and flowers
  • Mold and mildew

Irritants (smells and other things that you might inhale (breathe in) through your nose, mouth and into your lungs):

  • Cigarette smoke – both smoke from your own cigarette or someone else’s
  • Strong smells – perfumes, make up, cleaning products, scented candles, fresh paint, room deodorizers, gasoline
  • Chalk dust, wood smoke
  • Air pollutants-smog, diesel fuel and factory emissions

Weather:

  • Cold air
  • Hot temperatures, humidity or “sticky weather”

Exercise:

  • Sports and other physical activities (such as running) that cause sudden and rapid breathing

Viral infections:

  • Colds and flu or other infections of the nose, throat, lungs, etc. that can cause coughing, sore throat, and/or trouble breathing

Dealing with Triggers

The thing about triggers is that one type of trigger (let’s say dust mites) may cause your friend’s asthma symptoms, but another kind of trigger (such as dog dander) may bring on your symptoms. Triggers can vary among people. While taking your medicine and avoiding your triggers is the best way to control asthma and prevent symptoms, you can’t always avoid triggers in the environment.

You can, however, be proactive about certain things such as:

  • If you are allergic to dust, keep your bed and bedroom as dust free as possible. (Carpets, drapes, and stuffed animals collect dust and dust mites – get rid of these items if possible.)
  • Cover your mattress with a protective zippered case to keep dust mites out.
  • Wash your sheets in hot water at least once a week.
  • Vacuum and dust your sleeping and living areas at least once a week.
  • Don’t buy scented health and beauty products or cleaning products with strong scents.
  • Quit if you smoke.
  • Stay in an air conditioned place if the air quality outside is especially bad (on humid/hot days).
  • Get a yearly flu shot.
  • WASH YOUR HANDS often – This is the #1 way to lower your risk of catching colds or the flu.

Try keeping a symptom diary. Jot down what the weather was like, what you were doing, what time of day it was, etc. when you have asthma symptoms.

What Next When Your Patient Doesn’t Respond to Therapy?

ABSTRACT: There are a number of options to consider in patients with difficult to control asthma. Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long-acting betaagonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.

A 23-year-old woman’s asthma symptoms have worsened during the past year. Specifically, she notes increased wheezing during the day and more nighttime attacks that wake her up. She has been using her inhaler several times each day and almost every night. During the past year, she has been hospitalized twice because of her asthma; in the past month, she has made 3 unscheduled office visits and 1 emergency department (ED) visit. This woman’s case exemplifies the fact that asthma cases are on the rise. Asthma is a chronic inflammatory disease of the airways that affects 24.6 million persons in United States.1 An estimated 10.6 million asthmarelated visits were made to physician offices, in addition to the 1.6 million ED visits in 2006 alone.2,3 Asthmarelated costs and expenditure amount to more than $30 billion each year.4 Asthma continues to be a significant burden on the medical infrastructure, in spite of ardent measures taken by the different organizations. In this article, we will discuss options to consider in a patient with difficult to control asthma.

ASTHMA MIMICS
Keep in mind that “all that wheezes is not asthma” (Table 1). When asthma does not respond to traditional therapy, it may be because the patient has another syndrome that mimics asthma, or because he or she has a comorbid condition that complicates it (Box I). The 2 most common syndromes that mimic asthma are vocal cord dysfunction and upper airway obstruction. Both may result in dyspnea and apparent wheezing, yet show little or no response to standard asthma therapy. Vocal cord dysfunction. Also called “factitious asthma,” vocal cord dysfunction causes recurrent, severe shortness of breath, and inspiratory stridor that is easily confused with wheezing. The condition typically occurs in women between the ages of 20 and 40 years. Keep in mind that concomitant asthma may be present. Patients often present in respiratory distress, and inspiratory stridor is the principal finding on physical examination, although this is often mistaken for wheezing. Arterial blood gas levels are usually normal, but there may be alveolar hypoventilation with increased carbon dioxide concentration.

Results of pulmonary function tests are also usually normal, although they may demonstrate a flattened inspiratory loop that is consistent with extrathoracic obstruction. The condition is often associated with psychological problems; many patients have depression, anxiety, or post-traumatic stress disorder. The physiologic basis is the paradoxical adduction of the vocal cords on inspiration (they normally abduct during both phases of the respiratory cycle). The diagnosis is thus confirmed by direct visualization of the cords. A bronchoprovocation test may also help rule out true reactive airway disease. Treatment of vocal cord dysfunction is difficult, although speech therapy to teach the patient to relax the throat muscles may help. The role of psychiatric therapy is controversial.

