In asthma treatment, one size does not fit all. Each person with asthma requires individual treatment. Choosing a treatment appropriate for you depends on an accurate assessment of how severe your asthma is.
Because symptoms may vary from week to week or month to month, a key part of managing your asthma is to assess your symptoms over time. When you visit your doctor for a checkup, he or she gets a snapshot of the severity of your asthma based on how you are doing at that moment. What the doctor needs is more like a motion picture, based on your experiences with asthma 24 hours a day, seven days a week. You can provide the equivalent of a motion picture by the way you describe your symptoms since you last saw the doctor.
It’s helpful to take a step back once in a while and assess how your asthma has been for the past few weeks to months. This will provide you and your doctor with information that might lead to adjustments in your asthma treatment program. When you and your physician assess your asthma control, this should involve not only consideration of your symptoms, but also an evaluation of possible future risks. These risks include the risk of an asthma exacerbation, worsening of your lung function, and potential side effects of asthma medications.
In one sense, you can judge the severity of your asthma based on how much it affects your life. If you are having frequent asthma symptoms, are limited in your ability to exercise because of asthma, have impaired lung function, and often experience attacks that require emergency care, your asthma is severe and out of control. If the opposite is true — you rarely have any asthma symptoms, you can exercise without provoking symptoms, your lung function is almost always normal, and you never suffer severe flare-ups — then you have well-controlled asthma.
How would you answer the following questions?
- How often in the past year have you had to go to the doctor’s office or to a hospital emergency room with a severe attack of asthma?
- How often have you had to stay home, miss work, or cancel plans for the day because of asthma?
- How often do you awaken at night because of cough, shortness of breath, or tightness in the chest?
- How often do you have to limit your physical activities because of your asthma?
- How often do you need to use your quick-acting bronchodilator medications for relief of your asthma symptoms?
Ideally, your answer to the first four questions is “never,” and your answer to the last is “no more than once or twice a week.” If you answered differently, it may be time to work with your doctor to reevaluate your asthma treatment regimen.
There are a number of validated instruments that can be used to evaluate your asthma control, all of which have questions similar to those listed above. Two commonly used tools are the Asthma Control Questionnaire (ACQ) and the Asthma Control Test (ACT). You can find these questionnaires online, and you may also see them at your physician’s office.
Keep a diary
One way of keeping track of your asthma symptoms is by keeping a detailed diary. Your physician may ask you to do this based on your symptoms or when making a change in your medication regimen. This diary should include a description of symptoms (cough, wheezing, shortness of breath) and when they occur, medications used, and peak flow readings (see below). Reviewing this diary with your physician provides important information about the control of your asthma in the weeks preceding your visit. A diary may also provide important clues about possible triggers for your asthma based on when symptoms are occurring.
Measure peak flow
The best assessment to find out exactly how well your lungs are functioning is to measure your peak flow to find out how fast you can exhale air. When your asthma is well controlled, air flows rapidly through the breathing tubes. When you are having difficulty, the breathing tubes are narrowed and air can be forced only slowly out of the lungs.
You can measure your peak flow quickly and easily, using the same device doctors sometimes use to assess asthma in their offices. First, set the indicator at zero. Then, take a deep breath in, grip the mouthpiece tightly with your lips, and exhale quickly and forcefully. Make a note of how far the indicator moved on the scale. Then set the indicator back to zero and repeat the procedure twice more. The best of your three attempts is your peak flow.
With a peak flow meter, you can compare your breathing to that of a person without asthma. You can also compare your breathing today with your own peak flow measured on a day when you are free of any asthma symptoms (your “personal best” peak flow). By using a peak flow meter and keeping track of results, you can know exactly how your asthma is doing. This is valuable information for you and your physician.
At one time, doctors routinely encouraged patients to check their peak flow every day, but this is no longer a uniform recommendation. For one thing, it places an added burden on already busy lives. For another, it is unclear that daily peak flow recordings will reliably alert you to asthma flare-ups before your symptoms do.
Still, having a peak flow meter at home is useful when it comes to assessing the severity of your asthma symptoms. It’s best to keep a peak flow meter at home and think of it like a thermometer. If you are sweaty or chilly and feel feverish, you’ll probably find it useful to take your temperature with a thermometer rather than guessing about your temperature. Similarly, if you were to develop persistent coughing and shortness of breath, it would be useful to check your peak flow rather than to guess whether your symptoms are due to asthma and, if so, how severe the flare-up is. In addition, improvement in your peak flow measurement with asthma treatment is an important indicator that an exacerbation is getting better.
Match treatment to severity
The first goal of treatment is to gain control over asthma symptoms. Once you and your doctor have determined how severe your asthma is, you can tailor your treatment to level of severity.
