Last-modified: 17 September 2000
Original-author: Patricia Wrean <email@example.com>
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alt.support.asthma FAQ: Asthma -- General Information ====================================================== Introduction: ------------ Welcome to alt.support.asthma! This newsgroup provides a forum for the discussion of asthma, its symptoms, causes, and forms of treatment. Please note that postings to alt.support.asthma are intended to be for discussion purposes only and are in no way to be construed as medical advice. Asthma is a serious medical condition requiring direct supervision by a physician. This FAQ attempts to answer the most frequently asked questions about asthma on the newsgroup alt.support.asthma. It was compiled by Patricia Wrean <firstname.lastname@example.org> and is currently maintained by Marie Goldenberg <email@example.com>. The Asthma Medications FAQ is also posted monthly as a companion to this one. For information about allergies, please see the alt.support.asthma FAQ: Allergies -- General Information (still under construction), and its companion posting, the Allergy Medications FAQ. Please be aware that the information in this FAQ is intended for educational purposes only and should not be used as a substitute for consulting with a doctor. Most of the contributors are not health care professionals; this FAQ is a collection of personal experiences, suggestions, and practical information. Please remember when reading this that every asthmatic responds differently; what is true for some asthmatics may or may not be true for you. Although every effort is made to keep this information accurate, this FAQ should not be used as an authoritative reference. Comments, additions, and corrections are requested; if you do not wish your name to be included in the contributors list, please state that explicitly when contributing. I will accept additions upon my own judgement -- I'll warn you right now that I'm a confirmed skeptic and am not a great believer in alternative medicine. All unattributed portions are my own contributions or those of the original maintainer, Patricia Wrean <firstname.lastname@example.org>. + = added since last version & = updated/corrected since last version ====================================================================== Table of Contents: ----------------- General Information: 0.0 Changes since the last version 1.0 What is asthma? 1.0.1 What is chronic asthmatic bronchitis? 1.0.2 What is status asthmaticus? 1.0.3 What is anaphylactic shock? 1.0.4 What is COPD? 1.0.5 What is emphysema? 1.0.6 What is bronchitis? 1.0.7 What is pneumonia? 1.0.8 What is cystic fibrosis? 1.1 What is an asthma attack? 1.1.1 What is wheezing? 1.1.2 Do all asthmatics wheeze? 1.1.3 What is "coughing asthma"? 1.1.4 Is asthma hereditary? 1.2 How is asthma diagnosed? 1.2.1 What is a spirometer? 1.2.2 What is a peak flow meter? 1.3 How is asthma normally treated? 1.3.1 How is an acute asthma attack treated? 1.4 What are the most common triggers of asthma? 1.4.1 What is intrinsic/extrinsic asthma? 1.4.2 Can gastric reflux trigger asthma? 1.4.3 What is occupational asthma? 1.5 Asthma and Pregnancy Medications: 2.0 What are the major classes of asthma medications? 2.1 What are the names of the various asthma medications? 2.1.1 Are salbutamol and albuterol the same drug? 2.1.2 Can albuterol be taken while taking salmeterol? 2.2 Are some asthma drugs banned in athletic competitions? 2.3 What kinds of inhalers are there? 2.3.1 Do inhaler propellants bother some asthmatics? 2.3.2 What is a spacer? What is a holding chamber? 2.3.3 What is "thrush mouth" and how can I avoid it? 2.3.4 Is Fisons still making the Intal Spinhaler? 2.3.5 What's the difference between Spinhalers and Rotahalers? 2.3.6 Why are so many asthma drugs taken via inhaler? 2.3.7 How can I tell when my MDI is empty? 2.3.8 Are my aerosol inhalers going to disappear? 2.4 What kinds of tablets are there? 2.4.1 Why do I need a blood test when taking theophylline? 2.4.2 Why are combination pills not commonly prescribed? 2.5 What is a nebulizer? 2.6 What medications should asthmatics be careful about taking? 2.6.1 What about corticosteroids and chicken pox? Miscellaneous: 3.0 What resources are there for asthmatics? 3.1 Where can I get the latest copy of the FAQs? 3.2 What is an FAQ, anyway? What is a Usenet newsgroup? + 3.3 How about some other WWW links? List of Contributors References Disclaimer ====================================================================== 0.0 Changes since the last version ----------------------------------- September 17, 2000 ------------------ Asthma Gen: Added 3.3 WWW links section Asthma Gen: Added reference to Living Well With Asthma book Asthma Gen: Added reference to The Doser (inhaler counter) in section 2.3.7 Asthma Med: Added reference to Advair (salmeterol / fluticasone) Asthma Med: Added reference to Bambec (bambuterol) Asthma Med: Added reference to Combivent (ipratropium / salbutamol) Asthma Med: Noted that Bronkaid and Isuprel appear to have been discontinued in Canada Asthma Med: Added reference to Xopenex (levalbuterol) Asthma Med: Added reference to Oxeze (formoterol) turbuhaler Asthma Med: Added reference to Pulmicort neb soln available in US September 17, 1998 ------------------ Asthma Med: Added note that Foradil (formoterol) now available in Canada February 17, 1998 ----------------- Asthma Med: Added Serevent Diskus, Flovent Rotahaler, Pulmicort, Airomir, Tilade nebulizer solution, and Singulair (newly approved medications) Asthma Med: Added note that Medihaler-Epi has been discontinued Allergy Med: Added note that Seldane has been discontinued Allergy Med: Added Nasonex (newly approved medication) Asthma General: Added section 1.4.3, Occupational asthma December 6, 1997 ---------------- Asthma General: Split web version of FAQ document into multiple-page format. August 17, 1997 --------------- Asthma General: Added section 1.5, "Pregnancy and Asthma" Asthma General: Added reference to new version of NHLBI report Asthma General: Added reference to Adams book Asthma General: Correct reference to Gershwin to reflect 2nd edition June 17, 1997 ------------- Asthma General: Correct publication information on "Children With Asthma" by Dr. Plaut Asthma General: Added links to archived version of Allergy Medication FAQ May 17, 1997 ------------ Asthma Med: Added note that Nasalcrom now Over-The-Counter (OTC) in US. Asthma Med: Added Zyflo to Leukotriene Receptor Inhibitor section Asthma Med: Added Proventil HFA MDI Asthma General: Added discussion of phaseout of CFC (chlorofluorocarbon) MDIs Asthma General: removed comment that "both spinhaler and rotahaler are available in the US" (the spinhaler is not available in the US) 1.0 What is asthma? -------------------- Asthma is best described by its technical name: Reversible Obstructive Airway Disease (ROAD). In other words, asthma is a condition in which the airways of the lungs become either narrowed or completely blocked, impeding normal breathing. However, in asthma, this obstruction of the lungs is reversible, either spontaneously or with medication. Quickly reviewing the structure of the lung: air reaches the lung by passing through the windpipe (trachea), which divides into two large tubes (bronchi), one for each lung. Each bronchi further divides into many little tubes (bronchioles), which eventually lead to tiny air sacs (alveoli), in which oxygen from the air is transferred to the bloodstream, and carbon dioxide from the bloodstream is transferred to the air. Asthma involves only the airways (bronchi and bronchioles), and not the air sacs. The airways are cleaned by trapping stray particles in a thin layer of mucus which covers the surface of the airways. This mucus is produced by glands inside the lung, and is constantly being renewed. The mucus is then either coughed up or swept up to the windpipe (trachea) by cilia, tiny hairs on the lining of the airways. Once the mucus reaches the throat, it can again be coughed up or, alternatively, swallowed. Although everyone's airways have the potential for constricting in response to allergens or irritants, the asthmatic's airways are oversensitive, or hyperreactive. In response to stimuli, the airways may become obstructed by one of the following: - constriction of the muscles surrounding the airway; - inflammation and swelling of the airway; or - increased mucus production which clogs the airway. Once the airways have become obstructed, it takes more effort to force air through them, so that breathing becomes laboured. This forcing of air through constricted airways can make a whistling or rattling sound, called wheezing. Irritation of the airways by excessive mucus may also provoke coughing. Because exhaling through the obstructed airways is difficult, too much stale air remains in the lungs after each breath. This decreases the amount of fresh air which can be taken in with each new breath, so not only is there less oxygen available for the whole body, but more importantly, the high concentration of carbon dioxide in the lungs causes the blood supply to become acidic. This acidity in the blood may rise to toxic levels if the asthma remains untreated. 1.0.1 What is chronic asthmatic bronchitis? -------------------------------------------- Chronic asthmatic bronchitis is the condition in which the airways in the lungs are obstructed due to both persistent asthma and chronic bronchitis (see sections 1.0 and 1.0.6). People with this disease generally also have a persistent cough which brings up mucus. Chronic asthmatic bronchitis which also involves emphysema is usually classified under the more general category of COPD. 1.0.2 What is status asthmaticus? ---------------------------------- Status asthmaticus is defined as a severe asthma attack that fails to respond to routine treatment, such as inhaled bronchodilators, injected epinephrine (adrenalin), or intravenous theophylline. 