Upper airway obstruction. Although less common, this can have the same presentation as vocal cord dysfunction and is also frequently misdiagnosed as asthma. Possible causes of upper airway obstruction include benign or malignant neoplasm, increased soft palate tissue, tonsillar hypertrophy, foreign-body aspiration, goiter, and tracheal stenosis. As with vocal cord dysfunction, diagnosis of upper airway obstruction usually requires direct visualization of the oropharynx, either through physical examination or by bronchoscopy. Other mimics. Other conditions that may be confused with asthma include chronic obstructive pulmonary disease, bronchitis, congestive heart failure, bronchiectasis, and recurrent aspiration. Each of these requires specific therapy and may need to be ruled out if an “asthmatic” patient fails to respond to standard asthma medications.
WHAT IS ASTHMA CONTROL?
A considerable portion of the newest guidelines (National Asthma Education and Prevention Program Expert Panel Report 3 ) is devoted to defining and helping clinicians understand the concept of asthma control.5 Simply, asthma control is the level of control patients achieve while they are receiving their current therapy. It refers to current symptoms (eg, need for use of beta-agonists, nighttime awakenings) and future risk of exacerbations. The guidelines recommend the use of simple patient questionnaires, which can be easily scored to determine asthma control. If asthma is not well controlled, therapy needs to be stepped up to achieve better control. One simple test, the Asthma Control Test, can be accessed online or at www.asthmacontrol.com.
HURDLES IN ACHIEVING OPTIMAL CONTROL
Good asthma control entails occurrence of daytime symptoms not more than twice per week, nighttime symptoms not more than twice per month, use of rescue inhalers no more than twice per week, forced expiratory volume in 1 second (FEV1) or peak flow levels higher than 80% of the predicted or personal best, and no more than 1 exacerbation during the previous year.5 It has been noted through different surveys that both patients and physicians underestimate the severity of symptoms or overestimate the patient’s level of disease control.6
Asthma education. Asthma self-management education, with specific plans for daily management and recognizing and handling worsening disease, is associated with favorable outcomes in persons with chronic asthma.5 Patient education decreases asthma-related hospitalization and improves daily function. 5,7,8 Encourage patients and family members to be active partners in the management of the disease. This can be achieved by identifying concerns and preferences regarding treatment, developing treatment goals, and encouraging active selfassessment and self-management of asthma.

Inhaler technique. Improper use of the device limits the effectiveness of the medication delivered and results in considerable disruption to the daily life of an asthmatic patient. Three different basic inhalers are available on market now: metereddose inhalers (MDIs), dry powder inhaler (DPIs), and nebulizers. Poor inhaler technique can markedly reduce the proportion of drug that reaches the lung and, thus, result in inadequate treatment—which both patient and physician may mistake for failure to respond. When a patient uses an MDI, the inhalation should be slow, whereas with a DPI, it should be as deep and hard as possible.9 Metered-dose inhalers. Poor coordination, which is especially common among those who are ver y young or very old, is one of the most frequent mistakes patients make when using an MDI and it significantly reduces lung deposition.9 Patients often inhale too fast when using an MDI. Stopping inhalation at the time of actuation is another common mistake. Educational and motivational programs aimed at teaching the proper inhaler technique should be instituted at each visit (Box II).

After instruction, observe the patient’s technique. Choosing a device preferred by the patient on the basis of ease or comfort is also helpful. Spacers. An alternative in patients with poor technique is to use a spacer or a holding chamber. It decreases drug deposition in the oropharynx by facilitating delivery, reducing local adverse effects, and improving lung deposition. To use the spacer, the patient discharges the MDI into the chamber and within 3 to 5 seconds begins to inhale slowly. It still requires some coordination, and it can decrease the output of an MDI because of deposition and static electricity in the chamber. Most commercially available spacers seem to offer similar results, and they can certainly improve deposition in patients with poor technique.10 However, spacers may also reduce compliance, since these bulky devices are inconvenient to carry. Many insurance companies will not pay for the device, and they can be difficult to clean. Dry powder inhalers. DPIs improve delivery for patients who are unable to use an MDI properly. Their drug delivery has been shown to be equivalent to or slightly better than that of MDIs. The patient’s inhalation flow interacts with the resistance inside the DPI to generate a turbulent flow, which releases the formulation. Patients must perform a rapid inhalation of 1 to 2 seconds. If this does not occur, the emitted particles are too large and are deposited in the oropharynx. Another problem with DPIs is reduced effectiveness during periods of severe wheezing and in patients with low pulmonary function, because the devices are effort dependent.

Nebulizers. Yet another option is aerosolized delivery via a nebulizer. Although the drug delivery of a nebulizer is equivalent to that of a properly used MDI, a nebulizer may provide better delivery for patients who are unable to learn other methods. However, these devices can be bulky and expensive, and many newer controller medications are not available by this route.

Noncompliance. One of the main reasons for uncontrolled asthma is noncompliance with medication. Poor compliance can result from inadequate understanding of the disease and treatment, fear of adverse effects, and insufficient communication between the patient and physician. In one survey, 87% of physicians believed that their patients stopped controller medications without their advice. Inhaled corticosteroids are associated with the poorest rates of compliance.11 In another survey, at least 50% of patients refused to use higher inhaled corticosteroid doses prescribed for regaining asthma control.12 There are no easy shortcuts to take to improve patient adherence to medication regimens. Take time to teach patients about the disease, its pathogenesis, and its triggers. Frequent follow-up visits are an ideal way to provide time for education, to assess compliance, and to remind patients to continue appropriate therapy. Have written action plans for the management of exacerbations. Make sure patients understand the importance of maintenance therapy despite lack of symptoms; in particular, stress the need to use inhaled corticosteroids regularly.

Allergen exposure. A number of allergic triggers clearly influence asthma severity (Table 2).

