Living With Asthma

Finding out that your child has asthma can be tough. And in the early days, sorting out the right medication—and how and when to take it—can be tougher still.

The good news is that the more you know about asthma, the better your chance of stopping the coughing, wheezing, and shortness of breath that led to the diagnosis in the first place. There is no cure for asthma, but the condition can be managed successfully by taking medication and identifying (and avoiding) asthma triggers.

The tricky part is that as time goes on, people with asthma can start to feel perfectly healthy, due to the medication. It can be hard to remember that even though the asthma symptoms are gone, the disease is still there. It can be dangerous to stop or cut back on medication in the belief that asthma has disappeared. This can leave your child vulnerable to serious breathing trouble or hospitalization the next time he or she encounters an asthma trigger. (Some children may eventually “outgrow” asthma, but only a doctor can say for sure if it’s safe to taper off medication.)

Your doctor can help you set up an asthma plan for your child, but the ball’s in your court to stick with it. Following this plan will help minimize your child’s symptoms and allow him or her to be as active as possible.

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Allergic Asthma: What It Is, How to Beat It

What is allergic asthma? Of the more than 22 million adults and children in the United States who have asthma, at least half of adults and about 80% of children have allergic asthma. In any kind of asthma, the lungs overreact to triggers by 'tightening up' airways, which causes persistent coughing (particularly at night), wheezing, shortness of breath, and difficulty breathing.

But in the case of allergic asthma, those triggers are substances—animal dander, dust mites, pollen, mold, cockroach proteins, or other allergy-causing particles—that don't bother most other people.

Non-allergic asthma triggers, on the other hand, can include exercise, cold air, pollution, and stress. Many people have a combination of both types, and the treatments are often similar for both—mostly to ease the swelling and inflammation in the lungs and open up the airways.

So why does it matter what's causing your symptoms? Well, the more you know about your triggers—allergic or not—the better your chances of avoiding breathing problems.

James Thompson's graduate studies in biopsychology required him to spend a lot of time working with rats. Already plagued by seasonal asthma attacks due to a pollen allergy, he became sensitized to rodents too. His lung function became so compromised that he nearly died of pneumonia at age 25. (Respiratory infections can make asthma worse.)

Two decades later, Thompson is still allergic to rodents, but he's also learned a whole lot more about how to cope with his allergic asthma.

"Over the past 10 years I've just been trying to understand the triggers more," he says. Thompson has found he has a combination of both allergic and non-allergic asthma. The Maplewood, New Jersey-based non-profit manager knows auto exhaust is a problem for him too. Now he tries to make sure his home is free of dust-collecting clutter and he'll cross the street to avoid inhaling bus exhaust. "When you're in your 20s you really don't notice, you don't make all these connections with your environment."

What's causing your asthma?
The first step to figuring out how to treat your asthma is to realize that you have it. That's harder than it sounds. Do you have persistent nighttime coughing or shortness of breath? It's easy to dismiss it as due to a cold, lack of exercise, postnasal drip, or just about anything else other than an allergy to the pet sleeping in your bedroom.

Many people with allergic asthma attribute their symptoms to a garden-variety cold, says John Winder, MD, an allergist based in Toledo, Ohio and the chair of the American College of Allergy, Asthma and Immunology's Nationwide Asthma Screening Program. The free screening, offered at about 200 sites across the United States, includes a breathing test and an interview with an asthma specialist.

To date, more than 100,000 people have been screened through the program, Dr. Winder notes, and half of them were referred to a specialist for further diagnosis.

If you do indeed have allergic asthma, the next step is to find ways to limit your exposure to the allergens that affect you. "Avoidance is the best defense," Dr. Winder says.

To nail down the specific triggers, it's best to see an allergist, says Robert A. Nathan, MD, director of the Asthma and Allergy Associates and Research Center in Colorado Springs, Colo. While primary care doctors may suspect that a person has allergic asthma, they typically do not delve deeper to confirm the diagnosis with a skin or blood test.

Skin prick testing is the most common way to determine if someone is allergic to a particular substance. This involves placing a tiny amount of a specific allergen (like pollen protein) into a person's skin. If redness or swelling develops within 20 to 30 minutes it indicates an allergy to the substance.

Some allergens are easier to avoid than others, and sensitivity varies widely among individuals. For example, some people can nip a pet allergy in the bud by living in an animal-free home and taking medication for their symptoms when they visit a friend or family member who does have pets.