1.0.3 What is anaphylactic shock? ---------------------------------- Anaphylactic shock is defined as a severe and potentially life-threatening allergic reaction throughout the entire body. It occurs when an allergen, instead of provoking a localized reaction, enters the bloodstream and circulates through the entire body, causing a systemic reaction. (There may also be an intrinsic trigger, as some cases of exercise-induced anaphylaxis have been reported.) The symptoms of anaphylactic shock begin with a rapid heartrate, flushing, swelling of the throat, nausea, coughing, and chest tightness. Severe wheezing (asthma), cramping, and a rapid drop in blood pressure follow, which may lead to cardiac arrest. Hives and vomiting are also common features. The treatment for anaphylaxis is intravenous epinephrine (adrenalin), with antihistamines and steroids also being used in selected cases. Aminophylline may also be given for pronounced asthmatic reactions that do not respond to epinephrine. 1.0.4 What is COPD? -------------------- COPD is chronic obstructive pulmonary disease, also known as either COAD, for chronic obstructive airway disease, or COLD, for chronic obstructive lung disease. COPD is a disease in which the airways are obstructed due to a combination of asthma, emphysema, and chronic bronchitis. The 1987 Merck Manual notes that "the term COPD was introduced because these conditions often coexist, and it may be difficult in an individual case to decide which is the major one producing the obstruction." [Maintainer's note: the entries for COPD, emphysema, bronchitis, pneumonia, and cystic fibrosis have been included because of common confusion between the various diseases which can affect the lungs.] 1.0.5 What is emphysema? ------------------------- Emphysema is the disease in which the air sacs themselves, rather than the airways, are either damaged or destroyed. This is an irreversible condition, leading to poor exchange of oxygen and carbon dioxide between the air in the lungs and the bloodstream. 1.0.6 What is bronchitis? ------------------------- Bronchitis is an inflammation of the bronchi, the large airways inside the lungs. (Bronchiolitis is the inflammation of the bronchioles, the small airways.) This inflammation often leads to increased mucus production in the airways. Bronchitis is generally caused either by a virus or by exposure to irritants such as dust, fumes, or cigarette smoke. If caused by a virus, the bronchitis will likely be only temporary. In the case of prolonged exposure to irritants, particularly cigarette smoking, if there is permanent damage to the bronchi, bronchitis may become chronic. 1.0.7 What is pneumonia? ------------------------- Pneumonia is an infection of the lung tissue. In adults, it is generally caused by bacterial infections, though viruses, fungi, and protozoa may also be culprits. The latter microorganisms have become very common as causes of pneumonia in immunosuppressed persons, such as those with HIV infection. However, for those with chronic illnesses, especially cardiac or respiratory diseases, or those at increased risk for pneumonia, there is a pneumococcal pneumonia vaccination available as a preventive measure for the most common of these bacterial infections, streptococcus pneumoniae. In children, pneumonia is most commonly caused by viruses. 1.0.8 What is cystic fibrosis? ------------------------------- Cystic fibrosis is a disease in which excessive amounts of unusually thick mucus are produced throughout the body. Because this mucus production also occurs in the lungs, people with cystic fibrosis are extraordinarily prone to bacterial infections which result in progressive lung damage. Cystic fibrosis can be diagnosed by a "sweat test" as people with cystic fibrosis have elevated chloride levels in their perspiration. This condition often resembles asthma in children. 1.1 What is an asthma attack? ------------------------------ An asthma attack, also known as an asthma episode or flare, is any shortness of breath which interrupts the asthmatic's well-being and requires either medication or some other form of intervention for the asthmatic to breathe normally again. 1.1.1 What is wheezing? ------------------------ Wheezing is the whistling or rattling sound that occurs when air flows through obstructed airways. At the start of an asthma attack, wheezing usually only occurs while exhaling, or breathing out, but as the attack progresses, wheezing may then be heard both while inhaling and exhaling. If after the attack progresses further, the asthmatic then stops wheezing, this may indicate that many bronchioles (small airways) have become completely blocked, which is a very serious condition. 1.1.2 Do all asthmatics wheeze? -------------------------------- No, not all asthmatics wheeze. Although wheezing is extremely common in asthmatics, in _All About Asthma_, Dr. Paul says, "It is important to note that not all asthmatic symptoms need be present for one to experience an asthma attack. For instance, not all asthmatics wheeze. And sometimes wheezing is so slight, it can only be heard with a stethoscope. With some asthmatics, coughing is the only symptom present." Similarly, in _Children with Asthma_, Dr. Plaut states that children with chronic coughs "may have asthma even though no wheezing is present." He diagnoses such children with asthma if their peak flow improves when given an inhaled bronchodilator. 1.1.3 What is "coughing asthma"? --------------------------------- In _Children with Asthma_, Dr. Plaut defines "coughing asthma" as "a form of asthma in which coughing is the only symptom and there is no abnormality in any lung function test." This condition is also known as "cough variant asthma." Coughing asthma often improves when standard asthma medications are taken. 1.1.4 Is asthma hereditary? ---------------------------- No, asthma itself is not hereditary, but there does seem to be a hereditary component to the tendency to develop asthma. In _All About Asthma_, Dr. Paul states that if neither parent has asthma, the chances of each of their children having asthma are less than 10%. When one parent has asthma, the chances rise to 25%, and when both parents have asthma, the chances climb to 50%. (Actually, there is considerable disagreement among my sources as to the exact numbers, but all agree that the chances climb dramatically if one or both parents have asthma.) Similarly, if one or both parents have allergies, the chances of each of their children having allergies are 35% and 65%, respectively, compared to a less than 10% chance if neither parent has allergies. However, Dr. Paul cautions that "children don't inherit asthma itself, but the tendency to develop it." Whether or not an individual develops asthma is also influenced by their exposure to various other factors such as infections, irritants, and allergens. 1.2 How is asthma diagnosed? ----------------------------- Asthma is diagnosed based on a physical examination, personal history, and lung function tests. The physical examination looks for typical asthma symptoms such as wheezing or coughing, and the personal history provides additional clues such as allergies or a familial tendency towards asthma. Although lung function tests have not always been used for diagnosis in the past, the NHLBI Guidelines for the Diagnosis and Management of Asthma state that "Pulmonary function studies are essential for diagnosing asthma and for assessing the severity of asthma in order to make appropriate therapeutic recommendations. The use of objective measures of lung function is particularly important because subjective measures, such as patient symptom reports and physicians' physical examination findings, often do not correlate with the variability and severity of airflow obstruction." Lung function tests may be as simple as measuring peak flow with a peak flow meter, or using a simple spirometer, or may involve a battery of spirometry tests in a pulmonary function lab. 1.2.1 What is a spirometer? ---------------------------- A spirometer is a machine for testing lung function that you breathe in and out of through a hose attached to a mouthpiece. You are usually given nose clips so that all the air you breathe goes through the machine. One I've been tested on had a little expanding tank surrounded by water into which the air goes, and I could see the top rising and falling as I breathed out and in. It can measure a fair number of characteristics of your lungs, including FVC, FEV1, and PEPR. FVC, or forced vital capacity, is the amount of air that you can exhale forcefully after taking a deep breath. FEV1, or forced expiratory volume in one second, is the amount of air that you can be exhale in one second. Peak flow, or PEPR, is described in section 1.2.2. The sophisticated spirometers I've seen have a PC attached, and have neat little curves generated with each breath, which apparently have characteristic shapes for different respiratory diseases. There is a slightly less sophisticated machine that I've blown into, and I'm not sure if this is also classed as a spirometer or not, but you take a deep breath and blow into it, much like a peak flow meter, except that it draws a little graph of how much volume you've blown out, and I'd imagine that you can get the FVC and FEV1 off this graph. For more information, I recommend the book by Drs. Haas, _The Essential Asthma Book_, which goes into more detail about the various things you can find out from spirometry. 1.2.2 What is a peak flow meter? --------------------------------- A peak flow meter is a little plastic device which you blow hard into, after having taken a deep breath. It records the rate at which you've blown into it in litres exhaled per minute (L/min) -- this is called the peak expiratory flow rate (PEF or PEFR). The meter is essentially a cylinder with a mouthpiece at one end, a place for the air to escape at the other end, and a calibrated meter along the side. When you blow into it, a marker is pushed along the scale and comes to rest at a point which indicates your PEF. Since you want to measure your maximum peak flow, it is important to take a deep breath and blow as hard and as fast as you can. Many asthmatics find that their maximum peak flow provides a good objective measure of how their asthma is doing, so peak flow meters now are used extensively for self-monitoring of asthma, and also for monitoring the effectiveness of asthma medications. 