Identifying and reducing exposure to these triggers is a worthwhile goal for all patients with asthma; for those with refractory asthma, it is vital. Question the patient about seasonal and food allergies, environmental conditions in the home, pets, occupation, and hobbies. The key is to minimize exposure. Radioallergosorbent test (RAST) serology— which determines the presence of specific IgE antibodies—or skin testing by an allergist may be helpful. The most common outdoor allergens that act as triggers are pollens and mold spores. Advise patients to remain indoors in an air-conditioned environment as much as possible during the spring and fall seasons, especially during the afternoon when pollen counts peak. Common indoor allergens include animal dander, dust mites, cockroaches, and mold. Encourage patients to encase their pillows and mattresses in impermeable covers and wash all linens frequently in hot water to avoid dust mites.13 Instruct them to reduce humidity levels to less than 50% with an air conditioner or dehumidifier. Occupational exposure to allergens can usually be determined only by the history—either by asking patients about the presence of chemicals, dust, or fumes in the workplace or by documenting the presence of symptoms. Patients often report that their symptoms abate over the weekend and are exacerbated when they return to work. Air flow measurements that demonstrate reduced peak flow values while at work can be confirmatory.

Finally, be alert for irritants, such as air pollution, fumes, smoke, and sprays. Common sources include per fumes; cigarettes; cleaning agents; and indoor stoves, fireplaces, or heaters that lack proper ventilation. Affected patients will benefit from immunotherapy, which is discussed below.
COMORBID CONDITIONS
There are several co-existent diseases that might cause worsening of asthma control. Conditions that complicate the diagnosis of asthma are gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), chronic sinusitis/rhinitis, obesity, chronic stress/depression, and allergic bronchopulmonary aspergillosis (ABPA).

Gastroesophageal reflux disease. GERD is increasingly recognized as a trigger for asthma exacerbations. The exact nature of the interaction is not yet understood. Hypotheses include micro-aspiration of acid, which causes bronchospasm, or a reflex action in which refluxed acid causes an increase in vagal tone that in turn results in increased airway resistance. Consider GERD in any patient whose asthma worsens at night, when reflux is more likely to occur. Medical management with a proton pump inhibitor often ameliorates asthma symptoms.14 In addition to drug therapy, lifestyle modifications— weight loss, low-fat diet, avoiding food before going to bed, and sleeping with the head of the bed elevated—can be beneficial. In patients with asthma who are receiving GERD therapy, monitor the clinical response and measure peak flow. If there is no evidence of improvement, change or discontinue antireflux therapy. If there is any question about the diagnosis or treatment of GERD in such patients, consider referral to a gastroenterologist.

Obstructive sleep apnea. A high prevalence of OSA has been reported in patients who have unstable asthma.15 Patients with concurrent OSA and asthma have worsened nighttime symptoms. This can be attributed to dual mechanisms: hypoxemia during obstructive apnea episodes may predispose to increased bronchial reactivity5 and sleep disruption secondary to nocturnal asthma results in periodic breathing with decreased upper airway muscle activity, contributing to upper airway obstruction. Therefore, patients with difficult to control asthma and a higher likelihood of OSA should undergo screening nocturnal sleep oximetry. Rhinitis/sinusitis. Whether related to an allergic or infectiouscause, these disorders are often under- recognized as causes of asthmatic flares. Since upper and lower respiratory tract mucosal properties are identical and exist in continuity, rhinitis and sinusitis have been shown to induce inflammatory markers in the bronchial epithelium.16 Treat asthmatic patients who have co-existing rhinitis or sinusitis with nasal corticosteroid preparations or antibiotics as indicated.

Obesity. Improvement in FEV1, reduction in exacerbations, and improved quality of life were noted in obese asthmatic patients following weight loss.17 EPR-3 guidelines suggest that physicians encourage weight loss in obese and overweight asthmatic patients.5

Psychosocial factors. Stress and depression can precipitate asthma.5 Inquire about possible stressors in patients with difficult to control asthma at every office visit.

Allergic bronchopulmonary aspergillosis. Suspect ABPA in patients with asthma, recurrent cough, and pulmonary infiltrates on a chest radiograph. Patients with ABPA will have a positive skin test to Aspergillus species, elevated total serum IgE level, and central bronchiectasis on a chest CT scan. Treatment consists of oral corticosteroids and antifungal agents (eg, itraconazole).

Drug-induced asthma. At least 30% of patients with asthma may have a sensitivity to aspirin. Samter’s triad, or “triad asthma,” is a syndrome that involves aspirin sensitivity, asthma, and nasal polyps. The syndrome can be triggered not only by aspirin but also by NSAIDs. Strict avoidance of NSAIDs is the first line of therapy. Leukotriene modifiers are used to treat NSAID-induced asthma; these agents seem particularly effective and may become the mainstay of therapy. In those patients who absolutely need aspirin treatment, desensitization is another option to decrease disease activity.18 Consider nonselective beta-blockers as a potential cause of bronchospasm, especially in cardiac patients with asthma. Bronchospasm can also be precipitated by topical ophthalmic solutions that contain beta-blockers. Switching to an alternative agent is preferable, but if a beta-blocker is absolutely necessary, use a cardioselective agent.
PHARMACOTHERAPY
After a thorough workup (Table 3), what more can you do for patients who continue to have asthma symptoms, even though they are compliant with their inhaled corticosteroid regimen, have good technique, and have no alternative diagnoses or comorbid conditions? Such patients need additional medication to control their disease. The general approach to asthma has been to target airway inflammation and to relieve bronchoconstriction (Table 4).

Inhaled corticosteroids. These are the mainstay of asthma treatment. Increasing the dose of the inhaled corticosteroid may provide modest benefit. However, inhaled corticosteroids, especially at high doses, have been associated with growth retardation in children and with glaucoma, cataracts, skin bruising, and osteoporosis in adults. It may be preferable to achieve control by adding another agent and by keeping the corticosteroid dose low or moderate.

