Clinics for Asthma

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Severe Asthma Clinic

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Asthma – General Information

Asthma is a chronic or life-long condition that is characterized by symptoms of cough, shortness of breath, wheezing, and/or chest tightness. Most of the times, these episodes are generally not sustained and occur in episodes, usually related to triggering events, and they tend to come and go during the day or night, depending on the degree of airway narrowing in the lungs. During these episodes, the small airways of the lungs tighten up enough to cause symptoms. This tightening is reversible in most cases with asthma treatments.

Although being diagnosed with asthma can be challenging, advancements in pulmonology have made it possible to effectively manage and regulate the condition. The ultimate aim of treatment is to manage symptoms and avoid future asthma attacks as much as possible.

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Diagnosis and Testing

The diagnosis of asthma requires a careful review of current and past medical history, family history, and a physical examination. Specialized testing is sometimes needed to diagnose asthma and to rule out other possible causes of symptoms. Many people with asthma appear and sound completely normal between episodes/exacerbations. The diagnostic testing for asthma may include:

• Spirometry testing: measures the flow and volume of air that is exhaled. This test is often performed before and after a bronchodilator (inhaler) is administered to see the degree of airflow improvement. This is performed in the clinic.
• Bronchial Challenge testing— This test may be recommended to diagnose asthma, especially if the spirometry is not sufficient for the diagnosis. This testing is designed to trigger the airways to narrow in patients with asthma. This is performed in a specialized pulmonary function testing center that is capable of providing emergency asthma care if needed.
• Fractional Excretion of Nitric Oxide (FeNO): This is a test performed in the clinic that measures how much nitric oxide is exhaled in the breath. A high level of exhaled nitric oxide generally indicates a large amount of inflammation in the airways which can assist in the diagnosis of asthma. This test can also be useful in the monitoring of treatment response.

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Asthma Triggers:

Allergens are substances that can trigger an allergic reaction and an asthma exacerbation in some cases. In general, we pay special attention to the home and environment of those with asthma. The bedroom of a person with asthma should be given significant consideration since the greatest number of hours are typically spent there, along with living and work area.

• Indoor allergens— Sensitivity to indoor allergens is the most common trigger in asthma patients. Below is a list of the most common:
  • Dust mites — Dust mites are tiny organisms that can be found in most homes, particularly in areas with high humidity, such as mattresses, bedding, furniture, carpets, and curtains. These mites don’t drink but instead absorb moisture from the air. To reduce their presence, it’s recommended to use impermeable fabric covers on pillows and mattresses, followed by organic and unbleached cotton to minimize exposure to other chemicals. Bedding and pillows should be washed weekly and dried on high heat. To minimize the amount of fabric in a room, carpets, rugs, stuffed toys, and furniture should be reduced. Dust mites are attracted to humidity, so it’s important to control it in the home by using air conditioning in humid areas and a dehumidifier. The ideal household humidity level should be between 30 and 50 percent.
  • Mold — Mold also thrives in moist environments and can cause symptoms of asthma and allergic rhinitis in sensitive individuals. Any area of the house that contains or stores water is susceptible to mold growth, such as air conditioning vents, water traps, refrigerator drip trays, shower stalls, leaky sinks, and damp basements. To reduce the growth of mold, existing mold should be removed, and humidity should be reduced to prevent future growth. Measures to reduce humidity include eliminating sources of standing water and dampness, removing house plants, fixing plumbing leaks, and removing carpeting that is exposed to excessive steam or moisture. Old items in the house, such as books, newspapers, clothing, and bedding, can also harbor mold. Areas with soap and water, like bathroom tiles, sinks, and showers, should be given special attention. Areas with visible mold growth should be cleaned at least every four weeks.
  • Animal dander — Dead skin cells shed by animals can trigger asthma in some people. Certain breeds of dogs and cats can be more allergenic than others, but all breeds have some level of allergenicity. Other animals like hamsters, mice, birds, and ferrets can also trigger asthma. If someone with asthma is allergic to a pet, the best option is to remove the pet from the home completely. Simply restricting the animal to a certain area in the home is not effective in preventing allergic reactions since animal proteins can be carried on clothing or spread through the air. After a pet has been removed from a home, a thorough cleaning of all furniture, carpets, rugs, and clothes is necessary. However, even after this cleaning is done, allergic symptoms can persist for months since it is difficult to eliminate all potential sources of allergens.
  • Cockroaches — Cockroaches can shed or excrete particles that contain allergens, and they tend to thrive in warm or hot environments. Unfortunately, controlling cockroach populations in infested areas can be very challenging. However, there are some measures that can be taken, including using multiple traps or toxins, sealing cracks, holes, and crevices, removing any sources of food like garbage and food waste, washing dirty dishes and cooking utensils immediately after use, and eliminating any standing water in the home.
  • Respiratory infections — Asthma can be triggered by infections that cause inflammation in the airways, such as colds, flu, bronchitis, and sinus or ear infections. To avoid getting these viruses, it’s important to take preventive measures like getting a yearly flu shot, getting vaccinated against pneumococcal disease if recommended, and washing hands regularly.
• Outdoor allergens — If asthma symptoms worsen during certain times of the year while outside, it’s probable that you may be allergic to pollen or mold that is often found in decaying vegetation. To manage this, those affected should try to stay indoors as much as possible during the season when your asthma tends to flare, use air conditioning when available, and keep windows shut. It’s best to avoid outdoor exercise or activities that require physical effort when pollution or pollen levels are high. After spending time outside during high pollen or mold counts, patients can take a bath and wash their hair to get rid of any remaining allergens.
• Medicines — Certain patient populations are at risk of experiencing asthma exacerbation due to certain medications. Among these medications are aspirin and some anti-inflammatory drugs like ibuprofen (brand names Advil and Motrin) and naproxen (brand names Aleve and Anaprox). Additionally, beta-blockers used for treating heart disease, blood pressure, anxiety or eye problems may also trigger an asthma attack in some individuals.
• Cigarette smoke and ashes – People with asthma should not be around any type of smoke. Second hand smoke can also trigger an asthma attack.
• Aerosol sprays and perfumes – Avoid using any perfumes, aerosol deodorants or anything with strong scents.
• Gas stoves, fireplace smoke, and cooking odors – Avoid cooking with wood or coal. Make sure cooking areas are well ventilated.
• Air pollution, car exhaust, and gas fumes – Patients should avoid unnecessary exposure to car exhaust, and outdoor exercise should be avoided when pollution levels are high. Always check the Air Quality Index (AQI) prior to leaving the house. Try to avoid the outdoors if that number is above 50.
• Formaldehyde and volatile organic compounds – Odors from new linoleum flooring, carpeting, particleboard, wall coverings, furniture, and recent painting may worsen asthma symptoms in some people.
• Physical activity — Even though exercise may cause asthma symptoms in some individuals, it is important not to avoid it. Exercise has the potential to strengthen the cardiovascular system and possibly reduce sensitivity to asthma triggers.
• Climate — Asthma triggers can be affected by variations in weather conditions. For instance, areas with elevated ozone levels may have a higher risk of asthma attacks on hot and sunny days. Therefore, it is important to take appropriate precautions during such weather conditions. Moreover, it is advisable to avoid places with high mold growth due to damp indoor environments. Thunderstorms can also lead to the bursting of pollen grains, resulting in the release of allergens. Individuals with pollen allergies are likely to experience asthma symptoms in the hours after a thunderstorm, particularly during the pollen seasons.
• Sulfites — Sulfites are a type of preservative utilized in certain foods to prevent spoilage and discoloration. Food items such as potatoes, shrimp, dried fruit, beer, wine, and vinegar may contain sulfites, which can potentially trigger asthma symptoms in susceptible individuals. If someone has a known sensitivity to sulfites, it is crucial to read food labels to avoid consuming them. The effect of other food additives on asthma has not been extensively studied.
• Menstrual cycle – around 20-40% of women who have a diagnosis of asthma experience a worsening of their symptoms before or during their menstrual cycle. This subtype of asthma is considered hormonally-induced and is generally more severe than those are not affected by these hormonal fluctuations.
• The role of air filters — Air purifiers that use various types of filters, such as HEPA filters, electrostatic filters, and other mechanical filters, are commonly advertised as a way to reduce indoor allergens. These air filtering devices can be marketed as standalone units or as components of heating or cooling systems, and some can even be worn by individuals. While air purifiers can be costly, some studies suggest that they may help alleviate allergy symptoms and asthma. However, not all studies support the use of air purifiers for this purpose. In addition to reducing indoor allergens, air filters have also been shown to reduce particulate matter in the air, which can benefit individuals with asthma.