1.3 How is asthma normally treated? ------------------------------------ Treatment of mild asthma usually tries to relieve occasional symptoms as they occur by use of short-acting, inhaled bronchodilators. Treatment of moderate or severe asthma, however, attempts to alleviate both the constriction and inflammation of the airways, through the use of both bronchodilators and anti-inflammatories. Bronchodilators are drugs which open up or dilate the constricted airways, while drugs aimed at reducing inflammation of the airways are called anti-inflammatories. Taking anti-inflammatory drugs (usually inhaled corticosteroids) daily for moderate to severe asthma is a relatively new approach to treating asthma. The idea behind it is that if the underlying inflammation of the airways is reduced, the bronchi may become less hyperreactive, making future attacks less likely. Such anti-inflammatory therapy, however, must be taken regularly in order to be effective. For asthma which is strongly triggered by allergies, allergen avoidance can often greatly reduce the amount of medication needed to control the asthma. Taking anti-allergic medications or taking shots for allergy desensitization are other alternatives. For more information about allergen avoidance and allergies in general, please see the alt.support.asthma FAQ: Allergies -- General Information (still under construction). 1.3.1 How is an acute asthma attack treated? --------------------------------------------- An acute asthma attack is usually treated with bronchodilators to reduce the constriction of the airways. Intravenous adrenalin and theophylline are often given in emergency rooms for this purpose, if short-acting bronchodilators given by nebulizer haven't sufficiently controlled the attack. Once the acute attack is over, anti-inflammatories may be used to reduce the inflammation of the airways. Inhaled steroids are usually the first choice, but for a sufficiently severe attack, oral steroids such as prednisone may also be given. 1.4 What are the most common triggers of asthma? -------------------------------------------- The most common triggers of asthma are: - viral respiratory infections, such as influenza (the flu) or bronchitis; - bacterial infections, including sinus infections; - allergic rhinitis; - irritants, such as pollution, cigarette smoke, perfumes, dust, or chemicals; - sudden changes in either temperature or humidity, especially exposure to cold air; - allergens, for people with allergies; - emotional upsets, such as stress; and - exercise. 1.4.1 What is intrinsic/extrinsic asthma? ------------------------------------------ Intrinsic and extrinsic asthma are outdated terms which have now been replaced by terms related to the asthma trigger, since the inflammatory response of the airways is the same independent of the cause of the asthma. What was known as extrinsic asthma is now called allergic asthma, while asthma triggered by non-allergic factors, formerly called intrinsic asthma, is separated into such categories as exercise-induced asthma and occupational (chemical- induced) asthma. 1.4.2 Can gastric reflux trigger asthma? ---------------------------------------- Yes, gastric reflux can act as an irritant which triggers asthma. Reflux, properly known as gastroesophageal reflux, occurs when the liquids in the stomach pass up the esophagus, or feeding tube. Because these liquids are usually highly acidic, they can irritate and inflame the esophagus, and also the airways of the lung, should any of this liquid be aspirated. This irritation can trigger an asthma attack. Asthma flares caused by reflux are more common at night, for it is easier for material to pass up the esophagus when one is lying down. Some simple treatments to prevent reflux include raising the head of the bed, not eating close to bedtime, or using either antacids or medications such as ranitidine (Zantac) which reduce the amount of acid produced by the stomach. Contributed by: Betty Bridges email@example.com 1.4.3 What is Occupational Asthma? ----------------------------------- Occupational Asthma is asthma that is caused by sensitization from exposures in the workplace. Asthmatics whose asthma is exacerbated by exposures in the workplace would not be classified as having occupational asthma. There are over 200 substances that have been documented as causing occupational asthma, but there are probably more that have not been recognized. The substances that are known to cause occupational asthma can be divided into two main categories. High molecular weight proteins of animal or plant origins are common causes. Things like animal dander, flour proteins, and animal scales are frequently causes of occupational asthma. These same things are also common causes of non-occupational asthma. These are usually IgE-mediated responses. Low molecular weight chemicals that have the ability to bind with proteins or act as haptans are causes of occupational asthma. There may be other mechanisms involved besides the classic IgE-mediated responses as not all those that are sensitized have specific antibody production. Reactions may have reflex, inflammatory, pharmacological, or immunologic pathways or a combination of several. Often occupational asthma is difficult to diagnosis. There are may be immediate, late, or biphasic reactions. In late reactions the symptoms may not occur until away from the work place. Frequently the asthma worsens as the workweek progresses and improves over the weekend. Treatment for occupational asthma is basically the same as any other asthma with a few very important exceptions. For those that have chemically induced asthma from sensitization to that chemical; avoidance of the trigger is essential. While steroids and other medications are helpful in treating the symptoms, they do not prevent the underlying sensitivity from increasing. Once sensitized to a substance, some react to minute amounts. Levels below current TLV levels still trigger reactions. For a sensitized individual any exposure can cause symptoms. Continued exposure to the triggering chemical can cause permanent lung damage, chronic asthmatic conditions, and even death. Medication should never be used to allow the worker to continue to work in an environment where there is exposure to the triggering substance. Early recognition and removal from exposure is essential in preventing long term disability from asthma. Chemically induced asthma can occur both in the workplace and outside of the workplace. There are many exposures outside of the workplace that there are exposures to chemicals that can induce asthma. Most physicians are not familiar with this type of asthma. For anyone that has chemically induced asthma, avoidance of the trigger is essential. 1.5 Asthma and Pregnancy ------------------------- Many people have posted to ask about whether it is safe to become pregnant while suffering from asthma, and in particular whether it is safe to use their asthma medications while pregnant. The general consensus (from the doctors I have consulted) is that asthmatics can safely become pregnant without undue worry about whether the mother and the baby will be all right. Most doctors talk about a "rule of 1/3" by which they mean that roughly 1/3 of all asthmatics get better while pregnant, 1/3 stay the same, and 1/3 find their asthma is aggravated (I improved with one pregnancy, and stayed the same with the next). In any event, the bottom line when pregnant is ensuring that the baby receives sufficient oxygen - and medications should be used as appropriate to control the asthma and protect mother and child. It is inadvisable to stop or reduce asthma medication solely because of the pregnancy without careful supervision, as this can lead to poorly controlled asthma, unnecessary ER visits, and poor outcome for the baby and/or mother. Most commonly-used asthma medications appear to be safe when used in pregnancy; notable exceptions include the combination pills (Marax, Tedral etc.) and those containing iodine (e.g. Theo-Organidin). Many people are concerned in particular with the use of inhaled, intranasal, and/or oral steroids but it has been my experience that most doctors are quite willing to use these as needed, especially the inhaled and intranasal steroids. It is my understanding that ephedrine (alone or in combination drugs), and phenobarbital (an ingredient in Tedral and other combination drugs) should be avoided. There are choices in most classes of drugs, e.g., the bronchodilators, and many doctors will elect to put their patients on those drugs with the longest history of use in pregnant women - the assumption is that the longer a drug has been in use, the likelier it is that any problems would have become evident. For this reason, beclomethasone (Beclovent, Vanceril) is the preferred inhaled corticosteroid. Cromolyn Sodium (Nasalcrom, Intal) also appears to be safe for use in pregnancy. In addition, if you need to use systemic steroids for a brief flareup, old concerns over fetal abnormalities (cleft palate etc.) appear to be less worrisome; I know of one case in which a woman used prednisone for something other than asthma for several months while pregnant and her baby had no problems. Antibiotics may be used if needed; there are some such as tetracycline which should be avoided but others (such as penicillin) appear to be safe. There is some anecdotal evidence from one contributer to the newsgroup that Serevent, the longer-acting B2-agonist, might be related to several cases of fetal abnormalities; I have not seen any official reports supporting or denying this but it may be worth discussing with your doctors if you use Serevent and are considering pregnancy. Note: the above is a compilation of my own experiences as a