Long-acting beta-agonists. The EPR-3 guidelines suggest adding a long-acting beta-agonist (LABA) to an inhaled corticosteroid regimen if greater control is required.5 The addition of a LABA ameliorates symptoms and improves lung function more effectively than an increase in the dose of the inhaled corticosteroid. 19 LABAs are particularly useful for controlling nighttime symptoms. These agents provide effective relief of asthma symptoms, although they do not address the underlying inflammation and are not recommended as monotherapy. A combination inhaler that delivers both a LABA and an inhaled corticosteroid in one device has theadditional benefit of simplicity and may improve compliance.

Recently, the FDA approved several newer combinations (Symbicort, Dulera) that provide prolonged bronchodilation and symptom control. Studies have suggested that LABA therapy can be dangerous and has been linked to worse outcomes, including asthma-related deaths. This has led to a series of FDA warnings about the use of these agents.20 However, many experts (including the authors) continue to find the use of LABAs in combination with inhaled corticosteroids to be safe and effective therapy when a patient’s asthma is not controlled on a low or medium corticosteroid dose alone. Long-acting anticholinergics. Recent data suggest that the use of long-acting anticholinergics has similar efficacy compared with adding a LABA to an inhaled corticosteroid and is superior to doubling the dose of the corticosteroid.21 This may provide an alternative approach in patients who cannot tolerate LABAs. These data, however, have not yet been incorporated into national guidelines or received FDA approval.


Leukotriene modifiers. They are not as potent an additive agent as LABAs, but they work in conjunction with inhaled corticosteroids to provide additional asthma control.22 In addition, leukotriene modifiers have the advantage of oral dosing, which is especially helpful for patients who have dif ficulty in using an MDI. They also are effective in patients with allergic rhinitis, which makes them an attractive option for those who have both allergic rhinitis and asthma.

Theophylline. It is now used only for add-on therapy because of its adverse effects (eg, tachycardia and numerous drug interactions). Use caution when prescribing theophylline, particularly in elderly patients who may have concomitant heart disease; be sure to monitor blood levels in such patients.

Systemic corticosteroids. Although systemic corticosteroids have a poor side-effect profile, some patients may fail to respond to any other therapy, particularly during acute exacerbations. When these agents must be used, taper the dosage as rapidly as possible. Watch for and counsel patients about adverse effects, which include glucose intolerance, cataracts, and osteoporosis. For those who are receiving longterm systemic corticosteroids, bone densitometry measurements at the start of therapy and 6 months later may be indicated.

Immunotherapy. The EPR-3 guidelines suggest consideration of immunotherapy for patients who continue to have severe asthma symptoms despite treatment with a multidrug regimen.5

Omalizumab. This is an alternative add-on agent for those patients with moderate to severe allergic asthma. 23 It is a monoclonal antibody that binds IgE and thus works early in the inflammatory cascade. Omalizumabreduces both symptoms and exacerbations, and studies have demonstrated the effectiveness of adding this drug to the regimen of patients who have poor control with combination LABA–inhaled corticosteroid therapy. Rare anaphylactic reactions have been associated with its use, and the drug should be administered by injection in a physician’s office.
FUTURE THERAPY
Newer combination therapies are expected to be introduced over the next few years. A number of noncor ticosteroid anti-inflammator y medications are being studied. New, more potent, once-daily LABA–inhaled corticosteroid combinations are in late stages of development as well.

When The Inhaler Just Won’t Cut It

I’ve blogged about this before – whether to use my inhaler or my nebulizer.

Example of a real-life instance

Well, here’s a real example of having to decide and what worked and what didn’t.

I had a fun time this week! I was exposed to something that my over-active little asthma lungs did NOT like.

It started first with the tickle in the back of the throat.

Then came the cough.

I quickly grabbed my asthma inhaler and took two puffs (spaced 1 minute apart as they should be!)

I continued to cough. I coughed so hard that I thought I was going to throw up. I sounded like Wheezy from Toy Story.

Except Wheezy could talk. When I have a REALLY bad asthma attack, I lose my voice (I’m sure my husband LOVES it when that happens! )

Nebulizer to the rescue!

Several hours later, I was still having bad coughing spells and it felt like my lungs were on fire. So I pulled out the nebulizer to have a breathing treatment. If you haven’t used a nebulizer, National Jewish Hospital in Denver has a short video that shows how they work.

When I use my nebulizer, I can just sit on the couch and take small breaths and get the medicine into my lungs. With my inhaler, I have to breathe in deeply to suck the medicine in. And sometimes I just can’t do that. If I try to breathe deep, I instantly start coughing.

For me, the inhaler works fine for “minor” asthma attacks, but when a “major” attack hits, only a nebulizer will do. I KNEW I would feel better when I used the nebulizer. The horrible cough stopped, my voice came back (much to my husband’s chagrin!) and the burning pain in my lungs stopped.

Use what’s right for you. Sometimes you can use your inhaler and be fine. Other times only the nebulizer will do.

Talk with your doc and come up with a plan.

Let’s keep breathing!

7 Ways Your Doctor Can Help if Your Current Asthma Treatment Isn’t Working

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If you’re taking your asthma medications as prescribed, but still experiencing symptoms or frequent asthma attacks, it may be time to talk to your doctor about adjusting your treatment plan. While there’s no cure for asthma, the condition can be controlled with proper treatment, according to the National Heart, Lung, and Blood Institute (NHLBI).