"Other people are so reactive that they just have to go out to dinner with people who have dander on their clothes to have a reaction," Dr. Nathan notes.

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20 Questions About Allergy-Triggered Asthma

Robert A. Nathan, MD, is a clinical professor of medicine at the University of Colorado Health Sciences Center and director of the Asthma and Allergy Associates and Research Center in Colorado Springs, Colo.

Q: What's the difference between asthma that is due to allergies and asthma that is not?

A: Allergic asthma is an overreactive immunologic response that occurs because a person's body makes too much of an immune system component called immunoglobulin E (IgE). People with allergic asthma are bothered by common allergens like animal dander, dust mites, pollen, mold, or cockroaches, and they are often allergic to more than one of these things.

When a person has asthma that isn't related to allergies, but is instead triggered by factors that act directly on the lungs, such as infections, exercise, cold air, pollution, and stress, they have non-allergic asthma. Many people with asthma have a combination of non-allergic and allergic asthma. Of the nearly 19 million adults in the United States with asthma, about half have asthma that's related to allergies. But just 20% of adults with asthma have symptoms triggered by just allergies alone.

Q: How can you tell if your asthma is due to allergies?

A: First and foremost is the medical history. If a patient says he only has symptoms when he's near a cat or dog, for example, or only during pollen season, it's likely to be due to allergies.

Q: How can you know for sure what's triggering your asthma?

A: Skin tests, also known as 'skin prick tests,' are the gold standard. They involve putting a tiny amount of the allergen into the very top layer of your skin. The area will then swell, itch, and turn red if you are sensitive to that allergen.

Q: Do you need to see an allergist or a pulmonologist to be diagnosed with allergic asthma, or can your primary care doctor do the job?

A: Pulmonologists deal with a myriad of lung diseases, but allergists deal primarily with asthma and other allergic conditions, so they are better prepared to diagnose and treat allergic asthma. Most importantly, we're trying to identify triggers and help the patient understand how to deal with those triggers. The primary care physician may suspect that asthma is related to allergies, but it's the allergist who can confirm the diagnosis by using objective measures, like the skin test.

Q: Is asthma harder or easier to treat if it's due to allergies?

A: Avoidance is the main way to treat any allergic disease. In a way, it's easier to treat allergic asthma than non-allergic asthma, because you can just stay away from the allergen. But this depends on what the allergen is, and how sensitive you are to it. The ace in the hole that patients with allergic asthma have that patients with non-allergic asthma don't have is immunotherapy, or as it's more commonly known, allergy shots. It is potentially curative, whereas medication can only address symptoms.

Q: Does allergic asthma ever get better on its own?

A: While some children will 'grow out of' their allergic asthma once they reach puberty, it's exceedingly rare for an adult's disease to go into remission.

Q: Can allergic asthma be life threatening?

A: It's rare but certainly possible, depending on the extent of exposure, how bad an attack gets, and how long it takes for you to get treatment. Every year, 3,500 Americans die from asthma, and some will have had allergy-induced asthma.

Q: Will allergy shots help? What do they entail?

A: Allergy shots, or immunotherapy, can definitely help, but they're a major commitment. For allergy shots to be effective, a person needs to visit an allergist regularly for several years. And while insurers typically cover immunotherapy, copayment costs can add up.

At first, a person undergoing immunotherapy will go to the allergist once or twice a week, for three to six months, receiving slightly larger amounts of the allergen with each visit. The shot itself is very quick, but patients must wait in their doctor's office for 20 to 30 minutes to see if a reaction occurs. After this initial phase, the patient's visits are spread out to every two to four weeks. This maintenance phase can take two to five more years. A person is considered to be free of an allergy if he or she can go for two years without symptoms, which in essence means not having to take allergy medication.

Q: At what age do people typically develop allergic asthma?

A: Usually symptoms start before age 10, but a person can develop allergic asthma at any point in his or her life. It's rare for someone in their 60s or older to develop allergic asthma for the first time.

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Swine Flu and Asthma: Here's What to Do

Nearly one-third, or 28%, of adults and children hospitalized with H1N1, also known as swine flu, have asthma. That’s more than any other chronic condition, according to a recent analysis of cases published in the New England Journal of Medicine.

(The next most common complications on the list were diabetes and a weakened immune system, at 15% each.)

“Asthma was the most common underlying medical condition that we saw,” says Seema Jain, MD, a medical epidemiologist at the Centers for Disease Control and Prevention (CDC). Dr. Jain’s team analyzed 272 people who were hospitalized with H1N1 for more than 24 hours between April and June.