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Treatment of Asthma:

Inhaled Corticosteroids
This category of inhalers is considered controller or “maintenance” therapy. Research shows that treatment with inhaled corticosteroids significantly reduces asthma exacerbations in those who have two or more exacerbations per month. These inhalers work by decreasing the level of inflammation in the airways to prevent future exacerbations. Inhaled corticosteroids are considered first-line treatment in the prevention of future exacerbations. The most common side effect of these medications is oral thrush, which is a fungal infection of the mouth. To prevent this, it is imperative to rinse your mouth after administration of the inhaler.

Oral Corticosteroids
Also known as systemic steroids, they are considered long-acting corticosteroids used for reducing inflammation in the airway, especially at times when a patient remains symptomatic despite inhaled therapy or when acute exacerbations occur despite maximal treatment. These medications are typically taken in short bursts and weaned off when there is an improvement of symptoms. The side-effects of oral steroids are typically worse than when inhaled since the medication is not being administered locally, instead, it is ingested and courses through the rest of the body. Some of these side effects include increased blood sugar and blood pressure, tremors, anxiety and more long-term effects such as weight gain, osteoporosis, and cardiovascular disease.

Long-Acting Bronchodilators
These medications are typically used in conjunction with inhaled corticosteroids, either in the same inhaler, or a separate inhaler. The are typically taken every 12-24 hours. Although uncommon, some side effects of these medications include elevated heart rate and tremors. These are more likely to occur in the short acting bronchodilators.

Short-Acting Bronchodilators
These inhaled medications work by reducing the level of bronchoconstriction by relaxing the smooth muscle around the airways. These are also known as “rescue” inhalers since they work within seconds to minutes after administration. Most patients feel improvement in their symptoms almost immediately. These inhaled medications come in either inhaler or nebulized form. They can also be used as pre-medication for those who experience symptoms after known exposures such as exercise, workplace exposures or inhalation triggers such as allergens, smoke, etc.

Tailored Biologic Therapy
This class of therapy is a relatively newer way of treating asthma. These medications are currently only available in subcutaneous injection form and they include the medications omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab. Reslizumab is another biologic that is only given through an intravenous catheter. These medications work by changing the way our immune system responds to specific triggers by reducing the release of antibodies and/or inflammatory cells. The side effect profile of these medications is very mild and includes injection site reactions and, rarely, anaphylaxis. Depending on which medication you qualify for, the injection is given every 2, 4 or 8 weeks.

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