There are a number of published guidelines for the diagnosis and management of asthma. The two most widely accepted expert guidelines are produced by the National Asthma Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA). These guidelines are developed by panels of experts in order to help doctors and patients manage asthma, with the goal of reducing chronic disability and premature deaths while allowing patients with asthma to lead productive and fulfilling lives. The different organizations use slightly different labels to describe the various levels of control, but the underlying information and goals are very similar.
The GINA guidelines emphasize asthma management based on control of asthma symptoms. The step-care guidelines help doctors establish each patient’s current level of treatment and control, then adjust treatment to gain and maintain control. This means that asthma patients should experience no or minimal symptoms (including at night) and very infrequent flare-ups, have no limitations on their activities (including physical exercise), need rescue medications only rarely, and have near-normal lung function.
The GINA guidelines define three levels of asthma control.
Controlled. If your asthma is controlled, it means you have achieved all of the following:
- daytime symptoms twice or less per week
- no limitation of activities
- no nighttime symptoms or awakening
- need for reliever or rescue treatment no more than twice per week
- normal lung function
- no flare-ups.
Partly controlled. If your asthma is partly controlled, it means you have any of the following:
- daytime symptoms more than twice a week
- any limitation of activities
- any nighttime symptoms or awakening
- need for reliever or rescue treatment more than twice a week
- lung function less than 80% of predicted or personal best (if known)
Uncontrolled. Your asthma is uncontrolled if you have three or more features of partly controlled asthma present in any week or if you have had any exacerbation within a week
Remember that any asthma exacerbation should prompt a discussion with your physician about your current therapy.
Treating to achieve control
Under the GINA guidelines, your current level of asthma control and treatment will determine which treatment you and your doctor select. For example, if your asthma is not controlled on your current treatment regimen, treatment should be stepped up until your asthma is under control. If your asthma control has been maintained for at least three months, your treatment can be stepped down with the aim of establishing the lowest step and dose of treatment that maintains control. If your asthma is partly controlled, your doctor may consider an increase in treatment, depending on whether more effective options are available (such as an increased dose or an additional treatment), safety and cost of possible treatment options, and how satisfied you are with your level of asthma control.
The GINA guidelines recommend the following five steps for asthma treatment. Most patients with persistent asthma symptoms who have never been treated will start at Step 2. If you are diagnosed with severely uncontrolled asthma, treatment should begin at Step 3. At each treatment step, the doctor should provide a reliever medication (rapid-onset bronchodilator) for quick relief of symptoms. But regular use of reliever medication is one of the elements defining uncontrolled asthma and indicates that controller treatment should be increased. Reducing or eliminating the need for reliever treatment is both an important goal and a measure of success of treatment.
Step 1: As-needed reliever medication
You’re a Step 1 patient if you haven’t been treated for asthma before and you have occasional daytime symptoms (cough, wheeze, breathing problems twice or less per week, or less frequently if they occur at night) that last only a few hours. Importantly, in between these episodes you have no symptoms, have normal lung function, and do not wake from sleep due to your asthma. The treatment for most Step 1 patients consists of a rapid-acting inhaled beta-agonist, to be used as needed. Albuterol is the most common rapid-acting beta-agonist used in the United States. Alternative treatments — a distant second choice — include an inhaled anticholinergic, short-acting oral beta-agonist, or short-acting theophylline, although they take longer to work and have a higher risk of side effects.
If your symptoms are more frequent, or worsen periodically, you’ll need to move up to Step 2, which requires regular controller treatment in addition to as-needed reliever medication.
Step 2: Reliever medication plus a controller
Treatment Steps 2 through 5 combine an as-needed reliever treatment with regular controller treatment. The controller medication is intended to be taken regularly to control symptoms, rather than as needed when symptoms develop. At Step 2, a low-dose inhaled corticosteroid is recommended as the initial controller treatment for asthma patients of all ages. There are several inhaled steroids available with different types of delivery devices and dosing schedules. Two commonly used steroids are Budesonide and Fluticasone. All of these are inhaled medications with similar effects. As stated earlier, these medications should be taken every day (or twice daily), and not only when you develop symptoms.
Alternative controller medications include leukotriene modifiers, such as montelukast and zafirlukast. These medications may be a good choice if you are unable or unwilling to use inhaled corticosteroids, or if you experience intolerable side effects such as persistent hoarseness from inhaled corticosteroid treatment.
Other options are available but not recommended for routine use as initial or first-line controllers in Step 2. These include sustained-release theophylline, which is not as effective as the above-mentioned treatments and has a higher risk of side effects, and cromolyn, which is also not as effective.