Twenty-five percent were admitted to the intensive care unit and 7% died. Overall, 29% of children and 27% of in adults in the study had asthma, while only about 8% of the U.S. population has asthma, according to Dr. Jain.

Richard Gower, MD, the president of the American College of Allergy, Asthma, and Immunology, says about 25 million people in the United States have the chronic lung condition, including 8 million children.

Asthma is an accident waiting to happen
Asthma is more common in children than in adults, and swine flu seems to strike younger people more often than older ones—a complete flip-flop from seasonal flu.

In the study, 45% of the hospitalized patients were under age 18, and only 5% were 65 or older. “If you are a young adult and you have asthma, you are in double jeopardy,” says Dr. Gower.

For many people, swine flu symptoms include fever, congestion, and possibly nausea, diarrhea, and vomiting, which are some of the symptoms that differ from seasonal flu. (Seasonal flu rarely causes nausea or an upset stomach). Most of the time, the symptoms can be successfully battled with time, liquids (chicken soup, anyone?), and bed rest.

But for people at high risk, including those with asthma, an H1N1 infection can be a different story.

“Asthma is sort of an accident waiting to happen,” says Dr. Gower, who is also an allergist/immunologist at Marycliff Allergy Specialists, in Spokane, Wash. People with asthma are at risk for breathing trouble with infections in general, not just H1N1.

The lungs of people with asthma tend to bronchospasm, meaning they tighten in response to triggers, such as pollen, pet allergens, bacteria, viruses, or other insults. In the case of an infection like H1N1, the lungs produce mucus in response to the germ, and the mucus can get trapped in the narrow airways, setting the stage for pneumonia.

“You add an insult and it just triples, quadruples, gets 10 times worse very suddenly, and flares the asthma,“ says Dr. Gower. “The bronchospasm occurs and it squeezes the airways dramatically down to narrow, narrow passages—and, in fact, closure—and the mucus that is dramatically increased gets trapped and that’s a setup for pneumonia.”

So what should you be doing about H1N1 if you—or your children—have asthma?

Take your medication
People with chronic asthma often need to take controller medications that fight underlying lung inflammation. The problem is, they need to take this type of medication every day, even if they are feeling fine. It can help protect the lungs from triggers like infections.

But many people forget to take the medicine or skip doses when they aren’t having asthma symptoms.

If you have a young child with asthma, make sure they take their medication as directed, says Dr. Gower. It gets tricky if your child is a teen, because they are notorious for skipping asthma medication, and may lie about it too, he says.

Parents need to talk to teens and explain that although they may have gotten away with skipping asthma drug doses in the past, “this is a brand new ball game,” he says. “They really should raise the threshold of their lungs by taking chronic medicines if they have chronic asthma.”

Dr. Gower also recommends that patients have—and use—a peak flow meter, which is a device that you can blow into to gauge lung function.

“It empowers the patient or the parents,” says Dr. Gower. “Even if the patient says they are doing fine and they are giving their best effort to blow into the peak flow meter and it’s going down and it gets into the yellow zone then into the red zone, that’s a real warning sign that that asthma is getting worse no matter what you are doing.”

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For Olympians and Weekend Warriors Alike, Winter Sports Can Trigger Asthma

Do you cough, wheeze, or get short of breath when you exercise in cold weather? You could have asthma, but you’ve got plenty of company. Exercise-induced asthma is surprisingly common among people who work out in cold climates, whether they’re jogging around the neighborhood or gunning for gold in Vancouver.

This week, for example, Norwegian cross-country skier Marit Bjørgen won the bronze medal in the women’s 10-kilometer race, even though she uses asthma medication. In fact, half of cross-country skiers and one-quarter of aspiring winter Olympians in general have exercise-induced asthma according to a 2000 study of 170 athletes conducted by the United States Olympic Committee.

"Any [exercise] outdoors on a mountaintop is a culprit, but just jogging in Central Park will do it as well," says Len Horovitz, MD, a pulmonary specialist with Lenox Hill Hospital, in New York City. Exercise-induced asthma doesn’t have to slow you down, however. With the right medications and precautions, exercise-induced asthma won’t keep you from your daily workout, or even from competing at an elite level.

How cold and exercise cause asthma
Wheezing, chest tightness, and the other symptoms of exercise-induced asthma generally begin several minutes after you begin working out. For some people, the symptoms start soon after they finish exercising.

