What is asthma

Asthma is a chronic breathing problem. The airways in the lungs (the bronchi) become inflamed, swollen, narrowed, and make more mucous than usual. The airways become reactive or sensitive to such things as smoke, dust, and pollen.

Typical changes in the airways include:

Inflammation

Recent research has shown that inflammation of the lining of the airways is the most common feature of asthma. When they are stimulated, certain cells lining the airways release chemical substances (mediators) which lead to inflammation. This causes the airway lining to swell and narrow. The inflammation may last for weeks following an episode. Most people with asthma have some degree of inflammation all of the time. Some long-term control medications can help prevent and reduce inflammation.

Normal Airway	Airway with inflammation	Airway with inflammation, bronchoplasm, and mucus production

Increased Sensitivity

Another characteristic of asthma is increased sensitivity of the airways. When inflammation occurs in the airways, the airways become more sensitive. When the airways are more sensitive, you are more likely to have asthma symptoms when exposed to things that make asthma worse. When there is less inflammation, the airways are less sensitive and you are less likely to have asthma symptoms when exposed to things that make asthma worse.

Airway Obstruction

In additoin to inflammation narrowing the airways, additional
processes contribute to airway narrowing in asthma. Obstruction worsens when the muscles around the airways tighten; this usually occurs in response to exposure to a substance which increases airway inflammation or sometimes in response to cold air or exercise. This tightening of the airway muscles is referred to as bronchospasm. Inhaled bronchodilators, or quick relief medications, are generally very effective in reversing the bronchospasm within a few minutes. Symptoms may recur when the bronchodilators wear off, especially if increased airway inflammation has not been treated adequately. Mucus glands lining the airways alos produce excessive mucus when exposed to various triggers; this further contributes to airway narrowing.

What about asthma attacks?
Asthma is a chronic breathing problem. The airways in the lungs (the bronchi) become inflamed, swollen, narrowed, and make more mucous than usual. The airways become reactive or sensitive to such things as smoke, dust, and pollen.

Some people have exercise induced asthma. These people have asthma symptoms that start during exercise, work, or play. The symptoms reach a peak after stopping physical activity. People of any age can develop asthma. It may even go away and then come back later in life. Some people develop it for the first time when they are older.

What causes asthma?
Scientists are not sure what causes asthma. Some people have a tendency for it to develop. People who smoke or have allergies are at increased risk for asthma.

What are the signs and symptoms of asthma?

• Cough, especially at night
• Frequent respiratory infections
• Chest tightness
• Shortness of breath
• Wheezing

What is the treatment?
Several kinds of medicines are used to control asthma and prevent attacks.

Relievers
Relievers provide quick relief and lessen asthma symptoms when they are present. Bronchodilators open and relax the airway muscles so that air can move in and out of the lungs. For people with mild asthma, this may be the only treatment needed. An example of a reliever is Albuterol®. Anticholinergics open airways and block increased mucous production. An example is Atrovent®.

Controllers

Controllers are used to control asthma. Anti-inflammatory medications help control airway inflammation and can prevent asthma attacks. They are inhaled or taken by mouth to reduce airway swelling and lessen mucous production. People who have asthma symptoms 2 or more times a week should take anti-inflammatory medications. Example: Fluticasone® or prednisone. Long acting forms of bronchodilators are used as controllers, for example Salmeterol®. It is important to know that Salmeterol reduces asthma symptoms, but should not be used unless an anti-inflammatory medicine is also being used. The reason for this is that salmeterol might be masking asthma symptoms without reducing airway inflammation. As a result, asthma attacks could occur more frequently and be more severe. Leukotriene modifiers are pills that lessen airway inflammation. Example: Montelukast.

How do I care for myself?
Key points:

• Learn to recognize the early warning signs of an asthma attack. Know when medical help is needed and get it!
• Talk with your doctor about using a Peak Flow Meter to help you assess your asthma.
• Watch for changes in your breathing and use your quick relief medicine before your attack becomes severe.
• Always carry your quick relief inhaler. Use it within 5 minutes after attack symptoms begin.
• If you are getting a cold or feeling short of breath or tight in your chest, use your quick relief inhaler (2 puffs, 4 or 5 times a day). If you feel you need more puffs than this, call your doctor.
• Take your controller medicines regularly even when you feel well. This will help prevent an asthma attack.
• When you travel, take your medicines and asthma supplies with you on the plane. Do not pack them in your luggage.
• Talk with your doctor about making an 'Asthma Action Plan' to help you know what to do when your condition changes.

About your dry powder inhaler (DPI)

What are dry powder inhalers?
Dry powder inhalers are breath activated. They allow the medicine to be inhaled with the force of your own breath. Currently there are 3 types of DPIs: The Serevent Diskus®, Advair Diskus®, and the Pulmicort Turbuhaler®.