Step 3: Reliever medication plus one or two controllers
At Step 3, the recommended controller therapy is a combination of a low dose inhaled corticosteroid with an inhaled long-acting beta-agonist, either in a combination inhaler device (such as Advair or Symbicort) or as separate components. Usually the additive effect of the combination treatment is sufficient, but if you don’t get your asthma under control within three or four months, your doctor may increase the dose of the inhaled steroid.
Other treatment options at this stage include:
- A medium dose of inhaled corticosteroid. If you are using a medium or high dose of inhaled corticosteroid delivered by a pressurized metered-dose inhaler, using a spacer device will improve delivery of the medication to your airways and reduce side effects (see “Spacers”).
- A combination of a low-dose inhaled corticosteroid with a leukotriene modifier.
- A combination of a low-dose inhaled corticosteroid with a low dose of sustained-release theophylline.
Step 4: Reliever medication plus two or more controllers
If your asthma hasn’t been controlled on Step 3 treatments, you should see a health professional with expertise in the management of asthma who can determine whether you are suffering from something other than asthma, or find the causes of your asthma.
The preferred treatment at Step 4 is to combine a medium or high dose of inhaled corticosteroid with a long-acting inhaled beta-agonist. However, in most patients, increasing from a medium dose to a high dose of inhaled corticosteroid provides relatively little additional benefit. The high dose is recommended only on a trial basis for three to six months when your asthma cannot be controlled with a medium-dose inhaled corticosteroid combined with a long-acting beta-agonist. Many patients with asthma of this severity are prescribed three controller medications, or “triple-controller” therapy. This typically includes an inhaled corticosteroid, a long-acting inhaled beta-agonist, and a leukotriene modifier.
Prolonged use of high-dose inhaled corticosteroids can increase the risk of side effects. Also at medium and high doses, you generally need to use your inhaled corticosteroids at least twice daily, but your physician should review the dosing schedule for each medication in detail.
Step 5: Reliever medication plus additional controller options
Adding oral corticosteroids to other controller medications may be effective but can cause severe side effects and should be considered only if your asthma remains severely uncontrolled on Step 4 medications — meaning you are still experiencing daily limitation of your activities and frequent flare-ups.
For some people with allergic asthma (determined by skin or blood tests), adding injections of the anti-IgE antibody omalizumab (Xolair) to other controller medications has been shown to improve control of allergic asthma when other options haven’t worked. Although omalizumab is quite effective for some people, it is costly.
Although the majority of asthma patients can control their asthma with proper treatment, a small number of patients will continue to have symptoms even with the best therapy. Patients who do not reach an acceptable level of control at Step 4 have what is known as “difficult-to-treat asthma.” These patients may not respond well to corticosteroids, and may require higher doses of inhaled corticosteroids than the majority of patients. They may have ongoing exposure to potent triggers of asthmatic inflammation or may have difficulty complying with their prescribed treatment program. Uncontrolled nasal and sinus disease or gastroesophageal reflux disease (GERD) may also be a cause of difficult-to-treat asthma.
Your doctor may wish to consider the following:
- Confirm the diagnosis of asthma with further testing such as a methacholine challenge test. Two alternative diseases which are frequently considered in patients with “difficult-to-treat asthma” are chronic obstructive pulmonary disease (COPD) and vocal cord dysfunction. These conditions may have very similar symptoms to asthma, yet may not respond to typical asthma therapy.
- Go over your treatment to make sure you are using your medicines exactly as prescribed. Incorrect or inadequate use of medications remains the most common reason for failure to achieve control. The delivery devices for many of these medications are complex, and your physician may want to watch you using your inhalers in order to confirm proper use.
- Talk about smoking. If you used to smoke, this may help explain your current difficult-to-treat asthma. If you currently smoke, quit — smoking can reduce the effectiveness of inhaled and oral corticosteroids and worsen bronchial inflammation.
- Investigate the presence of other medical conditions that may aggravate your asthma. Chronic sinusitis, gastroesophageal reflux disease (GERD), and obesity with obstructive sleep apnea are more common in patients with difficult-to-treat asthma. Psychological and psychiatric disorders should also be considered. If your doctor finds you do have any of these other conditions, you should be treated for them, although it’s no guarantee that this will bring your asthma under control.
If your doctor has addressed all these issues with you and your asthma still isn’t under control, the goal will be to minimize flare-ups and need for emergency medical treatment, while achieving as high a level of control as possible with as little disruption of activities and as few daily symptoms as possible. You may still need to use rescue medication often.