So why aren’t you seeing results when you use your controller and rescue therapies? Your doctor may need to do additional tests to determine the answer and the right strategies to provide you relief. And it’s important that you do. Not only can uncontrolled asthma accelerate loss of lung function and lead to more frequent hospitalizations, it can be life-threatening.

A couple signs to watch for: If you have daily symptoms that limit work or school attendance, interfere with daily activities, or disrupt sleep, or if you’re using your rescue inhaler more than usual.

“It’s also important for patients with asthma to have regular visits with their doctors because sometimes changes in asthma activity can be relatively silent and only detected by physical examination or lung function testing,” says Bruce Levy, MD, the Parker B. Francis Professor of Medicine and the division chief of the pulmonary and critical care division at Brigham and Women’s Hospital in Boston.

Here are seven things your doctor might do if your current treatment plan isn’t keeping your asthma symptoms under control.

1. Adjust or change your medication

Treatment for asthma generally consists of quick-relief (or rescue) inhalers, taken when your symptoms flare up, and long-term controller medications, which are taken daily to help reduce inflammation and prevent symptoms. If you’re already taking these medications but still having shortness of breath, wheezing, and coughing, a first step may be to make sure you’re using them correctly. “Some of the inhaled medications can be difficult for patients to use correctly, so doctors often spend time teaching patients how to get the most out of their medications,” explains Dr. Levy.

Your doctor may also increase the dose of your current medications. “In all but the most severe asthma patients, this usually provides relief,” says Levy.

The next step is to try an add-on medication or explore other treatment options altogether. “Asthma therapies come in a wide array of options,” says Levy. “They are formulated as inhalers, nebulized solutions, pills, and injections. For the most severe asthma, there are even therapies that target the bronchial smooth muscle — they are administered directly through the airway by a specialized bronchoscopy procedure called thermoplasty. Patients can explore these different treatment options with their healthcare provider.”

If your doctor changes your medication dose or prescribes a new treatment, you should schedule a follow-up appointment to discuss how the treatment is working, according to Asthma UK. Together, you can continue monitoring your condition to optimize the treatment plan for your needs.

2. Test for airflow obstruction and inflammation

A variety of tests can help your doctor tailor your treatment to your specific asthma. For example, your doctor might ask you to breathe into a machine for a lung function test known as spirometry. You might then be asked to repeat the test, possibly after taking a puff from an inhaler, so that your doctor can compare results and check whether the inhaler helped improve your airflow.

Additional tests look for signs consistent with inflammation, in particular allergic inflammation, says Levy. These tests might include a peripheral blood eosinophil count, serum immunoglobulin E (IgE) level, and exhaled nitric oxide level.

3. Determine if you have a more severe form of asthma

If your asthma is uncontrolled or partially controlled despite taking high-dose inhaled steroids plus a second controller medication, or taking oral corticosteroids, you may have severe asthma, according to guidelines from the American Thoracic Society and European Respiratory Society. Severe asthma doesn’t respond to standard treatments, but there may be other options for you.

For instance, nearly half of people with severe asthma have high levels of eosinophils in their lungs and blood, according to the NHLBI. These white blood cells can build up and cause inflammation and swelling in your airways, and today, medications called biologics can be prescribed to target those eosinophils. To diagnose eosinophilic asthma, your doctor will perform a blood test, a sputum induction test, or a bronchial biopsy to measure your level of eosinophils.

4. Identify hidden triggers

Does your asthma get worse in certain situations? Many people have triggers — often allergies. To figure out your triggers and where they’re lurking, your doctor might ask detailed questions, help you recognize patterns, and even order a blood test. If we identify asthma triggers, we can develop strategies to help you avoid those triggers, says Levy. “This can be challenging and is a bit like detective work,” he says.

Here’s how you can help: Keep an asthma diary that tracks your symptoms, where you were and what you were doing when you experienced an asthma attack, and any factors that may have triggered it.

5. Diagnose conditions that make asthma worse

Sometimes the problem isn’t just your asthma; something else may be aggravating your symptoms. For example, chronic sinusitis with post-nasal drip, gastroesophageal reflux disease, and obesity can all aggravate asthma or make it more difficult to control, says Levy.

6. Provide tips for healthy habits

While lifestyle changes won’t cure asthma, people tend to manage their symptoms better when they eat a healthy, well-balanced diet, exercise regularly, and sleep well, says Levy. Stress-reduction techniques like mindfulness, meditation, and deep breathing can also be beneficial: Stress and anxiety can lead to shortness of breath, too, so keep them in check to better manage asthma.

7. Help you develop an emergency plan

Asthma attacks can sometimes become emergencies, and during severe symptoms you may not be able to speak up and ask for help. Be prepared: “It’s very important for patients with severe asthma to develop plans for seeking urgent help from friends and family members, which might include assisting with a home treatment or transporting you for an emergency evaluation and treatment,” says Levy.

Your emergency plan should also include a list of all your medications, allergies to medications, healthcare providers’ names and contact information, and your preferred urgent care center or hospital, says Levy. Make it digital to easily share with family, friends, or coworkers. “I also suggest that patients with severe asthma keep an updated record of their most recent pulmonary function tests and blood test results to share with providers who may be unfamiliar with their history,” he says.

Can I stop depending on an inhaler to control my breathing problems?

Based on the information you have provided, your symptoms seem to be compatible with asthma that is not completely controlled. Asthma can present at any age.

While salbutamol is of benefit as a “rescue inhaler,” it should not be used on a daily or very frequent basis. Patients with frequent asthma symptoms generally need a “controller inhaler,” which includes an inhaled steroid. Asthma is a very controllable disease, but so far there is no “cure” for asthma.