How do I use the Serevent® or Advair® Diskus?
The Serevent® and the Advair® Diskus contain 60 pre-measured doses (puffs). It has a built-in dose counter and shows how many doses are left. Before each use, check the dose counter to see how many doses are left. You do not need to prime it before use.

1. Hold the Diskus® level in one hand.
2. Open it. Put the thumb of your other hand on the thumb grip. Push the thumb grip away from you as far as it will go, until it clicks. Slide the lever away from you as far as it will go until it clicks.
3. Hold the Diskus® level, away from your mouth
4. Exhale (breathe out) slowly, as much as you can.
5. Put the mouthpiece to your lips and inhale (breathe in) deeply and steadily through your mouth. Do not inhale through your nose.
6. Remove the Diskus® from your mouth and hold your breath for 5 to 10 seconds (10 seconds is best).
7. Breathe out slowly.
8. Close the Diskus®. Put your thumb on the thumb grip and slide it back toward you as far as it will go. It will click shut.
   ONE PUFF IS ALL YOU NEED.

How do I use the Pulmicort Turbuhaler®?
This contains 200 doses (or puffs). It does not have a dose counter, but a red mark will appear at the top of the window just below the mouthpiece when 20 doses are left. When the red mark reaches the bottom of the window, the inhaler is empty.

You must prime a new Turbuhaler® before you use it for the first time. To prime it:

• Hold it upright
• Turn and remove the cover
• Turn the brown bottom part all the way to the right then all the way to the left, until it clicks. Repeat this once more. It is now ready for use.

To use the Turbuhaler®:

1. Hold it upright
2. Turn and remove the cover
3. Twist the brown bottom part all the way to the right, and then all the way to the left until it clicks.
4. Turn the Turbuhaler® sideways
5. Exhale slowly as much as you can
6. Put the mouthpiece to your lips and inhale deeply and quickly.
7. Remove the Turbuhaler® from your mouth and hold you breath for 5 to 10 seconds (10 seconds is best)
8. Breathe out slowly
9. Repeat for the second dose
10. Replace the cover and turn it closed
11. Rinse your mouth to prevent Thrush (an infection that can occur in the mucous membranes of the mouth).

How do I care for my DPI?
Keep your DPI clean and dry. Never wash it.

How do I know when I need a new one?
Check the dose counter on the Diskus® or the window on the Turbuhaler® before each dose. Get a new DPI a few days before the old one is empty.

What else do I need to know about DPIs?

• You will not taste the medicine or feel any sensation when you use a DPI as the powder is very fine.
• Never exhale into a DPI.
• Do not shake the DPI. Shaking will not tell you if it is empty. The sound you hear is the dehydrating agent used to keep the powder dry. You will hear it even when the DPI is empty.

About your Metered Dose Inhaler and Spacer

Metered Dose inhalers (MDIs)
What are they?
Metered Dose inhalers use propellants (CFCs - or chloroflourocarbons) to push the medicine out of the inhaler canister so you can breathe it in or inhale it.

How do I prime a new MDI for use the first time?
Firmly insert the metal canister into the end of the mouthpiece
Do a test spray. Push down on the canister and spray it into the air 3 times. Be careful not to spray it into your eyes.
It is also a good idea to do a test spray if you haven't used your MDI in a few days.

How do I use it?
1. Remove cap and hold the canister upright
2. Shake the MDI for 5 seconds
3. Tilt your head back slightly, exhale (breathe out) slowly, as much as you can
4. Put the mouthpiece into your mouth
5. Push down once on the inhale canister and breathe in at the same time
6. Breathe in slowly and deeply for 3 to 5 seconds
7. Hold your breath for 5 to 10 seconds (10 seconds is best)
8. Wait one minute and repeat for the second dose (puff)
9. Replace the cap.

Spacers
What are spacers?
Spacers attach to your MDI. They make it easier to breathe the medicine into your lungs. A spacer holds the medicine in its chamber long enough for you to take 1 or 2 slow deep breaths. It can reduce the coughing sometimes caused by MDIs. If you use inhaled steroids, a spacer must be used. This can help prevent oral candida (thrush). Spacers with a mask are always used when giving medicine to infants and young children. There are many types of spacers. Follow the directions that come with your spacer for use and cleaning. Talk with your doctor or nurse if you have any problems using your spacer.