pregnant asthmatic, anecdotes from the newsgroup, and excerpts from The Asthma Sourcebook and the National Asthma Education and Prevention Program Expert Panel Report. It should in no way substitute for consultation with qualified medical personnel. ====================================================================== 2.0 What are the major classes of asthma medications? ------------------------------------------------------ There are seven major classes of asthma medications: - steroidal anti-inflammatories, - non-steroidal anti-inflammatories, - beta-agonists, - xanthines, - anticholinergics, - leukotriene receptor antagonists, and - anti-allergics. The first two categories of drug treat the underlying inflammation of the lung. All steroidal anti-inflammatories are glucocorticosteroids, which are entirely different from the anabolic steroids that have become notorious for their abuse by athletes. There are many different corticosteroids available for the treatment of asthma, almost all available via inhaler to reduce the amount of side effects (see section 2.3.6). The non-steroidal anti-inflammatories currently available are nedocromil sodium and cromolyn sodium, though cromolyn sodium is perhaps more properly known as a mast cell stabilizer, since it blocks both the release of histamine and inflammatory mediators, which means that although it blocks the inflammatory response, it cannot reverse inflammation once it has taken place. For this reason, I have classed it as an anti-allergic since it is mostly commonly taken for asthma that has a strong allergy component. The second two classes of asthma medications, beta-agonists and xanthines, are both bronchodilators, meaning that they relax the muscles lining the airways, allowing the airways to expand to their normal size. Beta-agonists are chemically related to adrenalin, but are specifically tailored to be more effective on the muscles of the lung while having little effect on the muscles in the heart. They are usually taken in inhaled form, and all but one (salmeterol) are short-acting. Theophylline, the major xanthine, is chemically related to caffeine, since caffeine is also a xanthine derivative, and is present in tea. Theophylline is taken orally, often in a sustained-action form (see section 2.4). Because its therapeutic range is close to its toxic range, asthmatics taking theophylline should have their blood levels monitored to ensure that their blood concentrations of theophylline lie within the therapeutic range (see section 2.4.1). There are some asthmatics, however, who cannot tolerate even very low doses of theophylline. Anticholinergics, the fourth class of medication, work by blocking the contraction of the underlying smooth muscle of the bronchi. Although used to treat asthma in Canada, the anticholinergic ipratropium bromide (Atrovent) has not approved by the US Food and Drug Administration for the treatment of asthma, but is used for the treatment of COPD. (It is interesting to note, however, that in the April 1982 issue of The FDA Drug Bulletin, the FDA states that "the FD&C Act does not, however, limit the manner in which a physician may use an approved drug. Once a product has been approved for marketing, a physician may prescribe it for uses or in treatment regimens or patient populations that are not included in a approved labeling." The FD&C Act is the Food, Drug, and Cosmetic Act.) The newest class of asthma medications is leukotriene receptor antagonists. My information as to how they work is sketchy, but as I understand it, the leukotriene receptor starts off the inflammator response of the immune system when it detects an allergen, so presumably an antagonist would block the receptor from responding to the presence of an allergen. Zeneca Pharmaceuticals has just now announced that its new leukotriene receptor antagonist, zafirlukast (Accolate), has been approved by the FDA (the US Food and Drug Administration) and will be available in November of 1996. Abbott Laboratories now produces a second drug in this class: zileuton (Zyflo). The last class, the anti-allergics, has been included because the two anti-allergic drugs, cromolyn sodium and ketotifen, are commonly taken for the prevention of allergic asthma. Cromolyn sodium is a mast cell stabilizer -- it blocks the release of histamine from mast cells, which acts to prevent asthma flares since histamine is a very strong bronchoconstrictor. However, it isn't considered an antihistamine because it cannot prevent the effects of histamine once the histamine has been released from the cell. Similarly, it blocks the release of inflammatory mediators from the mast cell, and so prevents the inflammatory response, although it cannot reverse inflammation once the mediators have been released. Ketotifen fumarate (Zaditen), a non-sedating antihistamine used mostly for the treatment of pediatric allergic asthma, is not currently available in the United States. 2.1 What are the names of the various asthma medications? ---------------------------------------------------------- For a complete listing of asthma medications, please see the alt.support.asthma FAQ: Asthma Medications. Allergy medi- cations are listed in the alt.support.asthma FAQ: Allergy Medications. They are posted monthly as companions to this general information FAQ. 2.1.1 Are salbutamol and albuterol the same drug? -------------------------------------------------- Ventolin is the brand name of salbutamol, which is the WHO (World Health Organization) recommended name for the medication. Unfortunately, in the US this same drug is called albuterol, leading to endless confusion. In fact, it's one of the few drugs in which the brand name stays the same from country to country, while the chemical name changes! Ventolin is made in the U.S. by Allen & Hanburys, and Proventil is the same drug manufactured by Schering. You can also get this drug in a sustained-action tablet, called either Repetabs (by Schering, again) or Volmax (Muro). 2.1.2 Can albuterol be taken while taking salmeterol? ------------------------------------------------------ Yes. Quoting from the Product Information Sheet that comes with the Serevent (salmeterol) inhaler, manufactured by Allen & Hanburys: "Serevent Inhalation Aerosol should not be used more frequently than twice daily (morning and evening) at the recommend dose. When prescribing Serevent Inhalation Aerosol, patients must be provided with a short-acting, inhaled beta2-agonist (e.g., albuterol) for treatment of symptoms that occur despite regular twice-daily (morning and evening) use of Serevent." "When patients begin treatment with Serevent Inhalation Aerosol, those who have been taking short-acting, inhaled beta2-agonists on a regular daily basis should be advised to discontinue their regular daily-dosing regimen and should be clearly instructed to use short-acting, inhaled beta2-agonists only for symptomatic relief if they develop asthma symptoms while taking Serevent Inhalation Aerosol." "The safety of concomitant use of more than eight inhalations per day of short-acting beta2-agonists with Serevent Inhalation Aerosol has not been established." So the above quotes seem to imply that it is okay for asthmatics taking Serevent regularly to also use Ventolin (albuterol) as needed, provided one doesn't need it too often. 2.2 Are some asthma drugs banned in athletic competitions? ----------------------------------------------------------- The determination of whether a drug or substance is banned or allowed in amateur athletic competitions is not based on whether it is medically necessary. Rather, such a determination is based on whether the substance in question can be performance-enhancing and offer an unfair competitive advantage. There are several organizations that make this determination and an athlete on an asthmatic drug should check with his coaches, physician, and appropriate athletic authority. Different athletic organizations may differ on what is banned or allowed. For example, the United States Olympic Committee (USOC) follows International Olympic Committee guidelines for testing at Olympic events. Many amateur athletic organizations (termed National Governing Bodies) adopt USOC guidelines for drug testing at their events. In contrast, the NCAA has less stringent guidelines for certain substances used by asthmatics in during competitions. Further complicating an athlete's understanding of the situation, some substances that are banned in tablet form are allowed in inhaled form. As an example, the USOC allows inhaled forms of the beta-2 agonist albuterol with written notification by a treating physician but bans tablet forms of albuterol. Certain other beta-adrenergic agonists (e.g. ephedrine, bitolterol, metaproterenol) are banned by the USOC. An athlete who participates in an amateur athletic event where drug testing may occur should check with his or her coaches and physicians regarding the allowed vs. banned status of any substance while competing. The United States Olympic Committee Drug Hotline, (800) 233-0393, or NCAA, (800) 546-0441, may provide information to specific questions on drugs, and educational materials in this regard. An asthmatic should also not assume that an over-the-counter (OTC) status of any drug implies its allowed status in athletic competitions; many OTC agents (e.g. combination decongestant-bronchodilators containing ephedrine) or herbal preparations bought in food stores (e.g. Ma Huang) contain stimulants useful for asthma but banned in certain athletic competition settings. Contributed by: Lyn Frumkin, M.D., Ph.D. firstname.lastname@example.org 2.3 What kinds of inhalers are there? -------------------------------------- aerosol inhalers: ---------------- MDI - metered-dose inhaler, consisting of an aerosol unit and plastic mouthpiece. This is currently the most common type of inhaler, and is widely available. autohaler - MDI made by 3M which is activated by one's breath, and doesn't need the breath-hand coordination that a regular MDI does. Available in U.S., UK, and NZ. integra - MDI