Allergies can create airway inflammation in allergic patients and make patients more sensitive to other triggers such as cold air and running. However, not everyone with asthma has allergies.

Your allergist can assist to determine if you are allergic to inhalant allergens such as pollen or dust mites.

If a patient has inhaled allergen sensitivities, treatment with allergen immunotherapy (allergy shots) may help to relieve asthma symptoms. Allergen immunotherapy is the closest thing that we have to a cure for asthma.

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When a baby is sick with fever, cough, and a wheeze, it’s natural to think that what they need is medication — like an antibiotic, or one of the medications used to treat wheezing in children with asthma (such as albuterol). But it turns out that if a condition called bronchiolitis is the culprit, the best treatment is no treatment.

Bronchiolitis is a bad cold (caused by various viruses) that settles into the lungs. When it does, it leads to fever, lots of congestion, cough, and noisy or wheezy breathing. It’s incredibly common. In fact, one in five babies under 12 months ends up at the doctor’s office for bronchiolitis — and 2% to 3% end up hospitalized. It can be quite serious, especially when it’s caused by a particular virus called respiratory syncytial virus (RSV). While here in the US it’s rarely fatal, in other countries with fewer medical resources, thousands of babies die of bronchiolitis every year.

If it can be so serious, why do the latest guidelines say that doctors shouldn’t use antibiotics, albuterol, or other treatments? Because they don’t help — and they can have side effects that aren’t good for babies.

It’s not that we can’t do anything at all to help babies with bronchiolitis. We just need to help them in different ways.

Certain babies have a higher risk of getting really sick with bronchiolitis. Those include babies who are born prematurely, babies with lung disease or heart disease, and those who have a problem with their immune systems. For those babies, we recommend that they get a monthly shot, called Synagis, during the winter (roughly September to March) to help prevent RSV. If your baby falls into one of those categories and is less than a year old, you should absolutely talk to your doctor about this treatment.

For other babies, what we recommend is that families and caregivers use non-medical ways to help them feel more comfortable and breathe easier. They include:

  • lots of fluids — dehydration can make all that congestion worse
  • a humidifier, to loosen the congestion
  • a bulb syringe to clear out the baby’s nose (nasal saline drops, available at any pharmacy, can help you get more out of the nose)
  • acetaminophen or ibuprofen for fever.

You should always check in with your doctor if you think your baby has bronchiolitis, and your doctor may want to see the baby to be sure that it’s not something else that does need treatment. You should also call your doctor if, after being diagnosed with bronchiolitis, your baby develops

  • a high fever (more than 102 degrees Fahrenheit), or a new fever after being sick for a few days
  • trouble breathing that doesn’t get better with the humidifier or the bulb syringe (signs of trouble breathing include rapid breathing or sucking in around the ribs)
  • a pale or blue color to the skin
  • sleepiness or irritability that is much worse than normal
  • refusal to take fluids, or not wetting diapers every 6 hours.

It’s most likely that these won’t happen, and that your baby will be just fine. As with so much in medicine and parenthood, what babies with bronchiolitis mostly need is lots of TLC — and some patience.

(Watch the video right above this sentence!)

COUGHING

Find someone who doesn’t have kids and ask them to describe a toddler in winter, and you’ll get a picture of a boogery, oozy, coughing little person. (Actually, asking a parent with kids will probably give you the same answer!)

The first few years of childhood are riddled with dozens of colds. In fact, because the average child’s colds last between 15 and 25 days each and come 8 to 12 times a year, it can often seem like your kid has a cough from September straight through March.

So knowing what’s going on and how to fix it can make your life—and your child’s—so much easier!

What’s going on?

Most common cold symptoms are caused by mucus. You see, the nose, throat, ears, and sinuses are all connected. Mucus from a stuffy nose drips down the back of the throat—both during the day and especially at night—and irritates the back of the throat. Even without a runny nose, the same thing happens with mild sinus congestion. The result is that your child ends up coughing for two reasons: first, to clear away the mucus that’s dripped down, then because the back of the throat feels irritated.

Why does it sound so bad?

Kids can’t cough mucus up and out on purpose until they are 6 to 10 years old! Yup, years. So that means that all your child can do is move the mucus around, making for some nasty-sounding, old man hacking coughs.

Why does it take so long to go away?

Parents’ jaws often drop when I say that the average kid cold lasts between 15 and 25 days. Why so long? Once the back of the throat is irritated by mucus, it can take a week to two weeks to heal—and it doesn’t really start healing until the mucus stops dripping down.

So what can you do for it?

The absolute best thing that you can do for a basic cough is to try and attack that postnasal drip mucus. As simple as the following tools seem, they are definitely the best for the job:

  • Saline nasal spray – Kids tend not to like this, but it’s the best. A few sprays in each nostril before bed can help to reduce or thin out the mucus that would drip down while they sleep.
  • Shower steam & humidifiers – These also help to moisten the airway & thin out the mucus.
  • Water – Drinking a glass of water (or breastmilk/formula for an infant) as soon as your child wakes up can help to wash away whatever mucus did drip down overnight.
  • Cut down on lactose – This is somewhat controversial, but many people report that lactose causes the sensation of thicker mucus in the throat. Trying lactose-free milk for a few days might help prevent this.

These things may not make your child feel better that same day, but they’ll help to shorten the duration of the cough.