If you have difficult-to-treat asthma and are not already under the care of an asthma specialist, ask your primary care doctor for a referral. The specialist can test you to see if you have allergic asthma; if so, you might benefit from anti-IgE treatment with omalizumab (Xolair). You may also be referred to an allergist for consideration of immunotherapy, which involves repeated injections. The specialist can also determine if you are aspirin-sensitive, a condition that can be treated with leukotriene modifiers and aspirin desensitization followed by aspirin maintenance therapy. Asthma specialists may also prescribe less common medications for patients with asthma that is resistant to standard treatment. Tiotropium is an inhaled anticholinergic medication which is typically used for patients with chronic obstructive pulmonary disease (COPD). Some patients with asthma have an improvement in symptoms with addition of this medication to their regimen.
One novel therapy that is available at some centers is bronchial thermoplasty. This is a form of therapy which applies radiofrequency waves to the airways in order to decrease the constriction of the airways which occurs in asthma. Thermoplasty is performed using a bronchoscope, which is a flexible tube with a camera that is inserted through the nose or mouth. This is performed on three separate occasions. The treatment may actually cause worsening of asthma symptoms for the first month after therapy, but some patients experience an improvement in symptoms after that time. This therapy is new, and the long term effects are not fully known at this time. Given the risks associated with the treatment, this is only utilized for very select patients and must be performed at specialized centers.
The ultimate goal of treatment is to keep your asthma well controlled with the least amount of medication necessary. At first, you may need more intensive therapy to achieve rapid control over symptoms. Then, as you gain control over your asthma, your medications can be reduced (or “stepped down”). This is particularly important when it comes to inhaled steroids. In collaboration with your doctor, find the lowest dose of inhaled steroids that will maintain good control in order to avoid the potential side effects associated with long-term use of high-dose inhaled steroids (see “Inhaled corticosteroids”).
There are some caveats to consider when stepping down your asthma therapy. The obvious one is that your asthma could get worse. If you find that your symptoms return and you are relying more frequently on your quick-acting bronchodilator inhaler, it may be necessary to “step back up” to the treatment program you were using before. With a little trial and error, and by paying attention to your symptoms and peak flow, you can usually find the right balance of therapy without suffering adverse effects.
More troublesome, however, is the possibility that stepping down the intensity of your asthma treatment will put you at increased risk for an asthma attack. It is entirely possible that you can reduce your medications to the point where you become vulnerable to a severe flare-up, even though you feel good and your peak flow remains normal. One study found, for instance, that people who had good control of their asthma and stopped their inhaled steroid, while continuing with the long-acting inhaled bronchodilator, had breathing capacities that were near normal but experienced asthma attacks more often. As this study showed, without any treatment of asthmatic inflammation, your bronchial tubes remain twitchy and you are at risk for asthma attacks. Continuing some anti-inflammatory therapy every day is therefore a good idea for all but the mildest form of asthma.
But how small a dose keeps you protected? It’s not easy to answer this question. There is no direct way of measuring asthmatic inflammation of the bronchial tubes to determine whether inflammation is being adequately suppressed, although researchers are exploring experimental techniques such as measurement of nitric oxide levels in exhaled breath. However, one currently available indicator — variation in your peak flow — provides an indirect measure of inflammation and enables you to keep an eye on possible deterioration that could lead to an asthma attack. As an example, imagine that when your asthma is under good control, your peak flow is consistently 350 to 400 liters per minute (L/min). When you reduce your medications, you may start noticing greater fluctuations in your peak flow readings: Some mornings you hit 400; other mornings it’s only 280, but when you check your peak flow later, it’s back up to 400. This variability of peak flow is a warning that an asthma flare-up may be coming. It would be best to increase your medications again, until the peak flow readings are once again steady in the 350 to 400 range.
Talk with your physician and have an action plan
Patients with asthma are at risk for exacerbations, or “flare-ups” of their asthma. In order to avoid potentially dangerous consequences it is important to monitor your symptoms as described above and discuss the details of your asthma with your physician regularly. A strong partnership with your physician is key to managing your asthma successfully, and you should take an active role in discussions about your symptoms and management. Research has shown that when physicians thoroughly educate and inform patients about asthma, their patients have fewer hospitalizations for asthma, improved daily function, and are more satisfied with their care.
It is also important to know what to do when your symptoms worsen. All patients with asthma should have a written asthma action plan. This plan should clearly explain your regular daily medications as well as what steps to take if you develop worsening symptoms or a decrease in your peak flow measurements. For example, if there is only a mild decrease in your peak flow, the action plan may inform you to use your rescue inhaler and repeat your peak flow in one hour. If you are experiencing severe symptoms or a large decrease in your peak flow, your plan may tell you to take additional medications and seek medical attention immediately.