with compact spacer device. Available in UK. respihaler - aerosol inhaler for Decadron. I have no idea how this differs from the usual MDI. Available in the U.S. syncroner - MDI with elongated mouthpiece, used as training device to see if medication is being inhaled properly. Available in Canada and UK. dry powder inhalers: ------------------- accuhaler - dry powder inhaler for use with Serevent. It contains a foil strip with 60 blisters, each containing one dose of the drug. Pressing the lever punctures the blister, allowing the drug to be inhaled through the mouthpiece. Available in the UK. diskhaler - dry powder inhaler. The drug is kept in a series of little pouches on a disk; the diskhaler punctures the pouch and drug is inhaled through the mouthpiece. Currently available in Canada, South Africa, and UK, not in U.S. insufflator - dry powder nasal inhaler used with Rynacrom cartridges. Each cartridge contains one dose; the inhaler opens the cartridge, allowing the powder to be blown into the nose by squeezing the bulb. Available in Canada. rotahaler - dry powder inhaler used with Rotacaps capsules. Each capsule contains one dose; the inhaler opens the capsule such that the powder may be inhaled through the mouthpiece. Available in the U.S., Canada, and UK for Ventolin. In Canada, Beclovent Rotacaps are also available, as are Becotide Rotacaps in the UK. spinhaler - dry powder inhaler used with Intal capsules for spinhaler. Each capsule contains one dose; the inhaler opens the capsule such that the powder may be inhaled through the mouthpiece. Available in Canada, UK, and the Netherlands. No longer manufactured in the U.S. turbuhaler - dry powder inhaler. The drug is in form of a pellet; when body of inhaler is rotated, prescribed amount of drug is ground off this pellet. The powder is then inhaled through a fluted aperture on top. Available in Australia, Canada, Denmark, Switzerland, and the UK (spelled 'turbohaler' in the UK). 2.3.1 Do inhaler propellants bother some asthmatics? ----------------------------------------------------- Some asthmatics find the dry powder inhalers more effective than their MDI (aerosol) counterparts. It is suspected that the aerosol or propellant in the MDI may act as an irritant to some asthmatics, as in the following article: J.R.W. Wilkinson et al., Paradoxical bronchoconstriction in asthmatic patients after salmeterol by metered dose inhaler, British Medical Journal 305 (1992) 931. The first sentence in the conclusion is: "Bronchoconstriction after both salmeterol and placebo by metered dose inhaler but not after salmeterol by diskhaler suggests that the irritant is not the salmeterol itself." . . . "The similarity in characteristics of bronchoconstriction after beclomethasone by metered dose inhalers implicates one or both chlorofluorocarbons . . . as the irritant. That salbutamol caused no bronchoconstriction was attributed to its faster onset of action opposing any bronchoconstrictor effects of the propellants." ** However, according to the 1994 Physicians' Desk Reference, Intal Spinhaler capsules are "contraindicated in those patients who have shown hypersensitivity to . . . lactose." So asthmatics who are lactose-intolerant may not have this form of cromolyn sodium as an option. 2.3.2 What is a spacer? What is a holding chamber? ---------------------------------------------------- Metered dose inhalers (MDIs) for asthma medications typically consist of a metal aerosol canister (containing the medication and a propellant) in a plastic sleeve with a mouthpiece. The patient inhales one or more metered doses of a medication through the mouthpiece. Most people find it difficult (at least initially) to time the spraying of an MDI and the inhalation of the medicine: the patient must exhale fully and inhale and release the metered dose just at the beginning of the inhalation so as to draw the medication as fully and deeply into the lungs as possible. All too often the puffs are mis-timed and only make it part of the way into the airways, and some of the medication is invariably deposited into the mouth and on the back of the throat instead of into their lungs. In addition to being less effective, this can lead to other side effects (e.g., for inhaled steroids, an increased potential for thrush, an oral fungal infection described in section 2.3.3). Several devices have become available that address these difficulties to varying degrees. The devices are generally referred to as "spacers" since they place additional space between the patient and the MDI. The medication is sprayed into the spacer instead of the mouth. As the patient inhales, the column of medication passes through the mouth and throat relatively quickly, leaving little opportunity for the medication to be deposited in the mouth or throat. This is a more efficient means of delivering the medication to the airways where it's most needed. The simplest kind of spacer is basically a tube. The patient sprays the medication in one end of the tube and inhales it out the other end. Azmacort has a simple spacer attached to it. A cardboard tube from the core of a roll of bathroom tissue can be used as a spacer (as long as it's clean, lint-free and germ-free). While a simple spacer reduces the amount of medication that gets deposited in the mouth and throat, it still requires you to carefully time your inhalation with the discharge of the medication to minimize the amount of the medication that escapes from the spacer. A "holding chamber" is a more sophisticated device. It is a sealed chamber (once the inhaler is inserted) that traps and holds the medication, allowing the patient to spray the medication into the chamber and take a few seconds to inhale the medication. Since the medication is temporarily suspended in the holding chamber, the timing of the inhalation is not nearly as critical as with simple spacers or no spacer. AeroChamber is a brand of holding chamber. It's a plastic tube with a mouthpiece on one end and a place to insert the MDI on the other. The mouthpiece has a one-way valve built in that temporarily contains the sprayed medication, and also allows the patient to exhale without displacing the medication in the chamber (as without a spacer, the patient should exhale as completely as possible before taking in any medication, so that the medication can be inhaled as deeply as possible). In addition to improving the timing of the inhalation, a holding chamber makes it possible to take in the medication more slowly than is possible without a spacer or with a simple spacer. This is important for the symptomatic patient, since rapid inhalation of the medication is more likely to trigger coughing and cause the patient to lose the medication before it has had a chance to be absorbed. Some spacers are clear so that you can see the puff of medicine, and so that you can see when the medication is building up on the inside, indicating that the spacer needs cleaning. Spacers and holding chambers need periodic cleaning; clean carefully, following the manufacturer's instructions so as not to damage any delicate internal parts or allow molds or other contaminants to be introduced. There are special holding chambers for younger children. There's a pediatric Aerochamber that has a mask built in; the child breathes normally for a few seconds with the mask held over his/her mouth and nose. This is typically used when a nebulizer is not available or not required, and for medications that are not available in a nebulized form, such as Beclovent or Vanceril. There is also a device for children (and for people that have trouble holding their breath) called an InspirEase. It's kind of like a plastic bellows or balloon with a plastic mouthpiece. The patient inflates it, the medicine is sprayed into it, and the patient inhales, holds his/her breath for the count of 5 (or whatever the doctor recommends), exhales into the device, and then repeats. Some patients are instructed to breath slowly in and out several times instead of holding their breath. The InspirEase really helpful for younger children who yet aware of the difference between breathing in and breathing out or don't yet know how to hold their breath or breathe evenly and slowly. It gives them immediate physical feedback, and it also has a whistle built in to tell them when they're breathing too fast (although they seem to like making it whistle, so it's positive reinforcement for something that they shouldn't be doing). As the child grows, the Inspirease becomes less effective, since it has a limited capacity, although I've been told that it is available in different capacities. Knowing the difference between a simple spacer and a holding chamber can help you use each in its proper way. If you use both a holding chamber *and* a simple spacer (e.g., a holding chamber for your Ventolin and the simple spacer attached to your Azmacort), you need to remember which you're using and adjust your style accordingly. Spacers and holding chambers are sometimes provided by some HMOs and covered by some insurers. Contributed by: Mark Feblowitz mfeblowitz@GTE.com [Maintainer's note: Some spacers seem to be prescription only, while others are not. Whether you need a prescription also seems to vary from state to state in the US. When in doubt, ask. As to why you would need a prescription (i.e. how could you abuse this simple plastic tube?), the nurses at National Jewish were as puzzled as I was.] 2.3.3 What is "thrush mouth" and how can I avoid it? ----------------------------------------------------- Thrush, or thrush mouth, is the popular term for a yeast infection (candida albicans) in the back of throat. The major symptom of thrush is a white film located at the back of the throat and tonsil area. It is usually cured by the use of an antifungal mouthwash. Thrush is a very common side effect of taking inhaled corticosteroids, since steroids alter the local bacteria and fungal population of the mouth, enhancing fungal growth. The way to avoid this complication is to ensure that the back of the throat doesn't remain coated with corticosteroid after use of the inhaler, either by using a spacer or by rinsing the mouth very thoroughly afterwards. Unfortunately, some people still get it even when they are very thorough about rinsing. 