You can also help your child by coating the irritated throat to reduce the urge to cough. For a child over one year old, a teaspoon of honey can be used; for a child under one, use agave nectar. Some companies, such as Zarbee’s, make cough syrups that are honey- and agave-based.

When it comes to most other cough medicines, however, we pediatricians usually discourage using them. Not only do they tend not to work, they can also have some potentially serious side effects.

How can you tell if it’s pneumonia?

This is a question that many parents ask when their child’s cough sounds terrible. In order to determine that a child has pneumonia, you really need a doctor to hear it with a stethoscope or to see it in an X-ray. However, some signs that you might see include breathing faster than normal (even when any fever is down); pain in the chest, back, or belly even in between coughing fits; or fever that either is hard to bring down or lasts longer than three days.

When to get checked out

This is often the toughest decision. Some parents prefer to wait and see how things go, whereas others come the morning after their child starts coughing. In addition to following your gut, use the points below as basic guidelines for when to call your doctor:

  • Urgently – if there are any of the Signs of Distress
  • Within 24 hours – if there is cough + fever and:
  • You can’t bring the fever down with a proper dose of Tylenol or ibuprofen (see the blue bar at the top of the page here for proper dosing), OR
  • The fever lasts 3 or more days, OR
  • The fever came on in the middle of the illness—this means that the infection has changed, so we’d need to rule out pneumonia, an ear infection, or some other secondary infection.
  • Within a day or two – if the cough has lasted longer than two weeks. While the average cold in kids lasts 15-25 days, I like to take a listen to any child who’s coughed longer than two weeks just to make sure that we aren’t missing a wheeze or mild pneumonia.

CROUP

Croup is one of the most common infections that kids get—and also one of the scariest.

The typical story is that a child is perfectly fine when you put him down to sleep, but then he wakes up at 2AM with a seal-bark cough and a hard time breathing. Whenever I get a phonecall in the middle of the night in the winter, I know it’s likely about a child with croup.

This can be nerve-wracking for parents, but it’ll be less so if you know what’s going on and how to fix it.

Croup is a process caused by several different viruses that attack the upper part of the airway (think: in the neck near the vocal cords & Adam’s apple). This part of the airway is already small in kids, so the swelling caused by the infection ends up blocking a lot of the passage that air is supposed to travel.

Sometimes, significant postnasal drip, usually in allergy season or from a bad cold, can do the same thing: a large amount of mucus drips down, essentially blocking a big portion of the upper airway.

The result of all of this is that it’s hard for your child to breathe in.

Think of it like this: Have you ever sucked through a straw when there’s an ice cube stuck at the bottom? The straw collapses on itself, right? With croup, the part of the airway that’s swollen or full of mucus is the ice cube, and the airway’s highest part is the straw—trying to breathe in against the swollen part makes the upper part of the airway collapse on itself.

What are the signs of croup?

Your child is likely to have at least one of the following: a seal-like barky cough and/or stridor (see “Signs of Distress” above).

The seal-like barky cough is the result of coughing against the swollen airway, and stridor is the result of trying to breathe in through that swelling.

If your child is really working hard to breathe, you might even see retractions above the collarbone with each inhalation.

Traditional croup usually lasts about five days, with the worst being the first three nights. Croup is always worst at night.

What can you do for it?

There are two ways to treat croup at home, and they are exact opposites: shower steam and cold air.

  • Shower Steam – Turn your shower on to hot. Shut the bathroom door and allow the room to fill with steam. Sit with your child on the floor or on the toilet, allowing her to breathe in the steam for 10-20 minutes.
  • Cold Air – Bundle your child up and sit outside in the cold for 10-20 minutes. If it’s not cold outside, open the freezer door and let your child breathe the cold air that escapes. (For my own kids, I’ve often found cold air to be more effective than steam.)

What happens in the ER?

The goal of using shower steam or cold air is to help your child get comfortable enough to fall back asleep. However, if you’ve tried 10-20 minutes of each of these tricks and your child either can’t fall asleep or can’t stay asleep, then the next step is a trip to the ER.

In the, ER, your child will likely receive an oral steroid or a steroid shot. The steroid quickly reduces the swelling in the upper airway, basically eradicating the cause of croup’s symptoms. One steroid that’s often used (dexamethasone) lasts for up to 72 hours, essentially covering your child for the three worst days of croup.

Some children will also require nebulized epinephrine in the ER. This is a medicine in a mist-form that your child breathes in to help relax some of the tightening of the airway.

NOTE: Your pediatrician can prescribe the oral steroid for use at home. Most of us try to avoid steroids when we can, so we don’t use this for every child with croup. Instead, we tend to prescribe the steroid when a child has stridor or retractions in the daytime—knowing that croup will be worse at night, we’ll err on the side of treating with the steroid when the daytime already looks bad.

Croup can often be treated at home with the shower steam or cold air. However, use these as guidelines for when to call your doctor or be seen:

  • Urgently – if there are any Signs of Distress and 20 minutes of steam and/or cold air haven’t gotten rid of them
  • Urgently – if your child’s breathing sounds a little better, but you can’t get her to settle and get back to sleep
  • Within 24 hours – If you feel that you need more guidance from your pediatrician. Usually, if none of the “Urgently” criteria are met and your child is doing well in the daytime, there isn’t much more to be done. However, always seek advice from your pediatrician if you have any questions or concerns.

WHEEZING

Together with croup, wheezing is one of the most potent causes of cough and breathing troubles in kids. In fact, wheezing is an experience that often lands kids in the ER, especially in the fall and winter months.