NEVER use a spacer with a dry powder inhaler (DPI)

How do I use a spacer?
Every spacer is different. Follow the instructions on the package insert. Talk with your doctor or nurse if you have a problem or questions.
For most spacers:
1. Remove the inhaler cap and hold the MDI upright. Shake it for 5 seconds
2. Put the MDI mouthpiece into the end of the spacer
3. Tilt your head back slightly. Exhale slowly, as much as you can.
4. Put the spacer mouthpiece into your mouth. Push down once on the MDI and start to inhale. Breathe in slowly and deeply for 3 to 5 seconds.
5. Hold your breath for 5 to 10 seconds (10 seconds is best)
6. Wait one minute and repeat for the second dose (puff).
7. Remove the MDI from the spacer and recap it.
8. Rinse your mouth.

How can I help my infant/young child use an MDI with a spacer?
Make sure the spacer and mask are the correct size for the child. The mask should cover the nose and mouth and seal well against the skin with a gentle pressure.

1. Shake the MDI for 5 seconds
2. Put the MDI into the spacer opening (the opposite end from the mask)
3. Hold your infant in your arms. Hold toddlers and pre-schoolers on your lap with the child's back against your chest. If your child must stand, support his neck with your hand. Your baby/child's head should be tilted back slightly.
4. Hold the MDI and the end of the spacer with your strong hand (the hand that you use most often); place the mask on the child's face. Make sure it covers the nose and mouth to make a good seal. If needed, hold the mask against the child's face with your other hand. Encourage your child to hold onto the spacer chamber.
5. Push down once on the MDI canister with your strong hand. Toddlers and pre-schoolers can help with this.
6. Hold the spacer and mask in place. Watch the spacer valves while the child takes at least 6 breaths (about 15 seconds). You should be able to see the valves open and close.
7. Remove the mask and spacer from your child's face and rest for a moment. Repeat for the second dose.

How do I care for my spacer?
Clean your spacer every day. Follow the directions on the package insert. Usually you can wash it in warm water and a mild detergent, rinse it well and let it air-dry before use. Some spacers can be cleaned in the dishwasher.

About your peak flow meter

What is a peak flow meter?
A peak flow meter measures airflow when you breathe out. This is known as the peak expiratory flow rate, or peak flow. It tells you how well your lungs are working and how well your asthma is controlled. Finding changes in lung function leads to early treatment and better control of asthma. There are meters for small children, young adults, and older children. Since adults and older children have much larger airways than young children, they use a standard range meter. A normal peak flow is based on your child's age, sex and height. Your normal peak flow (your personal best) is based on your highest peak flow reading over 2 to 3 weeks when your asthma is in good control.

What is it used for?
Keeping asthma in control
A peak flow meter helps you and your doctor keep your asthma in control. It shows you how open your airways are and how well you are breathing. It tells you your normal peak flow and helps you develop an 'Asthma Action Plan'. When peak flow stays lower than your normal reading, your asthma may be getting out of control.

Shows changes in lung function
Peak flows also show change in how your lungs are working before you feel any change. It can warn you that an attack is on the way by detecting worsening lung function. You can then take your medicines to stop things from getting worse.

To tell how well your medicine is working
Peak flow readings also let your doctor know how well your medicines are working and when they may need to be changed. This can prevent calls to your doctor, emergency room visits, and hospital stays.

Who should use a peak flow meter?
Patients who have moderate to severe asthma (asthma symptoms more than twice per week) may benefit from using a peak flow meter. People who have frequent asthma attacks may be able to detect the attacks earlier by using a peak flow meter. Children as young as four years old may taught to use these devices..

When should I use it?
Your doctor will tell you when to use your peak flow meter. You may be asked to check your peak flow once or twice a day when you are having asthma symptoms, and/or after using your quick relief inhaler. If you use your peak flow meter daily to help detect asthma attacks, you should check your peak flow at the same times each day, usually upon awakening and again in the afternoon or evening.

Your doctor will have you find your normal peak flow. To do this you check your peak flow over 2 to 3 weeks when your asthma is under control. Your "personal best" is the highest of the readings. Write your personal best number on your peak flow record. On some meters, you can set a pointer to it.

How do I use it?
There are different types of meters. Ask your doctor or nurse to show you how to use your meter.
In general you usually need to:
1. Move the sliding marker or arrow to the bottom of the meter (the lowest setting). Stand up or sit upright. Take a deep breath and put the mouthpiece into your mouth.
2. Blow out as hard and fast as you can
3. Look at the scale to see where the marker is and write that number down.
4. Do this three times.
5. If you cough, wheeze, or make a mistake when checking your Peak Flow, do not write that number down. Do it again.
6. The highest reading you get is your peak flow. Record the highest number of the three on your peak flow record.
Once you know your personal best number, use it to set up the zones on your peak flow meter. The zones are the colors of a traffic light. Use the sliders on the meter to mark your zones.