2.3.4 Is Fisons still making the Intal Spinhaler? -------------------------------------------------- In the US, Fisons is no longer manufacturing either the Intal Spinhaler (a dry powder inhaler for cromolyn sodium) or the capsules for it. However, the Spinhaler and capsules are still available in Canada and the United Kingdom. For further information, Fisons Corporation's number in the US for Rx Customer Service is (800) 334-6433. 2.3.5 What's the difference between Spinhalers and Rotahalers? --------------------------------------------------------------- [Maintainer's note: the Rotahaler is a dry powder inhaler for Ventolin (albuterol), manufactured by Allen & Hanburys, while the Spinhaler is a dry powder inhaler for Intal (cromolyn sodium), manufactured by Fisons Corporation. ] The Rotahaler and the Spinhaler are very different animals. The Rotahaler is a pussycat, the Spinhaler a ferocious lion. The Rotahaler is a two-part mouthpiece that you snap apart, put a capsule in, twist, and inhale. When you twist the device, the capsule breaks open. When you inhale, the medicine lands in your lungs. The Spinhaler is a three-piece device: a mouthpiece, a tiny fan, and a cap to cover the fan. You open it, put the capsule in a space on the fan, close it, push down then up on the cap (this breaks the capsule) and then tilt your head back, put the mouthpiece in your mouth, and inhale. The fan throws the medicine into the back of your throat. Then you gag. I don't like the propellants in MDIs, so I was highly motivated to get a Spinhaler. It took me a month to get my drugstore to find it, and now I must admit I'm disappointed. I tried using an Intal capsule in the Ventolin Rotahaler, since that device works so well, but the medicine seems to be of the wrong consistency, and the capsule is too large for the space it should go into. Another difference: The Spinhaler comes in a little container like a medicine bottle, but the lid doesn't stay on very well in a purse. The Rotahaler comes in a little plastic case sort of like a compact and stays shut (i.e. clean) in a purse, backpack, or jeans pocket. Contributed by: Paula Ford email@example.com 2.3.6 Why are so many asthma drugs taken via inhaler? ------------------------------------------------------ Medications taken orally almost always have a much higher systemic concentration (concentration in your entire body) than inhaled medications. So if the side effects are due to systemic concentrations, then an inhaled drug is less likely to have these side effects, or may have them much less severely. The idea behind an inhaler is that the full dose is delivered to the lungs, where it is immediately absorbed by the lung tissue, and starts to take effect locally. Excess drug may be absorbed by the bloodstream and delivered to the rest of your body, but this amount tends to be minimal. So your lungs receive an immediate, high concentration of the drug, and the rest of your body receives very little. If you take the drug orally in tablet or capsule form, then you need a much higher dose. The reason is that for the same amount of drug to reach the lungs through the bloodstream, you need the same concentration of drug in the rest of your body. For example, most people take one or two puffs of albuterol (Ventolin or Proventil) every four to six hours, and each puff is 90 micrograms of albuterol. The usual dosage of Ventolin in tablets is 2-4 milligrams three or four times a day, which is something like 200 times the amount inhaled. However, one advantage that tablets have is that the medication may be available in a time-release format. So for a short-acting medication like albuterol, the inhaled version might need to be taken every four to six hours, while a extended-release tablet such as Volmax would need to be taken only every twelve hours. 2.3.7 How can I tell when my MDI is empty? ------------------------------------------- The float test (in which you take the MDI canister out of the mouthpiece and place it in a container of water to see if it sinks) is no longer the recommended way to determine whether your MDI (metered dose inhaler) is empty. Glaxo, the manufacturer of Ventolin and Beclovent, claims that the float test is inaccurate, and recommends that doses be counted instead. Other manufacturers agree: the triamcinolone acetonide (Azmacort) package insert recommends dose counting also and the cromolyn sodium (Intal) inhaler package insert states that the metal cylinder should never be immersed in water. The number of doses per canister should be clearly written on the canister label. One variation of dose counting, for medications that are taken regularly, is to calculate the date on which the medication will be used up, and discard the old canister for a new one on that date. + There is also a gadget called The Doser. It fits on top of any MDI, and keeps track of how many doses you've dispensed from the inhaler. It provides daily totals for the past 30 days, and is useful if (like me) you tend to forget whether you've taken your maintenance inhalers already! See http://www.doser.com for more information. The Doser is over the counter, but the units can be hard to locate - if a drugstore can get them at all, the pharmacist usually has to special order them. 2.3.8 Are my aerosol inhalers going to disappear? -------------------------------------------------- As you may know, CFC (chlorofluorocarbon) chemicals, which are used as propellants in aerosol products including asthma inhalers (MDIs), damage the ozone layer. As a result, there has been a worldwide ban on the production of these chemicals for all but essential uses. Products which relied on CFCs, such as air conditioning units, refrigerators, and most aerosol products, have been modified to use alternative chemicals which do not damage the ozone layer. Due to their nature, however, metered dose inhalers have been granted an "essential use" exemption to the worldwide ban, which grants the manufacturers an extra few years to develop alternatives. Since the inactive ingredients (i.e., everything but the drug itself) must be changed, it's not as simple as using a different chemical for the propellant - the new device must go through much the same approval process as the original inhaler did, to ensure that the same dosage is delivered to the patient, that there are no side effects, that patients tolerate the new formulation well, etc. The FDA has already approved one new non-CFC inhaler, Proventil HFA (albuterol), which uses hydrofluoralkane instead of CFC propellants. Other non-CFC devices are currently in the works. It is expected that future non-CFC inhalers may be reviewed and approved more quickly than the earlier ones. CFC-based MDIs will continue to be available for some time. Proposed guidelines for final phaseout include that there be at least 3 multi-use (see below) non-CFC devices available in a drug class (i.e., bronchodilators, corticosteroids), providing at least 2 different drugs, before all CFC inhalers in that class are banned. As an example, CFC-based bronchodilators would be permitted as long as Proventil HFA is the only alternative; if Ventolin (also albuterol) and Alupent (metaproterenol) had non-CFC versions, then all CFC formulations might be banned. The term "multi-use" refers both to aerosol inhalers and multi-use dry-powder inhalers such as the diskhaler. It does not include single-use dry-powder inhalers such as the rotahaler, which requires insertion of a new capsule of medication with each use. 2.4 What kinds of tablets are there? ------------------------------------- CR - controlled release. This means that the drug has a constant rate of release. DR - delayed release. This generally refers to enteric- coated tablets which are designed to release the drug in the intestine where the pH is in the alkaline range. ER - extended release. Dosage forms which are designed to release the drug over an extended period of time, such as implants which release the drug over a period of months or years. SA - sustained action. Used interchangeably with CR (above), except that SA usually refers to the pharmacologic action while CR refers to the drug release process. TD - time delayed. This is slightly different from DR in that the drug release is designed to occur after a certain period of time, such as pellets coated to a certain thickness, multi-layered tablets, tablets within a capsule, or double-compressed tablets. Contributed by: Susan Graham firstname.lastname@example.org 2.4.1 Why do I need a blood test when taking theophylline? ----------------------------------------------------------- Theophylline is commonly used as a third-line agent in the management of asthma, after beta-agonists and anti-inflammatories. Unfortunately, its therapeutic level is quite close to its toxic level. This means that the dose that the asthmatic needs to get the full benefit of the drug is not very much lower than the dose which causes side effects which range from unpleasant to dangerous. This would not be such a problem if there weren't such large variations in the rate at which people metabolize theophylline. Apparently, if a group of people are given the same dose of theophylline, the concentration of the drug in their bloodstreams may vary by up to a factor of seven. Therefore, the best way to monitor that the asthmatic is receiving the optimal amount of theophylline is to take a blood level concentration. 