Keeping this on your radar and knowing what to do will be ever so helpful, should your little one ever wheeze in the future, so read on to understand all the ins & outs of wheezing!

My favorite way to explain wheezing is to have parents (and kids!) imagine the lungs as an upside-down tree: a long trunk coming down the middle (the trachea), two big branches coming off, one on either side (the bronchi), and lots of small branches at the ends (the bronchioles). Around these small branches are tiny muscles. When there is inflammation around the small branches, the tiny muscles tighten up, making the bronchioles squeeze shut. The result is that you cough to try and open them up, and when I listen with a stethoscope as you breathe, I hear a harmonica-like sound—a wheeze.

Is it asthma?

This is one of the first things parents want to know when I tell them that their child is wheezing. Is it asthma?

The truth is that most wheezing in kids is caused by a viral infection. In fact, a particular virus called RSV causes wheezing in up to 25-40% of kids by the time they’re in preschool. Some kids will never wheeze, some will wheeze once with a single infection, some wheeze with most respiratory infections, and some will end up with true asthma.

So I break it down like this:

  • Bronchiolitis – this is the name we give when kids are wheezing with a single respiratory infection; many kids will experience this
  • Reactive Airway Disease – this is what we say kids have when they tend to wheeze with most respiratory infections they get; this is fairly common in young kids, and most will outgrow it, which is why we don’t label this as “asthma”
  • Asthma – this is what we say when an older child (say, 8 years old or older) is still wheezing with respiratory infections, OR pretty much any time a child tends to wheeze with non-infectious triggers, like pollen, cat hair, exercise, cold air, etc.; this is more difficult to fully outgrow, though not impossible

How can you tell if your child is wheezing?

It’s not always easy to tell. In fact, 3 out of 4 times a parent comes in saying that their child is “wheezing,” what they’re really describing is the rattly sound you hear when a kid has mucus stuck in the upper part of the airway (sometimes you can even feel this rattle on your child’s back).

Still, there are some signs you might see. Your child may have mild retractions or might be breathing faster than normal. Usually, you might simply get the sense that the cough sounds different from or is more aggressive than a regular cold.

More often than not, though, if your child doesn’t have anything worse than a mild wheeze, a cough might be the only sign and it’ll be your pediatrician who discovers that your child is wheezing.

How it’s treated

Getting rid of a wheeze almost always requires medicine.

However, there is something you can try at home. If you don’t have any albuterol (see below) and think your child might be wheezing, you can have her sit in a steamy bathroom to try and relieve the symptoms. If, however, 20 minutes of steam doesn’t seem to help, and especially if you’re seeing any of the Signs of Distress, then seek medical help right away.

The following are the medications used to treat wheezing (they all require a prescription):

  • Albuterol – This is a medicine that your child inhales through a nebulizer or an inhaler.
    • It relaxes those tiny muscles around the small airways, opening them up for 4 to 6 hours.
    • I think of albuterol as kind of like Tylenol or Motrin: when your child has a fever, Tylenol and Motrin don’t fix the cause of the problem (an infection), they just cover the symptom (the fever) for a few hours. It’s the same with albuterol—it doesn’t fix the underlying cause of the wheeze (usually a virus), it just gets rid of the wheeze for a few hours. But since we can’t do anything about a virus, and because breathing is pretty darn important, albuterol is an incredibly helpful tool when your child is wheezing.
      • My albuterol guidelines: *Note: this is what I tell my patients; talk with your doctor and use his/her guidelines. Albuterol can be used every 4 hours if needed. If you find that your child needs albuterol before 4 hours are up (i.e., she is retracting or has a terrible cough), then you can give one extra dose once. If you find that you have to give a second extra dose before 4 hours are up, or if you find that you have to “break” another 4-hour period, then you need to contact your pediatrician—your child needs the next level of treatment.
  • Oral steroids – When albuterol alone isn’t doing a good enough job—if it doesn’t seem to last for four hours, or if it’s not working at all—then your pediatrician or an ER doc will likely prescribe an oral steroid. Remember how I said that albuterol was kind of like Tylenol in that it doesn’t fix the cause, only the symptom? Well, the oral steroid essentially fixes the cause—while it can’t fix the infection, it gets rid of the inflammation that causes the wheezing in the first place
  • Inhaled steroids (i.e., budesonide & fluticasone) – Kids who routinely need albuterol three or more days a week, plus kids who end up hospitalized for wheezing, are often given inhaled steroids to take every day. These low-dose steroids are given to prevent inflammation from infection and other triggers from ever developing, hopefully preventing a wheeze before it starts

A child who is wheezing should always be seen by a doctor right away, unless you already have the right tools to treat it at home (albuterol) and you feel comfortable doing so.

Otherwise, follow these guidelines and get checked out:

  • Urgently – If you see any Signs of Distress and you either don’t have albuterol or albuterol hasn’t fixed them
  • Urgently – Any time you think your child is wheezing and you either have never dealt with it before or have, but are uncomfortable dealing with it at home without being seen first
  • Urgently – If you already have albuterol at home, but it isn’t lasting 4 hours (i.e., your child has retractions, rapid breathing, or intensive cough before 4 hours are up)

If you are a parent, then you are bound to experience some impressive coughing in your home over the next few years, and quite possibly croup and wheezing, as well. I know that this article is a lengthy read, but I don’t think you’ll find a more thorough yet straightforward resource out there—and I hope you’ve found it helpful!

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