What do the zones tell me?
The zones tell how you are doing and what to do when your peak flow number changes. Normal peak flow can change as much as 15% throughout the day; morning peak flow is usually lower than afternoon peak flow.

How do I care for my peak flow meter?
Dirt can collect in your meter and make measurements wrong. Germs and mucous from respiratory infections like colds and flu can also collect in the meter. Use mild detergent in warm water to clean it. Rinse it thoroughly. Let it air dry before use. Clean your meter at least once a week to keep it working properly.

Common asthma triggers

Triggers are things than can make your asthma worse and start an asthma attack. Not everyone has the same triggers. Most people have more than one trigger. You need to know what makes your asthma worse. Here is a list of common triggers and how to avoid them. Check the ones that bother you.

Tobacco smoke
If you smoke ask your doctor for ways to help you quit. Don't allow anyone to smoke in your home, around you, or at your child's day care center.

Dust mites
Dust mites are tiny bugs that live in cloth and carpet. Cover your mattress and pillows with vinyl covers. Wash pillows in water hotter than 130 degrees if you don't cover them.
Wash bed linens and stuffed toys in water hotter than 130 degrees each week.
Use a damp cloth to dust or sweep.
Use a de-humidifier to reduce indoor humidity to less than 50%.
Remove carpets from your bedroom if you can.
Do not lie or sleep on upholstered furniture.

Animal Dander
Dander is flakes of skin or dried saliva from animals with fur or feathers

• Keep furred and feathered pets out of your home. If you can't keep the pet outdoors, keep the pet out of your bedroom and keep the bedroom door closed
• Cover bedroom air vents with heavy materials to filter the air.
• Remove carpets and upholstered furniture from your home or keep pets out of the rooms where these are.

Cockroaches
Many people with asthma are allergic to dried cockroach droppings and remains.
Keep all food out of your bedroom.
Keep your garbage in closed containers. Dispose of it regularly.
Use poison baits, powders, gels or paste. If a spray is used, stay out of the room until the odor goes away.
Never leave food out. Keep it in closed containers.

Vacuum cleaning
If you can, get someone else to vacuum once or twice a week. Stay out of the room while they vacuum and for a little while afterwards.
If you do vacuum, use a dust mask. You can get these at the hardware store and use a double layered or microfilter vacuum cleaner bag or a vacuum with a HEPA filter.

Indoor mold
Fix leaky faucets and pipes.
Clean moldy surfaces with white vinegar and water.
Keep your bathroom, kitchen and basement well ventilated.
Get a dehumidifier.
Check houseplants for mold. Get rid of any plants that have it.
Change your air conditioner and heater filters often.
Avoid damp places like the basement if you can.

Pollen and outdoor mold
When pollen and mold spores counts are high:
Stay indoors with the windows closed during the afternoon when the counts are the highest.
Use an air conditioner if you can and clean the filter often.
Do not hang clothes outside to air-dry.
Change your clothes when you come in from outdoors.
Talk with your doctor about seeing an allergy specialist.

Sprays and odors
Avoid strong odors and sprays like perfumes, hair spray, talcum powder, cleaning agents, paint, and similar items. Avoid kerosene heaters, fireplaces and wood-burning stoves if you can.

Exercise, sports, play and work
Regular exercise can reduce shortness of breath, improve your overall health and give you more energy. If you have asthma symptoms when you are active

• Talk with your doctor about taking medicines before activity to prevent symptoms.
• Warm up before exercise or other vigorous activity
• Avoid vigorous outdoor activity when air pollution is high and when it is very cold or humid

Respiratory infections
Talk with your doctor about what to do to avoid an asthma attack when you have a cold or the flu. Get your flu shot each year. Ask your doctor if you should get the pneumonia vaccine. Avoid people with colds

Cold or windy weather
If you must go out in cold or windy weather

• Cover your mouth and nose with a scarf
• Breathe through your nose so the air is warmed before it reaches your lungs

Foods with sulfites
If you are allergic to sulfites avoid beer, wine, shrimp, dried fruits, or processed potatoes. Read food labels carefully.

Medicines
Aspirin or drugs related to aspirin are asthma triggers for some people. If this is a problem for you, be sure to check with your doctor or pharmacist before using any over-the-counter cold or pain medicines
Sleeping pills and tranquilizers can make you breathe more slowly and less deeply. Avoid them.
Always tell your doctors about all the medicines you are taking including eye drops, cold medicines, herbs and vitamins, especially when a new medicine is added.

This material gives you brief, general information about this health care topic. It does not take the place of instructions you receive from your health care providers. For answers to other questions talk to your doctor or other health care provider.

Copyright NewYork-Presbyterian Hospital. 2002. All rights reserved.