2.4.2 Why are combination pills not commonly prescribed? --------------------------------------------------------- The combination drugs such as Tedral and Marax commonly contain theophylline, ephedrine, and some form of sedative such as phenobarbital. These combination pills are no longer commonly prescribed because the amount of theophylline in the pill cannot be varied with respect to the other drugs. Since there is great variation in the rate at which an individual metabolizes theophylline, it is now considered better to take theophylline separately, for better adjustment of theophylline levels. In fact, Tedral is no longer manufactured by Parke-Davis in the U.S. Also, ephedrine is no longer considered the bronchodilator of choice. From Drs. Haas, _The Essential Asthma Book_, "ephedrine initiates the release of catecholamines -- including adrenaline -- that are already stored in the body. This is its biggest drawback. Its effects depend on the availability of catecholamine in the body at the time it is given, and these concentrations vary." Since much better bronchodilators are now available, ephedrine is no longer commonly prescribed. 2.5 What is a nebulizer? ------------------------- A nebulizer is a device that uses pressurized air to turn a liquid medication into a fine mist for inhalation. If you've ever received emergency treatment for asthma, they've probably used a nebulizer on you. The term nebulizer is often used to describe both the pump that pressurizes the air, and the part that holds and "nebulizes" the medication. There are hand-held nebulizer units and ones with masks that you strap onto your face. The pressurized air typically comes from a portable pump unit that internally consists of a motor-driven air pump that resembles the fancier types of aquarium pumps. It forces air through a plastic tube into the plastic nebulizer unit. Inside, the nebulizer unit acts much like a perfume atomizer, creating a fine mist that is directed either through a tube that you inhale through or a mask that directs the mist into your nose and mouth. Since the nebulizer takes a few minutes to deliver the medication, you inhale it over a longer period of time than if you were using an inhaler. This can really help, especially if your passages are not fully open and you're taking a bronchodilator. As you breathe the medication, your lungs can gradually accept more and more of the medication. In addition to the medication, many people find the accompanying mist (typically a sterile saline solution) to be soothing. For very young children, the nebulizer is the only practical means of administering inhaled medications. Older children and adults have the options of using inhalers and a variety of spacers to make the timing a bit easier. The doctor overseeing the treatment decides which is the most effective/appropriate delivery mechanism. At least in Massachusetts, the nebulizer pump unit, the hand-held nebulizers, the medications, and the sterile saline inhalation solution are all prescription items. Replacement parts for the pumps are not available to the general public (if there are sources, I'd like to hear about them). The portable nebulizer pump units cost little ($100-$300) relative to the cost of an emergency room visit, so some health plans / insurers provide them to patients for times when an asthma episode is "manageable but not dangerous." This seems to be a trend in the management of pediatric asthma. Our family has been able to successfully avoid a few trips to the ER, and have even been able to head off some more severe allergic asthma episodes with early intervention. After a few rather gruesome visits to the Mass. General Hospital's waiting room on a Saturday night, we welcome opportunity to treat our children at home, when it's safe. We tend to go in to the doctor or ER for the more severe episodes or those that don't respond well enough to early intervention. Contributed by: Mark Feblowitz mfeblowitz@GTE.com 2.6 What medications should asthmatics be careful about taking? ---------------------------------------------------------------- Aspirin can trigger an asthma attack in approximately one in five asthmatics. This is especially common in those asthmatics who also have nasal polyps. As acetominophen (Tylenol), also known as paracetamol overseas, doesn't have this effect, it may be used as an alternative for anyone who suspects that they might have aspirin sensitivity. Cough medicines should also be treated with caution. In general, suppressing a productive cough (one which is bringing up mucus) is not a good idea, since the mucus can obstruct the airways and also irritate them further. Also, in _Asthma: Stop Suffering, Start Living_, the authors caution that "prescription cough suppressants (including those with codeine) are potentially dangerous for asthmatics. They may make you sleepy and reduce your breathing effort. They may also dry out your secretions, making mucus harder to raise." Antihistamines, however, should not pose a problem for most asthmatics, in spite of many warning labels. In _Children with Asthma_, Dr. Plaut states, "Most asthma experts see no problems with using antihistamines between or during asthmatics . . . Theoretically these drugs might dry up the mucus in the windpipes, thus making it harder to cough it up, but this has never been proved." Asthmatics taking theophylline should be careful when taking any of the following medications: the ulcer medications cimetidine (Tagamet) and troleandomycin (TAO), beta-blocker drugs such as propranolol, and the antibiotics erythromycin and ciprofloxacin. These medications may increase the concentration of theophylline in the bloodstream, possibly even to the toxic level (see section 2.4.1). People taking theophylline should be alert for signs of possible toxicity such as rapid or irregular heartrate, nervousness, or nausea, when taking these medications. In fact, asthmatics taking theophylline should check with their physician before taking any OTC medication, as the list of drugs, including antihistamines, which affect theophylline levels is almost endless. Beta-blockers, usually taken for hypertension, can pose problems even for those asthmatics not taking theophylline. Beta-blockers work by blocking the hormone adrenalin, but as adrenalin and other adrenergic drugs help keep airways dilated, the use of beta-blockers may aggravate asthma symptoms. 2.6.1 What about corticosteroids and chicken pox? -------------------------------------------------- According to the pamphlet "Advice from your Allergist", published by the American College of Allergy & Immunology, children taking oral or injected corticosteroids may be at increased risk of complications from chicken pox. Such children should avoid exposure to chicken pox -- if the child has been exposed, their physician should be notified. However, the child's medications shouldn't be changed without advice from their physician, since corticosteroid therapy should not be stopped abruptly. Children taking inhaled corticosteroids are not at this increased risk, according to the pamphlet, since the system concentrations of the medication are so small. ====================================================================== 3.0 What resources are there for asthmatics? --------------------------------------------- Please see the alt.support.asthma Reading/Resource List. It is maintained by Lynn Short <email@example.com>, and is posted periodically to alt.support.asthma, alt.med.allergy, sci.med, and misc.kids. I highly recommend it! I also strongly recommend the following guidelines: the "Global Initiative for Asthma", the "NHLBI Executive Summary: Guidelines for the Diagnosis and Management of Asthma", and the "Executive Summary: Management of Asthma during Pregnancy" (full citations in References section). They may be ordered in the U.S. by calling (301) 251-1222 and asking for publication numbers 95-3659, 94-3042A, and 93-3279A, respectively. When I ordered them, and asked that they be sent to a US address, there was no charge. Another set of guidelines which has been recommended to me but which I haven't seen myself yet is "NAEPP. Nurses: Partners in Asthma Care", publication number 95-3308, which I assume is also available at the number given above. The newsgroup misc.kids also has an allergy and asthma FAQ, which is available either by following the instructions posted on misc.kids.info, or by accessing the World Wide Web, <URL: http://www.cs.unc.edu/~kupstas/FAQ.html>. In addition, I maintain an Asthma and Allergy WWW Resources Page, <URL: http://www.cco.caltech.edu/~wrean/resources.html>, and two FAQs on allergies. For information on how to access these allergy FAQs, please see section 3.1. 3.1 Where can I get the latest copy of the FAQs? ------------------------------------------------- The two asthma FAQs I maintain, alt.support.asthma FAQ: Asthma -- General Information alt.support.asthma FAQ: Asthma Medications are posted once a month, on or about the 17th, to the following newsgroups: alt.support.asthma, alt.med.allergy, sci.med, alt.answers, sci.answers, and news.answers. If these FAQs have already expired at your site, you can get them by sending mail to firstname.lastname@example.org, with a blank subject line, and with one or more of the following commands in the message: send usenet/news.answers/medicine/asthma/general-info send usenet/news.answers/medicine/asthma/medications Alternatively, if you're really in a hurry, you can get them via anonymous ftp from rtfm.mit.edu, with the path names: /pub/usenet/news.answers/medicine/asthma/general-info /pub/usenet/news.answers/medicine/asthma/medications The general information FAQ is also available in html format on the World Wide Web, at <URL: http://www.radix.net/~mwg/asthma-gen.html>; a plaintext version of the FAQ is at http://www.radix.net/~mwg/asthma-gen.txt. Of the two allergy FAQs I maintain, alt.support.asthma FAQ: Allergies -- General Information alt.support.asthma FAQ: Allergy Medications the first is still under construction. The second is posted monthly to the following newsgroups: alt.support.asthma, alt.med.allergy, sci.med, alt.answers, sci.answers, and news.answers. If the allergy medication FAQ has already expired at your site, you can get it by sending mail to email@example.com, with a blank subject line, and with the following command in the message: send usenet/news.answers/medicine/allergy/medications Alternatively, if you're really in a