Although athletes who compete in warm-weather sports may suffer from exercise-induced asthma as well, mixing exercise and cold, dry air is especially problematic. For many people with regular asthma, in fact, just stepping outside in frigid temperatures is enough to cause symptoms.

"Both cold air and exercise in and of themselves can trigger asthma symptoms, but doing them together is more likely to trigger an exacerbation," says Thomas M. Leath, MD, an assistant professor of pediatrics at Texas A&M Health Science Center College of Medicine.

When the air is dry—as it often is in cold climates during the winter—your lungs can become even more irritated, Dr. Horovitz adds. "The evaporative loss and cooling of the airways triggers the process of bronchial constriction," he says. "One sport you don’t see exercise-induced asthma in so much is swimming. The humidity at water level is such that there isn’t as much evaporation as in running or winter sports." (Chlorine, however, can trigger asthma symptoms, Dr. Horovitz notes.)

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Why Asthma Symptoms Can Vary With the Weather

Fall brings with it school days, crisp air, turning leaves—and a spike in asthma symptoms. But spring can be tough for people with asthma, too, particularly if they have a pollen allergy. And summer heat waves are notorious for sending asthmatics, particularly asthmatic children in urban areas, to the emergency room.

So why do asthma symptoms seem to get worse with every change in the weather? Although it seems confusing, there are some annual trends, as well as reasons why asthma symptoms are worse at particular times of the year.

For example, severe asthma episodes tend to peak during the autumn months, especially among children. A 2001 study that examined tens of thousands of asthma hospitalizations in Canada over a 12-year period, for instance, found that there were more than twice as many hospitalizations in October as there were in July or August. Other studies have discovered similar patterns.

However, one study conducted in Detroit found that when there was a rapid 10-degree rise in temperature or a 10% rise in humidity—as can happen in spring and summer—hospitalizations for children with asthma increased in the next day or two.

In truth, asthma symptoms can flare at any time of year due to well-known asthma triggers, such as pet dander, secondhand smoke, and exercise. But knowing the triggers that can vary by season—such as pollen, temperature, humidity, pollution, and viruses—can help people with asthma figure out if they should be stepping up their medication.

Fall
Cold air can cause an asthmatic’s lungs to tighten up, so you might guess that a fall peak in asthma episodes is due to cooler weather. But the patterns found in the Canadian study have also been reported in far-flung places including Hong Kong and the tropical island of Trinidad—so cold weather isn’t entirely to blame.

In fact, the main culprit is believed to be cold-and-flu season, which kicks into gear once kids head back to school. Classrooms filled with runny noses, and grimy hands are breeding grounds for cold and flu viruses, which schoolchildren inevitably spread to their families.

People with asthma aren’t more likely to catch a virus than people without asthma, but when they do, their illness tends to be longer and more severe. Respiratory tract infections aggravate the chronic lung inflammation of asthma, which can lead to wheezing, coughing, difficulty breathing, and asthma attacks. (The flu, common cold, and other respiratory infections are responsible for about 80% of wheezing episodes in children, and about 50% of such episodes in adults.)

“The old adage, ‘If you treat a cold, it lasts a week; if you ignore it, it lasts seven days’, is not true for an asthmatic,” says Bradley Chipps, MD, a pediatric pulmonologist and allergist in Sacramento, Calif. “Unless treated, the symptoms will go on for weeks sometimes.”

The flu, whether it’s swine flu (H1N1) or seasonal flu, can be even more perilous. A recent analysis of cases found that 28% of people hospitalized with swine flu had asthma. People with asthma are more vulnerable to complications stemming from the flu—such as pneumonia—and are more likely to be hospitalized, which is why the Centers for Disease Control and Prevention recommends that all people with asthma over six months old get the seasonal and swine flu shot. And it has to be the shot, whether it’s a seasonal or swine flu vaccine. (The FluMist vaccine, which is delivered via nasal spray, can cause wheezing and should be avoided by asthmatics.)

The sudden spike in asthma-related doctor’s appointments and ER visits among children that coincides with the start of the school year—a pattern that has been observed all around the Northern Hemisphere—is so predictable that it has come to be known as the September epidemic.

Allergens also are a problem in the fall. The ragweed season begins in late summer, but in some areas it can last well into October. This plant, which is found in the greatest quantities in the East and Midwest, is a nightmare for people with asthma who are sensitized to this allergen. Each plant produces up to a billion grains of pollen in a season, and the lightweight grains can carry on the wind for hundreds of miles.

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