Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
17, October 2007

SHORTNESS OF BREATH – 2  TREATMENT OF ASTHMA

            One of the basic properties of a muscle is that it is irritable.  There is two kinds of muscle in our body, one is the so called striated muscle that is voluntary muscle.  This type allows our arms and legs to move when we want to.  The second kind of muscle is under involuntary control.  It is called smooth muscle.  We don’t really have any say when it is going to twitch or contract.  This muscle is contained in our blood vessels, the airways of our lungs, the walls of our bowel and the delivery system for urine from our kidneys.  These muscles have nerves to control them from our involuntary nervous system.  This whole involuntary system is one of natures great gifts freeing us from having to think about our blood pressure, our digestion, our breathing or the delivery of urine from our kidneys to our bladder.  But sometimes having something out of control is not always a good deal as when people get a condition called asthma. 

            Asthma results from an irritation to the smooth muscle lining the airways to our lungs.  It would seem a counterproductive design flaw to put something in our airways that constricts them down so that air can’t through them.  But be that as it may, that is what we have got and when these muscles get irritated, they constrict and air can’t get into our lungs as easily as we want. 

            The irritants that can cause asthma are many and varied.  I have taken care of a lady who nearly died from eating potato salad with pimento in it.  She was extremely allergic to pimento and within 5 minutes of taking the first bite, she could barely breath.  Other patients have more chronic problems such as living in severe air polluted communities.  The air pollution in Tokyo, Japan, is a well known cause of so called “Tokyo Yakima Asthma” that occurred in many of our armed personnel and their families when they were stationed in Japan.  Other individuals develop irritation to the smooth muscle in their lungs when they are around cats or birds or even certain perfumes.

            Asthma comes in two basic forms.  One would be the acute asthmatic attack that occurs with exposure to a cat or a perfume or a pimento.  These individuals often have to carry an epinephrine pin with them so that they can have immediate injection of epinephrine to counteract the bronchospasm that occurs from the smooth muscle contraction in their airways.  Some individuals without so severe disease can overcome their asthma with an inhaler that they carry with them all the time.  When not exposed to the specific allergic causing product, they do just fine and don’t need any medication. 

            The other type of asthma is much more of a problem.  It is a chronic condition in which a person struggles with their respiratory effort everyday. Sometimes, this type of asthma only occurs in certain allergic season such as the spring and summer when there is a large amount of pollen in the air.  These individuals require the use of medications everyday.  This type of asthma can occur at any age but usually under age 40.  The amount of secretions they make is relatively little.  They are usually not smokers or if they are smokers, they are very slow learners that is a bad thing to do.  In most cases, chronic asthma can be effectively treated with appropriate medications.

            Just as blood pressure is best measured in the home environment in order to effective treat it, asthma is best monitored with an airflow meter that helps a person determine how obstructed they are.  This type of device can help detect early worsening of the condition so that the person can react in time without getting in severe trouble.  Airflow systems called spirometry can be done in the healthcare providers office and are critical in long term gauging of how an asthmatic patient is doing.

            Once the asthmatic condition is diagnosed, the important step is suppression of the irritability of the smooth muscle in the lungs.  Very clearly, the most clinically effective and cost effective treatment for chronic asthma is an inhaled cortisone product.  Over the years, many different types of products have been developed.  These range from the relatively cheaper Azmacort (triamcinolone) to the still patent protected Flovent (fluticasone) and Pulmocort (budesonide).  These are very effective used regularly on the long-term basis for a chronic asthmatic.  However, they do not deal with the sudden onset of an asthmatic attack.  Rather they are preventive of those attacks but unfortunately, incompletely effective.

            For the prevention of the sudden onset of an asthma attack, an epinephrine pen maybe necessary but most individuals use a metered dose inhaler carried in one’s pocket or purse.  These can be used on demand when an asthmatic attack is beginning.  Unfortunately, many individuals use this type of inhaler too frequently, and that has been associated with an increased rate of asthmatic complications. 

            Another product called Levalbuterol (Xopenex) works about as fast as Albuterol and has less likelihood of causing the fast heartbeat and jittery feeling that individuals sometimes get with Albuterol.

            The third family of medications to treat asthma is the long-acting bronchodilators. Albuterol acts only for 3-4 hours.  Xopenex for perhaps 5-8 hours but there are products that work up to 12 hours.  These are called salmeterol (Serevent) and formoterol (Foradil).  These are powders that are inhaled twice daily.  They can prevent asthma that is chronic but really do not work at all to treat the sudden onset of an asthmatic attack like Albuterol does. 

            The third family of medications for an asthmatic include drugs that dry up secretions and relax a smooth muscle.  An older drug called tiotropium (Atrovent) is now being supplanted by a long acting more effective drug called tiotropium (Spiriva).  Spiriva works as once a day inhaled powder.

            The best treatments for asthma that is chronic includes combination products.  Among these are a product called Combivent (Hypotropias and Albuterol together) used for immediate relief of asthmatic attacks.  Many individuals will use this type of inhaler 4 x a day for relief. 

            A better answer for asthma that is chronic include something Advair discus which is a powder inhaled containing a steroid along with a long acting bronchodilator.  New on the market is a product called Sinvacor which is a metered dose inhaler for those who do not like powders.  This seems to act more quickly than Advair but the choice between these two products is one of personnel comfort of whether one likes the powder inhaled or the metered dose inhaler.

            Lastly, there is a family of drugs called leukogram inhalers, the most common of which is called Singular.  This is a pill taken once a day that prevents asthmatic attacks from coming.  It is very effective for some individuals and sometimes the only medicine that is needed. 

            I am sure that all of the medications described above have been at least as confusing as they have been helpful but it brings the point out that in today’s world, there are many medications to help asthma.  The most important step in care is to first make the diagnosis.  Often times, asthma can be diagnosed simply from a chronic cough.  Other times, the person will have simple intermittent wheezing and slight shortness of breath and sometimes, asthma will present very traumatically.  The healthcare providers at your local clinics, are the first place to start with care for this type of problem.  Referral to specialists for other considerations such as desensitization can be arranged through your local clinics.  The last column on this series of shortness of breath considerations, will deal with chronic obstructive lung disease. 

This and other columns available at www.macpierre.com.