hurry, you can get it via anonymous ftp from rtfm.mit.edu, with the path name: /pub/usenet/news.answers/medicine/allergy/medications 3.2 What is an FAQ, anyway? What is a Usenet newsgroup? --------------------------------------------------------- The term FAQ is an acronym which stands for Frequently Asked Questions. Often the term is also used for any document, such as this one, which attempts to answer questions which are frequently posted to a specific Usenet newsgroup. For example, this is one of the three alt.support.asthma FAQs which attempt to answer questions frequently posted to the newsgroup alt.support.asthma. A newsgroup is a world-wide electronic forum of discussion which generally takes place over the Internet, each newsgroup having its own topic of discussion. For more information about FAQs and newsgroups in general, I recommend any of the periodical postings in the newsgroup news.announce.newusers, particularly "FAQs about FAQs" and "What is Usenet?" These last two may also be accessed by sending mail to firstname.lastname@example.org, with a blank subject line, and with one or both of the following commands in the message: send usenet/news.answers/faqs/about-faqs send usenet/news.answers/usenet/what-is/part1 Alternatively, if you're really in a hurry, you can get them via anonymous ftp from rtfm.mit.edu, with the path names: /pub/usenet/news.answers/faqs/about-faqs /pub/usenet/news.answers/usenet/what-is/part1 +3.3 How about some other WWW links? --------------------------------------------------------- The original Asthma Resources page that Pat maintained is temporarily unavailable. In the meantime, I'm compiling a list of a few sites whose URLs I have handy. As with any website, these are not intended to substitute for competent medical advice, nor do I vouch for the currency or accuracy of information on these sites. http://asthma.about.com http://www.virtualdrugstore.com http://www.cs.unc.edu/~kupstas/FAQ.html http://nationaljewish.org http://www.vh.org/Providers/ClinGuide/AsthmaIM/staging/chronic/classif.html http://www.pslgroup.com http://www.srs.org.uk http://www.gpiag-asthma.org/asthma/GPIAG/welcome.htm http://www.nhlbi.nih.gov/index.htm http://www.nhlbisupport.com/asthma/index.html ====================================================================== List of Contributors: --------------------- Kevin Ball email@example.com Betty Bridges firstname.lastname@example.org Mark Delany email@example.com Mark Feblowitz mfeblowitz@GTE.com Bill Ellis Fleenor firstname.lastname@example.org Paula Ford email@example.com Lyn Frumkin, M.D., Ph.D. firstname.lastname@example.org Joe Gems email@example.com Susan Graham firstname.lastname@example.org Gwenith Jones email@example.com Philip D. Mayo, M.D., FCCP firstname.lastname@example.org Judith B. Paquet, R.N. email@example.com ====================================================================== References: ---------- The Physicians' Desk Reference is published annually by: Medical Economics Data Production Company Montvale, NJ 07645-1742 ISBN 1-56363-061-3 It is a compendium of official, FDA-approved prescription drug labeling. The FDA is the U.S. Food and Drug Administration. The Compendium of Pharmaceuticals and Specialties is published annually by: Canadian Pharmaceutical Association Ottawa, Ontario, Canada K1G 3Y6 ISBN 0-919115-94-2 Robert Berkow, M.D., editor in chief, _The Merck Manual of Diagnosis and Therapy_, 15th ed., (Merck & Co., Inc., USA) 1987. ISBN 0911910-06-09 The Merck Manual provides an overview of the diagnosis and therapy of the whole range of medical disorders that can occur in infants, children, and adults. I am told that the 16th edition is now available, with ISBN 0911910-16-6, and that the 17th edition should be available sometime in 1997. "Global Initiative for Asthma: Global strategy for Asthma Management and Prevention. NHLBI/WHO Workshop Report. March 1993", National Institutes of Health/NHLBI, Publication No. 95-3659, January 1995. These are often called the "GINA Guidelines". National Asthma Education Program Expert Panel Report, "Executive Summary: Guidelines for the Diagnosis and Management of Asthma", U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, Publication No. 94-3042A, Reprinted July 1994. Often called the "NHLBI Guidelines", this is a summary of the current wisdom on asthma treatment and prevention for physicians. I found it very readable. The above report, written in 1991, has now been superseded by: National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (revised 6/18/97) This report provides clinicians with recommendations for the diagnosis and management of asthma. These recommendations are organized into four components of therapy: measures of assessment and monitoring, control of factors contributing to asthma severity, pharmacologic therapy, and education for a partnership in asthma care. The recommendations are an update of the 1991 Expert Panel Report. The report can be accessed directly from http://www.ama-assn.org/special/asthma/treatmnt /guide/guidelin/guidelin.htm Report of the Working Group on Asthma and Pregnancy, "Executive Summary: Managment of Asthma during Pregnancy", National Institutes of Health/NHLBI, Publication No. 93-3279A, March 1993. The American College of Allergy & Immunology, (ACAI), publishes a pamphlet titled "Advice from your Allergist." It may be ordered from: ACAI 85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 (708) 427-1200 + Michael R. Freedman, Samuel J. Rosenberg, Cynthia L. Divino Living Well With Asthma (Guilford Press, USA) 1998. ISBN 1572303182 hardback, 1572300515 paperback The authors are former associates of National Jewish Medical and Research Center. M. Eric Gershwin, M.D., and E.L. Klingelhofer, Ph.D., _Asthma: Stop Suffering, Start Living_, 2nd ed., (Addison-Wesley, USA) 1986. ISBN 0-201-60847-2 The first author is Chief of Allergy and Immunology, University of California, Davis, Medical School. He is board-certified in internal medicine, allergy, and clinical immunology. Drs. Francois Haas and Sheila Sperber Haas, _The Essential Asthma Book_, (Ballentine Books, USA) 1987. ISBN 0-8041-0287-2 Dr. Francois Haas is the director of the Pulmonary Function Laboratory at the Medical Center of the New York University School of Medicine, and is on the faculty of the Department of Physiology there. Paul J. Hannaway, M.D. _The Asthma Self Help Book: how to live a normal life in spite of your condition_, 2nd ed., (Prima Publishing, USA) 1992. ISBN 1-55958-166-2, 1-55958-434-3 paperback The author is Assistant Clinical Professor of Tufts University School of Medicine. The first edition of this book won an American Medical Writers Association Award. Glennon H. Paul, M.D. and Barbara A. Fafoglia, _All About Asthma & How to Live with It: the complete guide to understanding and controlling asthma_, (Sterling Publishing Co., NY, USA) 1988. ISBN 0-8069-6808-7, 0-8069-6809-5 paperback Dr. Paul is the medical director of respiratory therapy at St. John's Hospital in Springfield, Illinois, and specializes in allergy and respiratory diseases. Thomas F. Plaut, _Children with Asthma -- A Manual for Parents_, (Pedipress, Inc., Amherst, Massachusetts, USA) 2nd edition 1995. ISBN 0-914625-03-9 Richard N. Podell, M.D. and William Proctor, _When Your Doctor Doesn't Know Best: medical mistakes that even the best doctors make -- and how to protect yourself_, (Simon & Schuster, USA) 1995. ISBN 0-671-87112-9 Nancy Sander, _A Parent's Guide to Asthma_, (Doubleday, USA) 1989. ISBN 0-385-24478-9 The author is the founder of Mothers of Asthmatics. Genell Subak-Sharpe, _Breathing Easy -- A Handbook for Asthmatics_, (Doubleday, NY, USA) 1988. ISBN 0-385-23440-6 This book was written in consultation with the National Jewish Center for Immunology and Respiratory Medicine. Allan M. Weinstein, M.D., _Asthma - The Complete Guide to Self- Management of Asthma and Allergies for Patients and their Families_, (Fawcett Crest, NY, USA) 1987. ISBN 0-449-21562-8 The author is Assistant Clinical Professor of Medicine at Georgetown University, and is a board-certified allergist who practices in Washington, D.C. Stuart H. Young, M.D. with Susan A. Shulman and Martin D. Shulman, _The Asthma Handbook -- A Complete Guide for Patients and Their Families_, (Bantam Books, USA) 1985. ISBN 0-553-24797-2 Dr. Young is the Chief of Allergy Clinics in both the Department of Medicine and Department of Pediatrics at the Mount Sinai Medical Center. He is also a clinical assistant professor of Medicine and a clinical associate professor of Pediatrics at the Mount Sinai Medical School. Francis V. Adams, MD, _The Asthma Sourcebook_ (Lowell House, Los Angeles CA) 1996 ISBN 1-56565-471-471-4 Dr. Adams is an award-winning pulmonary specialist in the field of asthma. He is currently Assistant Professor of Clinical Medicine at New York University and Attending Physician at Bellevue Hospital in New York. The following citations were used in compiling the Occupational Asthma section: O'Neil, CE: Review: Mechanisms of Occupational Airways Diseases Induced by Exposures to Organic and Inorganic Chemicals. Am j Med Sci 1990; 299(4) 265-275 Bernstein, DI: Respiratory Sensitization to Chemical Allergens. Masters in Allergy Vol 1, (1) 17-21 Grammer, LC: Occupational Asthma. Immunology and Allergy Clinics of North America Vol 13 (4) Nov 1993 769-783 Chan-Yeung, M: A Clinician's Approach to Determine the Diagnosis, Prognosis, and Therapy of Occupational Asthma. Medical Clinics of North America Vol 74 (3) May 1990 811-822 ====================================================================== Disclaimer: I am not a physician; I am only a reasonably well-informed asthmatic. This information is for educational purposes only, and should be used only as a supplement to, not a substitute for, professional medical advice. Copyright 1996 by Patricia Wrean, 1997-2000 by Marie Goldenberg. Permission is given to freely copy or distribute this FAQ provided that it is distributed in full without modification, and that such distribution is not intended for profit.